Original Article

Proc IMechE Part M:

J Engineering for the Maritime Environment
2021, Vol. 235(1) 93–109
A Human Reliability Analysis to Ó IMechE 2020
Article reuse guidelines:
Crankshaft Overhauling in Dry- sagepub.com/journals-permissions
DOI: 10.1177/1475090220948338

Docking of a General Cargo Ship journals.sagepub.com/home/pim

Samet Bicen1 , Cagatay Kandemir1 and Metin Celik2

Abstract
This study conducts a practical application of shipboard operation human reliability analysis (SOHRA) to a crankshaft
overhauling operation of a general cargo ship at dry-docking period. The SOHRA approach includes error producing
condition (EPC) and general task type (GTT) parameters to consistently calculate the human error probability (HEP) val-
ues of operation steps. In this case, a comprehensive overhauling of main engine was planned at shipyard since the ship
has experienced a catastrophic failure. An onboard survey to ship engine room is conducted to monitor the operational
conditions. The targeted operation, involves disassembly, maintenance, and reassembly stages, is monitored based on 39
sub-tasks. According to the initial findings, immediate recovery actions are suggested to eliminate critical safety issues in
a timely manner. Moreover, an extended discussion through long-term safety recommendations are also provided. The
results revealed from case study illustrates that HEP values in maintenance operations are sensitive to ship operating
conditions. The proposed approach is found very useful by company executives to support ship technical superinten-
dents in critical operation monitoring. The further study is considered to develop mobile application of SOHRA specific
to maintenance operations onboard ships.

Keywords
Human reliability, human error, ship operations, safety research, ship dry-docking, applied maritime research

Date received: 22 February 2020; accepted: 8 July 2020

Introduction factor perspective. Training, certification, knowledge

The human error is the leading factor for the majority
of accidents in many industrial domains. According to
the researches, there are many reasons such as lack of
education and experience, poor communication, inade-
quate system monitoring, lack of learning of previous
accidents, fatigue, and stress, which lead humans to
make mistakes. Researchers such as Rasmussen,1
Reason,2 Shappell and Wiegmann3, and Rouse and
Rouse4 examined and classified human factors in order
to propose solutions to this question. Since human
errors can cause undesired consequences, more research
is required on this subject to increase operational safety
level. For this reason, Paua,5 Lundh et al.,6 Islam
et al.,7 and Xi et al.8 have conducted studies to identify
the latent and non-latent aspects of human errors.
There can be similar studies in the safety literature has
been carried out to contribute human factor analysis.
In the maritime, the International Safety
Management (ISM) Code9 is a set of safety require-
ments that also support the operations from human
acquisition, and communication are considered impor-
tant issues within the ISM code. The ISM code also
represents the basic outline of the plans and procedures
for the operations to implement a safety management
system (SMS) on board. The SMS requires cooperation
among designated person ashore, technical manager,
operations manager and related superintendents, and
shipboard crew. The critical operations onboard such
as repair and maintenance has increased the role of the
human factor. For this reason, ship crew must perform
risk assessments to eliminate safety issues before certain
1
Department of Marine Engineering, Istanbul Technical University,
Istanbul, Tuzla, Turkey
2
Department of Basic Science, Istanbul Technical University, Istanbul,
Tuzla, Turkey
Corresponding author:
Samet Bicen, Department of Marine Engineering, Istanbul Technical
University, Maritime Faculty, Postane Mah. Sahil Cad., Istanbul, Tuzla
34940, Turkey.
Email: sbicen@itu.edu.tr
94 Proc IMechE Part M: J Engineering for the Maritime Environment 235(1)
activities. However, existing risk assessment analysis
address the whole operation instead of executing a task
based analysis. In such cases, the analysis can be super-
ficial and some particular deficiencies could be ignored.
As a result, the human error rate may be obtained
inaccurately.
According to the recent statistical data obtained
from the port state controls, the most frequent reasons
of arresting ships are generally caused by human
error.10 In detail, emergency systems, fire safety, ISM
records, marine pollution, navigation safety, and ship
structural defects can be seen in the port state control
reports. Hence, more detailed approaches are welcomed
for human factor literature. For instance, Yu et al.11
applied the human error criticality analysis (HECA)
method to increase the safety of operators as well as to
identify certain human error modes. They showed that
the HECA can be utilized as a task based safety analy-
sis tool in an industrial process. To another aspect of
human factor, Nan and Sansavini12 evolved an analyti-
cal method based on the Cognitive Reliability Error
Analysis Method (CREAM) using a knowledge-based
approach. The CREAM has also been widely applied
to marine literature such as Zhang et al.13 as they pro-
posed a dynamic human reliability assessment method
for the human actors operating in submerges. Similarly,
Chen et al.14 have applied CREAM to predict the over-
all error probability for critical missions to be carried
out by submersible ships.
In maintenance operations, different aspects of
human error may come into prominence. In fact, main-
tenance operations can be more complex than a routine
operation. In this regard, Toriizuka15 investigated the
maintenance tasks of an industrial plant and consid-
ered the countermeasure through performance shaping
factor (PSF).
There are also many studies can be found in the mar-
itime literature on maintenance planning at shipboard
operations. For instance, Bayer et al.16 conducted a
study toward improving the planning process, ensuring
workload balance to improve functionality, performing
intelligent programming, and integrating safe working
modules into existing planned maintenance software.
Likewise, Tan et al.17 have intended an algorithm to
integrate with condition monitoring system in order to
decrease complexity of marine machinery systems. In
addition, Zhao et al.18 presented a generalized selective
maintenance optimization model in order to maximize
the system reliability as well as to help maintenance
decision makers while reducing human error frequency.
Kimera and Nangolo19 also conducted a study to opti-
mizing maintenance process. As another innovative
effort; Kandemir and Celik20 conducted a human relia-
bility analysis research by comparing the human factors
between classical maintenance operations and the main-
tenance 4.0 process.
Moreover, the International Convention on
Standards of Training, Certification, and
Watchkeeping for Seafarers (STCW) identifies
maintenance and repair at the operating level as a criti-
cal function for engineering officers who work on-
board. Herein, the main idea is to control human factor
as well as reduce the likelihood of errors.21 However,
high probability of human error rates can be resulted
from many factors such as stress, fatigue, and inade-
quate training level. Eventually, undesired conse-
quences as loss of life or property can be seen.22 Since
the human error is responsible for more than 60% of
all accidents in maritime, more detailed inspections to
this issue are required from both academia and indus-
trial organizations.21,23–25
In the HRA literature, many studies utilize EPC
parameters when seeking ways to minimize human
error at sea.26–29 In this sense, these parameters are
adopted from the HEART method in accordance with
the sectoral specifications to conduct more accurate
HRA research. To exemplify, Wang et al.30 suggested a
modified HEART method with railway action reliabil-
ity assessment (RARA) technique and fuzzy analytic
network process (FANP) to assess human error prob-
ability in high-speed railway dispatching tasks. They
selected train occupancy loss in high-speed railway
sending off tasks as an example to demonstrate the fea-
sibility of the proposed method. Likewise, Islam et al.31
proposed a hybrid HEART approach by obtaining
expert judgments with the intention of calculating
human reliability more accurately. They implemented
their proposed technique to the maintenance proce-
dures of a condensate pump for an offshore oil and gas
facility as a case study. The findings reveal that the
most important causes of human factor should be
determined correctly.32 In this respect, Wang et al.33
applied their study an optimization through a Bayesian
network (BN) model and human factors experiments
(HFEs) for a flexible intermediate bulk container man-
ufacturing plant. They trained the workers according to
the fault diagnosis results. In conclusion, they claimed
that the total number of errors and system failure rate
decreased significantly after the training. Similarly,
Abaei et al.34 also utilizing BN by proposing a dynamic
human reliability approach for marine and offshore
operations to minimize risk of human error.
In light of all these studies, the selection of the most
proper method depending on the characteristics of a
case study. Since the purpose of this paper is to deter-
mine the possibility of human errors that may arise dur-
ing the crankshaft replacement of a ship’s main engine,
the SOHRA approach comes forward for the safety
survey. There are two main reasons for this statement.
Firstly, the SOHRA has marine specific EPC values,
which make it significant for maritime applications.
Second, the SOHRA has already implemented in vari-
ous ship machinery cases and proved its functionality
in the maritime literature. Therefore, this study aims to
detect critical safety issues on a major crankcase over-
hauling of a general cargo ship as well as to suggest
proper solutions to responsible superintendents via
SOHRA. The SOHRA approach, task steps of
Bicen et al. 95

