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EN
This article focuses on issues related to risk assessment when maneuvering a loaded bulk carrier in close proximity to a vessel performing underwater work at the time. It is based on a detailed analysis of an incident that took place in the Gulf of Gdansk. The write-up explains real turns of events, conditions and factors that contributed to the incident, but also its consequences are explained. Some other aspects of this article focuses on, are the processes of examination of the direct causes of the incident and identification not compliance with regulations, requirements, or procedures that help to find out the human, technical, and organizational errors. The authors of this text indicate the safety guards that have failed, give the reasons for their failure and, where it was possible, point out the safety guards that should or must be established. The article does not take into account theoretical models for the described accidents, but only practical aspects, human errors and applicable local and international laws and regulations. Particular attention was devoted to the analysis of human errors made by officers maneuvering the surface vessel in the close vicinity of divers performing underwater works.
EN
Maritime education and training (MET) are under constant pressure from the maritime industry, characterized by extremely rapid development. Due to the high risk in the transport and handling of crude oil, seafarers employed on oil tankers are required to have skills and competencies well above the minimum education standards set by the International Maritime Organization (IMO) and the International Convention on Standards of Training, Certification and Watchkeeping (STCW). Therefore, tanker companies should provide additional training for their employees to ensure the fundamental goals of zero‐accident rates and reduce human error to a minimum. This especially applies to seafarers at the management level, who must have the competence and knowledge to operate oil tankers at the highest professional level. This paper examines the current challenges in education and the required competencies of seafarers at management levels concerning the rapid growth and development of the tanker industry. In addition, some shortcomings regarding the current form of education and training have been considered, and recommendations for the future upgrade of the education and training system for seafarers at the management level are provided.
EN
This paper presents a comparative analysis of manoeuvring patterns through the fairway which is marked with physical and virtual Aids to Navigation (AtoN). The impact of V-AtoN environment on decision-making and on consequent manoeuvres has never been studied in such a way. The results published in this paper were obtained using TRANSAS Navi Trainer 5000 and TRANSAS ECDIS 4000 simulators where 12 deck officers with at least 5 years of sea service participated. The results of the study indicate that there is a significant difference in manoeuvring patterns between the two environments. In case of virtual environment, more intense drift angles, ROTs as well as XTDs are observed. The paper demonstrates significant impact of virtual environment on behaviour of OOW.
EN
Electric shock accident is one of the main causes of fatal construction accidents. In this study, 101 electric shock accidents are analyzed to mine the potential associations of human errors. The modified Human Factors Analysis and Classification System (HFACS) is used to classify human factors of accident causes. Characteristics and potential causes of the accidents are identified by employing frequency analysis. Chi-square test and Apriori algorithm are utilized to explore the associations among the causes. Some significant association between any of two factors are shared. According to association rules using three criteria: support (S), confidence (C) and lift (L), the two key paths are extracted based on the hierarchy of the HFACS. One is: organizational process loopholes → failed to correct problem → perceptual and decision errors (S = 0.11, C = 0.423, L = 1.02), and the other is: organizational process loopholes → poor skill level of workers → routine violation (S = 0.149, C = 0.789, L = 1.945). Managerial implications are proposed to prevent or reduce accidents based on interconnections of factors and key paths.
PL
W artykule przedstawiono szacunkowe zestawienia wyników analiz zagrożeń, awarii i katastrof, jakie wystąpiły na terenie Polski w ostatnich 50 latach. Wyniki zestawiono w zależności od charakteru obiektów, technologii wykonania, rodzaju uszkodzeń lub zniszczeń, rodzaju elementów i ich funkcji w konstrukcjach oraz rodzaju materiałów. Wskazano również przyczyny techniczne powstawania zagrożeń, awarii i katastrof wynikające z błędów projektowych i wykonawstwa. Wnioski z analiz powinny stanowić podstawy do innowacyjnych rozwiązań w pracach badawczo-wdrożeniowych.
EN
The paper presents the estimated results of the analyzes risk of failure and building damage that occurred in Poland in the last 50 years. The results were compiled depending on the nature of the objects, technology of execution, the type of damage or destruction, the type elements and their functions in the structures and the type of materials. The technical reasons of risk of failure and building damage resulting from design and execution errors were also indicated. Conclusions from the analyzes should constitute the basis for innovative solutions in research and implementation works.
