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Maritime human factors and IMO policy

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Jens-Uwe Schröder-Hinrichs , Erik Hollnagel , Michael Baldauf
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Maritime human factors and IMO policy

JENS-UWE SCHRÖDER-HINRICHS†*, ERIK HOLLNAGEL‡,§,

MICHAEL BALDAUF†, SARAH HOFMANN† and ADITI KATARIA†
†
Maritime Risk and System Safety (MaRiSa) Research Group, World
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Maritime University, Malmö, Sweden

‡
University of Southern Denmark, Odense, Denmark
§
Center for Quality Improvement, Middelfart, Denmark

The development of human factor- (HF) related regulations of the International

Maritime Organization (IMO) has often been the result of responses to maritime
accidents. The typical reaction to an accident has been a combination of (mainly
technical) regulations, changing of procedures and training. Systemic evaluations and
changes have rarely been done. Statements made by IMO in recent years claim a shift
towards a proactive approach in maritime safety. Key documents, like the IMO Human
Element vision, would confirm such statements. This article reviews documents sub-
mitted to IMO’s Maritime Safety Committee (MSC) in order to evaluate the ‘mechan-
isms’ of decision-making and the priorities for setting the agenda in MSC regarding
maritime human factors. The review confirms that the IMO work related to HF was
reactive in the 1990s. There are a number of examples of more recent regulations that
can be considered proactive. However, it is too early to fully confirm a proactive policy
in the IMO rule-making process.

1. Introduction
The history of maritime safety is characterized by maritime accidents followed by regulatory
responses. The Code of Hammurabi established regulations about liability in case of losses
in ancient Babylon almost 3800 years ago (Mukherjee 2002). Load line regulations were
probably introduced even earlier in Crete in an attempt to reduce losses resulting from
overloaded ships. Load line requirements can be found in a number of legal instruments
throughout history—from ancient Rome to the Hanseatic League and further on. In contrast
to that, the commercial incentives to avoid the cargo capacity limitations set by the
regulations have always been high. Already 150 years ago, Samuel Plimsoll succeeded to
draw public attention in the United Kingdom to the intolerable loss of life at sea due to
missing effective controls of the maximal allowed cargo to be carried by ships. He managed
successfully to introduce more effective national load line rules in the United Kingdom.
However, this was only a national approach and applied to the United Kingdom only.
The foundering of the Titanic in 1912 marked the beginning of a new era in maritime safety
regulations and ended the national attempts to govern maritime safety alone. The resulting
Safety at Sea Convention of 1914 was the first international treaty related to maritime safety
(International Conference on Safety at Sea 1914). It nevertheless still took some time until the
International Maritime Organization (IMO) was given the mandate to safeguard the further
development of maritime safety and marine environmental protection standards on a global

*To whom correspondence should be addressed. E-mail: [email protected]

© 2013 Taylor & Francis

 244 J.-U. Schröder-Hinrichs et al.

level. The achievements of the IMO related to maritime safety and marine environmental
protection are impressive. However, almost all important IMO instruments have been linked
to specific maritime accidents. The former Secretary General of the IMO, William O’Neil,
described the IMO as swift and decisive in response to accidents (O’Neil 2011). He also
referred to a proactive policy that has helped to create a comprehensive regulatory infra-
structure aiming at the prevention of accidents on the one hand, and a minimization of damage
on the other hand if an accident occurs despite all precautions.
While such a statement sounds reassuring, the question must be asked what the word
‘proactive’ means in an IMO context (Psaraftis 2002)? It is certainly important to discuss
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how the member states in IMO identify issues for further action. In a recent publication
about the foundering of the Costa Concordia in 2012, it was argued that many maritime
accidents often involve combinations of similar contributing factors (Schröder-Hinrichs,
Hollnagel, and Baldauf 2012). This applies specifically to the human factor- (HF) related
aspects of those accidents. This insight is not new in the maritime domain. In fact, more
than 30 years ago, similar concerns were raised in this journal because HF problems
contributing to maritime accidents seemed to persist despite technological progress made
in shipping (King 1979). An obvious question is therefore why it has not been possible to
address those factors more effectively. A number of publications about maritime accident
investigation or accident investigations offer some general explanations. Frequently
reappearing arguments relate to the methodologies used in accident investigations
(Lundberg, Rollenhagen, and Hollnagel 2009; Schröder-Hinrichs, Baldauf, and Ghirxi
2011) or the focus of maritime accident investigation (Schröder 2003, 2004a). The fact
that a number of HF-related issues have not been addressed in IMO instruments therefore
challenges the claim made above about a proactive policy of IMO.
An evaluation made of how proactive the discussions in IMO are should not only focus
on the quality of and follow-up to maritime accident investigations. While accident
investigation reports are a valuable source of information regarding maritime HFs, other
sources should also be considered. The authors of this article understand the word
‘proactive’ to mean that an entity should try to identify safety problems and discuss
possible solutions on the basis of existing knowledge, without waiting for accidents to
happen. We would therefore expect to see both papers about HF-related aspects and their
influence on maritime operations and regulations in different IMO instruments based on
the evaluation and discussion of such papers.
This article will try to analyse the maritime HF-related documents handed in to IMO
and compare the content of these documents with the content published in two scientific
journals focusing on maritime issues in the last 40 years. The comparison of the two data-
sets should show if the HF-related decisions in IMO are still accident driven, that is,
reactive, or if they have become proactive.

