P&I Loss Prevention Bulletin② Forgetful, ③ Habituation behaviour, ⑤ Unconscious acts, ⑥ Sense of urgency andsensitively, ⑦ Mental shortcuts, ⑧ Cutting corners, ⑨ Judgement based on speculation,and ⑪ Habituation phenomenon.
Also, as individual skills (insufficient knowledge), ③ Lack of a sense of urgency
and awareness and ④ Mistakes regarding work procedure and forgetfulness are incommonly found in human error.

3 Accident Cause Analysis (Unsafe conditions) (Fig. 49 and Attachment 18)
Attachment 18
㻹㼍㼞㼕㼠㼕㼙㼑㻌㻭㼏㼏㼕㼐㼑㼚㼠䚷㻭㼏㼏㼕㼐㼑㼚㼠㻌㻯㼍㼡㼟㼑㻌㻔㼁㼚㼟㼍㼒㼑㻌㻯㼛㼚㼐㼕㼠㼕㼛㼚㼟㻕㻦㻌㼂㼑㼟㼟㼑㼘㻌㻭䚷㻽㼡㼍㼥㻌㻌㼏㼛㼘㼘㼕㼟㼕㼛㼚㻌㼍㼏㼏㼕㼐㼑㼚㼠㻭㼠㼠㼍㼏㼔㼙㼑㼚㼠㻌㻝㻤㻹㼍㼚㻹㼍㼏㼔㼕㼚㼑

㻯㼍㼡㼟㼑㻌㻔㼁㼚㼟㼍㼒㼑㻌㼎㼑㼔㼍㼢㼕㼛㼡㼞㻕㻠㻌㻵㼚㼐㼕㼢㼕㼐㼡㼍㼘㻌㼟㼗㼕㼘㼘㼟㻝㻌㻼㼟㼥㼏㼔㼛㼘㼛㼓㼕㼏㼍㼘㻠㻙㻝㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㼗㼚㼛㼣㼘㼑㼐㼓㼑㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼒㼍㼏㼠㼛㼞㼟㻌㼍㼚㼐㻌㼛㼞㼓㼍㼚㼕㼦㼍㼠㼕㼛㼚㻡㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻠㻙㻞㻠㻙㻟㻌㻼㼛㼛㼞㻌㼣㼛㼞㼗 㼛㼒㻌㼔㼑㼍㼘㼠㼔㻌㼍㼚㼐㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㼣㼛㼞㼗㼕㼚㼓
㼑㼠㼔㼕㼏㼟㼗㼕㼘㼘㼟
㼑㼚㼢㼕㼞㼛㼚㼙㼑㼚㼠㻹㼍㼕㼚㼘㼥㻌㼛㼚㻌㼠㼔㼑㻌㼢㼑㼟㼟㼑㼘㼀㼔㼑㻌㼢㼑㼟㼟㼑㼘㻘㼟㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㼏㼛㼙㼜㼍㼚㼥

㻿㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼏㼛㼙㼜㼍㼚㼥㻻㼚㻌㼠㼔㼑㻌㼢㼑㼟㼟㼑㼘㻢㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼟㼡㼜㼑㼞㼢㼕㼟㼕㼛㼚㻌㼛㼒㻌㼔㼕㼟㻛㼔㼑㼞㻌㼟㼡㼎㼛㼞㼐㼕㼚㼍㼠㼑㼟㻡㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼘㼍㼥㼛㼡㼠㻌㼍㼞㼞㼍㼚㼓㼑㼙㼑㼚㼠㻠㻌㻸㼍㼏㼗㻌㼛㼒㻌㼑㼐㼡㼏㼍㼠㼕㼛㼚㻌㼍㼚㼐㻌㼠㼞㼍㼕㼚㼕㼚㼓㻺㼑㼏㼑㼟㼟㼕㼠㼥㻌㼛㼒㻌㼞㼑㻙㼕㼚㼢㼑㼟㼠㼕㼓㼍㼠㼕㼛㼚㻟㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼟㼍㼒㼑㼠㼥㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼜㼘㼍㼚㼚㼕㼚㼓㻞㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻛㼕㼚㼏㼛㼙㼜㼘㼑㼠㼑㻌㼞㼑㼓㼡㼘㼍㼠㼕㼛㼚㼟㻌㼍㼚㼐㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㻌㼙㼍㼚㼡㼍㼘㻝㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻛㼛㼞㼓㼍㼚㼕㼦㼍㼠㼕㼛㼚㻢㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼟㼡㼜㼑㼞㼢㼕㼟㼕㼛㼚㻌㼛㼒㻌㼔㼕㼟㻛㼔㼑㼞㻌㼟㼡㼎㼛㼞㼐㼕㼚㼍㼠㼑㼟㻡㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼘㼍㼥㼛㼡㼠㻌㼍㼞㼞㼍㼚㼓㼑㼙㼑㼚㼠㻠㻌㻸㼍㼏㼗㻌㼛㼒㻌㼑㼐㼡㼏㼍㼠㼕㼛㼚㻌㼍㼚㼐㻌㼠㼞㼍㼕㼚㼕㼚㼓㻟㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼟㼍㼒㼑㼠㼥㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼜㼘㼍㼚㼚㼕㼚㼓㻞㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻛㼕㼚㼏㼛㼙㼜㼘㼑㼠㼑㻌㼞㼑㼓㼡㼘㼍㼠㼕㼛㼚㼟㻌㼍㼚㼐㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㻌㼙㼍㼚㼡㼍㼘㻝㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻛㼛㼞㼓㼍㼚㼕㼦㼍㼠㼕㼛㼚㻡㻌㻼㼛㼛㼞㻌㼣㼛㼞㼗㼕㼚㼓㻌㼑㼚㼢㼕㼞㼛㼚㼙㼑㼚㼠㻌㼏㼛㼚㼐㼕㼠㼕㼛㼚㼟㻠㻌㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼣㼛㼞㼗㼕㼚㼓㻌㼟㼜㼍㼏㼑㻟㻌㻵㼚㼍㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㻌㼣㼛㼞㼗㻌㼙㼑㼠㼔㼛㼐㻞㻌㼃㼛㼞㼗㻌㼜㼞㼑㼜㼍㼞㼑㼐㼚㼑㼟㼟㻛㼕㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼣㼛㼞㼗㼕㼚㼓㻌㼏㼛㼚㼐㼕㼠㼕㼛㼚㼟㻝㻌㻸㼍㼏㼗㻌㼛㼒㻌㼕㼚㼒㼛㼞㼙㼍㼠㼕㼛㼚㻌㼞㼑㼓㼍㼞㼐㼕㼚㼓㻌㼣㼛㼞㼗㻌㼠㼛㻌㼎㼑㻌㼏㼍㼞㼞㼕㼑㼐㻌㼛㼡㼠㻢㻌㻸㼍㼏㼗㻌㼛㼒㻌㼙㼍㼏㼔㼕㼚㼑㼞㼥㻌㼍㼚㼐㻌㼒㼍㼏㼕㼘㼕㼠㼥㻌㼙㼍㼕㼚㼠㼑㼚㼍㼚㼏㼑㻘㻌㼑㼠㼏㻚㻡㻌㻸㼍㼏㼗㻌㼛㼒㻌㼟㼠㼍㼚㼐㼍㼞㼐㼕㼦㼍㼠㼕㼛㼚㻠㻌㻸㼍㼏㼗㻌㼛㼒㻌㼏㼛㼚㼟㼕㼐㼑㼞㼍㼠㼕㼛㼚㻌㼞㼑㼓㼍㼞㼐㼕㼚㼓㻌㼑㼞㼓㼛㼚㼛㼙㼕㼏㻌㼒㼍㼏㼠㼛㼞㼟㻟㻌㻸㼍㼏㼗㻌㼛㼒㻌㼒㼡㼚㼐㼍㼙㼑㼚㼠㼍㼘㻌㼟㼍㼒㼑㼠㼥㻌㻔㼐㼑㼟㼕㼓㼚㻌㼍㼚㼐㻌㼑㼞㼓㼛㼚㼛㼙㼕㼏㼍㼞㼞㼍㼚㼓㼑㼙㼑㼚㼠㻕㻞㻌㻰㼑㼒㼑㼏㼠㼕㼢㼑㻌㼜㼞㼛㼠㼑㼏㼠㼕㼛㼚㻌㼍㼓㼍㼕㼚㼟㼠㻌㼔㼍㼦㼍㼞㼐㼟㻝㻌㻰㼑㼟㼕㼓㼚㻌㼒㼘㼍㼣㻌㼕㼚㻌㼠㼔㼑㻌㼙㼍㼏㼔㼕㼚㼑㼞㼥䐠䚷㼀㼛㼛㼘㻌㼎㼛㼤㻌㼙㼑㼑㼠㼕㼚㼓㻌㼣㼍㼟㻌㼚㼛㼠㻌㼕㼙㼜㼘㼑㼙㼑㼚㼠㼑㼐䐟䚷㻴㼑㼍㼘㼠㼔㻌㼏㼔㼑㼏㼗㻌㼚㼛㼠㻌㼕㼙㼜㼘㼑㼙㼑㼚㼠㼑㼐㻌㼜㼞㼕㼛㼞㻌㼠㼛㻌㼣㼛㼞㼗㼕㼚㼓䐢䚷㻼㼞㼛㼠㼑㼏㼠㼕㼢㼑㻌㼣㼑㼍㼞㻌㼚㼛㼠㻌㼣㼛㼞㼚䐡䚷㻯㼛㼢㼑㼞㼟㻌㼡㼜㻌㼛㼞㻌㼠㼛㼘㼑㼞㼍㼠㼑㼟㻌㼐㼕㼟㼔㼛㼚㼑㼟㼠㻌㼣㼛㼞㼗䐠䚷㻵㼚㼠㼑㼚㼠㼕㼛㼚㼍㼘㼘㼥㻌㼐㼕㼟㼔㼛㼚㼑㼟㼠㻌㼞㼑㼓㼍㼞㼐㼕㼚㼓㻌㼣㼛㼞㼗㻘㻌㼍㼚㼐㻌㼎㼞㼑㼍㼗㼟㻌㼠㼔㼑㼞㼡㼘㼑㼟䐟䚷㻺㼛㼠㻌䇾㼞㼑㼍㼐㼥䇿㻌㼠㼛㻌㼣㼛㼞㼗䐡㻌㻌㼀㼔㼑㻌㼎㼑㼘㼕㼑㼒㻌㼠㼔㼍㼠㻌㼠㼔㼑㻌㼣㼛㼞㼗㻌㼐㼛㼚㼑㻌㼕㼟㻌㼟㼍㼠㼕㼟㼒㼍㼏㼠㼛㼞㼥㻘㻌㼣㼔㼑㼚㼛㼎㼖㼑㼏㼠㼕㼢㼑㼘㼥㻌㼕㼠㻌㼕㼟㻌㼕㼚㼍㼐㼑㼝㼡㼍㼠㼑䐠㻌㻌㻺㼛㼠㻌㼑㼚㼛㼡㼓㼔㻌㼠㼞㼍㼕㼚㼕㼚㼓䐟䚷㼁㼚㼍㼏㼏㼡㼟㼠㼛㼙㼑㼐㻌㼠㼛㻌㼣㼛㼞㼗㻘㻌㼕㼚㼑㼤㼜㼑㼞㼕㼑㼚㼏㼑㼐㻘㻌㼕㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼟㼗㼕㼘㼘㼟䐣䚷㻸㼍㼏㼗㼟㻌㼎㼍㼟㼕㼏㻌㼗㼚㼛㼣㼘㼑㼐㼓㼑㻌㼛㼒㻌㼠㼔㼑㻌㼣㼛㼞㼗䐢䚷㻹㼕㼟㼠㼍㼗㼑㼟㻌㼞㼑㼓㼍㼞㼐㼕㼚㼓㻌㼣㼛㼞㼗㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㻛㻌㼒㼛㼞㼓㼑㼠㼒㼡㼘㼚㼑㼟㼟䐡䚷㻸㼍㼏㼗㻌㼛㼒㻌㼍㻌㼟㼑㼚㼟㼑㻌㼛㼒㻌㼡㼞㼓㼑㼚㼏㼥㻌㼍㼚㼐㻌㼍㼣㼍㼞㼑㼚㼑㼟㼟䐠䚷㼃㼛㼞㼗㻌㼏㼛㼚㼠㼑㼚㼠㻌㼚㼛㼠㻌㼡㼚㼐㼑㼞㼟㼠㼛㼛㼐㻌㼛㼞㻌㼙㼕㼟㼡㼚㼐㼑㼞㼟㼠㼛㼛㼐䐟䚷㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼛㼞㻌㼕㼚㼍㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㻌㼗㼚㼛㼣㼘㼑㼐㼓㼑㻌㼍㼎㼛㼡㼠㻌㼠㼔㼑㻌㼣㼛㼞㼗㼠㼛㻌㼎㼑㻌㼏㼍㼞㼞㼕㼑㼐㻌㼛㼡㼠䐢䚷㻯㼛㼙㼙㼕㼠㼙㼑㼚㼠㻌㻔㼞㼑㼟㼜㼛㼚㼟㼕㼎㼘㼑㻌㼕㼚㼠㼑㼞㼢㼑㼚㼠㼕㼛㼚㻕䐡㻌㻌㻯㼛㼙㼙㼡㼚㼕㼏㼍㼠㼕㼛㼚䐠䚷㻸㼑㼍㼐㼑㼞㼟㼔㼕㼜㻌㼍㼚㼐㻌㼠㼑㼍㼙㼣㼛㼞㼗䐟䚷㻰㼑㼟㼕㼞㼑㻌㼍㼚㼐㻌㼣㼕㼘㼘㼕㼚㼓㼚㼑㼟㼟䐣䚷㻭㼓㼑㼕㼚㼓

