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Safety Science 110 (2018) 102–109 Contents lists available at ScienceDirect Safety Science journal homepage:

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Safety Science

journal homepage: www.elsevier.com/locate/safety

Science journal homepage: www.elsevier.com/locate/safety Prediction of human error probabilities in a critical marine

Prediction of human error probabilities in a critical marine engineering operation on-board chemical tanker ship: The case of ship bunkering

Emre Akyuz a , , Metin Celik b , Ilker Akgun c , Kadir Cicek b

a Department of Maritime Transportation and Management Engineering, Istanbul Technical University, Tuzla 34940, Istanbul, Turkey

b Department of Marine Engineering, Istanbul Technical University, Tuzla 34940, Istanbul, Turkey

c Department of Business Administration, Marmara University, Bakirkoy, Istanbul, Turkey

T
T

ARTICLE INFO

Keywords:

Maritime safety Human reliability Bunkering operation Chemical tanker ship Decision-making

ABSTRACT

Ship bunkering, a safety critical operation in marine engineering, can cause drastic environmental damage at sea. Though bunkering presents high safety procedures, minor accidents also can pose potential harm for marine environment and human life. Indeed, it is well-known that numerous bunker accidents can be attributed to di erent types of human error. Therefore, control of human factor during bunkering operation plays critical role to enhance safety aboard and prevent environmental pollution at sea. This study presents a comprehensive human error prediction during bunkering operation demonstrated with a case study at chemical tanker platform. To achieve this purpose, a Shipboard Operation Human Reliability Analysis (SOHRA) method, which has been developed as a marine-speci c approach to quantify human error, is employed. In the view of outcomes, human error reduction measures are recommended. In conclusion, the paper is expected to give practical contribution to the systematically prediction of human error for designated tasks, enhancement of safety control level in op- erational aspect and protection of the marine environment.

1. Introduction

Human factor is one of paramount topics in maritime industry since it may directly in uence the operational performance. The majority of failures are attributed to the human factors which may cause serious consequences such as environment pollution. The ndings show that most of maritime accidents are due to human errors (Akyuz, 2017; Corovic and Djurovic, 2013; Akyuz, 2015a ). In order to minimize maritime accidents, it is essential to focus on the types of human errors ( Abujaafar, 2012; Akyuz, 2016 ). The maritime authorities have been adopting a set of rules and regulations to minimize human error and enhance safety awareness such as SOLAS, STCW, ISM Code ( Akyuz et al., 2016; Karahalios, 2014; Chauvin, 2013; Karahalios, 2011 ). On the other hand, maritime safety practitioners are also seeking creative solutions to reduce human error. However, human error prediction is quite onerous task in maritime transportation due to the uncertainty and inadequacy of quantitative human error data ( Akyuz and Celik, 2018 ). To overcome these limitations, some scienti c researches have been undertaken in the past decades. For instance, Macrae (2009) conducted an extensive study to identify potential human error in the event of two major types of marine accident: grounding and collision. A similar study has been performed in recent time to quantify human

Corresponding author. E-mail addresses: emreakyuz@hotmail.com.tr , eakyuz@itu.edu.tr (E. Akyuz).

errors related to grounding and collision accidents at sea ( Akyuz, 2017 ). Furthermore, a couple of scienti c research papers have been con- ducted through human error and system failure in maritime and o - shore industries ( Hou et al., 2017; Abbassi et al., 2015; Akyuz and Celik, 2015; Lavasani et al., 2015; Noroozi et al., 2014; Deacon et al., 2013; Abascal et al., 2010 ). The papers contributed guidelines to adopt various human error assessment techniques such as HEART (Human Error Assessment and Reduction Technique), SLIM (Success Likelihood Index Method) and THERP (Technique of Human Error Rate Prediction) in the application of numerous procedures on maritime and o shore industries in order to reduce human error and improve operational safety. Akyuz and Celik (2014) proposed a hybrid tool to analyse human error during maritime events. Another study was performed to systematically estimate human error probability towards the gas in- erting process in crude oil tanker ships ( Akyuz, 2015b ). Although a set of researches on human error prediction have been carried out in the past decade, those dedicated to critical shipboard operations in maritime transportation have remained very limited. The assessment of human error probability is a critical task to enhance safety. Bunkering, for example, is one of the critical shipboard opera- tions under the ISM Code (SOLAS, 1974 ) since adverse consequences can pose potential harm to marine environment and human life.

Received 17 October 2017; Received in revised form 25 June 2018; Accepted 3 August 2018

0925-7535/ © 2018 Elsevier Ltd. All rights reserved.

