Abstract:
This study aims to analyze the influence of human factors (human error) on the
failure of safety procedures during lifeboat drills aboard MV. Glovis Desire. The
research employed a qualitative descriptive method, with data collected through in-depth
interviews, document review, and incident report analysis. The data were analyzed using
the Swiss Cheese Model to identify the contributing factors leading to the accident. The
results indicate that the accident was not solely caused by mechanical failure but by a
series of human-factor failures across multiple layers of the safety system. The deviation
from procedures by the Chief Officer, who entered and operated the lifeboat from the
embarkation phase, eliminated the visual supervisory function on the main deck, resulting
in spatial judgment errors and command ambiguity. This condition was further
aggravated by ineffective communication between the officer inside the lifeboat and the
officers on deck, causing the lifeboat to maneuver astern at excessive speed and become
difficult to control. The Swiss Cheese Model analysis revealed that the breakdown of the
safety system resulted from a combination of weaknesses within organizational
influences, unsafe supervision, preconditions for unsafe acts, and unsafe acts themselves.
The Job Safety Analysis (JSA) was conducted merely as a formality, the implementation
of the Safety Management System was ineffective, supervisory functions were weakened,
maneuvering decisions were flawed, and the Able Seaman's (AB) reflexive action of using
his leg to stop the lifeboat at a pinch point ultimately led to a severe injury. Therefore,
this study concludes that human factors played a dominant role in the failure of safety
procedures during the lifeboat drill aboard MV. Glovis Desire. The findings emphasize
the importance of strengthening safety culture, ensuring compliance with procedures, and
improving supervision and communication during safety drills.
