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Human Factors Accident Classification System Report (Assessment)

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Updated: May 22nd, 2021

Briefly identify the specifications of the vessel and explain the accident scenario (i.e. What happened, when did it happen and to whom did it happen?).

This report will analyze the events that led to the grounding of the Attilio Levoli vessel. The vessel under study was constructed and overseen by an Italian organization. The manufacturers managed the vessel with the capacity of 6,239 dwt. The tanker was enrolled in Italy and had a group of 16 individuals from various nationalities. As a result, the vessel transported oil products through various routes within Europe and its environs. On one Thursday, Attilio Levoli was included in a mishap; she was sailing to Barcelona in the wake of stranding in Southampton. The loss happened at around 1500hours while she was of course from Falwey in Barcelona with a team of experts on board and refloated with the rising tide by around 1900 hours, without pulling help. A report from an investigative survey revealed that the misfortune of the stacked tanker was caused by poor scaffold administration with the captain being occupied with navigational obligations by long phone discussions. The report revealed that the mishap occurred when the captain of the Attilio Ievoli assigned to explore the vessel was relieved and a new command was introduced. The new command paved way for inefficiency and groundings of the loaded vessel.

Consequently, the report revealed that the passage route had no accessible pilotage benefit, with draft vessels that are greater and profound utilizing the passageway. By implication, such vessels cannot be assisted in emergencies. Moreover, the Marnavi S.p.A Company had given directions to their vessels to utilize the East Solent entry, however, by utilizing the alternate route to Spain, the captain wanted to save a few hours. In the wake of dropping the pilot, the navigator was conning the ship on autopilot and the transport floated off the channel and moved northward until it grounded, in this way bringing about the plate on the base for space frontward however, there was no infiltration. Although the vessel was stacked with styrene and toluene products the fortifications and freight did not spill after the mishap, the Attilio Levoli tanker floated with the tide. The report is presumed that there was an unseemly division of errands and poor scaffold group administration between the chain of command. The chain of command includes the navigator officer, the cadet, captain, and the vessel designer who was situated in one of the two seats at the navigational support. Clearly, the navigating officer had cautioned the captain when he found that the vessel was off the track toward the north, however, he was distracted with trivial matters that affected his performance.

Explain how accident causation has changed over time from individual models such as domino theory to more complex models such as the ‘Swiss-Cheese’ model.

Heinrich created one of the formal mischance causation hypotheses in 1931. He built up the “domino” hypothesis of mishap causation in the wake of examining vessel reports from organizations guaranteed by insurance. From this examination, he reasoned that 86% of accidents are influenced by hazardous acts. By implication, 86% of vessel accidents are human errors. Consequently, 12% of accidents were brought about by perilous conditions while two percent of the mishaps could be credited to a demonstration of God. Based on the analysis, Heinrich categorized five causative factors of vessel accidents. These components incorporate the social condition and family; dangerous act or potentially physical/mechanical conditions; human blame and heedlessness; the mischance; and the damage (Lees 2012). Social condition and family included learning custom and social practice in the working environment. The element of “lack of regard” includes pessimistic individual qualities of the person, hazardous demonstrations of physical conditions and specialized disappointments, which influence vessel accidents.

Heinrich’s mischance causation hypothesis is a straight grouping of occasions that clarifies what happened, however it does not give much data on why the mishaps happened and lays the obligation on the risk demonstration or mechanical conditions without considering other fundamental contributory elements. Early mischance causation hypothesis has been superseded by advanced hypotheses of mishap causation. A more overwhelming domino hypothesis proposes that antagonistic occasions have prompt causes, hidden causes and, main drivers. The hypothesis gives a concise portrayal of how the managerial traits of vessel mishap interface with human misfortunes, and how individual blunders can be the aftereffect of arrangement of occurrence grouping. The hypotheses infer that dangerous demonstrations are required in episodes more than hazardous conditions. Hence, its logic of occurrence counteractive action accentuated hazardous acts and individual related variables prompting them. The domino hypothesis of mischance causation gave an insight with an appropriate ideological match because the approach accentuated the money related expenses included in mishaps as opposed to giving a complete comprehension of mischance causations.

