Çatışan gemilerin kök sebeplerinin incelenmesi ve örnek kaza analizi
Analysis of the root causes of colliding ships and accident analysis
Yazar: NUMAN ÇIĞ
Danışman: DR. ÖĞR. ÜYESİ ELİF BAL BEŞİKÇİ
İstanbul Teknik Üniversitesi / Fen Bilimleri Enstitüsü / Deniz Ulaştırma Mühendisliği Ana Bilim Dalı / Deniz Ulaştırma Mühendisliği Bilim Dalı
Derece: Yüksek Lisans, 2019
Konu: Denizcilik = Marine
Dizin: Analitik hiyerarşi süreci = Analytical hierarchy process ; Deniz kazaları = Maritime accidents ; Operasyonel risk = Operational risk

Özet:
Çatışma başta olmak üzere, deniz kazaları; can, mal ve çevre felaketlerine yol açmaktadır. Bu durumun önüne geçebilmek için geçmiş kazalardan alınacak dersler, tehlikenin bertaraf edilmesi için gereklidir.
Çatışma durumu, su üzerinde hareket eden iki geminin birbirine temas halidir. Can, mal ve çevre için büyük felaketlere yol açan bu durum, birden fazla gemiyi etkilediği için diğer kazalardan daha kritik olabilmektedir.
İnsan hatası, dikkatsizlik ve yorgunluk gibi kaza sebeplerinin yanı sıra, prosedürlerin olmaması veya uygulanmaması da kazaya sebep olabilmektedir. Risk analiz yöntemleri kullanılarak kazaların sebepleri ve etkileri bulunabilir. Bu sayede, kazaların önüne geçilmesi amaçlanır. Risk analiz yöntemleri, iki ana başlık altında incelenir. Bunlar, kalitatif ve kantitatiftir. Uzman kişilerin görüşlerinden elde edilen sayısal verilerin yanı sıra, yorumlar ile de risk analizi yapılabilmektedir.Tez çalışmasında kullanılan Analitik Hiyerarşi Süreci (AHP) metodu Thomas Saaty tarafından keşfedilmiştir.
AHP metodu, kök sebeplerin anket ile değerlendirilerek sayısal veriler elde edilmesi ile kullanılmaktadır. Bu sayısal değerler ile yüksek ve düşük riskli sebepler belirlenmekte ve kazaların önüne geçebilmek hedeflenmektedir. AHP metodu, denizcilik sektörünün yanı sıra, jeoloji, finans gibi çok farklı alanlarda da kullanılabilmektedir.
Denizcilik teknolojisindeki yenilikçi eğilimlere ve emniyetle ilgili düzenlemelerin uygulanmasına rağmen deniz kazaları, küresel denizcilik ilgi alanları için hala önemli bir konudur. Gemi kaza raporlarının kendi içinde tutarlılığının sağlanması, bu kazaların kök sebeplerini açıkça tanımlamak için önemli bir amaç olarak kabul edilmektedir.
Bu tez çalışmasında; Türkiye Cumhuriyeti Ulaştırma ve Altyapı Bakanlığının Kaza Araştırma ve İnceleme Kurulunun raporları, İngiltere Deniz Kazaları Araştırma Şubesi raporları, Amerika Ulusal Ulaştırma Emniyeti Kurulu Kaza Raporları ve Danimarka Deniz Kazaları Araştırma Kurulu kaza raporları incelenmiştir. Bu kaza raporları içerisinden, çatışma tipi kaza seçilerek çatışmanın kök sebepleri belirlenmiştir. Kök sebepler, gemi adamları ve uzman kişiler için hazırlanan anket ile Analitik Hiyerarşi Prosesi metodu uygulanmıştır. Kazaların kök sebepleri ile bu anket sonuçları karşılaştırılmıştır.
Kök sebeplerin analizine farklı bir bakış getirmek üzere seçilen 1 Temmuz 2017 tarihinde Dover Kanalı'nda Huayang Endeavour ve Seafrontier arasında gerçekleşen kaza fonksiyonel rezonans analiz (FRAM) yöntemi ile analiz edilmiştir. İki geminin çatışması ile sonuçlanan bu kazada her bir gemi için analiz tabloları oluşturulmuş ve sonuçlar karşılaştırılmıştır. Bu metot, Erik Hollnagel tarafından geliştirilmiştir. İnsan ve makinenin bir arada olduğu kazaları incelemek için geliştirilmiş bir metottur. 
Ayrıca, incelemenin genelinde ele alınan kazalara karışan gemilerin son girdiği liman devleti denetlerinde yazılan remarklar da yapılan analizleri desteklemek üzere sunulmuştur. Bu gemilerden bazılarının standart altı durumda işletilmesi nedeniyle liman devletleri tarafından yetersiz bulundukları ve alıkonuldukları da tespit edilmiştir.

Abstract:
Marine accidents, the collisions, lead to lethal and environmental disasters. In order to avoid such situations, lessons from past accidents are necessary to eliminate the danger.
Collision is the contact of two ships moving on water. This situation, which causes great catastrophes for life and environment, can be more critical than other accidents
because it affects more than one ship.
