挪威海軍海事碰撞案人為肇因之研究

The Research of the Human Causal Factors of the Collision in Norwegian Navy

軍艦始終被認定在航行紀律上要求最高且航行當班編組最完整之船舶，但軍艦碰撞事件也不單只有挪威海軍發生；「人多勢眾」似乎對航行安全並無明顯的提升。到底是哪個環節出了問題，引起本研究的發想。本文係運用由SHELL模型發展改良符合航行需求之HFACS-MA五層架構分類法，經由時間表列、肇因表列以及層級屬性區分程序，分析出事故發生的主要層面，並參考國際海上避碰章程（International Regulations for Preventing Collisions at Sea）討論各項人因疏失作為，讓事故發生之破窗一一顯露，除可用來自我檢視及案例分享精進外，亦期能運用在人員訓練或風險管控上，提供更清楚精確的預防或避免事故發生之用途。

Warships are considered the highest standard in cruising discipline and the most complete team on the voyage. However, warships collisions still happen and it's not only happened in Norwegian Navy. Despite “Safety in numbers”, there is not significant improvement for raising the cruising safety. What causes this problem? This brings about my motivation to research it. This paper is according to the Five-layer Classification Method of the HFACS-MA system which is developed by the SHELL model in order to improve the navigation requirements to analysis the main aspect of the accident by the timetable tabulation, the table of causal factors and attributing classification program of the HFACS-MA system. Referring to the rule of International Regulations for Preventing Collisions at Sea discuss each factor in order to prevent or avoid more accidents happen, not only self-examination and capability promotion, but used in personnel training and risk management to provide clearer and more precise prevention or avoid any accidents occurred.