Tutorial 5: Case Study

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Tutorial 5Case Study

• Zzzs in Zeebrugge
• SY DE 142 June 21, 2004
• Introduction to Human Systems Engineering
• Waterloo, Ontario, Canada

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Outline

• Case 1 Zzzs in Zeebrugge
• Question and Discussion on Case 1

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Case Study 1Zzzs in Zeebrugge

• Place English Channel
• Time March 1987
• Result
• - Ferry sank
• - 188 passengers and some members of
• the crew died

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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?

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• 1. Personnel characteristics

• - age - ability -
  experience
• - stress - fatigue -
  drugs/alcohol
• - motivation

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Zzzs in ZeebruggeSolutions

• 2. Job characteristics

- boredom level - timing -
ergonomic hazard - work/rest/shifts -
physical workload - mental workload
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Zzzs in ZeebruggeSolutions

• 3. Equipment characteristics

• - controls and displays
• - electrical/mechanical/thermal/pressure hazards
• - toxic substances
• - explosive hazards