Foto : Kersandt, D.
Aus den "Definitionsbereich"
Unter einem “Seeunfall” (marine casualty) versteht man :
„A marine casualty is any event associated with a marine system (vessel, terminal, port, offshore platform, etc.) that leads to adverse effects on mariners, the public, property, commerce, or the environment.” / 31 /
Maritime Unfälle haben danach folgende Merkmale :
“• They are unplanned
• They involve human errors, equipment failures, or external events
• They have an impact on the economy, safety and health, or the environment
• They generally have underlying root causes that create error-likely situations for people and conditions leading to equipment failure
• They are frequently preceded by related events that can be detected and corrected
• They will always be possible, but can be effectively managed” / 31 /
/ 31 / - : Prevention Through People Quality Action Team Report.
Reports and Studies . - July 1995. U.S. Coast Guard (Quelle : INTERNET)
Die IMO definiert “Marine casualties” in ihrem “Code for the Investigation of Marine Casualties and Incidents” / 32 / wie folgt :
“4.1 Marine casualty means an event that has resulted in any of the following:
.1 the death of, or serious injury to, a person that is caused by, or in connection with, the operations of a ship; or
.2 the loss of a person from a ship that is caused by, or in connection with, the operations of a ship; or .3 the loss, presumed loss or abandonment of a ship; or
.4 material damage to a ship; or
.5 the stranding or disabling of a ship, or the involvement of a ship in a collision; or
.6 material damage being caused by, or in connection with, the operation of a ship; or
.7 damage to the environment brought about by the damage of a ship or ships being caused by, or in connection with, the operations of a ship or ships.
4.2 Very serious casualty means a casualty to a ship which involves the total loss of the ship, loss of life or severe pollution.
4.3 Serious casualty means a casualty which does not qualify as a very serious casualty and which involves:
.1 a fire, explosion, grounding, contact, heavy weather damage, ice damage, hull cracking or suspected hull defect, etc., resulting in;
.2 structural damage rendering the ship unseaworthy, such as penetration of the hull underwater, immobilization of main engines, extensive accommodation damage etc.; or
.3 pollution (regardless of quantity); and/or
.4 a breakdown necessitating towage or shore assistance.
4.4 Marine incident means an occurrence or event being caused by, or in connection with, the operations of a ship by which the ship or any person is imperilled, or as a result of which serious damage to the ship or structure or the environment might be caused.
4.5 Causes means actions, omissions, events, existing or pre-existing conditions or a combination thereof, which led to the casualty or incident.
4.6 Marine casualty or incident safety investigation means a process held either in public or in camera conducted for the purpose of casualty prevention which includes the gathering and analysis of information, the drawing of conclusions, including the identification of the circumstances and the determination of causes and contributing factors and, when appropriate, the making of safety recommendations.” / 32 /
/ 32 / - : Resolution A.849(20)Code for the Investigation of Marine Casualties and Incidents (Quelle : INTERNET)
Seit vielen Jahren bemühen sich Hersteller und Betreiber von Schiffen sowie Behörden und Bildungseinrichtungen, durch geeignete Maßnahmen die Anzahl der Unfälle auf See zu reduzieren bzw. deren Auswirkungen einzuschränken. Heute können wir davon sprechen, dass Schiffe zu den hochtechnisiertesten, zuverlässigsten und wirtschaftlichsten Transportmitteln gehören.
Aber warum hat sich nicht gleichermaßen das Unfallrisiko verringert ? Und warum liegt der durch den sogenannten „Human Error“ verursachte Anteil an den Seeunfallursachen noch immer bei etwa 80 % ?
„Zieht man jedoch die Unfallstatistiken zu dem Zweck heran, den Erfolg dieser vielfältigen Bemühungen (um die Schiffssicherheit - der Verf.-) sichtbar zu machen, so stellt man nicht ohne Verblüffung fest, dass dieser Versuch zum Scheitern verurteilt ist.