2. Historical developments of human factors (HFs)

As pointed out above, accidents have been important for the development of maritime
safety regulations. The maritime sector has also considered HFs as a main contributing
factor to accidents, in common with other industrial sectors. But this was not always so.
Frederick Taylor’s work from 1882 is a good example of how early HF research focused on
work itself. Taylor was convinced that there was ‘one best way’ to carry out a task to
maximize performance, and studied the selection and training of industrial workers using
 Maritime human factors and IMO policy 245

time and motion studies (Badge-Schaub, Lauche, and Hofinger 2012). Following techno-
logical developments after World War II, the capabilities of machines started to exceed the
control capabilities of human operator, which created a demand-capacity gap. The industrial
workplace also started to become complex with tightly coupled interactions between sub-
systems (Perrow 1984). Accidents like Three Mile Island in 1979 demonstrated that HFs
had become a critical part of plant safety and made clear that the conditions for successful
functioning were created by a combination of social and technical factors. Socio-technical
systems today are often non-linear and outcomes are often intractable. Resilience engineer-
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ing has therefore recently been introduced as an approach to safety management. Resilience
is here understood as the intrinsic ability of a system to adjust its functioning prior to, during
or following changes and disturbances, so that it can sustain required operations under both
expected and unexpected conditions (Hollnagel et al. 2011).
Maritime transport today is an industry with tight couplings between the different sub-
systems. Even so, the overall system is perceived as linear rather than complex. This may
explain why discussions about maritime safety differ from other domains, such as aviation
and offshore. The fact that accidents in other industries typically lead to more casualties and
attract more public interest and concerns than the shipping business may also play a role.
David Moreby (1975) published one of the early dedicated attempts to look into specific
maritime HFs. He described organizational and technical changes that took place in seafar-
ing as well as the seafarer as an individual, the work on board a ship and the economic
system that influences it all. However, such examples of academic work dedicated to
seafarers are rare. Hetherington, Flin, and Mearns (2006) confirmed the remarks made by
Moreby in 1975 since they could not find many specific studies focusing on the seafarer. It
therefore seems that maritime HFs is a discipline that still requires efforts to shape it up and
define an agenda for future research. There are a number of publications in more recent
years that allow being optimistic that this work is on its way. Grech, Horberry, and Koester
(2008) can be used as an example of the more recent publications.

3. IMO and human factors

The IMO—formerly known as IMCO—was established in 1948 to work as a technical
agency for the improvement of maritime safety and related aspects (United Nations 1958).
The setting up of the IMO was not easy, and the only common denominator for the
member states was the agreement that an international forum to discuss technical stan-
dards for ship construction and equipment was desirable. As the interest of the global
shipping community was limited, it took almost 10 years before the IMO met for the first
time. This also explains why the IMO kept a rather low profile in the beginning. It was not
until 1967 that the IMO was given a chance to develop a comprehensive profile. The
foundering of the Torrey Canyon in that year highlighted loopholes in the international
legislative framework, which prevented the IMO member states involved from reacting
effectively to the accident. As a result, a number of new treaties were suggested to address
issues related to marine environmental protection, civil liability, the circumstances allow-
ing an intervention at the seas as well as maritime education and training. In the following
years, whenever another significant accident occurred, similar responses followed and
further treaties were added or the existing ones extended.
The reactions listed in Table 1 focused on technical regulations while the human
operator—the ship officer, the marine engineer or the rating—generally was ignored. The
 246 J.-U. Schröder-Hinrichs et al.

Table 1. Selected accidents and the reactive follow-up in IMO (based on Schröder 2004b).

Year of In force
accident Ship name Resulting measure/instrument since

1912 Titanic SOLAS, 1914a

1967 Torrey Canyon Intervention Convention, 1969 1975
Civil Liability Convention, 1969 1975
MARPOL Convention, 1973 1983
STCW Convention, 1978 1984
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1976 Argo Merchant MARPOL Convention, Protocol of 1978 1983

1987 Herald of Free ISM Code, 1994 1998
Enterprise
1989 Exxon Valdez OPRC Convention, 1990 1995
MARPOL Convention, 1992 amendments (double hull) 1995
1994 Estonia SAR Convention, 1998 amendments (improvement of 2000
cooperation)
1999 Erika Res. 949(23) Guidelines on places of refuge for ships in 2003b
2002 Prestige need of assistance

Notes: aThe first SOLAS never entered into force as a result of World War I. The convention was revised in 1929
and 1948, and the fourth version of 1960 was the first version adopted in IMO.
b
IMO resolutions, if not specifically referred to in IMO mandatory instruments, are of advisory nature and not
legally binding.

only exception was the International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers, 1978 (STCW Convention) (United Nations 1984). The Torrey
Canyon accident raised doubts about the previously practised system of nationally defined
criteria for maritime education and training as well as certification, which meant that all
IMO member states had different interpretations about what was required before a certificate
of competence could be issued. The adoption of the STCW Convention, which replaced the
old International Labour Organization (ILO) Officers’ Competency Certificates Convention
(No. 53) of 1936, was therefore a major step towards global standards in this area (Morrison
1997). Nevertheless, it was not until the capsizing of the Herald of Free Enterprise in 1987
that the IMO started looking at human and organizational factors in a different light. The
developments in IMO between 1991 and 1997, when HF-related issues were discussed in
more detail, led to a more holistic approach to HFs and a recognition of the impact that HFs
make on maritime safety.

4. Review of human factor-related publications

In order to discuss how the IMO addresses HF-related issues, an analysis of the contents
of documents submitted to IMO’s Maritime Safety Committee (MSC) was carried out and
discussed in relation to papers published in two academic journals specialized in maritime
affairs. The two selected journals—Maritime Policy & Management and the Journal of
Navigation—have a history of more than 40 years. It is therefore expected that the
published papers reflect issues of concern in the maritime community over this time
span. The comparison of the content of the two journals and the content of the documents
submitted to MSC should enable a discussion how the IMO selects issues for further
consideration and how decisions are made regarding those issues. The main question for
this survey is when and how certain topics are considered relevant to be included to the
 Maritime human factors and IMO policy 247

agenda of MSC. It was assumed that a special interest in topics during certain years might
be linked to papers published in academic journals. It was furthermore assumed that the
comparison of the journal and the IMO document contents could help to determine how
proactive the IMO has been over the years.