䐢䚷㻼㼔㼥㼟㼕㼏㼍㼘㻌㼍㼎㼕㼘㼕㼠㼥䐡䚷㻭㼘㼏㼛㼔㼛㼘㻘㻌㼙㼑㼐㼕㼏㼕㼚㼑㻌㼛㼞㻌㼐㼕㼟㼑㼍㼟㼑䐠䚷㻸㼍㼏㼗㻌㼛㼒㻌㼟㼘㼑㼑㼜䐟䚷㻲㼍㼠㼕㼓㼡㼑䐪䚷㻼㼑㼞㼟㼛㼚㼍㼘㼕㼠㼥䐩䚷㻴㼍㼎㼕㼠㼡㼍㼠㼕㼛㼚㻌㼜㼔㼑㼚㼛㼙㼑㼚㼛㼚䐨䚷㻹㼕㼟㼠㼍㼗㼑㼟㻌㼍㼚㼐㻌㼜㼑㼞㼏㼑㼜㼠㼡㼍㼘㻌㼕㼘㼘㼡㼟㼕㼛㼚䐧㻌㻌㻶㼡㼐㼓㼑㼙㼑㼚㼠㻌㼎㼍㼟㼑㼐㻌㼛㼚㻌㼟㼜㼑㼏㼡㼘㼍㼠㼕㼛㼚䐦䚷㻯㼡㼠㻌㼏㼛㼞㼚㼑㼞㼟䐥䚷㻹㼑㼚㼠㼍㼘㻌㼟㼔㼛㼞㼠㼏㼡㼠㼟䐤䚷㻿㼑㼚㼟㼑㻌㼛㼒㻌㼡㼞㼓㼑㼚㼏㼥㻌㼍㼚㼐㻌㼟㼑㼚㼟㼕㼠㼕㼢㼑㼘㼥䐣䚷㼁㼚㼏㼛㼚㼟㼏㼕㼛㼡㼟㻌㼍㼏㼠㼟䐢䚷㻼㼑㼞㼟㼛㼚㼍㼘㻌㼜㼞㼛㼎㼘㼑㼙㼟䐡䚷㻴㼍㼎㼕㼠㼡㼍㼠㼕㼛㼚㻌㼎㼑㼔㼍㼢㼕㼛㼡㼞䐠䚷㻲㼛㼞㼓㼑㼠㼒㼡㼘䐟䚷㻵㼙㼜㼡㼘㼟㼕㼢㼑㻌㼍㼏㼠㼕㼛㼚㻵㼚㻌䐟㻘㻌㼣㼞㼕㼠㼑㻌㼐㼛㼣㼚㻌㼍㻌㼐㼕㼞㼑㼏㼠㻌㼏㼍㼡㼟㼑㻌㼣㼔㼕㼏㼔㻌㼣㼍㼟㼕㼚㼢㼑㼟㼠㼕㼓㼍㼠㼑㼐㻌㼎㼍㼟㼑㼐㻌㼛㼚㻌㼠㼔㼑㻌㼒㼍㼏㼠㼟㻚㻭㼒㼠㼑㼞㻌䐠㻘㻌㼣㼞㼕㼠㼑㻌㼐㼛㼣㼚㻌㼠㼔㼑㻌㼞㼛㼛㼠㻌㼏㼍㼡㼟㼑㻌㼡㼟㼕㼚㼓㻌㼠㼔㼑㻌㼃㼔㼥㼃㼔㼥㻌㻭㼚㼍㼘㼥㼟㼕㼟㻚㼀㼔㼑㼚㻘㻌㼏㼕㼞㼏㼘㼑㻌㼑㼍㼏㼔㻌㼍㼜㼜㼘㼕㼏㼍㼎㼘㼑㻌㼏㼍㼡㼟㼑㻚䚷䚷䚷㻾㼑㼓㼍㼞㼐㼕㼚㼓㼕㼠㼑㼙㼟㻌㼛㼠㼔㼑㼞㻌㼠㼔㼍㼚㻌㻹㼍㼚㻌㻔㻴㼡㼙㼍㼚㻌㼒㼍㼏㼠㼛㼞㼟㻕㻘㻌㼑㼚㼠㼑㼞㻌㼠㼔㼑㼟㼡㼎㻙㼕㼠㼑㼙㻌㼚㼡㼙㼎㼑㼞㻌㼛㼒㻌㼑㼍㼏㼔㻌㼕㼠㼑㼙㻌㼕㼚㻌㼠㼔㼑㻌䠐㻹㻯㼘㼍㼟㼟㼕㼒㼕㼏㼍㼠㼕㼛㼚㻌㻸㼕㼟㼠㻚㻟㻻㼞㼓㼍㼚㼕㼦㼍㼠㼕㼛㼚㼍㼘㻞㻌㻱㼙㼛㼠㼕㼛㼚㼍㼘㻹㼑㼐㼕㼍㻹㼑㼏㼔㼍㼚㼕㼏㼍㼘㻌㼒㼍㼏㼠㼛㼞㼟㻌㼟㼡㼏㼔㻹㼑㼐㼕㼍㻌㼏㼛㼚㼚㼑㼏㼠㼕㼚㼓㼍㼟㻌㼙㼍㼏㼔㼕㼚㼑㼞㼥㻌㼚㼛㼠㻹㼍㼚㻌㼣㼕㼠㼔㻌㻹㼍㼏㼔㼕㼚㼑㼞㼥㼣㼛㼞㼗㼕㼚㼓㻌㼜㼞㼛㼜㼑㼞㼘㼥㻌㼛㼞㼎㼑㼕㼚㼓㻌㼛㼡㼠㻌㼛㼒㻌㼛㼞㼐㼑㼞㻴㼡㼙㼍㼚㻌㼒㼍㼏㼠㼛㼞㻌㻔㼀㼔㼑㻌㼢㼑㼟㼟㼑㼘㻘㻌㼟㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼏㼛㼙㼜㼍㼚㼥䠅㻹㼍㼟㼠㼑㼞㻦䚷㼀㼔㼑㻌㻹㼍㼟㼠㼑㼞㻌㼕㼚㼠㼑㼚㼐㼑㼐㻌㼠㼛㻌㼠㼡㼞㼚㻌㼠㼔㼑㼞㼡㼐㼐㼑㼞㻌㼏㼛㼚㼠㼞㼛㼘㻌㼟㼣㼕㼠㼏㼔㻌㼠㼛㻌㼞㼑㼙㼛㼠㼑㻌㼏㼛㼚㼠㼞㼛㼘㻌㼎㼡㼠㼐㼕㼐㻌㼚㼛㼠㻌㼢㼑㼞㼕㼒㼥㻌㼠㼔㼍㼠㻌㼠㼔㼕㼟㻌㼔㼍㼐㻌㼕㼚㼐㼑㼑㼐㻌㼎㼑㼑㼚㻌㼐㼛㼚㼑㻚䐟䐠 㼃㼔㼥㻌㼏㼛㼡㼘㼐㻌㼔㼑㻌㼚㼛㼠㻌㼏㼔㼑㼏㼗㻫䚽 䚽䚽䐡 㼃㼔㼥㻌㼣㼍㼟㻌㼠㼔㼑㼞㼑㻌㼚㼛㻌㼣㼍㼞㼚㼕㼚㼓㻌㼟㼛㼡㼚㼐㻫