crankcase overhauling, task based HEP values, sug- Table 1. EPC values.
gested recovery actions, lessons learned, and compre-
hensive discussions are provided under relevant Code Error producing condition Maximum
sections of this paper. EPC1 Unfamiliarity 17.00
EPC2 Time shortage 14.01
EPC3 Low signal-noise ratio 3.31
Methodology EPC4 Features over-ride allowed 8.72
EPC5 Spatial and functional incompatibility 5.76
In this section, the SOHRA method is examined in EPC6 Model mismatch 2.64
details with EPC, GEP, and APOA parameters. EPC7 Irreversibility 2.23
Additionally, the proposed framework of this study is EPC8 Channel overload 14.45
introduced as a basis of case study. EPC9 Technique unlearning 5.29
EPC10 Knowledge transfer 11.00
EPC11 Performance ambiguity 8.60
The SOHRA approach EPC12 Misperception of risk 12.51
EPC13 Poor feedback 12.55
Williams35 evaluated the likelihood of human reliability EPC14 Delayed/incomplete feedback 6.72
and developed the ‘‘Human Error Assessment and EPC15 Operator inexperience 10.03
Reduction Technique’’ method to optimize overall sys- EPC16 Impoverished information 8.42
EPC17 Inadequate checking 2.79
tem designs and identify human factors. The HEART EPC18 Objectives conflict 2.15
method connects the probability of human error into EPC19 No diversity 2.74
two variables: EPC20 Educational mismatch 2.88
EPC21 Dangerous incentives 3.62
EPC22 Lack of exercise 1.64
(1) Error producing conditions (EPC): Defined coef-
EPC23 Unreliable instruments 5.69
ficients depending on the working environment EPC24 Absolute judgments required 1.17
conditions. EPC25 Unclear allocation of function 1.22
(2) Generic error probability (GEP): Condition coef- EPC26 Progress tracking lack 3.28
ficients of tasks assigned to an operator. EPC27 Physical capabilities 4.35
EPC28 Low meaning 2.56
EPC29 Emotional stress 1.59
In the HEART method, 38 different EPCs and nine dif- EPC30 ill-health 0.89
ferent GEPs are identified. Each EPC has its own EPC31 Low morale 3.00
weight depending on the operating environment condi- EPC32 Inconsistency of displays 9.43
tions. Each GEP has different weights according to dif- EPC33 Poor environment 9.90
EPC34 Low mental workload 2.63
ferent conditions such as the complexity of the given EPC35 Sleep cycles disruption 10.30
task, the unfamiliarity of the operator, the time limit of EPC36 Task pacing 3.85
the task, whether it is a routine task or not. It is thought EPC37 Supernumeraries 4.14
that there should be EPCs with different weights in EPC38 Age 3.61
every field of the industry and HEART principles are
adapted for the maritime sector.36 This method, which
is adapted to systematically solve human error in
experiences, labor morale, organizational quality, crew
marine operations, is called SOHRA (Shipboard
collaboration, familiarity, time availability etc. as listed
Operation Human Reliability Analysis). The main dif-
in Table 1.28 Every EPC present in the working field
ference between SOHRA and HEART is the different
may increase the rate of HEP. Regulations for the elim-
EPC weights obtained by examining accidents in the
ination of EPCs can reduce the rate of HEP.
maritime field. Recently, the practical applications of
GEP is the second parameter used to calculate the
SOHRA have become widespread in the literature.7,37–39
HEP ratio. There are nine general types of tasks in
EPC and GEP parameters are required to calculate
SOHRA. Each GEP aims to provide a general descrip-
HEP in the SOHRA technique. EPCs and GEPs are
tion of a task and an estimated HEP rate for such a
determined for the work. HEP is calculated using the
general task.25–30,32,33,35 Table 2 shows the general task
parameters in the following formula.
types and GEP values. These task types and values are
( )
Y values calculated by the HEART method. Task types
HEP = GEP3 ½(EPCi  1Þ3APOApi + 1 ð1Þ with increasing coefficients from ‘‘H’’ to ‘‘A’’ increase
i
the probability of operator error. So, more difficult
and complex tasks make operational tasks more
unreliable.40
EPC and GEP parameters
SOHRA has two parameters called EPC and GEP to
measure the probability of human error that may occur APOA parameter
during the completion of a given task. EPC is deter- APOA determines the effective rate of each EPC deter-
mined by factors such as working environment, age, mined during EPC selection. SOHRA provides a
96 Proc IMechE Part M: J Engineering for the Maritime Environment 235(1)

Table 2. Generic task types and GEP values.

