Abstract
Occupational fatal injury rate per 10,000 population of Korea is still higher among the OECD member countries. To prevent fatal injuries, the causes of accidents including human error should be analyzed and then appropriate countermeasures should be established. There was an severe converter furnace accident resulting in five people death by chocking in 2013. Although the accident type of the furnace accident was suffocation, many safety problems were included before reaching the death of suffocation. If the safety problems are reviewed throughly, the alternative measures based on the review would be very useful in preventing similar accidents. In this study, we investigated the converter furnace accident by using human error analysis and accident scenario analysis. As a result, it was found that the accident was caused by some human errors, inappropriate task sequence and lack of control in coordinating work by several subordinating companies. From the review of this case, the followings are suggested: First, systematic human error analysis should be included in the investigation of fatal injury accidents. Second, multi man-machine accident scenario analyis is useful in most of coordinating work. Third, the more provision of information on system state will lessen human errors. Fourth, the coordinating control in safety should be performed in the work conducting by several different companies.
