489
1 INTRODUCTION
Japan Transportation Safety Board (JTSB) did
investigationforallaccidentsinmaritime,land,train
andair.Allthereportsareopensourceinitswebsite
thus all stakeholders can utilize the reports to get
some lesson learnings. In maritime field, there were
3090accidentsin2008to2013(JTSB2016).
Therewerema
nypapersthathasbeenpublished
in order to analyze the accidents. Mutmainnah &
Furusho (2015) propose an easier method for
maritime accident, namely 4M Overturned Pyramid
(MOP)model,to find the causative factorsthat lead
accidentsaswellasthecausativechain(Mutmainnah
et al. in prep.). Authors has tri
ed MOP model to
analyzeseveralmaritime accidents, such as collision
in Japan, United Kingdom (UK) and Indonesia
(Mutmainnah&Furusho2015,2016a,b).Besides,this
methodhasalsobeenusedtoamorespecificsubject,
suchasfindingthemostcommonimproperlook‐out
(Mutmainnah & Furusho 2016b
) and the most
common causative factors for each time occurrence,
namely day, night and twilight (Mutmainnah et al.
2017).
There are so many types of accidents, such as
collision,accidentalwork,fire,sink,andsoon.Each
type of accident has different causative factors that
createdifferentcharacteristic.Theaimofthi
spaperis
toseethedifferencesofcausativechainsofaccidentin
collision and accidental work. From 50 accidents
occurredinJapanthatarepublishedonJTSBwebsite
in English, 20 cases are collision, 20 cases are
accidental work including fatality and injury, while
10 others are capsize, foundering, and so on, which
Causative Chain Difference for each Type of Accidents
in Japanese Maritime Traffic Systems (MTS)
W.Mutmainnah,L.P.Bowo&A.B.Sulistiyono
GraduateSchoolofMaritimeSciences,KobeUniversity,Kobe,Japan
M.Furusho
KobeUniversity,Kobe,Japan
ABSTRACT:Causativechain(CC)isafailurechainthatcauseaccidentasanoutcomeproductofthesecond
stepofMOPmodel,namelylinerelationanalysis(LRA).ThisCCisaconnectionofseveralcausativefactors
(CF), an outcome product of first step of MOP model, namely corner analysis (CA). MOP Model is an
a
bbreviationfrom4MOverturnedPyramid,createdbyauthorsbycombining2accidentanalysismodels.There
are two steps in this model, namely CA and LRA. Utilizing this model can know what is CF that happen
dominantlytotheaccidentsandwhatisadangerCCtha
tcharacterizeaccidentsinacertainplaceandcertain
period.Byknowingthecharacteristics,thepreventiveactioncanbedecidedtodecreasethenumberofaccident
inthenextperiod.TheaimofthispaperisprovidingthedevelopmentofMOPModelthathasbeenupgraded
andunderstandingthecharact
eristicsofeachtypeaccident.ThedatathatisanalyzedinthispaperisJapanese
accidentsfrom2008until2013,whichisavailableonJapanTransportationSafetyBoard(JTSB)’swebsite.The
analysisshowsthateverytypeofaccidentshasauniquecharacteristic,shownbytheirCFsandCCs.However,
ManFactorisst
illplayingroletothesystemdominantly.
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 11
Number 3
September 2017
DOI:10.12716/1001.11.03.15
490
countedonlyone,two,ormaximum5cases.Because
of that difference number of accident case in each
type, authors decide to compare collision and
accidentalwork.Thusintotal,thereare40casesthat
areanalyzedinthispaperfrom2008–2013.
Same like previous papers, in this paper we

