Human and organisational factors in maritime accidents: Analysis of collisions at sea using the HFACS
Human and organisational factors in maritime accidents: Analysis of collisions at sea using the HFACS
复制标题
DOI：
10.1016/j.aap.2013.05.006
复制
发表时间：
2013-10-01
影响因子：
5.9
通讯作者：
Langard, Benoit
中科院分区：
文献类型：
--
作者：
Chauvin, Christine;Lardjane, Salim;Langard, Benoit
在过去十年中，航运业实施了一系列旨在提高安全水平的措施（如新法规或新形式的团队培训）。尽管有这种演变，航运事故，特别是碰撞，仍然是一个主要问题。本文介绍了一个修改后的人的因素分析和分类系统，该系统已被修改为适用于海上环境，并用于分析由海事事故和调查分支（英国）和运输安全委员会（加拿大）报告的碰撞中的人和组织因素。分析表明，大多数碰撞是由于决策错误。在前提条件层面，它强调了以下因素的重要性：能见度差和仪器滥用（环境因素），失去态势感知或注意力不足（操作员条件），船际通信或驾驶台资源管理不足（人员因素）。在领导层层面，分析揭示了经常计划不适当的操作和不遵守安全管理系统（SMS）。多重事故分析提供了关于三类事故的重要发现。船舶间通信问题和驾驶台资源管理缺陷与在限制沃茨发生的碰撞和涉及引航船的碰撞密切相关。另一类碰撞与远海能见度差的情况有关，并显示出社会技术系统（技术环境、操作员条件、领导层和组织层）各个层面的缺陷。第三类的特点是不符合SMS。这项研究表明，驾驶台资源管理的重要性，在限制沃茨航行的情况下，在船上的试点。并指出对于公海航行情况，有必要调查船长在危急情况下的决定以及不遵守SMS的原因。(C)2013爱思唯尔有限公司保留所有权利。
Over the last decade, the shipping industry has implemented a number of measures aimed at improving its safety level (such as new regulations or new forms of team training). Despite this evolution, shipping accidents, and particularly collisions, remain a major concern. This paper presents a modified version of the Human Factors Analysis and Classification System, which has been adapted to the maritime context and used to analyse human and organisational factors in collisions reported by the Marine Accident and Investigation Branch (UK) and the Transportation Safety Board (Canada).The analysis shows that most collisions are due to decision errors. At the precondition level, it highlights the importance of the following factors: poor visibility and misuse of instruments (environmental factors), loss of situation awareness or deficit of attention (conditions of operators), deficits in intership communications or Bridge Resource Management (personnel factors). At the leadership level, the analysis reveals the frequent planning of inappropriate operations and non-compliance with the Safety Management System (SMS). The Multiple Accident Analysis provides an important finding concerning three classes of accidents. Inter-ship communications problems and Bridge Resource Management deficiencies are closely linked to collisions occurring in restricted waters and involving pilot-carrying vessels. Another class of collisions is associated with situations of poor visibility, in open sea, and shows deficiencies at every level of the socio-technical system (technical environment, condition of operators, leadership level, and organisational level). The third class is characterised by non-compliance with the SMS.This study shows the importance of Bridge Resource Management for situations of navigation with a pilot on board in restricted waters. It also points out the necessity to investigate, for situations of navigation in open sea, the masters' decisions in critical conditions as well as the causes of non-compliance with SMS. (C) 2013 Elsevier Ltd. All rights reserved.