Visualization of holes and relationships between holes and latent conditions

研究成果: Chapter in Book/Report/Conference proceedingChapter

2 被引用数 (Scopus)


The objective of this research is to find the relationships between holes and latent conditions in collisions. If the relationships can be determined, efforts can be directed to specified latent conditions in order to prevent collisions. 28 collision cases published by the Japan Transport Safety Board were studied. This research considered the Safety Management System and risk management imbedded in the collision avoidance action as defensive layers in the Swiss cheese model. The research found the following results. First, most holes at the organizations opened during the process of Do of the Plan-Do-Check-Act (PDCA) cycle. Second, most holes at the local workplaces opened during the risk analysis of the risk management process. Finally, inadequate conditions of operators were the most common among other latent conditions. Visualization of holes and awareness of latent conditions will show people where efforts are directed for the prevention of collisions effectively and efficiently.

ホスト出版物のタイトルActivities in Navigation
ホスト出版物のサブタイトルMarine Navigation and Safety of Sea Transportation
出版社CRC Press
出版ステータス出版済み - 1 1 2015

All Science Journal Classification (ASJC) codes

  • 工学(全般)


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