utilized a MOP model to analyze Maritime Traffic
System(MTS),includepastaccidents,anddetermine
their causative factors and causative chains to
generatethecharacteristics.TheMOPmodelisbased
on the combination of the Septigon model (society
and culture, physical environment, practice,
technology, individual, group, and organizational
environmentnetwork)
createdby Grech et al. (2008)
andtheIMmodelproposedbyFurusho(2000,2013).
TheIMmodelconsistsof4Mfactors(man,machine,
media, and management) that are connected by the
individualelement(I)asthe coreofthesystem.The
MOP model is drawn as a three‐dimensional
relationship
 that appears as a three‐sided inverted
pyramid,whereeachcornerofthepyramidrepresent
one 4M factor. Each corner (factor) is connected to
and affects the other factors. The man factor should
always be at the bottom of the inverted pyramid
because it is the intrinsic factor that significantly
affectsallotherfactors. Because the model is drawn
three‐dimensionally as a three‐sided inverted
pyramid, it has four corners representing the 4M
factors, and six edges representing interaction
between the two factors that are connected by the
edges. The edges, which are called line relations,
show that the system
 is the result of interactions
amongthe4MFactors.Thus,toobtainasafesystem,
allcornersandedgesshouldbereliableandbalanced.
Theseinvestigationreportswereanalyzedintwo
steps,aswillbeexplainedinthesection2.Thereare
three accident development stages: the beginning of
the
accident, the accident itself, and the evacuation
process; these stages are labeled as Stage 1, Stage 2,
and Stage 3, respectively (Nurwahyudi 2014). When
characterizing the accidents in the reports, failure
events at every stage of accident development are
described.Severalfailuresthatoccurarecategorized
intothesestages.Ifwe
knowthefailuresthatoccurat
every stage until the evacuation process, we can
predict the loss caused by the accident and also
developcountermeasures.
2 JAPANESEMTSACCIDENTS
JTSB posted 50 accidents in English that happen in
2008‐2013. Figure 1 shows the number of each
accident type. As
explained in Section 1, a total
number of 40 cases are analyzed in this study that
contains of 20 cases of collisions and 20 cases of
accidental work. We can see from figure 1 that the
numberofcollisionandaccidentalwork are slightly
different with other accident types. Figure 2
 shows
thenumberofeachaccidenttypeineachyear.

21
20
2
1
4
1
2
0
5
10
15
20
25
Collision
Accidental
work
Fire
Grounding
Foundering
Listing
Capsizing
Number of Accidents
Accident types

Figure1.Numberof accidentineachtype from2008–2012
(JTSB2016)
1
22
5
6
4
1
3
1
4
6
5
0
1
2
3
4
5
6
7
2008 2009 2010 2011 2012 2013
Number of accidents
Year
Accidental work
Collision

Figure2.Numberofcollisionandaccidentalworkcasesin
Japanineachyearfrom2008–2012(JTSB2016)
3 MOPMODEL
MOPmodelwasdeveloped in the maritime domain
by the authors which is a combination of the
epidemiological, Septigon, and IM models. The
SeptigonmodelisaconceptthatcategorizestheMTS
into seven domains: society and culture, physical
environment,practice,technology,individual,group,
andorganizationalenvironmentnetwork
(Grechetal.
2008).Alldomains are connected to and affected by
eachotherinasystem.Anyerrorinonedomaincan
affect the system. In 2000, Furusho proposed a
simpler system called the IM model. This model
consists of 4M factors (man, machine, media, and
management) that are
connected by the individual
element (I) as the core of the system (Furusho 2000,
2004).MTSisbetterexplainedbytheepidemiological
modelthatconsistsoflatentconditions,barriers,and
activeconditions,asshowninFigure3.

491

Figure3.MOPmodel
TheMOPmodelisdrawnthree‐dimensionallyasa
three‐sided inverted pyramid that has four corners,
representing the 4M factors, and six edges,
representing an interaction between two 4M factors
thatareconnectedbytheedges,asshowninFigure3.
The edges, called line relations, show that the
system
 is a result of interactions among the 4M
factors.Failures that areclassified into the corner of
the MOP model do not occur only because of that
particularcorner.Often,thefailureiscausedbyother
corners. When there are failures that are caused by
several corners, it implies that
the line relations
connectingthosecornersare also contributing to the
instability of the system. For example, consider a
failureincommunication.Communicationcannotbe
classified into one corner because communication is
related to all four corners. The failure in
communicationamong seafarers is classifiedas man
factor (M1) because this
 type of communication
dependsontheperson.Often,severalseafarersdonot
share information with other seafarers. However,
communication failure among ships and port
administrationsdoesnotbelongtothemanfactor.It
canbelongtoeitherthemanagementorthemachine
factor that is affected by the media factor.
The
classification of failure depends on the condition of
theaccidents.Whenalinerelationcontributestothe
accident,apreventiveactionforthelinerelationhas
tobedetermined.Thus,forasafesystem,allcorners
andedgesshouldbereliableandbalanced.
Because the MTS consists of latent conditions,

