Investigated Vessel Incidents in Washington
Vessel incidents can include a wide range of accidents, including groundings, loss of propulsion, loss of steering, near collisions, allisions, and spills of oil or other hazardous materials. Ecology investigates vessel incidents to determine immediate contributing factors for enforcement (in the case of spills) and prevention. The types of commercial vessels investigated have included bulk carriers, car carriers, container ships, ferries, fishing vessels, tugs, tank barges and tank ships.
Immediate cause and contributing factors
Vessel incident investigations focus on two important areas: discovering the immediate cause of the incident and determining the factors that led to the immediate cause. For example, a
vessel may have lost propulsion due to a failure in the electrical system, but the factors that lead to the electrical system failure may have included lack of maintenance, lack of crew training,
or human error. Investigating beyond the immediate cause can help vessel operators understand why the problem occurred and what issues need to be addressed to prevent further problems.
What do the graphs suggest?
The “key few” immediate causes are dominated by factors falling into the “human factor” and “equipment failure” categories, while the “key few” contributing factors more commonly fall into the
“organizational factor” and “human factor” categories. This suggests that immediate causes tend to be related to human performance and failures of equipment, while contributing factors
- factors that create the underlying environmentfrom which event chains progress into incidents - are largely based on how a vessel is managed.
Three of these factors - together creating the highest percentage of key contributing factors - relate to the design, installation, and maintenance of equipment. All of these factors can be controlled
through robust management systems. However, the high incidence of procedural/policy-related and management oversight factors indicates that the existence of a management system does not
guarantee success - especially if it is incomplete, not implemented by personnel, and not monitored or enforced by vessel operators.
Ecology’s findings track with the often-cited statistic that human and organizational factors are responsible for 80% of incidents. It also tracks very closely with the findings of a 2007 U.S.
National Aeronautics and Space Agency (NASA) sponsored analysis of U.S. National Transportation Safety Board
NTSB) maritime accident data for a 10-year period (1996-2006) which concluded, in part “The subsequent classifications showed that only 37% of causal factors in the NTSB study related to
individual human error. In contrast, 48% of causes and contributory factors can be categorized as organizational. 12% related to equipment. ‘Other’ causes accounted for 3%.”
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