257
1 INTRODUCTION
MOPModelwasdiscoveredin2013byauthorswhich
is a development of man, machine, media and
management (4M) factors concept, originated by IM
ModelandSeptigonmodel.Authorstriestodevelop
theconcepttobeapplicableinmoregeneralaspectin
characterizing maritime traffic system (MTS),
especially accident at sea beca
use many errors can
leadtoincidentsand/oraccidentsinoperatingships.
Because the characteristics of each type of maritime
accidentaredifferent,itisnecessarytoanalyzeeach
type of accident separately. In this study, authors
decided to re‐analyzed accident in Indonesia and
Japan because in the Asian region, Indonesia and
Japan are the largest archip
elagoes. Thus, it is
important to maintain transportations at sea, which
actastheirlifelinesandsupporttheirproductivities.
Authorsconsidertheshipcollisionaccidentbecauseit
involves problems associated with more than one
ship. Often, ship collision results in explosion,
sinking, grounding, etc. Therefore, in an effort to
reducethenumberofaccidentscausedbycollisions,
oneofthestepscouldbetoanalyzepreviouscollision
accidentstoident
ifytheircharacteristics.
In Japan, the Japan Transportation Safety Board
(JTSB)investigatesmajoraccidentsintheJapanarea,
andinIndonesia,theNationalTra
nsportationSafety
Committee (NTSC) performs the same function as
JTSB.Allinvestigationreportscanbeviewedontheir
respectivewebpages.
The aim of this paper is to clarify the
characteristics of ship collision accidents that occur
both in Indonesian and Japanese maritime traffic
systems (MTS). By understanding the characteristics
ofshipcollisionaccidents,necessarycountermeasures
canbeproposed.
In tota
l, there are 22 collision cases that are
analyzed in this paper; 14 from Japan and 8 from
Indonesia,from2008–2012.Theanalyzedcasesarethe
investigation reports from each government. Note
that,notallreportsontheJTSBorNTSCwebsiteare
4M Overturned Pyramid (MOP) Model Utilization: Case
Studies on Collision in Indonesian and Japanese
Maritime Traffic Systems (MTS)
W.Mutmainnah
GraduateSchoolofMaritimeSciences,KobeUniversity,Kobe,Japan
M.Furusho
KobeUniversity,Kobe,Japan
ABSTRACT: 4M Overturned Pyramid (MOP) model is a new model, proposed by authors, to characterized
MTSwhichisadoptingepidemiologicalmodelthatdeterminescausesofaccidents,includingnotonlyactive
failuresbut also latentfailures and barriers. This model is still being developed. One of utilizationof MOP
modelischaract
erizingaccidentsinMTS,i.e.collisioninIndonesiaandJapanthatiswritteninthispaper.The
aimofthispaper istoshowthecharacteristicsofshipcollisionaccidentsthat occur bothin Indonesianand
Japanesemaritimetrafficsystems.Therewere22collisioncasesin2008–2012(8casesinIndonesiaand14cases
inJapan).Thecharact
eristicspresentedinthispapershowfailureeventsateverystageofthethreeaccident
developmentstages(thebeginningofanaccident,theaccidentitself,andtheevacuationprocess).
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 10
Number 2
June 2016
DOI:10.12716/1001.10.02.08
258
translated in English. Therefore, only the English
versionsoftheinvestigationreportswereconsidered
inthisstudyforanalyses.Thus,forJapan,thereare14
suchcasesfrom2008–2012andthesecasesinvolve27
ships.In Indonesia, there are 8 collision reports that
involve16shipsfrom2008–2012.
These investigation
reports were analyzed by
MOPmodelintwosteps,aswillbeexplainedinthe
section3Therearethreeaccidentdevelopmentstages:
thebeginningoftheaccident,theaccidentitself,and
the evacuation process; these stages are labeled as
Stage 1, Stage 2, and Stage 3, respectively
(Nurwahyudi 2014).
When characterizing the
accidentsinthereports,failureeventsateverystage
of accident development are described. Several
failuresthatoccurarecategorizedintothesestages.If
we know the failures that occur at every stage until
theevacuationprocess,wecanpredictthelosscaused
bytheaccidentandalso
developcountermeasures.
The characteristics of the Indonesian and
Japanese ship collision accidents can be determined
using the proposed MOP model. This paper shows
several analyses on the characteristics of these ship
collision accidents. In several terms, ship collision
accidents in Indonesia and Japan have the same
characteristics, for example, the
time of accidents
(night) and improper lookout. Both Indonesia and
Japan has a high ratio in these causative factors.
