Learning from Failures: employing fault tree analysis and reliability block diagram to investigate the two deadliest peacetime marine disasters
DOI:
https://doi.org/10.29015/cerem.996Keywords:
Failure learning, Organizational learning, Fault Tree Analysis (FTA), Reliability Block Diagram (RBD), Marine Disasters, Maritime Safety, MS Estonia, MV Dona PazAbstract
Aim: This study aims to investigate the root causes of the MS Estonia and Doña Paz maritime disasters and to derive interdisciplinary lessons that can enhance the safety and reliability of maritime operations.
Design/Research methods: The study takes a case study approach and adopts Labib & Read’s (2013) framework for learning from failures. This study addresses the following questions: a) What technical factors contributed to the MS Estonia and Doña Paz maritime disasters? b) What human and organizational factors played a role in these maritime disasters? c) How do the reliability and vulnerability of individual components influence the overall safety and failure risk of MS Estonia and Doña Paz? To answer these questions, Fault Tree Analysis (FTA) and Reliability Block Diagram (RBD) techniques are employed. These methods are used to identify a range of technical, organizational, and human factors that contributed to these accidents and to assess the reliability and vulnerability of individual components affecting the safety and failure risk of the vessels.
Conclusions/findings: The analysis revealed that multiple factors, including technical failures, human errors, and organizational shortcomings, contributed to the disasters. The study found that the emergency response and search and rescue systems were particularly vulnerable, where a failure in any component could lead to system-wide failure. Based on these findings, evidence-based recommendations were proposed to enhance safety management practices, regulations, and oversight in the maritime industry.
Originality/value of the article: This study underscores the importance of a systemic approach to learning from failures. It highlights the necessity of addressing technical, human, and organizational factors in maritime safety and provides a framework for future research and improvements in safety management practices. The findings offer valuable insights for maritime organizations aiming to enhance their safety protocols and prevent future disasters.
JEL: L92, D81, O33, C63, M48
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