應用「海難人因分析暨分類系統」解析案例間共通人因方法之探討

近十年來，人為因素居海難肇因之首的情況未見改變。故本研究嘗試提出一個海難事故共通人因的解析方法，為此問題提供一解決方案。本海難事故分析法係應用以瑞士乳酪模型為基石之「海難人因分析暨分類系統（HFACS-MA）」將事故進行系統化之共通人因分析；該流程可分成三部分：「個案人因解析」、「事故人因歸類」以及「共通人因篩選」等程序。本法除可釐清個別案例之涉案人因及其因果脈絡外，並可解析出相關案例間之共通人因，以做為矯正措施關注之對象。藉由兩個案例的演示，實證本法之分析結果的確能清楚地呈現這些共通人因所處的層級，亦能洞悉這些人因是如何造成系統防護上的漏洞。文末，關於本法之實用效益，以及使用上之限制與應注意事項，亦有所著墨。 Human factors have been recognised as the primary causal factor among marine casualties over the last decade. Therefore, an attempt to identify the common Human and Organisational Factors (HOFs) between two relevant casualties as one of the countermeasures is proposed in this paper. The proposed marine casualty analysis method mainly consists of three processes, the “HOFs identification”, the “HOFs classification” and the “common HOFs screening” to constitute a systematic analytic procedure using Human Factors Analysis and Classification System for Maritime Accidents (HFACS-MA), which is based on Swiss Cheese Model. The first two processes devote to identifying the HOFs involved in individual accidents and the causation among them, and then to categorise those HOFs using HFACS-MA. Having these analysis outcomes, the third process can sieve out the common HOFs associating with two concerned accidents for setting up some proper countermeasures. By analysing two actual cases, this paper has shown that the common HOFs of the accidents can successfully be acquired and manifested via the analysis results of the third process. Those analysis outcomes can not only illustrate what and where the common HOFs are, but can also show how the common HOFs caused the defects of the organization (or system) within individual cases. The potential benefits that the proposed methodology can be acquired are demonstrated in the case study. Some considerations, including the limitations, regarding the proposed analytic method are also discussed and concluded at the end of this paper.