Human Factors and
Emergency Preparedness on Ferries
Canadian Ferry Operators Association Conference 2011
Ken Potter and Jon Stuart
12 September 2011
Owen Sound, Ontario
1
TSB Mandate
• The Transportation Safety Board of Canada (TSB) is an
independent agency that investigates marine, pipeline,
railway and aviation transportation occurrences.
• Its sole aim is the advancement of transportation safety.
It does not assign fault or determine civil or criminal
liability.
• The mission of the TSB is to conduct independent safety
investigations and communicate risks in the
transportation system.
2
Marine Occurrences
• Over 600 marine occurrences reported annually
to TSB
• TSB investigates selected occurrences
• 8 to 10 occurrences per year for Marine Branch
• 22 marine investigators, 4 human factors
investigators
3
Integrated Safety Investigation
Methodology (ISIM)
• Scientific approach to investigations
• Built on best practices and safety science
• Backbone of TSB investigative processes
4
ISIM Process
Occurrence Assessment
Occu rre n ce
Occu rre n ce
Asse ssm e n t
Data Collection
Da ta Co l l e cti o n
Occurrence Sequence of Events
Occu rre n ce
Se q u e n ce o f
Eve n ts
Integrated Investigation Process
In te g ra te d
In ve sti g a ti o n
Pro ce ss
Risk Assessment Process
Defense Analysis
Risk Control Option Analysis
Safety Communication Process
Ri sk
Asse ssm e n t
Pro ce ss
De fe n se
An a l ysi s
Ri sk Co n tro l
Op ti o n An a l ysi s
Sa fe ty
Co m m u n i ca ti o n
Pro ce ss
5
Sequence of Events
Event - 1
Event - 2
Event n-1
Time or est..time
23:15
E 1400
Accident
Event n+1
Event n+2
Data source
Skipper
VDR
Actor
Action
List
increased
Pilot
ordered full astern
(Descriptors)
30 degrees to starboard
Event
Location
Event Location
6
6
Event
Why??
Because
Why??
Because
Why??
Because
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Basic Assumptions of Accident
Causes
• Clear relationship between number of
accidents and incidents
• Accidents and incidents are never the result of
one cause
• At least 80% of all accidents and incidents
involve human factors
8
Human Factors
“Ships are alright, it’s the men in
them”
Joseph Conrad
9
Human Factors
(Not “Human Error”)
• Human factors involvement is not restricted to
vessel crew
• Includes crew, shore management, board of
directors, and regulators
• Vessels and their crews operate within a
complex relationship
10
MANAGEMENT
CREW
Mission
VESSEL
ENVIRON.
11
Human Factors
The potential for an accident is created
when human actions interact with unsafe
conditions.
12
Unsafe Condition
• A situation that has the potential to initiate,
exacerbate, or otherwise facilitate an
accident or incident.
• E.g.:
Organizational factors such as
inadequate emergency
preparedness
13
Unsafe Act + Unsafe Condition
=
Accident
14
Human Factors Elements in
Marine Investigations
•
•
•
•
Fatigue
Training
Ergonomics
Medical Fitness
• Organizational Factors
15
16
MV Joseph and Clara
Smallwood, 2003
17
MV Joseph and Clara
Smallwood (2003)
Drop trailer fire damage
18
Fire Damage
Heat damage to private motor vehicle
19
Human Factors Aspects of the
Investigation
• Extensive interviews with bridge team,
crew, and passengers
– Knowledge and use of alarm system
– Decision on how to get passengers off vessel
– Search for, and management of, passengers
20
A Selection of Findings
• Passengers were unnecessarily exposed to a potentially
unsafe environment by driving their vehicles off deck 3,
rather than evacuating the vessel through the gangway.
• Crew members of non-convention passenger vessels
are not required to have crowd and crisis management
training or human behavior training.
• Convention and non-convention passenger vessels are
not required to record and retain the names of
passengers on board, with the exception of disabled
persons.
21
Queen of the North (2006)
22
Human Factors Aspects of the
Investigation
• Extensive interviews with bridge team,
crew and passengers
– Knowledge and use of alarm system
– Decision on how to get passengers off vessel
– Search for and management of passengers
23
A Selection of Findings
• The lack of a completed evacuation plan/procedure, in
addition to inadequate passenger safety training and
drills, left some crew members of the Queen of the North
underprepared to handle the abandonment, thereby
placing passengers at risk.
• No accurate head count of passengers and crew was
taken before abandoning the vessel, thus precluding a
focused search for missing persons at that time.
24
ECOLOS
25
TSB Watchlist
• The Watchlist identifies the safety issues
investigated by the TSB that pose the greatest
risk to Canadians.
• In each case, actions taken to date are
inadequate and concrete steps must be taken
on the part of industry and the regulator to
eliminate these risks.
26
TSB Watchlist
The Problem:
Emergency preparedness on large passenger
ferries in Canada needs improvement
The Solution:
Large ferry operators must adopt and practice
effective emergency preparedness procedures.
This includes maintaining detailed passenger
lists and practicing evacuations.
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Summary
• The TSB’s structured approach to human factors
investigations through the ISIM methodology has
identified systemic organizational safety issues within the
passenger vessel industry.
• While the TSB notes that improvements are being made,
the problems with emergency preparedness on
passenger ferries still exists as evidenced by continuing
occurrences on other vessels.
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