However,eachcountryalsohasuniquecharacteristics
thatarenotevidentintheothercountry.Thedetails
of the accident characteristics are provided in
Section2.
2 MTSACCIDENTSINJAPANAND
INDONESIA
As explained in Section 1, a total of 22 cases are
analyzedinthisstudy.Figure1showthenumberof
collision accidents that have occurred for each year
from2008until2012.
Figure1.NumberofcollisioncasesinIndonesiaandJapan
from2008–2012(NTSC2014,JTSB2014)
The accident reports available for Indonesia are
from2007to2013.However,therewerenoreportsof
collisions in 2008. On JTSB’s website, the English
versionsofthereportsareavailableforaccidentsfrom
2008–2013.Theanalysisinthispaperwascarriedout
forthe collisions in 2008–2012 because the collisions
in2013areyettobereported.
3 MOPMODEL
The proposed MOP model was developed in the
maritimedomain.Asstatedpreviously,MTSisbetter
explainedbytheepidemiological modelthatconsists
of latent conditions, barriers, and active conditions.
The proposed MOP model is a combination of the
epidemiological,
Septigon,andIMmodels.
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
networkasdefinedintable1(Grechetal.2008).All
domainsareconnectedtoandaffectedbyeachother
ina
system. Anyerror inone domain can affect the
system.
Table1.TheSeptigonModelTermDefinitions
_______________________________________________
TermDefinition
_______________________________________________
Societyand Itreferstothesociopoliticalandeconomic
culture.inwhichtheorganizationoperates.
_______________________________________________
Physical Itreferstothesurroundingenvironment,
Environment suchasweather,visibilityconditions,
obstructionstovision,physical
workspaceenvironment(airquality,
temperature,lightingconditions,noise,
smoke,vibration,shipmotion,etc.)
_______________________________________________
Practice. Itreferstosuchaspectsasinformalrules
andcustom.However,thesearenot
related
towrittenproceduresorinstructions.
_______________________________________________
Technology. Itreferstoequipment,vehicles,tools,
manuals,andsigns,andalsodealswith
humanmachineinteractionissues.
_______________________________________________
Individual. Itreferstothehumancomponent,and
incorporatessuchaspectsasindividual
physicalorsensorylimitations,human
physiology,psychologicallimitation,
individualworkloadmanagementand
experience,skill,andknowledge.
_______________________________________________
Group. Itreferstotherelationaland
communicationaspects,suchas
communication,interactions,
teamskills,crew/teamresource
managementtraining,supervision,and
regulatoryactivities.
Groupalsodealswithleadership,and
teamwork.
_______________________________________________
OrganizationalItreferstothecompanyandmanagement
environment. aswellastheprocedures,policies,norms,
andformalrules.
_______________________________________________
In2000,Furushoproposedasimplersystemcalled
theIMmodel.Thismodelconsistsof4Mfactors(man,
machine,media,andmanagement)thatareconnected
bytheindividualelement(I)asthecoreofthesystem
inshipnavigation(Furusho2000,2004).
The proposed MOP model is drawn three‐
dimensionallyas
athree‐sidedinvertedpyramidthat
hasfourcorners,representingthe4Mfactors,andsix
edges, representing an interaction between two 4M
factorsthatareconnectedbytheedges,asshownin
Figure2.
Table 2 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
259
accidentsusingtheepidemiologicalmodel,andthen,
prevention actions can be considered. Besides, the
characteristicsofseveralaccidentscanbeexploredby
analyzingseveralaccidentreportsandbyfindingthe
tendency,ascarriedoutinthispaper.
Table2.DefinitionandexamplesofeachcorneroftheMOP
Model
_______________________________________________
4MFactors Definition(Example)
_______________________________________________
ManAllelementsthataffectpeopledoingtheir
(M1)tasks
(Knowledge,skills,abilities,memory,
motivation,alertness,experience,etc.)
_______________________________________________
MachineAllelements,includingtechnology,which
(M2)helppeopletocompletetheirtasks
(Equipment,informationdisplay,
environmentaldesign,crewcomplements,
construction,etc.)
_______________________________________________
Media Allenvironmentsthataffectthesystem
(M3)and/orpeople
(Climatic/weathercondition(temperature,
noise,seastate,vibration,wave,tide,
wind,etc.),economiccondition,social
politics,culture,etc.)