E. Akyuz et al.

Bunkering operation is a critical shipboard process and also known as ship to ship transfer including fuel oil, diesel oil, etc. The operation requires utmost care to prevent any kind of oil spill or re on-board chemical tanker ship. It may be conducted either in berth or at an- chorage. The bunker barge come alongside of ship and secured properly prior to operation. All chemical tanker ships are governed by MARPOL Annex I and VI during bunkering operation. The statistics show that ship-sourced oil spill incidents are still a major source of oil pollution during bunkering operation. An extensive oil spill may spread out hundreds nautical miles from the source of accident and cause cata- strophic pollution for marine environment. Since consequences of oil spill are severely damaging to marine environment, performance of ship crew become a critical concern during bunkering operation. Ship crew performance become a serious concern at this point. The ship crew must exercise particular caution when attending a bunkering op- eration. In this context, prediction of human error probabilities pose a major challenge to retain a high level of safety in the maritime industry. The ship crew must perform utmost care during bunkering proce- dure. The operation follows a bunkering plan including agreed cargo quantity, pumping rate, time of completion and sampling. Master of ship carries out a safety meeting with all ship crew to discuss the op- eration and emergency response procedures. The bunkering operation is monitored by responsible ship crew in accordance with agreed bun- kering plan. Watchkeeping during the entire operation is provided by engine and deck crew rating. All events are properly recorded to log books. The sampling of cargo is carefully carried out throughout the operation. Cargo intake quantity is calculated at the end of transfer. In the literature, most of studies concerning the bunkering opera- tions have focused on management strategies such optimal costs, ports, ship routes or contracts to minimize fuel-related costs (Zhen et al., 2016; Pedrielli et al., 2015; Wang et al., 2014 ) rather than focusing on operational aspect to enhance safety control level on-board ships. To remedy the gap, this paper aims at conducting a systematic human error prediction and assessment during bunkering operation in che- mical tanker ship. The SOHRA (Shipboard Operation Human Reliability Analysis), a marine-speci c human error prediction technique, is adopted to assess human error for designated tasks in bunkering op- eration. The human error probabilities are evaluated and necessary human error control measures are recommended to improve perfor- mance of ship crew. Within this context, the paper is organised as fol- lows. Section 1 gives motivation and brief literature reviewing about human error prediction and bunkering operation in the maritime in- dustry. Section 2 explains theoretical background of method. Section 3 demonstrates model application through bunkering operation at che- mical tanker ships. Section 4 gives conclusion, contribution and future researches. A list of symbols and abbreviations, meantime, is provided in Table 1 for easy perusal of readers.

2. Methodology

2.1. Theoretical background of SOHRA

Shipboard Operation Human Reliability Analysis (SOHRA) was de- veloped to quantify human error and predict human reliability in cri- tical shipboard operations ( Celik et al., 2014; Akyuz et al., 2016 ). The method introduces m- EPC (marine speci c error producing condition) values which was validated by analysing a hundred of real-marine ac- cident cases ( Akyuz et al., 2016 ). The SOHRA is based on tailoring the basic principle of human error assessment and reduction technique (HEART) ( Williams, 1988; Akyuz et al., 2018 ) . The method has a si- milar structure with HEART. It presents consistency of usage during assessed proportion of aect (APOA) calculation which is the key aspect of human error weighting in m-EPC calculation. Also, the SOHRA adopts the m-EPCs to de ne the performance shaping factors (PSF) of human beings for specic tasks in the maritime industry ( Kirwan and Gibson, 2008; Kirwan, 1987 ).

103

Table 1

Nomenclature.

Safety Science 110 (2018) 102–109

A

a ij

A/B

AHP

APOA

Matrix

Each criteria Able seaman Analytic hierarchy process Assessed proportion of aect

CI Consistency index

CR

EPC

m-EPC

GEP

GTT

HEP

HEART

HTA

HRA

Consistency ratio

Error-producing condition Marine-specic error producing condition Generic error probability

Generic task type Human error probability Human error assessment and reduction technique Hierarchical task analysis Human reliability analysis

i Constant in Eq. (2)

MARPOL

MSDS

n

PSF

SLIM

SOHRA

SOPEP

SOLAS

SPM

STCW

STS

SMS

RI

w i

λ max .

THERP

j Constant in Eq. (2)

Maritime pollution prevention convention Material safety data sheet Constant in Eq. (3) Performance shaping factor Success likelihood index method

Shipboard human reliability analysis

Shipboard Oil Pollution Emergency Plan Safety of life at sea Single point mooring

Standard training certi cation Watchkeeping Ship to ship Safety Management System Random index

Priority weight Maximum matrix eigenvalue vector

Technique of human error rate prediction

The SOHRA provides a consistent approach to quantify human error. It is quite applicable tool to calculate HEP in the critical ship- board operations such as cargo loading, discharging, berthing, un- berthing, bunkering, ballasting, gas inerting, tank cleaning, hold cleaning, etc ( Akyuz et al, 2018 ). The method is comprised of two fundamental parameters: generic task type (GTT) and m-EPC respec- tively ( Akyuz et al., 2016 ). The GTT allows user to select appropriate task in perfect condition. The GTT is associated with generic error probability (GEP) which is provided in Table 2 ( Williams, 1988 ). The second parameter is the m-EPC which in uences ship crew

Table 2 GTT and GEP values.