4.1. Methodology and data used in the study

4.1.1. Model and taxonomy for the review of HF-related publications. In a recent
review of HF-related studies in the maritime domain, Hetherington, Flin, and Mearns
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(2006) used an onion model and a related taxonomy based on earlier publications by HSE
(1997), Jørgensen (2002) and Stanton (1996) for the classification of the studies reviewed
in their article. Since this model has similarities with the model suggested for formal
safety assessment (FSA) in the IMO context (IMO 2002), it was used as a basis for the
development of a model and a related taxonomy in the current study. Hetherington, Fin,
and Mearns (2006) have used three layers in their model (design, personnel, organization
and management). Following the ideas of Reason (1990) about latent and active condi-
tions, a distinction is made between immediate (personnel) and underlying (organization
and management) causes leading to accidents. Since the IMO has adopted an approach
that is also based on ideas of Reason (1990), as well as Edwards (1972) and Hawkins
(1987) as guidance for accident investigation (IMO 1999), it was considered appropriate
to expand and revise the model and the taxonomy used by Hetherington, Flin, and Mearns
(2006). A fourth layer was therefore added to consider environmental issues (physical,
economic and regulatory). In addition, the taxonomy used was brought in line with the
philosophy of the Human Factors Analysis and Classification System (HFACS) by
Shapell and Wiegmann (2001), a tool that is often used when Reasons model is the
basis for a review (Schröder-Hinrichs, Baldauf, and Ghirxi 2011). The taxonomy devel-
oped for this study provides for a three-level coding and allows for a more in-depth
discussion of the reviewed content. The model and taxonomy are shown in Figure 1 and
Table 2.

Figure 1. Taxonomy used in this study based on IMO’s FSA approach (IMO 2002).
 248 J.-U. Schröder-Hinrichs et al.

Table 2. Detailed overview about the taxonomy used for the coding of documents in this study.

Level 1 Level 2 Level 3

Environmental Context Physical environment Weather conditions

Ergonomics
Economic environment Financial situation of owner
Market situation
Regulatory environment Flag state regulation
International standards
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Port state regulations

Organizational Infrastructure Resources Human resources
Technical resources
Organizational climate Organizational structure
Organizational policies
Organizational culture
Organizational processes Operations
Procedures
Supervision
Personnel Sub-System Crew condition Cognitive factors
Physiological state
Personnel factors Crew interaction
Personal readiness
Technical System Usability Automation
Design
Availability Shortage of equipment
Unsuitable equipment
Non-existence of good equipment

4.1.2. Data sources for the review of HF-related publications. In order to carry out a
review of the content of HF-related publications and to compare them with submitted
documents to the IMO, two appropriate academic journals were selected as described
above. There are other journals with a publication history similar to Marine Policy.
However, the papers published are more related to marine environmental issues
rather than to maritime HFs. There are also a couple of more recent maritime
journals, such as the WMU Journal of Maritime Affairs. However, they have only
published for about 10 years, which does not allow for a study that covers the active
HF-related IMO times following the floundering of the Herald of Free Enterprise in
1987.
As far as IMO documents were concerned, all documents submitted to the IMO’s MSC
were analysed in this study. MSC is one of the parent bodies of the technical subcommit-
tees. It was therefore assumed that the documents submitted to MSC would automatically
reflect discussions in the other subcommittees, whether an issue of interest was discussed
under standards, training and watch-keeping, flag state implementation or a more techni-
cal agenda point. Since all subcommittees report back to MSC, relevant discussion items
in the different subcommittees will be visible in the documents coming from the sub-
committees to MSC.
 Maritime human factors and IMO policy 249

4.1.3. Methodology applied in the study. Two HF experts reviewed the contents of the
Journal of Navigation and Maritime Policy & Management from 1973 to 2012 and coded
all HF-related manuscripts according to the taxonomy introduced above. A manuscript
could be linked to several items of the taxonomy if it covered several HF-related aspects.
In order to increase the reliability of the coding process, the experts worked indepen-
dently. The results of the coding were subsequently compared, and in case of different
coding results, the different opinions were resolved through mutual discussions.
The same methodology was used for the coding of the documents submitted to IMO’s
MSC. Since the agenda item Human Element shows up in 1991 for the first time, it was
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decided that a full review of 40 years of IMO documents would not be necessary. The
coding was therefore only done for MSC documents between 1985 and 2012. It was
furthermore decided that a review of documents submitted before 1985 would only be
undertaken, if the review of the first 27 years left room for speculation.

4.2. Results of the review

The review of the HF-related content of the two journals identified 380 manuscripts from
the Journal of Navigation. They were coded and tabulated as 626 entries in the taxonomy.
The identified 133 manuscripts from Maritime Policy & Management resulted into 238
entries in the taxonomy. The review of the MSC documents identified 2158 HF-related
documents, which resulted into 6646 individual entries in the taxonomy. The problem
with the MSC documents was that there are years with two meetings and years with only
one meeting. While the alteration was more regular in recent years, there were periods
earlier without a regular meeting alteration. In order to allow a comparison with the
annually published content of the academic journals, it was decided to use average figures
in the years with more than one MSC meeting. As a result the original number of 6646
records in the taxonomy reduced to 4555 entries. The reduced number forms the basis for
the further analysis.
Table 3 shows the focus of HF-related publications and documents in the three data
sources. It should be kept in mind that the MSC documents cover a period of 27 years
only, while the journal review covers a 40-year period. Before the journal content is
commented on in more detail, some general comments about the MSC documents should
be made.
As shown in Figure 2, the review identified that HF-related documents in MSC
have a first peak in the years between 1991 and 1997. This is the period when MSC
introduced the term Human Element (HE) for the first time to its agenda and started a
follow-up to the Herald of Free Enterprise accident. The discussion in MSC resulted
in a number of previously mentioned instruments that were adopted by the IMO
assemblies in the years 1991 (17), 1993 (18), 1995 (19) and 1997 (20) (for an
overview about the discussions in the different committees and subcommittees and
the adopted instruments, see Eriksson and Mejia (2000)). Apart from the International
Safety Management (ISM) Code addressing important organizational conditions for
safe shipboard operations, the IMO HE vision was developed (IMO 1997, 2003a). The
HE vision in its revised form of 2003 is an ambitious document. It provides some kind
of a definition for the term HE in the principles section of the resolution. The HE is
referred to as a ‘complex multi-dimensional issue’, involving ‘the entire spectrum of
human activities performed by ships crews, shore-based management, regulatory
bodies, recognized organizations, shipyards, legislators, and other relevant parties, all
 250 J.-U. Schröder-Hinrichs et al.