_______________________________________________
Management Allelementsthatcancontrolthesystem
(M4)and/orpeople
(Trainingscheme,communicationamong
companies/institution,workschedule,
supervising/monitoring,regulatory
activities,procedures,rules,maintenance,
etc.)
_______________________________________________
The edges, called line relations, show that the
system is a result of interactions among the 4M
factors.Failures that are classifiedinto the corner of
the MOP model do not occur only beca use of that
particularcorner.Often,thefailureiscausedbyother
corners. When there are failures that
are caused by
several corners, it implies that the line relations
connectingthosecornersarealso contributing tothe
instabilityofthesystem.
Figure2.MOPmodel
Forexample,considerafailureincommunication.
Communication cannot be classified into one corner
becausecommunicationisrelatedtoallfourcorners.
The failure in communication among seafarers is
classified as man factor (M1) because this type of
communicationdependsontheperson.Often,several
seafarers do not share information with
other
seafarers. However, communication failure among
shipsandportadministrationsdoesnotbelongtothe
manfactor.Itcanbelongtoeitherthemanagementor
themachinefactorthatisaffectedbythemediafactor.
Theclassificationoffailuredependsonthecondition
of the accidents. When a line relation
contributes to
theaccident,apreventiveactionforthelinerelation
has to be determined. Thus, for a safe system, all
cornersandedgesshouldbereliableandbalanced.
Because the MTS consists of latent conditions,
barriers, and active conditions, any accident that
occursintheMTSshouldbetracedfor
eachofthese
factors separately. Each factor (corner) of the MOP
model represents the epidemiological model as
shown in Figure 1. In Figure 1, the individual from
M1(manfactor)receivessomeinformationfromM3
(media factor: environment) and from M2 (machine
factor: crew complement) factors; then, this
information is
used for decision making. Hazard
perceptionsare alsoinfluenced byM4 (management
factor).
4 ANALYSISONTHEMTSACCIDENTSUSING
THEMOPMODEL
Theinvestigationreportsexplainallfactsandcauses
ofthe accidents. Were‐analyzedthose reportsusing
theMOPmodel.Theanalyseswerecarriedoutintwo
steps:
corner analysis, which is listing causative
factors for each corner of the MOP model; and line
relationanalysis,wheretherelationshipbetweeneach
causativefactorinthecornerisexplored.
4.1 CornerAnalysis
Corner analysis (CA) is listing all causative factors
(CF)thencategorizethemintoeach corner basedon
the definition for each corner. The CF is all failures
thatcausingaccidents.AftercategorizingtheCF,we
countedthenumberoffailuresafterallreportswere
analyzed.Tables3–6listthecausesandthenumberof
failuresforeachcausativefactorforeachcornerofthe
MOPmodel.
From Tables
3–6, the most common failures for
eachcorneroftheMOPmodelcanbeidentified.They
are “improper lookout,” “cannot place the object on
radar,”and“insufficientlight”forman,machine,and
media factors, respectively. For the management
factor,therearefourfailuresthathavethesametotal
number, they
are “seaman has an expired
certificate/no certificate,” “poor management of
personnel on board in rotating personnel,” “poor
communicationabouttrafficroutefromthecompany
(onshore),”and “poor communication in monitoring
andsupervisingfromonshore.”
