2017 4th International Conference on Transportation Information and Safety (ICTIS), August 8-10, 2017, Banff, Canada
Marine Accident Analysis Based on Organizational
Resilience
Jinhui Huang
Intelligent Transportation System Research Center, Wuhan
University of Technology
National Engineering Research Center for Water Transport
Safety
1040 Heping Avenue, Wuhan, 430063, China
huangjinhui@whut.edu.cn
Abstract—System resilience has become a new perspective of
safety engineering in recent years. It focuses on full-time response
to adverse events. The different resilience system strategies are
studied to enhance the system’s ability to tolerate negative events.
Organizational resilience applies resilience methods to the
organizational structure, function and interactive behavior of the
social-technology system. Water transport system is a complex
social-technical system and development of technology makes the
degree of coupling between the staff and physical system increase,
so that human and organizational factors play a more important
role in system safety.
The water transport system is a kind of transportation with
high risk, high concentration, high autonomy and decentralized
system. This paper mainly studies group unit formed by people
and organizations in water transport system and discusses the
role of organizational factors in water traffic accidents by
establishing the interaction of organizational units. Finally, this
paper analyzes the occurrence and evolution of the accident from
the perspective of organizational resilience through a case study
of the “Oriental Star” accident.
Keywords—water transport safety; organizational resilience;
accident analysis
I. INTRODUCTION
As a large shipping country, China has a busy waterway
transport system but bears a higher risk of accidents at the same
time. As one of the special forms of engineering accidents,
water transport accidents have the characteristics of difficulty
in search and rescue, great loss and great social influence [1],
e.g., “Oriental Star” liner capsized when it sailed to Jianli in
Hubei Province on 2015-6-1 which resulted in 442 people dead.
At present, the risk analysis of water transport accidents is
mostly regression analysis, fitting of accident law, probability
prediction of the accident based on historical accident statistics.
Risk analysis means to analyze and evaluate the related factors
in the system. The water transport system is highly coupled and
organizations are complex and large. At the same time,
accident form and accident cause is full of uncertainty,
flexibility and fuzzy[2] which causes that it is difficult to avoid
emergent catastrophic accidents or reduce losses through risk
assessment, and the research on how to improve the ability to
cope with unexpected adverse event become more and more
important.
978-1-5386-0437-3/17/$31.00©2017 IEEE
993
Yang Wang
Intelligent Transportation System Research Center, Wuhan
University of Technology
National Engineering Research Center for Water Transport
Safety
1040 Heping Avenue, Wuhan, 430063, China
wangyang.itsc@whut.edu.cn
Therefore, this paper reviews the mainstream theories of
the engineering accident and analyzes group unit composition
and interactive behavior of water transport system from the
perspective of organizational resilience. At last, the suggestions
of improving the ability to cope with water transport risk are
also given through analysis of typical accident case.
II. RESEARCH OF ENGINEERING ACCIDENTS ANALYSIS
In the field of engineering accidents, many scholars
propose different accident analysis methods and theories based
on different perspectives, and mutual learning and mutual
absorption of these theories greatly promote the development
of engineering accident theories and make important
contributions to enhancing safety and reliability of engineering
system. This section reviews some dominant views from
aspects of accident modeling and human reliability.
Accident modeling is the abstract expression of occurrence
mechanism of accident and evolution law [3]. Accident
modeling is mainly about the analysis of causes of the accident
and simplified representation of accident process, so as to learn
from the lessons and avoids the similar accident from
happening again. Therefore, Leveson puts forward the theory
of “systems-theoretic accident model and processes, STAMP”
model [4] which is based on the system theory and control
theory. This theory mainly focuses on constraints in safety
management instead of events and main causes of the accident
is considered as insufficient or unreasonable control, or due to
the constraints related to safety in the process of system
development, design and running. Control may be driven by
management functions in the organization or may be
determined by social and political systems of organization.
Nowadays, many researchers have used STAMP model to
analyze the major accidents and made lots of achievements.
Hollnagel proposes the “cognitive reliability and error analysis
method, CREAM” model [5] which belongs to the second
generation “human reliability analysis, HRA” methods. He
believes that all human errors happen in an environment which
can influence the human behaviors so that analysts need to
make quantized subjective judgments to performance
conditions related to environment and determine the
propagation path of failures. On the other hand, Hollnagel
presents “Functional Resonance Accident Model, FRAM”
2017 4th International Conference on Transportation Information and Safety (ICTIS), August 8-10, 2017, Banff, Canada
model [6] from the perspective of the whole system. This model
does not rigidly adhere to system structure decomposition and
the causing factors analysis but holds the view of that the
nature of the accident is a sudden change of normal operation
of the system and avoids regarding accident as the orderly
occurrence of a single event or the level-superposed of
potential factors. It pays more attentions to the formation
process of induced accident conditions. Mosleh establishes the
