Study On Management Factors Of Water Traffic Accident Based On MAIB Accident Reports

In the study of water traffic safety,the concept of "management" as the "organization" factors,has long been regarded asthe deep reason ofhuman factors,however,"hiding" in the shadow of thehuman factors leads to that there is no unified definition and scope of "management",and the way "management" causes affect accidents has not been well recognized.The Water Traffic Safety Management and Guaranteeing System was describedin this paper,and based of which the concept of the management factor of the water traffic accidentwas put forward,namely: the omission or negligence behaviors in the process of implementing management and supervision on ships and relevant environment and crews by each main body of the Water Traffic Safety Management and Guaranteeing System,and also include the deficiencies of the macro rules and regulations caused by the limitation of cognition at different periods.The Management Factors Analysis and Classification System on Sea(MFACS-OS)was constructed in this paper,referred to theHFACS.The MFACS-OSclassified the orderof different management factors in the development process of accident based on the theory of water traffic accident,divided 5 layers of the social factors,the organizational factors,the unsafe prevention,the precondition of unsafe acts and the unsafe acts from the positive error to the underlying factors,from the position on ship to far away from the ship.The Multiple Correspondence Analysis(MCA)dig out the correlation of different factors of different levels.This paper based on 91 MAIB accident investigation reports,using the MCA dig out the management factors characteristics of ship company management,ship management,maritime management,port management,as well as the management factors characteristics of grounding,collision,fire,sinking touchingaccident.Referred to the level classification of MFACS – OS,by using the principle of the SHEL,build the key incident chain of management factors of grounding,collision,fire accident.The management factors characteristics such as: “ship company safety policy and philosophy” has correlation with “supervision on ship” and “ship maintenance”,“ship company SMS”has correlation with“training and drill on ship”,“resource management on ship”,“voyages planning”;among the management factors of maritime administration,only VTS has correlation withcollision and grounding accident;there is no obviousmanagement factor has correlation withthe main accident types associated with port management--touching accident.The key incident chain of management factors of grounding accident is:(deficiencies of SMS/ deficiencies oftraining ? deficiencies ofknowledge and skills)/(lack of teamwork)?voyages planningerrors?improper supervision on ship/improperuse ofdevices ? grounding.The key incident chain of management factors of collision accident is:(unreasonablearrangement of crews/lack of teamwork/improperuse ofdevices?improper outlook)/lack of teamwork/(insufficient training of ship company ? deficiencies ofknowledge and skills)? not timely operation?collision.