Title Page
Abstract
초록
Contents
Nomenclature 13
Chapter 1. Introduction 14
1.1. Motivation 14
1.2. Research objectives and goals 19
1.3. Organization of dissertation 20
Chapter 2. Related Research 21
2.1. Overview of related research 21
2.2. SA View on complex collaborative system 21
2.2.1. SA 22
2.2.2. DSA 25
2.2.3. Relation with suggested framework 26
2.3. Safety analysis and management researches 27
2.3.1. Safety-II 27
2.3.2. FRAM 28
2.3.3. Relation with suggested framework 29
2.4. Social network 30
Chapter 3. Safety management framework considering human collaborative relation 32
3.1. General 32
3.2. Flow of Integrated FRAM-HCRN framework 33
3.3. Concept of HCRN and HCR 34
3.3.1. Concept of HCRN 34
3.3.2. Classification of HCR 37
3.4. HCRN and Integrated FRAM-HCRN analysis 41
3.4.1. HCRN analysis 41
3.4.2. Integrated FRAM-HCRN analysis 43
3.5. Enhancement of system FRAM network and HCRN 46
3.6. Summary 47
Chapter 4. Case studies 48
4.1. General 48
4.2. Case 1: Capsizing of MV Herald of Free Enterprise 49
4.2.1. Background of case 1 49
4.2.2. System FRAM network of case 1 50
4.2.3. HCRN and integrated FRAM-HCRN analysis 53
4.2.4. Enhancement of System FRAM network and HCRN 73
4.2.5. Discussion with enhanced FRAM-HCRN 76
4.3. Case 2: MT Hebei Spirit oil spill 82
4.3.1. Background of case 2 82
4.3.2. System FRAM network of case 2 82
4.3.3. HCRN and Integrated FRAM-HCRN analysis of case 2 85
4.3.4. Enhancement of system FRAM network and HCRN 108
4.3.5. Discussion of case 2 111
4.4. Case 3: Sinking of MV Sewol ferry 113
4.4.1. Background of case 3 113
4.4.2. System FRAM network of case 3 114
4.4.3. HCRN and Integrated FRAM-HCRN analysis of case 3 117
4.4.4. System FRAM network and BCRN redesign 125
4.4.5. Discussion 127
Chapter 5. Exploratory study to apply the concept of the HCRN 131
5.1. Introduction of exploratory study 131
5.2. Literature survey for exploratory study 131
5.3. Semi-quantitative approach to the concept of HCRN 133
5.3.1. Application to integrated FRAM-HCRN analysis 133
5.3.2. Application to evaluation of strategy for variability management 135
5.4. Exploratory case studies 135
5.4.1. Exploratory case 1: Capsizing of MV Herald of Free Enterprise 135
5.4.2. Exploratory case 2: MT Hebei Spirit oil spill 140
5.5. Summary 143
Chapter 6. Conclusion 145
Bibliography 148
Curriculum Vitae 156
Table 1. Major maritime accidents with similarities for half century 14
Table 2. Classification of HCR for HCRN 38
Table 3. Template for BCRN analysis 42
Table 4. Matrix of HCRN 43
Table 5. Matrix of FRAM-HCRN 44
Table 6. Template for Integrated FRAM-HCRN analysis 46
Table 7. Template for deriving strategy to enhance the HCRN and system FRAM network 47
Table 8. List of selected maritime accidents for case study 48
Table 9. Events during the capsizing of the MV Herald of Free Enterprise 49
Table 10. FRAM analysis of case 1 51
Table 11. Related human and abbreviation for case study 53
Table 12. HCRN matrix of specified HCR 56
Table 13. HCRN matrix ofunspeeified HCR 56
Table 14. HCRN matrix including specified... 56
Table 15. Matrix for FRAM-HCRN of specified HCR for case 1 57
Table 16. Matrix for FRAM-HCRN of unspecified for case 1 58
Table 17. Detailed matrix of HCRN for case 1 59
Table 18. Matrix of HCRN for case 1 under accident condition 61
Table 19. Matrix of FRAM-HCRN for case 1 under accident condition 62
Table 20. Findings using checkpoint rules for case 1 69
Table 21. Comparison between FRAM-HCRN and emiched FRAM-HCRN 77
Table 22. Variability of Output for the case 1 80
Table 23. Function nodes in system FRAM network of case 2 83