Table 3. Summary of the coding results of the MSC documents and the journal manuscripts.

Journal of Maritime Policy &

Navigation Management IMO MSC

No Taxonomy No. % No. % No. %

E000 Environmental Context 158 25.2 85 35.8 1716 37.7

E101 Weather conditions 37 5.8 4 1.7 78 1.7
E102 Ergonomics 2 0.3 0 0 50 1.1
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E201 Financial situation of owner 6 1.0 28 11.8 5.5 0.1

E202 Market situation 1 0.2 5 2.1 0.5 0
E301 Flag state regulation 4 0.6 19 8.0 120.5 2.6
E302 International standards 102 16.3 23 9.7 1365.5 30.1
E 303 Port state regulations 6 1.0 6 2.5 96.5 2.1
O000 Organizational Infrastructure 31 5.0 62 26.1 1400.5 30.7
O101 Human resources 19 2.8 35 14.7 453 9.9
O102 Technical resources 1 0.2 5 2.1 356 7.8
O201 Organizational culture 1 0.2 0 0 27.5 0.6
O202 Organizational policies 2 0.4 13 5.5 105.5 2.3
O203 Organizational culture 1 0.2 1 0.4 65 1.4
O301 Operations 3 0.5 3 1.3 182.5 4.0
O302 Procedures 3 0.5 4 1.7 199 4.4
O303 Supervision 1 0.2 1 0.4 12 0.3
P000 Personnel Sub-System 106 16.9 67 28.1 518.5 11.4
P101 Cognitive factors 46 7.3 22 9.2 98.5 2.2
P102 Physiological state 22 3.5 9 3.8 147.5 3.2
P201 Crew interaction 10 1.6 21 8.8 93.5 2.1
P202 Personal readiness 28 4.5 15 6.3 179 3.9
T000 Technical System 331 52.9 24 10.0 920.5 20.2
T101 Automation 207 33.2 12 5.0 409 9.0
T102 Design 24 3.8 4 1.7 326.5 7.2
T201 Shortage of equipment 0 0 0 0 1 0
T202 Unsuitable equipment 71 11.3 7 2.9 168.5 3.7
T203 Non-existence of good equipment 29 4.6 1 0.4 15.5 0.3
Total 626 100 238 100 4555.5 100

of whom need to co-operate to address human element issues effectively’. This can be
seen as an indicator for the recognition of the socio-technical context of HFs. The
goals section of the same resolution defines the need to ‘conduct a comprehensive
review of selected existing IMO instruments from the human element perspective’. It
also refers to the promotion of safety culture and the provision of a ‘framework to
encourage the development of non-regulatory solutions and their assessment, on the
basis of human element principles’. In this respect, it should be recognized, for
example, that the discussions about the so-called large passenger vessels between
2000 (IMO 2000) and 2006 (IMO 2006a), as well as the review of the STCW
Convention in 2010 (IMO 2010a) were not accident driven. Whether this is a
confirmation of the new proactive way of addressing HF issues in IMO is difficult
to say at this point in time. The last accidents that had significant HF implications
were probably the tanker accidents of the Erika in 1999 and the Prestige in 2002,
which caused a review of the policies for granting places of refuge (IMO 2003b).
 Maritime human factors and IMO policy 251

400

350

300

250
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200

150

100

50

0
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Total (environmental) Total (organizational) Total (personnel) Total (technical)

Figure 2. Overview of the coding results of the MSC documents.

However, this was more a consideration of organizational rather than individual HFs.
Other accidents like the capsize of the ferry Le Joola off Gambia in 2002 or fire on
the ferry al-Salam Boccaccio 98 in the Red Sea in 2006 did not cause a major reaction
in IMO. This highlights the dilemma of the IMO Secretariat. The IMO Secretariat has
no influence on the agenda of a meeting. This depends on the member states and the
topics that they are willing to discuss. In the case of the Herald of Free Enterprise, the
UK recognized the importance of this accident and could convince the other member
states to carry out a systemic change of shipping operations through the ISM Code. In
case of other accidents, no such fundamental change happened at later occasions if
only maritime safety-related issues are concerned.
Other peaks in HF-related discussions can be seen in 2002, 2004, 2006 and 2011. The
discussions from 2002 to 2006 reflect another busy period of HF considerations. The
revised HE vision of the IMO is a significant outcome. This later on led to the IMO
strategy to address the HE (IMO 2006b). In 2005 and 2006, a number of interesting
documents were submitted to MSC targeting near misses (IMO 2006c), human-machine
interfaces (IMO 2006d), organizational factors (IMO 2006e) and leadership (IMO 2005).
However, the interest in HF has suddenly decreased afterwards. It is noteworthy that a
consultation proposal made by the ILO in 2008 on issues related to training, hours of
work and rest, manning levels, seafarer fatigue, carrier and skill development and
opportunities for seafarers’ employment was rejected (IMO 2008). The Joint MSC/
Marine Environment Protection Committee (MEPC) Working Group on HE in IMO
saw no need to establish a working group with the ILO as the issues are partly covered
by the Standards of Training and Watchkeeping (STW) Sub-Committee in IMO. In
 252 J.-U. Schröder-Hinrichs et al.

