“Swiss Cheese Holes TRPG” is a game based on a fictional maritime accident. The instructor will proceed with the basic scenario that leads to the catastrophe of the maritime accident. If the story continues as the basic scenario, it will end in a catastrophe. Therefore, the players must take various risk management measures to prevent or reduce the risk of catastrophe. Specifically, the game aims to reinforce the holes in the predetermined barrier (Swiss cheese) cards by filling them with risk management (m-SHEL) cards. The players will become superintendents of a fictional ship management company and manage the risks related to the operation and maintenance of the ships. They will also recognize that the barrier (Swiss cheese) cards themselves can be risk factors that create holes in the risk, and the effectiveness of the risk management (m-SHEL) cards as risk assessment or recurrence prevention measures. We hope that the insights gained through this game will contribute to the acquisition of skills for writing Corrective Action Reports. 

・ How to grasp the cause of the accident　Organizational and system risk factors 

(i)   What is the purpose of accident investigation? 

(ii)  How to grasp the cause of the accident  

(ⅲ)   How to grasp the cause of the accident in the investigation report 

・ Methodology of accident investigation  

(i)   Analysis from the perspective of organizational accidents  

(ii)   Analysis of human factors  

(ⅲ)   Analysis of the conditions that could have prevented the accident  

(ⅳ)  Analysis of the safety culture of the organization