Generic task type (GTT)

Generic error probability (GEP) (5 th 95th percentile Bounds)

A

Totally unfamiliar; performed at speed with no real idea of likely consequences

0.55

(0.35 0.97)

B

Shift or restore system to a new or original state on a single attempt without supervision or procedures

0.26

(0.14 0.42)

C

Complex task requiring high level of comprehension and skill

0.16

(0.12 0.28)

D

Fairly simple task performed rapidly or given scant attention

0.09

(0.06 0.13)

E

Routine, highly practiced, rapid task involving relatively low level of skill

0.02

(0.07 0.045)

F

Restore or shift a system to original or new state following procedures with some checking

0.003

(0.0008 0.007)

G

Completely familiar, well-designed, highly practiced, routine task occurring several times per day, performed to highest possible standards by highly motivated, highly trained, and experienced personnel, with time to correct potential error, but without the bene t of signi cant job aid.

0.0004

(0.00008 0.009)

H

Respond correctly to system command even when there is an augment or automated supervisory system providing accurate interpretation of system state

0.00002

(0.000006 0.0009)

M

Miscellaneous task for which no description can be found

0.03

(0.008 0.11)

E. Akyuz et al.

Table 3 List of m-EPC.

No

Error producing condition

Max. aect

EPC1

Unfamiliarity Time shortage Low signal noise ratio Features over-ride allowed Spatial and functional incompatibility Model mismatch Irreversibility Channel overload Technique unlearning Knowledge transfer Performance ambiguity Misperception of risk Poor feedback Delayed/incomplete feedback Operator inexperience Impoverished information Inadequate checking Objectives con ict No diversity Educational mismatch Dangerous incentives Lack of exercise Unreliable instruments Absolute judgements required Unclear allocation of function Progress tracking lack Physical capabilities Low meaning Emotional stress ill-health Low morale Inconsistency of displays Poor environment Low mental workload Sleep cycles disruption Task pacing Supernumeraries Age

17.00

EPC2

14.01

EPC3

3.31

EPC4

8.72

EPC5

5.76

EPC6

2.64

EPC7

2.23

EPC8

14.45

EPC9

5.29

EPC10

11.00

EPC11

8.60

EPC12

12.51

EPC13

12.55

EPC14

6.72

EPC15

10.03

EPC16

8.42

EPC17

2.79

EPC18

2.15

EPC19

2.74

EPC20

2.88

EPC21

3.62

EPC22

1.64

EPC23

5.69

EPC24

1.17

EPC25

1.22

EPC26

3.28

EPC27

4.35

EPC28

2.56

EPC29

1.59

EPC30

0.89

EPC31

3.00

EPC32

9.43

EPC33

9.90

EPC34

2.63

EPC35

10.30

EPC36

3.85

EPC37

4.14

EPC38

3.61

performance negatively and leads to increase GEP value ( Gibson et al., 2012 ). The m-EPC is addressed to internal or external factors that in- uence the crew performance at shipboard environment. A list of m- EPCs are generated for SOHRA approach and relevant m-EPCs are chosen from the list of SOHRA ( Akyuz et al., 2016 ). Table 3 illustrates the list of the m-EPC and their maximum e ect. The m-EPC re ects performance shaping factors such as crew experiences, organisation quality, workforce moral, time limitation, working environment, age, crew collaboration, familiarity, etc. and shows how these conditions a ect relevant task ( Akyuz et al., 2018 ). The SOHRA method involves seven main steps to quantify human error. The steps of SOHRA are as follows.

2.2. Process of SOHRA

A ow diagram of SOHRA methodology is depicted in Fig. 1 . The main steps of methodology are explained as follows. Step 1. Task analysis: The purpose of this step is to identify re- levant task with respect to the scenario. A task can be dened as an activity or step which needs to be completed by ship crew within a period. This is performed in accordance with hierarchical task analysis (HTA) where main tasks are divided into sub-tasks respectively ( Akyuz and Celik, 2016a; Shepherd, 2001 ). The HEP value is calculated for each sub-task to monitor human error changes. Step 2. Scenario denition: In this step, a set of shipboard sce- narios representing various situations are de ned to nominate the GTT and m-EPC properly. The scenario involves a wide range of environ- mental conditions such as experience, working environment, stress level, time availability, noise level, weather condition, fatigue,

