tightly and are operated in a limited narrow range of allowance. Once a
trouble or abnormality appears some place, it propagates to neighbors in a moment, and an
accident occurs. This domino game or chain reaction puzzles the operator, and delays the
action against trouble while the cause is still unknown.
No matter how many safe guards are equipped, another trouble might be
hidden because the additional system itself has the possibility to have seed of trouble.
6. Measures to be taken
We have to draw a distinct line between an accident or abnormal state
and a damage or loss. Damage is the result of an accident, and is not always arisen even
if an accident occurs. There are many accidents without any damage, called near accident,
since preventing or precaution measures become effective.
What we have to do to prevent accidents is to keep watching and
catching even a small sign. According to H.W.Heinrich's law, there are 29 slight injurys
and 300 accidents arisen behind 1 catastrophic damage. Next shows the several fundamental
actions which we have to do.
First, make a human conscious system. Many systems will be highly
automated in future. But men have superb sensibilities and good judgment than machine in
many aspects, and accidents may have avoided by their knowledge and withdom. This positive
factor of human must be admitted to improve systems, and a equipment which allows human
interfarence is desirable at sea. I know there is a thought that full automatic control is
the final goal in maneuvring ships and planes. But final decision made by captain and
officer is preferable at sea.
Second, standardization of equipment. There is only about 25 types of
airplanes since the beginning of service in commercial jets. On the contrary, ships are
"tailor made", and everything is all different on every ships. Everytime a
seaman goes to another ship, he has to study his new systems and to be an expert. So
standardized systems and equipments are desirable as much as possible.
Third, education and training: Science and recurrent education must be
emphasized. And one of the most effective measures to prevent some kind of accident is
simulator training. A simulator can create a similar situation to real danger based on
various scenarios, and coordination among crew, machine systems and other environments can
be investigated. But we have to keep in mind that a simulator does not reproduce
situations perfectly.
Fouth, informations owned in common: it is very important for all
members to make certain where they are to achieve a common purpose. Having informations
and knowledge in common, we could foresee a trouble, and increase a possibility to avoid a
catastrophe.
Accident happens beyond our imaginations. To educate young people who
can observe nature and have an ability to judge his situation properly is our goal. ISM
code and other measures have been discussed at the SOLAS Conference in IMO, and the good
effects are assured. In addition of such a ship management point of view, much attention
must be made to the fact that new technolgy itself has a risk inside. Establishing safety
engineering at sea, so to speak, is urgent.
