Development of Incident Reporting System concerned Human factor on Marine disaster

由于人为失误，发生了许多海难。这一事实表明，人在桥梁上的可靠性是很重要的。国际海事组织承认事故调查的有效性，但对其细节的研究很少。作者关注了研究，并发现了下一个要点。(1)根据事件调查第一次尝试的结果(a)可收集相当于海难调查机构400次以上的经验。(b)海上事故与实际海难有许多相似之处。(2)关于事故数据的分析方法，需要事件调查的结果来明确原因，以便采取预防措施。在海上事故中，许多因素是相互联系的。多变量权变分析是考察其他因素在相互联系中参与的最基本的方法。(3)在应调查的项目和因素上，导航员的内部和外部条件决定了他们的行为和行动，这些因素被认为是绩效形成因素。作者列出了95个考虑安全措施的重要因素，并评估了它们对导航员表现的影响。(4)在事件问卷和第二次事件调查的设计上，笔者设计了一份调查问卷，对海上事件中值班人员的绩效形成因素进行了调查，并以第一次试验的三倍效率收集了许多有用的回答。在问卷的设计和调查程序中，有一个诀窍的关键。对这项调查的积极态度增加了。通过这次调查，也可以收集到危险情况下事件的客观数据。结果表明，设计初期的预期目标几乎全部实现。

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.