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Safety Science 110 (2018) 102–109

familiarity to task, time of day, etc. Step 3. GTT selection: The GTT selection is applied to determine generic human error probability which were extracted from a variety of sources in the area of petrochemical and oshore industries. A decision- maker selects appropriate GTT for each sub-task with respect to the task analysis. Thus, the GEP value is determined for each sub-task in ac- cordance with relevant GTT which best matches the specic task being assessed ( Kirwan and Gibson, 2008 ). Step 4. m-EPC selection: In this step, decision-maker selects the most appropriate m-EPC based on the identied scenario for each sub- task. The m-EPC is selected from the list of thirty-eight possible state- ments elicited in the SOHRA approach for each sub-task. The decision- maker choses more than one m-EPC based on the scenario. If the de- cision-maker nominates more than one m-EPC for sub-task, the APOA calculation is needed to determine weight priorities. Step 5. APOA calculation: The APOA calculation nominates pro- portion e ect of each m-EPC. The SOHRA adopts a sensitive weighting process by adopting Analytic Hierarchy Process (AHP) to enhance consistency of calculation. The AHP is a powerful multi-criteria deci- sion making (MCDM) tool to quantify the subjective judgment and con rm the consistency of collected data ( Saaty, 1980 ). It enables user to generate ratio scale from comparison pair-wise matrix. The tech- nique is considerably reliable as the consistency of evaluation can be calculated through consistency and random index ( Soner et al., 2017 ). The process of method is comprised of three steps. I. Composing a pair-wise comparison matrix: In the rst step, a pair-wise comparison matrix is established to obtain relative weight of each m-EPC. In this context, Saaty s 19 linguistic relative importance scale is used ( Saaty, 1986 ). A comparison matrix matrix A is a n × n real matrix, where n states the number of evaluated m-EPC. Each m-EPC

a ij (i, j = 1, 2, 3,, n) is inserted in the matrix A represents the relative importance of the i th against to the j th . It means that i th m-EPC is more important than jth , if the a ij > 1. Otherwise, i th m-EPC is less important than jth in case a ij < 1. Within this context, in case two m-EPCs have similar relative weight, then a ij = 1. In the view of above de nition, the following Eq. (1) is used to compose a comparison matrix A ( Saaty,

1986 ).

a

(1)

II. Calculating criteria weights: The aim of this step is to calculate relative weight (w ) of each m-EPC. At this point, Eq. (2) is used.

ij

×a = 1

ji

1

n

j = 1

a

ij

w

(2)

III. Checking consistency rate: This step is to check consistency of data inserted in a pair-wise comparison matrix. The consistency rate (CR) is calculated in accordance with Eqs. (3) (5) respectively ( Saaty, 1994; Vargas, 1982 ). If the CR (consistency ration) value is less than 0.10(10%) or equal to 0.10 (10%), the consistency of expert judgments is acceptable.

i

=

n

n

k

= 1

a

kj

λ

max .

n

n 1

αw

ij

j

=

λ

max

CI =

n

j

= 1

 

(3)

w

i

 

(4)

(5)

CR = CI / RI

Step 6. HEP calculation: After performed sensitive APOA calcu- lation, the HEP value is determined for each sub-task. To achieve this purpose, Eq. (6) is used (Williams, 1988 ). In the equation, EPC i is the i th ( i = 1, 2, 3, n; n 38) m-EPC and APOA pi (0 < pi 1) is i th the assessed of proportion a ect which has been calculated in APOA.

HEP

=

GEP

×

i

[(EPC 1) APOA

i

pi

+

1]

(6)

E. Akyuz et al.

Safety Science 110 (2018) 102–109

Task analysis

et al. Safety Science 110 (2018) 102–109 Task analysis Scenario definition GTT selection m-EPC selection Composing

Scenario definition

110 (2018) 102–109 Task analysis Scenario definition GTT selection m-EPC selection Composing a pair-wise

GTT selection

102–109 Task analysis Scenario definition GTT selection m-EPC selection Composing a pair-wise comparison matrix

m-EPC selection

Composing a pair-wise comparison matrix APOA calculation HEP reduction measures HEP prediction Calculating criteria
Composing a pair-wise
comparison matrix
APOA calculation
HEP reduction measures
HEP prediction
Calculating criteria weights
Checking consistency rate
No
Yes
HEP
acceptable
?
Yes
No

No

CR acceptable ?
CR
acceptable
?

Do operation

Fig. 1. Flow diagram of SOHRA.

Table 4 HTA of bunkering operation.

