Lab-STICC, UMR CNRS 6285, University of South Brittany, Centre de recherche, rue de Saint-Maudé, 56321 Lorient Cedex, France.
Accid Anal Prev. 2013 Oct;59:26-37. doi: 10.1016/j.aap.2013.05.006. Epub 2013 May 18.
Over the last decade, the shipping industry has implemented a number of measures aimed at improving its safety level (such as new regulations or new forms of team training). Despite this evolution, shipping accidents, and particularly collisions, remain a major concern. This paper presents a modified version of the Human Factors Analysis and Classification System, which has been adapted to the maritime context and used to analyse human and organisational factors in collisions reported by the Marine Accident and Investigation Branch (UK) and the Transportation Safety Board (Canada). The analysis shows that most collisions are due to decision errors. At the precondition level, it highlights the importance of the following factors: poor visibility and misuse of instruments (environmental factors), loss of situation awareness or deficit of attention (conditions of operators), deficits in inter-ship communications or Bridge Resource Management (personnel factors). At the leadership level, the analysis reveals the frequent planning of inappropriate operations and non-compliance with the Safety Management System (SMS). The Multiple Accident Analysis provides an important finding concerning three classes of accidents. Inter-ship communications problems and Bridge Resource Management deficiencies are closely linked to collisions occurring in restricted waters and involving pilot-carrying vessels. Another class of collisions is associated with situations of poor visibility, in open sea, and shows deficiencies at every level of the socio-technical system (technical environment, condition of operators, leadership level, and organisational level). The third class is characterised by non-compliance with the SMS. This study shows the importance of Bridge Resource Management for situations of navigation with a pilot on board in restricted waters. It also points out the necessity to investigate, for situations of navigation in open sea, the masters' decisions in critical conditions as well as the causes of non-compliance with SMS.
在过去的十年中，航运业已经采取了多项措施来提高其安全水平（例如新法规或新形式的团队培训）。尽管有了这种发展，航运事故，特别是碰撞事故，仍然是一个主要关注点。本文提出了一种改进的人为因素分析和分类系统版本，该系统已适应海上环境，并用于分析由英国海上事故和调查处（UK）和加拿大运输安全局（Canada）报告的碰撞事故中的人为和组织因素。分析表明，大多数碰撞事故是由于决策错误造成的。在前提条件层面，它强调了以下因素的重要性：能见度差和仪器使用不当（环境因素）、情景意识丧失或注意力不足（操作人员状况）、船舶间通信或桥梁资源管理（人员因素）不足。在领导层层面，分析揭示了经常计划不适当的操作和不遵守安全管理系统（SMS）的情况。多事故分析提供了关于三类事故的重要发现。船舶间通信问题和桥梁资源管理不足与在限制水域内发生的涉及引航船的碰撞密切相关。另一类碰撞与开阔海域中的低能见度情况有关，显示出社会技术系统各个层面（技术环境、操作人员状况、领导层和组织层面）的缺陷。第三类与不遵守 SMS 有关。这项研究表明了在限制水域内引航员在船上的航行情况下，桥梁资源管理的重要性。它还指出了有必要对开阔海域中的航行情况进行调查，了解在关键条件下船长的决策以及不遵守 SMS 的原因。
