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Core task analysis in accident investigation: analysis of maritime accidents in piloting situations

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Abstract

This article discusses the difficulties in utilising accident analysis as the basis for the development of complex socio-technical systems, and how to improve accident analysis to better meet such aims. It focuses on two themes: accident models and experts’ involvement in accident investigation. The article describes the development of a new core task analysis-based method for accident analysis. It also elaborates on the method by presenting summarising results of an investigation in which several maritime accidents were first analysed case-by-case, followed by a comparative analysis and a synthesis. The latter phases aimed at providing evident-based generic explanations for the accidents. The accidents occurred in Finnish coastal waters during sea or canal piloting between 1997 and 2000. The authors participated in both phases of the investigation for which the Finnish Accident Investigation Board was responsible. The presented method is argued to promote solutions to two current problems in accident investigation: generalisation from the results, and integration of the experts’ work.

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Notes

  1. C 11/1997 M, C 4/1998 M and C 5/1998 M also available in English (http://www.onnettomuustutkinta.fi/2601.htm)

  2. The different interactions (table 2): op = operator-process; oo = operator-operator and ei = expert identity, to own actions.

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Acknowledgments

We wish to thank the investigation team for good times, flaming cooperation and many fruitful discussions during the work. The team comprised Administrative Director Pirjo Valkama-Joutsen, Chief Maritime Accident Investigator Martti Heikkilä and Maritime Accident Investigator Sea Captain Risto Repo from the Accident Investigation Board, Director Sea Captain Antti Haapio from the Maritime Safety Training Centre, Sea Captain (emeritus) Kari Larjo, and psychologist Kristiina Hukki, and the authors from VTT. We also wish to give special thanks to Sea Captain Kari Larjo for his admirable maritime expertise, which made the world of the sea approachable. We also appreciate the comments on our approach from those who participated in the Risky Work workshop in Paris in 2003. The work on the accident investigation and the summarising of its results were funded by AIB. This work was funded by VTT.

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  1. VTT, P.O. Box 1000, 02044, VTT, Finland

    Maaria Nuutinen & Leena Norros

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  1. Maaria Nuutinen
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  2. Leena Norros
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Correspondence to Maaria Nuutinen.

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Nuutinen, M., Norros, L. Core task analysis in accident investigation: analysis of maritime accidents in piloting situations. Cogn Tech Work 11, 129–150 (2009). https://doi.org/10.1007/s10111-007-0104-x

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