EN
Many lives and aircrafts have been lost due to human errors associated with mental workload overload (MWLOL). Human errors are successfully considered in existing Fault Tree Analysis (FTA) methods. However, MWLOL is considered through Performance Shaping Factors indirectly and its information is hidden in FT construction, which is not conducive to analyze the root causes of human errors and risks. To overcome this difficulty, we develop a risk analysis method where Multiple Resources Model (MRM) is incorporated into FTA methods. MRM analyzes mental workload by estimating the resources used during performing concurrent tasks, probably including abnormal situation handling tasks introduced by basic events in FT. Such basic events may cause MWLOL and then trigger corresponding human error events. A MWLOL gate is proposed to describe MWLOL explicitly and add these new relationships to traditional FT. This new method extends previous FTA methods and provides a more in-depth risk analysis. An accident, a helicopter crash in Maryland, is analyzed by the proposed method.
PL
W pracy przedstawiono wieloletnie zestawienia analiz zagrożeń, awarii i katastrof według ITB, GUNB, Rzeczoznawców Budowlanych, Wyższych Uczelni i PIIB. Omówiono również analizy zagrożeń bezpieczeństwa obiektów budowlanych w 2019 r. z podziałem na okres eksploatacji, rodzaje przyczyn (losowych i obiektywnych), rodzaje obiektów, technologie wykonania, rodzaje zniszczenia, rodzaje materiałów, wysokości i kubatury.
EN
The paper presents summaries of long-term analyses of threats, failures and catastrophes according to ITB, GUNB, Building Experts, Higher Education Institutions and PIIB. It also discusses the analyses of safety hazards of construction objects in 2019 with a breakdown by period of exploitation, types of causes (random and objective) and objects, technologies of execution, types of destruction, types of materials, heights and volumes.
8
Content available A review of human error in marine engine maintenance
EN
Maritime safety involves minimizing error in all aspects of the marine system. Human error has received much importance, being responsible for about 80% of the maritime accident worldwide. Currently, more attention has been focused to reduce human error in marine engine maintenance. On-board marine engine maintenance activities are often complex, where seafarers conduct maintenance activities in various marine environmental (i.e. extreme weather, ship motions, noise, and vibration) and operational (i.e. work overload and stress) conditions. These environmental and operational conditions, in combination with generic human error tendencies, results in innumerable forms of error. There are numerous accidents that happened due to the human error during the maintenance activities of a marine engine. The most severe human error results in accidents due to is a loss of life. Moreover, there are other consequences too such as delaying the productivity of marine operations which results in the financial loss. This study reviews methods that are currently available for identifying, reporting and managing human error in marine engine maintenance. As a basis for this discussion, authors provide an overview of approaches for investigating human error, and a description of marine engine maintenance activities and environmental and operational characteristics.
EN
A paradigm shift is presently underway in the shipping industry promising safer, greener and more efficient ship traffic. In this article, we will look at some of the accidents from conventional shipping and see if they could have been avoided with autonomous ship technology. A hypothesis of increased safety is often brought forward, and we know from various studies that the number of maritime accidents that involves what is called “human error” ranges from some 60‐90 percent. If we replace the human with automation, can we then reduce the number of accidents? On the other hand, is there a possibility for new types of accidents to appear? What about the accidents that are today averted by the crew? This paper will present a method to assess these different aspects of the risk scenarios in light of the specific capabilities and constraints of autonomous ships.
EN
The purpose and scope of this paper is to describe anchoring procedures and typical human errors that are the cause of many marine accidents related to the anchoring of vessels and their manoeuvring in anchorage areas. In this paper the author focuses on typical marine accidents recorded for very large crude carriers (VLCC). As a result of the analyses, it can be seen that in the vast majority of cases these accidents are caused by human error and are related to the violation of accepted maritime anchor practices and a failure to observe the relevant safety and security procedures. The consequences of the accidents vary from the minor (e.g. slight structural damage to the anchor winches or other marine equipment) to the serious, which result in dry dock repairs due to hull damage, loss of stability and/or loss of navigability. The described cases refer to both favourable and extremely unfavourable hydro meteorological conditions, the latter including strong winds, currents and waves within the confined anchorage area.
11
Content available Human error in pilotage operations
EN
Pilotage operations require close interaction between human and machines. This complex sociotechnical system is necessary to safely and efficiently maneuver a vessel in constrained waters. A sociotechnical system consists of interdependent human- and technical variables that continuously must work together to be successful. This complexity is prone to errors, and statistics show that most these errors in the maritime domain are due to human components in the system (80 ? 85%). This explains the attention on research to reduce human errors. The current study deployed a systematic human error reduction and prediction approach (SHERPA) to shed light on error types and error remedies apparent in pilotage operations. Data was collected using interviews and observation. Hierarchical task analysis was performed and 55 tasks were analyzed using SHERPA. Findings suggests that communication and action omission errors are most prone to human errors in pilotage operations. Practical and theoretical implications of the results are discussed.
