Journal of the Korean Society of Marine Environment & Safety (해양환경안전학회지)

The Korean Society of Marine Environment and safety (해양환경안전학회)
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A Study on Human Error of DP Vessels LOP Incidents

DP 선박 위치손실사고의 인적오류에 관한 연구

  • Chae, Chong-Ju (Korea Institute of Maritime and Fisheries Technology)
  • Received : 2015.09.02
  • Accepted : 2015.10.27
  • Published : 2015.10.31
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Abstract

This study reviewed 612 DP LOP(Loss of Position) incident reports which submitted to IMCA from 2001~2010 and identified 103 human error caused incidents and classified it through HFACS. And, this study analysis of conditional probability of human error on DP LOP incidents through application of bayesian network. As a result, all 103 human error related DP LOP incidents were caused by unsafe acts, and among unsafe acts 70 incidents(68.0 %) were related to skill based error which are the largest proportion of human error causes. Among skill based error, 60(58.3%) incidents were involved inadvertent use of controls and 8(7.8%) incidents were involved omitted step in procedure. Also, 21(20.8%) incidents were involved improper maneuver because of decision error. Also this study identified that unsafe supervision(68%) is effected as the largest latent causes of unsafe acts through application to bayesian network. As a results, it is identified that combined analysis of HFACS and bayesian network are useful tool for human error analysis. Based on these results, this study suggest 9 recommendations such as polices, interpersonal interaction, training etc. to prevent and mitigate human errors during DP operations.

본 연구에서는 10년간(2001 2010) IMCA에 보고된 DP 선박 LOP(Loss of Position)사고 612건에서 인적오류에 의한 사고 103건을 확인하여 이를 HFACS로 분류하였다. 그리고 이를 베이지안 네트워크에 적용하여 인적오류의 조건부 확률을 확인해 보았다. 그 결과 103건의 인적오류관련 사고는 모두 불안전한 행동에 의해서 발생하였고 이들 중 기술 기반 오류가 70건(68.00 %)으로 가장 큰 인적오류 비율을 차지하였다. 기술 기반 오류 중에서는 부주의한 DP 선박 운용 60건(58.3%), 절차 미 준수 8건(7.8%)이었고, 의사결정 오류에 의한 잘못된 조종이 21건(20.8%)을 차지하였다. 이러한 HFACS 분류의 베이지안 네트워크 적용을 통해서는 불안전한 감독(68%)이 불안전한 행동의 가장 큰 잠재적 요인으로 작용하고 있다는 것을 확인 할 수 있었다. 결론적으로 HFACS와 연계한 베이지안 네트워크는 인적오류를 분석하는 데 유용한 도구임을 확인 할 수 있었고, 분석 결과를 바탕으로 DP 선박안전 운용을 위한 정책, 내부 관계, 훈련등과 같은 인적오류를 경감 및 제거하기 위한 권고 9가지를 제안하였다.

Keywords

References

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