• Title/Summary/Keyword: Complex System Accident

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A FRAM-based Systemic Investigation of a Rail Accident Involving Human Errors (인적오류가 관여된 철도 사고의 체계적 분석을 위한 FRAM의 활용)

  • Choi, Eun-Bi;Ham, Dong-Han
    • Journal of the Korea Safety Management & Science
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    • v.22 no.1
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    • pp.23-32
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    • 2020
  • There has been a significant decline in the number of rail accidents in Korea since system safety management activities were introduced. Nonetheless, analyzing and preventing human error-related accidents is still an important issue in railway industry. As a railway system is increasingly automated and intelligent, the mechanism and process of an accident occurrence are more and more complicated. It is now essential to consider a variety of factors and their intricate interactions in the analysis of rail accidents. However, it has proved that traditional accident models and methods based on a linear cause-effect relationship are inadequate to analyze and to assess accidents in complex systems such as railway systems. In order to supplement the limitations of traditional safety methods, recently some systemic safety models and methods have been developed. Of those, FRAM(Functional Resonance Analysis Method) has been recognized as one of the most useful methods for analyzing accidents in complex systems. It reflects the concepts of performance adjustment and performance variability in a system, which are fundamental to understanding the processes of an accident in complex systems. This study aims to apply FRAM to the analysis of a rail accident involving human errors, which occurred recently in South Korea. Through the application of FRAM, we found that it can be a useful alternative to traditional methods in the analysis and assessment of accidents in complex systems. In addition, it was also found that FRAM can help analysts understand the interactions between functional elements of a system in a systematic manner.

Study on the Improvement of Event Data Recorders through Accident Analysis (사고분석 사례를 통한 사고기록장치 개선방안에 대한 고찰)

  • Park, Giok;Kang, Heejin;Jun, Joonho;Kim, Heejune
    • Journal of Auto-vehicle Safety Association
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    • v.13 no.4
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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.

A Study on Forecasting Traffic Safety Level by Traffic Accident Merging Index of Local Government (교통사고통합지수를 이용한 차년도 지방자치단체 교통안전수준 추정에 관한 연구)

  • Rim, Cheoulwoong;Cho, Jeongkwon
    • Journal of the Korean Society of Safety
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    • v.27 no.4
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    • pp.108-114
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    • 2012
  • Traffic Accident Merging Index(TAMI) is developed for TMACS(Traffic Safety Information Management Complex System). TAMI is calculated by combining 'Severity Index' and 'Frequency'. This paper suggest the accurate TAMI prediction model by time series forecasting. Preventing the traffic accident by accurately predicting it in advance can greatly improve road traffic safety. Searches the model which minimizes the error of 230 local self-governing groups. TAMI of 2007~2009 years data predicts TAMI of 2010. And TAMI of 2010 compares an actual index and a prediction index. And the error is minimized the constant where selects. Exponential Smoothing model was selected. And smoothing constant was decided with 0.59. TAMI Forecasting model provides traffic next year safety information of the local government.

Research Trends of Cognitive Systems Engineering Approaches to Human Error and Accident Modelling in Complex Systems (복잡한 시스템에서의 인적오류 및 사고모형의 인지시스템공학적 연구의 동향)

  • Ham, Dong-Han
    • Journal of the Ergonomics Society of Korea
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    • v.30 no.1
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    • pp.41-53
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    • 2011
  • Objective: The purpose of this paper is to introduce new research trends of human error and accident modeling and to suggest future promising research directions in those areas. Background: Various methods and techniques have been developed to understand the nature of human errors, to classify them, to analyze their causes, to prevent their negative effects, and to use their concepts during design process. However, it has been reported that they are impractical and ineffective for modern complex systems, and new research approaches are needed to secure the safety of those systems. Method: Six different perspectives to study human error and system safety are explained, and then seven recent research trends are introduced in relation to the six perspectives. The implications of the new research trends and viable research directions based on them are discussed from a cognitive systems engineering point of view. Results: Traditional methods for analyzing human errors and identifying causes of accidents have critical limitations in complex systems, and recent research trends seem to provide some insights and clues for overcoming them. Conclusion: Recent research trends of human error and accident modeling emphasize different concepts and viewpoints, which include systems thinking, sociotechnical perspective, ecological modelling, system resilience, and safety culture. Application: The research topics explained in this paper will help researchers to establish future research programmes.

A Study on Development of Traffic Accident Merging Index for Local Governments (지방자치단체 교통사고통합지수 개발방안에 관한 연구)

  • Rim, Cheoul-Woong;Cho, Jeong-Kwon;Kim, Su-Yeol;Kim, Ju-Young
    • Journal of the Korean Society of Safety
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    • v.27 no.3
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    • pp.147-152
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    • 2012
  • Traffic Accident Merging Index (TAMI) is developed for TMACS (Traffic Safety Information Management Complex System). TAMI is calculated by combining 'Severity Index' and 'Frequency'. The existing indexes are Traffic deaths per 100,000 population, Traffic deaths per 100,000 inhabitants/per billion veh-km, etc. However, there is no consistency in using them among local governments, so it can create confusion. Moreover, the index level is too complicated to understand. Therefore, this study suggests new traffic safety index, TAMI. It will work to improve the weaknesses and present accurate status of traffic safety in local governments.

