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A Study on Accident Theories and Application to Maritime Accidents
Available online at www.sciencedirect.com
ScienceDirect Procedia Engineering 194 (2017) 298 – 306
10th International Conference on Marine Technology, MARTEC 2016
A Study on Accident Theories and Application to Maritime Accidents Zobair Ibn Awala,∗, Kazuhiko Hasegawab a Assistant
Professor, Bangladesh University of Engineering and Technology (BUET), Dhaka 1000, Bangladesh b Professor, Osaka University, Osaka 565-0871, Japan
Abstract Maritime accidents, when taking place, often affect in large scale over the environment, society and economy. Many such accidents have occurred in the past century. In this study, it is observed that the traditional approach towards maritime safety, in general, is reactive. It indicates that accidents are unpredictable, and this is the most fundamental problem in safety science. In this connection, a review on some notable accident theories/models was conducted where the attributes of different accident theories/models were compared. The literature review suggests that over the years accident theories/models have been originated from different disciplines and the theories/models have been evolving with the changes in the society. The study reveals that maritime accidents take place in a complex socio-technical context. In such accidents, a single root cause may be traced back in the cause-effect chain, but it is not enough for preventing similar accidents in the future. The accident of Titanic (1912) and the accident of Costa Concordia (2012) justify this argument. Therefore, the paper discusses the development and usage of a new technique, such as Logic Programming Technique (LPT), for analyzing and understanding accidents. From an engineering point of view, the study concludes that accidents may be treated as a system control problem and modern innovative technologies like LPT may be further developed and utilized in this regard. c 2017 by Elsevier Ltd.is an open access article under the CC BY-NC-ND license 2017The The Authors. Published © Authors. Published by Elsevier Ltd. This (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of the 10th International Conference on Marine Technology. Peer-review under responsibility of the organizing committee of the 10th International Conference on Marine Technology. Keywords: Safety science; accident theory; accident model; maritime safety; Logic Programming Technique (LPT)
1. Introduction Maritime accidents have shocked the world every now and then. Historically, the list of maritime accidents is quite long and extensive, and the number of casualties is grievously high. There are specific accidents, which essentially reshaped the maritime industry. These accidents occurred over the last one hundred years and forced the maritime community to reach international agreements on safety, liability, and environmental protections. A timeline produced by Awal [1] is shown in Fig. 1 which can be considered in this regard. The figure chronologically shows the notable maritime accidents that occurred over the past century and the necessary measures taken thereafter. ∗
Corresponding author. Zobair Ibn Awal Tel.: +880 177 9021 091 ; fax: +880 2 9673 605 E-mail address: [email protected]; [email protected]
1877-7058 © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of the 10th International Conference on Marine Technology.
doi:10.1016/j.proeng.2017.08.149
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Zobair Ibn Awal and Kazuhiko Hasegawa / Procedia Engineering 194 (2017) 298 – 306
Perhaps, the most famous accident of all is the sinking of Titanic, which struck the first blow for real international cooperation on safety regulations, known as the International Convention for the Safety of Life at Sea (SOLAS). In 1914 two years after the Titanic tragedy, SOLAS was adopted. The 1934 sinking of the Morro Castle off the New Jersey coast, which went up in flames, led to new fire suppression, protection and control regulations and equipment requirements as a significant upgrade to SOLAS. The Torrey Canyon oil spill off French and Cornish coasts in 1967 led to the International Convention for the Prevention of Pollution from ships (MARPOL) in 1973. On March 16, 1978, the Amoco Cadiz tanker ran aground three miles from the coast of Brittany, France due to a steering gear failure. It split into three before sinking, creating the largest oil spill of its kind in history to that date, more than one and half a million barrels. Public outcry and political pressure resulted in significant updates to both MARPOL and SOLAS, and the addition of safety and pollution audits that led to 1982 Paris Memorandum of Understanding (Paris MoU), which established Port State Control. The significance of port state control is that it enabled an international port inspection system that makes it impossible for non-compliant ships to hide [2]. The remarkable capsizing of the Herald of Free Enterprise in 1987 took place minutes after leaving the harbor in Zeebrugge, Belgium. Incredibly, the bow door was left open, resulted in the loss of one hundred ninety three out of the five hundred and thirty nine passengers and crew. This accident led to adoption of International Safety Management (ISM) Code. This code is designed to prevent damage to life and the environment at sea, by requiring each vessel to have a working, audited, Safety Management System (SMS). It also required shipping companies to have a license to operate [2]. In recent times, several accidents have shocked the world as well. The accident of MV Costa Concordia and accident of MV Sewol are mentionable in this regard. On January 13th, 2012 the Italian cruise ship Costa Concordia listed after striking an underwater rock obstruction off Isola del Giglio, Italy. Thirty-two people lost their lives. The accident of MV Sewol in 2014 shocked the world when she capsized while carrying four hundred and seventy-six lives, and most of them were secondary school students. The sinking of MV Sewol resulted in widespread social
Costa Concordia, 2012
Measures adopted (following the accident), Year
EU Initiatives (Erika and Prestige), 2003 Prestige, 2002
Notable Marine Accident, Year
Erika, 1999 Revised SOLAS for RORO Ferries (MS Estonia), 1997 MS Estonia, 1994 US Oil Pollution Act (Exxon Valdaez), 1990 Exxon Valdaez, 1989 FSA (Piper Alpha), 2002 Piper Alpha, 1988 ISM Code (Herald of Free Enterprize), 1989 Herald of Free Enterprize, 1987 Port State Control (Amoco Cadiz), 1982 Amoco Cadiz, 1978 MARPOL (Torrey Canyon), 1973 Torrey Canyon, 1967
SOLAS Update (Morro Castle), 1948 US Merchant Marine Act (Morro Castle), 1936 Morro Castle, 1934 SOLAS (Titanic), 1914
Titanic, 1912
1910
1930
1950
1970
1990
2010
2030
Year
Fig. 1. A timeline of notable maritime accidents and reactive measures taken by international communities [1].