Generic task type (GTT) Nominal human unreliability (GEP)

(5th–95th percentile bounds)

A Totally unfamiliar; performed at speed with no real idea of likely consequences 0.55 (0.35–0.97)
B Shift or restore system to a new or original state on a single attempt without 0.26 (0.14–0.42)
supervision or procedures
C Complex task requiring high level of comprehension and skill 0.16 (0.12–0.28)
D Fairly simple task performed rapidly or given scant attention 0.09 (0.06–0.13)
E Routine, highly practiced, rapid task involving relatively low level of skill 0.02 (0.07–0.045)
F Restore or shift a system to original or new state following procedures with 0.003 (0.0008–0.007)
some checking.
G Completely familiar, well-designed, highly practiced, routine task occurring several 0.0004 (0.00008–0.009)
times per day, performed to highest possible standards by highly motivated, highly
trained, and experienced personnel, with time to correct potential error, but
without the benefit of significant job aid.
H Respond correctly to system command even when there is an augment or 0.00002 (0.000006–0.0009)
automated supervisory system providing accurate interpretation of system state
M Miscellaneous task for which no description can be found 0.03 (0.008–0.11)

precise weighting process by addressing the Analytic X

Hierarchy Process (AHP) to improve computational
consistency. AHP is a powerful multi-criteria decision-
making tool for measuring subjective judgment and
validating the consistency of data collected.41
The process of the method consists of three main
stages:
(1) Composing a pair-wise comparison matrix: In the
first step, a pair-wise comparison matrix is formed
to obtain the relative weight of each EPC. In this
context, Saaty’s 1–9 linguistic relative significance
scale is used.42 Next, a comparison matrix A is an
actual matrix n 3 n; wherein n denotes the number
of EPC evaluated. Each EPC aij (i,j = 1,2,3,...,n )
added to matrix A shows the importance of ith to
jth. It means that ith EPC is more important than
jth, if the aij \ 1. Otherwise, ith EPC is less impor-
tant than jth in case aij \ 1. In this context, if two
EPCs have similar relative weight, aij = 1. In light
of the above definition, the following equation (2)
is used to form the comparison matrix A.42
aij + aji = 1
(2) Calculating criteria weights: Allows calculation of
the relative weight (w) of each EPC. At this point,
equation (3) is used.
n   is expected to be deteriorated. When recovery actions
1X a
wi = Pn ij ð3Þ
n j=1 k = 1 akj
(3) Checking consistency rate: The final step is to
check the consistency of the data added to a pair-
wise comparison matrix. The consistency rate
(CR), respectively (4, 5, 6) can be calculated
according to equations.43,44
lmax  n
CI =
n1
n
aij wj = lmax wi ð5Þ
j=1
CI
CR = ð6Þ
RI
Proposed framework
The proposed framework of this study is illustrated in
Figure 1. As seen in this figure, the first step is to collect
the required data. The data can be collected by observa-
tions and expert judgments who are authorized to mon-
itor the whole maintenance process. The operational
steps are identified from the engine manufacturer’s user
guide recommendations.
In subsequent meetings, company procedures and
recommendations should be combined and the most
appropriate operation steps for the ship are determined
by the consensus of experts and researchers. The engi-
neer crew can identify the EPCs and GTTs for each
operation step. These two parameters enable to calcu-
late HEP values. Hence, HEP values can be calculated
ð2Þ in accordance with the SOHRA method. According to
the HEP values, recovery actions can be taken for the
critical steps, which have considerably high error prob-
ability. Since the appropriate recovery actions can elim-
inate the relevant EPCs, the probability of human error
are taken, the data are re-evaluated and analyzed.
Precautions should be continued until the acceptable
human error rate results are obtained.
Case study
Operating conditions monitoring
Crankshafts are the most critical parts of a ship’s main
engine. In case of breakdowns, ships can lose their
ð4Þ mobilization ability. In such circumstances, a major
overhaul or complete replacement should be executed
Bicen et al.
Figure 1. Framework of this study.
by responsible marine engineers. Even so, these pro-
cesses often involve complex, lasting and labor intensive
activities that require additional attention of superin-
tendents. Hence, operational planning should be inves-
tigated sophisticatedly on attempt to prevent potential
human errors.
In this case, the ship is a general cargo vessel which
was manufactured in 2011 in China. The ship has 5558
DWT carrying capacity is equipped with a 4-stroke
trunk piston main engine. Due to the small size of the
ship, the engine room has narrow space. The ship is
equipped with a shaft generator connected to the main
engine. The main engine crankshaft and shaft generator
are connected by a gear mechanism. The main engine
revolution is fixed and the crankshaft revolution is
changed by reduction gear. The electronic governor,
which is equipped on the main engine, loads the engine
according to the shaft revolution. During the voyage,
the governor settings are changed out of procedure. As
a result, the main engine crankshaft and shaft bearings
are damaged due to governor failure during port berth-
ing maneuvering. To intervene in the malfunction, the
ship has pulled to the shipyard and examinations have
made on the main engine.
The ship is surveyed at the shipyard on 13.06.2019.
The examination is conducted with the engine superin-
tendent, the deck superintendent, the technical man-
ager, the captain, and chief engineer. After the meeting,
the whole team is landed on the engine room to moni-
tor the situation.
The engine room lighting is sufficient since all engine
components are visible. Due to the narrow space of the
engine room, it is found that it prevents the mobility of
the employees. Some tools and equipment are old and
neglected.
When the main engine is repaired, some additional
works are also carried out at the ship’s living space.
Welding, carpenter, and electrical works are continued
intensely. Separator and compressor overhauls are ini-
tiated by another working team in the engine room.
Crankshaft, fuel pump, cover, fuel injection valve,
97
piston, liner, crankshaft, coupled pumps, and air cooler
dismantling are continuing on the main engine.
As a result of deflection measurements on the crank-
shaft of the main engine, it is envisaged that the block
part of the main engine crankshaft and the shaft parts
in which the bearings fit can be corrected by grinding.
For the main engine crankshaft grinding, firstly all con-
nections on the main engine is disconnected, main
engine cooling water and system oil is drained and nec-
essary preparations are made for lifting the main engine
block. The empty weight of the block is calculated to
perform the appropriate lifting operation. The neces-
sary lifting equipment is assembled and the clearances
required for the removal of the crankshaft to be
removed from the ship are determined. The main bear-
ing studs are removed and all bearings are loosened
and the bottom caps are removed. The crankcase bolts
are removed and the crankcase is loaded to the floor
deck. The crankshaft is removed from the engine after
all bearings are removed, and they are sent to the work-
shop for grinding. The completely removed main
engine block is lifted and positioned in the safe region.
As a result of the grinding process applied to the shaft
bearings and crankshaft, laser measurements are made,
but it is found that the desired values could not be
reached as a result of grinding. It is decided to replace
the crankshaft and the manufacturer is requested to
supply new crankshaft.
Task analysis
The new crankshaft is taken to the ship (Figure 2),
cleaned and placed in the main engine. The main engine
block and pipes are connected, all maintenance on the
main engine is completed and the main engine is pre-
pared for the overhauling.
In Figure 3, the new main engine crankshaft is
shown which is intended to be installed to the ship.
To analyze human reliability and calculate human
error rates during maintenance and repair operations
onboard, the SOHRA method is selected. Besides,
98
Figure 2. Transferring main engine crankshaft from shore to
ship.
Figure 3. Replaced main engine crankshaft.
detecting the possibility of human error, the conditions
of the maintenance and repair operation area, the qua-
lifications of the employees, working hours, experi-
ences, stress levels, and planning of the operation are
taken into consideration.
Observations made by senior engineers authorized
by the company and researchers are noted. The mainte-
nance operation steps are listed from the engine manu-
facturer’s instruction manual recommendations. In
subsequent meetings, the observations and
Proc IMechE Part M: J Engineering for the Maritime Environment 235(1)
recommendations are combined and the most appro-
priate operation steps for the ship are determined by
experts and researchers.
Before the operation started, a meeting is held with
the maintenance crews and explained in which steps the
overhaul operation would be performed. Task distribu-
tions are made for 38 sub-steps, 39 sub-steps with a
safety meeting, and 3 main steps.
Main and sub-steps of the whole overhauling opera-
tion is listed in Table 3.
The main engine crankshaft overhaul has 38 sub-
steps designated by senior engineers. The steps are
divided into three main groups. Each main and sub-
step should be handled together with probabilistic
safety analysis and hierarchical task analysis.
Therefore, the sub-steps A1 to A14 are grouped as
the first main step. The sub-steps A15 to A22 are the
second main step. The sub-steps A23 to A38 are
grouped as the third main step. A sub-step that would
fail in any of these steps means that the main step will
fail. According to these steps, the EPCs and GTTs are
selected by the expert engineers and researchers. Hence,
assigned EPCs and GTTs are listed in Table 4.
Findings on HEP values
The correlation between the sub-tasks to calculate the
HEP value of the operational steps is defined using
probabilistic safety analysis and hierarchical task anal-
ysis. Therefore, the dependence between the main and
sub-tasks is provided to predict human reliability in the
overhaul of the main engine crankshaft. The depen-
dency notation is used to calculate the HEP value for
all steps.45,46
To calculate the HEP value, GEP values corre-
sponding to the GTT values determined by the experts
are selected. As stated in Formula 1, HEP value is cal-
culated by using EPC values and APOA values. The
APOA value is calculated by formulas 2, 3, 4, 5, and 6.
GTT and EPCs from Table 4 are used for each opera-
tion step. As an example, Step A1 will be applied.
For the Step A1 (Calculating the empty weight of the
main engine block, assembling the lifting equipment, and
determining the clearances required for the removal of
the crankshaft to be removed from the ship), the GTT is
set to ‘‘F.’’ GEP value for ‘‘F’’ is found as ‘‘0.003’’ from
Table 2. EPCs specified for step A1 are EPC4, EPC5,
EPC13, and EPC14. When Table 1 is examined; EPC4
value is 8.72, EPC5 value is 5.76, EPC13 value is 12.55,
and EPC14 value is 6.72. In the evaluation made by
experts, it is determined that the weight of each EPC is
equal. For this reason, each EPC weight can be deter-
mined by the ratio of 1/Total EPC quantity.
The data for the sample application will be as
follows:
GEP: 0.003 EPC4: 8.72 EPC5: 5,76 EPC13: 12,55
EPC14: 6.72 APOA: ¼=0.25
Bicen et al. 99

