The current explanation of accidents is derived from an analysis of proximate events and some contributing causal factors, whereas the role of a wider socio-technical context that give rise to systemic causal mechanisms is often left unexplained. The paper describes analysis results of a recent maritime incident with the purpose to illuminate the causal factors, including systemic ones, and offers a different, more comprehensive explanation of the incident causation to that which is given in the accident investigation report. The study seeks to provide valuable input for enhancements in overall maritime safety control and proactive safety management at the ship and shipping company levels. With the gained knowledge, resources committed to risk management can be better allocated, reducing associated costs and improving on business objectives.
|Number of pages||13|
|Publication status||Published - 21 Sep 2018|
|Event||The 7th International Maritime Conference on Design for Safety - Kobe, Japan|
Duration: 16 Sep 2018 → 21 Sep 2018
Conference number: 7
|Conference||The 7th International Maritime Conference on Design for Safety|
|Abbreviated title||DfS 2018|
|Period||16/09/18 → 21/09/18|
- accident anlaysis
- engine room
Puisa, R., Williams, S. M., & Vassalos, D. (2018). Systems approach to accident analysis: engine room fire on cruise ship "Le Boreal". Paper presented at The 7th International Maritime Conference on Design for Safety, Kobe, Japan.