Integrating SHIELD and SOAM for systemic human factors analysis in maritime collisions : the Helge Ingstad case

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Farag, Y.B.A. and Kurt, R.E. and Turan, O.; (2025) Integrating SHIELD and SOAM for systemic human factors analysis in maritime collisions : the Helge Ingstad case. In: Warship 2025. Proceedings of the Royal Institution of Naval Architects . Royal Institution of Naval Architects, GBR, pp. 323-347. ISBN 9781911649502

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Abstract

Effective human factors (HF) analysis is essential for understanding complex failures in high-risk maritime operations. While HF classification taxonomies exist, few offer integrated, scalable frameworks that support both structured factor identification and causal mapping across system layers. This study proposes a combined methodology that integrates the SHIELD Human Factors Classification System (SHIELD-HFACS), influence and certainty weighting, and the Systemic Occurrence Analysis Methodology (SOAM), anchored around functional safety barriers. The framework enables comprehensive classification of human and organisational factors across four levels: Acts, Preconditions, Operational Leadership, and Organisational Influences. It also assesses their impact and evidential strength. These factors are then linked to core collision safety barriers to trace how systemic failures propagate through socio-technical systems. SOAM mapping supports causal visualisation, highlighting interactions between latent conditions and frontline errors. The methodology is demonstrated through application to the 2018 KNM Helge Ingstad collision, where 32 contributory factors were identified and linked across barrier breakdowns. The analysis revealed how misperception, degraded supervision, interface gaps between VTS and navy protocols, and organisational oversights collectively undermined all active defences. These findings align with broader trends observed in a SHIELD-classified dataset of 106 maritime collisions, which commonly reveal systemic breakdowns in supervision, communication, and organisational oversight. The proposed SHIELD-SOAM framework contributes a replicable and scalable method for HF analysis in maritime accident investigations. By structuring classification, weighting influence, and mapping causal pathways, it enhances system-wide learning and supports evidence-based safety improvement. Future work will apply the full framework to the broader collision dataset to uncover recurring patterns and inform risk-informed design and intervention strategies.

ORCID iDs

Farag, Y.B.A. ORCID logoORCID: https://orcid.org/0000-0001-8883-9182, Kurt, R.E. ORCID logoORCID: https://orcid.org/0000-0002-5923-0703 and Turan, O. ORCID logoORCID: https://orcid.org/0000-0003-1877-8462;
CORE (COnnecting REpositories)