If there is insuﬃcient communication and cooperation between the person responsible
for the accident (L) and each resource, and if the team does not gel, this will create a gap
and safety cannot be established when a human error occurs.
If the squares (H, S, E, L) are well aligned, then even when a person causes a humanerror (L), the resources surrounding him/her will be aware of it and will communicate
this so that L is aware.
BTM and ETM training are effective methods that help us address communication
issues, however, there are many who still say that it is difficult to carry this out inpractice. The main reason has to do with the difficulty of communication. Figure 13
illustrates this.



100％    0％         Is this really common
knowledge among crew?
Does not know, forgets ordoes not understand enough  




A gap or distortion
during conveyance 100％of instructions

Gap
60％


 

  

    
40％

Distortion, notenough knowledge
Is this common
sense in the world?

Speculation,
judgement andown experience0％

Understands only 20% of what Capt. wants to convey

Fig. 13 Problems with oral instructions and communication (diﬃculty with communication)

15

The yellow coloured area on the extreme left shows what a Master intends to order
or what message he intends to convey (Full understanding is shown as 100%). Even
when the Master tries to relay information to an Ordinary Seaman (O/S), only 20% of
the information may be understood due to a misunderstanding, a lack of understandingor knowledge that the O/S may think is common sense, a lack of communication,
speculation or judgement on the part of the O/S, or he/she may compare what was
relayed to their own experience. Why is this the case?
It seems most likely that the reason why information cannot be conveyed successfully is
down to a diﬀerence in their level of understanding regarding technology. For example,
if the Master tries to convey the same message to another Master, his message will be
conveyed to the full (100%), because their technical backgrounds are almost the same.

16

§2

4M4(5)E Analysis

One preventive measure that we can use is the 4M4(5)E Analysis. This model takes into
account lessons learned from similar past accidents. This is a countermeasure (method)that seeks to prevent a re-occurrence of the same or a similar accident based on lessons
learned, in the event that such an accident should occur.

“Safety” is management’s top priority. In order to realize this, it is important to correctly
identify “the bud of a potentially new accident” and to prevent a re-occurrence based on thelessons learned. Most accidents at this bud forming stage can be referred to as events that
require attention or risky events and are often due to human error. Thus, it would be vitallynecessary to analyse such phenomenon thoroughly from a human factor perspective.

This method is derived from an accident investigation method adopted by the US National
Transportation Safety Board (NTSB) and has been used in various fields including theindustrial arena. With this method, we can not only look at error factors from multiple
perspectives but also examine preventive measures from a wide range of viewpoints.

２−１ Errors Made by an Involved Party andOrganizational Errors
Although we have established preventive measures for every time an accident occurs,
why then has the 4M4(5)E analysis been the subject of recent interest?

17

According to The Hudson Model: Types of Safety Culture (See Figure 14), Safety
Culture has been developed as follows:  

In

fo

rm

ed

Level 5 GENERATIVE

Ac
co
un
ta
bi
lit
y

cr

ea

sin

gl

y

Level 4 PROACTIVEIn

Level 3 CALCULATIVE

Tr
us
ta
nd

Level 2 REACTIVE

In

cr
ea
sin
g

Level 1 PATHOLOGICAL

Fig. 14

Level 1 Pathological

Safety problems are caused by the workers. Safety concerns
only the Safety department.

Level 2 Reactive

Safety is important, but we activate it only after an incident.
Mistakes are punished.

Level 3 Calculative

Safety driven by SMS and safety is improved through PDCA.
Emphasis on continuous monitoring using safety measures.

Level 4 Proactive

All staff understand the importance of safety. The
organization tries to prevent accidents with proactive
measures (manpower, equipment and cost to be included).

Level 5 Generative

Safety is an inherent aspect of a sustainable organization.
All staff unconsciously give priority to safety.

In other words, in the past, when an accident occurred, because almost all accident
causes were due to human error, the person who caused the accident was identified andthe mistakes that led to the accident investigated. Then, the case would have been closed
after having reprimanded the individual by saying something like, “Be careful in future”

18

or holding the individual to account by punishing him/her (“grave-post type”). The
above Level １ (Pathological) and Level 2 (Reactive) are applicable to this.
But, we have learned that this kind of preventive measure lacks in eﬃcacy. Therefore,
it is a must that we examine the factors behind human error and explore further as towhy an individual causes a human error. Then we can take eﬀective countermeasures(“preventive type”）to prevent future re-occurrence.
Figure 15 illustrates this.（Why are accidents repeated - the analysis of the human factor
written by Akira Ishibashi; from Japan Industrial Safety and Health Association (JISHA)）(Provisional translation)

