第35卷大连海事大学学报Vol.35 2009年6月Journal of Dalian Maritime U niversity J un. 2009
文章编号:100627736(2009)S120070203
多米诺骨牌理论中的人为失误与风险管理Ξ
刘付春南
(阳江海事局，广东阳江 529500)
摘要：通过介绍多米诺骨牌理论在风险管理中的作用原理，提出海事风险管理应主要以控制人为失误为主的观点，深入分析人为失误的原因，提出控制人为失误的方法，总结多米诺骨牌理论的优缺点.
关键词：多米诺骨牌理论；人为失误；海事风险管理
中图分类号:U692 文献标志码:A
H uman errors in Domino theory and
maritime risk management
L IU FU Chun2nan
(Yangjiang Maritime Safety Administration,Yangjiang529500,China)
Abstract:By introducing the principle of Domino’s theory in risk management,this paper puts forward the idea that the focus of maritime risk management should be on the control of human errors,analyzes the caus of human errors,comes up with ways of controlling human errors and finally sum up the advantages and disadvantages of Domino’s theory.
K ey w ords:Domino’s theory;human errors;maritime risk man2 agement
0 Introduction
In order to promote the safety of shipping and protection of marine environment,IMO has,since its founding,devoted itlf to two tasks:one task is to develop and establish high technical standards for the construction of ship;another is to specify high requirements on training,certification and watch keeping for afarers on an international level.How2 ever,in spite of all tho efforts IMO has made,the frequencies of maritime accidents are still very high. Statistics show that80percent of maritime accidents were caud by human errors[1].Shipping safety and marine environmental protection management,in es2nce,are managing risks.Since most maritime acci2 dents are related to human errors,the control of hu2 man errors will rve as an effective safety barrier to redu
ce maritime accidents from the point of view of risk management.This paper will introduce the Hein2 rich’s Domino Theory which emphasizes the impor2 tance of human factors in accidents and explain how the control of human errors can reduce maritime acci2 dents.
1 Heinrich’s domino theory for risk management
Heinrich’s Domino theory[2]is a risk manage2 ment model about accident causation put forward by H.W.Heinrich who insisted that human element should be prioritized as far as risk management is con2 cerned.After studying plenty of industrial accidents in America,H.W.
Heinrich found that88percent of accidents were caud by unsafe acts of workers,10percent due to un2 safe condition and2percent as unpreventable.Hein2 rich demonstrated his theory similar to five dominos placed end2on2end,knocking over one leads to each domino topple in turn:
The five dominos reprent respectively the five critical process which lead to injuries.Social envir2 onment may develop undesirable character of a person or may interfere with a person’s education,which can cau faults of person.Faults of person might be in2 herited or acquired,such as recklessness,hot temper, nervousness,carelessness,ignorance of safe practice, etc.,which constitute proximate reasons for commit2
Ξ收稿日期:2009204228.
作者简介：刘付春南(1979-)，男，广东化州人，工程师,E2mail:
ting unsafe acts or for the existence of hazards.Un 2safe acts are referred to as unsafe performance of per 2sons ,such as standing under suspended load ,starting machine without warning and removal of safeguards which will result directly in accidents.Accidents mean events that cau injuries such as falls of per 2sons ,striking of persons by flying objects.Injuries are fractures and lacerations that result directly from acci 2dents.The quential reaction and occurrence of the five process are the root cau of injury and the five process are integrated.Removing any of the knock 2down quences that is before injury can prevent the occurrence of injury.Heinrich suggests that the most effective way of reducing injuries is to remove unsafe acts of
persons.
Fig .1 H einrich ’s Domino Theory Model
As we all know ,an important part in risk reduc 2
tion or mitigation is the installation of safety barriers in the risk management model.Therefore ,we must try to install some safety barriers in the Domino Theo 2ry model in order to reduce accident.From the dem 2onstration of Domino Theory ,we can e that the sources of accidents and injuries are social environ 2ment ,person ’s faults and unsafe acts.Person ’s faults and unsafe acts come down to human errors.Hence ,the safety barriers in that model will the control of so 2cial environment ,person ’s faults and unsafe acts.However ,social environment are sometimes unpredict 2able and what is more ,according to Heinrich ,88per 2cent accidents were caud by unsafe acts of person ,so the main safety barriers will be on the control of hu 2man errors as far as risk management is concerned.Once the human errors are kept under control ,most accidents and injuries can be prevented or reduced.
2 Factors contributing to human errors
Since the control of human errors is an effective safety barrier ,we must first try to figure out what fac 2
tors will lead to human errors in order to control hu 2
man errors effectively.Human being is the most im 2portant factor in production activities and more free and flexible than machinery ,which make it more vul 2nerable to errors.Hence ,the caus of human errors are quite complicated.G enerally speaking ,human er 2rors are caud by the following four main factors :2.1 Skill factors
Skill factors involve afarers ’theory knowledge and practical operational shill.In theory ,the more skilled people are ,the less probably they will commit errors.That is why a green hand is more likely to make a mistake than an experienced worker at work.In addition to this ,if a person takes the task that is beyond his or her ability ,then he or she is vulnerable to make mistakes.For example ,a third mate does not hold a certificate of competence of chief mate ,so he is not competent to be a chief mate.If he is assigned to be a chief mate ,he will be liable to make mistakes which will lead to maritime accidents.2.2 Physiological factors
Physiological factors are referred to as the physi 2cal state of a person ,such as fatigue ,insufficient rest ,hunger and illness ,etc.Due to the relatively bad sleeping environment and insufficient medical treat 2ment on board ,afarers often suffer from sleep dis 2turbance and illness ,which have an adver effect on their working performance and easily lead to human errors.