addition, the suggested terms of reference for such a working group were considered as
too ‘wide and open-ended’. HF considerations have not been on a very high level since
2008, even though interesting studies on human behaviour (IMO 2010b) and just culture
(IMO 2010c) were submitted for discussion. There is a peak in 2011. This mainly relates
to the implementation of the 2010 Manila Amendments to the STCW Convention. HE
was not an agenda item for MSC 89 (November 2011) and 91 (November 2012).
Figures 3 and 4 provide more information on organizational and personnel factors that
were coded during the MSC document review.
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In addition, Figure 5 shows the number of submitted papers under the agenda item HE
in the MSC. It illustrates the decreasing focus on HF-related items in recent years.
The IMO in its strategy (IMO 2006b) suggests in Section 5 feedback and continuous
improvement to periodically consider current information related to research in the field of
human factors and ergonomics. This is one of the reasons why the content analysis of the
manuscripts published in the two journals was made. The coding results are given in
Figures 6 and 7.
The content in the Journal of Navigation shows an expected pattern with dominating
technical issues in relation to HF issues. The content assigned to the Technical System part
of the taxonomy represents the majority (331 out of the total of 626 taxonomy entries) and
mainly relates to automation (207 taxonomy entries) and design (24 taxonomy entries). The
Technical System articles show an even distribution over the whole considered period of 40
years. What has changed is the focus of the manuscripts over the years from design
(ergonomics—such as the display of information on a radar screen) to automation
(human-machine interfaces—such as accidents with an automatic navigation system on

140

120

100

80

60

40

20

0
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012

Human resources Operations Procedures Organizational policies

Technical resources Organizational structure Organizational culture Supervision

Figure 3. Content of the MSC documents in the sub-category Organizational Infrastructure.

 Maritime human factors and IMO policy 253

70

60

50

40
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30

20

10

0
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Personal readiness Physiological state Crew interaction Cognitive factors

Figure 4. Content of the MSC documents in the sub-category Personnel Sub-System.

30

25

20

15

10

0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012

Figure 5. Average number of documents submitted to MSC under the agenda item Human
Element.

board a passenger ship). The other main categories of the taxonomy are represented to a
lesser degree. The second largest main category is Environmental Context (158 taxonomy
entries). The articles here mainly relate to international standards. There are not many
articles about personnel or organizational factors. In the beginning of the 1970s, the issue
 254 J.-U. Schröder-Hinrichs et al.

45

40

35

30

25
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20

15

10

0
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Total (environment) Total (organizational) Total (personnel) Total (technical)

Figure 6. Overview about the coding results of manuscripts published in the Journal of
Navigation.

20

18

16

14

12

10

0
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012

Total (environment) Total (organizational) Total (personnel) Total (technical)

Figure 7. Overview about the coding results of manuscripts published in Maritime Policy &
Management.
 Maritime human factors and IMO policy 255

of collisions and groundings was discussed in detail. However, these were mere observa-
tions of the trends and areas where collisions and groundings happened. The manuscripts
did not address the human involvement in the collisions and groundings. Manuscripts
focusing on these issues, such as the already-mentioned bridge automation system
(Lützhöft and Dekker 2002), represent exemptions in the content reviewed.
The analysis of the Maritime Policy & Management journal reveals no overall focus
either on the Environmental Context, the Organizational Infrastructure or the Personnel
Sub-System, but the journal pays less attention to the Technical System, which is to be
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expected. The Maritime Policy & Management journal shows a decline in the coverage of
maritime HFs in the beginning of the 1980s and then again after a peak in 2000. The
majority of the articles focus on the Environmental Context (85 out of the total of 238
taxonomy entries). In the early years, most of those articles focus on the ‘financial
situation of owners’, and subsequently the focus shifts to legal issues. The
Environmental Context is not evenly distributed over the years but has significant peaks
in 1978, to 1980 as well as from 1984 till 1990. After 1990, the Environmental Context is
still mentioned in articles but does not get the same attention as before. The
Organizational Infrastructure and the Personnel Sub-System receive comparable attention
with 67 and 62 articles, respectively, from a total of 238. Even with similar numbers, these
topics are not evenly distributed over the years but are concentrated in peaks. The articles
about Organizational Infrastructure peak in 1978–1980, 1989–1990, 1996, 1999–2001
and 2004–2005. The main topics within the Organizational Infrastructure are ‘human
resources’ and ‘organizational policies’. The Personnel Sub-System focuses primarily on
‘cognitive factors’ and ‘crew interaction’ and has three peaks in the years 1973–1975,
1978–1980 as well as 1999 and 2000. After the year 2000, the Personnel Sub-System is
not prominent anymore. The Technical System is not the main focus of the Maritime
Policy & Management journal with only 24 out of 238 articles. Articles on technical
issues depict a more or less equal distribution with only two major peaks in 1979 and
1980 as well as 2000 and 2001. The focus of those articles lies on ‘automation’ and
‘unsuitable equipment’. It is worth noting that within the technical issues, the focus of the
articles shifts from ‘automation’ to ‘design’ to ‘unsuitable equipment’ from 1973 to 1996
and thereafter the focus is on both ‘unsuitable equipment’ and ‘automation’. The content
analysis of the Maritime Policy & Management journal reveals an overall decline in the
coverage of maritime HFs.