260
Table3.Numberoffailuresforeachcausativefactorofthe
MTSaccidentsinJapanandIndonesiacategorizedasM1
_______________________________________________
Code CausativeFactorsJapan Indonesia
Total
_______________________________________________
SLIPSHODWORKMANSHIP
M1‐01 Inconsistencyinthe 3 14
navigationcourse
M1‐02 Wrongcoursedecision0 33
M1‐03 Wrongspeeddecision 3 36
M1‐04 Lackofcommunication 4 37
amongtheseamen
M1‐05 ImproperLookout7 411
M1‐06 Misunderstandingconditions
50
5
(wrongjudgment)
M1‐07 Lightinginappropriate 1 01
(navigationallight)
INCAPABILITYOFSEAFARER
M1‐08 InutilizingAIS*6 17
M1‐09 InutilizingRadar1 12
M1‐10 IncommunicatingbyVHF 2 02
M1‐11 Incommunicatingwith 0 44
othervessel
M1‐12 Inunderstandinghowto 0 44
avoidcollision
M1
‐13 Inconductingabandoned 0 11
ship
_______________________________________________
*AISmeansAutomaticIdentificationSystem
Table4.Numberoffailuresforeachcausativefactorofthe
MTSaccidentsinJapanandIndonesiacategorizedasM2
_______________________________________________
Code CausativeFactors Japan Indonesia Total
_______________________________________________
M2‐01 Cannotplacetheobject 2 02
onRadar
M2‐02 Lackofcommunication 0 11
tools
M2‐03 Theanchorcouldnot 0 11
beplaced
_______________________________________________
Table5.Numberoffailuresforeachcausativefactorofthe
MTSaccidentsinJapanandIndonesiacategorizedasM3
_______________________________________________
Code CausativeFactors Japan Indonesia Total
_______________________________________________
M3‐01 Rain3 03
M3‐02 Insufficientvisibility 2 02
M3‐03 Strongwind1 12
M3‐04 High/Strongwave1 01
M3‐05 Insufficientlight9 615
M3‐06 Tidalstream1 12
M3‐07 LowTidal0 11
M3‐08 Traffic
routewascrowded 0 11
_______________________________________________
There are some classifications in Table 3 and 6.
When classifying the failures for the man and
management factors, M1‐01 until M1‐07 can be
classified again into slipshod workmanship. This
classificationisonlyformakingiteasytodivideand
analyzethefailures.Failuresthatcausedaccidentsin
Indonesia
and Japan can be broadly classified into
slipshod workmanship and incapability of seafarer.
Then, in terms of the management factors (Table 6),
the failures were poor management of personnel on
board, poor communication, poor management of
emergency drill, and poor application of safety
managementsystem.
Only observing the number of
failures is not
sufficienttoobtainthecharacteristicoftheaccidents
for each country because the number of analyzed
accidents in Indonesia and Japan are different. The
ratio of occurrence from among the analyzed report
should be known. Figures 3–6 show the occurrence
ratio(onthehorizontalaxes)ofeachcausativefactor
ontheverticalaxes.
Table6.Numberoffailuresforeachcausativefactorofthe
MTSaccidentsinJapanandIndonesiacategorizedasM4
_______________________________________________
Code CausativeFactors Japan Indonesia Total
_______________________________________________
POORMANAGEMENTOFPERSONNELONBOARD
M4‐01 Seamanhasanexpired 2 24
certificate/nocertificate
M4‐02 Inunderstandingthe 0 22
passageplan(innewarea)
M4‐03 Lackofpersonnel0 33
M4‐04 Inrotatingpersonnel 1 34
POORCOMMUNICATION
M4‐05 Abouttrafficroutefromthe3 14
company(onshore)
M4‐06 Inmonitoringand2 24
supervisingfromonshore
M4‐07 Amongonshoreandother0 11
vesselsutilizingradio
M4‐08 Poormanagementof 0 11
emergencydrilling
M4‐09 Poorapplicationofsafety1 2
3
managementsystem
_______________________________________________
Figure3.ComparisonofoccurrenceratiobetweenJapanese
and Indonesian MTS accidents for each causative factor
categorizedasthemanFactor(M1)
To understand the figure 3‐6, the following
example will explain how to calculate the ratio. A
total of 11 failures were attributed to the improper
lookoutcausativefactorinthemanfactors.Fromthe
14 reports, improper lookout was the reason for 7
261
cases. This means that the occurrence ratio for this
causativefactoris0.5(7dividedby14).Inthecaseof
Indonesiancollisions,improperlookoutwasthecause
for 4 of 8 accidents. Thus, the occurrence ratio of
improperlookoutinJapanandIndonesiaisthesame.
Figure4.ComparisonofoccurrenceratiobetweenJapanese
and Indonesian MTS accidents for each causative factor
categorizedasthemachineFactor(M2)
Figure5.ComparisonofoccurrenceratiobetweenJapanese
and Indonesian MTS accidents for each causative factor
categorizedasthemediaFactor(M3)
Figure6.ComparisonofoccurrenceratiobetweenJapanese
and Indonesian MTS accidents for each causative factor
categorizedasthemanagementFactor(M4)
4.2 LineRelationAnalysis
Causative factors written in Tables 3–6 are not pure
belongstoonecorner.Thislinerelationanalysisstep
connects one corner to the other corners that are
related to the causative factors that occurred. The
causativefactorinacornerthatisrelatedtoanother
corneris
markedtotherelatedcorner,andthen,the
line relation that connects these corners is obtained.