barriers, and active conditions, any accident that
occursintheMTSshouldbetracedforeachofthese
factors separately. Each factor (corner) of the MOP
model represents the epidemiological model as
shown in Figure 3. In Figure 3, the individual from
M1(manfactor)receivessomeinformationfromM3
(media factor: environment) and from M2 (machine
factor: crew complement) factors; then, this
information is used for decision making. Hazard
perceptionsarealsoinfluenced by M4 (management
factor). The detail explanation how MOP model is
created is written in Mutmainnah & Furusho (2014)
andthenithasbeendevelopedmorein
Mutmainnah
etal.(2016).
Thereare2stepsinanalyzingaccidentreportsby
MOPModel,namelyCornerAnalysis(CA)andLine
RelationAnalysis(LRA).Section4willexplainmore
aboutthisstepsaswellastheresultinthisstudy.
Table 1 lists the definition and examples of the
corners
in the MOP model. By understanding the
definition, it is easier to determine the causes of the
accidentsusingtheepidemiologicalmodel,andthen,
prevention actions can be considered. Besides, the
characteristicsofseveralaccidentscanbeexploredby
analyzingseveralaccidentreportsandbyfindingthe
tendency,ascarriedout
inthispaper.
Table1.DefinitionandexamplesofeachcorneroftheMOP
Model
_______________________________________________
4MFactors Definition(Example)
_______________________________________________
ManAllelementsthataffectpeopledoingtheir
(M1)tasks(Knowledge,skills,abilities,
memory,motivation,alertness,experience,
etc.)
_______________________________________________
MachineAllelements,includingtechnology,which
(M2)helppeopletocompletetheirtasks
(Equipment,informationdisplay,
environmentaldesign,crewcomplements,
construction,etc.)
_______________________________________________
Media  Allenvironmentsthataffectthesystem
(M3)   and/orpeople
(Climatic/weathercondition(temperature,
noise,seastate,vibration,wave,tide,
wind,etc.),economiccondition,social
politics,culture,etc.)
_______________________________________________
Management Allelementsthatcancontrolthesystem
(M4)and/orpeople
(Trainingscheme,communicationamong
companies/institution,workschedule,
supervising/monitoring,regulatory
activities,procedures,rules,maintenance,
etc.)
_______________________________________________
4 RESULTANALYSISUSINGTHEMOPMODEL
Theinvestigationreportsexplainallfactsandcauses
oftheaccidents.Were‐analyzedthosereportsusing
theMOPmodel.Theanalyseswerecarriedoutintwo
steps: corner analysis, which is listing causative
factors for each corner of the MOP model; and
 line
relation analysis, where the relationship among
causativefactorinthecornerisexplored.
The CF list of collision has been written in
previouspaper.Thus,inthispaperweonlyshowthe
result analysis of accidental work. But in the next
section, we will review again the result analysis
of
collision the compare them with the result of
accidentalwork.
4.1 CornerAnalysis(CA)
In this step, we traced and listed all failures that
caused accidents and divided them based on the
definitionofeachcorneroftheMOPmodel.Then,we
countedthenumberoffailuresafterallreports
were
analyzed.Thefailuresthathasbeenlistedarenamed
as causative factors (CFs). Tables 2–5 list the causes
andthenumberoffailuresforCFforeachcornerof
theMOPmodel.
CFs that are listed in table 2‐5 above belong to
accidental work because the CFsβ€™ξˆ± collision
has been
showninMutmainnahetal.(2016).
492
Thereareseveralcategorizationsineachcornerto
makeiteasiertobeunderstand.Forexample,inM1,
the failures can be divided into careless
workmanship, doing personal decision, disobeying
proceduremanual, carryingoutirregularprocedure,
incapabilityofseafarers/workers,andhumanelement
problem. Careless workmanship means that the
failures that
 has been done are with no intention of
being fail meanwhile disobeying procedure manual
meanstheworkersknowthatwhatwouldtheydoare
not based on the procedure manual but they keep
doing (they made a deal with other workers/some
workersknowbutnotallcrewmembersandworkers
agree). Disobeying procedure manual without any
deal with other workers is classified into β€˜doing
personaldecisionβ€™ξˆ±whichmeanshedidnotconfirmto
another worker that he will do something which is
written in the manual. However, carrying out
irregular procedure means that all the workers
includeseafarersagreetodo
someproceduresthatis
differentwiththeirproceduremanual.
InM2,theclassificationbecomesshipequipment,
ship construction, port facility failure/damage and
fallingitems.Thisclassificationismadebecausethere
are many failures in M2 which is not like what
happenincollisioncases.
Table2.NumberoffailuresforeachCFcategorizedasM1
_______________________________________________
Code CausativeFactorsNumberoffailures
_______________________________________________
CARELESSWORKMANSHIP
M11‐01 Incommunicationamongtheseamen8
M11‐02 Misunderstandingcondition9
(WrongJudgement)
M11‐03 Indecidingspeed1
M11‐04 apersonfelldown4
M11‐05 Inusingpropertools3
DOINGPERSONALDECISION7
DISOBEYINGPROCEDUREMANUAL
M13‐01 Startcleaningwithoutasking
masterʹs1
permission
M13‐02 Enterenclosetankwithout2
askingmasterʹspermission
M13‐03 Notmeasuregasconcentration5
M13‐04 Workingaloneindark1
M13‐05 Lubricatingwithoutstopping1
CARRYINGOUTIRREGULARPROCEDURE
M14‐01 Inmooringoperation2
M14‐02 Incleaningtank
process1
M14‐03 Inloading/unloadingprocess3
INCAPABILITYOFSEAFARERS/WORKERS
M15‐01 Inoperationprocess6
M15‐02 SpeakinginEnglish1
M15‐03 Inunderstandinghazards6
M15‐04 Inwearingcorrectmask1
M15‐05 Inmonitoring/identifyinganyaccidentrisk 9
M15‐06 Inutilizinggasdetector
2
M15‐07 Inunderstandingweathercondition1
(secondaryundulation)
M15‐08 Inunderstandingcreationoftoxic1
bychemicalreaction
HUMANELEMENTPROBLEM
M16‐01 Alcoholeffect1
M16‐02 Feltimpatient2
M16‐03 Couldnotsmelltheodorgas1
_______________________________________________