2050
300
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and political reaction within South Korea and the world as well. These two terrible incidents somehow remind that accidents seem to happen for the same underlying human and organizational reasons even though a century of improvements to technology and safety regulations had taken place since the accident of Titanic[3]. Nevertheless, in summary, it may be concluded that every time a major accident takes place then the international community reacts and adopts preventive measures. But before the accident it remains unknown that how the accident will take place. Therefore, traditional approach towards maritime safety is reactive, rather than proactive. This study, therefore, further investigates the science behind accidents and attempts to uncover the existing deficiencies in the contemporary accident theories and models. 2. Review of accident theories and models An accident theory is a collection of propositions to illustrate the principles of causation of accidents. Similarly, an accident model is a simplified description, of a system or process, to assist presentations of accident occurrence based on an accident theory. In this section, a review on accident theories and models is presented. During the review several key points were considered, such as the type, goal, hypothesis and method of analysis of the theories/models. It was observed that there exists a diverse range of accident theories and models. Several researchers have attempted to classify these theories and models into different classes. Laflamme [4], Qureshi [5] and Khanzode et. al. [6] can be cited in this context. A simple classification can also be found in Awal and Hasegawa [7] as well. However, in this particular study, the authors classify the accident theories and models in the following manner: • • • • •
Statistical analysis and trends Risk analysis Domino theory Epidemiologic theory Control and system theoretic models
The following sections describe the attributes of the above group of accident theories and models in detail. 2.1. Statistical analysis and trends Perhaps, the scientific approach of studying accidents started in England at the beginning of 20th century when Vernon [8] published his extensive study on the causation of industrial accidents. Vernon considered fifty thousand industrial accidents collected from four different factories across the United kingdom and produced a statistical analysis of hourly variation of distinctive categories of industrial accidents. Perhaps this is the very first publication that showed a systematic approach of identifying various accident causation factors. Vernon classified factors into two main headings: (i) factors of personal origin and (ii) factors of external origin. One of the interesting trends in statistical accident analysis is accident proneness. Newbold [9] studied accidents statistically in the industrial context and concluded that certain individuals are accident prone than the other. According to Froggatt and Smiley [10], the designation of accident prone implies, irrespective of environment; that individual is more likely at all times to incur an accident than his colleagues even though exposed to equal risk, and that this is due to some characteristics or summation of some characteristics associated with corporal dexterity, sensory-motor skill, personality, or higher cognitive function. Several other researchers studied the frequency distributions and trends of the accident causing factors; the proneness is discovered not only in personality but also in geographical and temporal factors. Greenwood and Yule [11], Awal [12], Awal et al. [13] and Hossain et al. [14] may give some insight into this topic. In short, the goal of statistical analysis is to identify some trend(s) correlating with some probable factors. Different types of hypotheses have been proposed and tested using this approach. Table 1 shows a comparative summary on this topic. 2.2. Risk Analysis One of the most acclaimed branches of statistical analysis of accidents is risk analysis, which gained a popularity after the introduction of Fault Tree Analysis (FTA) [15] [16]. Since then a significant number of studies has been
Zobair Ibn Awal and Kazuhiko Hasegawa / Procedia Engineering 194 (2017) 298 – 306
conducted on the development and application of risk analysis in solving practical problems. The study by Li et al. [17] on quantitative maritime risk assessment can be referred and considered as a resourceful literature in this context. In traditional risk analysis, the principal task is to identify distinctive threats and simultaneously determine consequences of the respective threats if they are to occur in reality. There are two types of risk analysis: (i) quantitative risk analysis and (ii) qualitative risk analysis. Risk analysis is popular in real engineering problems and academic exercises because of its technical facility and a wide range of applicability. Hasegawa and Yamazaki [18] can be cited as an example in this regard. However, there lies a fundamental weakness in quantitative risk analysis, it is unable to predict how an accident may occur. It can only quantify certain risk value against a set of risk control options (RCO) for a known type of accident. Nevertheless, the goal of risk analysis is to assist decision makers making a choice out of several RCOs which provide different risk values for different RCOs. Table 1 summarizes and compares this further. 2.3. Domino Theory Heinrich [19] proposed that accident occurs in a chain of events after conducting studies on statistical accident analysis. Heinrich elaborated that the individual fault can be related to other factors in sequence, just like a domino. There are five dominoes according to this theory as shown in Fig. 2 (a). Heinrich explains that undesirable personality traits can be passed along through inheritance or develop from person’s social environment and both inheritance and environment contribute to faults of a person. This can be considered as the first domino. The second domino deals with worker personality traits. Heinrich explains that inborn or obtained character flaws contribute to accident causation. According to Heinrich, natural or environmental flaws in the worker’s family or life cause these secondary personal defects, which are themselves contributors to unsafe acts or the existence of hazardous conditions. The third domino is the direct cause of incidents - the unsafe act. Heinrich defines four reasons why people commit dangerous acts: (i) improper attitude, (ii) lack of knowledge or skill, (iii) physical unsuitability and (iv) improper mechanical or physical environment. Heinrich later subdivides these categories into ’direct’ and ’underlying’ causes and concludes that combination of multiple causes creates a systematic chain of events that leads to the accident. The goal of domino theory is to establish a linear cause-effect relationship among various social and individual factors using five metaphoric dominoes. The idea compared in Table 1. 2.4. Epidemiologic Theory Gordon [20] is the first proposer of the epidemiologic theory of accidents. Gordon considered accident as an ecologic problem. This research states that the causative factors in accidents have been seen to reside in agents, in the host and in the environment, as shown in Fig. 2 (b). The mechanism of accident production is that process by which the three components interact to produce a result, the accident. Therefore, the cause of accident comes from the
Ancestry and Social Environment
Host
Fault of the person
Unsafe Act
Accident
Accident Injury
Agent
(a)
Environment
(b)
Fig. 2. Concepts of (a) Domino theory and (b) Epidemiologic theory.
