Human factors at sea: common patterns of error in groundings and collisions

摘要

This research aimed to identify and map the common patterns of human and organizational causes underlying two types of marine accident: groundings and collisions. Generalizing patterns of causality from relatively unique and individual accident events required a structured and exploratory analytical approach. Two complementary human factor analysis tools were employed to analyse a set of 30 detailed marine accident reports produced by the Australian Transport Safety Bureau. Common patterns of causality were identified for both groundings and collisions. Groundings commonly resulted from a failure to adequately plan a passage, coupled with either a problem locating the vessel, or communication problems on the bridge. Collisions often involved a fishing vessel and a bulk carrier or cargo vessel, and commonly resulted from both a problem identifying the existence or speed of the other vessel and, again, an inadequate planning process. Generalizing these common causal patterns from a number of accidents identifies a range of points at which crews, managers and policymakers can intervene to forestall the development of these accidents. The method developed here may also be productively extended and applied to other accident types and used as an ongoing risk management tool.