Fig. 15 Why are accidents repeated - the analysis of the human factor written by Akira Ishibashi
Source: Seminar on Analysis and Countermeasures of Accidents Learned from Case Studies, by Japan
Industrial Safety and Health Association (JISHA) (Provisional translation)

19

In the event that an accident is considered to have been caused by human error, it is easy
to take remedial measures for visible and technical errors. Moreover, it seems clear atfirst glance that the parties involved should be punished and that the technology shouldbe improved.
For example, as for collision accidents, most of their direct causes are related to humanerror such as insufficient lookout and non-compliance with the navigation act. As aresult, compliance with Article 5 of the Act on Preventing Collision at Sea (Lookout)
and its 2nd Chapter (Navigation act) are followed, and the party involved is punished,
then the case is closed.
However, each Master and Navigation Officer who has a seaman’s competency
certificate fully understands the importance of lookout and compliance with the
Navigation act. True preventive measures cannot be established unless we analyse indepth as to why professional qualified mariners “neglected appropriate lookout andcould not comply with the navigation act”. For example, as organizational errors thatare not readily apparent manifest themselves, shown in Figure 15, we must construct
recurrence preventive measures by analysing the “Underlying causes”, to establish if
there are errors in the organization or team, such as an inappropriate manual, insuﬃcienttraining, poor working conditions and excessive paperwork.

２−２ 4M4(5)E Analysis
As mentioned above, the 4M4(5)E analysis considers the cause of the accident to be a
result of organizational error. A matrix table of specific causes behind the accident andcountermeasures is formulated. The specific causes behind the accident are described(4M）、and then countermeasures (5E) in terms of training, technology, reinforcement/
enforcement, examples, and environment (organization both within the company andonboard), are added.

20

4M

４（5）E

Shows speciﬁc factors

Reveals countermeasuresbehind an accident●

Education

●

Man

●

Engineering●

Machine●

Enforcement●

Media（Environment）●

Example●Management●（5）Environment （within company
and on-board ship etc.）

When considering the conditions that cause occupational accidents, it can be said that
85.6% occur as a result of a combination of “unsafe behaviour” and “unsafe conditions”.
(See Figure 16）〈    〉                 

                
     !        

Percentage of accidents that occur when the two overlap ⇨85.6％
Fig. 16
Source: Seminar on Analysis and Countermeasures of Accidents Learned from Case Studies, byJapan Industrial Safety and Health Association（JISHA) (Provisional translation)21

On considering the reasons behind “unsafe behaviour” or “unsafe conditions”, theroot cause is often found in an “organization’s safety management deficiencies”.（SeeFigure 17）for 4M4(5)E analysis, whereby these “root causes” and “direct causes” areorganized into a table, analysed, and preventive measures formulated.

 

    
     



 











Management
Root Cause

Direct Cause

Accidents

Fig. 17

２−３ 4M4(5)E Analysis Plus Why Why Analysis:
Investigation, Analysis and Countermeasures
The 4M4(5)E analysis and countermeasure planning workflow is shown in Figure 18.

   Man

Direct Cause

Accident Cause          

Management４(or5)Es

Countermeasure＊Because it is important to check the facts, countermeasures are not to be made based on own speculation.
Conduct a further investigation, if necessary.
Fig. 18

22

An outline of the analytic procedure will be explained below.（See Attachment 1 P.93）
1. Site investigation

Carry out investigation in as much detail as possible, ideally by a third party (such asa surveyor or marine consultant etc.)
2. Analysis of site investigation report
・Clarify accident cause/s (4M), using a classification table and so on.

（See Attachments 2-1, 2-2 and example in Figure 19.)
・Organize these into a matrix to examine the facts (See Attachment 3).
➊ Facts extracted from the accident investigation report that caused theaccident have been identiﬁed and listed under each factor in the table to
the right.

➋ Classify into Unsafe Behaviour or Unsafe Conditions by factor.
➌ After clarifying the accident cause/s, in order to analyse this, assess
accident cause by prioritizing according to the scale of the cause.

➍ Furthermore, clarify which items need to be inspected/investigatedagain.
＊ Accident Reports
Ship reports, ship management company reports, survey reports,
attorney (maritime auxiliary）reports, transportation security
reports, and as much information as possible, such as accident
investigation reports of all committees and decisions of the Japan
Marine Accident Tribunal, are to be collected.

23

Example
Vessel superintendent was aware of the
low visibility weather forecast, but, as heassumed that the Master also knew, he
did not report it.

