A Study on System-Based Accident Analysis : An Accident at In-house Subcontractor of a Manufacturing Company |
Seo, Dong-Hyun
(Occupational Safety Research Bureau, OSHRI, KOSHA)
Choi, Yi-Rac (Occupational Safety Research Bureau, OSHRI, KOSHA) Park, Jang-Hyun (Occupational Safety Research Bureau, OSHRI, KOSHA) Han, Ou-Sup (Occupational Safety Research Bureau, OSHRI, KOSHA) |
1 | K. Brandford, N. Naikar and A. Hopkins, "Learning from High Reliability Organizations. Chapter: Guidelines for AcciMap Analysis", CCH, pp. 193-212, 2009. |
2 | N. Leveson, "A New Accident Model for Engineering Safer Systems", Safety Science, Vol. 42, No. 4, pp. 237-270, 2004. DOI |
3 | D. Seo and O. Han, Y. Choi, A Study on the Systematic Cause Analysis of Fire and Explosion Accidents in Chemical Plants, OSHRI, 2020. |
4 | D. Seo, O. Han, Y. Choi and J. Park. A System Theoretical Analysis Study on the Structure and Accidents of Subcontractors in Chemical Plants, OSHRI, 2021. |
5 | S. A. Shappell and D. A. Wiegmann, The Human Factors Analysis and Classification System-HFACS, Technical Report, pp. 2-8, 2000. |
6 | J. K. Choi and B. H. Kwon, "The Introduction and Operation of HFACS(The Human Factors Analysis and Classification System), The KJAsEM, Vol.25, No. 2, pp. 37-42, 2015. |
7 | N. Leveson, CAST HANDBOOK: How to Learn More from Incidents and Accidents, 2019. |
8 | A. Hulme, N. A. Stanton, G. H. Walker, P. Waterson and P. M. Salmon, "What do Applications of Systems Thinking Accident Analysis Methods Tell us about Accident Causation? A Systematic Review of Applications between 1990 and 2018", Safety Science, Vol. 117, pp. 164-183, 2019. DOI |
9 | A. P. Goncalves Filho, G. T. Jun and P. Waterson, "Four Studies, Two Methods, One Aaccident - An Examination of the Reliability and Validity of Accimap and STAMP for Accident Analysis", Safety Science, Vol. 113, pp. 310-317, 2019. DOI |
10 | H. Jung, In the Era of One Million in-house Subcontractors, the Problems and Policy Alternatives, Labor Review, Korea Labor Institute, 2017. |
11 | Ministry of Employment and Labor, Announcement Results of 2018 Employment type, 2018. |
12 | Ministry of Employment and Labor, Announcement Results of 2019 Employment type, 2019. |
13 | Ministry of Employment and Labor. Announcement Results of 2020 Employment type, 2020. |
14 | C. Park, In-house subcontracting and industrial Safety, Labor Review, Korea Labor Institute. 2016. |
15 | Ministry of Employment and Labor, Announcement of the Company List according to Integrated Occupational Accident Management System for a Primary Company and the Subcontractors (Press release), 2020. |
16 | C. Park, J. Park, K. Kim, J. Kim, H. Jeon, S. Noh, J. Park and K. Hwang, In-house Subcontracting and Industrial Safety-Focused on Manufacturing, Korea Labor Institute, 2015. |
17 | W. Song, Socio-technical System Theory and Policy Significance, Issue & Policy 60, Science and Technology Policy Institute, 2012. |
18 | F. W. Geels, "From Sectoral Systems of Innovation to Socio-thchnical Systems: Insights about Dynmics and Change from Sociology and Institutional Theory" Research Policy, Vol. 33. Issues 6-7, pp. 897-920, 2004. DOI |
19 | J. Lim, J. Choi, T. Kang, B. Kim and D. Ham, "HFACS-K: A Method for Analyzing Human Error-Related Accidents in Manufacturing Systems: Development and Case Study", J. Korean Soc. Saf., Vol. 35, No. 4, pp. 64-73, 2020. |
20 | J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem", Safety Science, Vol. 27, No. 2-3, pp. 183-213, 1997. DOI |
21 | N. Leveson, "A New Accident Model for Engineering Safer Systems", Safety Scienc, Vol. 42, Issue 4, pp. 237-270, 2004. DOI |
22 | A. Yousefi, M.R. Hernandez and V. L. Pena, Systemic Accident Analysis Models: A Comparison Study between Accimap, FRAM, and STAMP. AIChE. Process Safety Progress, Vol. 38, No. 2, 2018. https://doi.org/10.1002/prs.12002 DOI |