䚽

䚽 䚽

䚽 䚽

䚽 䚽

䚽 䚽 䚽

䚽

䐢
䐣
䐤
䐟

䐠

㻯㼛㼙㼜㼍㼚㼥㻦䚷㻻㼜㼑㼞㼍㼠㼕㼚㼓㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㼟㻌㼒㼛㼞㼕㼙㼜㼛㼞㼠㼍㼚㼠㻌㼑㼝㼡㼕㼜㼙㼑㼚㼠㻌㼔㼍㼐㻌㼚㼛㼠㻌㼎㼑㼑㼚㼕㼚㼏㼛㼞㼜㼛㼞㼍㼠㼑㼐㻌㼕㼚㼠㼛㻌㻿㼍㼒㼑㼠㼥㻌㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㻯㼛㼐㼑㻔㻿㻹㻿㻕㻚
㼃㼔㼥㻌㼣㼍㼟㻌㼠㼔㼕㼟㻌㼚㼛㼠㻌㼕㼚㼏㼛㼞㼜㼛㼞㼍㼠㼑㼐㻌㼕㼚㼠㼛㻌㼠㼔㼑㻌㼟㼍㼒㼑㼠㼥㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼞㼑㼓㼡㼘㼍㼠㼕㼛㼚㼟㻫

䚽

䐡

䚽

䚽

䚽
䚽

䐢
䐣
䐤
䐟
䐠
䐡
䐢
䐣
䐤
䐟
䐠
䐡
䐢
䐣
䐤

Fig. 49

Vessel A 's “Unsafe conditions” (Attachment 18）

The Unsafe conditions identified in the Summary of related facts are as follows:
The Master operates the rudder mode control switch by himself. However, considering thatthe safety measures for the equipment are inadequate in terms of human characteristics,① Human beings sometimes make mistakes, ③ Human beings sometimes forget, and⑨ Human beings sometimes make assumptions; it is considered to be unsafe (condition).
Also, in terms of company management, unsafe conditions are highlighted by the lack of
80

JAPAN P& I CLUBprocedure manuals and safety management codes. If we circle the items in Attachment 18,
the following points emerge as common for both Master and company management:
Machine (Mechanical factors such as machinery not working
properly or being out of order)

2 Defective protection against hazards and 4 Lack of consideration regarding
ergonomic factors
Management (Control factors and organization)

On the vessel ：2 Inadequate/incomplete regulations and procedure manual and3 Inadequate safety management planning
Company：2 Inadequate/incomplete regulations and procedure manual and3 Inadequate safety management planning

