Abstract
This study reviewed 612 DP LOP(Loss of Position) incident reports which submitted to IMCA from 2001~2010 and identified 103 human error caused incidents and classified it through HFACS. And, this study analysis of conditional probability of human error on DP LOP incidents through application of bayesian network. As a result, all 103 human error related DP LOP incidents were caused by unsafe acts, and among unsafe acts 70 incidents(68.0 %) were related to skill based error which are the largest proportion of human error causes. Among skill based error, 60(58.3%) incidents were involved inadvertent use of controls and 8(7.8%) incidents were involved omitted step in procedure. Also, 21(20.8%) incidents were involved improper maneuver because of decision error. Also this study identified that unsafe supervision(68%) is effected as the largest latent causes of unsafe acts through application to bayesian network. As a results, it is identified that combined analysis of HFACS and bayesian network are useful tool for human error analysis. Based on these results, this study suggest 9 recommendations such as polices, interpersonal interaction, training etc. to prevent and mitigate human errors during DP operations.
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