4.3. Validity of the study

With regard to the validity of the data, a number of factors influenced the coding of the
IMO documents. When major IMO events occur, a number of submissions are made
related to these events. An example highlighting the consequences is the implementation
of the 2010 Manila Amendments to the STCW Convention. The interest in HF was
relatively low in the years the amendments were adopted. In 2011, however, a large
number of documents were submitted considering implementation issues related to those
amendments. If one only looks into the coding results without this information, it may
seem as if renewed interest for HF could be concluded from this peak. However, no HF-
related documents were otherwise submitted to MSC under the agenda item HE. In fact,
HE was not an agenda item in MSC 89 and 91. Despite this artificial peak, it is still
possible to look at the overall development of HF considerations at IMO.
 256 J.-U. Schröder-Hinrichs et al.

4.4. General trends identified

Given the remarks regarding the validity of the study, a couple of trends were identified
during the content analysis of the HF manuscripts and documents:
(1) It was not possible to establish a relationship between the journal publica-
tions and the IMO documents.
The topics of the papers published in the journals reviewed are independent from
the discussions in IMO. There are only a few instances where comments on IMO
discussions in the journals can be found. Research results are submitted to MSC.
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However, they often refer to research in non-maritime domains or were not

published in journals.
(2) The work in IMO in the 1990s was mainly accident driven.
The HF discussions started following the foundering of the Herald of Free
Enterprise in 1987. It took until 1991 for the term Human Element to be added
to the MSC agenda. In light of the findings of the Herald of Free Enterprise
accident investigation, a thorough review of potential HF-related implications
was carried out by different subcommittees working under MSC. The reviews
were finalized in 1997 and resulted in a number of revised regulations and
recommendations as well as a number of new resolutions. The HF-related
discussions have afterwards not continued on a similar high level.
(3) The majority of work related to HF at IMO was done between 1991 and
1997 and reflects mainly the state of the art at that time.
As stated before, the majority of HF-related discussions were carried out between
1991 and 1997. In this phase, academic work related to HF has been taken into
consideration. However, it reflects the state of the art of the early 1990s. The
IMO resolutions about casualty investigation refer to models of Reason (1990) or
Hawkins (1987). This represents the epidemiological view of accident causation.
Today, other approaches are available, but it does not look as if the casualty
guidance will be revised. On the contrary, it seems that no specific guidance is
given anymore in order to avoid that it becomes obsolete at one time in the
future. The accident investigation guidelines are only one example for HF-related
discussions. The ISM Code, for example, has not seen a major review following
its introduction in 1993, although the tanker industry has recently adopted the
Tanker Management and Self Assessment (TMSA) scheme (OCIMF 2008),
where compliance with the ISM Code is only considered level 1 out of four
possible levels to maintain safe operations on-board tankers. Other examples
could be quoted in this context.
(4) IMO follows an own routine in dealing with HF-related issues.
Once an agenda item is introduced in an IMO committee, it develops its own
dynamic. Committees only meet once or twice a year and refer items under
discussion to subcommittees for further analysis. This lowers the speed of
decision-making. In order to deliver the facts that allow for the formulation of
decisions at the highest level, that is, during the assembly every second year,
concentrated and coordinated efforts are needed. This may be one explanation
why topics treated by academics are not considered in an appropriate way.
Academic work is mainly taken into consideration, when the discussions in
IMO come to a point where academic backing is considered helpful. It is only
 Maritime human factors and IMO policy 257

then that a targeted search for information is carried out and member states
present samples of national research for further discussion and consideration in
IMO meetings.
(5) It was not possible to determine if the IMO has truly become proactive in
HF-related issues.
Recent years have fortunately not seen major accidents that required a HF-related
response at IMO. The 2010 Manila amendments of the STCW Convention
cannot be fully related to accidents. This could be seen as a positive sign. It
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will nevertheless require a few more years of evidence before it can be confirmed
that the IMO is now becoming truly proactive. It is slightly worrying that
documents related to leadership, just culture, etc., submitted in recent years
have not received the attention they should. One critical step to evaluate how
proactive IMO is will certainly be the follow-up to the Costa Concordia accident
last year.
Another comment should be made with respect to maritime HFs and related academic
publications. From the review of the journal content, the conclusion was drawn that they
only became ‘popular’ as a subject for publication more recently. The number of studies
and manuscripts related to maritime HFs in earlier years was not significant. This confirms
comments made by Moreby (1975), King (1979) or Hetherington, Flin, and Mearns
(2006). A search for the keyword ‘maritime human factors’ in ScienceDirect produces
hits mainly after 2000. Maybe, this is a trend where more academics realize that results
from other HF domains, such as aviation, cannot be transferred to the maritime context
without careful adaptations.

5. Discussion and conclusions

Decision-making, whether for regulations, safety, design, etc., must be based on a con-
ceptualization of the system for which the decisions are made. This is indeed a prerequi-
site to move from reactive to proactive regulation.
The current premise is that a system can be described in terms of its parts, and that their
functioning can be explained in terms of causes or factors. While this thinking has been
immensely successful and helped us to design, build and operate even very large and
complicated technological systems (with the possible exception of some cruise liners), it
does not work well to explain how humans and organizations interact, or indeed to explain
how complex socio-technical systems work. Despite that, nearly all industries and
domains continue to use design methods that reflect the conditions of the 1970s and
1980s, even though these are no longer valid. Whereas it was defensible 30–40 years ago
to focus on individual ‘components’, factors and functions, the nature of systems has
changed beyond recognition. Rather than being orderly and decomposable, systems are
now a ‘blooming, buzzing confusion’ made up of countless, interconnected systems. This
not only taxes each system’s ability to persevere but also challenges the appropriateness of
our design methods.
Thinking in terms of layered models, such as the onion model, will be inadequate for
future maritime activities (and may even be so for some today). It is a positive sign that
IMO recognizes the state of the art, even though changes could be faster. Good system
design and good regulations require the ability to ‘think big’ while ‘thinking small’
(Hollnagel 2006). They must at the same time ensure the stable functioning of the local
 258 J.-U. Schröder-Hinrichs et al.

