The Human Factor Above All

Authors of a new risk assessment of work accidents in container terminals built their analysis around data from the Port of Tanjung Priok. As Felicity Landon reports, all container terminals can learn from the conclusions drawn.

Fire, loading/unloading accidents, non-loading/ unloading accidents, traffic accidents, work accidents and environmental/pollution accidents; in their research and analysis of work accidents in container terminals, Muhammad Arif Budiyanto and Haris Fernanda identified six categories to cover all relevant hazards and risks.

They then set about analysing the frequency of accidents, pinpointing the direct and underlying causes, and drawing up a table of risk control options. Probably the least surprising finding (and a timely reminder) is this – that human factors are the most common causes of accidents.


The authors, from the department of mechanical engineering at Universitas Indonesia, carried out their formal safety assessment method, combined with the ‘Fault Tree Analysis’ approach to assessing the risks, at container terminals 2 and 3 at Tanjung Priok. Their research was based on interviews, direct observation and accident data over a five-year period to 2017, and accidents were categorised according to the level of severity and frequency.

During the five years analysed at the Tanjung Priok terminals, there were 117 accidents, with the highest rate being in 2015. The most prevalent type of incident during the period was traffic accidents, which accounted for almost 42 per cent of the total.

More notable is the analysis which showed that across all types of accidents, human factors were the most common cause – at 53 per cent. This included driver/pilotage error (at 36 per cent easily the highest), poor supervision, negligence when working, inadequate tool or equipment maintenance, and miscommunication when working or navigation error.

Nearly 30 per cent of accidents had machinery as their common cause, including equipment damage, engine damage and electrical error. “The machinery factor is also important because it contributed almost 30 per cent, especially engine damage which was discovered to be 25 per cent,” says the report. “These are generally related to other factors such as improper training for humans operating the equipment leading to unexpected damage or abnormal operation.”

The accidents caused by environmental factors accounted for almost 15 per cent but, as the report explains, these factors were sometimes controllable and sometimes not.

“The uncontrollable ones include floods or other disasters, while the controllable ones are road damage, lack of lighting, cargo spills or noisy equipment which are closely related to poor supervision and maintenance,” says the report. If a floor is slippery, roads are damaged or warning signs are missing, one would imagine these could be moved across to the ‘human error’ column too.


By bringing together the severity and frequency stats, the authors produced a Risk Index. The resulting high-risk incidents were container damage when unloading, stacking or transferring to truck trailer; equipment damage when loading and unloading; traffic accidents involving loading/ unloading equipment, other trucks, vehicles and port support facilities; and workers getting run over or knocked over.

In the next category, ‘significant risk’ incidents were loading/ unloading equipment fires; trucks crashing into a guardrail; workers falling from the top of a container or a ship; and environmental pollution from the contents of containers.

The authors list 16 root causes of high-risk accidents – from poor weather, which is no one’s fault, to not sticking to the safety rules, which clearly is. The root causes were used as the basis for drawing up 14 detailed Risk Control Options (RCOs), which range from coordination over the maintenance of tools and facilities to ensuring clarity of regulations relating to matters such as speed limits.

There are also ‘soft’ steps such as adjusting working hours and putting in place double supervision during certain work hours when people have begun to experience fatigue – through increasing the number of supervisors or general monitoring via surveillance cameras.

Importantly, the authors also align the short-term benefits of the RCO actions with long-term benefits – for example, fostering a good working atmosphere; delivering good cooperation and coordination in order to improve the quality, safety and welfare of several parties; operators acting faster and more precisely, working more professionally and providing better service; increased discipline and professionalism of port management; improving port performance; and reducing the costs of damage to equipment.

“The use of containers in the world is increasing every year in line with international trade flows,” say the authors. Some of the largest container terminals in the world are competing to improve terminal productivity through various approaches, and measures are being introduced to increase energy efficiency and reduce emissions.

“In very complex container terminal operations, the risk of work accidents is inevitable and can happen at any time,” they say. There are complex work processes on a container terminal, and they include stevedoring, delivery and receiving, “each of which is contributing to the unexpectedly high risk” experienced by people, the environment, properties and facilities at the port.


In their conclusion, they also point out that the safety of the port is not restricted to the activities being conducted on the site, but also affects other parties such as the police, the ministry of transport and shipping companies.

The COVID-19 pandemic has served to concentrate minds on a different type of ‘health and safety’, with ports having to set up work patterns that keep groups of workers apart and maximise social distancing to minimise the risk of infection.

That does not mean a lack of focus on other safety matters – far from it. In mid-September 2020, five freight transport and cargo handling organisations announced they were collaborating on packing standards for freight containers and other cargo units.

The Container Owners Association, the Global Shippers Forum, the International Cargo Handling Co-operation Association, the TT Club and the World Shipping Council say they are working together on a range of activities to improve safety practices throughout the global supply chain.

They have published a ‘Quick Guide’ to the Code of Practice for Packing of Cargo Transport Units (CTU Code), and a checklist of actions and responsibilities for those packing containers.

“There have been several widely reported container fires aboard ships, where containerised cargoes may have been the cause of, or contributed to, such fires,” said the group. “The organisations believe that consistent, widespread and diligent adherence to the CTU Code by all parties within global CTU supply chains would significantly reduce these types of incidents.”

Poor packing practices can lead to incidents such as container stack failures, vehicle rollovers, train derailments, internal cargo collapses and invasive pest contamination, it added, and greater awareness of the CTU Code could help to reduce these.

Lars Kjaer, senior vice president of the World Shipping Council (WSC) said: “We believe it is important to proactively review and, where needed, revise existing regulatory provisions to enhance ship, crew and worker safety.”

James Hookham, secretary general of the Global Shippers Forum, said the publication of the CTU Code guide by the five organisations was “a marker on a journey to raise wider awareness of this critical issue across the globe and adoption of safe practices”.

He added: “Our organisation cannot do this on their own and we are reaching out to other bodies in the supply chain and in governmental agencies to join with us in promoting high standards of the packing of all cargo transport units and understanding the inter-connectedness of different objectives.”

PSS launches safety in ports survey

The UK organisation Port Skills and Safety (PSS) has launched a Safety in Ports (SiP) impact survey, based on guidance from the Health & Safety Executive (HSE), trade union Unite and the wider industry.

It aims to help ports benchmark their procedures against nationally recognised standards, and to develop improvement actions tailored to their needs.

“We were spurred on to develop the survey process by an HSE challenge,” said PSS chief executive Richard Steele. “The Safety in Ports Guidance is best in class. It is endorsed by HSE, Unit and the whole industry. The question was, how to make sure that it was being used.”

Rather than just going out and ticking things off a list, he said, ports needed to have real opportunities for value-added learning.

The survey will be split into two phases – the first using a remote questionnaire, the second to be a physical, COVID-secure visit using a bespoke SiP analysis tool. This second part, to be carried out jointly by PSS and port staff, will check the practical implementation of SiP guidance.

Leave A Reply

Your email address will not be published. Required fields are marked *