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1 INTRODUCTION
Human operators play crucial roles in the safe,
resilient, and efficient conduct of maritime and air
transport operations. Maritime and aviation, like
other safety-critical industries, expose their human
operators to high risks because of the complexity of
the industries and working environments. These high-
risk environments, far from becoming safe, pose new
risks to human operators. It has been evidenced that
impacts of human factors (HF) on safety will probably
evolve and become more prominent due to aspects
such as increased automation, unmanned vessels and
aircraft, and the trend to harmonise modes of
transport’ practices among others. Moreover, new
technology and more automation change human
work, which leads to new kinds of “human error”
[15]. Consequently, new dimensions to the risk of
accidents and system breakdowns appear,
transforming human-machine interfaces and creating
opportunities for more and “novel “risks, even risks
we are not able to identify yet. The COVID-19 is a
clear example of how the supply chain can be
unexpectedly affected by new risks in which human
operators play a central role as part of the whole
system.
There is a need in the shipping and aviation
industries to compile and analyse a large quantity of
global real-world accident, incident, near-miss, and
other safety event data with the aim of effectively
managing human risk factors and producing cross-
domain learning. Those data should derive in
capturing systematically all contributing factors to
accidents, beyond proximal or imminent causes
referring to actions or omissions by operators. Those
data should also bring learning to be used not just to
improve training and changing procedures of
Effective Learning from Safety Events Reporting Takes
Two: Getting to the Root & Just Culture
M. Carrera Arce & R. Baumler
World Maritime University, Malmö, Sweden
ABSTRACT: SAFEMODE is an EU-funded project under the Horizon 2020 programme. The project brings
together experience from the whole safety value chain including manufacturers, service providers, regulators,
academia, and small-medium enterprises. This paper focuses on two core aspects the project is addressing: 1)
the systematic collection, analysis, and categorization of Human Factors (HF) data from maritime and aviation
safety events, and 2) the development of a Just Culture framework for maritime to encourage reporting of safety
events and learning from them, and at which respondents feel they are treated in a fair and just manner when
reporting. Learning from safety events is only possible if root causes of accidents and incidents are properly and
systematically identified, analysed, and categorized, and reporters know that reporting is a “safe” and beneficial
practice. The implementation of these two outcomes as part of the institutionalization strategy of the project
includes recommendations to industry guidance and practice and proposals to the International Maritime
Organization (IMO).
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 15
Number 2
June 2021
DOI: 10.12716/1001.15.02.08
332
operators who cope with usually poorly design
systems, but also to develop methodologies and
practices that integrate HF in the design and safety
assessment stages.
“Human errors” are often reported as the main
cause or contributor to maritime and airline accidents
[1]. For maritime, in the literature, more than 80% of
shipping accidents are attributed to “human error”.
About 75-96% of the marine accidents are caused, at
least in part, by some form of “human error” [8].
Human and organizational factors are involved in
most of maritime accidents, but the human element
has not been evolving in the same way as technology
[26]. For aviation, “human error” is also identified, at
least in part, as a contributory or causal factor in 60-
80% of aviation accidents [24]. However, for both
domains, “human error” is not just about human
operators and their individual characteristics, but
about how other elements of people’s jobs, working
environments and organizations they work in
influence systematically their performance [5].
The approach used for understanding and
investigating why casualties occur determines the
focus either on the individual or on the system and as
a result, the information investigated. Behavioural-
based safety management approaches are widespread
in all kinds of organizations and their limitations have
been described in shipping [3, 13]. These approaches
stress people’s behaviours and individual differences,
which are usually indicated as the causes of accidents
and the target of casualty investigations. A behaviour-
based safety approach establishes a causal
relationship between the unsafe act and its imminent
cause, and this is clearly insufficient [5]. Casualty
investigations collect imminent or proximal causes of
accidents and incidents but do not systematically
capture root-latent causes or contributors beyond
unsafe behaviours. Alternatively, to a behavioural-
based safety management, the system approach
includes all those elements that affect people’s work,
including human, social, environmental, working and
organizational factors. Under the system approach
casualty investigations would explore all these factors
as contributors to accidents beyond “human error”, so
it would not limit accidents to people’s behaviour but
include all those features connected to behaviour
including tools, tasks, and operating and
organizational environment.