2 radars were equipped on board, but the magnetron of
No.1 radar was to be replaced by the manufacturer at thenext port. The Master was requested to navigate using
only No. 2 by the vessel superintendent, and agreed
despite feeling uneasy about it.

Attachment ３

Maritime Accident Summary of Related Facts

Date

Check facts and problem areas

Approx. 3 p.m.

Vessel superintendent

Did not report a forecast of low visibility
to the Master2

Unspeciﬁed
dateApprox. 4 p.m.

Vessel radar

No. 1 radar was out of order

〇
△

4
〇

3

〇

〇

5

〇

3

Unspeciﬁed
dateApprox. 5 p.m.

Vessel superintendent

Requested the Master to navigate using
only No. 2 radar until next port, because
arrangement to ﬁx No. 1 radar at the port
had been made4

Unspeciﬁed
dateApprox. 5 p.m.

MasterApproved navigation to the next port using only one radar.

〇

6

〇

2

〇

1

5

Unspeciﬁed
dateUnspeciﬁed
time

2/O

Did not report to the Master, although
there was the low visibility (less than 2
nautical miles) (According to the Safety Management Code, low visibility is deﬁned as less than 3 nautical miles.)6

Unspeciﬁed
dateUnspeciﬁed
time

2/O

Searched for the other vessel at 6.6 nautical miles via radar, but did not notice
the image captured on ARPA, because hebelieved he could pass starboard to starboard

Re-examination necessity

Caused byUnspeciﬁed
dateUnsafe conditions

Time

1

Unsafe behaviour

Reference No.

Identiﬁed problems from survey ﬁndings

Accident cause evaluation

Directcause

Accident cause assessment: Prioritized according to the scale of the cause

At XX:XX (unspecified time), the 2/O
knew that there was low visibility ofless than 2 nautical miles, but he did
not report it to the Master.

At XX:XX (unspecified time), Although the 2/O
searched for Vessel △△ at approximately 6.0 degrees
on their starboard bow in the vicinity of <015> 6.5
nautical miles via radar, he believed he could pass
starboard to starboard, but did not notice the image
captured on ARPA.

Fig. 19（P.98 Attachment 3)

24

3. Once the above have been established, compile this information
into an accident cause/s matrix (unsafe behaviour and unsafe
conditions).

（See Attachments 4 and 5）
Pick out the relevant facts, and compare “unsafe behaviour” and “unsafe conditions”
using the 4M classification table and carry out a “Why Why Analysis”. Circle thecorresponding items.
❶ Enter relevant factors into Analysis Tables 1 to XX, and enter why these occurred in (2)to (6) below.

❷ Then, circle each applicable column.
❸ Enter the sub-item number of each item in the 4M Classification List for Machine,
Media, and Management.

❹ For items requiring re-investigation, circle the corresponding column to the right.
4. Once the above 3 has been completed, analyse and devise
countermeasures.

(See Attachments 6 and 7)●

Classify the direct cause and indirect/root cause of the accident
referring to the 4M4(5)E table.

●

Devise a countermeasure for every 4(5) item.

❶ Copy over the risk factors from the analysis chart (including the applicable
numbers).

❷ Copy over countermeasures to reduce or improve the risk factors into the 4(5)E
table.

Why Why Analysis
The Why Why Analysis method is a way of finding and verifying the efficacy ofsolutions to a certain problem. By repeatedly asking the question “Why?”, the methodseeks to identify what caused the problem, what factors led to that cause, and so on andso on. This is a mainstay component of the Toyota Production System.

25

Method (Figure 20)• The first stage is to present the problem in question. In order to make a logicalprogression to the next stage, it is helpful at this point to go through a processof elimination of irrelevant causative factors.
• A list of potential causes can then be created. This is the result of the first “Why?”
There may be multiple causes but they must all have a logical connection to theoriginal problem.
• The next stage is to come up with the potential factors which led to thosecauses. This is the result of the second “Why?” As with the first stage, there
may be a number of different factors involved, but each must have a logicalconnection to the subsequent cause.
• This process is repeated in the same manner with the 3rd and 4th stage of“Why?s”.

It is difficult to say at what point it is best to suspend this repeated process, but inpractical terms the ultimate goal is to find a logically proven solution whereby removalof the causative factors leads to elimination of the original problem.
During the “Why Why” process, some causative factors, be they a particular
phenomena or something of a more systemic nature, may well be deemedunavoidable. In which case, the analytic process should be suspended. Conversely
though, through this same process, it is also possible that factors, which were
thought to be unavoidable, are actually shown to be no more than a preconception.
The Toyota Motor Corporation first pioneered this methodology and advocated a 5“Whys” technique. However, this method is now employed in a variety of diﬀerent
fields and is not restricted to a set number of whys. The important thing is to arrive at
the root cause of the problem.