Thelinerelationthatconnectsthemanfactor(M1)to
themachinefactor(M2)islabeledasM12.Therefore,
M23 implies the line relation that connects the
machinefactor(M2)tothemediafactor
(M3).
Inthisstep,of all thecausative factors listed,the
relationshipamongthecornersoftheMOPmodelis
explored.Byperforminglinerelationanalysis,wecan
understandwhichlinerelationisthemostvulnerable
to failure for each country or in both countries. The
causative factors listed in Figures
7–10 show the
comparison of the line relations causing ratio that
connects causative factors to several corners of the
MOPmodelbetweenIndonesiaandJapan.
The causing ratio for a corner is obtained by
dividing the number of causative factors that are
related to other corners with the total number
of
causativefactorinthatcorner.
Figure7. Comparison of the line relation causing ratio
betweenJapaneseand IndonesianMTS accidentsinwhich
thecausativefactorsarecategorizedasmanfactors(M1)
Figure8.Comparisonoflinerelationcausingratiobetween
Japanese and Indonesian MTS accidents in which the
causativefactorsarecategorizedasmachinefactors(M2)
262
Figure9.Comparisonoflinerelationcausingratiobetween
Japanese and Indonesian MTS accidents in which the
causativefactorsarecategorizedasmediafactors(M3)
Figure10.Comparisonoflinerelationcausingratiobetween
Japanese and Indonesian MTS accidents in which the
causative factors are categorized as management factors
(M4)
The following example can help reader to
understand how to calculate by seeing in the man
factorcorner.Thereare13causativefactorsintotalin
thiscorner.However,notallcausativefactorscaused
theaccidentsinIndonesiaorJapan.InIndonesia,for
the corner man factor there were 9 causative
factors
(referTable3).Ofthese9factors,5wererelatedtothe
management factor, i.e., M1‐04, M1‐05, M1‐8, M1‐9,
and M1‐10. Thus, the M14 line is causing the man
factorcornerwitharatioof0.56(5dividedby9).
5 DISCUSSION
The characteristics
of ship collision accidents in any
country should be known to prepare preventive
actions to decrease the number of accidents. In this
research,weproposeanewmethod,calledtheMOP
model, for obtaining these characteristics. We
analyzed accidents for two countries to demonstrate
howtheMOPmodelcanexplorethe
characteristicsas
wellas thedifferences in the accident characteristics
foreachcountryorforbothcountries.However,this
research does not aim at debating which country is
better.
Figures 3–10 illustrate the comparison of the
occurrence ratio for the corner and line relation
analysesbetweenIndonesiaandJapan.These
figures
indicate that there are several causative factors that
affect each country differently; there are factors that
affectbothcountriesequallyaswell.Insubsection5.1,
the result of each will be discussed. In the last part,
thisdiscussionalsoprovidesthecharacteristicsofthe
failureeventsineachstageof
accidentdevelopment.
5.1 CharacteristicsofMTSaccidentsinIndonesia
Atotalof54failuresoccurinthe8casesofcollisions.
25ofthesefailuresarerelatedtomanfactorswith10
types of causative factors, 2 failures are related to
machine factors, 10 failures are related to media
factors
with 5 types of causative factors, and 17
failures are related to management factors with 9
types of causative factors. These numbers indicate
that failures in the man factor are dominant among
the8collisionsaccidents.
Severalcausative factorsonly occur in Indonesia.
For example, slipshod workmanship in deciding
course, incapability
of seafarers in communicating
with other vessels, understanding how to avoid
collision, and conducting abandoned ship measures
(categorized as man factors), lack of communication
toolsandtheanchorcouldnotbeplaced(classifiedas
machine factors), low tidal and traffic route was
crowded (classified as media factors), and poor
communication
among onshore and other vessels
utilizing radio and poor management of emergency
drilling(classifiedasmanagementfactors).Amongall
causativefactorsmentionedabove,themostcommon
istheincapabilityofseafarersincommunicatingwith
other vessels and in understanding how to avoid
collision with the occurrence ratio of 0.5 (Figure 3).
Thisimpliesthattherewere4outof8collisionsthat
werecausedbythesecausativefactors.