However, there is still scarce human and
organizational data derived from accident
investigations and safety events reporting. Research-
based evidence has highlighted the role of human and
organizational factors in this respect as previously
described. The U.S. National Transport Safety Board
(NTSB) has concluded recently in a report on the most
important lessons learned from marine accident
investigations completed during 2019 that 1 in 3
accidents in shipping is caused by insufficient
organizational oversight [17]. In a review of accident
investigation reports, Schröder-Hinrichs et al. [23]
concluded that organizational factors were not
identified by maritime accident investigators to the
extent expected had the IMO guidelines been
observed. Instead, contributing factors at the lower
end of organizations are over-represented. This
scarcity of good HF data derived from safety events
affects the effective loops from design back into end
users. Hence, the SAFEMODE project is conducting a
systematic identification, collection, and analysis of
these human and organizational factors and apply
them to the design and safety assessment stages.
2 SAFEMODE PROJECT: SUPPORTING THE
HUMAN ELEMENT
The SAFEMODE project is a three-year Research and
Innovation Action project funded under the Horizon
2020 programme (http://www.safemodeproject.eu/).
The project is being conducted by a consortium of
partners from maritime and aviation, from Europe
and outside Europe, and includes service providers,
builders, shipping companies and manufacturers,
academia, European safety agencies, and small and
medium enterprises.
The main aim of the project is to develop a novel
Human Risk-Informed Design (HURID) framework in
order to identify, collect and assess data for Human
Factors in a systematic way. HURID will offer tools
and data for designers and risk assessors, enabling
them to take human factors risk-based considerations
when designing transport systems and operations.
SAFEMODE strengthens synergies between the
aviation and maritime transport sectors in order to
create shared methodologies for capturing Human
Factors.
The objectives of the project include:
− Create a Safety Human Incident & Error Learning
Database (SHIELD) for the maritime and aviation
sector.
− Create tools and methodologies for assuring
human performance.
− Create HURID, a Human Risk-Informed Design
framework to support designers in Human Factors
analysis in design and operations.
− Customize HURID to the specific characteristics of
both domains.
− Create a Just Culture framework that will facilitate
better reporting and learning from safety incidents
and accident.
− Exploit project results by supporting Regulatory
Framework developments in the industry.
Figure 1. SAFEMODE diagram-main developments.
The two developments introduced in the paper are
key for effective learning from safety events data; and
include the development of a Just Culture and the
systematic capture and analysis of human and
organizational factors because of accidents, incidents,
near-miss and other safety events reporting:
333
Human and organizational factors data. Casualty
Investigation reports contain mostly “human error”
and contributing factors at the sharp end, but not
deeper and latent causes contributing to accidents.
This information must be compiled and analysed
systematically to capture root causes beyond
operators’ failure. So the question is how to get to the
root of accidents and derive effective learning?
A Just Culture in maritime. If people feel that
reporting leads to punishment, they are not being
treated consistently and fairly or they do not trust the
system they will be unlikely to report. If there is not
reporting of near-misses or events, there is no data. If
the reporting is not honest, the data obtained is not
effective and meaningful. Hence, if reporting is
compromised there will not be learning. Contrary to
maritime, Just Culture is embedded in most aviation
organisations, which allows facilitating honest
reporting and learning from safety concerns, and
criminalization is extremely rare. This contrasts with
Maritime, so the question is whether Maritime could
benefit from Just Culture?
2.1 Human Factors Taxonomy and systematic analysis of
safety events
Identifying the root causes of incidents is essential for
the prevention of accidents in the future. The Casualty
investigation Code (MSC.255(84)) section 16.5 [9]
provides valuable guidance:
“Proper identification of causal factors requires
timely and methodical investigation, going far beyond
the immediate evidence and looking for underlying
conditions, which may be remote from the site of the
marine casualty or marine incident, and which may
cause other future marine casualties and marine
incidents. Marine safety investigations should
therefore be seen as a means of identifying not only
immediate causal factors but also failures that may be
present in the whole chain of responsibility.”
However, root cause analysis in incident
investigations must avoid the assumption that
accidents will have one particular, identifiable, and
single “root” cause, but multiple causes [5, 25]. Hence,
root cause analysis should aim to bring together a
large number of contributory factors as root causes,
which are rarely active failures but latent conditions
over which we have control [5]. Further that, the
purpose of root cause analysis is not (primarily) to
identify causes, but to identify solutions to system
design flaws (and thereby prevent accidents).
SAFEMODE is using a systems approach to
explore and capture systematically contributing
factors of accidents. A unified HF taxonomy for
maritime and aviation has been developed. The
taxonomy de-codifies the HF iceberg (Figure 2) to
make sure that all HF data are identified, analysed,
and classified.