2.3 Psychological factors
Psychological factors include stress ,interpersonal relationship between colleagues and so on.Stress can be found in many jobs and it is especially common among afarers.Life events ,such as divorce ,loss of family members and homesickness can cau great stress.Misunderstanding ,quarrel and conflicts from work can lead to bad relationship among colleagues.Stress and bad interpersonal relationship between col 2leagues are common contributing factors to human er 2rors.When afarers are under great pressure and ex 2perience bad interpersonal relationship between col 2leagues ,they will be inclined to commit unsafe acts.2.4 E nvironmental factors
As far as afarers are concerned ,environmental factors which are cloly related to human errors can be divided into living conditions and working environ 2ment.The noisy living conditions will make afarers suffer from insomnia and the bad working environ 2ment such as noisy engine room ,slippery floor on
17 刘付春南：多米诺骨牌理论中的人为失误与风险管理
board and poor design of workstations and machine are likely to affect afarers’performance and make them commit unsafe acts.
3 Control of human errors
Since most maritime accidents are caud by hu2 man errors,then control of human errors will be the most effective safety barrier for reducing maritime ac2 cidents.Nevertheless,human errors are quite compli2 cated,so the control of human errors is difficult.The following three principles should be borne in mind in order to mitigate the conquences of human errors: 3.1 To eliminate all the potential caus that will
contribute to human faults
As the old saying goes,prevention is better than cure.The best way of risk management is to eliminate the caus that may lead to accidents before accidents happen.We can try the following means to reduce the underlying human errors:
a.Enhancing the training and education of afar2 ers:In my opinion,training and education are differ2 ent from each other.Training focus on knowledge and operational skills about safety while education in2 volves moral,business ethics and social responsibility. To put it another way,the aim of training is to im2 prove afarers’amanship whereas the objective of education is to rai afarers’awareness about the importance of safety and hold them responsible social2 ly.
b.Emphasizing the importance of land2bad hu2 man errors:As far as marine safety is concerned,h
u2 man errors can be divided into two categories:on board human errors and land2bad human errors.On board human errors are referred to as afarers and land2bad human errors mean shipowner’manage2 ment.Land2bad human errors cannot be ignored in maritime risk management.For the purpo of cut2 ting cost and making as high profits as possible,many shipowner put old age ships into operation,reduce the manning and fly the flag of convenience,which to a large extent contributed to the high percentage of maritime accidents today.In order to eliminate the land2bad human faults,IMO adopted the ISM Code to hold ship2owners accountable for the safety of ships.
3.2 To make human errors harmless or prevent hu2
man errors from leading to accidents once they
occur
It is best to eliminate human errors before acci2dents happen,but there are always times when human errors occur unexpectedly.As a matter of fact,human errors cannot be eliminated completely in reality. Once human errors happen,efforts should be made to make human errors harmless or prevent them from leading to accidents.For example,if a afarer com2 mits an unsafe act to cau
a fire on board,he or she should put out the fire as early as possible,preventing the fire from causing any damage to life and property on board.
3.3 To mitigate the conquences of the accidents
once human errors lead to accidents
Efforts should be made to prevent the accidents from deteriorating once human errors lead to acci2 dents.If a ship collided with anther ship due to a2 farers’negligence and is flooded,afarers must pump out the water quickly to mitigate the conquences of the collision and prevent the ship from sinking.
4 Pros and cons of Domino theory for risk management
The Heinrich’s Domino theory,also called hu2 man element theory,looks at accidents and loss from the point of human element.Facts have proven that it is effective in risk reduction.In terms of marine safe2 ty,maritime accidents were reduced greatly after the implementation of ISM Code which lays emphasis on human element.However,although it is true that most of accidents are related to human element and it makes n to consider human errors to be an impor2 tant reason for accidents,we
cannot deny the fact that human being’s activities are not isolated from physical environments.Hence,we cannot ignore the influences of physical factor such as machinery failure when studying accidents and loss.
5 Conclusion
All in all,the control of human errors is an effec2 tive safety barrier to reduce maritime accidents and great achievement has been made on the control of hu2 man errors.Nevertheless,the achievement is far from meeting the demanding need of safety nowadays.We still need to work hard on it.
R eferences:
[1]Marine Directorate,Department of Transport,U K.The hu2
man element in shipping casualties.London:HMSO,1991.
[2]XU Jinliang.Risk Management[M].Beijing:China Finan2
cial Publishing Hou,2003:21.
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大连海事大学学报 第35卷