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interaction between the host, agent and environment. The hypothesis is if home accidents are primarily a public health problem then the problem is reasonable to be approached in the manner and through techniques that have proved useful for other mass disease problems. Haddon [21] in 1968 proposed a 2D dimensional matrix for injury control which was mainly developed for the car crash. Such matrix helps to identify the host, agent and environmental factors in temporal order (prior to the event, during the event and post event) and helps identifying preventive measures. Haddon [22] later in 1970 gave ten strategies for reducing losses which were based on the energy transfer concept. The reason behind this energy transfer concept is because that major class of ecologic phenomena involves the transfer of energy. In 1990, Reason [23] proposed that there are latent human failures which results in accidents without any visible causes. The proposal included the following three concepts: (i) latent failure, (ii) local triggering event, (iii) system defenses. The study discussed the differences between active and latent human failure and a framework for the dynamics of accident causation. Later on Reason [24] developed and proposed the Swiss cheese model and the organizational Accident Model (shown in Fig. 3). Organizational accidents occur within modern complex technological societies having multiple causes. The accidents involve many people operating at different levels of their respective companies. Hazard cause losses and barriers are there to prevent. Like a Swiss Cheese, there are holes in the barriers. When all the holes align then hazards pass through and cause losses. Each barrier represents each level of organizational defenses against losses. 2.5. Control and system theoretic models Suchman [25] proposed the social deviance hypothesis for accident causation. In this study, an accident is considered as a social problem and rejection of social constraint is considered as the cause of an accident. Kjellen and Larsson [26] proposed Deviation Concept for occupational accident control. The proposal stated that deviation from the norm causes accidents in a production process. Rasmussen [27] discussed risk management in dynamic society and proposed AcciMap for accident investigation. Rasmussens work fundamentally considers accidents as a control problem, which utilizes control engineering metaphores in social context. Branford’s research [28] can be considered as an example who applied AcciMap and studied loss of control at various levels of the Uberlingen mid-air collision. Perrow [29] proposed the term ’Normal Accident’ which became very popular in various high-tech industries. According to Perrow, a normal accident is a characteristic of a system. Given the characteristics of the system, multiple and unexpected interactions of failures are inevitable. The interactive complexity and tight coupling the system characteristic inevitably produces an accident; therefore, it is called ’Normal Accident’ or ’System Accident’. The premises of this idea are: (i) people make mistakes, (ii) big accidents begin from small beginnings and (iii) many failures originate due to organization/technology. Hollnagel and Goteman [30] proposed Functional Resonance Accident Model (FRAM). The idea suggested that accidents occurred due to functional resonance within a system. Leveson [31] introduced System Theoretic Accident Model and Process (STAMP) which is essentially a model of control system applied in social structure. She suggested that accidents occur when there is a lack of constraints. In general, control and system theoretic models attempt to discover weaknesses within the concerned system and
Defenses
Danger Hazards Latent Condition
Active Failure Local workplace Factors Organizational Factors (a)
(b)
Fig. 3. (a) Swiss cheese model and (b) Organizational accident model.
Losses
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prescribes various control parameters to prevent accidents. The comparative summay of control and system theoretic accident models are shown in Table 1. 2.6. Summary of review The literature review suggests that over the years, particularly the past century, researchers from diverse fields, including engineers, medical doctors, psychologists, and other professionals have studied accidents and attempted to theorize the science of accidents. Most of the theories explain the accident phenomenon using some metaphor in order to make the concepts easily apprehensible. It has been found that the accident theories have transformed from a single root cause to linear cause-effect models, from epidemiologic concepts to organizational accident models and evolution of control and system theoretic concepts. This transformation and evolution of a broad range of accident theories/models suggest that understanding the science of accidents requires a vast perspective and large knowledge domain. Table 1 summarizes the above discussed points. Traditionally, accidents are analyzed considering linear cause-effect relationships. In this respect, fault tree analysis or event tree analysis is highly effective in determining how various initiating events can result in accidents. However, these techniques have two defeciencies: (1) limited to one initiating event and (2) can overlook subtle system dependencies. The accident of Titanic (1912) and the accident of Costa Concordia (2012) are classic examples in this regard. None of the accidents can be predicted with reasonable accuracy using the existing technique. Therefore, there is a need for new technique that can overcome the existing shortcomings. 3. Logic Programming Technique (LPT) It has been found in this study that the current need in safety science is to develop new techniques that can predict ’how’ an accident will take place with reasonable accuracy. Logic Programming Technique (LPT) is a new accident analysis tool in this regard which has been proposed recently and under development, as described in Awal [1], Awal and Hasegawa [7] [33] [34]. LPT is a method of logical deductions which utilize heuristics to search through given knowledge and attempts to discover ’how’ accident may take place. The fundamental principal of LPT is logical Table 1. A comparative analysis of accident theories and models Group Name
Goal
Statistical analysis and theories
The goal of such analysis is to identify the trends.