Table3.NumberoffailuresforeachCFcategorizedasM2
_______________________________________________
Code CausativeFactorsNumberoffailures
_______________________________________________
SHIPEQUIPMENTFAILURE/DAMAGE
 Mooringlineproblems:
M21‐01ξˆ±β€Insufficientlinelength1
M21‐02ξˆ±β€Mooringlinewasbroken3
M21‐03ξˆ±β€Linewasbounced1
M21‐04ξˆ±β€Pendantwirediameterwassmall1
M21‐05ξˆ±β€Heavinglinewasold1
M21‐06 Exhaustfanwasnotworking2
M21‐07
Gasdetectorwasnotthere1
 Hookassemblyproblem:
M21‐08ξˆ±β€Existenceoftwistedshackle1
M21‐09ξˆ±β€Shearfractureinshacklesplit1
M21‐10ξˆ±β€Therewererustedbolts1
SHIPCONSTRUCTIONFAILURE/DAMAGE
M22‐01 Nofallprotectionfence2
 Someconstructionpartswerenotsecuredwell:
M22‐02
ξˆ±β€Decksupportwasnotstated1
M22‐03ξˆ±β€Tweendeckhatchcoverfixing1
pinswerenotinserted
 Someconstructionpartswerefracture/rupture:
M22‐04ξˆ±β€Weldlinewasruptured1
M22‐05ξˆ±β€doublingplateweldbrittle1
M22‐06ξˆ±β€Therewerefatigue&ductilefracturebolts  1
M22‐08 Support
deckpaneloverlapped1
M22‐09 Lackofdunnageandsmall1
PORTFACILITYFAILURE/DAMAGE
M23‐01 Existenceofsmallcrack1
M23‐02 Fractureofmainsheave1
M23‐03 Wirewasbroken1
M23‐04 Existenceofabnormalnoise1
FALLINGPARTS
M24‐01 Rescueboatfell1
M24
‐02 Cargofell2
M24‐03 Cranecollapse1
M24‐04 Deckpanelfell1
_______________________________________________
Table4.NumberoffailuresforeachCFcategorizedasM3
_______________________________________________
Code CausativeFactorsNumberoffailures
_______________________________________________
M31‐01 Strongwind1
M32‐01 Highwave1
M33‐01 Secondaryundulation1
M34‐01 Existenceofodorousgas4
_______________________________________________
Table5.NumberoffailuresforeachCFcategorizedasM4
_______________________________________________
Code CausativeFactorsNumberoffailures
_______________________________________________
POORCOMMUNICATION
M41‐01 Amongcompanies2
MANAGEMENTFROMONSHORE
M42‐01 Couldnotidentifying/monitoring/4
communicatinganyriskaccident
M42‐02 Therewaschangingroute1
M42‐03 Companydidnotestablishsomeprocedures 5
M42‐04 Companyhadgivenincorrectexplanation  3
_______________________________________________

