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Human Error as a Safety Risk in Maritime Shipping: Analysis of Maritime Disasters from the Perspective of Human Error Management



The maritime industry is a central pillar of the global economy and enables the transport of approximately 80–90% of worldwide trade by sea. With the continuous increase in ship sizes, the growing complexity of modern navigation systems, and the rising intensity of international maritime traffic, the demands for safety at sea are also increasing. Despite numerous technological advancements and extensive international regulations, human beings remain a decisive factor in the operation of ships and maritime facilities.

One key concept for improving safety is Human Error Management (HEM). This refers to the systematic identification, analysis, and prevention of human errors in complex work systems. In maritime operations, this concept plays a particularly important role, as studies show that a large proportion of maritime accidents can be at least partially attributed to human error. Mistakes in navigation, poor communication within the crew, organizational weaknesses, or incorrect decisions made under time pressure can have serious consequences.

Several well-known maritime disasters highlight the importance of effective error management. Examples include the sinking of the ferry Herald of Free Enterprise in 1987, the oil spill of the tanker Exxon Valdez in 1989, the explosion of the offshore drilling platform Deepwater Horizon in 2010, and the grounding of the cruise ship Costa Concordia in 2012. More recent events such as the sinking of the ferry MV Sewol in 2014, the blockage of the Suez Canal by the container ship Ever Given in 2021, and the collision between the destroyer USS Fitzgerald (DDG-62) and the container ship ACX Crystal demonstrate that human error continues to play a significant role even in modern, technologically advanced maritime operations.

These events demonstrate that maritime accidents are rarely caused by a single factor. Instead, they often result from a chain of human, technical, and organizational failures. The aim of this paper is therefore to examine the importance of Human Error Management in maritime shipping, analyze key causes of human error, and illustrate—through selected case studies—the consequences of missing or insufficient error management. In addition, the study considers measures and strategies that have been developed to improve maritime safety in the long term.

The Sinking of the Herald of Free Enterprise (1987)
On March 6, 1987, the car ferry Herald of Free Enterprise sank shortly after leaving the port of Zeebrugge in Belgium.
Causes
The primary cause was human error:
The ship’s bow doors were not closed before departure.
Additional contributing factors included:
  • lack of control systems for verifying that the bow doors were closed,
  • poor communication between crew members, and
  • organizational deficiencies within the shipping company.
Consequences
  • 193 people lost their lives.
  • International reforms in ferry safety were introduced.
  • Stricter safety control procedures were implemented.
This disaster is considered a classic example of systemic failure due to the absence of effective Human Error Management.

The Exxon Valdez Oil Spill (1989)
On March 24, 1989, the oil tanker Exxon Valdez ran aground on a reef in Prince William Sound, Alaska.
Causes
The accident resulted from several human errors:
  • crew fatigue,
  • insufficient monitoring of navigation,
  • delayed reaction to course deviations, and
  • inadequate supervision by the captain.
Consequences
  • Approximately 37,000 tons of crude oil were spilled.
  • Massive environmental damage to coastlines and wildlife.
  • One of the worst oil spills in history.
Significance for HEM
The accident led to new international regulations, including:
  • stricter monitoring of maritime traffic,
  • the introduction of double-hull tankers, and
  • improvements in risk management systems.

Explosion of the Deepwater Horizon (2010)
On April 20, 2010, the offshore drilling platform Deepwater Horizon exploded in the Gulf of Mexico.
Causes
The disaster resulted from a series of incorrect decisions:
  • misinterpretation of pressure test results,
  • time pressure due to economic interests, and
  • poor communication between engineers and management.
Consequences
  • 11 fatalities.
  • The largest oil spill in U.S. history.
  • More than 4 million barrels of oil released into the sea.
This event sparked a global debate about safety culture and decision-making processes in high-risk industries.

The Costa Concordia Disaster (2012)
The cruise ship disaster involving the Costa Concordia occurred on January 13, 2012, near the island of Isola del Giglio, Italy.
Causes
Captain Francesco Schettino intentionally navigated the ship too close to the coast in order to perform a so-called “salute” to the island—an unofficial maneuver that was not part of the planned route.
Additional factors included:
  • violation of navigation rules,
  • delayed evacuation decision,
  • poor communication between the bridge and the crew, and
  • lack of coordinated emergency management.
Consequences
  • 32 people died.
  • The ship ran aground and partially capsized.
  • Damages totaling several billion euros.
Significance for HEM
The disaster clearly illustrates:
  • risks arising from individual decision-making errors by leadership personnel,
  • insufficient control mechanisms within the organization, and
  • inadequate emergency management procedures.