third generation HRA method “the information, decision, and
action in crew context, IDAC” model [7-11]. It introduces
performance influencing factors (PIFs) in process of
information acquisition, decision-making and action of crews,
and analyzes the interaction between PIFs as well as the
influences on operators in each action stage in details. Finally,
the dynamic probabilistic simulation method is used to validate
the IDAC model. Compared with the second generation HRA
method, IDAC model makes a more comprehensive analysis of
the influence of the mental state, physical factor, organizational
factors and environmental factors on the process of information
acquisition, decision-making and action with specific
experimental verification.
III. ORGANIZATIONAL RESILIENCE
Resilience (also known as elasticity) first proposed by
Holling in the 1970s which were originally used as the
expression of cyclical growth patterns of forest in the field of
ecology including proliferation, attenuation, and regeneration
of tree groups [12]. Vogus defined the resilience as the active
adjustment and maintenance by the organization to become
stronger and more flexible in adverse conditions [13]. He holds
the opinion that the key factors of organizational resilience are
emotion, cognition, relationship, and structure. Li Peng-cheng
thinks that the organizational factors are main causes of human
failures and analyzes the causalities between organizational
factors and human reliabilities [14]. He also establishes a fuzzy
Bayesian network model based on human reliability analysis to
quantify the impacts of organizational factors on human
failures. Reason (1997) believes that human error is only the
result rather than the cause, and the errors are mainly caused by
high level of the workplace and organizational factors [15]. In
fact, 20-90% of the accidents are related to the failures of
personnel, and most of the failures of personnel involved in
organizational factors, which can be avoided by formulating
appropriate organizational strategies or organizational
constraints.
Organizational resilience is the ability of organizations to
deal with internal or external destruction through advanced
strategic awareness and interconnected management. When
preparing in advance to prevent adverse events, organizational
resilience is static; when dealing with damage caused by
adverse events and maximizing the recovery of the system state,
the organization is dynamic. The basic attributes of the
organization are organizational structure, organizational
personnel, organizational environment and organizational
strategy.
The resilience system is composed of different levels of the
interdependent organization. Each organization is composed of
several sub-organizations forming a nested structure. There is
978-1-5386-0437-3/17/$31.00©2017 IEEE
994
the interaction of action, information, and resources between
organizations. The upper layer organization dominates the
lower ones, and the lower ones carry on the information
feedback to the upper organization in order to ensure the
normal interaction.
Organizational personnel is one of the core components of
the organization. Although with the development of science
and technology, many manual handlings have been replaced by
mechanical equipment and personnel plays a role of monitoring
and management, but human link is still one of the main weak
points of the whole system on account of the fact that staffs are
more prone to failure than instruments, which is one of the
reasons that high-reliability organizations (such as aircraft
carrier and nuclear submarines) are safer than lower one.
Personnel often have greater uncertainties and uncontrollability,
and personnel performance will be affected by professional
skills, physical state, mental state, interaction among the
operators and team atmosphere. Personnel models are
composed of decision makers and operators. The decision
maker is mainly responsible for command, coordination while
the operator is mainly responsible for the equipment operation,
equipment state monitoring and feedback, abnormal condition
reporting and handling etc.
Complex organization system often involves interaction
with the environment. Organizational environment factors
consist of work environment (mechanical equipment conditions,
noise and vibration etc.) and natural environment
(meteorological conditions, temperature, humidity etc.)
Organization strategy connects the various organizations of
the system and controls the rule and directions of organization-
driven. It is often developed and implemented by the upper-
level organizations including rule-making, operator assessment,
and design of contingency plan, safety supervision and
management. As shown in Fig. 1.
IV. MARINE ACCIDENT ANALYSIS
Water transport system is a complex organizational
interaction system. Applying organizational resilience theory to
water transport accident analysis can contribute to studying the
roles each organizational units play in accidents, analyzing
interactive-behavior strategies, exploring the occurrence and
evolution mechanism of the accident to make more effective
prevention and control of accident.
A. Organizational units of water transport system
In order to ensure the normal operation, water transport
system instituted many organizational units from top to
bottoms such as macroscopically ones (maritime management
departments, maritime regulatory agencies, ship companies)
and microcosmic ones (water transport law enforcer, ship-
control organizations and passengers).This section focuses on
the organizations of maritime regulators, ship crews, and
passengers. Maritime regulators is mainly responsible for the
related regulations-making, surveillance of water transportation,
maritime personnel assessment, emergency plan-making,
emergency command decision-making etc. ; The ship crews are
responsible for navigation information acquisition, ship control,
2017 4th International Conference on Transportation Information and Safety (ICTIS), August 8-10, 2017, Banff, Canada