Ifweseefromthetables,thereisnoclassification
inM3becauseithasonly4CFsthatisstilleasytobe
understood. In other side, M4 has 2 classification
which are poor communication and management
fromonshore.
Generally speaking, the number of CF in
accidentalwork
ishigherthanincollisioninM2,M3,
and M4. Even total failures that happen is not so
muchdifferent.
493
4.2 LineRelationAnalysis 
Causative factors written in Tables 2–5 are not pure
belongstoonecorner.Inthisstep,ofallthecausative
chains listed, the relationship among the corners of
the MOP model is explored. The chains that is
performedbyseveralCFsiscalledascausativechains

(CCs). By performing line relation analysis, we can
understandwhichlinerelationisthemostvulnerable
tofailure.
Table6.NumberofCausativeChain
_______________________________________________
No. CausativeChain(CC) 
_______________________________________________
1. M16‐02> M14‐03> M11‐05> M11‐04 
2.M14‐03> M11‐04 
3. M22‐08> M15‐01> M11‐05> M15‐05> M11‐04 
4.M22‐01> M11‐04 
5. M23‐01> M23‐02> M23‐03> M24‐02> M11‐04 
6.  M22‐06> M24‐03>M11‐04  
7.  M21‐10> M24‐03>M11‐04
8.  M14‐01> M15‐01   
9. M21‐04> M14‐01> M15‐01> M15‐03 
10.  M14‐03> M15‐01>M15‐04  
11. M42‐03> M42‐01> M15‐01> M15‐04 
12. M42‐03> M34‐01 
13. M42‐03> M11‐02 
14. M41‐01> M42‐01> M11‐02> M22‐05> M22‐09 
15. M42‐04> M11‐02> M22‐05> M22‐09 
16. M15‐02> M11‐02> M12‐01  
17. M11‐01> M11‐02 
18. M11‐01> M11‐02 
19.  M11‐02> M13‐03   
20.  M11‐02> M11‐01>M15‐04  
21. M22‐01> M24‐02> M11‐02> M15‐05  
22.  M11‐01> M15‐05   
23. M42‐04> M42‐01> M15‐08> M15‐05> M11‐01>M15‐03> M12‐01
24.  M15‐03> M15‐05  
25. M15‐08> M12‐01> M15‐05> M15‐03 
26.  M15‐01> M15‐05>M12‐01  
27.  M16‐01> M16‐03>M12‐01 
28. M42‐04> M15‐06> M13‐03> M21‐07  
29. M22‐04> M22‐07> M24‐04 
30. M22‐02> M22‐07> M24‐04
31. M21‐05> M21‐02 
32. M32‐01> M21‐02 
33. M33‐01> M21‐02 
34. M11‐03> M21‐03
35. M21‐01> M21‐03
36. M15‐04> M13
‐03 
37. M21‐09> M24‐01 
38. M42‐02> M41‐02 
39. M15‐08> M34‐01
_______________________________________________