Bunkering operation

1. Prior to bunkering

1.1 Keep safety meeting

1.2 Take sounding and record bunker quantities

1.3 Check if crew on deck use PPE

1.4 Make sure that all deck scupper are plugged

1.5 Check if over ow tanks are empty

1.6 Make sure that smoking notice is positioned

1.7 Hoist necessary warning sign

1.8 Make sure that other bunker manifold valves are shut-o and blanked

1.9 Check if all equipments in SOPEP are in position

1.10 Make sure that bunker barge is safely secured to the ship

1.11 Make sure that proper communication is established with bunker barge

1.12 Agree on bunkering procedure with bunker barge

1.13 Verify pumping rate

1.14 Connect exible hose to the ships manifold

2. During bunkering

2.1 Open manifold valve and start bunkering

2.2 Make sure that pumping rate is kept low at the beginning

2.3 Monitor bunkering process continuously

2.4 Take sounding regularly

2.5 Check temperature of bunker

2.6 Take sampling

2.7 Check trim and draft of ship frequently

2.8 Close manifold valve

3. After bunkering

3.1 Take sounding of all the tanks bunkered

3.2 Calculate nal bunker intake quantity

3.3 Sign bunker receipt

3.4 Disconnect exible hose from ship s manifold

3.5 Cast obunker barge moorings from the ship

Step 7. HEP reduction measures: The aim of this step is to take control measures for minimizing human error. The experts evaluate impacts of HEP over the critical shipboard operation. The control measures are recommended for the highest HEP values.

3. Application

In this section, prediction of human error probabilities during bunkering operation on-board chemical tanker ships is demonstrated. The use of expert judgements is one of the techniques in most of human reliability analysis (HRA) since there is a scarcity of numerical data on human error for maritime transportation ( Modarres, 2006 ). To de- monstrate the model, a real-shipboard bunkering operation was se- lected. In this context, master of a chemical tanker ship cooperatively provided opinions. The ship is an oil/chemical tanker and cargo car- rying capacity is about 10,745 dwt. The master has wide experience about bunkering operation. A comprehensive survey forms was sent to master of ship and asked to select the most appropriate GTT and m-EPC for each sub-task being completed.

3.1. A real-shipboard environment de nition and task analysis

A real-shipboard bunkering operation was performed at Ceuta an- chorage. The chemical tanker ship arrived early morning at Ceuta an- chorage area to intake about 845 mt IFO180 CST. The weather was partly cloudy and sea state was calm at the time of operation. According to the deck log book, the wind speed was about 10 12 knots per hour as per Beaufort scale. There were small waves with breaking crests. The ship s crew took rest enough prior to bunkering operation. Chief en- gineer, chief ocer, third engineer, bosun, pumper and able seamen (A/B) participated bunkering operation. A bunker barge came along- side to chemical tanker and bunkering commenced around morning time. The bunkering operation took about 9 h. After con rmed the amount of bunker intake, exible hose was disconnected and bunker barge left. The bunkering operation in accordance with HTA is provided in Table 4 ( BIMCO, 2016 ). The master of ship selected relevant GTT and m-EPC/s for each sub-tasks during bunkering. Since a real-shipboard bunkering operation was handled, the master of ship (expert) simulta- neously performed assessment by considering instant shipboard en- vironment condition and crew performance. The operating

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E. Akyuz et al.

Table 5 Selected GTT and m-EPC/s.

Sub-task

GTT

Selected EPC/s

Prior to bunkering

1.1

G

EPC2, EPC13, EPC14

1.2

E

EPC22, EPC17

1.3

E

EPC17, EPC20

1.4

D

EPC17, EPC22

1.5

G

EPC1, EPC10, EPC14, EPC33

1.6

H

EPC2, EPC15, EPC17

1.7

H

EPC1, EPC14, EPC35

1.8

E

EPC14, EPC23

1.9

F

EPC14, EPC33

1.10

G

EPC13, EPC15, EPC17

1.11

E

EPC3 EPC22

1.12

G

EPC2, EPC11, EPC25

1.13

D

EPC14, EPC17

1.14

E

EPC23

During bunkering

2.1

G

EPC3, EPC33

2.2

D

EPC15, EPC17

2.3

E

EPC2, EPC17

2.4

G

EPC1, EPC14

2.5

H

EPC22, EPC23, EPC27

2.6

G

EPC15, EPC33, EPC34

2.7

H

EPC2, EPC17

2.8

F

EPC14

After bunkering

3.1

G

EPC2, EPC27, EPC33

3.2

H

EPC14

3.3

G

3.4

E

EPC23

3.5

G

EPC27, EPC33

environment is depending on the system installation ( Celik, 2008; Cebi et al., 2012 ) and procedural implementations ( Celik, 2009; Celik and Topcu, 2009 ).

3.2. GTT and m-EPC selection

The master of ship selected relevant GTT and m-EPC/s for each sub- tasks during bunkering. A comprehensive survey forms in excel format was sent to master by email. Table 5 shows selected GTT and m-EPC/s.