Table 24. Related human node and its abbreviation for case 2 85
Table 25. Matrix of HCRN for case 2 87
Table 26. Matrix of FRAM-HCRN of specified HCR for case 2 88
Table 27. Matrix of FRAM-HCRN of unspecified HCR for case 2 89
Table 28. Matrix of HCRNfor case 2 under ab-hoc condition 93
Table 29. Matrix of FRAM-HCRN of specified HCR for case 2 under ab-hoc condition 94
Table 30. Matrix of FRAM-HCRN of unspecified HCR for case 2 under ab-hoc condition 95
Table 31. Matrix of HCRN for case 2 under accident condition 99
Table 32. Matrix of FRAM-HCRN of specified HCR for case 2 under accident condition 100
Table 33. Matrix of FRAtvl-HCRN of unspecified HCR for case 2 under accident condition 101
Table 34. Checked rules for case 2 103
Table 35. Related human and its abbreviation for case 3 114
Table 36. Function index and name for case 3 115
Table 37. Finding and rules for case 3 117
Table 38. Matrix of HCRN for case 3 119
Table 39. Matrix of FRAM-HCRN for case 3 120
Table 40. Comparison with literatures for case 3 129
Table 41. Template for semi-quantitative approach to integrated FRAM-HCRN analysis 133
Table 42. Template for semi-quantitative approach to evaluation of strategy 135
Table 43. Semi-quantitative analysis of exploratory case 1 136
Table 44. Semi-quantitative analysis of exploratory case 2 141
Fig. 1. Steady emerging maritime accident and improvement of regulations after accidents 15
Fig. 2. Related researches to maritime accident analysis method 17
Fig. 3. Overview of related research 21
Fig. 4. Three level model of SA in dynamic decision making 23
Fig. 5. Team situation awareness 24
Fig. 6. Representation of DSA concept 25
Fig. 7. Researches on SA in maritime domain 27
Fig. 8. Visualization of six aspects for FRAM analysis 29
Fig. 9. Flow of Integrated FRAM-HCRN analysis framework 34
Fig. 10. Schematic diagram of integrated FRAM-HCRN analysis 36
Fig. 11. HCRN unit diagram 42
Fig. 12. Unit diagram of FRAM-HCRN 43
Fig. 13. Example of representation of integrated FRAM-HCRN analysis on HCRN unit diagram 46
Fig. 14. FRAM analysis of case 1 52
Fig. 15. HCRN diagram for case 1 55
Fig. 16. Integrated FRAM-HCRN diagram for case 1 60
Fig. 17. HCRN for case 1 under accident condition 63
Fig. 18. FRAM-HCRN for case 1 under accident condition 64
Fig. 19. Example 1 of integrated analysis using checkpoint 66
Fig. 20. Example 2 of integrated analysis using checkpoint 67
Fig. 21. Example 3 of integrated analysis using checkpoint 68
Fig. 22. Example of enhanced HCRN with complement of human node in case 1 75
Fig. 23. Example of enhanced system FRAM network with complement of upstream-... 76
Fig. 24. Enriched FRAM-HCRN for case 1 78
Fig. 25. Enriched HCRN for case 1 79
Fig. 26. Instantiation of the FRAM model for case 1 81
Fig. 27. Arrangement of the towing convoy 82
Fig. 28. System FRAM network of case 2 84
Fig. 29. HCRN for case 2 86
Fig. 30. FRAM-HCRN for case 2 90
Fig. 31. HCRN for case 2 under ab-hoc condition 92
Fig. 32. FRAM-HCRN for case 2 under ab-hoc condition 96
Fig. 33. HCRN for case 2 under accident condition 98
Fig. 34. FRAM-HCRN for case 2 under accident condition 102
Fig. 35. Example 1 of analysis for case 2 using checkpoint rules 104
Fig. 36. Example 2 of analysis for case 2 using checkpoint rules 105
Fig. 37. enriched FRAM-HCRN for case 2 111
Fig. 38. System FRAM network for ease 3 116
Fig. 39. HCRN for case 3 118
Fig. 40. FRAM-HCRN for case 3 123
Fig. 41. Weighted graph of human network with normalized HCRN variability score in... 138
Fig. 42. Weighted graph of human network with normalized HCRN variability score in... 142