system and the persistence and survival of the larger, global system. This requires not only
a revision of many commonly held design ideals, but also the development of methods
that do not have decomposition as their main principle. Humans are essential to make a
system work, but not just as a factor among other factors. Regulation and design instead
require a perspective that emphasizes the intrinsic ability of joint systems and organiza-
tions to adjust their functioning prior to, during or following changes and disturbances, so
that they can sustain required operations under both expected and unexpected conditions.
The role of human factors in maritime policy must go beyond the classical human factor,
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as in the Människa-Teknik-Organisation (MTO; swedish meaning Human-Technology-

Organization) thinking (Hollnagel 2010), and recognize that humans are necessary to
ensure that systems work and that things go right. Only in this way can we become
genuinely proactive and think of wholes rather than of parts.
The Herald of Free Enterprise was in many ways a turning point in the maritime safety
regulations as discussed in IMO. Prior to this accident, the related follow-up to an accident
was mainly done by new technical requirements hoping to cover the identified safety
problem. It seems, however, that this accident made clear that such an approach only had
a limited potential. Instead, a focus on the human operator and a consideration of the human
and organizational factors was needed. This realization was manifested by the adoption of
the ISM Code (IMO 1993), the introduction of formal safety assessment (FSA) as part of
the IMO rule-making process (IMO 2002) or the provision of guidelines for the investiga-
tion of HF aspects in maritime accidents (IMO 1999). IMO went even a step further and
introduced a Human Element (HE) vision for the work of the organization (IMO 1997,
2003a). This acknowledges the importance of this issue vis-à-vis maritime safety and clearly
addresses the complexity of human and organizational factors in a maritime context. As
such, it could be seen as a starting point where IMO may identify HF-related safety issues in
a more proactive way. In fact, it could be argued that a reactive approach was unavoidable at
the beginning of the IMO activities as there was no adequate system of international treaties
dealing with all relevant aspects of maritime safety. With the full spectrum of IMO
instruments now at hand, it should be easier to be proactive. The day-to-day business is
not characterized by loopholes in the legislative framework anymore. Thus, time-consuming
treaty negotiations may be less and less an issue. Instead, there should be time to identify
proactively issues that require action from IMO member states. The 2010 amendments of
the STCW Convention is an example for a revision of a major IMO instrument that does not
seem to have its roots in maritime accidents (IMO 2010a). It is hoped that more instruments
will confirm the proactive developments in IMO in future years.

References
Badge-Schaub, P., K. Lauche, and G. Hofinger. 2012. Human Factors—Psychologie Sicheren
Handelns in Risikobranchen. Berlin: Springer.
Edwards, E. 1972. “Man and Machine: Systems for Safety.” In Proceedings of British Airline Pilots
Association Technical Symposium, 21–36. London: British Airline Pilots Association.
Eriksson, P., and M. Mejia. 2000. IMO’s Work on the Human Element in Maritime Safety. Lund
University Centre for Risk Analysis and Management Report 2003. Lund: Lund University.
Grech, M. R., T. J. Horberry, and T. Koester. 2008. Human Factors in the Maritime Domain. Boca
Raton, FL: CRC Press.
Hawkins, F. H. 1987. Human Factors in Flight. Aldershot: Ashgate.
 Maritime human factors and IMO policy 259

Hetherington, C., R. Flin, and K. Mearns. 2006. “Safety in Shipping: The Human Element.” Journal
of Safety Research 37: 401–411.
Hollnagel, E. 2006. “Thinking Big When Thinking Small: Coping with the Complexity of
Interaction Design”. In Proceedings of the 7th Asia-Pacific Computer Human Interaction
Conference (APCHI 2006), Taipei, October 11–14.
Hollnagel, E. 2010. “The Diminishing Relevance of Human-Computer Interaction.” In Handbook of
Human-Machine Interaction, edited by G. A. Boy, 417–430. Farnham: Ashgate.
Hollnagel, E., J. Paries, D. D. Woods, and J. Wreathall. 2011. Resilience Engineering in Practice: A
Guidebook. Farnham: Ashgate.
Health, Safety and the Environment (HSE). 1997. Successful Health and Safety Management. HSG
Downloaded by [World Maritime University], [Jens-Uwe Schröder-Hinrichs] at 00:30 20 May 2013

