Personal Identification (PIN) Safe Model to Analyze Unsafe Actions that Characterize Maritime Accidents

摘要

This research focuses attention on safety challenges in maritime accidents, as the basis of conditions of unsafe actions of the human factor. Analyzing data is based on reports from JTSB (Japan Transport Safety Board) during 1991-2008. udAll equipment and systems has sensitive operations in working environment. While interacting of human in working performance have limitations in human element. In the strategy of Personal Identification (PIN) Safe model within working environment considering two condition about substandard practices of operators and substandard working conditions of operators. Substandard conditions are broken down from attribution of causes interacting with adverse mental states, adverse physiological states, and physical/mental limitations. Types of substandard practices include crew resource mismanagement and personal readiness. Each of these subcategories is discussed in the model of the characteristic of the human element in analyzing data. In the theory of causation in the maritime field is mentioned that one of the root cause analysis problems considered using 4 M (Man, Machine, Media, Management) Factors. Every factor while interacting where the center is a human who has the limitation in decision-making/taking actions will result in unsafe conditions or unsafe actions. While generating have a significant error from standard performance, can be said to be human error. Any unsafe actions or conditions lead to incident or accident has risks.udReliability of safety critical system is implemented in risks for human beings in its environment, such as unsafe actions in maritime accident. Critical systems engineering is to avoid disasters. A critical system is any system whose 'failure' could threaten human life, the system's environment of the organization which operates the systems. These people may interact with system or not. In safety critical system, people need to be aware of these risks and know what to do in the case of problems. Any reasonable conclusion possible as Personal Identification (PIN) Safe model is done in logic of pattern in working environment.udIn this research (as shown in fig.1.3) Logic of patterns (AND/OR), as developed by the author, is used to illustrate how a combination of both can occur. In the logic of the patterns, the author has conducted research how to implement logic such as AND / OR to determine the exposure of sensitive situation using taxonomy error codes which is implemented in a union set. It is integrated into a model called a Personal Identification (PIN) Safe model. Based on this reasoning, Personal Identification (PIN) Safe model is done in logic of patterns of human beings.udThe result of this research is:uda. Identifying human elements in risk.udIdentifying human elements is based on unsafe actions and their root cause to determine any kind of risk in maritime accidents. Any unsafe actions have different characteristics that lead to kinds of maritime accidents. The assessment step is applied in probability weight as a measure to determine the level of risk associated with a specific hazard. The result indicates the level of consequences from a risk. Minimizing the decrease of quality human performance as impacted in unsafe actions is implemented with 3A (awareness, action and attitude) behavior in part of PIN Safe model.udb. Improving quality of decisions in response to unsafe actionsudQuality of decisions is increasing quality sense of decisions by input, process and output to get situational awareness and situational familiarity in working environment to minimize any significant deviations, particularly in the maritime transport system. These elements are embedded in very complex, interdependent, and dynamic relationships. The maritime transport system is a very complex and large-scale socio-technical environment system consisting of human actions that interact with each other and operate in a physical environment in the term man-machine-media and management. Knowledge of working environment is one part of decreasing the risk value of an individual ship. Every risk will reach to accident. Considering further that it has the probability accident which is determined by the ship???s time and location. Effective analysis and practice is the counter measure for reducing the human elements??? involvement by studying the patterns that have the same value as of probability weight in taxonomy error. These have been developed in order to get the performance shaping factors by PIN Safe model as anticipation of engineering controls.udc. Controlling the patterns of unsafe action in risk udRisk is the probability and severity of loss from exposure to the hazard. The accident probability for an individual ship is determined using so called ???exposures??? and a casualty rate. The exposures are the number of potential casualty sensitive situations in which the ship can be involved that could lead to an accident. This process definition will be easier to recognize by the taxonomy error in the performance of the seafarer. udThe probability weight and severity of accident that could result produce a pattern from the hazard, based upon the exposures of personal unsafe actions within the hazard. From such pattern there can be shown how navigation problems contribute as the highest input to the collision accident. It is expected that the exposures are a key to developing human performance. During operations of workers, it can be seen how they will be affected by a given event or, over time, by repeated events. udd. Monitoring the patterns of unsafe actionudRepeated events as unsafe actions need evaluation. Regarding these situations, the author has been researching methods in the control of taxonomy error of unsafe actions till within 4M factors as a comprehensive monitoring information process in PIN Safe model. These are needed for the role of management to evaluate. Strong management to analyze events??? characteristics of unsafe actions is important in establishing the evaluation strategies. Monitoring all factors should be done to avoid critical situations and to minimize human casualty. In chapter 5, there is a result that highest cases of human casualty come from unsafe actions such as improper management for ship operation, management of electrical equipment, improper handling and other tasks, improper fishing work, poor management of passengers and cargo loading; and others. There is the need for keeping continuous and specific training in a limited time. Knowing the kind of monitoring in unsafe actions can help to map features of human limitations to get a unique approach to improving human performance.