• 자동차안전학회지
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• 제13권4호
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• pp.66-72
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• 2021

This study was initiated to improve of the defect investigation method using event data recorders (EDR) and suggested a solution through the regulation and system analysis of EDR. The EDR data has been used for various purposes such as the vehicle defect investigation and the traffic accident investigation. However the EDR regulation has not been updated since the implementation in 2012. "Trigger Threshold" can be used to analyze a single accident such as the frontal crash, the side crash, and the rollover. In the case of a complex accident in which a rollover accident and a crash accident occur simultaneously, it is difficult to analyze a complex accident due to current "Trigger Threshold". This study proposed the method of separating the "Trigger Threshold" into a crash accident and a rollover accident so that accidents can be analyzed using the EDR data even when a complex accident occurs. In addition, it proposed the improvement method to quickly use the data of EDR in accident reconstruction software.

• 대한인간공학회지
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• 제36권5호
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• pp.485-498
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• 2017

Objective: This study aims to survey and compare three systemic accident investigation techniques of Accimap, STAMP and FRAM, based on the application studies of the Sewol ferry accident. Background: Traditional accident investigation methods such as domino models, FTA, etc. work well for losses caused by physical component failures or actions of human in relatively simple systems, but are unable to depict mechanisms generating errors and violations in the current complex socio-technical systems. For better understanding the structure and behavior of the socio-technical systems, systemic techniques have been developed and used. Method: This study was mainly based on survey of literatures through surfing webpages of ScienceDirect and Google, and ergonomics relevant journals. The key words of Sewol, Sewol ferry, Sewol ferry accident, etc. were used in the survey. Results: Three systemic accident investigation methods included similar actors in the Sewol ferry accident including government, Ministry of Ocean and Fisheries, Korean Coast Guard, Korean Register of Shipping, Korea Shipping Association, Chonghaejin Marine Company, crew members. The methods graphically represented each level's failures or performance variabilities of relevant functions and relationships between them. It was shown that the systemic methods consider the entire system, ranging from the environment in which the accident occurred, to the role of government in shaping the system of work. Each method has its own comparative pros and cons, but the Accimap has advantages in terms of time of analysis, data required, model complexity and degree of comprehensiveness. Conclusion: This study reviewed and compared three systemic accident investigation methods, which showed that there are systemic characteristics and pros and cons in the methods. Application: The results would be used as a guideline when selecting accident investigation methods.

• 한국철도학회:학술대회논문집
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• 한국철도학회 2009년도 춘계학술대회 논문집
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• pp.1360-1364
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• 2009

The basic concept of analysis of human error that induced railway accident is that errors are consequences, not causes. But in most cases, it is likely that direct causes of the accident could be concluded as real causes, which make it difficult to find out root causes. Design, training, staffing, culture and condition are general category applied to investigate human error. In order to examine how those approach could help accident analysis, this paper studied accident investigation reports of UK RAIB(Rail Accident Investigation Branch). Rather than consider specific investigation method, we focus investigation result on how to describe causal factors and how to indicate recommendations to prevent similar accident. The reports show that they try to find out causes more in organizational, environmental and job factors, which implies the necessity to improve investigation process of human error accident in Korea.

• 한국항공운항학회지
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• 제8권1호
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• pp.41-56
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• 2000

In the Aircraft Incident Reporting System(AIRS), It is important to collect and gather date about aircraft incidents by means of systemic methods and make it materials for study in the view point of aircraft accident in the future. Especially, the development of such effective tools can be one of main factors determining whether the investigation of potential accident factors succeeds or fails. For such a reason and the purpose of aircraft accident prevention, the AIRS compatible to each county has been developed early and been adopting now in several countries involving USA. First this study examine the actual condition about investigation method tools of potential accident factors used in several countries and investigation and analyze them, finally present the method which can improve more acceptable forms to flight crew used at the KAIRS(Korean AIRS).

• 한국ITS학회 논문지
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• 제9권2호
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• pp.75-86
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• 2010

본 연구는 지역 교통사고 원인조사의 관리주체인 도로관리청에서 교통사고를 효율적이면서 효과적으로 관리하고 시행할 수 있는 교통사고 원인조사 기법 및 절차를 제시하였다. 또한, 시범도시를 선정하여 최근 3년간 교통사고 중 사망사고 자료를 바탕으로 사고형태지도, 구조분석표 및 사고도표의 작성, 사고누적지점 및 구간의 선정과 우선순위, 현장조사 및 개선시책의 결정, 기회비용의 추정, 모니터링 방안 등 향후 도로관리청의 교통사고 원인조사의 기술적, 조직적 및 행정적 프로세스를 적용하여 예상되는 사고감소효과에 대해 분석하였다.