Table 3. Operation steps of main engine crankshaft overhaul.

Step Operation

1. Disassembly of Main Engine Crankshaft

A0 Safety meeting.
A1 Calculating the empty weight of the main engine block, assembling the lifting equipment and determining the
clearances required for the removal of the crankshaft to be removed from the ship.
A2 Dismantling the main engine pipe connections.
A3 Lifting the main machine block and removing all equipment that will prevent crankshaft replacement.
A4 Draining cooling water and system oil from the main engine.
A5 Marking and removing the elastic coupling between the main engine and reduction gear.
A6 Removal of all equipment (pressure gauges, thermometers, alarm sensors, electrical cables, and pipe connections)
that may break on the main engine.
A7 Dismantling of the main engine sub-equipment (cylinder cover, piston, fuel pumps, coupled pumps, front cover,
flywheel, rear cover, etc.).
A8 Transferring of dismantled main engine equipment to the workshop for repair and maintenance.
A9 Removing the main bearing studs, loosening all bearings and dismantling lower caps with order (1-3-5-7-8).
A10 Taking the No-1 cylinder piston to top dead center, lifting the crankshaft from No-1 and No-8 crankpin journal.
A11 Removing the main engine crankcase bolts, lowering the crankcase onto the floor deck.
A12 Dismantling and lowering the other bearings (2,4,6), taking down the caps, lowering the crankshaft into the
crankcase.
A13 Removing the main engine block foundation bolts, breaking the chockfast, lifting the block, carrying in the safe
region.
A14 Transferring the crankshaft from the material transfer cover at the workshop to shore.
2. Maintenance Operations
A15 Moving the main engine block onto the foundation, and tightening the main bearing bottom caps without bearing.
A16 Checking the alignment of the main engine block from all bearing housings by laser.
A17 Carrying out hardness, MPI cracks, measurement, and ovality checks of the main engine crankshaft (These
inspections should be made within the manufacturer’s authority).
A18 Inspecting and maintaining of all parts dismounted from the main engine in the workshop.
A19 Removing and cleaning of the main engine block and oil pipes.
A20 Inspecting and maintaining the governor, turbocharger, and reduction gear which may be damaged due to
overspeed failure.
A21 Lifting the block, carrying in the safe region.
A22 Transferring and placing the new crankshaft from the shore to the main engine by the joint operation of shore
crane and repair team.
3. Reassembly of the Crankshaft
A23 Cleaning of the main engine crankshaft protecting wax.
A24 Lying the main engine block onto the foundation, and placing the main engine upper parts in the shell (except 1
and 8 main bearings).
A25 Lifting the main engine crankshaft from 1 and 8 crankpins, placing the upper bearings and checking the marks on
the gear (No.1 top dead center mark).
A26 Lifting the main engine lower caps together with bearings, connecting to the crankshaft and tightening in torque.
A27 Solving the slings of the crankshaft and checking the rotation of crankshaft by apparatus.
A28 Lifting the block of the main machine, lowering to the chockfast parts, tightening from 6 points as fore-starboard-
aft-port sides.
A29 Installing of all parts into the main engine (front cover, rear cover, piston, liner, cylinder cover, fuel pumps, coupled
pumps, vibration damper, etc.)
A30 Connecting of the main engine lower crankcase, cleaning the inside of the block, flushing all oil pipes in idle (from
crankcase to crankcase) for 72 h and cleaning the filter once in 2 h.
A31 Connecting the oil pipes to the block, removing the sump oil after flushing, cleaning filters, and adding new oil to
the sump, flushing out the sump oil in the whole main engine lubricating system for 48 h, removing the dirty oil
from the sump tank.
A32 Dismantling of connected oil pipes for flushing, connecting of the flywheel, and connecting of elastic coupling
between the reduction gear and the main engine.
A33 Checking of alignment between reduction gear and main engine.
A34 Spreading the chockfast (to be carried out by Class approved authorized company).
A35 Tightening the main engine foundation studs.
A36 Measuring the deflection of the main engine crankshaft.
A37 Checking of alignment between reduction gear and main engine again.
A38 Connecting of all pipes of the main engine (oil, fuel, water, air, exhaust etc.).
100 Proc IMechE Part M: J Engineering for the Maritime Environment 235(1)

Table 4. Selected GTT and EPCs. Table 5. HEP values.

