• 대한인간공학회지
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• 제29권2호
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• pp.241-248
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• 2010

In accident analysis, it is essential to understand the causal pathways of the accident. Although numerous accident models have been developed to help analysts understand how and why an accident occurs, most of them do not include all elements related to the accident in various fields. Thus analysis of human error accidents in railway operations using these existing models may be possible, but inevitably incomplete. For a more thorough analysis of the accidents in railway operations, a more exhaustive model of accident causation is needed. This paper briefly reviews four recent accident causation models, and proposes a new model that overcomes the limitations of the existing models for the analysis of human error accidents in railway operations. In addition, the usefulness and comprehensiveness of the proposed model is briefly tested by explaining 12 railway accident cases with the model. The proposed accident causation model is expected to improve understanding of how and why an accident/incident occurs, and help prevent analysts from missing any important aspect of human error accidents in railway operations

• Journal of Advanced Marine Engineering and Technology
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• 제40권8호
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• pp.721-725
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• 2016

This paper reviews the analysis of a given scenario according to the Hybrid Model, and why accident causation models are necessary in casualty investigations. The given scenario has been analyzed according to the Hybrid Model using its main five components, fallible decisions, line management, psychological precursors to unsafe acts, unsafe acts, and inadequate defenses. In addition, the differences between the SHEL and the Hybrid Model, and the importance of a safety barrier during an accident investigation, are shown in this paper. One unit of SHEL can be linked with another unit of SHEL. However, it cannot be used for the analysis of an accident. Therefore, we must use an accident causation model, which can be a Hybrid Model. This can explain the "How" and "Why" of accident, so it is a suitable model for analyzing them. During an accident investigation, the reason we focus on a safety barrier is to create another safety barrier or to change an existing safety barrier if that barrier fails. Hence, the paper shows how a sea accident can be investigated, and we propose a preventive way of avoiding the accident through combining the methods of different models for the future.

• 대한안전경영과학회지
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• 제8권2호
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• pp.13-23
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• 2006

The present study has investigated the patterns and the causes of safety -accidents on the accident-data in semiconductor Industries through near miss report the cases in the advanced companies. The ratio of incomplete actions to incomplete state was 4 to 6 as the cases of accidents in semiconductor industries in the respect of Human-ware, Hard- ware, Environment-ware and System-ware. The ratio of Human to machine in the attributes of semiconductor accident was 4 to 1. The study also investigated correlation among the system related to production, accident, losses and time. In semiconductor industry, we found that pattern of safety-accident analysis is organized potential, interaction, complexity, medium. Therefore, this study find out that semiconductor model consists of organization, individual, task, machine, environment and system.

• 대한안전경영과학회지
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• 제6권4호
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• pp.39-46
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• 2004

The Study lay Emphasised on to Investigate Human Related Causes of a Pointed End Equipment Accident and the Basic data for Analyzing Human-Error Prevention Program. Peter Son's Model of Human-Error Accident Causation and Cooper's Model of Safety Culture Were Applied to Analyze the Severe Cause of a Pointed End Equipment for Last 5 Years. Through to Analyzing the Cause of Equipment Accident of Human-Error, Expert's Opinion and Experience Theory Method was Reflected. The Analyses Showed What the Immature and Inexperient Error Were Major Causes of a Pointed and Equipment Accident. The Cause of Human-Error was Found with Respect to Human, Tasks, Acknowledge, Organization.

• 대한안전경영과학회:학술대회논문집
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• 대한안전경영과학회 2004년도 추계학술대회
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• pp.311-318
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• 2004

The Study lay Emphasised on to Investigate Human Related Causes of a Pointed End Equipment Accident and the Basic data for Analyzing Human-Error Prevention Program. Peter Son's Model of Human-Error Accident Causation and Cooper's Model of Safety Culture Were Applied to Analyze the Severe Cause of a Pointed End Equipment for Last 5 Years. Through to Analyzing the Cause of Equipment Accident of Human-Error, Expert's Opinion and Experience theory Method was Reflected. The Analyses Showed What the Immature and Inexperient Error Were Major Causes of a Pointed and Equipment Accident The Cause of Human-Error was Found with Respect to Human, Tasks, Acknowledge, Organization.

• 대한인간공학회지
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• 제30권1호
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• pp.137-150
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• 2011

Nationally and internationally reported statistics on marine accidents show that 80% or more of all marine accidents are caused fully or in part by human error. According to the statistics of marine accident causes from Korean Maritime Safety Tribunal(KMST), operating errors are implicated in 78.7% of all marine accidents that occurred from 2002 to 2006. In the case of the collision accidents, about 95% of all collision accidents are caused by operating errors, and those human error related collision accidents are mostly caused by failure of maintaining proper lookout and breach of the regulations for preventing collision. One way of reducing the probability of occurrence of the human error related marine accidents effectively is by investigating and understanding the role of the human elements in accident causation. In this paper, causal factors/root causes classification systems for marine accident investigation were reviewed and some typical human error analysis methods used in shipping industry were described in detail. This paper also proposed a human error analysis method that contains a cognitive process model, a human error analysis technique(Maritime HFACS) and a marine accident causal chains, and then its application to the actual marine accident was provided as a case study in order to demonstrate the framework of the method.