Risk analysis
The goal is to assist the decision makers by providing a set of risk values against a set of risk control options.
Domino Theory
The goal is to establish the chain of events that leads to an accident.
Epidemiologic Theory
The goal is to treat accident as a disease (metaphorically) and find treatment (metaphorically) to prevent or minimize the severity.
Control and system theoretic models
The goal is to define a system and apply various techniques to control the system so that unwanted events can not take place.
Hypothesis Various kinds of hypothesis have been formulated, for example: (i) Some people are accident prone than the other [11]. (ii) Carelessness and inattention is the cause of accidents [8]. (iii) In Bangladesh the predominant cause of maritime accidents are cyclone, overloading and collision [12] [13]. Various kinds of hypothesis have been formulated, for example: i. In Puget Sound and surrounding waters, an application of one of the following interventions yield significant risk reduction compared to base case: one-way zone, an escorting and a double hull requirement [32]. An accident event is part of a cause-effect relationship which can be described by domino effect. The dominoes are: social environment, fault of a person, unsafe act or condition, accident itself and injury [19]. There are several hypothesis in this group, for example: i. If home accidents are primarily a public health problem then the problem is reasonably to be approached in the manner and through techniques that have proved useful for other mass disease problems [20]. ii. Reason [23] proposed that there are latent human failures which cause accidents without any visible causes. Some of the hypothesis developed are: i. Suchman [25] proposed the social deviance hypothesis for accident causation. In this study an accident is considered as a social problem and rejection of social constraint is considered as the cause behind accident. ii. According to Perrow [29] accident is Normal. Because: a. People make mistake, b. Big accidents begin from small beginnings, c. Many failures originate due to organization/technology.
Type of analysis
Computational analysis
Computational analysis
Subjective analysis
Subjective analysis
Subjective analysis
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Determined by subjective analysis/fixed Traditional Accident Analysis The path is determined by subjective analysis or fixed during risk analysis.
Event A
Event B
Accident
Automatically deduced by the logic program/dynamic Logic Programming Technique (LPT) The path is logically deduced by the logic program using heuristic search.
Event A
Event B
Accident
Fig. 4. Difference between traditional accident analysis and logic programming technique.
deductions using deductive arguments. Propositional logics are utilized to develop logic worlds and find out how accidents take place within the world. Propositions logics are simple sentences which have one or more premise(s) and one conclusion. This simple format allows modelling systems of various disciplines. This is a significant advantage while studying accidents in multidisciplinary platform. Awal and Hasegawa [7] discussed the advancement of LPT into the agent based perception-action technique. In this technique all agents search through respective perceptions and actions. Thereby, logical deductions reveal all the possible sequence of events that may take place. Some of these events may lead to accidents which is of particular interest to achieve safety. Hence, Logic Programming Technique (LPT) can automatically deduce ’how’ accidents can take place. Such deductions are generally difficult to produce by human judgment or subjective analysis alone because of the complexity and size of the problem space. Traditional accident analysis also becomes very difficult when there is a change in the system; whereas logic programming can handle system changes easily. For example, an addition of an event or an agent is simply done by adding arguments in the logic program; while in traditional accident analysis (e.g. fault tree analysis) such change complicates the total structure (tree in this case) and requires reconstructing the structure again. Also in traditional accident analysis the (e.g. fault tree) the combination of events is known. However, in Logic Programming Technique (LPT) the combinations of events are deduced automatically. This gives Logic Programming Technique (LPT) a significant advantage over other accident analysis techniques. Fig. 4 shows this concept graphically.
4. Concluding Remarks In this study, an attempt was undertaken to understand the nature and characteristics of maritime accidents. The study reviewed various accident theories and models, which resulted in a conclusion that the problem space of safety science is diverse and incorporation of knowledge from multiple disciplines is necessary. There are various perspectives of accident causation as well. For effective accident analysis and accident prevention, this knowledge is indispensable. Different types of accident theories and models have different applications in maritime safety. Statistical analysis can only identify trends in maritime accidents. Since most maritime accidents are one-off events, trend identification may not be always useful. Risk analysis has been widely used in the maritime context. But the application is only limited to employing risk control options. Domino theory is not useful since it’s descriptions are unable to incorporate the complexity of maritime systems. Perhaps, epidemiologic theories are well suited compared to other groups of theories when human and organizational factors become important in accident analysis. These theories may uncover the hidden factors when a subjective analysis is done. The control and system theories seem to have significant potential. But subjective analysis and pragmatic application in the maritime context still require further research and investigation.
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The shortcoming of the existing accident theories and models have been identified and the benefits of a new accident analysis technique called Logic Programming Technique (LPT) is discussed. The study thus concludes that LPT may be further developed and utilized in solving maritime accident problems.