However, these two causative factors do not
entirelybelongtothemanfactor.Theyarerelatedto
themanagementfactoraswell,forexample,theterm
oftraining.AsshowninFigure7,
theM14lineisthe
most causing line to the man factor corner, with a
causingratioof0.7.IfweseeFigures7–10carefully,
themostcausinglineforIndonesiaisthelinethatis
connected to the management factor, such as M14
causingmanfactor,M24causingmachinefactor,
M34
causingmediafactor.Inthemanagementfactoritself,
themostcausinglineisM14withacausingratioof1,
which means that all the causative factors in the
managementfactorarerelatedtothemanfactor.
Fromanotherperspective, thecharacteristicsofthe
accidentcanbeseenfrom
thefailurethathappensin
thethreestagesofaccidentdevelopment.Fromthe54
failures that occurred, 33 failures occurred in the
beginning of accidents, 18 failures occurred in the
accident or in an effort to avoid the collision, and 3
failuresoccurredintheevacuationprocess.However,
therewereno
failuresinmachineandmedia factors
in Stages 2 and 3. All failures in Stages 2 and 3 are
failuresinthemanandmanagementfactors.
The failures that occur in the evacuation process
arealsodangerousbecausetheyresultinanincrease
inthenumberofpeoplewhoare
missing,whosustain
injuries, or those that are fatally wounded. Two
collisions had failures in Stage 3. The failures are
slipshodworkmanshipincommunicatingamongthe
seafarers (M1‐04), incapability of seafarer in
conducting abandoned ship (M1‐13), and poor
communication among onshore and other vessels
utilizingradio(M4‐07).
263
In Stage 2, 15 out of 18 failures belong to man
factors with 5 types of failures/ causative factors.
ThesecausativefactorsareM1‐01,M1‐02,M1‐03,M1‐
11,andM1‐12.Allcommonfailuresthatoccurinall8
collisions in Indonesia occur in Stage 2. Thus,
the
incapability of the seafarers in communicating with
other vessels (M1‐11) and in understanding how to
avoid the collision (M1‐12) caused the collision. If
these failures were addressed, the collisions could
havebeenaverted.
InStage1,mostfailureswereinthemanagement
factor,whichimplieslatentfailures,
andinthemedia
factor. However, the most common failure that
occurred in this stage also occurred in the cases in
Japan.
Therefore, from the discussion above, the most
vulnerable condition is the man factor corner, man–
managementlinerelationandStage2oftheaccident
developmentprocess.Toavoidcollisions,
thesethree
points must be considered for taking preventive
actions.
5.2 CharacteristicsofMTSaccidentsinJapan
Japan had 60 failures in the 14 collision cases from
2008–2012. 32 of these failures belong to the man
factor with 9 types of causative factors, 2 of them
belongtothemachinefactor,
17belongtothemedia
factors,with6typesofcausativefactors,and9belong
to the management factor with 5 types of causative
factors. Similar to Indonesia, the man factor
dominates the system. The difference is the
composition of the media and the management
factors.Althoughthemanagementfactor
inIndonesia
is much higher than the media factor, in Japan, the
media factor is much higher than the management
factor.
Thenumberofcausativefactorsthatonlyoccurin
JapanissmallercomparedtoIndonesia;thesefactors
are slipshod workmanship in misunderstanding
condition/ wrong judgment (M1‐06), lighting
inappropriate navigational
light (M1‐07), and
incapability of seafarers in communicating by VHF
(M1‐10) in man factor; cannot place the object on
radar (M2‐01) in machine factor; rain (M3‐01),
insufficient visibility (M3‐02), and high/strong wave
(M3‐04) in media factor. There are no management
factors that occur only
in Japan. From all causative
factors mentioned above, failures in
misunderstanding condition/wrong judgment (M1‐
06) has the highest causing ratio in the system. The
causingratiowas0.36(PleaserefertoFigure3).There
were5outof14casesthathadthiscausativefactor.
The master on board judged something
wrong
regarding the opposite vessel. The master assumes
thattheothervesselwillperformamaneuverthatcan
avoidtheaccident,andtherefore,onlythemastercan
perform an action that can positively avoids the
accident.
InthelinerelationanalysisofJapaneseaccidents,
thereisnospecialcharacteristicsthat
canbeextracted
becausethehigh causing ratio ofthe line relationin
Japan is the same as in Indonesia. However, the
causing ratio in Japan is smaller than that in
Indonesia,exceptinthemachinefactorcorner.Inthe
machine factor corner, M12 and M13 entirely cause
themachinefactor
failureswithacausingratioof1.