The taxonomy is the core of the Safety Human
Incident & Error Learning Database (SHIELD) and
describes the data elements and their relations. For the
occurrences that will be gathered in SHIELD, at the
highest level three classifications are used: 1)
Occurrence facts, describing facts of the occurrence,
such as location, date, injuries, type of vehicle,
involved actors, and contextual conditions. 2)
Occurrence assessment, describing the classification of
the severity and the types of human factors that
contributed to the occurrence. 3) Safety positive
actions and learning, describing actions of human
operators and/or technical systems that prevented
occurrences getting worse (accident prevention) or
that limited the consequences of an accident
(consequences mitigation), and describing lessons
learned following a safety occurrence, e.g. changes in
system design, training or procedures.
Figure 2. Human Factors Iceberg-SAFEMODE project.
The methodology applied to develop the HF
taxonomy initially includes a comprehensive review
of Safety Occurrence Reporting and Analysis systems
(SORAS) adopted in safety-critical industries. The
taxonomy has been drawn on the review and analysis
of 16 taxonomies from maritime, aviation, railway,
nuclear, and space domains. The layers were defined
after an extensive literature review and largely based
on HERA, HFACS, TRACEr, HEIST, and
NASAHFACS. The taxonomy is unified for maritime
and aviation to facilitate cross-domain learning. This
implies not that has been imported from marine to
aviation or vice versa but it has been made sufficiently
generic to be applicable to both domains, but
considering domain specificities.
The SHIELD HF taxonomy includes four layers
(see Figure 3), describing acts by human operators
that contributed to an occurrence, preconditions
affecting human performance, supervision issues, and
organizational aspects. It is a layered HF taxonomy
that enriches other existing taxonomies by capturing
along with individual aspects, contextual and
organizational factors.
Figure 3. SAFEMODE Human Factors Taxonomy.
334
It is been designed to adapt to different users
including frontline operators, designers and casualty
investigators among others end-users.
2.2 Implementing a Just Culture in Maritime
The report on the investigation of the fatal crush
accident on the general cargo vessel Karina C at
Seville (Spain) on 24 May 2019 concluded that the lack
of Just Culture was one of the safety issues (not
directly) contributing to the accident that was
addressed or resulted in recommendations:
“The vessel did not appear to have a Just Culture
in that the crew did not report such a serious accident
to the shore-based senior management.” [16]
Underlying causes of accidents are not
systematically captured in all accident investigations,
and the above report is a good example of the value of
understanding the causes of safety occurrences by
focusing on why people did what they did, not
judging them for what they did not do. In fact, there
was a delay of 4½ months in reporting the accident as
it was initially considered to have been due to a
medical event. Consequently, the company was
prompted to take action and update its SMS and
company procedures to ensure all serious incidents
are fully investigated until the underlying causes are
established.
Investigations, usually, focus on operator error or
technical failures, while ignoring other systemic
causal factors which are also the most likely to be left
out of accident reports [14]. Examples like the one
described in which deep causes of accidents are
captured (i.e., safety culture and other organizational
and human factors) are scarce. A Just Culture is not
probably identified in other accident reports because
is not extensively implemented in the maritime
organizations despite a key feature of a good SMS is
an open and Just Culture of reporting accidents and
incidents. Other reasons involve the HF training in
event investigations and resources and commitment
to thorough investigations.
In aviation, Just Culture is not new and has been
embedded, both implicitly and explicitly, within
aviation legislation for many years. It has been
successfully implemented in the aviation industry to
improve the level of safety aspects of organizations. A
Just Culture is one aspect of a safety culture and the
prerequisites to achieve a Just Culture include
independence, feedback, acknowledgment, ease of
reporting, motivation to report, and trust [7] (Figure
4).
Figure 4. Pre-requisites of a Just Culture. Adapted from
Eurocontrol [7].
Aviation adopts the definition of Just Culture
provided by the European Commission (Regulation
376/2014) [21] as ‘A culture in which front-line
operators or other persons are not punished for
actions, omissions or decisions taken by them that are
commensurate with their experience and training, but
in which gross negligence, willful violations and
destructive acts are not tolerated.’ What is needed for
a “Just Culture”, is an atmosphere of trust in which
people are encouraged, even rewarded, for providing
essential safety-related information, but in which they
are also clear about where the line must be drawn
between acceptable and unacceptable behaviour [20].
Just Culture builds a trusting atmosphere where
employees have the assurance to report safety events
without fear of blame. Employees must believe that
they will not be punished, the report will be
confidential and that the information they submit will
be acted upon, otherwise they will decide that there is
no benefit in their reporting [19]. The challenge is to
create a culture of accountability that encourages
learning [5].
Contrary to what exists in the aviation industry,
the quasi-absence of a Just Culture in shipping affects
any form of reporting requirements [27]. One of the
recommendations of the report “A Culture of
Adjustment” produced by WMU [27] refers to
companies’ promotion of the concept of a Just Culture
to strengthen their reporting systems. These reporting
systems would include all kinds of reporting such as
work and rest hours but also near-miss, incidents and
accidents and others.