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[32] J.R. van Dorp and J.R. Merrick, On a risk management analysis of oil spill risk using maritime transportation system simulation. Annals of Operations Research, Vol. 187 (2011), No. 1, pp. 249-277. [33] Z.I. Awal and K. Hasegawa, Analysis of marine accidents due to engine failure Application of Logic Programming Technique (LPT), Technical Information at the Journal of the Japan Institute of Marine Engineering (JIME), Vol. 50 (2015), No. 6, pp. 39-46. [34] Z.I. Awal and K. Hasegawa, A New Approach to Accident Analysis: Multiple Agent Perception-Action, Transactions of the Society of Naval Architects and Marine Engineer (SNAME), USA, (In Press).
ScienceDirect Procedia Engineering 194 (2017) 298 – 306
10th International Conference on Marine Technology, MARTEC 2016
A Study on Accident Theories and Application to Maritime Accidents Zobair Ibn Awala,∗, Kazuhiko Hasegawab a Assistant
Professor, Bangladesh University of Engineering and Technology (BUET), Dhaka 1000, Bangladesh b Professor, Osaka University, Osaka 565-0871, Japan
Abstract Maritime accidents, when taking place, often affect in large scale over the environment, society and economy. Many such accidents have occurred in the past century. In this study, it is observed that the traditional approach towards maritime safety, in general, is reactive. It indicates that accidents are unpredictable, and this is the most fundamental problem in safety science. In this connection, a review on some notable accident theories/models was conducted where the attributes of different accident theories/models were compared. The literature review suggests that over the years accident theories/models have been originated from different disciplines and the theories/models have been evolving with the changes in the society. The study reveals that maritime accidents take place in a complex socio-technical context. In such accidents, a single root cause may be traced back in the cause-effect chain, but it is not enough for preventing similar accidents in the future. The accident of Titanic (1912) and the accident of Costa Concordia (2012) justify this argument. Therefore, the paper discusses the development and usage of a new technique, such as Logic Programming Technique (LPT), for analyzing and understanding accidents. From an engineering point of view, the study concludes that accidents may be treated as a system control problem and modern innovative technologies like LPT may be further developed and utilized in this regard. c 2017 by Elsevier Ltd.is an open access article under the CC BY-NC-ND license 2017The The Authors. Published © Authors. Published by Elsevier Ltd. This (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of the 10th International Conference on Marine Technology. Peer-review under responsibility of the organizing committee of the 10th International Conference on Marine Technology. Keywords: Safety science; accident theory; accident model; maritime safety; Logic Programming Technique (LPT)
1. Introduction Maritime accidents have shocked the world every now and then. Historically, the list of maritime accidents is quite long and extensive, and the number of casualties is grievously high. There are specific accidents, which essentially reshaped the maritime industry. These accidents occurred over the last one hundred years and forced the maritime community to reach international agreements on safety, liability, and environmental protections. A timeline produced by Awal [1] is shown in Fig. 1 which can be considered in this regard. The figure chronologically shows the notable maritime accidents that occurred over the past century and the necessary measures taken thereafter. ∗
Corresponding author. Zobair Ibn Awal Tel.: +880 177 9021 091 ; fax: +880 2 9673 605 E-mail address: [email protected]; [email protected]
1877-7058 © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of the 10th International Conference on Marine Technology.
doi:10.1016/j.proeng.2017.08.149
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Perhaps, the most famous accident of all is the sinking of Titanic, which struck the first blow for real international cooperation on safety regulations, known as the International Convention for the Safety of Life at Sea (SOLAS). In 1914 two years after the Titanic tragedy, SOLAS was adopted. The 1934 sinking of the Morro Castle off the New Jersey coast, which went up in flames, led to new fire suppression, protection and control regulations and equipment requirements as a significant upgrade to SOLAS. The Torrey Canyon oil spill off French and Cornish coasts in 1967 led to the International Convention for the Prevention of Pollution from ships (MARPOL) in 1973. On March 16, 1978, the Amoco Cadiz tanker ran aground three miles from the coast of Brittany, France due to a steering gear failure. It split into three before sinking, creating the largest oil spill of its kind in history to that date, more than one and half a million barrels. Public outcry and political pressure resulted in significant updates to both MARPOL and SOLAS, and the addition of safety and pollution audits that led to 1982 Paris Memorandum of Understanding (Paris MoU), which established Port State Control. The significance of port state control is that it enabled an international port inspection system that makes it impossible for non-compliant ships to hide [2]. The remarkable capsizing of the Herald of Free Enterprise in 1987 took place minutes after leaving the harbor in Zeebrugge, Belgium. Incredibly, the bow door was left open, resulted in the loss of one hundred ninety three out of the five hundred and thirty nine passengers and crew. This accident led to adoption of International Safety Management (ISM) Code. This code is designed to prevent damage to life and the environment at sea, by requiring each vessel to have a working, audited, Safety Management System (SMS). It also required shipping companies to have a license to operate [2]. In recent times, several accidents have shocked the world as well. The accident of MV Costa Concordia and accident of MV Sewol are mentionable in this regard. On January 13th, 2012 the Italian cruise ship Costa Concordia listed after striking an underwater rock obstruction off Isola del Giglio, Italy. Thirty-two people lost their lives. The accident of MV Sewol in 2014 shocked the world when she capsized while carrying four hundred and seventy-six lives, and most of them were secondary school students. The sinking of MV Sewol resulted in widespread social
Costa Concordia, 2012
Measures adopted (following the accident), Year
EU Initiatives (Erika and Prestige), 2003 Prestige, 2002
Notable Marine Accident, Year
Erika, 1999 Revised SOLAS for RORO Ferries (MS Estonia), 1997 MS Estonia, 1994 US Oil Pollution Act (Exxon Valdaez), 1990 Exxon Valdaez, 1989 FSA (Piper Alpha), 2002 Piper Alpha, 1988 ISM Code (Herald of Free Enterprize), 1989 Herald of Free Enterprize, 1987 Port State Control (Amoco Cadiz), 1982 Amoco Cadiz, 1978 MARPOL (Torrey Canyon), 1973 Torrey Canyon, 1967
SOLAS Update (Morro Castle), 1948 US Merchant Marine Act (Morro Castle), 1936 Morro Castle, 1934 SOLAS (Titanic), 1914
Titanic, 1912
1910
1930
1950
1970
1990
2010
2030
Year
Fig. 1. A timeline of notable maritime accidents and reactive measures taken by international communities [1].