23 | E. Grant, P. M. Salmon, N. J. Stevens, N. Goode and G. J. Read, "Back to the Future: What do Accident Causation Models Tell us about Accident Prediction?", Safety Science, Vol. 104, pp. 99-109, 2018. DOI |
24 | D. Seo, G. Bae, Y. Choi and O. Han "Analysis of a Fire Accident during a Batch Reactor Cleaning with AcciMap, STAMP and FRAM", J. Korean Soc. Saf., Vol. 36, No. 4, pp. 1-39. 2021. |
25 | A. Hopkins, Lessons from Longford: The Esso Gas Plant Explosion, CCH, Sydney, 2000. |
26 | C. W. Johnson and I.M. de Almeida, An Investigation into the Loss of the Brazilian Space Programme's Launch Vehicle VLS-1 V03", Safety Science, Vol. 46, Issue 1, pp. 38-53, 2008. DOI |
27 | P. M. Salmon, A. Williamson, M.G. Lenne, E. Mitsopoulos, and C.M. Rudin-Brown, "Systems-based Accident Analysis in the Led Outdoor Activity Domain: Application and Evaluation of a Risk Management Framework", Ergonomics, Vol. 53, Issue 8, pp. 927-939, 2010. DOI |
28 | S. Lee, Y. B. Moh, M. Tabibzadeh, and N. Meshkati, "Applying the AcciMap Methodology to Investigate the Tragic Sewol Ferry Accident in South Korea", Applied Ergonomics, Vol. 59, pp. 517-525, 2017. DOI |
29 | A. J. Ball, Identification of Leading Indicators for Producibility Risk in Early-stage Aerospace Product Development, Massachusetts Institute of Technology, 2015. |
30 | C. W. Johnson and C. M. Holloway, "The ESA/NASA SOHO Mission Interruption: Using the STAMP Accident Analysis Technique for a Software Related 'Mishap' ", Softw: Pract Exp, Vol. 33, Issue 12, pp. 1177-1198, 2003. DOI |
31 | D. Helferich John, A Systems Approach to food Accident Analysis, PhD thesis, 2011. |
32 | M. Ouyang, L. Hong, M. Yu, Q. Fei, STAMP-based analysis on the railway accident and accident spreading: Taking the China-Jiaoji railway accident for example, Safety Science, Vol. 48, pp. 544-555, 2010. DOI |
33 | A. Dong, Application of CAST and STPA to Railroad Safety In China, Massachusetts Institute of Technology, 2012. |
34 | T. Li, Systems Theoretic Accident Model and Process Application: Quality Control in Medical Device Manufacturing, Massachusetts Institute of Technology, Massachusetts, 2013. |
35 | Economic and Social Development Commission. Progress of discussion by the Labor Market Advancement Committee, 2011. |
36 | M. B. Spencer, Engineering Fnancial Safety: A Systemtheoretic Case Study from the Financial Crisis, PhD thesis, 2012. |
37 | M. O'Neil, Application of CAST to Hospital Adverse Events, Massachusetts Institute of Technology, 2014. |
38 | N. Leveson, A. Samost, S. Dekker, S. Finkelstein and J. Raman, "Systems Approach to Analyzing and Preventing Hospital Adverse Events", J. Patient Saf., 2006. DOI:10.1097/PTS.0000000000000263. DOI |
39 | J. Yang, J. Ko, S. Lee, J. Lim and Y. Kim, Establishing Systemic Strategy to Introduce Innovative Safety Concepts and Methods, OSHRI, KOSHA, 2019. |
40 | P. M. Salmon, M. Cornelissen and M. J. Trotter, "Systems-based Accident Analysis Methods- A comparison of Accimap, HFACS, and STAMP", Safety Science, Vol. 50 , pp. 1158-1170, 2012. DOI |
41 | S. F. Budde, Modeling Blowouts during Drilling Using STAMP and STPA, Degree of Master of Science, Norwegian University of Science and Technology, 2012. |
42 | M. Rodriguez and I. Diaz, "System Theory Based Hazard Analysis Applied to the Process Industry", Int. J. Reliab. Saf., Vol. 10, pp. 72-86, 2016. DOI |
43 | Y. Kwon, System Theoretic Safety Analysis of the Sewol-Ho Ferry Accident in South Korea, Degree of Master of Science, MIT, 2016. |
44 | X. Meng, G. Chen, J. Shi, G. Zhu, and Y. Zhu, "STAMP-based Analysis of Deepwater Well Control Safety", J. Loss Prev. Process Ind., Vol. 55, pp. 41-52, 2018. DOI |
45 | A. Yousefi et al., "Systemic Accident Analysis Models: A Comparison Study between AcciMap, FRAM, STAM", Process Safety Progress, Vol. 38, Issue 2, 2018. |