SamewithlistofCFsabove,theCCslistedabove
only belong to accidental works. Different with
collision, the accidental work do not have core CC
because we can not find CC that happen in several
times.Perhapstherearesomeconfusionreadingtable
6.The first CFcode
that is writtenin table 6 means
that that CF causing the next CF writer after β€˜>’. In
example, CC number 1 is M16‐02>M14‐03>M11‐
05>M11‐04. This means that M16‐02 (Felt impatient)
cause M14‐03 (carrying out irregular procedure in
loading/unloadingprocess)andsoon.TheCClist
are
notorderedbasedonhowtheyhappenbutonlytobe
easiertogetsomecharacteristic.
5 DISCUSSION
Different accident type has different characteristic.
This paper shows the difference characteristic of
collision and accidental work. There are other
accidenthappeninJapanbutthenumberofavailable
investigationreports
inEnglish are not many. Thus,
weonlypick2accidentsthathasbiggernumber.The
MOPmodelanalysisofcollisionhasbeenwrittenin
Mutmainnah (2016) in detail. Thus, only result of
accidentalworkisshowninthispaperindetail and
severalcomparisonsofcollisionandaccidentalwork
will
bediscussedhere.
OutofCFsthathappenincollisionandaccidental
work, there are several differentiations. While in
accidentalwork,CFsinM1areclassifiedinto6parts
aswrittenintable2,CFsthathappenincollisionare
classified 3 parts, namely careless workmanship,
incapability of seafarers, and
human element
problem.CFthatisthemosthappeninbothaccidents
isfailureinidentifying/monitoringaccidentrisk.
CFs that are listed in M2 are very different
between what happen in collision and accidental
work. There are only 4 CF that happen in collision
which are only classified into equipment
 failures.
However,thereare17CFsthathappeninaccidental
work that are classified into 4 parts. This
differentiation means that there are view
contributionsofM2tocollision,notlikeinaccidental
work.
There is also one thing different in M3. In
accidental work accident, not only natural condition
thatcontributetoaccidentsbutalsothereisexistence
of odorous gas or toxic gas. Meanwhile in collision,
only natural condition that contribute to accidents.
However, there are no special different in M4
betweencollisionandaccidentalworkaccident.
The special CF that only happen in collision are
carelessworkmanshipin
maintainingproperlookout
(M1), erratic/ineffective action in avoiding accident
(M1), and poor management of personal on board
(M4). Besides, the special CF that only happen in
accidentalworkarethoseinM2,existenceofodorous
gas(M3), and all CF that is related to tank cleaning
procedure. The other difference
thing is the get
involvedships.Incollision,mostofthegetinvolved
shipsarefishing vesselwhileinaccidental work are
generalcargo.
Accidental work accident can be divided into 4
categories, namely at mooring operation (4 cases),
loading/unloading cargo (10 cases), tank cleaning
work(4cases)andother(2
cases).
AfterdoingLRA,wecanknowseveralchainsthat
consistedofseveralCF.ThereisCFthathappenonly
attheendofthechain,namelyM11‐04(apersonfell
down).However,thecausingCFaredifferent.There
areCFthatoftenhappeninthemiddleofCC,
namely
M15‐01 (incapability of seafarer/worker in operation
process), M11‐02 (misunderstanding condition/
wrong judgement), and M15‐05 (incapability of
worker in monitoring/identifying any accident risk).
Mostly M15‐01 are happen because of there were
irregularprocedurehasbeencarriedout.
494
TheLRAresultofaccidentalworkaccidentshows
different style with what happen in collision. In
collision, there are core causative chain, head of CC
that causing the core CC and tail of CC that are
causedbythecoreCC.
6 CONCLUSION
There are several conclusion that can be
 seen from
analyzingcollisionandaccidentalwork.Herearethe
conclusion:
ο€­ Thecharacteristicofcollisionandaccidentalwork
arequitedifferent.
ο€­ Aswrittenindiscussion,theresultofre‐analyzing
collision and accidental work with MOP model
shows that the characteristic of those accident is
different.Therewere
moreCFsinM2thathappen
inaccidentalworkcomparetocollision.
ο€­ ThespecialCFthathappeninaccidentalworkare
failures related to tank cleaning that generate
toxic.Whileincollision,thespecialCFisimproper
look‐out
ο€­ Bothcollisionandaccidentalworkaredominated
byfailurein
M1.
This paper provide an alternative method to re‐
analyze accident investigationreports to understand
whatarethemostcriticalpointthatcanbechosenin
order to reduce the number of accident by knowing
thecharacteristicofaccidents.


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