• 대한안전경영과학회:학술대회논문집
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• 대한안전경영과학회 2005년도 추계학술대회
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• pp.74-82
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• 2005

안전사고 원인에 대하여 Near-Miss Report 분석을 근거로 하여, 재해원인에 대하여 접근해 보고, 이 Data를 참고로 첨단산업에서의 재해 유형을 분석해보고, 유형에 따른 기여인자를 기존 Human-ware, Hard-ware, System-ware를 구성요소로 해서 첨단산업에서의 각각의 수행인자의 비율 분석을 통한 판단한 결과는 Human-ware와 Hard-ware 비율은 4:1로 나타났고, 첨단사업장에서의 5년간의 사고건수를 근거로 원인에 대한 수행인자의 ANOVA로 분석하여 4개인자에 대한 분산 분석을 도출하였고 이에따른 Loss와 Time과 Accident 관계와 Effect of Intervention관계와 Reason's Accident Causation Model과 Perrow's Normal Accident Theory Model를 연관시켜서 첨단산업에서의 사고이론 Model를 추출해서 첨단산업에서의 안전사고에 대한 유형을 분석해서 사고를 사전에 제거키 위한 새로운 모델을 제시하고자 한다.

• 한국항해항만학회지
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• 제35권9호
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• pp.729-733
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• 2011

The maritime risk assessment is important not only to evaluate the safety level of the ports and waterways but also to reduce potential maritime accidents at sea in terms of the proactive measures of the maritime accidents. In this paper, the collision risk assessment in Mokpo waterways has been carried out based on the IALA recommended model, IWRAP. To evaluate the accident probabilities in Mokpo waterways, all data of vessels were collected from AIS and Radar observations data and the computer simulations were carried out. To assess the risk on the traffic, the scenario-base approach has been applied to the Mokpo waterway by using the maritime accident statics over the past 5 years.

• 대한인간공학회지
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• 제35권3호
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• pp.143-153
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• 2016

Objective: The purposes of this study are to survey needs for changing accident investigation from blaming to systems approach and to briefly summarize systems-based accident analysis techniques. Background: In modern complex socio-technical systems, accidents are caused by a variety of contributing factors including human, technical, organizational, social factors, not by just a single violation or error of a specific actor, but accidents investigation used to be focused on the incorrect action of individuals. A new approach investigating causes of accidents as a symptom of a deficient system is required. Method: This study was mainly based on survey of literatures related to accidents, accidents investigation, which included academic journals, newspapers, etc. Results: This study showed that accidents investigation of Korea focusing on blaming is problematic. This was confirmed by two concepts of migration and hindsight bias frequently found in accident causation studies, and an attribute of accidents having varying causes. This was illustrated with an example of Sewol ferry capsizing accident. Representative systems-based accident analysis models including Swiss cheese model, AcciMap, HFACS, FRAM and STAMP were briefly introduced, which can be used in systematic accidents investigations. Finally, this study proposed a procedure for establishing preventive measures of accidents, which was composed of two steps: public inquiry and devising preventive measures. Conclusion: A new approach considering how safety-critical components such as technical and social elements, and their interactions lead to accidents is needed for preventing reoccurrence of similar accidents in complex socio-technical systems. Application: The results would be used as a reference or guideline when the safety relevant governmental organizations investigate accidents.

• 한국도로학회논문집
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• 제10권4호
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• pp.117-125
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• 2008

최근 녹색교통수단으로서 자전거의 이용자수는 급격하게 증가하고 있으나 차대 자전거사고 감소와 자전거 이용자의 안전성 향상에 대한 노력은 미비한 설정이다. 따라서 본 연구에서는 최적의 교차로 설계지침 제공 및 자전거 사고유형에 영향을 미치는 요인들을 면밀히 분석하여 교차로에서의 자전거사고 안전성 향상에 그 목적이 있다. 이를 위해 본 연구에서는 2005년도 인천광역시 사지교차로에서 발생한 56건의 자전거사고 자료에 대한 분석과 사고발생 교차로에 대한 현장조사를 실시하였으며, 다항로짓모형을 이용하여 3가지 경우에 대한 자전거 사고유형 분석모형을 개발하였다. 모형분석결과, 사망사고 유무, 부도로 교통섬 유무, 도로위계, 사고당시 날씨, 주도로 버스정류장 유무, 주도로 차로폭, 인적유발요인이 자전거 사고 유형에 중요한 변수로 나타났다.