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Explore the factors contributing to the tragic ferry accident in Zeebrugge in March 1987. Analyze personnel, job, and equipment characteristics and their impact on the incident. Gain knowledge in human systems engineering principles.
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Tutorial 5:Case Study Zzzs in Zeebrugge SY DE 142 – June 21, 2004 Introduction to Human Systems Engineering Waterloo, Ontario, Canada
Outline • Case 1: “Zzzs in Zeebrugge” • Question and Discussion on Case 1
Case Study #1Zzzs in Zeebrugge • Place: English Channel • Time: March 1987 • Result: - Ferry sank - 188 passengers and some members of the crew died
Zzzs in Zeebrugge Questions Which personnel characteristics contributed to this accident? Which job characteristics contributed to this accident? Which equipment characteristics contributed to this accident?
1. Personnel characteristics: -age - ability - experience - stress -fatigue - drugs/alcohol - motivation
Zzzs in ZeebruggeSolutions 2. Job characteristics: - boredom level - timing - ergonomic hazard - work/rest/shifts - physical workload - mental workload
Zzzs in ZeebruggeSolutions 3. Equipment characteristics: - controls and displays - electrical/mechanical/thermal/pressure hazards - toxic substances - explosive hazards