Step GTT EPC Step HEP HEP %

A0 – EPC – A0 0.00E + 00 0
A1 F EPC 4, 5, 13, 14 A1 1.82E–01 18.20
A2 G EPC 16, 17 A2 3.57E–03 0.36
A3 F EPC 5, 13, 14, 16, 17, 23 A3 1.59E–01 15.90
A4 H EPC 34 A4 5.26E–05 0.01
A5 E EPC 4, 8 A5 7.51E–01 75.10
A6 F EPC 2, 4, 8, 17 A6 2.36E –01 23.60
A7 E EPC 13,14,17, 25 A7 2.89E–01 28.90
A8 H EPC 3, 12, 23, 25 A8 2.80E–03 0.28
A9 E EPC 5, 15, 23 A9 5.32E–01 53.20
A10 F EPC 2, 3, 4 A10 1.01E–01 10.10
A11 E EPC 17 A11 5.58E–02 5.58
A12 E EPC 5, 15, 23 A12 5.32E–01 53.20
A13 F EPC 4, 5, 8, 13, 14 A13 3.90E–01 39.00
A14 G EPC 3, 4, 5, 8, 15, 16 A14 4.13E–02 4.13
A15 F EPC 4, 5, 8, 13, 14 A15 3.90E–01 39.00
A16 G EPC 17, 23 A16 2.54E–03 0.25
A17 G EPC 17, 23 A17 2.54E–03 0.25
A18 G EPC 34 A18 1.05E–03 0.11
A19 G EPC 23, 34 A19 2.43E–03 0.24
A20 D EPC 8, 23 A20 1.00E + 00 100.00
A21 F EPC 4, 5, 8, 13, 14 A21 3.90E–01 39.00
A22 G EPC 3, 4, 5, 8, 15, 16 A22 4.13E–02 4.13
A23 H EPC 17, 34 A23 6.88E–05 0.01
A24 F EPC 4, 5, 8, 13, 14 A24 3.90E–01 39.00
A25 F EPC 4, 5, 8, 13, 14 A25 3.90E–01 39.00
A26 F EPC 4, 5, 8, 13, 14, 17 A26 2.96E–01 29.60
A27 G EPC 13, 14, 17 A27 9.00E–03 0.90
A28 F EPC 4, 5, 8, 13, 14 A28 3.90E–01 39.00
A29 G EPC 13, 14, 17 A29 9.00E–03 0.90
A30 F EPC 12, 13, 14, 17 A30 1.59E–01 15.90
A31 F EPC 12, 13, 14, 17 A31 1.59E–01 15.90
A32 F EPC 12, 13, 14, 17 A32 1.59E–01 15.90
A33 E EPC 16, 17, 23 A33 2.84E–01 28.40
A34 H EPC 7, 17, 18 A34 6.23E–05 0.01
A35 G EPC 4, 5, 13, 14, A35 2.42E–02 2.42
A36 G EPC 4, 5, 15, 16, 23 A36 2.68E–02 2.68
A37 E EPC 16, 17, 23 A37 2.84E–01 28.40
A38 F EPC 16, 17 A38 2.68E–02 2.68