2050
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and political reaction within South Korea and the world as well. These two terrible incidents somehow remind that accidents seem to happen for the same underlying human and organizational reasons even though a century of improvements to technology and safety regulations had taken place since the accident of Titanic[3]. Nevertheless, in summary, it may be concluded that every time a major accident takes place then the international community reacts and adopts preventive measures. But before the accident it remains unknown that how the accident will take place. Therefore, traditional approach towards maritime safety is reactive, rather than proactive. This study, therefore, further investigates the science behind accidents and attempts to uncover the existing deficiencies in the contemporary accident theories and models. 2. Review of accident theories and models An accident theory is a collection of propositions to illustrate the principles of causation of accidents. Similarly, an accident model is a simplified description, of a system or process, to assist presentations of accident occurrence based on an accident theory. In this section, a review on accident theories and models is presented. During the review several key points were considered, such as the type, goal, hypothesis and method of analysis of the theories/models. It was observed that there exists a diverse range of accident theories and models. Several researchers have attempted to classify these theories and models into different classes. Laflamme [4], Qureshi [5] and Khanzode et. al. [6] can be cited in this context. A simple classification can also be found in Awal and Hasegawa [7] as well. However, in this particular study, the authors classify the accident theories and models in the following manner: • • • • •
Statistical analysis and trends Risk analysis Domino theory Epidemiologic theory Control and system theoretic models
The following sections describe the attributes of the above group of accident theories and models in detail. 2.1. Statistical analysis and trends Perhaps, the scientific approach of studying accidents started in England at the beginning of 20th century when Vernon [8] published his extensive study on the causation of industrial accidents. Vernon considered fifty thousand industrial accidents collected from four different factories across the United kingdom and produced a statistical analysis of hourly variation of distinctive categories of industrial accidents. Perhaps this is the very first publication that showed a systematic approach of identifying various accident causation factors. Vernon classified factors into two main headings: (i) factors of personal origin and (ii) factors of external origin. One of the interesting trends in statistical accident analysis is accident proneness. Newbold [9] studied accidents statistically in the industrial context and concluded that certain individuals are accident prone than the other. According to Froggatt and Smiley [10], the designation of accident prone implies, irrespective of environment; that individual is more likely at all times to incur an accident than his colleagues even though exposed to equal risk, and that this is due to some characteristics or summation of some characteristics associated with corporal dexterity, sensory-motor skill, personality, or higher cognitive function. Several other researchers studied the frequency distributions and trends of the accident causing factors; the proneness is discovered not only in personality but also in geographical and temporal factors. Greenwood and Yule [11], Awal [12], Awal et al. [13] and Hossain et al. [14] may give some insight into this topic. In short, the goal of statistical analysis is to identify some trend(s) correlating with some probable factors. Different types of hypotheses have been proposed and tested using this approach. Table 1 shows a comparative summary on this topic. 2.2. Risk Analysis One of the most acclaimed branches of statistical analysis of accidents is risk analysis, which gained a popularity after the introduction of Fault Tree Analysis (FTA) [15] [16]. Since then a significant number of studies has been
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conducted on the development and application of risk analysis in solving practical problems. The study by Li et al. [17] on quantitative maritime risk assessment can be referred and considered as a resourceful literature in this context. In traditional risk analysis, the principal task is to identify distinctive threats and simultaneously determine consequences of the respective threats if they are to occur in reality. There are two types of risk analysis: (i) quantitative risk analysis and (ii) qualitative risk analysis. Risk analysis is popular in real engineering problems and academic exercises because of its technical facility and a wide range of applicability. Hasegawa and Yamazaki [18] can be cited as an example in this regard. However, there lies a fundamental weakness in quantitative risk analysis, it is unable to predict how an accident may occur. It can only quantify certain risk value against a set of risk control options (RCO) for a known type of accident. Nevertheless, the goal of risk analysis is to assist decision makers making a choice out of several RCOs which provide different risk values for different RCOs. Table 1 summarizes and compares this further. 2.3. Domino Theory Heinrich [19] proposed that accident occurs in a chain of events after conducting studies on statistical accident analysis. Heinrich elaborated that the individual fault can be related to other factors in sequence, just like a domino. There are five dominoes according to this theory as shown in Fig. 2 (a). Heinrich explains that undesirable personality traits can be passed along through inheritance or develop from person’s social environment and both inheritance and environment contribute to faults of a person. This can be considered as the first domino. The second domino deals with worker personality traits. Heinrich explains that inborn or obtained character flaws contribute to accident causation. According to Heinrich, natural or environmental flaws in the worker’s family or life cause these secondary personal defects, which are themselves contributors to unsafe acts or the existence of hazardous conditions. The third domino is the direct cause of incidents - the unsafe act. Heinrich defines four reasons why people commit dangerous acts: (i) improper attitude, (ii) lack of knowledge or skill, (iii) physical unsuitability and (iv) improper mechanical or physical environment. Heinrich later subdivides these categories into ’direct’ and ’underlying’ causes and concludes that combination of multiple causes creates a systematic chain of events that leads to the accident. The goal of domino theory is to establish a linear cause-effect relationship among various social and individual factors using five metaphoric dominoes. The idea compared in Table 1. 2.4. Epidemiologic Theory Gordon [20] is the first proposer of the epidemiologic theory of accidents. Gordon considered accident as an ecologic problem. This research states that the causative factors in accidents have been seen to reside in agents, in the host and in the environment, as shown in Fig. 2 (b). The mechanism of accident production is that process by which the three components interact to produce a result, the accident. Therefore, the cause of accident comes from the
Ancestry and Social Environment
Host
Fault of the person
Unsafe Act
Accident
Accident Injury
Agent
(a)
Environment
(b)
Fig. 2. Concepts of (a) Domino theory and (b) Epidemiologic theory.
