Development of Incident Reporting System concerned Human factor on Marine disaster

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Owing to human errors, many maritime disasters are happened. This fact shows that human reliability on bridge is important. IMO recognized the effectiveness of incident investigation but research of the detail was hardly done. Authors paid attention to the research and found the next points.(1) On results of the first try of the incident survey(a) Experiences equal to more than 400 times of Marine Disaster Inquiry Agency could be collecd.(b) The marine incidents have many similarities to the real marine disaster.(2) On the analysis method of incident dataA result of the incident survey should be needed to get clear causes for the prevention measures. Many factors are related mutually in marine incidents. Authors found that Multivariable Contingency Analysis is the most fundamental method to examine the participation of other factors in the connection that factors are mutual.(3) On items and factor that should be investigatedNavigators' internal and external conditions bring their behavior and action, which are recognized as performance shaping factors. Authors listed up ninety-five important elements considering safety measures, and evaluated their effects for a navigator's performance.(4) On the design of the incident questionnaire and the 2nd incident surveyAuthors planed a questionnaire and investigated into watch-keepers' Performance Shaping Factor at maritime incidents and could collect many useful responses by the efficiency of three times of the 1st trial. There was a key of the know-how in a design of the questionnaire and procedures of survey. The positive attitude to this survey increased. And also, it became possible to collect objective data of incidents in dangerous situation by this survey.It is concluded that almost whole of intended objectives at the biginning were satisfied.