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April 2012www.sname.org/sname/mt (opinion )Despite the steady growth of regulations over the years, it remains axiomatic that approximately 80% of accidents are caused by, or associated with, human error. Studies have indicated that the num- ber may actually lie between 60% and 90%, depending on how accidents are dened and how the various causal ele- ments are weighed, but 80% remains a good rule of thumb. Regulations have been e ective in reducing the number and severity of accidents, but they have tended to address pri- marily mechanical or physical things. is is because the human performance aspects have been considered sec- ondary or are little understood, dicult to address, or hard to implement. e low-hanging fruit for marine safety has been design and equipment. Too often, when an accident can be attributed clearly to the action or inaction of a per- son, the cause is identied as human error, and that is the end of the story. It has been deemed impractical to burden an entire industry with new requirements based on a one- o mistake by one person. Of course, having people operating ships is a neces- sity. The oldest concepts in marine safety address that fact, through navigation and operational rules, require- ments for manning, qualications, training, experience, drills, and minimum physical standards. What more can be done to identify and address the things that cause peo- ple to make mistakes or to avoid situations for which they are unprepared? More consistency, better oversight e traditional approach to addressing the human element in marine safety has been through licensing, qualifica- tions, and training. In 1978, the International Convention on Standards of Training, Certication and Watchkeeping for Seafarers was adopted. However, this resulted in a wide range in competencies of mariners with commensurate impacts on safety. Even with the 1978 convention, many standards were open to interpretation by individual gov- ernments. Since then, the convention has been amended to provide more consistency in its application and better oversight. New regulations address the human element in such areas as hours of work and rest, prevention of drug and alcohol abuse, medical tness, leadership and teamwork, and modern technology such as electronic charts. In 1987, the European ferry Herald of Free Enterprise capsized as it was leaving port, killing 193 people. The International Maritime Organization (IMO) recognized that a systematic management framework, such as the newly published ISO 9000 quality management standard, could be applied to safety as well. is was a paradigm shift for the maritime community in that the top-level responsibility for safe ship operation would rest with the ship owner and not just with the ships master. is was the rst time the IMO asserted its authority over companies ashore. e resulting International Management Code for the Safe Operation of Ships and for Pollution Prevention addresses human perfor- mance through organizational and operational procedures aboard ships and through its mandatory feedback mecha- nisms. However, the e ectiveness of the code in reducing human error depends on a number of factors, such as man- agement commitment and safety culture (including the ships master and ocers), implementation aboard indi- vidual ships, and crew training. e international maritime community now recog- nizes that the many types of safety issues have a common thread in human factors. ere were a number of people who had that insight for decades, but it wasnt until 1997 that the IMO published its vision, principles, and goals relating to the human element, which acknowledge that human factors are complex and multidimensional and that everyone in the marine industry and at the IMO needs to appreciate the impact of human-related activi- ties in the safe operation of ships and in reducing maritime accidents. e stated vision of the IMO for the human ele- ment is to signicantly enhance maritime safety and the quality of the marine environment by addressing human element issues to improve performance.? As the marine industry changes, new situations are introduced that can lead to human error. Ships and other marine systems continue to become larger, more complex, and technically more advanced. In 2006, the passenger ship Crown Princess heeled 24 degrees in a maneuver executed by the second ocer. He admitted to making a mistake in trying to counteract a turn being executed by the ships inte- grated navigation system (INS). Years ago, the investigation might have stopped there, with the accident simply attrib- uted to human error. However, on deeper examination, it BY JACK SPENCER Analyzing Error Safer maritime systems demand the integration of human performance