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interaction between the host, agent and environment. The hypothesis is if home accidents are primarily a public health problem then the problem is reasonable to be approached in the manner and through techniques that have proved useful for other mass disease problems. Haddon [21] in 1968 proposed a 2D dimensional matrix for injury control which was mainly developed for the car crash. Such matrix helps to identify the host, agent and environmental factors in temporal order (prior to the event, during the event and post event) and helps identifying preventive measures. Haddon [22] later in 1970 gave ten strategies for reducing losses which were based on the energy transfer concept. The reason behind this energy transfer concept is because that major class of ecologic phenomena involves the transfer of energy. In 1990, Reason [23] proposed that there are latent human failures which results in accidents without any visible causes. The proposal included the following three concepts: (i) latent failure, (ii) local triggering event, (iii) system defenses. The study discussed the differences between active and latent human failure and a framework for the dynamics of accident causation. Later on Reason [24] developed and proposed the Swiss cheese model and the organizational Accident Model (shown in Fig. 3). Organizational accidents occur within modern complex technological societies having multiple causes. The accidents involve many people operating at different levels of their respective companies. Hazard cause losses and barriers are there to prevent. Like a Swiss Cheese, there are holes in the barriers. When all the holes align then hazards pass through and cause losses. Each barrier represents each level of organizational defenses against losses. 2.5. Control and system theoretic models Suchman [25] proposed the social deviance hypothesis for accident causation. In this study, an accident is considered as a social problem and rejection of social constraint is considered as the cause of an accident. Kjellen and Larsson [26] proposed Deviation Concept for occupational accident control. The proposal stated that deviation from the norm causes accidents in a production process. Rasmussen [27] discussed risk management in dynamic society and proposed AcciMap for accident investigation. Rasmussens work fundamentally considers accidents as a control problem, which utilizes control engineering metaphores in social context. Branford’s research [28] can be considered as an example who applied AcciMap and studied loss of control at various levels of the Uberlingen mid-air collision. Perrow [29] proposed the term ’Normal Accident’ which became very popular in various high-tech industries. According to Perrow, a normal accident is a characteristic of a system. Given the characteristics of the system, multiple and unexpected interactions of failures are inevitable. The interactive complexity and tight coupling the system characteristic inevitably produces an accident; therefore, it is called ’Normal Accident’ or ’System Accident’. The premises of this idea are: (i) people make mistakes, (ii) big accidents begin from small beginnings and (iii) many failures originate due to organization/technology. Hollnagel and Goteman [30] proposed Functional Resonance Accident Model (FRAM). The idea suggested that accidents occurred due to functional resonance within a system. Leveson [31] introduced System Theoretic Accident Model and Process (STAMP) which is essentially a model of control system applied in social structure. She suggested that accidents occur when there is a lack of constraints. In general, control and system theoretic models attempt to discover weaknesses within the concerned system and
Defenses
Danger Hazards Latent Condition
Active Failure Local workplace Factors Organizational Factors (a)
(b)
Fig. 3. (a) Swiss cheese model and (b) Organizational accident model.
Losses
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prescribes various control parameters to prevent accidents. The comparative summay of control and system theoretic accident models are shown in Table 1. 2.6. Summary of review The literature review suggests that over the years, particularly the past century, researchers from diverse fields, including engineers, medical doctors, psychologists, and other professionals have studied accidents and attempted to theorize the science of accidents. Most of the theories explain the accident phenomenon using some metaphor in order to make the concepts easily apprehensible. It has been found that the accident theories have transformed from a single root cause to linear cause-effect models, from epidemiologic concepts to organizational accident models and evolution of control and system theoretic concepts. This transformation and evolution of a broad range of accident theories/models suggest that understanding the science of accidents requires a vast perspective and large knowledge domain. Table 1 summarizes the above discussed points. Traditionally, accidents are analyzed considering linear cause-effect relationships. In this respect, fault tree analysis or event tree analysis is highly effective in determining how various initiating events can result in accidents. However, these techniques have two defeciencies: (1) limited to one initiating event and (2) can overlook subtle system dependencies. The accident of Titanic (1912) and the accident of Costa Concordia (2012) are classic examples in this regard. None of the accidents can be predicted with reasonable accuracy using the existing technique. Therefore, there is a need for new technique that can overcome the existing shortcomings. 3. Logic Programming Technique (LPT) It has been found in this study that the current need in safety science is to develop new techniques that can predict ’how’ an accident will take place with reasonable accuracy. Logic Programming Technique (LPT) is a new accident analysis tool in this regard which has been proposed recently and under development, as described in Awal [1], Awal and Hasegawa [7] [33] [34]. LPT is a method of logical deductions which utilize heuristics to search through given knowledge and attempts to discover ’how’ accident may take place. The fundamental principal of LPT is logical Table 1. A comparative analysis of accident theories and models Group Name
Goal
Statistical analysis and theories
The goal of such analysis is to identify the trends.