4 Preventive measures for Unsafe behaviour of Master(Fig. 50 and Attachment 19)
Attachment 19㻹㼍㼞㼕㼠㼕㼙㼑㻌㻭㼏㼏㼕㼐㼑㼚㼠䚷㻭㼚㼍㼘㼥㼟㼕㼟㻌㼡㼟㼕㼚㼓㻌䠐㻹䠑㻱㻌㼍㼚㼐㻌㻯㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㻌㻸㼕㼟㼠㻌㻔㼁㼚㼟㼍㼒㼑㻌㻮㼑㼔㼍㼢㼕㼛㼡㼞㻕㻦㻌㼂㼑㼟㼟㼑㼘㻌㻭䚷㻽㼡㼍㼥㻌㼏㼛㼘㼘㼕㼟㼕㼛㼚㻌㼍㼏㼏㼕㼐㼑㼚㼠㻹㼍㼚㻌㼀㼔㼑㻌㼢㼑㼟㼟㼑㼘㻘㻌㼟㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼏㼛㼙㼜㼍㼚㼥㻭㼘㼘㻌㼠㼔㼞㼑㼑㻌㼛㼒㻌㼠㼔㼑㻌㻹㼍㼟㼠㼑㼞㻓㼟㻌㼡㼚㼟㼍㼒㼑㻌㼎㼑㼔㼍㼢㼕㼛㼡㼞㼟㻌㼔㼍㼢㼑㻌㼍㻌㼏㼛㼙㼙㼛㼚㻌㼐㼕㼞㼑㼏㼠㻌㼏㼍㼡㼟㼑㻚㻹㼍㼏㼔㼕㼚㼑
㻌㻹㼍㼕㼚㼘㼥㻌㼛㼚㻌㼠㼔㼑㻌㼢㼑㼟㼟㼑㼘㻺㼛㻌㼣㼍㼞㼚㼕㼚㼓㻌㼒㼛㼞㻌㼕㼚㼏㼛㼞㼞㼑㼏㼠㻌㼛㼜㼑㼞㼍㼠㼕㼛㼚㻭㼠㼠㼍㼏㼔㼙㼑㼚㼠㻌㻝㻥㻹㼑㼐㼕㼍㻌㼀㼔㼑㻌㼢㼑㼟㼟㼑㼘㻘㻌㼟㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼏㼛㼙㼜㼍㼚㼥㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㻻㼚㻌㼠㼔㼑㻌㼢㼑㼟㼟㼑㼘㻿㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼏㼛㼙㼜㼍㼚㼥㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼔㼍㼚㼐㼘㼕㼚㼓㻌㼕㼚㼟㼠㼞㼡㼏㼠㼕㼛㼚㼟㻌㼒㼛㼞㻌㼏㼞㼕㼠㼕㼏㼍㼘 㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼔㼍㼚㼐㼘㼕㼚㼓㻌㼕㼚㼟㼠㼞㼡㼏㼠㼕㼛㼚㼟㻌㼒㼛㼞㻌㼏㼞㼕㼠㼕㼏㼍㼘㼑㼝㼡㼕㼜㼙㼑㼚㼠㼑㼝㼡㼕㼜㼙㼑㼚㼠㻌㻾㼕㼟㼗㻌㼒㼍㼏㼠㼛㼞㼟䠄㻰㼕㼞㼑㼏㼠㻌㼏㼍㼡㼟㼑㻌㼍㼚㼐㻌㼕㼚㼐㼕㼞㼑㼏㼠㻛㼞㼛㼛㼠㻌㼏㼍㼡㼟㼑䠅 䐟䚷㻵㼙㼜㼡㼘㼟㼕㼢㼑㻌㼍㼏㼠㼕㼛㼚䠄㼟㼕㼚㼓㼘㼑㻙㼙㼕㼚㼐㼑㼐㻌㼒㼛㼏㼡㼟㻌㼛㼚㻌㼠㼔㼑㻌㼢㼑㼟㼟㼑㼘㻌㼟㼜㼑㼑㼐㻌㼍㼚㼐㻌㼐㼕㼟㼠㼍㼚㼏㼑㻌㼠㼛㻌㼠㼔㼑㻌㼝㼡㼍㼥㻕䚷䐠䚷㻲㼛㼞㼓㼑㼠㼒㼡㼘䠄㼁㼚㼍㼎㼘㼑㻌㼠㼛㻌㼙㼡㼘㼠㼕㻌㼠㼍㼟㼗䠅䐡䚷㻴㼍㼎㼕㼠㼡㼍㼠㼕㼛㼚㻌㼎㼑㼔㼍㼢㼕㼛㼡㼞㻦㻌㼎㼍㼐㻌㼔㼍㼎㼕㼠㻌㻔㻴㼡㼙㼍㼚㻌㼎㼑㼕㼚㼓㼟㻌㼔㼍㼢㼑㻌㼙㼛㼙㼑㼚㼠㼟㻌㼛㼒㻌㼕㼚㼍㼠㼠㼑㼚㼠㼕㼛㼚㻕䐣䚷㼁㼚㼏㼛㼚㼟㼏㼕㼛㼡㼟㻌㼍㼏㼠㼟䐤䚷㻿㼑㼚㼟㼑㻌㼛㼒㻌㼡㼞㼓㼑㼚㼏㼥㻌㼍㼚㼐㻌㼟㼑㼚㼟㼕㼠㼕㼢㼑㼘㼥䐥䚷㻹㼑㼚㼠㼍㼘㻌㼟㼔㼛㼞㼠㼏㼡㼠㼟䠄㻴㼡㼙㼍㼚㻌㼎㼑㼕㼚㼓㼟㻌㼍㼞㼑㻌㼟㼛㼙㼑㼠㼕㼙㼑㼟㻌㼕㼚㻌㼍㻌㼔㼡㼞㼞㼥㻕䐦䚷㻯㼡㼠㼟㻌㼏㼛㼞㼚㼑㼞㼟㻦㻌㼎㼞㼑㼍㼗㼟㻌㼠㼔㼑㻌㼞㼡㼘㼑㼟㻌㼐㼡㼑㻌㼠㼛㻌㼑㼤㼠㼞㼍㻌㼣㼛㼞㼗㻌㼍㼘㼘㻌㼛㼒㻌㼍㻌㼟㼡㼐㼐㼑㼚㻌㼛㼞㻌㼒㼍㼠㼕㼓㼡㼑䐧䚷㻶㼡㼐㼓㼑㼙㼑㼚㼠㻌㼎㼍㼟㼑㼐㻌㼛㼚㻌㼟㼜㼑㼏㼡㼘㼍㼠㼕㼛㼚㻦㻌㼟㼡㼎㼖㼑㼏㼠㼕㼢㼑㻌㼐㼑㼏㼕㼟㼕㼛㼚㻌㼍㼚㼐㻌㼣㼕㼟㼔㼒㼡㼘㻌㼛㼎㼟㼑㼞㼢㼍㼠㼕㼛㼚㻌㻔㻴㼡㼙㼍㼚㼎㼑㼕㼚㼓㼟㻌㼟㼛㼙㼑㼠㼕㼙㼑㼟㻌㼙㼍㼗㼑㻌㼍㼟㼟㼡㼙㼜㼠㼕㼛㼚㼟㻕䐩䚷㻴㼍㼎㼕㼠㼡㼍㼠㼕㼛㼚㻌㼜㼔㼑㼚㼛㼙㼑㼚㼛㼚㻦㻌㼒㼍㼘㼟㼑㻌㻌㼟㼡㼏㼏㼑㼟㼟㻌㼑㼤㼜㼑㼞㼕㼑㼚㼏㼑㻌㻔㻴㼡㼙㼍㼚㻌㼎㼑㼕㼚㼓㼟㻌㼔㼍㼢㼑㻌㼙㼛㼙㼑㼚㼠㼟㻌㼛㼒㼕㼚㼍㼠㼠㼑㼚㼠㼕㼛㼚㻕㻱㼐㼡㼏㼍㼠㼕㼛㼚㻱㼐㼡㼏㼍㼠㼕㼛㼚㻌㼍㼚㼐㻌㼠㼞㼍㼕㼚㼕㼚㼓㻷㼚㼛㼣㼘㼑㼐㼓㼑㻘㻌㼟㼗㼕㼘㼘㼟㻘㻌㼏㼛㼚㼟㼏㼕㼛㼡㼟㼚㼑㼟㼟㻘㻌㼎㼑㼕㼚㼓㻌㼓㼕㼢㼑㼚㼕㼚㼒㼛㼞㼙㼍㼠㼕㼛㼚㻘㻌㼑㼠㼏㻚㻭㼟㻌㼍㼚㻌㼑㼤㼜㼑㼞㼕㼑㼚㼏㼑㼐㻌㼟㼜㼑㼏㼕㼍㼘㼕㼟㼠㻘㻌㼔㼑㻌㼕㼟㻌㼠㼛㻌㼎㼑㻌㼣㼑㼘㼘㻌㼍㼣㼍㼞㼑㻌㼛㼒㻌㼠㼔㼑㻌㼕㼙㼜㼛㼞㼠㼍㼚㼏㼑㻌㼛㼒㻌㼏㼛㼙㼜㼘㼥㼕㼚㼓㻌㼣㼕㼠㼔㼣㼛㼞㼗㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㼟㻚㻌㼀㼔㼑㼞㼑㼒㼛㼞㼑㻘㻌㼔㼑㻌㼚㼑㼑㼐㼟㻌㼠㼛㻌㼎㼑㻌㼠㼞㼍㼕㼚㼑㼐㻌㼠㼛㻌㼞㼑㼏㼛㼓㼚㼕㼟㼑㻌㼜㼟㼥㼏㼔㼛㼘㼛㼓㼕㼏㼍㼘㻌㼒㼍㼏㼠㼛㼞㼟㻚㻱㼚㼓㼕㼚㼑㼑㼞㼕㼚㼓㼀㼑㼏㼔㼚㼛㼘㼛㼓㼥㻌㼍㼚㼐㻌㼑㼚㼓㼕㼚㼑㼑㼞㼕㼚㼓㻭㼐㼖㼡㼟㼠㻌㼠㼔㼑㻌㼐㼑㼢㼕㼏㼑㻌㼟㼛㻌㼠㼔㼍㼠㻌㼍㻌㼘㼍㼙㼜㻌㼘㼕㼓㼔㼠㼟㻌㼡㼜㼍㼚㼐㻌㼍㻌㼣㼍㼞㼚㼕㼚㼓㻌㼕㼟㻌㼟㼛㼡㼚㼐㼑㼐㻌㼕㼒㻌㼕㼠㻌㼕㼟㻌㼛㼜㼑㼞㼍㼠㼑㼐㼕㼚㼏㼛㼞㼞㼑㼏㼠㼘㼥㼀㼑㼏㼔㼚㼛㼘㼛㼓㼕㼏㼍㼘㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟䚷㻱㼝㼡㼕㼜㼙㼑㼚㼠㻌㼕㼟㻌㼕㼚㼟㼠㼍㼘㼘㼑㼐㻌㼠㼛㻌㼍㼟㼟㼕㼟㼠㻌㼔㼡㼙㼍㼚㼏㼔㼍㼞㼍㼏㼠㼑㼞㼕㼟㼠㼕㼏㼟㻦㻌㻴㼡㼙㼍㼚㻌㼎㼑㼕㼚㼓㼟㻌㼟㼛㼙㼑㼠㼕㼙㼑㼟㼙㼍㼗㼑㻌㼙㼕㼟㼠㼍㼗㼑㼟㻌㼍㼚㼐㻌㼒㼛㼞㼓㼑㼠㻱㼚㼒㼛㼞㼏㼑㼙㼑㼚㼠㻯㼞㼑㼍㼠㼕㼛㼚㻌㼛㼒㻌㼙㼍㼚㼡㼍㼘㼟㻌㼍㼚㼐㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㼟㻌㼕㼚㻌㼑㼍㼏㼔 㻰㼑㼢㼑㼘㼛㼜㻌㼣㼞㼕㼠㼠㼑㼚㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㼟㻘㻌㼟㼡㼏㼔㻌㼍㼟㻌㼛㼚㻙㼟㼕㼠㼑㼕㼚㼟㼠㼞㼡㼏㼠㼕㼛㼚㼟㻌㼒㼛㼞㻌㼕㼙㼜㼛㼞㼠㼍㼚㼠㻌㼑㼝㼡㼕㼜㼙㼑㼚㼠㻘㻌㼍㼚㼐㻌㼕㼚㼏㼛㼞㼜㼛㼞㼍㼠㼑㼢㼑㼟㼟㼑㼘
㼠㼔㼑㼙㻌㼕㼚㼠㼛㻌㻿㼍㼒㼑㼠㼥㻌㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㻯㼛㼐㼑㻌㻔㻿㻹㻿㻕㻚㼀㼔㼛㼞㼛㼡㼓㼔㻌㼓㼡㼕㼐㼍㼚㼏㼑㻌㼍㼚㼐㻌㼑㼚㼒㼛㼞㼏㼑㼙㼑㼚㼠㻿㼠㼍㼚㼐㼍㼞㼐㼕㼦㼍㼠㼕㼛㼚㻘㻌㼜㼞㼛㼏㼑㼐㼡㼞㼍㼘㼕㼦㼍㼠㼕㼛㼚㻘㼍㼘㼑㼞㼠㼕㼚㼓㻘㻌㼞㼑㼣㼍㼞㼐㻌㼍㼚㼐㻌㼜㼡㼚㼕㼟㼔㼙㼑㼚㼠㻷㼅㼀㻘㻌㼏㼍㼙㼜㼍㼕㼓㼚㼟㻌㼑㼠㼏㻚㻱㼤㼍㼙㼜㼘㼑㼟
㻯㼍㼟㼑㻌㼟㼠㼡㼐㼕㼑㼟㻘㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻌㼍㼚㼐㼞㼡㼘㼑㼟㼀㼔㼑㻌㼏㼍㼞㼞㼥㼕㼚㼓㻌㼛㼡㼠㻌㼛㼒㻌㼠㼞㼍㼕㼚㼕㼚㼓㻌㼛㼚㻌㼞㼑㼏㼡㼞㼞㼑㼚㼏㼑㻌㼜㼞㼑㼢㼑㼚㼠㼕㼛㼚㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻳㼑㼠㻌㼕㼚㼢㼛㼘㼢㼑㼐㻌㼣㼕㼠㼔㻌㼏㼞㼑㼍㼠㼕㼚㼓㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㻌㼙㼍㼚㼡㼍㼘㻚㻌㻭㼘㼟㼛㻘㻌㼔㼑㻌㼣㼕㼘㼘㻌㼎㼑㼏㼛㼙㼑㻌㼍㼚㻌㼕㼚㼟㼠㼞㼡㼏㼠㼛㼞㻌㼒㼛㼞㻌㼠㼞㼍㼕㼚㼕㼚㼓㼎㼍㼟㼑㼐㻌㼛㼚㻌㼔㼕㼟㻌㼛㼣㼚㻌㼑㼤㼜㼑㼞㼕㼑㼚㼏㼑㻌㼠㼛㻌㼠㼑㼍㼏㼔㻌㼛㼠㼔㼑㼞㻌㻹㼍㼟㼠㼑㼞㼟㻌㼍㼚㼐㻌㼛㼠㼔㼑㼞㻌㼞㼑㼘㼍㼠㼑㼐㻌㼍㼡㼐㼕㼑㼚㼏㼑㼟㻚㻸㼑㼍㼐㻌㼎㼥㻌㼑㼤㼍㼙㼜㼘㼑㻘㻌㼑㼤㼜㼑㼞㼕㼑㼚㼏㼑㻌㼛㼒㻌㼟㼡㼏㼏㼑㼟㼟㻵㼚㼠㼞㼛㼐㼡㼏㼑㻌㼙㼛㼐㼑㼘㻌㼏㼍㼟㼑㼟㻘㻌䇾㻴㼕㼥㼍㼞㼕㻙㻴㼍㼠㼠㼛䇿㻔㼚㼑㼍㼞㻌㼙㼕㼟㼟㼑㼟㻕㻘㻌㼑㼠㼏㻚㻱㼚㼢㼕㼞㼛㼚㼙㼑㼚㼠㻌㼃㼛㼞㼗㼕㼚㼓㻌㼑㼚㼢㼕㼞㼛㼚㼙㼑㼚㼠㻘㻌㼛㼒㼒㼕㼏㼑㻌㼕㼚㼠㼑㼞㼚㼍㼘㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻘㻌㼛㼚㻙㼎㼛㼍㼞㼐㻌㼛㼞㼓㼍㼚㼕㼦㼍㼠㼕㼛㼚㻘㻌㼑㼠㼏㻚