EN
Humans are one of the important factors in the assessment of accidents, particularly marine accidents. Hence, studies are conducted to assess the contribution of human factors in accidents. There are two generations of Human Reliability Assessment (HRA) that have been developed. Those methodologies are classified by the differences of viewpoints of problem-solving, as the first generation and second generation. The accident analysis can be determined using three techniques of analysis; sequential techniques, epidemiological techniques and systemic techniques, where the marine accidents are included in the epidemiological technique. This study compares the Human Error Assessment and Reduction Technique (HEART) methodology and the 4M Overturned Pyramid (MOP) model, which are applied to assess marine accidents. Furthermore, the MOP model can effectively describe the relationships of other factors which affect the accidents; whereas, the HEART methodology is only focused on human factors.
EN
Many ship collisions have been caused by a navigator’s error in the situation awareness (SA) of the navigator. In congested sea areas, navigators classify ships on the basis of different priority levels. For safety measures against ship collision, it is imperative for navigators to recognize the ships with high priority levels. In previous study, navigators’ SA was measured in a ship maneuvering simulator using the Situation Awareness Global Assessment Technique (SAGAT). From the results of the previous study, we proposed a new risk category, named as “attention area,” that covers ships with high priority level in the SA of navigators. However, the extent of data for navigators’ SA was limited. Therefore, the purpose of this study is to confirm the validity of the category using additional data of navigators SA. In this study, the validity of the proposed category was confirmed, and a limit line surrounding ships with high priority levels was identified. In addition, it was evident that the category was able to detect ships with high priority level around the time when the collision avoidance was performed.
14
Content available remote Human error in maritime accidents
EN
It is presently acknowledged that Human Error Factor is the single leading force that keeps maritime industry at bay. It is well known that it is an issue in a desperate need of solving and one that will have to be reduced. The main problem, however, is that we do not take lessons from maritime accidents. Man is a flawed creature, but we can prevent much of his fails by looking into history of them. The following study is set to look out for the root of the problem - problem with education of young officers.
PL
Jak wiadomo, czynnik ludzki jest zasadniczym problemem wstrzymującym rozwój przemysłu morskiego. Rozwiązanie tego problemu jest kluczowe dla postępu naszej branży. Główną przeszkodą jest to, że nie uczymy się na błędach. Człowiek jest istotą niedoskonałą, ale można zapobiec wielu jego błędom, patrząc w przeszłość. W artykule próbujemy znaleźć źródło problemu, którym, jak sądzimy, jest edukacja młodych oficerów.
EN
Risk assessment can be classified into two broad categories: traditional and modern. This paper is aimed at contrasting the functional resonance analysis method (FRAM) as a modern approach with the fault tree analysis (FTA) as a traditional method, regarding assessing the risks of a complex system. Applied methodology by which the risk assessment is carried out, is presented in each approach. Also, FRAM network is executed with regard to nonlinear interaction of human and organizational levels to assess the safety of technological systems. The methodology is implemented for lifting structures deep offshore. The main finding of this paper is that the combined application of FTA and FRAM during risk assessment, could provide complementary perspectives and may contribute to a more comprehensive understanding of an incident. Finally, it is shown that coupling a FRAM network with a suitable quantitative method will result in a plausible outcome for a predefined accident scenario.
PL
W prezentowanym artykule zwrócono uwagę na problem organizacji pracy w przedsiębiorstwie. Przedstawiono zachowania pracownika w warunkach zagrożenia oraz w sytuacji niedostatku informacji i deficytu czasu. Zagadnienia poruszone w artykule w istotny sposób wpływają na doskonalenie metod profilaktycznych związanych z warunkami środowiska i organizacją pracy, w tym także poprawę procesu komunikowania się w przedsiębiorstwie.
EN
In this article the attention is paid to the problem of work organization in an enterprise. The article describes the behavior of the employee in terms of risk, dearth of information and time deficit. Issues raised in the article significantly affect the improvement of methods of prevention related to environmental conditions and the organization of work, including the improvement of the process of communication in the enterprise.
Logistyka
|
2015
|
nr 3
840--850, CD 1
PL
Niniejsze opracowanie przedstawia negatywne zjawiska i zdarzenia w ruchu drogowym, których sprawcą jest człowiek. Opracowanie ukazuje człowieka jako organizatora ruchu, błędy, jakie w tej roli popełnia i błędy człowieka uczestnika ruchu, a także realne i potencjalne zagrożenia za tym idące. Przedstawiając człowieka jako sprawcę wielu negatywnych zdarzeń i sytuacji drogowych będziemy szukać wytłumaczenia i rozwiązania tych bardzo ważnych problemów, które dotyczą całego społeczeństwa, wobec których nie możemy pozostać obojętni.