65. Sudbury: HSE Books.

IMO. 1993. International Management Code for the Safe Operation of Ships and for Pollution
Prevention (International Safety Management (ISM) Code). IMO Document Res. A.741(18)
Adopted November 4, 1993. London: IMO.
IMO. 1997. Human Element Vision, Principles and Goals for the Organization. IMO Document
Res. A850(20) Adopted November 27, 1997. London: IMO.
IMO. 1999. Amendments to the Code for the Investigation of Marine Casualties and Incidents
(Resolution A.849(20)). IMO Document Res. A.884(21) Adopted November 25, 1999. London:
IMO.
IMO. 2000. Enhancing the Safety of Large Passenger Ships. Note by the Secretary General. IMO
Document MSC 72/21 Dated December 1, 2000. London: IMO.
IMO. 2002. Guidelines for Formal Safety Assessment (FSA) for Use in the IMO Rule-Making
Process. IMO Document MSC/Circ. 1023 Dated April 5, 2002. London: IMO.
IMO. 2003a. Human Element Vision, Principles and Goals for the Organization. IMO Document
Res. A947(23) Adopted November 27, 2003. London: IMO.
IMO. 2003b. Guidelines on Places of Refuge for Ships in Need of Assistance. IMO Document Res.
A949(23) Adopted December 5, 2003. London: IMO.
IMO. 2005. Assessment of the Impact and Effectiveness of Implementation of the ISM Code. Note by
the Secretariat. IMO Document MSC 81/17/1 Dated December 21, 2005. London: IMO.
IMO. 2006a. Report of the Maritime Safety Committee on Its Eighty-First Session. IMO Document
MSC 81/25 Dated May 24, 2006. London: IMO.
IMO. 2006b. The Organization’s Strategy to Address the Human Element. IMO Document MSC-
MEPC.7/Circ.4 Dated May 22, 2006. IMO: London.
IMO. 2006c. Using ‘Near Miss’ Information in Support of the Human Element. Submitted by the
United Kingdom. IMO Document MSC 82/INF. 8 Dated September 26, 2006. London: IMO.
IMO. 2006d. Research into Interaction with Automated Systems. Submitted by the United Kingdom.
IMO Document MSC 82/15/2 Dated August 18, 2006. London: IMO.
IMO. 2006e. Research into the Influence of the Organizational Structures on Safety Management
Performance. Submitted by the United Kingdom. IMO Document MSC 82/15/3 Dated August
18, 2006. London: IMO.
IMO. 2008. ILO Proposal for Inter-Secretariat Consultations on the Possible Common Areas of the
Human Element to Be Discussed by ILO and IMO. Note by the Secretariat. IMO Document
MSC 85/16 Dated October 17, 2008. London: IMO.
IMO. 2010a. Adoption of the Final Act and Any Instruments, Resolutions and Recommendations
Resulting from the Work of the Conference. IMO Document STCW/CONF.2/32 Dated July 1,
2010. London: IMO.
IMO. 2010b. A Guide to Human Behaviour in the Shipping Industry. Submitted by the United
Kingdom. IMO Document MSC 87/INF 10 Dated March 8, 2010. London: IMO.
IMO. 2010c. Just Culture – Essential for Safety. Submitted by the United Kingdom. IMO Document
MSC 88/16/1 Dated August 20, 2010. London: IMO.
International Conference on Safety at Sea. 1914. London: H.M. Stationary Office.
Jørgensen, K. 2002. En taxonomi for Arbejdsulykker – en systematisk beskrivelse af
årsagssammenhæng. BYG-DTU Report R-027. Copenhagen: Technical University of Denmark.
King, J. 1979. “The Adequacy of Ships and the Competence of Seaman.” Maritime Policy &
Management 6 (1): 1–3.
 260 J.-U. Schröder-Hinrichs et al.

Lundberg, J., C. Rollenhagen, and E. Hollnagel. 2009. “What-You-Look-For-Is-What-You-Find—

The Consequences of Underlying Accident Models in Eight Accident Investigation Models.”
Safety Science 47: 1297–1311.
Lützhöft, M., and S. W. A. Dekker. 2002. “On Your Watch: Automation on the Bridge.” Journal of
Navigation 55 (1): 83–96.
Moreby, D. 1975. The Human Element in Shipping. Colchester: Seatrade Publication.
Morrison, W. S. G. 1997. Competent Crews = Safer Ships—An Aid to Understanding STCW 95.
Malmö: WMU Publications.
Mukherjee, P. K. 2002. Maritime Legislation. Malmö: WMU Publications.
Oil Companies International Marine Forum (OCIMF). 2008. Tanker Management and Self
Downloaded by [World Maritime University], [Jens-Uwe Schröder-Hinrichs] at 00:30 20 May 2013

Assessment 2. Bermuda: OCIMF.

O’Neil, W. A. 2011. “Raising World Maritime Standards.” Maritime Policy & Management 31 (1):
83–86.
Perrow, C. 1984. Normal Accidents—Living with High-Risk Technologies. New York: Basic Books.
Psaraftis, H. N. 2002. “Maritime Safety: To Be or Not To Be Proactive.” WMU Journal of Maritime
Affairs 1 (1): 3–16.
Reason, J. 1990. Human Error. Cambridge: Cambridge University Press.
Schröder, J. U. 2003. “The Human Element (HE) in Marine Casualties—Are We Prepared to
Address the Real Issues?” In Risk and Safety Management in Industry, Logistics, Transport
and Military Service: New Solutions for the 21st Century, 48–53. Tallinn: Technical University.
Schröder, J. U. 2004a. “SEMOMAP—A SEquential MOdel of the Maritime Accident Process.” In
Human Error, Safety and Systems Development, edited by C. W. Johnson, and P. Palanque, 239–
253. Boston, MA: Kluwer Academic Publishers.
Schröder, J. U. 2004b. Datenerfassung bei Unfallursachen und begünstigenden Faktoren für
Unfälle in der Seeschifffahrt [Data collection at accident causes and contributing factors of
accidents in the maritime]. Bremerhaven: Wirtschaftsverlag NW Verlag für neue Wissenschaft.
Schröder-Hinrichs, J. U., M. Baldauf, and K. T. Ghirxi. 2011. “Accident Investigation Reporting
Deficiencies Related to Organizational Factors in Machinery Space Fires and Explosions.”
Accident Analysis and Prevention 47 (10): 1187–1196.
Schröder-Hinrichs, J. U., E. Hollnagel, and M. Baldauf. 2012. “From Titanic to Costa Concordia—
A Century of Lessons Not Learned.” WMU Journal of Maritime Affairs 11 (2): 151–167.
Shapell, S. A., and D. A. Wiegmann. 2001. “Applying Reason: The Human Factors Analysis and
Classification System (HFACS).” Human Factors and Aerospace Safety 1: 59–86.
Stanton, N. 1996. Human Factors in Nuclear Safety. London: Taylor & Francis.
United Nations. 1958. “No. 4214. Final Act of the United Nations Maritime Conference. Done at
Geneva, on 6 March 1948.” United Nations – Treaty Series 289: 3–109.
United Nations. 1984. “No. 23001. International Convention on the Standards of Training,
Certification and Watchkeeping for Seafarers, 1978.” United Nations – Treaty Series 1361:
190–298.