Fig. 50 Vessel A's Preventive measures for “Unsafe behaviour” (See Attachment 17）

81

P&I Loss Prevention Bulletin
In 2 Analysis of Accident Cause (Unsafe behaviour) (Attachment 17), we analysed
the causes applicable with Man, Machine (machinery and equipment) and Management(management and organization). For each of these items, it will be a requirement that thefollowing improvement measures be considered and carried out:

① Man
Education/training: knowledge, skills, consciousness, being given information, etc.

As an experienced Master, he is to be well aware of the importance of complying withwork procedures. Therefore, an eﬀective measure will be for him to receive training thathelps him recognise psychological factors.
Example(Case studies, countermeasures and rules：Lead by example, experienceof success, introduce model cases, Hiyari-Hatto (near misses), etc.)

The Japan Marine Accident Tribunal judged that the Master’s third grade maritime
officer (Navigation) certificate be suspended for one month. However, he should befully aware of what caused the accident and how the vessel was manoeuvred to this end.
Therefore, instead of letting this experience go to waste, it would be useful for him to
get involved with creating procedure manuals, and becoming an instructor for training topass on such valuable experience to other Masters and related audiences.
② Machine (machinery and equipment)
Regarding Machine (machinery and equipment), the risk factors mentioned refer to theequipment not warning the operator (e.g. alarm sounds) when it is operated incorrectly,
so the following countermeasures should be considered.
Engineering (Technology and engineering：Physical countermeasures)

As human beings sometimes make mistakes and forget, equipment is to be installed toassist such characteristics, whereby a lamp lights up and a warning is sounded in caseof incorrect operation (error in the output process). After this accident, the shipowner
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JAPAN P& I CLUBrequested the manufacturer to modify the rudder switch on the control stand so that it
sounds an electronic tone for a few seconds when it is in the remote position.
③ Management (management and organization)
The vessel and the company (shipowner) are requested to create operation manuals andoperating procedure manuals, in particular on-site instructions for important equipment
such as rudder control and radar. In addition, such a procedure manual should be
included into the safety management code and SMS manuals.

5 Preventive measures for Unsafe conditions for Master and Company(Fig. 58 and Attachment 20)

Similar to “ 4 Preventive measures for unsafe behaviour of Master” and preventive
measures for unsafe conditions will be considered here as well.
Attachment 20㻹㼍㼞㼕㼠㼕㼙㼑㻌㻭㼏㼏㼕㼐㼑㼚㼠䚷㻭㼚㼍㼘㼥㼟㼕㼟㻌㼡㼟㼕㼚㼓㻌䠐㻹䠑㻱㻌㼍㼚㼐㻌㻯㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㻌㻸㼕㼟㼠㻌㻔㼁㼚㼟㼍㼒㼑㻌㼏㼛㼚㼐㼕㼠㼕㼛㼚㼟㻕䠖㻌㼂㼑㼟㼟㼑㼘㻌㻭䚷㻽㼡㼍㼥㻌㼏㼛㼘㼘㼕㼟㼕㼛㼚㻌㼍㼏㼏㼕㼐㼑㼚㼠㻹㼍㼚㻹㼍㼏㼔㼕㼚㼑

㻌㻌㼀㼔㼑㻌㼢㼑㼟㼟㼑㼘㻘㻌㼟㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼏㼛㼙㼜㼍㼚㼥㻹㼍㼕㼚㼘㼥㻌㼛㼚㻌㼠㼔㼑㻌㼢㼑㼟㼟㼑㼘㻺㼛㻌㼣㼍㼞㼚㼕㼚㼓㻌㼒㼛㼞㻌㼕㼚㼏㼛㼞㼞㼑㼏㼠㻌㼛㼜㼑㼞㼍㼠㼕㼛㼚㻭㼠㼠㼍㼏㼔㼙㼑㼚㼠㻌㻞㻜㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻹㼑㼐㼕㼍㼃㼛㼞㼗㻌㼍㼚㼐㻌㼑㼚㼢㼕㼞㼛㼚㼙㼑㼚㼠䍦㻌㻹㼑㼐㼕㼍㼏㼛㼚㼚㼑㼏㼠㼕㼚㼓㻌㻹㼍㼚㻌㼣㼕㼠㼔㻌㻹㼍㼏㼔㼕㼚㼑㼞㼥㼀㼔㼑㻌㼢㼑㼟㼟㼑㼘㻘㻌㼟㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼏㼛㼙㼜㼍㼚㼥㻌㻻㼚㻌㼠㼔㼑㻌㼢㼑㼟㼟㼑㼘㻿㼔㼕㼜㼛㼣㼚㼑㼞㻌㼍㼚㼐㻌㼟㼔㼕㼜㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㼏㼛㼙㼜㼍㼚㼥

㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼔㼍㼚㼐㼘㼕㼚㼓㻌㼕㼚㼟㼠㼞㼡㼏㼠㼕㼛㼚㼟㻌㼒㼛㼞㻌㼏㼞㼕㼠㼕㼏㼍㼘㼑㼝㼡㼕㼜㼙㼑㼚㼠㻵㼚㼍㼐㼑㼝㼡㼍㼠㼑㻌㼔㼍㼚㼐㼘㼕㼚㼓㻌㼕㼚㼟㼠㼞㼡㼏㼠㼕㼛㼚㼟㻌㼒㼛㼞㻌㼏㼞㼕㼠㼕㼏㼍㼘㼑㼝㼡㼕㼜㼙㼑㼚㼠㻯㼞㼑㼍㼠㼕㼛㼚㻌㼛㼒㻌㼙㼍㼚㼡㼍㼘㼟㻌㼍㼚㼐㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㼟㻌㼕㼚㻌㼑㼍㼏㼔㼢㼑㼟㼟㼑㼘

㼀㼔㼑㻌㼏㼍㼞㼞㼥㼕㼚㼓㻌㼛㼡㼠㻌㼛㼒㻌㼠㼞㼍㼕㼚㼕㼚㼓㻌㼛㼚㻌㼞㼑㼏㼡㼞㼞㼑㼚㼏㼑㼜㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻾㼕㼟㼗㻌㼒㼍㼏㼠㼛㼞㼟䠄㻰㼕㼞㼑㼏㼠㻌㼏㼍㼡㼟㼑㻌㼍㼚㼐㻌㼕㼚㼐㼕㼞㼑㼏㼠㻛㼞㼛㼛㼠㻌㼏㼍㼡㼟㼑䠅㻱㼐㼡㼏㼍㼠㼕㼛㼚㻱㼐㼡㼏㼍㼠㼕㼛㼚㻌㼍㼚㼐㻌㼠㼞㼍㼕㼚㼕㼚㼓㻷㼚㼛㼣㼘㼑㼐㼓㼑㻘㻌㼟㼗㼕㼘㼘㼟㻘㻌㼏㼛㼚㼟㼏㼕㼛㼡㼟㼚㼑㼟㼟㻘㻌㼎㼑㼕㼚㼓㼓㼕㼢㼑㼚㻌㼕㼚㼒㼛㼞㼙㼍㼠㼕㼛㼚㻘㻌㼑㼠㼏㻚㻱㼚㼓㼕㼚㼑㼑㼞㼕㼚㼓㼀㼑㼏㼔㼚㼛㼘㼛㼓㼥㻌㼍㼚㼐㻌㼑㼚㼓㼕㼚㼑㼑㼞㼕㼚㼓㼀㼑㼏㼔㼚㼛㼘㼛㼓㼕㼏㼍㼘㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻭㼐㼖㼡㼟㼠㻌㼠㼔㼑㻌㼐㼑㼢㼕㼏㼑㻌㼟㼛㻌㼠㼔㼍㼠㻌㼍㻌㼘㼍㼙㼜㻌㼘㼕㼓㼔㼠㼟㻌㼡㼜㻌㼍㼚㼐㻌㼍㼣㼍㼞㼚㼕㼚㼓㻌㼕㼟㻌㼟㼛㼡㼚㼐㼑㼐㻌㼕㼒㻌㼕㼠㻌㼕㼟㻌㼛㼜㼑㼞㼍㼠㼑㼐㻌㼕㼚㼏㼛㼞㼞㼑㼏㼠㼘㼥㻚㻱㼝㼡㼕㼜㼙㼑㼚㼠㻌㼕㼟㻌㼕㼚㼟㼠㼍㼘㼘㼑㼐㻌㼠㼛㻌㼍㼟㼟㼕㼟㼠㻌㼔㼡㼙㼍㼚㼏㼔㼍㼞㼍㼏㼠㼑㼞㼕㼟㼠㼕㼏㼟㻦㻌㻴㼡㼙㼍㼚㻌㼎㼑㼕㼚㼓㼟㻌㼟㼛㼙㼑㼠㼕㼙㼑㼟㻌㼙㼍㼗㼑㼙㼕㼟㼠㼍㼗㼑㼟㻌㼍㼚㼐㻌㼒㼛㼞㼓㼑㼠㻚㻱㼚㼒㼛㼞㼏㼑㼙㼑㼚㼠㼀㼔㼛㼞㼛㼡㼓㼔㻌㼓㼡㼕㼐㼍㼚㼏㼑㻌㼍㼚㼐㻌㼑㼚㼒㼛㼞㼏㼑㼙㼑㼚㼠㻿㼠㼍㼚㼐㼍㼞㼐㼕㼦㼍㼠㼕㼛㼚㻘㻌㼜㼞㼛㼏㼑㼐㼡㼞㼍㼘㼕㼦㼍㼠㼕㼛㼚㻘㼍㼘㼑㼞㼠㼕㼚㼓㻘㻌㼞㼑㼣㼍㼞㼐㻌㼍㼚㼐㻌㼜㼡㼚㼕㼟㼔㼙㼑㼚㼠㻰㼑㼢㼑㼘㼛㼜㻌㼣㼞㼕㼠㼠㼑㼚㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㼟㻘㻌㼟㼡㼏㼔㻌㼍㼟㻌㼛㼚㻙㼟㼕㼠㼑㼕㼚㼟㼠㼞㼡㼏㼠㼕㼛㼚㼟㻌㼒㼛㼞㻌㼕㼙㼜㼛㼞㼠㼍㼚㼠㻌㼑㼝㼡㼕㼜㼙㼑㼚㼠㻘㻌㼍㼚㼐㼕㼚㼏㼛㼞㼜㼛㼞㼍㼠㼑㻌㼠㼔㼑㼙㻌㼕㼚㼠㼛㻌㻿㼍㼒㼑㼠㼥㻌㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻯㼛㼐㼑㻌㻔㻿㻹㻿㻕㻚㻷㼅㼀㻘㻌㼏㼍㼙㼜㼍㼕㼓㼚㼟㻌㼑㼠㼏㻚㻱㼤㼍㼙㼜㼘㼑㼟
㻯㼍㼟㼑㻌㼟㼠㼡㼐㼕㼑㼟㻘㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻌㼍㼚㼐㻌㼞㼡㼘㼑㼟㻸㼑㼍㼐㻌㼎㼥㻌㼑㼤㼍㼙㼜㼘㼑㻘㻌㼑㼤㼜㼑㼞㼕㼑㼚㼏㼑㻌㼛㼒㻌㼟㼡㼏㼏㼑㼟㼟㻘㻵㼚㼠㼞㼛㼐㼡㼏㼑㻌㼙㼛㼐㼑㼘㻌㼏㼍㼟㼑㼟㻘㻌䇾㻴㼕㼥㼍㼞㼕㻙㻴㼍㼠㼠㼛䇿㻔㼚㼑㼍㼞㻌㼙㼕㼟㼟㼑㼟㻕㻘㻌㼑㼠㼏㻚㻱㼚㼢㼕㼞㼛㼚㼙㼑㼚㼠㻌㼃㼛㼞㼗㼕㼚㼓㻌㼑㼚㼢㼕㼞㼛㼚㼙㼑㼚㼠㻘㻌㼛㼒㼒㼕㼏㼑㻌㼕㼚㼠㼑㼞㼚㼍㼘㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻘㻌㼛㼚㻙㼎㼛㼍㼞㼐㻌㼛㼞㼓㼍㼚㼕㼦㼍㼠㼕㼛㼚㻘㻌㼑㼠㼏㻚

Fig. 51 Vessel Aʼs Preventive measures for “Unsafe conditions” (See Attachment 20）

83

P&I Loss Prevention Bulletin① Machine (machinery and equipment)
Similar to Unsafe behaviour, there was no warning sound or warning light to indicatethat the equipment was being operated incorrectly, so it was in an Unsafe condition. The
remedy is the same as for Unsafe behaviour.

② Management (management and organization)
There were deficiencies in handling procedures etc. for important equipment, which had
not been incorporated into the Safety Management Code (SMS), thus, it was determined
to be in an Unsafe condition. In order to prevent the recurrence of unsafe conditions,unlike unsafe behaviour, the creation of procedures and operation manuals and theirincorporation into the Safety Management Code (SMS) have been incorporated into
Enforcement (thorough guidance).

5-6 Accident cause from the perspectiveof human error
Let us analyse the Master’s unsafe behaviour that caused the accident with 12 Human
characteristics and 5 Psychological factors (Figure 52) which invite human error,
introduced in Loss Prevention Bulletin Vol.50.

Twelve human characteristics
1

Human beings sometimes make mistakes

7

Human beings are sometimes in a hurry2

Human beings are sometimes careless8

Human beings sometimes become emotional3

Human beings sometimes forget

9

Human beings sometimes make assumptions

4

Human beings sometimes do not notice10

Human beings are sometimes lazy5

Human beings have moments of inattention

11

Human beings sometimes panic

6 ㅤHuman beings sometimes are able to see or

12

Human beings sometimes transgress when
no one is looking

think about only one thing at a time84

JAPAN P& I CLUBFive psychological factors
1

Psychological reactance（self-eﬃcacy）
This is when people do not wish to do something that is not of their own
volition. They may be inclined to say, “I won’t do what you tell me.”2

Entrainment phenomenon and peer pressureThis is when people follow the crowd, e.g., “What will the neighbours think?”