( )
Y an error occurring in this step is 100%. When the third
HEP = GEP3 ½(EPCi  1Þ3APOApi + 1
i
( )
Y
4
HEPA1 = 0:0033 ½(EPCi  1)3APOApi + 1
i=1
HEPA1 = 0:0033f½ð8:72  1Þ30:25 + 1
3½ð5:76  1Þ30:25 + 13½ð12:55  1Þ
30:25 + 13½ð6:72  1Þ30:25 + 1g
HEPA1 = 0:0033f½2:933½2:193½3:88753½2:43g
HEPA1 = 0:18185 = 1:82E  01
When the HEP values are calculated for each EPC, the
values in Table 5 will be obtained.
The HEP value of the main steps is determined by
the sub-step with the highest error rate in the sub-steps.
Therefore, when Table 5 is examined, it is seen that the
HEP value of the first main step is 7.51E–01 (75%).
Similarly, the second main step shows that the HEP
value is 1.00E + 00. This means that the probability of
step is considered, it is seen that the HEP value is
3.90E–01 (39%). HEP distributions of main steps 1, 2,
and 3 are displayed in Figures 4–6, respectively. In
Figure 7, overall HEP values of the main steps are also
illustrated.
The 100% probability of error for main step 2 is a
prediction which signals a certain error in this opera-
tion. When the technical reports of the overhaul opera-
tion are examined, the sub-step A20 identified the parts
damaged due to overspeed failure and performed the
necessary maintenance and repair.
There are some difficulties in implementing the A20
sub-step. The most important factor of difficulties is
the failure to supply the replacement parts of reduction
gears, governors, and turbochargers that are damaged
due to overspeed failure. When the system components
are examined for maintenance and repair, parts that
are too damaged to be repaired are found. Since these
equipments are critical parts for the main machine and
Bicen et al.
Figure 4. HEP distribution graph of Main Step 1.
Figure 5. HEP distribution graph of Main Step 2.
Figure 6. HEP distribution graph of Main Step 3.
are highly sensitive, both the supply and assembly
processes are carried out by special repair
teams. Engine parts that need to be replaced are manu-
factured in China. Shipyard’s process is taking place in
Turkey. Delays are experienced both due to the pro-
duction of spare parts, shipping and customs proce-
dures. Due to the delay of the materials that need to be
changed, a 21-day delay occurred in the completion of
the repair.
101
Recovery actions
Immediate actions
According to human error probabilities in Table 5, it
can be observed that the error probability values are
higher in sub-steps A5, A9, A12, A13, A15, A20, A21,
A24, A25, and A28 compared to other steps. These
tasks are also noted in the technical reports prepared
by the company as a result.
102 Proc IMechE Part M: J Engineering for the Maritime Environment 235(1)
Figure 7. HEP values of main steps for crankshaft overhauling.
Table 6. Widely occurred EPCs and related operation steps.
EPC code EPC mean Value
2 Time shortage 14.01
4 Features over-ride allowed 8.72
5 Spatial and functional 5.76
incompatibility
8 Channel overload 14.45
13 Poor feedback 12.55
14 Delayed/incomplete feedback 6.72
16 Impoverished information 8.42
17 Inadequate checking 2.79
23 Unreliable instruments 5.69
The sub-step A20 includes maintenance and repair
operation for damaged parts of sensitive governors,
turbochargers and reduction gears. For this reason,
GTT of this sub-step is specified as ‘‘D’’ which is the
most complex assignment among all sub-tasks. In addi-
tion, the crew was overloaded in that time (EPC8) and
majority of the tools was inadequate (EPC23). High
values of GTT and EPC combination makes this sub-
task’s HEP 100%. The prolongation for the procure-
ment of spare parts has extended the operating time,
because of continuously for the same kind of tasks, the
special team exposure to working blindness and due to
the lack of reliability of the dismantling-tools and mea-
suring instruments used in the ship environment.
Preventing failures in this sub-step can be achieved by
detecting potentially damaged parts beforehand, and
by requesting spare parts earlier to avoid delays. To
prevent the work blindness, special repair teams can be
assigned to different jobs. Maintenance and repair of
engine parts that require precision work can be com-
pleted at the ashore workshop or away from noise and
vibration in the working space for healthy operation.
Widely occurred EPCs are listed in Table 6 accord-
ing to related operation steps. When the data is
Operation steps
A6, A10
A1, A5, A6, A10, A13, A14, A15, A21, A22, A24, A25,
A26, A28, A35, A36
A1, A3, A9, A12, A13, A14, A15, A21, A22, A24, A25,
A26, A28, A35, A36
A5, A6, A13, A14, A15, A20, A21, A22, A24, A25, A26,
A28
A1, A3, A7, A13, A15, A21, A24, A25, A26, A27, A28,
A29, A30, A31, A32, A35
A1, A3, A7, A13, A15, A21, A24, A25, A26, A27, A28,
A29, A30, A31, A32, A35
A2, A3, A14, A22, A33, A36, A37, A38
A2, A3, A6, A7, A11, A16, A17, A23, A26, A27, A29, A30,
A31, A32, A33, A34, A37, A38
A3, A8, A9, A12, A16, A17, A19, A20, A33, A36, A37
examined, it has high values that these EPCs, which
affect operation steps. The widely occurred EPCs are 2,
4, 5, 8, 13, 14, 16, 17, and 23. These EPCs increase the
HEP rate of the related operation step.
Considering all the operational steps, the general
problems can be listed as follows:
(1) Trying to perform multiple commands or tasks at
the same time.
(2) Using inadequate location or equipment.
(3) Difference between perceived risk and actual risk.
(4) Inadequate reporting by crew performing the
work.
(5) Insufficient knowledge of the crew.
(6) Missing/incorrect information transfer between
the team and the responsible engineer.
(7) Using dangerous and unreliable tools.
(8) Uncertainty in the division of duties and
responsibilities.
(9) Loss of concentration due to low workload.
Recovery actions to be taken to eliminate or mini-
mize the EPC effects in the working environment is
listed in Table 7. The influence of time shortage (EPC2)
Bicen et al.
Table 7. Recovery actions for reducing EPC effects.
EPC code EPC mean
2 Time shortage
4 Features over-ride allowed
5 Spatial and functional incompatibility
8 Channel overload
13 Poor feedback
14 Delayed/incomplete feedback
16 Impoverished information
17 Inadequate checking
23 Unreliable instruments
is higher than all EPCs, except unfamiliarity (EPC1)
and channel overload (EPC8). Attempting to complete
a task within a short time period affects human actors
notwithstanding the industrial domains. For this rea-
son, this highly important EPC should be eliminated by
reviewing the working schedule, as an immediate
action.
Features over-ride allowed addresses the over-riding
or suppressing information which is easily accessible
(EPC4). In this case, maintenance manuals provided
from the manufacturer have some deficiencies thus con-
sidered as unreliable. This EPC has appreciable impact
on HEP values. For this reason, a reviewing is required
on technical manuals via support of manufacturer
crew.
Spatial and functional incompatibility (EPC5) means
that there is no way to convey spatial and functional
information of equipment in a working environment.
This condition can be sourced by many reasons so it is
important to detect this reason before disqualify it. In
this case, the main problem is wrong establishment of
initial working area which makes the place narrower so
some functional features of equipment cannot be acces-
sible. In conclusion, a re-establishment in accordance
with the operation is recommended.
Channel overload (EPC8) issues a capacity overload
caused by simultaneous presentation of non-redundant
information. This safety issue is arisen by the low
knowledge level of some operators toward such opera-
tion hence; the requirement of giving them additional
information causes an overload. Then, employment
and assignment of new and qualified personnel is
required.
Poor and incomplete feedbacks (EPC13, EPC14)
often sourced by lack of communication between
operators. Impoverished information (EPC16) means
the poor quality of information exchange between the
crew. Lack of communication in conjunction with the
103
Action
An appropriate working plan should be prepared to prevent
problems and delays.
Technical manuals should be reviewed especially for the
maintenance process by the manufacturer.
The appropriate working area should be created in accordance
with the equipment functionality.
The knowledge and skill levels of all personnel to be employed
should be determined by considering previous work experience.
Interval short meetings should be held at regular intervals to
provide sufficient feedback about the operation.
At the safety meetings, the crew should be informed about
communication in cases where rapid feedback is required.
Tasks should be clearly defined at the safety meeting to be held.
Every work to be done should be audited with more detailed
checklists.
Tools to be used during operation should be renewed with
proper ones.
impoverished information exchange can lead serious
safety threats so they need to be eliminated. As an
immediate action, interval safety meetings that can pro-
vide effective communication and guidance for opera-
tors for critical tasks are suggested.
Inadequate checking (EPC17) has relatively low
influence on the HEP values, however this EPC
involves with many sub-tasks so this situation makes it
critical to take an immediate countermeasure for
EPC17. In order to achieve, the existing checklists are
reviewed and more detailed, task specific checklists are
suggested.
Unreliable instrumentation (EPC23) can be caused
if there are more than one major operations in a work-
ing place. There can be complexity of assignment phase
of utilizing tools due to inadequate inventory monitor-
ing systems. As an immediate action, the tools can be
renewed by the most proper and more adequate ones
that exist in the storehouse.
Additional recovery actions for all operation can be
listed as follows:
(1) Ensure adequate illumination of the work area.
(2) More comprehensive risk analyzes should be per-
formed prior to the operation.
(3) Attention should be paid to the cleanliness of the
work area and responsible pre-operation crew
should be established for possible contamination.
In order to take immediate recovery actions, the EPCs
(8, 13, 14, and 16) which require less time and low cost
with high reduction rate for HEP are considered to be
eliminated. In this scenario, the knowledge and skill lev-
els of all the personnel to be employed are determined
by taking into consideration the previous work experi-
ence. Short meetings are held at regular intervals to
provide adequate feedback on the operation. At the
safety meeting, the crew is informed about
104 Proc IMechE Part M: J Engineering for the Maritime Environment 235(1)

Figure 8. Comparison of Main Step’s HEP values between existing operating conditions and operating conditions after recovery
actions.