• 한국ITS학회 논문지
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• 제8권3호
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• pp.34-41
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• 2009

최근 IT 첨단기술의 발전과 더불어 국민들의 정보화 수준이 지속적으로 향상되고 있는 가운데 교통 분야에 IT기술의 최신분야인 유비쿼터스 기술 및 모바일 기술 등 첨단기술을 접목하려는 시도가 늘어나고 있는 추세이다. 이러한 경향에 발맞춰 교통사고 조사를 신속하고 효율적으로 실시할 수 있는 PDA 조사 장치가 개발되었다. 본 논문에서는 교통사고 조사를 위해 개발된 PDA에 대해 평가방법론을 설정하고, 정성적 및 정량적 평가를 실시하였다. 평가 결과, PDA를 활용한 교통사고 조사는 수기조사에 비해 자료의 정확성 및 편리성, 그리고 조사시간 측면에서 비교 우위에 있는 것으로 평가되었다. 그리고 사고데이터를 입력하는 형식에 관한 일부 개선이 필요한 면도 파악되었다. 향후 이러한 문제점을 개선한다면 사고조사 분야에 큰 기여를 할 것으로 판단된다.

• 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.

• 한국항공운항학회지
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• 제28권2호
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• pp.63-70
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• 2020

Many organizations apply reactive safety management to prevent the same or similar types of accidents by through investigation and analysis of the accident cases. Although research on investigation techniques has contributed a lot to the objective results of safety accidents and the preparation of countermeasures, many accident investigation techniques currently in use treat accidents from a linear perspective, revealing limitations in reflecting current systems dominated by complexity and uncertainty. In order to overcome these limitations, this study will review recent studies and concepts from a system safety perspective and predict future research trends through a case analysis of aviation accident. The models used in the analysis are STAMP, HFACS, and FRAM, and the characteristics of each technique are presented so that analysts who perform related tasks in the field can refer to them.

• 항공우주정책ㆍ법학회지
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• 제19권1호
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• pp.109-139
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• 2004

라이트형제에 의한 비행기(飛行機)의 개발(開發)은 동세기(同世紀) 항공공학(航空工學)의 급속(急速))한 발전(發展)을 이루어 항공기를 이용하여 태평양을 횡단하고, 소리의 속도보다 빠르게 비행하게 되었으며, 수백명이 우주(宇宙) 비행(飛行)을 하였고, 10여명이 달에 다녀왔다. 그러나 이 경이로운 인간의 기술이면에는 항공기의 개발과 더불어 항공사고라는 난점이 자리하고 있다. 항공의 발달은 운송수단으로서 타 교통수단의 경쟁을 유도하였고, 항공산업의 획기적인 발달을 이룩하여 모든 여행객들과 물류수송에 선도적인 역할을 담당하고 있다. 그러나, 항공활동의 증가는 대조적으로 항공사고를 수반하게 되고, 사고시는 막대한 인명과 재산피해를 동반하게 된다. 따라서 향후 개발되는 항공기 의 초대형화와 신기술 개발 및 항공 교통량의 증가에 비례하여 항공사고건수 또한 증가할 것이며 항공사고는 인명 및 재산피해의 초대형화를 동반할 것이다. 이러한 항공사고 방지를 위해 사고조사의 전문화, 체계화 및 과학화가 필수적이다. 이를 달성하기 위한 항공사고 조사기구의 효율적인 역할을 수행하기 위하여는 사고조사위원회 위원의 상근화, 통합적사고 조사기구의 신설, 사고조사관의 제도적 신분보장, 인적요소분야 사고조사관의 확보(確保), 사고조사관의 법적 책임 한계, 사고(accident)와 중대한 준사고(serious incident)에 대한 정의와 조사범위, 그리고 민간항공기와 국가항공기가 연관된 사고 발생시 조사의 주체가 관련규정에 명시될 필요성이 개선방안(改善方案)으로 연구되었다.

• 한국재난정보학회 논문집
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• 제1권1호
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• pp.121-136
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• 2005

Most human-error case of accident database is written by various description and expression because accident database is produced by two or more person. And extracted information by searching of database varies in researcher's judgment criteria and the capability. Furthermore, much time and effort are required to examine manually information related to the human error from each accident case. Accordingly, it is difficult to explore objectively the accidents relevant to the human-error from the accident data base which is accumulated enormously. In this study, to solve these problems, it was developed an searchig method which is not influenced by researcher's judgment criteria and capability. For this, human-error keywords were extracted from a Japanese-English dictionary to examine objectively the accident case related to human-error in data base. This searching method by the human-error keywords can be applicable in most accident databases, although a database will be accumulated in future. Also, using the searching technique of this research, knowledge obtained by searching result can be compared with other research's results by the same method. Although the number of accident case increasese, searching results from database have the objectivity because it is not necessary to modify the based searching method or change the human-error keywords. However, as subject of future investigation, it would be necessary that the extension and investigation on human-error keywords improve and the technique to enhance searching accuracy would be modified.