3

Normalcy bias ➡ justiﬁcation, cognitive dissonance
When people believe, “I’m special, nothing can hurt me!”4

Conﬁrmation bias
People are unconsciously prone to believe only “what they want to believe” and“information that supports what they believe” rather than purposefully seeking
information to the contrary. They may say something like, “Stop exaggerating!”
or “Everything will be fine!”

5Social loaﬁng
This is when someone does not choose to take the initiative. They may say,“Someone will do it for me.”Fig. 52

12 Human characteristics and 5 Psychological factors

The items corresponding to the “12 Human characteristics” and “5 Psychologicalfactors” shown in Figure 52 are summarised in Table 53 (Attachment 21) corresponding
to the human errors described in 5-2 Timeline of events leading up to the accident.

85

P&I Loss Prevention Bulletin
Attachment 21
㻭㼠㼠㼍㼏㼔㼙㼑㼚㼠㻌㻞㻝㻴㼡㼙㼍㼚㻌㼏㼔㼍㼞㼍㼏㼠㼑㼞㼕㼟㼠㼕㼏㼟㻘㻌㻴㼡㼙㼍㼚㻌㼑㼞㼞㼛㼞㻌㼍㼚㼐㻌㻼㼟㼥㼏㼔㼛㼘㼛㼓㼥䠖㼂㼑㼟㼟㼑㼘㻌㻭䚷㻽㼡㼍㼥㻌㼏㼛㼘㼘㼕㼟㼕㼛㼚㻌㼍㼏㼏㼕㼐㼑㼚㼠㻌㻰㼍㼠㼑㻌㼍㼚㼐㻌㼠㼕㼙㼑㻹㼛㼢㼑㼙㼑㼚㼠

㻴㼡㼙㼍㼚㻌㼑㼞㼞㼛㼞㼃㼔㼛㻫㻴㼡㼙㼍㼚㻌㼏㼔㼍㼞㼍㼏㼠㼑㼞㼕㼟㼠㼕㼏㼟㻼㼟㼥㼏㼔㼛㼘㼛㼓㼕㼏㼍㼘㻌㼒㼍㼏㼠㼛㼞㼟䐟 㻴㼡㼙㼍㼚㻌㼎㼑㼕㼚㼓㼟㻌㼟㼛㼙㼑㼠㼕㼙㼑㼟㻌㼙㼍㼗㼑㻌㼙㼕㼟㼠㼍㼗㼑㼟㻦䚷㻭㼙㼕㼟㼠㼍㼗㼑㻌㼕㼟㻌㼍㼜㼜㼍㼞㼑㼚㼠㼀㼔㼑㻌㻹㼍㼟㼠㼑㼞㻌㼕㼚㼠㼑㼚㼐㼑㼐㻌㼠㼛㻌㼡㼟㼑㻌㼠㼔㼑㻌㼖㼛㼥㼟㼠㼕㼏㼗㻌㼐㼑㼢㼕㼏㼑㻌㼠㼛㼏㼛㼚㼠㼞㼛㼘㻌㼠㼔㼑㻌㼂㼑㼏㼀㼣㼕㼚㻌㻾㼡㼐㼐㼑㼞㻌㼟㼥㼟㼠㼑㼙㻌㼠㼛㻌㼙㼍㼚㼛㼑㼡㼢㼞㼑㻌㼠㼔㼑㼟㼔㼕㼜㻌㼠㼛㻌㼠㼔㼑㻌㼟㼔㼛㼞㼑㻘㻌㼍㼚㼐㻌㼟㼣㼕㼠㼏㼔㻌㼠㼔㼑㻌㼞㼡㼐㼐㼑㼞㻌㼏㼛㼚㼠㼞㼛㼘㻌㼠㼛㼞㼑㼙㼛㼠㼑㻌㼏㼛㼚㼠㼞㼛㼘㻚㻝㻞㻦㻜㻜㻮㼑㼒㼛㼞㼑㻌㼜㼍㼟㼟㼕㼚㼓㼎㼞㼑㼍㼗㼣㼍㼠㼑㼞㻌㻺㼛㻚㻌㻡䐢 㻴㼡㼙㼍㼚㻌㼎㼑㼕㼚㼓㼟㻌㼟㼛㼙㼑㼠㼕㼙㼑㼟㻌㼐㼛㻌㼚㼛㼠㻌㼚㼛㼠㼕㼏㼑㻦㻌㻿㼣㼕㼠㼏㼔㼜㼛㼟㼕㼠㼕㼛㼚䐤 㻴㼡㼙㼍㼚㻌㼎㼑㼕㼚㼓㼟㻌㼍㼞㼑㻌㼟㼛㼙㼑㼠㼕㼙㼑㼟㻌㼛㼚㼘㼥㻌㼍㼎㼘㼑㻌㼠㼛㻌㼟㼑㼑㼛㼚㼑㻌㼠㼔㼕㼚㼓㻌㼍㼠㻌㼍㻌㼠㼕㼙㼑䠖㻌㻹㼛㼢㼑㼐㻌㼣㼕㼠㼔㼛㼡㼠㻌㼏㼔㼑㼏㼗㼕㼚㼓㻹㼍㼟㼠㼑㼞䐢*QYGXGTJGFKFPQVTGCNKUGVJCVVJGTWFFGTUYKVEJYCUUVWEMKPVJGPQPHQNNQYWRRQUKVKQP PQVUYKVEJKPIVQTGOQVGTWFFGTCPFOQXGFVQVJGRQTVUKFGQHVJGDTKFIGKP
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Table 53 Accident cause from the perspective of human error

The numbers given in the table in “Human characteristics” and “Psychological factors”
columns correspond with the numbers in Figure 52.

Human characteristics

The human characteristics regarding incorrect rudder switch control on the control stand,and the subsequent behaviour up to 12:08 (100m from the quay), can be summarised asfollows:① Human beings sometimes make mistakes：
The erroneously operated rudder control switch④ Human beings sometimes do not notice：
Did not notice switch position and did not notice the indication on therudder angle indicator⑥ Human beings are sometimes only able to see one thing at a time：

86

JAPAN P& I CLUBWithout checking the rudder control switch, moved to the port side of
the bridge in front of the control stand. Focussed on the operation of thejoystick only.
⑦ Human beings are sometimes in a hurry:
He was distracted by the berthing manoeuvre.
⑨ Human beings sometimes make assumptions：
VecTwin Rudder was in the neutral (hover) position, so the speed was only
reduced naturally, yet he believed that the ship speed had decelerated due
to his own manoeuvring.
⑪ Human beings sometimes panic：
When the quay was so close this caused a panic, and the situation could
not be calmly judged.

Psychological factors③ Normalcy bias：I always use the same ship-handling techniques and I neverfail. This is when people believe, I'm special, nothing can hurt me!
④ Conﬁrmation bias：People are psychologically prone to believe only what
they want to believe and information that supports what they believe
rather than purposefully seeking information to the contrary (Did not checkthe indication of each display panel).

These were the root causes behind the chain of human errors that led to the accident.

5-7 Risk assessment (Fig. 54, see Attachment 22)
Now let us carry out a risk assessment based on the report from the Japan Transport
Safety Board in hindsight of the accident.

87

P&I Loss Prevention Bulletin
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㼀㼔㼑㻌㼞㼕㼟㼗㻌㼍㼟㼟㼑㼟㼟㼙㼑㼚㼠㻌㼣㼍㼟㻌㼏㼍㼞㼞㼕㼑㼐㻌㼛㼡㼠㻌㼍㼟㻌㼐㼑㼟㼏㼞㼕㼎㼑㼐㻌㼍㼎㼛㼢㼑㻚㻭㼟㻌㼍㻌㼞㼑㼟㼡㼘㼠㻌㼛㼒㻌㼠㼔㼑㻌㼞㼕㼟㼗㻌㼍㼟㼟㼑㼟㼟㼙㼑㼚㼠㻘㻌㼣㼑㻌㼔㼑㼞㼑㼣㼕㼠㼔㻌㼏㼛㼚㼒㼕㼞㼙㻌㼠㼔㼍㼠㻌㻌㻌㻌㼟㼍㼒㼑㻌㼣㼛㼞㼗㻌㼕㼟 㻭㼟㻌㼍㼟㼟㼑㼟㼟㼑㼐㻌㼍㼟㻌㼍㼎㼛㼢㼑㻘㻌㼕㼠㻌㼕㼟㻌㼛㼡㼞㻌㼔㼛㼜㼑㻌㼠㼔㼍㼠㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻌㼍㼞㼑㼜㼛㼟㼟㼕㼎㼘㼑㻚㼕㼙㼜㼘㼑㼙㼑㼚㼠㼑㼐㻚㻿㼕㼓㼚㼍㼠㼡㼞㼑㻌㼛㼒㻌㼠㼔㼑㻌㼜㼑㼞㼟㼛㼚㻌㼞㼑㼟㼜㼛㼚㼟㼕㼎㼘㼑㻌㼒㼛㼞㻌㼠㼔㼑㻌㼛㼜㼑㼞㼍㼠㼕㼛㼚㻦㻹㼍㼟㼠㼑㼞㻓㼟㻌㼟㼕㼓㼚㼍㼠㼡㼞㼑㻌㻦㼅㼑㼟㻌㻌㻌㻌䚷䚷䞉㻌㻌㻌㻌䚷䚷㻺㼛㼀㼔㼑㻌㼞㼕㼟㼗㻌㼍㼒㼠㼑㼞㻌㼕㼙㼜㼘㼑㼙㼑㼚㼠㼕㼚㼓㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻌㼙㼡㼟㼠㻌㼎㼑㻌㼘㼑㼟㼟㻌㼠㼔㼍㼚㼛㼞㻌㼑㼝㼡㼍㼘㻌㼠㼛㻌㻎㻥㻎㻚