Die Messzahlen der Unsicherheit sind so konstant geblieben, dass sie zu der Annahme berechtigen, die vielen Gesetze, Vorschriften und sonstigen Maßnahmen des Gesetzgebers seien genauso wirkungslos geblieben, wie die kaum ernstlich zu bestreitenden Bemühungen der Schifffahrtsindustrie um die Sicherheit auf See. /34/
Trifft dieses aber zu, so muss ein grundlegender Fehler bei all dem zweifellos gut gemeinten Tun und Treiben mit im Spiel gewesen sein. In allgemeinster Form ausgedrückt : Es steht zu befürchten, dass man weltweit noch viel zu wenig von den Voraussetzungen weiß, von denen die Sicherheit des Seeverkehrs abhängt.
Die Untersuchung von Seeunfällen führt (selbst wenn man nicht unterstellt, dass sie ihrerseits erheblicher Verbesserungen bedürfte) im günstigsten Fall zu Aussagen über die Bedingungen, unter denen der seltene Fall der Unsicherheit zustande kam. Sie muss aber unvermeidlich die Bedingungen des Regelfalls, nämlich der Sicherheit, durch Annahmen ersetzen, gegen deren Richtigkeit manche neuere Untersuchung spricht.
Es bleibt damit in nahezu jedem Fall ungeklärt, wann, wo und wie in der untersuchten Unfallsituation der Zustand Sicherheit in den Zustand Unsicherheit überging. Es liegt auf der Hand, dass die Antworten auf die Frage, wodurch eben dieser Übergang bewirkt wurde, sehr oft in den Bereich purer Spekulation verwiesen werden müssten.“ / 34/
/ 34 / Kühn, R. ;
Stecher, W. : Schiffssicherheit und Sicherung der Seefahrt : ein Dilemma ? .- Schiff und Hafen.- 28.Jahrgang.- Heft 1 / 1976
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Definitionen zum „Human Error“ findet man u.a. in / 30 / :
RIGBY (1970) :
“A human action is to be evaluated as an error if, as a result of it, the requirements established by the system are not met or are not met adequately.”
SWAIN (1992) :
“The term ‘human error’ covers all activities or omissions by a person that either cause something undiserable or that have the possibility of causing something undiserable.
…. This definition of the human error is taken in the context of the system, even though the main factors that contribute to an error, for example, can be due to absence of ergonomic design, procedures, training, or a combination of the above. This is why no guilt should be connected with the term ‘human error’”.
REASON (1990) :
„A human error is construed as a generic term that covers all occasions in which a planned sequence of mental or physical activities can fail to achieve an intended result and where this failure cannot be blamed on the intervention of an accidental triggering source.”
/ 30 / Sträter, O. : Evaluation of Human Reliability on the Basis of Operational Experience. – Dissertaion.- Gesellschaft für Anlagen- und Reaktorsicherheit (GRS) mbH.- August 2000. GRS – 170. ISBN 3-931995-37-2
Die US Coast Guard bezieht den „Human Error“ auf menschliche Handlungen oder Unterlassungen außerhalb einer durch ein System eingeführten Toleranz, selbst wenn sich keine ernsthaften Konsequenzen ergeben :
„The term "human error" refers to human actions or inactions outside the tolerances established by a system, even if no immediate consequences occur. Systems within every industry are almost always subject to failure as a result of human error. 30)
30)http://www.uscg.mil/hq/gm/risk/e-guidelines(html/vol4/Volume4/Gen_Rec/ HumanErr.htm
Der “human error” umfasst :
- das Personal folgt nicht den vorgeschriebenen Verfahren oder hält Routinen nicht ein;
- unpassendes oder ungenügendes Training der Arbeiter oder der Mannschaft;
- Fehler in schriftlichen Betriebsanweisungen;
- Geräte- oder Systemgestaltung, Konstruktion oder Installationsfehler;
- ungeeignete oder ungenügende Inspektion, Prüfung oder Reparatur der Ausrüstung;
- mangelhafte Managementübersicht.
Der “human error” schließt keine beabsichtigten Handlungen ein, die im Zusammenhang mit schädlichen Absichten (z.B. Sabotage) auftreten.