Figure 9. Comparison of Main Step 1 HEP values between existing operating conditions and operating conditions after recovery
actions.

communication in cases where rapid feedback is
required, and tasks are clearly defined.
Elimination of EPC 8, 13, 14, and 16 reduce the
HEP value of the main step 1 from 7.51E–01 to 5.32E–
01. HEP value of main step 2 reduces from 1.00E + 00
to 5.12E–01. The HEP value of main step 3 reduces
from 3.90E–01 to 1.27E–01. Comparison of the HEP
values of three main steps are shown in Figure 8.
Besides, these values are displayed in sub-steps in the
Figures 9–11 for main steps 1, 2, and 3, respectively.
In the applied scenario, when EPC 8, 13, 14, and 16
are eliminated, the HEP values in the sub-steps are sig-
nificantly reduced. It is observed that there is a signifi-
cant decrease especially in the sub-steps A5, A9, A12,
A13, A15, A20, A21, A24, A25, and A28 which have
high HEP values. Sub-step A5 reduces from 7.51E–01
to 1.74E–01. Sub-step A13 reduces from 3.90E–01 to
4.93E–02. Sub-step A15 reduces from 3.90E–01
to 4.93E–02. Sub-step A20 reduces from 1.00E + 00 to
5.12E–01. Sub-step A21 reduces from 3.90E–01 to
4.93E–02. Sub-step A24 reduces from 3.90E–01 to
4.93E–02. Sub-step A25 reduces from 3.90E–01 to
4.93E–02. Sub-step A28 reduces from 3.90E–01 to
4.93E–02.
Moreover, comparison of operation steps with sig-
nificantly reduced HEP values between existing operat-
ing conditions and operating conditions after recovery
actions is listed in Table 8.
Lessons learned and further recommendations
The safety issues related to this case can be removed
limitedly by immediate recovery actions. Nevertheless;
they are not unimportant efforts and this can be seen
as HEP values of some critical tasks are reduced in this
way. Since the main objective is to eliminate all EPCs
for maximum occupational safety, there are some fur-
ther recommendations to the shipyard organization as
well. To achieve this goal, all safety issues sourced by
the organization should be identified. Therefore,
Bicen et al.
Figure 10. Comparison of Main Step 2 HEP values between existing operating conditions and operating conditions after recovery
actions.
Figure 11. Comparison of Main Step 3 HEP values between existing operating conditions and operating conditions after recovery
actions.
further recommendations can be made for permanently
providing more effective occupational safety. There are
safety issues that are identified during the crankcase
overhaul process, sourced by the organizational defi-
ciencies. Recovery of these issues is difficult in a short
period; hence these recommendations should be done
for the repair operations which will be conducted in the
future. In this way, these further recommendations can
reduce the HEP for any machinery operation in various
ships existing in the fleet of the company.
Firstly, prior to any major overhaul operation,
whole process should be reviewed through a proper
safety analysis model in order to estimate potential
risks. Since the human error is the most dominant fac-
tor for majority of industrial fields, a HRA can
105
contribute to safety level of a workplace. In the litera-
ture, there are several HRA methods which are custo-
mized for specific domains such as Nuclear Action
Reliability Assessment (NARA)47 for nuclear plants,
Controller Action Reliability Assessment (CARA)48
for air traffic management, Railway action reliability
assessment (RARA)49 for railway transportation.
Likewise, the SOHRA is the only method which has
been adopted for shipboard operations among HRA
studies. The marine specific EPC values in SOHRA
method are the main difference when compared to
other methods. These values have been determined by
a meticulous analysis involving the historical data of
100 shipboard accident investigation reports. For this
reason, the SOHRA has been applied in several HRA
106 Proc IMechE Part M: J Engineering for the Maritime Environment 235(1)
Table 8. Significantly reduced HEP values of existing operating
conditions and operating conditions after estimated recovery
actions.
Operation HEP value of HEP value of
step existing operating conditions
operating after recovery actions
conditions
A5 7.51E–01 1.74E–01
A6 2.36E–01 9.13E–02
A13 3.90E–01 4.93E–02
A20 1.00E + 00 5.12E–01
A25 3.90E–01 4.93E–02
A28 3.90E–01 4.93E–02
A32 1.59E–01 3.84E–02
A33 2.84E–01 1.27E–01
A37 2.84E–01 1.27E–01
studies which have been contributed to the maritime lit-
erature. Hence, the SOHRA can be considered as a
reliable model to identify potential human errors in
shipboard operations. For this reason, it is strongly rec-
ommended that the SOHRA should be applied to all
planned operations before any determined tasks in such
cases. Thus, safety issues that greatly increase the HEP
values can be identified and eliminated before the
beginning of an operation, notwithstanding the type of
a ship. Each eliminated HEP value helps to prevent
injury and loss of life along with the material losses.
Second, the most common problem of the case study
is ‘‘unreliable instruments.’’ The HEP values of the sev-
eral tasks are increased due to this issue. For this rea-
son, this problem should be eliminated sustainably.
Hence, company management should integrate an elec-
tronic inventory monitory system. By means of elec-
tronic inventory monitory system, both ship crew and
company managers can track the number and condition
of inventory in use. In this way, before starting an oper-
ation, improper tools, spare parts, and other instru-
ments can be replaced more rapidly and easily. Besides,
it can provide a knowledge bridge between the crews of
different ships of the fleet for this issue.
‘‘Poor feedback’’ between the crew is another issue
that is detected in several tasks. Since this issue is often
caused by verbal communication deficiencies; short
time meetings should be arranged to make proper brief-
ings during the shift changes. Such meetings should be
under the detection of superintendents. The operators
should share the latest information to provide more
effective communication efforts. The integration of this
countermeasure should be a permanent action in the
company. In addition to this, the written form of com-
munication procedure should be modified by superin-
tendents. The recordings should be modified in
accordance with the special requirements of the opera-
tions. Electronic recordings, computer software or
mobile devices can provide the easy implementation for
all ships.
As another problem which should be eliminated is
‘‘inadequate checking.’’ The immediate action is to
implement more detailed checklists to analyze situa-
tions with more reliable data, however; newly intended
technologic checking and inspection instruments are
recommended as an innovative effort for the company’s
next maintenance activities.
Throughout the operation, the manufacturer’s tech-
nical manual causes some confusion among the mainte-
nance crew. However, the source of this problem is not
the company. The recommendation for such an issue
can be establishing communication for ship manage-
ment about the condition of technical manuals. If
requires, an updated version of the manuals should be
obtained from the manufacturer before the operation.
This process can also be completed online.
In some special tasks, ‘‘insufficient knowledge of
crew’’ is detected due to job inexperience. The com-
pany’s internal training activities can be modified in
