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Investigating the influence of human errors in master-pilot information exchange on maritime accident risk during pilotage

Ocean Engineering(2024)

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摘要
Pilotage-related errors have led to too many accidents in recent years, resulting in significant economic losses and disruptions in global logistics. Despite its importance, Master-Pilot Exchange (MPX) can be overlooked due to several factors. This study focuses on MPX, a standard protocol for information exchange between shipmasters and maritime pilots to ensure safe ship handling. Deficiencies in MPX procedures have been highlighted in various accident reports, emphasizing the need for improvement. This research aims to identify an optimal MPX process, evaluate potential shortcomings, assess their likelihood and severity, and analyse the human factors contributing to these deficiencies. The study utilizes a fuzzy Bayesian Network (BN) to model the MPX process and identify factors that may lead to its failure. It also employs the Success Likelihood Index Method (SLIM) approach to calculate the probability of human errors in the MPX process and identify the performance-shaping factors triggering them. The finding of the Bayesian method shows that the machinery problem and the navigational equipment problem are the two most significant root causes of MPX process failure. According to the SLIM findings, providing details of "the ship's contingency plan", and "navigational information" are the two most significant tasks for this process. Among the identified performance-shaping factors, the degree of teamwork and harmony, experience and knowledge appear to be the three most significant contributors with the highest human error probability (HEP) in mentioned tasks. This study represents a significant contribution to research on master-pilot interactions, addressing a critical aspect of maritime safety.
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关键词
Master pilot information exchange,Bayesian network,SLIM,Maritime accident risk,Human factors,Human error
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