3.3. APOA calculation

After received evaluation of master for each sub-task, the APOA calculation is conducted to increase consistency of HEP calculation. This process quanti es the subjective judgement of expert and con rms consistency of collected data. Except sub-tasks 1.14 (Connect exible hose to the ship s manifold), 2.8 (Close manifold valve), 3.2 (Calculate nal bunker intake quantity), 3.3(Sign bunker receipt) and 3.4(Disconnect exible hose from ship s manifold); the rest of sub-steps have more than one m-EPCs. Accordingly, a pair-wise comparison matrices were established in excel form and sent to master of ship along with Saaty s 19 linguistic relative importance scale. One week later, the master sent back pair-wise comparison matrices. Furthermore, cri- teria weight of each m-EPC is calculated by using Eq. (2) . The CR is calculated by using Eqs. (3)(5) respectively. Table 6 illustrates the m- EPCs prioritization weights and CR values. Since CR values ( Table 6 ) are smaller than 0.1 (10%), the judgments inserted in expert are con- sidered to consistent.

3.4. HEP calculation

The HEP value of each sub-task is calculated by using Eq. (6). Table 7 shows HEP results for bunkering operation on-board chemical tanker ship.

Safety Science 110 (2018) 102–109

Table 6 m-EPCs prioritization weights and CR values.

Sub-task

m-EPC

m-EPC weight (APOA)

CR

1.1

EPC2

0.334

0.046

EPC13

0.525

EPC14

0.142

1.2

EPC17

0.817

0.001

EPC22

0.183

1.3

EPC17

0.750

0.001

EPC20

0.250

1.4

EPC17

0.398

0.024

EPC22

0.602

1.5

EPC1

0.311

0.035

EPC10

0.100

EPC14

0.182

EPC33

0.406

1.6

EPC2

0.320

0.015

EPC15

0.557

EPC17

0.123

1.7

EPC1

0.125

0.045

EPC14

0.369

EPC35

0.506

1.8

EPC14

0.315

0.06

EPC23

0.685

1.9

EPC14

0.290

0.003

EPC33

0.710

1.10

EPC13

0.320

0.026

EPC15

0.123

EPC17

0.557

1.11

EPC3

0.250

0.016

EPC22

0.750

1.12

EPC2

0.320

0.014

EPC11

0.557

EPC25

0.123

1.13

EPC14

0.366

0.008

EPC17

0.634

1.14

EPC23

1

2.1

EPC3

0.31

0.007

EPC33

0.69

2.2

EPC15

0.375

0.004

EPC17

0.625

2.3

EPC2

0.299

0.005

EPC17

0.701

2.4

EPC1

0.389

0.004

EPC14

0.611

2.5

EPC22

0.308

0.009

EPC23

0.453

EPC27

0.239

2.6

EPC15

0.478

0.025

EPC33

0.366

EPC34

0.156

2.7

EPC2

0.685

0.06

EPC17

0.315

2.8

EPC14

1

3.1

EPC2

0.406

0.007

EPC27

0.182

EPC33

0.412

3.2

EPC14

1

3.3

3.4

EPC23

1

3.5

EPC27

0.31

0.07

EPC33

0.69

3.5. Findings and discussion

In the view of the HEP for bunkering operation on-board chemical tanker ship, human error probability intervals are in the range of 1.34E 04 and 8.36E 01. Fig. 2 shows a graph where probability of human errors goes up and down bunkering operation. The centre of graph shows the most reliable area where the HEP value of each sub- task is depicted by the node. The maximum HEP values are related to pre-operational and op- erational activities. In order to categorize HEP values, a risk matrix can be used ( Deacon et al., 2013 ). In the matrix, probability of human error

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E. Akyuz et al.

Table 7

HEP results.

