Human Error: the number one threat to onboard safety

All commercial ships are required to have a Safety Management System (SMS) in place to establish safe ship management procedures. But no matter how thorough the SMS is, it takes humans to implement and follow the correct procedures.

The rules and guidelines for establishing the safety of a vessel, her crew, passengers and cargo have been firmly in place since the IMOs International Safety Management (ISM) Code became mandatory with its entry into force on July 1, 1998. Yet, unfortunately, accidents continue to happen.

In 2020, 49 ships were lost. Of these, 24 foundered, ten were lost as a result of fire or explosion, seven were wrecked or grounded, two went down following collisions, and the remaining six were the result of miscellaneous causes.

Accidents resulting in loss of life are, of course, worst case scenarios events. But accidents resulting in serious injury or even death occur on board ships around the world almost daily, regardless of Safety Management System in place.

Undoubtedly, the number one cause of onboard accidents or near-accidents is the failure to follow, or even to establish, proper procedures for specified tasks.

Exposure to gas when working in an enclosed space, electrical shock accidents, improper maintenance that can lead to generator, compressor or boiler explosions, falling from heights because of failures to the safety device, carrying out hot work in an enclosed space with flammable gases, accidents during mooring operations – the list of reasons why accidents happen is indeed lengthy. However, underlying all of them, in one way or another is human error.

The result of such errors can be felt by the environment, just as much as by personnel. For example, when the MV Wakashio ran aground off the coast of Mauritius on 25 July 2020, some 1,000 tons of fuel oil leaked into the sea, sparking an ecological emergency. The ship’s captain later admitted to drinking moderately during a birthday party onboard the vessel.

Why these errors occur and why proper procedures are not adhered to are often the offshoot of simple negligence. Typical causes include fatigue following long working hours and a lack of sleep, inexperience and inadequate training, reckless behaviour including the abuse of alcohol or drugs, language problems with a multi-cultural crew, personal onboard relationships, poor decision making, a lack of adequate onboard signage – these are all contributing factors. Unfortunately, it is just so easy for unsafe situations to be created.

First of all let it be said that there is no single solution that will eliminate accidents at sea. Nevertheless, more can be done to prevent unfortunate incidents and improve safety. The starting point has to be to analyse the reasons for and the lead-up to unsafe situations. In most cases where an incident has occurred — say for example a safety harness failed, or a crew member was burned —something similar probably happened onboard the same ship earlier, but without the same severe consequences. Unfortunately, no lessons were learned from the earlier incident.

This brings us to near-miss reporting. The U.S. Occupational Health & Safety Administration (OSHA) and National Safety Council describe a near-miss as being an unplanned event that did not result in injury, illness or damage – but which had the potential to do so.

Should any kind of a near-miss occur on a ship, it must be reported to the concerned management officer and to the master. The master must then report it to the authority and an investigation should be carried out. Onboard nearly vessels, this procedure should be clear and in place. The problem is that the procedure doesn’t always get followed, and there are numerous reasons for this.

First of all there is often a reluctance on the part of the individual involved to report such an incident. It may be because of embarrassment, knowing that he/she made an error, or perhaps the incident wasn’t considered to be that serious and not worth the effort of reporting. And then, there is always the chance that the incident, even if reported on by the individual involved, is not taken properly addressed even after it is reported.

There is maybe the temptation to avoid following a full safety procedure due to time constraints onboard a busy ship. After all, it takes time to file a formal report, which should describe in detail what happened when, with whom, where and in what sequence; what were the potential losses and the potential severity of such losses; and what was the likelihood of a loss being realized.

The report should be a proactive tool for accident prevention, but there can also be varying perceptions as to what constitutes a near-miss, Much depends on the safety culture of the company.

For every voyage, crews are required to fill in several reports that affirm compliance with the policies, practices and procedures that make up a vessel’s Safety Management System (SMS). The sheer volume of maritime regulations and compliance forms, both internal and external, can create hours of paperwork for crews and shoreside personnel alike, making for a system that is complex, time-consuming and costly.  

Having to file a near-miss report adds one more task to this responsibility. However, thanks to digital technology, the system can be simplified, thus increasing the likelihood that near-misses will be reported.

OneOcean’s Docmap is a digital solution that facilitates and simplifies ship-to-shore document exchange and administration. Docmap stores, categorizes, tracks, and keeps up-to-date the vast volume of documents that make up a vessel’s SMS. The solution can be accessed both online and via a mobile application. It can also be used in offline mode, permitting the ship’s officers to provide information while at sea. This is then automatically uploaded when the device is next connected to the internet.

It is a solution that supports safety, since it eases and speeds the reporting process. If near-misses are promptly and accurately reported, there is less likelihood of the incident being repeated. Human error will always remain the number one threat to onboard safety, but repetition of those errors can be reduced with the support of the right technology.