The Sinking of the MV Sewol (2014)
The ferry MV Sewol sank on April 16, 2014, off the coast of South Korea.
Causes
The investigation revealed several serious human errors:
  • an incorrect course change by an inexperienced officer,
  • overloading of the vessel,
  • improperly secured cargo, and
  • inadequate evacuation procedures.
Consequences
  • 304 people died, many of them students.
  • Severe criticism of authorities and the ferry operator.
Significance for HEM
The accident highlights:
  • the importance of training and competence of the crew,
  • risks caused by economic pressure and regulatory violations, and
  • failure of crisis management and evacuation planning.

The Collision of the USS Fitzgerald (2017)
The U.S. Navy destroyer USS Fitzgerald (DDG-62) collided with the container ship ACX Crystal in 2017 off the coast of Japan.
Causes
The investigation conducted by the United States Navy identified:
  • poor situational awareness on the bridge,
  • inadequate communication, and
  • insufficient navigation procedures.
Consequences
  • 7 sailors died.
  • Severe damage to the warship.
  • Reforms in U.S. Navy training programs.

The Blockage of the Suez Canal by the Ever Given (2021)
In March 2021, the container ship Ever Given ran aground in the Suez Canal, blocking one of the world’s most important trade routes.
Causes
Investigations identified several possible factors:
  • strong wind gusts,
  • navigational errors,
  • insufficient communication between pilots and crew, and
  • possible steering misjudgments.
Consequences
  • Blockage of the canal for six days.
  • Disruption of global supply chains.
  • Economic losses worth billions of dollars.
Significance for HEM
The incident demonstrates that even non-catastrophic human errors can have enormous economic consequences.

North Sea Ship Collision (2025)
A recent example is the North Sea ship collision of 2025.
On March 10, 2025, the container ship MV Solong collided with the oil tanker MV Stena Immaculate off the coast of England. Fires broke out on both vessels, and one crew member was reported missing.
The tanker was carrying approximately 220,000 barrels of jet fuel, raising concerns about potential environmental damage.
Investigations focused on possible gross negligence by the captain, who was later arrested. Early indications suggested that inadequate monitoring of navigation systems may have been a key contributing factor.
This incident demonstrates that even in modern, technologically advanced maritime operations, human error remains a central cause of accidents.

Overall Analysis of the Examples
The analyzed events reveal recurring patterns of human error:
1. Decision-making errors
Incorrect decisions by captains or officers are among the most common causes of accidents.
2. Communication problems
Misunderstandings between crew members or with maritime pilots can intensify critical situations.
3. Fatigue and workload
Crew fatigue is a frequently underestimated risk factor.
4. Weak safety culture
When economic interests or strict hierarchies overshadow safety considerations, the risk of accidents increases significantly.

Future Perspectives
The BSH SMART SEA initiative is increasingly developing new technologies aimed at reducing human error.
BSH SS – Artificial Intelligence
BSH SS artificial intelligence can analyze navigation data and provide early warnings of potential collision risks.
BSH SS – Fatigue Monitoring
BSH SS systems can detect crew fatigue and help optimize working hours.

Despite these developments, human operators remain a central element of the maritime system. The proposed solution is the BSH Human Error Management System, which integrates technological support with systematic error prevention strategies.

Conclusion
The analysis of various maritime disasters—including the sinking of the Herald of Free Enterprise, the explosion of the Deepwater Horizon, the grounding of the Costa Concordia, the Exxon Valdez oil spill, the sinking of the MV Sewol, the blockage of the Suez Canal by the Ever Given, and the collision of the USS Fitzgerald (DDG-62) with the ACX Crystal—clearly highlights the central role of the human factor in maritime safety.

Despite modern navigation systems, automated technologies, and extensive safety regulations, human beings remain a decisive element in the operation of ships and maritime infrastructure. In nearly all analyzed cases, recurring patterns can be identified: incorrect decisions under time pressure, poor communication within the crew, organizational deficiencies, and weak safety cultures. Often, a chain of several small errors ultimately leads to major accidents or disasters.

The examples also demonstrate that human errors not only pose direct threats to human life but can also have significant environmental and economic consequences. Oil spills, environmental pollution, disruptions of global supply chains, and the loss of ships can result in damages worth billions of dollars and long-term impacts on ecosystems and societies.

Human Error Management therefore plays a crucial role in improving safety at sea. Through structured training programs, a strong safety culture, improved communication processes, and the application of modern technologies, human errors cannot be entirely eliminated but can be significantly reduced. A systemic approach is essential—one that examines not only individual mistakes but also the organizational and technical conditions in which they occur.

In conclusion, maritime safety cannot be ensured by technological innovation alone. Only the interaction of technology, organizational structures, and human behavior can create an effective safety management system. The continuous development of Human Error Management is therefore essential to prevent future accidents and to sustainably improve safety in global maritime operations.