Sub-task GEP

m-EPC Max. m-EPC eect m-EPC APOA HEP

1.1

4.00E 04 EPC2

14.01

0.334

2.74E 02

EPC13 12.55

0.525

EPC14

6.72

0.142

1.2

2.00E 02 EPC17

2.79

0.817

5.50E 02

EPC22

1.64

0.183

1.3

2.00E 02 EPC17

2.79

0.750

6.89E 02

EPC20

2.88

0.250

1.4

9.00E 02 EPC17

2.79

0.398

2.13E 01

EPC22

1.64

0.602

1.5

4.00E 04 EPC1

17

0.311 4.50E 02

EPC10

11

0.100

EPC14

6.72

0.182

EPC33

9.9

0.406

1.6

2.00E 05 EPC2

14.01

0.320

7.60E 04

EPC15 10.03

0.557

EPC17

2.79

0.123

1.7

2.00E 05 EPC1

17

0.125 1.06E 03

EPC14

6.72

0.369

EPC35

10.3

0.506

1.8

2.00E 02 EPC14

6.72

0.315

2.36E 01

EPC23

5.69

0.685

1.9

3.00E 03 EPC14

6.72

0.290

5.84E 02

EPC33

9.9

0.710

1.10

4.00E 04 EPC13

12.55

0.320

7.92E 03

EPC15 10.03

0.123

EPC17

2.79

0.557

1.11

2.00E 02 EPC3

3.31

0.250

4.64E 02

EPC22

1.64

0.750

1.12

4.00E 04 EPC2

14.01

0.320

1.11E 02

EPC11

8.6

0.557

EPC25

1.22

0.123

1.13

9.00E 02 EPC14

6.72

0.366

5.94E 01

EPC17

2.79

0.634

1.14

2.00E 02 EPC23

5.69

1

1.14E 01

2.1

4.00E 04 EPC3

3.31

0.310

4.90E 03

EPC33

9.9

0.690

2.2

9.00E 02 EPC15

10.03

0.375

8.36E 01

EPC17

2.79

0.625

2.3

2.00E 02 EPC2

14.01

0.299

2.21E 01

EPC17

2.79

0.701

2.4

4.00E 04 EPC1

17

0.389 1.30E 02

EPC14

6.72

0.611

2.5

2.00E 05 EPC22

1.64

0.308

1.35E 04

EPC23

5.69

0.453

EPC27

4.35

0.239

2.6

4.00E 04 EPC15

10.03

0.478

1.14E 02

EPC33

9.9

0.366

EPC34

2.63

0.156

2.7

2.00E 05 EPC2

14.01

0.685

3.10E 04

EPC17

2.79

0.315

2.8

3.00E 03 EPC14

6.72

1

2.02E 02

3.1

4.00E 04 EPC2

14.01

0.406

1.89E 02

EPC27

4.35

0.182

EPC33

9.9

0.412

3.2

2.00E 05 EPC14

6.72

1

1.34E 04

3.3

4.00E 04

4.00E 04

3.4

2.00E 02 EPC23

5.69

1

1.14E 01

3.5

4.00E 04 EPC27

4.35

0.310

5.82E 03

EPC33

9.9

0.690

combines with consequence severity of a sub-task in order to determine the tolerability of the risk. High severity was assigned by marine experts since consequences of oil spill could potentially harm. The fuel oil (petroleum product) contains various volatile compounds which cause to health risks for marine environment and human. Contamination to the sea water and soil is another fatal consequences of oil spill due to human error on-board ship. In the view of risk matrix, the HEP values are in the range of 1.00E 01 and 1.00E+00 considered risky activities. They are sub-task 1.4 (Plugging scuppers on deck), 1.8 (Blanking other bunker manifold), 1.13 (Verifying pumping rate), 1.14 (Hose connection to manifold), 2.2

Safety Science 110 (2018) 102–109 HEP chart 9.00E-01 1.1 3.5 1.2 1.3 3.4 8.00E-01 1.4
Safety Science 110 (2018) 102–109
HEP chart
9.00E-01 1.1
3.5
1.2
1.3
3.4 8.00E-01
1.4
3.3 7.00E-01
3.2 6.00E-01
1.5
5.00E-01
3.1 4.00E-01
1.6
3.00E-01
2.00E-01
2.8
1.7
1.00E-01
0.00E+00
2.7
1. 8
2.6
1.9
2.5
1.10
2.4
1.11
2.3
1.12
1.13
2.2 2.1
1.14
Fig. 2. HEP distribution through sub-taks.

(Keeping low pumping rate), 2.3 (Monitoring bunkering continuously) and 3.4 (Hose disconnection from the manifold) respectively. In this context, sub-task 2.2 (Make sure that pumping rate is kept low at the beginning) has the highest HEP value among the all tasks. Prior to bunkering operation, the pumping rate agreed and is requested barge to keep low pumping rate at the beginning. In this task, inexperience duty engineer may skip to remind skipper of barge for low pumping rate. This failure may cause over owing or pipeline bursting. The consequences of such human error may cause serious oil spill around the ship and have fatal e ects on marine and costal environ- ment. Sub-task 1.13(Verify pumping rate) has the second highest HEP value during bunkering operation. Excessive bunker pumping rate may cause overowing and overpressure splitting the bunker pipeline. The consequences of such human failure can cause to burst line and mani- fold. The responsible duty engineer and pumper sometimes does not report the situation or monitor operation adequately. Likewise, sub-task 1.8(Make sure that other bunker manifold valves are shut-oand blanked) ranks in the third place since delayed or inadequate feedback and lack of exercise are the main contributory factors. Prior to com- mencement of the bunkering operations, unused manifold connections should be isolated and blanked o. The consequences of this human error can be crew injury or oil spill to the maritime environment. This task is normally performed by duty engineer. However, he may some- times delegated task of blanking to the pumper or A/B. The delegated crew member are not able to perform blanking. Furthermore, sub-task 2.3(Monitor bunkering operation con- tinuously) is another critical activity where time limitation and in- adequate checking are the major contributory conditions. The con- sequences of such human failure can be over owing of fuel oil. Duty engineer and A/B is the responsible crew to monitor bunkering op- eration. However, they may postpone the tasks due to time limitation. Sub-task 1.4(Connect exible hose to the ship s manifold) has also very high HEP values among the operation. The human errors can have fatal consequences since over owing of fuel oil into sea or serious crew in- jury can emerge The A/B is a responsible crew to plug all deck scuppers in position and ensure they are oil and watertight. However, the op- eration is sometimes skipped or not executed properly due to in- adequate inspection. Most of ship crew are still not familiar to place deck scupper in position due to lack of practical training. Sub-tasks 1.14(Connect exible hose to the ships manifold) and 3.4(Disconnect exible hose from ship s manifold) have also high HEP values. In these activities, unreliable equipment is the major contributing factor. Connection or disconnection of exible hose is under responsibility of duty engineer, pumper and A/B. Although utmost care is exercised by responsible ship crew in the process of hose connection/disconnection,

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Table 8 Human error reduction measures.