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䠍䡚䠎䠄㼂㼑㼞㼥㻌㼘㼛㼣䠅㻰㼍㼠㼑㻌㼞㼑㼢㼕㼟㼑㼐䠖㻰㻰㻛㻹㻹㻛㻞㻜㼅㼅㻸䠏䠄㻸㼛㼣䠅

㻹䠐䡚䠕㻌䠄㻹㼑㼐㼕㼡㼙䠅㻭㼒㼒㼕㼘㼕㼍㼠㼕㼛㼚㻌㼍㼚㼐㻌㼒㼡㼘㼘㻌㼚㼍㼙㼑㻌㻦㻴䠍䠌䡚䠍䠑㻌䠄㻴㼕㼓㼔䠅㻾㼑㼢㻚㻌㻺㼛㻚㻌㼄㼄

Fig. 54㻴㻴䠍䠒䡚䠎䠌㻌䠄㼂㼑㼞㼥㻌㼔㼕㼓㼔䠅㻺㼛㻚㻌㼛㼒㻌㼥㼑㼍㼞㼟㻌㼠㼛㻌㼎㼑㻌㼒㼕㼘㼑㼐㻌㼒㼛㼞㻦䚷㼄㻌㼥㼑㼍㼞㼟

Quay collision accident risk assessment

The following two items are identified as hazards:① Rudder control switch for remote control and joystick② Human characteristics and Psychological factors
Since people have 12 Human characteristics, such as making mistakes andassumptions, and 5 Psychological factors that induce Human error (Fig. 59),
we have identiﬁed Man: Master as a hazard.

5-7-1 Physical countermeasures
As to ways to improve the system, from an engineering point of view, it is a question of
how to make “the operator aware of their own human error”.
① Warning sound when switching modes
The ship owners had employed this system on vessel A, but since crew would

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JAPAN P& I CLUB
sometimes miss the sound, it was not deemed to be suﬃcient.

② Making the switch to remote mode a 2-stage operation③ Failure to complete both stages freeze the joystick rendering
it immobile② and ③ are based on the concept of foolproofing.

Foolprooﬁng
This is the idea of making machine operations “foolproof” by designing andincorporating mechanisms whereby operational errors do not lead to hazardous
situations. Concepts relating to safety engineering and design.
In cases like this, either the Master or the AB would be standing in front of thecontrol stand when switching modes.
When changing from manual mode to automatic, it is necessary to set a course
manually and then set the course heading automatically. It is therefore thought tobe not so necessary to build in a foolproof mechanism in this case.

Foolprooﬁng
Appropriate construction andequipment design so that mistakescannot be made in the first place

Safe
Trouble due
to mishandling

Accidental
operationp

The equipment operates as if nothing is wrong.
(We never know if a mistake has been made or not.)Fig. 55 Foolprooﬁng

Similarly, it is also thought to be of minimum necessity when switching from automatic
to manual or from manual to non-follow up mode since either the Master or the AB is89

P&I Loss Prevention Bulletin
directly operating the rudder at that time.
However, in cases like this the Master is handling the vessel alone. When he switches toremote control mode he must move from the steering pedestal to the remote control standon the port side of the bridge. There is plenty of scope for human error and as such it isnecessary to build in some kind of foolproofing mechanism.
Rather than ② simply switching from one mode to the next, one option would be to
make the switch to remote mode a 2-stage operation requiring the pulling (or pushing)of a lever to engage. Another alternative would be to build in some kind of required
verification check at the remote control stand.
“③ By modifying the system so that the joystick stays fixed unless it is switched toremote control”, or alternatively, the joystick could be locked when not switched toremote control.
For ocean going vessels which have both a Navigation Oﬃcer and an AB stationed inside
the bridge to operate the rudder, even if the Master makes a mistake, his actions stillneed to be verified by the other oﬃcers on duty. Therefore, putting good BRM (Bridge
Resource Management) into practice makes it possible to break the chain of sequential
errors.
However, for most coaster vessels, the Master is generally working alone. Considering
the limitations of BRM in these solo conditions, there is a need to incorporate some kindof engineering mechanism to make the system more foolproof.

5-7-2

Administrative countermeasures(How to break the chain of human error)

In section 5-2 Events that led to the accident, it has been explained that the accident
occurred as a result of a chain of following three human errors that could not be broken.

90

JAPAN P& I CLUBThe erroneously operated rudder control switch should have been changed from

1 automatic to manual, but was mistakenly stuck in the non-follow-up position andwas not checked afterwards.

Furthermore, the Master intended to switch from automatic to manual rudder, but

2 in fact switched from non-follow up to manual, and without realising it, moved to theremote control stand on the port side.

The Master thought he could control the course and speed by remote control withthe joystick lever. In fact, however, the vessel was heading straight ahead with no3 wind tide effect and the VecTwin Rudder was in the in neutral (hover) position, so
the speed was only reduced naturally. Also, the Master was operating the joystick
without checking the rudder angle indicator.

Summing up these three human errors, as explained in Figure 52 “12 Human
characteristics and 5 Psychological factors” of 5-6 Causes of accidents in terms ofhuman error, the rudder switch lever on the control stand was operated incorrectly andthis triggered the Master to operate it without checking the rudder indicator (He was too
preoccupied with the distance to the quay：Human beings are sometimes only able tosee one thing at a time). By chance, the vessel was heading straight ahead unaﬀected byexternal forces and the VecTwin Rudder was in the neutral (hover) position, so the speed
was only reduced naturally, but the Master thought he was controlling the course andspeed by remote control with the joystick lever.
As administrative countermeasures, we have to implement countermeasures suchas repeat training on how to operate the rudder control switch and a method of
confirmation.

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P&I Loss Prevention Bulletin§6

Conclusion

As described in Chapter 2, risk management is advocated by the Ministry of Health,Labour and Welfare (MHLW) for the manufacturing industry on land, in line with
the Industrial Safety and Health Act (Act No. 57, 1972), as a business management
technique to effectively deal with unforeseen losses caused by various hazards at
minimum cost. Also, the enforcement of the Companies Act 2006 requires joint-stockcompanies to have “systems related to management of the risk of loss” in place. In
addition, the Japanese version of Sarbanes-Oxley (SOX) Act came into force in 2008
and a “financial risk management system” has been required since then.
As a result of this, the shipping industry has been required to incorporate risk
management in safety management codes and SMS manuals since around 2010, but thishas been diﬃcult for ship management and the vessel to adopt in practice. One of thereasons why risk management has not permeated this industry is because the Master,Chief Engineer and experienced crew both on Deck and in the Engine departments havealready been practising risk assessment implicitly as part of their work.
However, it is now customary that a crew of several nationalities with diﬀerent culturesand customs be on board to achieve the safe operation of a ship. In this context, theapproach (top down) mentioned above, on board a vessel, where risk assessments
are practised individually and implicitly by following orders from experienced crew
members, may actually reduce the level of safety.
It is important that the management at the shore catering department, such as the ship92

JAPAN P& I CLUBowner or ship management company, understand what has been explained in this guide.
As explained in section 4-3 “Risk assessment procedures”, for example, regarding
countermeasures for rough weather, management is not to be left solely to the discretionof the Master/Chief Engineer or Chief Oﬃcer/First Engineer, but that all crew members
take time to participate in the discussion and share their opinions and countermeasures.
It is recommended that risk assessments are practised in a relaxed and systematicmanner, where unexpected oversight or other problems can be identified by evaluatingthem numerically in writing. As a result, we believe that the safety level of the vessel
will surely be improved.

References

・Japan Industrial Safety and Health Association (JISHA)・Risk assessment duties for person in charge
・Workplace risk assessment case studies
・Practical risk assessment training materials for health and safety
staﬀ

A range of training resources in risk assessment is available by the Japan Industrial
Safety and Health Association (JISHA). For details, please refer to the association’s
homepage below.
• Introduction to System Safety (Provisional translation)：
System Safety Engineering, Nagaoka University of Technology (Yokendo Ltd.)• The Forefront of Safety Engineering - The Concept of System Safety (Provisional translation) The Japan Society of Mechanical Engineers, ed.
(Kyoritsu Shuppan Co., Ltd.)93