Risk analysis
The goal is to assist the decision makers by providing a set of risk values against a set of risk control options.
Domino Theory
The goal is to establish the chain of events that leads to an accident.
Epidemiologic Theory
The goal is to treat accident as a disease (metaphorically) and find treatment (metaphorically) to prevent or minimize the severity.
Control and system theoretic models
The goal is to define a system and apply various techniques to control the system so that unwanted events can not take place.
Hypothesis Various kinds of hypothesis have been formulated, for example: (i) Some people are accident prone than the other [11]. (ii) Carelessness and inattention is the cause of accidents [8]. (iii) In Bangladesh the predominant cause of maritime accidents are cyclone, overloading and collision [12] [13]. Various kinds of hypothesis have been formulated, for example: i. In Puget Sound and surrounding waters, an application of one of the following interventions yield significant risk reduction compared to base case: one-way zone, an escorting and a double hull requirement [32]. An accident event is part of a cause-effect relationship which can be described by domino effect. The dominoes are: social environment, fault of a person, unsafe act or condition, accident itself and injury [19]. There are several hypothesis in this group, for example: i. If home accidents are primarily a public health problem then the problem is reasonably to be approached in the manner and through techniques that have proved useful for other mass disease problems [20]. ii. Reason [23] proposed that there are latent human failures which cause accidents without any visible causes. Some of the hypothesis developed are: i. Suchman [25] proposed the social deviance hypothesis for accident causation. In this study an accident is considered as a social problem and rejection of social constraint is considered as the cause behind accident. ii. According to Perrow [29] accident is Normal. Because: a. People make mistake, b. Big accidents begin from small beginnings, c. Many failures originate due to organization/technology.
Type of analysis
Computational analysis
Computational analysis
Subjective analysis
Subjective analysis
Subjective analysis
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Determined by subjective analysis/fixed Traditional Accident Analysis The path is determined by subjective analysis or fixed during risk analysis.
Event A
Event B
Accident
Automatically deduced by the logic program/dynamic Logic Programming Technique (LPT) The path is logically deduced by the logic program using heuristic search.
Event A
Event B
Accident
Fig. 4. Difference between traditional accident analysis and logic programming technique.
deductions using deductive arguments. Propositional logics are utilized to develop logic worlds and find out how accidents take place within the world. Propositions logics are simple sentences which have one or more premise(s) and one conclusion. This simple format allows modelling systems of various disciplines. This is a significant advantage while studying accidents in multidisciplinary platform. Awal and Hasegawa [7] discussed the advancement of LPT into the agent based perception-action technique. In this technique all agents search through respective perceptions and actions. Thereby, logical deductions reveal all the possible sequence of events that may take place. Some of these events may lead to accidents which is of particular interest to achieve safety. Hence, Logic Programming Technique (LPT) can automatically deduce ’how’ accidents can take place. Such deductions are generally difficult to produce by human judgment or subjective analysis alone because of the complexity and size of the problem space. Traditional accident analysis also becomes very difficult when there is a change in the system; whereas logic programming can handle system changes easily. For example, an addition of an event or an agent is simply done by adding arguments in the logic program; while in traditional accident analysis (e.g. fault tree analysis) such change complicates the total structure (tree in this case) and requires reconstructing the structure again. Also in traditional accident analysis the (e.g. fault tree) the combination of events is known. However, in Logic Programming Technique (LPT) the combinations of events are deduced automatically. This gives Logic Programming Technique (LPT) a significant advantage over other accident analysis techniques. Fig. 4 shows this concept graphically.
4. Concluding Remarks In this study, an attempt was undertaken to understand the nature and characteristics of maritime accidents. The study reviewed various accident theories and models, which resulted in a conclusion that the problem space of safety science is diverse and incorporation of knowledge from multiple disciplines is necessary. There are various perspectives of accident causation as well. For effective accident analysis and accident prevention, this knowledge is indispensable. Different types of accident theories and models have different applications in maritime safety. Statistical analysis can only identify trends in maritime accidents. Since most maritime accidents are one-off events, trend identification may not be always useful. Risk analysis has been widely used in the maritime context. But the application is only limited to employing risk control options. Domino theory is not useful since it’s descriptions are unable to incorporate the complexity of maritime systems. Perhaps, epidemiologic theories are well suited compared to other groups of theories when human and organizational factors become important in accident analysis. These theories may uncover the hidden factors when a subjective analysis is done. The control and system theories seem to have significant potential. But subjective analysis and pragmatic application in the maritime context still require further research and investigation.
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The shortcoming of the existing accident theories and models have been identified and the benefits of a new accident analysis technique called Logic Programming Technique (LPT) is discussed. The study thus concludes that LPT may be further developed and utilized in solving maritime accident problems.
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