A more unpredictable model by Reason was introduced in 1997. The Swiss hypothesis is a standout among complex, compelling, and generally utilized hypotheses of mishap causation among wellbeing experts. The hypothesis proposes that in any association, protections are utilized to keep the risk from becoming misfortunes. Hierarchical barriers can be “hard” and ‘delicate’. “Hard” guards incorporate programmed cautioning gadgets and alerts, designing specialized wellbeing highlights, and defensive powerless focuses composed into the framework. “Delicate” resistances are based on staff and systems, and incorporate management and administrative prerequisites; affirmation review; standard working systems; preparing and preparation; licenses to work; supervision and operation (Craggs & Rashid 2017, para. 3). The Swiss Model builds a positive technique for hazard mitigation, as opposed to attempting to break some imperceptible chain or upgrades the adequacy of the layers that exist. For example, one could include a layer of the group preparing or utilize additional care in route planning, or discover courses in the most proficient method to enhance the adequacy of the present organization.

Modern models of mischances recognize that mishaps are the result of a multi-factorial process in which botches assume a major factor. The models propose that shifted factors, for instance, social condition, administrative approach, the framework plan, gear, an outline of the whole occupation, and identity of the worker impact risky practices. Accordingly, it is basic to comprehend the components that assistance to avoid blunders and mishaps. In the analysis, we will focus on ways to deal with blunders. Consequently, we will evaluate the components that add to security and the variables are utilized for wellbeing contributions.

Explain the four levels of analysis in HFACS.

The Human Factor Analysis and Classification System (HFACS) was created to characterize the dormant and dynamic disappointments embroiled in Swiss model hypothesis so it could be utilized as a mischance examination and investigation apparatuses. Although the HFACS at first was intended to be utilized in the military flying setting, it has been viable for common flying and has been successful for military and common investigations. HFACS particularly depicts four levels of system disaster, each of which compares to one of the layers contained in the Swiss Model hypothesis. These comprise of dangerous acts, unsafe supervision, essentials for perilous acts, and the impacts of the association (Madigana, Golightlyb & Maddersc 2016, p. 125). The HFACS system goes past the basic recognizable proof of what an administrator fouled to give an unmistakable comprehension of the purposes behind the system failure. By implication, mistakes are seen because of framework disappointments and side effects of profound deliberate issues and not just as a blame of the representative. Administrators’ hazardous demonstrations can be separated into two classes: infringement and mistakes.

Blunders or mistakes, describe an individual’s physical or mental exercises that neglect to understand their expected outcome. Given that in actuality people by nature make blunders, these hazardous demonstrations have been found to rule most system failures and accident databases. Requirements for dangerous acts, which incorporate the state of the administrators, natural, and individual variables depict another level of HFACS structure. An independent survey in the US revealed that 85% of sea misfortunes can be specifically connected to the perilous demonstrations of the team. The individual state of mind influences the execution at work. These preconditions are sorted into ecological elements, status of the administrator regarding mental, physiological, physical state, and wellness for obligation.

Based on the Swiss model of mischance causation, management affects the conditions of navigators and the working environment. Dangerous supervision is the third level of investigation in HFACS. There are four recognized sorts of dangerous management, which include inadequate observation or control, inability to amend a recognized issue, improper operations, and supervisory infringement (Krebs 2016, para. 7). Hierarchical impacts are benefits of upper-level administration that affect supervisory practices, aside the administrators’ activities and conditions. Thus, the most cloud inert disappointments resolve around worries that identifies with the atmosphere of the association, the procedures of operation, and asset supervision.

Generate a HFACS classification for the Atilio Ievoli

Human Factors Analysis and Classification System (HFACS) can be utilized to break down and characterized the Atilio Ievoli causal variables. Utilizing the HFACS system of analysis, we will categorize four levels of human disappointment of the Atilio Ievoli.

Hazardous Acts

Choice blunders: The human components disappointments started when the navigator or captain, as opposed to the direction of the organization used a different route. This channel had no accessible pilotage benefit, with draft ships with greater and more profound perpetually utilizing the East Solent passageway.

Talented-based mistake: based on the report, the navigator neglected to organize his consideration, being occupied with navigational obligations that affected work efficiency and performance.

Infringement: the manufacturers had given guidelines to their vessels to utilize the specific passageway yet by utilizing the “alternate route” to Spain, the navigator had planned to save time. The infringement of administrative control caused the grounding of the Attilio Ievoli.