Thismeansthatallfailuresinthemachinefactorare
affectedbyM12andM13.
Now, let us discuss how the failures are divided
intostages1 and3.UnlikeIndonesia,the14casesin
Japan do not have any failure in the
evacuation
processexceptbecauseofbadweather(mediafactor).
Only1accidentoutof14has13peoplemissing.The
collision happened at night, in a rainy, wavy, and
extremelydark environment, and therefore, the ship
sufferedfromfataldamageandnoonewasfoundat
sea.Sixhoursafterthe
collision,anevacuationvessel
reachedtheaccidentpoint;however,itcouldnotfind
the 13 missing people. Other than that case, the
numberofinjuryanddeathisnotaslargecompared
tothecaseinIndonesiawhentheseafarercouldnot
carryouttheevacuationprocess.
Fromthe60
failures,16failuresoccurredinStage
2andtherestoccurredinStage1.Althoughthemost
common causative factors in Indonesia occurred in
Stage 2, the accidents in Japan have different
characteristics. The misunderstanding condition,
whichisthemostcommoncausativefactorinJapan,
occurredinbothStages1and
2.Inaddition,thereare
no special characteristics failures in Stage 2. Most
failures occurred in Stage 1 where the man factor
corner has 21 failures and there are no machine
factors.
5.3 CharacteristicsofMTSaccidentsinBothIndonesia
andJapan
In this subsection, we discuss the causative factors
that occur in both Indonesia and Japan. These
causative factors are listed in Tables 2–5. From all
causative factors, the insufficient light (M3‐05) from
mediafactorsisthemostcommoncausingfactorfor
thesysteminboth IndonesiaandJapan. The second
most common factor is improper lookout (M1‐05)
fromthemanfactor.Insufficientlightimpliesthatat
the time of the accident, it was too dark or the
accident occurred at night. Indeed, this condition is
more difficult. If it we note the occurrence ratio in
Figure 5, the accidents that occurred had a higher
occurrenceratioof
0.75inIndonesia,whileinJapan,
theratiois0.64.Inthecaseofimproperlookout,both
Indonesia and Japan have the same occurrence ratio
(0.5)ascanbeseeninFigure3.
In both Indonesia and Japan, the most causing line
relationistheM14Lineinthemanagementfactor,
as
seen in Figure 10. It has a 1.0 causing ratio, which
meansthatallfailuresinthemanagementfactorthat
occurinbothIndonesiaandJapanarerelatedtothe
manfactor.
6 CONCLUSION
From the result of utilizing MOP model, several
collision accident in Japan and Indonesia have
been
characterized. There are several characteristics that
only occur in Indonesia and Japan separately, and
those which happen both in Indonesia and Japan.
264
From the study, we can draw the following
conclusions:
1 CharacteristicofIndonesiancollision(nothappen
inJapan)isseafarerfailtoavoidtheaccident.
To avoid collisions, more attention needs to be
paidtothecapabilityofanIndonesianseafarer
Themostcommonfailureofallcausativefailures
in
8collisioncasesinIndonesiaoccurredinStage
2, that is, failure to avoid the accident. The most
common causative factors are incapability of the
seafarer in communicating with the other vessel
(M1‐11) and in understanding how to avoid
collision(M1‐12);thesecausativefactorsbelongto
theman
factor.
2 CharacteristicofJapanesecollision(nothappenin
Indonesia)is misunderstanding condition (wrong
judgment)fromMasters.
5ofthe14collisionscasesinJapanwerecausedby
this causative factor, and it does not occur in
Indonesia. In order to reduce the number of
accidents that have the same causes,
the seafarer
needstoreconsiderthejudgment.Itisnecessaryto
communicatewiththeoppositevessel sothatthe
rightactioncanbeperformedtoavoidcollision.
3 Mostaccidents in Indonesiaand Japan happened
atnightandtheseafarersdidnotensureaproper
look‐out.
Thesetwo causative
factorshavehighoccurrence
ratios compared with other causative factors.
Therefore,payingmoreattentiontothelookoutis
definitely required and when a transportation
occurs at night, the seafarer should be more
careful.
ACKNOWLEDGEMENT
IwouldliketothankMr.AleikNurwahyudy,oneof
the investigators at the Indonesian National
Transportation
SafetyCommittee,whosupportedme
by explaining several conditions of the Indonesian
MTS and by introducing the concept of the three
stagesofaccidentdevelopment.
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