In maritime (MSC-MEPC.7/Circ.7 – Guidance on
Near-miss reporting, paragraphs 1.3 and 1.4) a
definition of "Just Culture" features an atmosphere of
responsible behaviour and trust whereby people are
encouraged to provide essential safety-related
information without fear of retribution. However, a
distinction is drawn between acceptable and
unacceptable behaviour [10].
Just Culture is the essential component
underpinning safety and business success [12] and its
implementation and enforcement in maritime has
become more necessary now than ever before.
Effective Just Culture can lead to significant
improvements in organizational performance and
safety, which requires an effective safety information
system and trust of the workforce. In turn, this
depends on a culture that is, and is believed to be,
335
open and fair, i.e. "Just" [11, 12]. Consequently,
incentivizing seafarers’ feedback and incorporating
their views in safety are necessary to enhance safety in
shipping and close the gap between shore and ships
[2].
Building confidence between seafarers and
management and mutual understanding and
engagement is a necessary condition for
implementing a Just Culture [27]. Lack of trustful
relationships and blame culture in the industry are
probably the main barriers to the adoption of a Just
Culture as identified in previous studies. The amount
of trust between workers and their management is an
important element in the successful adoption of
effective reporting concerning their purpose and use
[4]. When companies fire employees who talk about
what they think is “right,” the consequences include
not just losing a good worker but also generating a
lack of trust in other employees [5]. Seafarers who
think that having disagreements with their managers
would result in future sanctions such as losing their
jobs discourage them from sharing information [22].
Because of a poor Just Culture, the lack of
reporting becomes a significant problem faced by the
maritime industry. Factors related to incidents and
accidents reporting frequency include a trusting
relationship among the crew, safety-oriented ship
management, and feedback on reported events,
among others [18]. Bhattacharya’s work [3] found that
employees' fear of losing jobs was a primary aspect
for not reporting incidents, which makes the incident
reporting clearly ineffective. The biggest challenge to
enhance trust is to change the culture of blame, where
mistakes are seen as failures but not as learning
opportunities to prevent future incidents. Moreover,
learning from every accident as a result of safety
information provided by reports and feedback
established is not well developed in the maritime
industry [6]. Indeed, to build trust, efforts are needed,
such as involving and empowering employees and
promoting their responsibility [20].
SAFEMODE project is analysing if the maritime
industry needs a Just Culture and the benefit of it by
conducting qualitative research through interviewing
seafarers and casualty investigators (both at flag and
organizational levels) mainly from Europe but also
outside Europe. Focus groups are also being
conducted to capture insights from trade unions,
training colleges, shipping companies, regulatory
bodies and policy makers.
Preliminary results indicate the existing
disconnection and mistrust between shore
management and ships, the fear of reprisals or
unwarranted sanctions of seafarers, and the scarce use
of reporting for learning purposes in most cases,
aspects all previously mentioned as fundamental in
Just Culture. The maritime industry for effective
learning needs an effective reporting culture, which
cannot exist without an effective Just Culture.
3 CONCLUSIONS
Maritime investigations teach us lessons by issuing
and reiterating safety recommendations until safety
improvements become realities onboard vessels.
However, many accident lessons have unfortunately
seen before [17]. SAFEMODE project developments
aim to contribute to safety reporting and analysis at
European and international levels. Two main
outcomes of the project concern a unified HF
taxonomy for maritime and aviation and a Just
Culture analysis in maritime.
The advantages of a unified HF taxonomy that
captures systematically individual, contextual, and
organizational factors involved in casualties and near-
misses for maritime and aviation include: 1) thorough
consideration of underlying factors contributing to
safety concerns beyond “human error”, 2) cross-
domain learning, and 3) harmonization of HF
solutions through modes of transport.
On the other hand, a Just Culture is far from being
a reality in maritime. Its implementation and
enforcement becomes more necessary now than ever
before, and then SAFEMODE is conducting work to
revitalize this strategic discussion. In the same way as
the aviation does, the maritime industry needs to
adopt a culture of learning from incidents based on an
effective Just Culture.
The implementation of these two outcomes as part
of the institutionalization strategy of the project
includes improved industry guidance and practice
and proposals to the IMO.
ACKNOWLEDGMENTS
This work is supported by the European Commission by
Horizon2020 project “SAFEMODE: Strengthening Synergies
between Aviation and Maritime in the area of Human
Factors toward achieving more Efficient and Resilient
MODE of transportation” (GA n. 814961).
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