Co-operation on bridge in piloting situations. Analysis of 13 accidents on Finnish fairways

Abstract

In the autumn of 1997 several accidents occurred on the Finnish fairways for foreign ship during piloting. The Finnish Accident Investigation Board (AIB) decided to launch a joint investigation for these accidents. The purpose of this paper is to present a method developed for the analysis of the piloting accidents. The target of the method is to enable parallel investigation of several accidents with the aim to create important knowledge of the domain, i.e. of the demands set by the sociotechnical system and of the contextual constrains to fulfil these demands. Based on the emerging cumulative picture of the domain a single accident can be analysed more profoundly. The developed method consists of two phases: a case examination and an organisational examination. The focus in the paper is on the case examination and co-operation on the bridge during the accident voyage. The main result of the investigation was that the demands of piloting activity have changed so that the prevailing practices and the prerequisites no more fully correspond with them.