Preconditions for Risky Acts

The state of administrators: In this mischance, weariness was not an issue. The navigator of Attilio Ievoli was very much refreshed, as he had rested the entire night. Reports indicated that his assistant was refreshed, although there was the plausibility of slight hazard weakness probability.

Hazardous Supervision

Lacking supervision: There were no instructions that occurred, and they made suppositions on the assignment each was expected to perform. Impaired by the distinctions in culture, was a critical consider this mishap. This was because of social dissimilarity and correspondence rehearses while on board. Please note that appropriate techniques are important to ensure that gadgets that help the vessel to explore are properly utilized. The port detector, thou functioning, was vacant because the central architect who was playing out her fuel utilization, looking at the UMS alerts and other voyage estimations were effective and efficient. The navigator’s assistant ought to have possessed the port workstation with the goal that he could screen the advance of the vessel with the utilization of parallel records and the port detector. Pre-cruising briefings were not made to characterize the different duties to be taken by each scaffold colleague. The operator did not adequately manage the echo device. Consequently, the navigator’s assistant was not utilizing the port radar and the standard setting position of the ship was expected.

Improper operations: The voyage did not take after the tenets and controls to the letter. The regulations stipulated the pilot embark and disembark when they approach the Solent. This was intended to persuade pilots were to utilize operations routes while exploring their vessels. For this situation, the navigator slighted what the organization had stipulated. The guides had not arranged an autonomous technique that could be utilized to affirm his cross-track mistake.

Hierarchical Influences: If the security administration framework was viable, the mischance would not have happened because they would have detected the vessel’s abnormal routes using the navigational systems.

Discuss the results of the HFACS classification. What are the lessons that need to be applied to navigation and safety management from this accident?

In summary, it is recognized that vessel accidents are influenced by different factors. We discussed factors that affect operations and safety. The HFCA structure describes the recognizable proof of what the marine team fouled during its voyage. Consequently, the system of analysis gives an unmistakable comprehension of the purpose behind the human error. Utilizing HFCA in dissecting Attilio Ievoli mishap, blunders are analyzed to understand the framework disappointments and orderly issues. The HFCA examination demonstrates that the stranding of the stacked tanker was a wrong decision by the navigator being diverted from navigational obligations (Schneier 2016, para. 5).

The stranding occurred when the navigator of the Attilio Ievoli assigned to explore the vessel through the right passageway was relieved of his duty. Thus, the alternative route had no accessible pilotage benefit, with draft delivers that is greater and profound utilizing. The voyage did not take after the tenets and controls to the letter. The regulations stipulated the pilot embark and disembark when they approach the Solent. This was intended to persuade pilots were to utilize operations routes while exploring their vessels. For this situation, the navigator slighted what the organization had stipulated. The guides had not arranged an autonomous technique that could be utilized to affirm his cross track mistake. The human components disappointments started when the navigator or captain, as opposed to the direction of the organization used a different route. This channel had no accessible pilotage benefit, with draft ships with greater and more profound perpetually using an alternative passageway.

Finally, we can infer that there was an unseemly division of assignments and poor group administration between the voyage crew. If the security administration framework was viable, the mischance would not have happened because they would have detected the vessel’s abnormal routes using the navigational systems. The management should have administered specific responsibilities to avoid complacency. Consequently, acts of insubordination should have been detected and punished to deter repetition. Those activities ought to incorporate an enhanced overview of traversable waters, a fitting pilotage administration, and essential of proper VTS scope. Inward techniques ought to be in a position to substantiate consistence with directions of the organization. Cell phones ought to be limited or prohibited in the cabin sections and other confined departments.

Reference List

Craggs, B & Rashid, A 2017, , Web.

Krebs, B 2016, Who makes the iot things under attack? Web.

Lees, F 2012, Lees’ loss prevention in the process industries: hazard identification, assessment and control, Technology & Engineering, Butterworth-Heinemann.

Madigana, R, Golightlyb, D & Maddersc, R 2016, ‘Application of human factors analysis and classification system (HFACS) to UK rail safety of the line incidents’, Accident Analysis & Prevention, vol. 97 , no. 1, pp. 122-131.

Schneier, B 2016, Security economics of the internet of things, Web.

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