Safety Science 110 (2018) 102–109

Sub-task

HEP

HEP reduction strategies

2.2

8.36E 01

Agreement should be made with bunker barge for low pumping rate and line pressure at start, at maximum ow and at the end.

 

A sequence should be prepared for pumping rate, including initial, maximum and topping orate.

A regular inspection should be carried out and minimum one watch-keeper should be on duty.

1.13

5.94E 01

Agreement should be made for pumping rate.

 

Regular inspection should be made for monitoring pumping rates and gauges to ensure that line pressures are not too high.

1.8

2.36E 01

An acknowledge report to duty engineer should be given by crew after nishing relevant task.

 

A

visual notice should be positioned at appropriate place to remind task.

 

Responsible ship crew should be aware that the equipment is not completely reliable.

2.3

2.21E 01

Monitoring of the operation should be carried out as per ship's SMS.

 

Minimum one watch-keeper should be eectively duty during the entire operation.

 

A

regular inspection should be carried out by chief engineer that the control measures are eectively in place.

 

Watch handovers should be kept minimum to save the time.

1.4

2.13E 01

A practical training should be provided for ship crew who are not familiar scuppers. Chief ocer should re-check whether deck scuppers are all in position or not. Scuppers are well maintained t for deck.

1.14

1.14E 01

A comprehensive inspection should be performed by duty engineer for exible hose. Duty engineer should carefully inspect the hose and ensure the gasket is tted bolts. Responsible ship crew should be aware that the equipment is not completely reliable.

3.4

1.14E 01

A comprehensive inspection should be performed by duty engineer for exible hose. Duty engineer should support pumper and A/B in the process of disconnection. Responsible ship crew should be aware that the equipment is not completely reliable.

most of bunker barges have substandard equipments such as gasket or bolts. This may cause a leakage in the vicinity of the connection/dis- connection to the manifold on the installation.

3.6. Human error reduction measures

In order to enhance safety level and reduce the probability of human error occurrence in bunkering operation, the human error control measures are recommended for the sub-tasks with high HEP values. Table 8 depicts some control measures human error during bunkering operation at chemical tanker ships.

4. Conclusion

Environmental sensitiveness is one of the most important concerns of sustainable maritime industry since a wide range of critical marine operations exercised on-board ships pose potential hazards for marine habitat. Bunkering operations, for instance, poses acute hazards due to oil spill risk. Human errors are key attributes of oil spill related to bunkering operation. Therefore, prediction of HEP in bunkering op- eration is vital to achieve and retain a high level of safety standards ( Akyuz and Celik, 2016b; Kristiansen, 2013 ). This paper aims to per- form a systematic HEP during bunkering operation at chemical tanker ship. The SOHRA, a marine specic method to quantify human error, is used. A real-shipboard bunkering case is applied to assess HEP values. According to the results, pre-bunkering and during bunkering activities relatively have high HEPs. Specically, sub-tasks 2.2(Make sure that pumping rate is kept low at the beginning), 1.13(Verify pumping rate), 1.8(Make sure that other bunker manifold valves are shut-o and blanked), 2.3(Monitor bunkering operation continuously), 1.4 (Make sure that all deck scupper are plugged), 1.14(Connect exible hose to the ship s manifold), 3.4(Disconnect exible hose from ship s manifold) have a signi cant e ect on the bunkering operation since they have the highest HEPs. Human error control measures are recommended to en- hance operational safety. While bunkering is considered as risky operation in the maritime transportation, the paper provides not only a theoretical insight but also practical application to enhance safety and protection of the marine environment. This method is applicable to any critical shipboard or o shore operations such as ballasting, de-ballasting, hold or tank cleaning, gas inerting, crude oil washing, ship to ship (STS) cargo op- eration, SPM or SBM cargo operations to enhance safety control level in

the maritime operations. The method can also be used to focus on evaluating human error during critical operations in oshore and ocean engineering since the m-EPC re ects general characteristics of seafarers employed in the maritime, ocean and o shore environment. The further work will include fuzzy logic approach to tackle with ambiguity and vagueness during APAO calculation.

Acknowledgment

The author wishes to thank the reviewers and editor in charge for their very constructive feedback.

Appendix A. Supplementary material

Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.ssci.2018.08.002 .

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