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Fig. 1 Organizational structure model

TABLE I. THE INTERACTING OF WATER TRANSPORT ORGANIZATIONS

Organization Maritime regulators Ship crews Passengers

Maritime regulators ---- Crew assessment; supervision of ship; information registration; accident
emergency alert information acquisition; execute the
emergency command

Ship crews Report navigation information and ---- Report ship conditions; guide and
accident information; execute the restrain behavior of passenger;
emergency command organize evacuation;

Passengers Report accident information; report Report abnormal information ; ----

complains; coordinate with emergency rescue
action;

equipment operation and maintenance and report of abnormal
situations; Passengers have limited ability to get safe during
serious accidents as vulnerable groups in water transport
system, and they are the service principals on the ship as well
as take the role of being rescued in most accidents
B. Interactive behavior
The inner organizations have an own independent rule of
operation, and there are interrelated and interact with each
other among organizations. The specific interactive behaviors
in each organization unit are shown in TABLE I in order to
analyze the role of organizational factors in accidents.
C. Case analysis
This section mainly analyzes the cascading events leading
to accidents from four aspects of organizational structure,
organizational personnel, organizational environment, and

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995
2017 4th International Conference on Transportation Information and Safety (ICTIS), August 8-10, 2017, Banff, Canada
organizational strategy based on the case study of “Oriental
Star” accident.
Organizational structure: The maritime regulatory
authorities and ship crew organization structure is reasonable
and completely staffed.
Organizational personnel: Maritime supervisors made a lax
assessment of ship crews, and the monitoring system of
Yangtze River exists in name only resulted in unknowing of
the accident information timely. The main operators of the ship
did bad emergency handling facing terrible weather, neglected
daily maintenance and safety inspection of ship equipment
leading to quickly capsized of the ship, and failed to alert the
passengers, organize an evacuation, as well as send a distress
message to outside resulting in delaying the rescued time as
well as great losses.
Organizational environment: there are extremely bad
weather and navigation conditions where the accident
happened. The “Oriental Star” ship had been transformed
several times as a result that wind resistance was descended
and correlation sealing devices were missing.
Organizational strategy: There was a lack of normal
interaction between maritime regulatory and ship-control
organization. The supervision, audit, and inspection were not
strictly implemented.
V. CONCLUSION
(1) A lot of mature theoretical systems have been
developed and have been applied in practical accidents
analysis. The causes of accidents are often complex,
and the researchers can better understand the accident
mechanism by using of comprehensive safety analysis
theories.
(2) The accident will inevitably involve personal factors,
and personal factors often connect with the
organizational factors. The establishment of more
comprehensive and more resilient system is good for
prevention of human failure accidents.
(3) There are some problems in the implementation of
regimes in water transport system. The professional
skills of ship crews need to be trained and assessed,
and the sense of danger and responsibility needs to be
improved. It is necessary to examine the organizational
structure and observe the organizational environment
frequently.
978-1-5386-0437-3/17/$31.00©2017 IEEE
996
ACKNOWLEDGMENT
This research is supported by grants from the Key Project
in the National Science & Technology Pillar Program (Grant
No.2015BAG20B05).
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