A criticism occasionally levelled at transport safety investigators is that we spend too much time examining the specifics of an incident and not enough time understanding the people involved, or broader underlying systemic influences. This may give rise to a related perception that investigations involving pilotage focus excessively on actions of individual marine pilots, rather than the environment in which they operate.
Having published more than 300 transport safety reports in my five years as chief commissioner, I would argue this perception is, while maybe well-intentioned, ……. misplaced.
The reality is, examining human factors is central to an ATSB investigation. We examine the decisions people make, the information available to them, the pressures and demands they faced, the communication that occurs between individuals, and the organisational environments in which they operate. ATSB documentation explicitly recognises that human factors elements are a core component of every ATSB safety investigation, including decision-making, workload, fatigue, attention management and other factors that shape human performance.
We specifically examine human factors to understand why sensible and experienced people did what they did, and why the system around them failed to detect or recover from those actions before safety margins were lost.
In the maritime environment, one of the most consistent human factor themes emerging from ATSB investigations over the past five years has been bridge resource management (BRM). When BRM is discussed in the industry, it is often reduced to a training course or a regulatory requirement. In reality, it is much more than that. Effective BRM is the practical application of teamwork, monitoring, communication, challenge and response, workload management and shared situational awareness on the bridge. It is the mechanism by which human error is identified and corrected before it develops into an accident.
The ATSB's investigation into the collision involving the bulk carrier Goliath and two tugs in Devonport provides a relevant case study. That investigation found that effective BRM was not exercised during the operation and was a contributing factor to the collision. The investigation highlighted how opportunities to detect and correct an incorrect steering configuration were missed, allowing a series of human errors to align and result in a collision.
Notably, the ATSB did not stop at identifying individual actions.
The investigation also examined training arrangements, bridge design, equipment interfaces and organisational controls. That is not an attempt to dilute personal accountability. Rather, it reflects the reality that safety outcomes are rarely the product of a single decision. They emerge from interactions between people, technology and organisational systems.
Another recent example is the ATSB’s investigation into the near grounding of the bulk carrier Rosco Poplar in Hydrographers Passage in the Great Barrier Reef. The ship was under coastal pilotage when one of its GPS units began providing incorrect position information, which was then reflected across the ship and pilot’s navigation systems. The vessel came within about 200 m of Bond Reef before the error was detected and corrective action was taken.
The ATSB found that while the pilot and bridge team had relied too heavily on GPS-derived information, ineffective bridge resource management also contributed to the occurrence. In particular, the master-pilot exchange did not establish clear roles and responsibilities for monitoring, communication and cross-checking the passage, while the second mate was given tasks that distracted them from their core watchkeeping duties.
This investigation reinforces a recurring pilotage lesson: safety depends on people maintaining a shared understanding of the plan, actively monitoring progress, and being prepared to challenge or intervene when the vessel is not where it should be.
Also of importance, the ATSB found that the coastal pilotage check pilot system was not giving the regulator the intended assurance that coastal pilots were being assessed consistently and reliably. Pilotage check-and-training is a core component in ensuring consistency and competency.
Maritime operations remain heavily dependent on human performance. Even on technologically advanced vessels, success relies on effective communication between masters, watchkeepers, pilots, tug crews, vessel traffic services and shore-based organisations.
ATSB marine investigations have examined fatigue, workload, situational awareness, master-pilot exchanges, passage monitoring, communication breakdowns, procedural inconsistencies and the effectiveness of challenge and response behaviours. We examine these things as key components to understanding how safety margins eroded during complex operations.
They are often the factors that often determine whether a hazard becomes an accident.
Human factors science tells us that people do not operate in isolation. Training influences decision-making. Safety management systems shape behaviour. Rostering affects fatigue. An operator's organisational culture influences whether people speak up, challenge assumptions or seek assistance when uncertainty arises.
A safety management system is one of the mechanisms through which human performance is supported or degraded. It is for this reason examining it is so important.
Pilotage operations are complex, dynamic and conducted at the interface between multiple organisations and multiple professionals. Language barriers and inconsistencies in international crew training and qualifications are also very present, but equally known, challenges facing our Australian coastal and harbour pilots. As such the pilot’s management of this complex environment is an important component of the system that safeguards our waterways; but so too are ship operators, bridge teams, harbour authorities, tug operators, training organisations and regulators.
The concept of pilot-in-command is arguably incompatible with modern safety thinking. No single person can safely manage every risk in a complex maritime environment. The strongest defence against error remains an engaged bridge team willing to monitor, question, communicate and intervene when necessary.
This is precisely why human factors and bridge resource management continues to feature so prominently in ATSB findings and safety messaging.
The broader lesson from the ATSB's marine investigations over the past five years is clear. Accidents rarely occur because someone simply makes a mistake. Human error is almost always shaped by factors such as workload, fatigue, expectations, communication pathways, training, procedures, organisational influences and the design of equipment and environments.
Understanding those influences is the essence of human factors in investigations. It is also where the greatest opportunities for safety improvement exist. As Australia's independent transport safety investigator, the ATSB will continue to examine safety management systems when the evidence requires it. We will continue to analyse individual actions, including training, when they are relevant. But most importantly, we will continue to investigate the interaction between people and the systems in which they work.
A review of the findings and safety issues identified by multiple ATSB marine investigation shows that human factors considerations are consistently the most significant contributors the safety improvements our investigations achieve.