Bowtie models as preventive models in maritime safety

Aquest treball ha sorgit d’una proposta del Dr. Rodrigo de Larrucea que ha acabat de publicar un llibre ambiciós sobre Seguretat Marítima. Com ell mateix diu, el tema “excedeix amb molt les potencialitats de l’autor”, així que en el meu cas això és més cert. Es pot aspirar, però, a fer una modesta contribució a l’estudi i difusió de la seguretat de la cultura marítima, que només apareix a les notícies quan tenen lloc desastres molt puntuals. En qualsevol cas, el professor em va proposar que em centrés en els Bowtie Models, models en corbatí, que integren l’arbre de causes y el de conseqüències (en anglès el Fault Tree Analysis, FTA, i l’Event Tree Analysis, ETA). Certament, existeixen altres metodologies i aproximacions (i en el seu llibre en presenta vàries, resumides), però per la seva senzillesa conceptual i possibilitat de generalització i integració dels resultats era una bona aposta. Així, després d’una fase de meditació i recopilació de informació, em vaig decidir a presentar un model en corbatí molt general on caben les principals causes d’accidents (factores ambientals, error humà i fallada mecànica), comptant també que pot existir una combinació de causes. De tota manera, a l’hora d’explotar aquest model existeix la gran dificultat de donar una probabilitat de ocurrència, un nombre entre 0 i 1, a cada branca. Normalment les probabilitats d’ocurrència són petites i degut a això difícils d’estimar. Cada accident és diferent, de grans catàstrofes n’hi ha poques, i cada accident ja és estudiat de manera exhaustiva (més exhaustiva quan més greu és). Un altre factor que dificulta l’estima de la probabilitat de fallada és l’evolució constant del món marítim, tant des del punt de vista tècnic, de formació, legal i fins i tot generacional doncs cada generació de marins és diferent. Els esforços estan doncs enfocats a augmentar la seguretat, encara que sempre amb un ull posat sobre els costs. Així, he presentat un model en corbatí pel seu valor didàctic i gràfic però sense entrar en detalls numèrics, que si s’escau ja aniré afinant i interioritzant en l’exercici de la professió. En aquest treball també he intentat no mantenir-me totalment al costat de la teoria (ja se sap que si tot es fa bé, tot surt perfecte, etc…) sinó presentar amb cert detall 2 casos ben coneguts d’accidents marítims: el petroler Exxon Valdez, el 1989 i el ferry Estonia en 1994, entre altres esmentats. Són casos ja una mica vells però que van contribuir a augmentar la cultura de la seguretat, fins a arribar al nivell del que gaudim actualment, al menys als països occidentals. Doncs la seguretat, com esmenta Rodrigo de Larrucea “és una actitud i mai és fortuïta; sempre és el resultat d’una voluntat decidida, un esforç sincer, una direcció intel·ligent i una execució acurada. Sens lloc a dubtes, sempre suposa la millor alternativa”. The work has been inspired in its initial aspects by the book of my tutor Jaime Rodrigo de Larrucea, that presents a state of the art of all the maritime aspects related to safety. Evidently, since it covers all the topics, it cannot deepen on every topic. It was my opportunity to deepen in the Bowtie Model but finally I have also covered a wide variety of topics. Later, when I began to study the topics, I realized that the people in the maritime world usually do not understand to a great extent statistics. Everybody is concerned about safety but few nautical students take a probabilistic approach to the accidents. For this it is extremely important to study the population that is going to be studied: in our case the SOLAS ships Also, during my time at Riga, I have been very concerned with the most diverse accidents, some of them studied during the courses at Barcelona. I have seen that it is difficult to model mathematically the accidents, since each one has different characteristics, angles, and surely there are not 2 equal. Finally, it was accorded that I should concentrate on the Bowtie Model, which is not very complex from a statistical point of view. It is simply a fault tree of events model and a tree of effects. I present some examples in this Chapter 2. The difficulty I point out is to try to estimate the probabilities of occurrence of events that are unusual. We concentrated at major accidents, those that may cause victims or heavy losses. Then, for the sake of generality, at Chapter 4, I have divided the causes in 4 great classes: Natural hazards, human factor, mechanical failure and attacks (piracy and terrorism). The last concern maybe should not be included beside the others since terrorism and piracy acts are not accidents, but since there is an important code dedicated to prevent security threats, ISPS, it is example of design of barriers to prevent an undesired event (although it gives mainly guidelines to follow by the States, Port Terminals and Shipping Companies). I have presented a detailed study of the tragedy of the Estonia, showing how a mechanical failure triggered the failure of the ferry, by its nature a delicate ship, but there were other factors such as poor maintenance and heavy seas. At the next Chapter, certain characteristics of error chains are analyzed. Finally, the conclusions are drawn, offering a pretty optimistic view of the safety (and security) culture at the Western World but that may not easily permeate the entire World, due to the associated costs

An analytic framework to assess organizational resilience

Background: Resilience Engineering is a paradigm for safety management that focuses on coping with complexity to achieve success, even considering several conflicting goals. Modern socio-technical systems have to be resilient to comply with the variability of everyday activities, the tight-coupled and underspecified nature of work and the nonlinear interactions among agents. At organizational level, resilience can be described as a combination of four cornerstones: monitoring, responding, learning and anticipating. Methods: Starting from these four categories, this paper aims at defining a semi-quantitative analytic framework to measure organizational resilience in complex socio-technical systems, combining the Resilience Analysis Grid (RAG) and the Analytic Hierarchy Process (AHP). Results: This paper presents an approach for defining resilience abilities of an organization, creating a structured domain-dependent framework to define a resilience profile at different levels of abstraction, to identify weaknesses and strengths of the system and thus potential actions to increase system’s adaptive capacity. An illustrative example in an anaesthesia department clarifies the outcomes of the approach. Conclusions: The outcome of the RAG, i.e. a weighted set of probing questions, can be used in different domains, as a support tool in a wider Safety-II oriented managerial action to bring safety management into the core business of the organization

Road traffic safety for work-related driving with heavy goods vehicles - it’s a shared responsibility

Doctoral thesis (PhD) - Nord University, 2022publishedVersio

Web-based Geographical Visualization of Container Itineraries

Around 90% of the world cargo is transported in maritime containers, but only around 2% are physically inspected. This opens the possibility for illicit activities. A viable solution is to control containerized cargo through information-based risk analysis. Container route-based analysis has been considered a key factor in identifying potentially suspicious consignments. Essential part of itinerary analysis is the geographical visualization of the itinerary. In the present paper, we present initial work of a web-based system’s realization for interactive geographical visualization of container itinerary.JRC.G.4-Maritime affair

Navigation/traffic control satellite mission study. Volume 4 - Critical technology, growth and economic summaries Final report

Navigation and traffic control satellite network developmen