accordance with such deficiencies which are identified
during the operation. Since the training needs of each
ship operator can be on a different subject, the context
of trainings can be planned specifically for the opera-
tion teams. Considering the evaluation reports prepared
by the ship’s captain, chief officer, or chief engineer,
training should be organized on the subjects where the
personnel are insufficient. That is because; one of the
most effective actions that can be taken to eliminate
human error is to provide effective training activities.
All of these recommendations should be completed
to reduce HEP values substantially. Each operation
can reveal valuable knowledge about the safety issues
via application of SOHRA. The financial concern of a
company can be a limitation to take proper counter-
measures toward identified issues, however; technical
managers can prioritize their options more efficiently
by the SOHRA approach.
Conclusion
In this study, the repair operation for the main engine
of a dry cargo ship is examined and discussed with the
SOHRA, which is the only HRA approach that specia-
lized for shipboard operations in the literature. In
HRA approaches, EPC and GTT are the most impor-
tant parameters to calculate HEP values. In this regard,
the SOHRA utilizes the marine specific EPC values to
obtain more accurate results. Since the EPC values
were determined from the historical data of the acci-
dent investigation reports; the SOHRA can be consid-
ered as the most reliable approach. For this reason,
this research is utilized via SOHRA by the cooperation
of ship crew, dock personnel, and researchers to the
implementation phase. Since this case is executed on
the dry dock environment, some other various opera-
tions are made simultaneously. For this reason, opera-
tional conditions are closely monitored and carefully
noted in order to specify EPCs, accurately. All findings
are reviewed with superintendents and responsible engi-
neers throughout the operation.
Bicen et al.
Taking the advantage of SOHRA approach, the
maintenance and repair operations of main engine’s
crankshaft is executed. As a result of a malfunction in
the governor, the main engine is given an overspeed
error and thereafter a crankshaft bearing seizure prob-
lem is occurred. Because of this failure, the ship is sent
to the shipyard and crankshaft maintenance is started.
At the same time, many maintenance and repair opera-
tions are carried out in machinery and deck area.
Many errors are occurred during the maintenance and
repair operations. When the errors are examined, it is
observed that there are errors caused mainly by human
factors.
The operation is divided into three main steps and
39 sub-steps and the probability of human error that
might occur at each step are evaluated. For each step
of the operation, EPC, GEP, and GTT parameters are
determined by the opinions of superintendents and
technical managers. HEP values are calculated with the
formula 1 using the determined parameters. The HEP
values of the main steps are considered as the HEP
value of the sub-step with the highest value.
As a result of the analyzes, the HEP values of sub-
steps A5, A9, A12, A13, A15, A20, A21, A24, A25, and
A28 are higher than other sub-steps. In particular, the
HEP value is calculated for the A20 sub-step is deter-
mined as 100%. This means that the probability of
human error in this step is certain. The calculated value
of sub-step A5 is 75.1%, the value of sub-steps A9 and
A12 are 53.2%, the value of sub-steps A13, A15, A21,
A24, A25, and A28 are 39%.
The most common EPCs are identified as 2, 4, 5, 8,
13, 14, 16, 17, and 23. EPC8, EPC13, EPC14, and
EPC16 can be eliminated when adjustments requiring
minimum time and least cost are made in the applied
scenario. When these EPCs are removed from the sys-
tem, the probability of human error is significantly
reduced. When HEP values are recalculated for the sce-
nario, the value for A5 decreases to 17.4%, the value
for A6 decreases to 9.13%, the values for A13, A25,
and A28 decrease to 4.93%, the value for A20 decreases
to 51.2%, the value for A32 decreases to 3.84%, and
the values for A33 and A37 reduce to 12.7%.
Elimination of EPC 8, 13, 14, and 16 reduce the
HEP value of the main step 1 from 75% to 53.2%.
HEP value of main step 2 reduces from 100% to
51.2%. The HEP value of main step 3 reduces from
39% to 12.7%. Comparison of the HEP values of three
main steps are shown in Figure 8.
Main step 2 is reached the maximum HEP value due
to calculation of sub-step A20. The HEP values which
are calculated with the EPC, GEP, and GTT para-
meters are consistent with the actual human errors on
the case study.
According to the operating data, some EPCs appear-
ing in the system can be eliminated simply by making
maintenance planning more effective and controls more
107
detailed. However, some EPCs can be eliminated by
long time efforts. As a result of the analysis, the most
common problems are identified as unreliable instru-
ments, poor feedback, inadequate checking, and insuffi-
cient knowledge of crew. In Section 4.1, immediate
actions that can be taken for identified deficiencies are
determined. These immediate actions are countermea-
sures that can be taken just before the operation which
may significantly affect the HEP value, in a time con-
straint. Section 4.2 should be perceived as the improve-
ments that the company should implement in the long
term. Personnel should be supported by both theoreti-
cal and practical special and effective training. In other
words, personnel deficiencies should be determined
individually and training planning should be done.
Besides, technological equipment such as mobile
devices can be implemented in critical areas to manage
assets more effectively. Recovery actions for both of
these situations are made under related sections sepa-
rately. In this way, decreasing the human error prob-
ability could minimize material, time losses, and other
unexpected incidents.
In addition, every accident and the near-miss inci-
dent should be recorded and analyzed continuously by
an inspection mechanism. The obtained results of such
analysis can be a guide while taking precautions toward
determining the human error that can cause accidents.
In this study, recommendations are made to techni-
cal managers and superintendents by considering the
conditions of the work area where the operation is car-
ried out and the employees doing the work. Since the
estimations of HEP is consistent with the actual case,
the proposed recommendations can reduce the poten-
tial human error occurrences for similar operations in
the future. For further studies, the SOHRA approach
can be expanded for more particular task descriptions
or specific operations in the maritime. Moreover, mak-
ing a decision for assignment of EPC and GTT to sub-
tasks takes long time for the safety experts. This pro-
cess should be transformed into more rapid, easier, and
practical job in order to take precautions more timely
and earlier.
Acknowledgement
The authors are grateful to operation managers and
shipboard personnel of STATU Shipping Company to
support field studies on-board ships.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
108 Proc IMechE Part M: J Engineering for the Maritime Environment 235(1)
ORCID iD
Samet Bicen https://orcid.org/0000-0003-0988-620X
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