Maritime Risk and System Safety Research Group, World Maritime University, Citadellsvägen 29, 201 24 Malmö, Sweden.
Accid Anal Prev. 2011 May;43(3):1187-96. doi: 10.1016/j.aap.2010.12.033. Epub 2011 Jan 26.
Careful accident investigation provides opportunities to review safety arrangements in socio-technical systems. There is consensus that human intervention is involved in the majority of accidents. Ever cautious of the consequences attributed to such a claim vis-à-vis the apportionment of blame, several authors have highlighted the importance of investigating organizational factors in this respect. Specific regulations to limit what were perceived as unsuitable organizational influences in shipping operations were adopted by the International Maritime Organization (IMO). Guidance is provided for the investigation of human and organizational factors involved in maritime accidents. This paper presents a review of 41 accident investigation reports related to machinery space fires and explosions. The objective was to find out if organizational factors are identified during maritime accident investigations. An adapted version of the Human Factor Analysis and Classification System (HFACS) with minor modifications related to machinery space features was used for this review. The results of the review show that organizational factors were not identified by maritime accident investigators to the extent expected had the IMO guidelines been observed. Instead, contributing factors at the lower end of organizational echelons are over-represented.
事故调查为审查社会技术系统中的安全措施提供了机会。人们普遍认为，大多数事故都涉及到人为干预。鉴于这种说法可能会对责任分配产生影响，一些作者强调了在这方面调查组织因素的重要性。国际海事组织（IMO）通过了具体规定，以限制航运作业中被认为不合适的组织影响。为调查与海上事故相关的人为因素和组织因素提供了指导。本文回顾了 41 份与机舱火灾和爆炸有关的事故调查报告。目的是查明在海上事故调查中是否确定了组织因素。在这项审查中，使用了经过轻微修改的、与机舱特点相关的人类因素分析和分类系统（HFACS）的改编版本。审查结果表明，组织因素并没有像IMO 指南所预期的那样，由海上事故调查人员充分确定。相反，组织等级较低的因素被过度代表。