26

〈 Analysis Chart for Incident ＆ Cause Factors（Model）〉
TimeSequence①

TimeSequence②

TimeSequence③

TimeSequence
④

Why?

Why?

Why?

Why?

ReasonReasonReasonReason

Why?

Why?

Why?

analyze

ReasonReasonReason

Cause

Why?

analyze

Why?

Conclusion

ReasonCause

Reasonanalyze

Conclusion

Why?

Cause
Conclusion

Incident

Measures

ReasonMeasuresanalyze

Cause
Measures

Conclusion

MeasuresFig. 20

27

Devise a countermeasure
Devise a countermeasure for each factor below regarding unsafe behaviour andconditions. The following items from ① to ⑤ are to be extracted from Attachment 4.
1

Education ：Education and training
Measures to improve the competency, awarenessand knowledge required to perform the task.

2

Engineering：Technology and engineering
Technical measures of handling equipment forsafety improvement and improvement of equipment
etc.

3

Enforcement：
Thorough guidance and enforcement
Measures related to thoroughly enhanced regulationin order to ensure the work done and revision of the
SMS etc.

4

Examples：Case studies, countermeasures and rules
Measures to show speciﬁc cases such as lead byexample, experience of success, introducing modelcases etc.

5

Environment：
Measures related to working environment, oﬃce
internal management, on-board organization, etc.

28

Figure 21 shows an example of recurrence prevention countermeasures.

ExampleRisk factors（direct cause and indirect/root cause）

It is considered eﬀective to have them attend training programs
such as behavioral psychology to learn awareness.
Risk factors（direct cause and indirect/root cause）
Vessel
１． Why wasn't this captured by ARPA?
（１−③,⑧,⑨,⑩,⑪,4−1−③）
２． Why was the problem of poor visibility not reported to the Master?
（1−②,⑥,⑪,⑫,2−①,3−③）
６． Why did he approve navigating with a single radar?
（1−①,⑤,⑥,⑧,⑨,⑪,4−1−③,4−3−②）
Shipowner and ship management company
５． Why did they request a single radar for navigating?
（1−①,⑥,⑦,⑨,⑪,4−1−①,②,③,④,4−2−①,4−3−②,③）
Education and training

ExampleKnowledge, skills, consciousness,

Case studies, countermeasures

being given information, etc.

and rules● Training in behaviour psychology⇒ Learn to notice things

Lead by example, experience of success,● Education to reinforce habitually that(near misses), etc.

optical illusions/errors and assumptions● Gain a sense of experience using navi-

can cause a risky behaviour

gation simulations, for example

introduce model cases, Hiyari-Hatto

Fig. 2129

5. Carry out and verify countermeasures based on the devised
example above, and Brush up using a PDCA cycle.

The key is (1) to ensure that the proposed countermeasures are always implemented,(2) that their effectiveness is evaluated and verified and (3) that any defects arecorrected. That is to say, PDCA (Plan・Do・Check・Action（for improvement）shallbe performed. If this is not done, the hard-earned measures to prevent recurrence willquickly become a mere formality. In the event of a major accident, it will be of value tohave a recurrence prevention campaign annually (so as not to forget).
When considering methods of prevention, for example the PDCA cycle mentioned in
Attachment 7, be sure to carry out the following to ensure that the intended preventive
measures do not become a mere formality.

Enforcement（thorough guidance and enforcement）

Thoroughly clarify procedures for low visibility
in the procedure manual.
Plan
Here, we will examine how to ensure that the existing procedures are reviewed
and clarified, as well as how to ensure compliance with the revised procedures atsea. In order to achieve this, 4 root causes (Technicians characteristics, Humanbehavioural traits, Psychological factors and Human brain capacity）described in
1-2 As a Mechanism behind Maritime Accidents Caused by Human Error, shall beconsidered. For example, a review of training programmes, internal audit frequency,
the launching of an evaluation committee etc. could be considered. The mostimportant is annual scheduling. If the scheduling is vague, these kinds of tasks will
be easily put oﬀ.

30

Do
It is important to carry out the planned schedule with certainty.

Check（evaluation）
An assessment committee will be held every 3 to 4 months in order to manage
the work plan progress and to assess the implementation report. It is important to
identify the problems by providing a general overview of the fiscal year at the end of
the year.

Action（improvement）
Analyse the problems identified in the evaluation（including the Why Why
Analysis), and formulate measures for improvement.
This outcome will be the Plan for the following fiscal year.

31