EN
This elaboration presents a couple of occurrences and effects in road traffic which the person is causer. The elaboration shows a man as a traffic organizer and shows what type of errors he can do too. The elaboration presents a man as a participant in road traffic, his errors and real and potential dangers by reason of this errors. Introducing man as a causer of many negative situations in the way we will be search an explanation and solution of each problems. These problems are very important and affect the whole society therefore we can not stay indifferent to this situation.
PL
Obszarem analiz są przejazdy kolejowe kategorii A, które jako jedyne wśród sześciu kategorii przejazdów występujących na sieci dróg w Polsce są kontrolowane przez człowieka – dróżnika przejazdowego. Posiadają one zatem złożony system bezpieczeństwa (system kontroli ruchu drogowego), którego kluczowym elementem jest człowiek. Nie gwarantuje to jednak braku zdarzeń niepożądanych (ZN) a szczególność roli człowieka jako operatora – dróżnika, kierowcy, maszynisty w takich systemach powoduje, że jego działania przyczyniają się do powstania ZN o poważnych skutkach. Ich powaga powoduje, że uzasadniona jest potrzeba prowadzenia analiz tych zdarzeń na różnych poziomach struktur zajmujących się zagadnieniami bezpieczeństwa. Szczególnie pożądane jest wskazanie przyczyn (źródeł) powstawania ZN co daje możliwość wdrożenia odpowiednich działań. Celem prac podjętych w niniejszym artykule jest przeprowadzenie analizy ZN na przejazdach kolejowych z uwzględnieniem błędów popełnianych przez człowieka oraz wykorzystaniem metody FTA.
EN
The area of analysis are level crossings of category A, which alone among the six categories of level crossings in Poland are controlled by human – level crossing attendant. There is therefore a complex system of safety (traffic control system), whose key element is human. This does not guarantee the absence of undesirable events (ZN) and the specificity of the role of man as the operator – level crossingattendant, the driver, the train driver in such systems means that its activities contribute to the creation of ZN with serious consequences. The seriousness of ZN justified the need for the analysis of these events at different levels of the structures dealing with questions of safety. In particular, it is desirable to identify the causes (sources) of ZN which gives the possibility of implementing appropriate action. The aim of the work undertaken in this article is to analyze ZN at level crossings, taking into account human error and using the method FTA.
EN
Accidents caused by human error are prominent in the medical field. The present study identified medical errors in the emergency triage area by assessing the tasks of all healthcare workers employed in the triage area of an educational hospital in Tehran, Iran in 2014. Data were collected using the systematic human error reduction and prediction approach (SHERPA). The tasks and sub-tasks were determined and analyzed using hierarchical analysis and the errors were extracted. A total of 199 human errors were identified in the different tasks. The rate of error for action was 46.8%, checking was 25.6%, retrieval was 8.5%, communication was 12.1% and selection was 7%. Rate of unacceptable and unfavorable risks were 21.1% and 38.6%, respectively. SHERPA was shown to be an appropriate technique for detecting medical errors. The establishment of control programs should be a high priority in the management and implementation of health facilities in triage areas.
PL
W prezentowanym artykule zajęto się tematyką organizacji warunków pracy, zwrócono uwagę na środowisko pracy i wpływ jego elementów, takich jak: mikroklimat, jakość oświetlenia, zanieczyszczenie powietrza, odpowiedni dobór barw a także hałas na organizm pracującego człowieka. Zwrócono uwagę na problem organizacji pracy w przedsiębiorstwie. Przedstawiono zachowania pracownika w warunkach zagrożenia, oraz sytuacji niedostatku informacji i deficytu czasu. Zagadnienia poruszone w artykule w istotny sposób wpływają na doskonalenie metod profilaktycznych związanych z warunkami środowiska i organizacji pracy, w tym także poprawy procesu komunikowania się w przedsiębiorstwie.
EN
In the present paper addresses the issues organizations working conditions, drew attention to the work environment and the impact of its components, such as climate, quality of light, air pollution, an appropriate choice of color and noise in the human body working. Drew attention to the problem of the organization of work in the company. Shows the behavior of workers in hazardous conditions, and the situation of lack of information and lack of time. The issues raised in the article have a significant impact on the improvement of methods of prevention in improving the organization of work, as well as improving the communication process within the company.
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