摘要：No advance in navigation has yet to prevent the occurrence of accidents (incidents are always implied when we discuss accidents) at sea. At the same time, advances in accident models are possible, and may provide the basis for investigations and analyses to help prevent future adverse events and improve the safety of marine transport systems. In such complex socio-technical systems models that treat accidents as the result of a chain or sequence of events are used most commonly. Such models are well suited to damage caused by failure of physical components in relatively simple systems. Although these often include methods for modeling human error, they do not cover broader aspects related to the management of the organization using the means of transport itself (shipowners) nor errors that may occur in the design phase. In particular, they do not cover changes in the systems over time. The paper presents accident investigation approaches and uses a modified causal model to analyze an incident that occurred in January 2019 on the city ferry in Świnoujście. The results of the analysis were used to provide guidelines for increasing safety at the crossing and to evaluate the accident analysis model used. Additionally, incidentally, through the study of this case we uncovered a problem in communication among stakeholders that unnecessarily complicates the models for the models for the improvement of safety.