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HINWEIS auf :
MCA RP545: Development of guidance for the mitigation of human error in automated shipborne maritime systemsIan Rowley
This document is supplied by QinetiQ for the Maritime and Coastguard Agency Contract No. RP545 MSA/10/9/210. - QINETIQ/06/00037. - April 2006
Executive Summary
Background
As with other high hazard domains, the use of automation is increasing within maritimesystems. Although automation can be beneficial to operators of complex systems in terms ofa reduction in workload or the release of resources to perform other on-board duties, it canalso be detrimental to system control if errors are introduced through its use. In the maritimearea, human errors related to the use of automated ship-borne maritime systems have beenidentified as possible contributory factors to accidents and incidents at sea.This report is produced in response to the Maritime and Coastguard Agency’s (MCA)contract MSA 10/9/210. The MCA has a requirement for a research programme aimed atdeveloping guidance for the mitigation of human error in automated ship-borne maritimesystems. It is envisaged that this guidance material will be used by industry to assist inunderstanding how complex automated systems should be used on-board ships.Maritime automation issues identified
A review of maritime incidents, accidents and related literature identified the following human element issues:
• Over-reliance on automation
• Lack of in-depth understanding
• Sub-optimal ergonomic design
• Sub-optimal Human-Computer Interface design
• Inherent system latency interfering with error recovery efforts
• Lack of awareness of automation failsafe modes
• Maintenance and calibration errors
• Poor support to development and maintenance of situation awareness
• Information overload issues
• Display inconsistencies between different manufacturers
• Poor appreciation of automation characteristics and limitations by operators
• Automation not designed around operators’ abilities and limitations
• Standardisation
• Human Factors
• Training
• Subsequent changes made to original automated system designs
The current taxonomy adopted for grouping maritime incidents may mean there are furthercases involving automation that cannot be retrieved with a standard search of the databases.…
List of contents
1 Introduction 8
1.1 Background 8
1.2 Requirement 81.3 Structure of report 8
2 Identification of automation issues in commercial shipping and other high-hazard industries 10
2.1 Review of accidents, incidents and near misses in commercial shipping 10
2.2 Case Studies involving accidents, incidents and near misses in the commercial shipping industry 11
2.3 Other automation issues identified from maritime literature review 15
2.4 Automation issues identified from other industries 24
2.5 Summary of automation issues identified 27
3 Standards and guidance for addressing automation issues 29
3.1 Human Factors Integration plan 29
3.2 Standards and guidance from other high-hazard industries 33
3.3 Standards and guidance from the general human factors and ergonomics field 41
4 Training requirements to address automation issues 45
4.1 Training in the aviation industry 45
4.2 Development of Maritime Resource Management (MRM) training 46
4.3 Pedagogical Issues in MRM training 47
4.4 Current MRM courses 49
4.5 Comparison of Syllabi 57
4.6 Improving MRM Training 59
4.7 Suggested MRM Training curriculum 60
5 Guidance for automated maritime systems 62
5.1 Guidance for shore-based company management 62
5.2 Guidance for shipboard management 63
5.3 Guidance for automation users (e.g. Seafarers) 64
5.4 Guidance for automated marine systems 64
6 Conclusions 67
6.1 Maritime automation issues 67
6.2 Standards and guidelines for addressing the effects of automation issues 67
6.3 Training requirements to address automation issues 68
6.4 Guidance for automated maritime systems 70
7 Recommendations 71
7.1 Recommendations for further research 71
8 References 72
A Appendix A – Review of existing MAIB accident and incident reports that cite automation as a causal factor 77
B Appendix B – IMO Safety of Life At Sea (SOLAS) Chapter V Regulation 15 79
C Appendix C - IMO Specification of minimum standard of competency in crises management and human behaviour 81
D Appendix D - STCW Guidance on keeping a navigational watch 86
E Appendix E - STCW Guidance on keeping an engineering watch [proposed] 88
F Appendix F - IMO Model courses relevant to the mitigation of human error in automated ship-borne maritime systems. 90
(QinetiQ-repeort for the Maritime and Coastguard Agency ) Nr. 28 PUBLICATION / DOWNLOAD
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