Root causes such as human error, carelessness, fatigue, as well as the absence or failure of procedures may lead to an accident. The causes and effects of accidents can be detected by using risk analysis methods. In this way, it is aimed to prevent accidents. Risk analysis methods are examined under two main headings. They are quantitative and qualitative. Besides the numerical data obtained from the opinion polls of the experts, the risk analysis can be done with their interpretation. The Analytic Hierarchy Process (AHP) method used in this thesis study was discovered by Thomas Saaty.
When using AHP method, the root causes of accidents are evaluated by the questionnaire and through this the numerical data are obtained. With these numerical data, high-risk and low-risk reasons are determined, and the prevention of accidents is aimed. AHP method can be used in many different fields, such as geology and finance, along with maritime sector.
Despite the innovative trends in marine technology and the implementation of security regulations, marine accidents are still an important issue for global maritime interests. Ensuring the accuracy of marine accidents reports are an important objective to clearly identify the root causes of these accidents.
In this thesis; Accident Research and Investigation Board report of the Republic of Turkey Transportation and Infrastructure Ministry, the UK Marine Accident Investigation Branch report, the US National Transportation Safety Board accident reports and the Danish Maritime Accident Investigation Board accident reports are investigated. The main reasons for the collisions were determined by choosing a type of collision accident. Analytical Hierarchy Process method and the questionnaire for the root causes, sailors and experts were applied. The root causes of accidents and the results of these surveys were compared. 
When the reports were examined, the root causes of the accidents were divided into two: Crew sourced and other factors. Root causes originating from crew were examined in 15 items. These items are neglected safety management system procedures, no information sharing between pilot and captain, no training on the subject, no team regulation on bridge team management, insufficient knowledge of engine personnel, lack of company manual on the subject in safety management system, inadequate training procedures, insufficient in-use of bridge devices, inexperience of officers, overconfidence of the captain, fatigue, negligence of bridge team management procedures, inadequacy by the regarding ensuring on-bridge discipline, mistakes during the International Regulations for Preventing Collisions at Sea applications, absence of watchkeeping on the bridge.
Other factors were examined in 5 items. These include machine failure, lack of communication between colliding ships, meteorological events, not acquiring the pilot at the recommended location, not knowing local rules and the region (Shallow and traffic separation scheme).
The rates of root causes of collision in the reports and the data obtained from expert opinions using AHP questionnaire are not consistent with each other. This result means that accidents will continue to occur.
The effects of these root causes on collision are also observed in the accident are examined in the thesis study. Maritime companies and maritime education institutions should analyse accident reports well and prevent possible accidents in the future.
In the accident analysis using functional resonance analysis method, root causes and their effects on the accident are seen. Simple negligence, which is perceived as simple, comes together with other root causes to cause collision. 
The sample accident that was picked, which was chosen to bring a different perspective to the analysis of root causes, happened between Huayang Endeavor and Seafrontier on the Strait of Dover in 1 July 2017. The accident was analysed by functional resonance analysis method. In this accident, which resulted in the collision of two ships, analysis tables were executed for each ship and the results were compared. This method was developed by Erik Hollnagel. It is a method that investigates accidents involving man and machine.
Functions used for functional resonance analysis method on Huayang Endeavor ship; It starts with the danger of collision, the lack of full observance, improper use of sound signals, non-compliance with the rules of standard marine communication phrases, lack of necessary understanding of very high frequency radio, followed up by nonconformity and ending with collision.
Functions used for the functional resonance analysis method on the Seafrontier; starting with the danger of collision, failure to follow safety management system procedures, fatigue, the captains first Strait of  Dover crossing, non-compliance with the International Regulations for Preventing Collisions at Sea, improper use of sound signals, lack of effective communications with very high frequency radio, lack of use of standard marine communication phrases and ending with collision.
There are 6 aspects used in the functional resonance analysis method. These are: input, output, control, time, resource, precondition.
Input (I): A signal that activates the conventional input and / or function is used or converted by the function (requires change of state for the function to start).
Output (O): The result of the function that represents the change in the state of the system or the change of the output parameters. 
Precondition (P): Conditions that must be completed before the function is executed.
Resource (R): The consumed substance that must be present when the function is active.
Control (C): Controls or regulates the function to achieve the desired output.
Time (T): Dimensions of time affecting the way the function is applied
In addition, the remarks written in the last port state inspections of the vessels involved in the accident were also mentioned. There are also histories of detention for the colliding ships because they have been considered inadequate by the port state in their past.
In addition to AHP and functional resonance analysis method used in the study, fault tree analysis, safety checklists, preliminary hazard analysis, event tree analysis, failure mode and effect analysis, Bayesian method, cause and effect analysis, risk matrix, bow tie methods were also mentioned.
In this study, the accident statistics reports prepared by Allianz and the International Maritime Insurance Association and European Maritime Safety Agency were examined. Accident Stability; the size of the accidents, their distribution according to ship types, accident types, operational conditions, cruise situations and the severity of accidents has given the opportunity to interpret data. It contains interpretations on the relationship between the regions where the accidents occur intensively, the traffic density and the size of the ships.