Needs for Changing Accident Investigation from Blaming to Systems Approach

  • Kee, Dohyung
    • Journal of the Ergonomics Society of Korea
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    • v.35 no.3
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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.

A Study on The Industrial Complex Disaster Surveillance and Monitoring System Using Drones (드론을 활용한 산업단지 재난감시 및 모니터링 시스템에 관한 연구)

  • Su-Ji Moon
    • The Journal of the Korea institute of electronic communication sciences
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    • v.19 no.1
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    • pp.233-240
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    • 2024
  • In this study, we introduce a system for real-time monitoring of field conditions within an industrial complex using a 5G network UAV (: Unmanned Aerial Vehicle). When a monitoring event occurs in a sensor mounted on a UAV (detection of fire, harmful gas, or industrial disaster type human accident), key information from the sensor is transmitted to the UAS (: Unmanned Aerial System) application server. As a result of this information transmission and processing, managers or operators of the Industrial Complex Corporation were able to secure legal basis data for fatal accidents, fires, and detection of harmful gases at sites within the Industrial Complex Corporation through trigger processing for each accident risk situation.

Integrated risk assessment method for spent fuel road transportation accident under complex environment

  • Tao, Longlong;Chen, Liwei;Long, Pengcheng;Chen, Chunhua;Wang, Jin
    • Nuclear Engineering and Technology
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    • v.53 no.2
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    • pp.393-398
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    • 2021
  • Current risk assessment of Spent Nuclear Fuel (SNF) transportation has the problem of the incomplete risk factors consideration and the general particle diffusion model utilization. In this paper, the accident frequency calculation and the detailed simulation of the accident consequences are coupled by the integrated risk assessment method. The "man-machine-environment" three-dimensional comprehensive risk indicator system is established and quantified to characterize the frequency of the transportation accidents. Consideration of vegetation, building and turbulence effect, the standard k-ε model is updated to simulate radioactive consequence of leakage accidents under complex terrain. The developed method is applied to assess the risk of the leakage accident in the scene of the typical domestic SNF Road Transportation (SNFRT). The critical risk factors and their impacts on the dispersion of the radionuclide are obtained.

Analysis for Traffic Accident of the Bus with Advanced Driver Assistance System (ADAS) (첨단안전장치 장착 버스의 사고사례 분석)

  • Park, Jongjin;Choi, Youngsoo;Park, Jeongman
    • Journal of Auto-vehicle Safety Association
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    • v.13 no.3
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    • pp.78-85
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    • 2021
  • Recently a traffic accident of heavy duty vehicles under the mandatory installation of ADAS (Advanced Driver Assistance System) is often reported in the media. Heavy duty vehicle accidents are normally occurring a high number of passenger's injury. According to report of Insurance Institute for Highway Safety, FCW (Forward Collision Warning) and AEB (Automatic Emergency Braking) were associated with a statistically significant 12% reduction in the rate of police-reportable crashes per vehicle miles traveled, and a significant 41% reduction in the rear-end crash rate of large trucks. Also many countries around the world, including Korea, are studying the effects of ADAS installation on accident reduction. Traffic accident statistics of passenger vehicle for business purpose in TMACS (Traffic safety information Management Complex System in Korea) tends to remarkably reduce the number of deaths due to the accident (2017(211), 2018(170), 2019(139)), but the number of traffic accidents (2017(8,939), 2018(9,181), 2019(10,095)) increases. In this paper, it is introduced a traffic accident case that could lead to high injury traffic accidents by being equipped with AEB in a bus. AEB reduces accidents and damage in general but malfunction of AEB could occur severe accident. Therefore, proper education is required to use AEB system, simply instead of focusing on developing and installing AEB to prevent traffic accidents. Traffic accident of AEB equipped vehicle may arise a new dispute between a driver's fault and vehicle defect. It is highly recommended to regulate an advanced event data recorder system.

A Study on the Systematic Cause Analysis of Shipboard Fire Accident Case using STAMP Methodology

  • JeongMin Kim;HyeRi Park
    • Journal of the Korea Society of Computer and Information
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    • v.28 no.10
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    • pp.207-215
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    • 2023
  • The ship system is complex and advanced, and the operation relationship between each element is very high. So it is necessary to approach it in terms of an overall and integrated system in addition to the traditional sequential approach of finding and removing the direct cause of the accident when analyzing the accident. In this study, it is analyzed the recent fire accidents on ships occurred the Korean terrestrial water using a STAMP methodology that is different from conventional accident analysis techniques. This analysis reviews a range of factors, including safety requirements to prevent fires in ships, inappropriate decisions and actions, situations, equipment defects, and recommendations derived from accident analysis results. Through a comprehensive approach to accident prevention using STAMP, alternative evaluations are presented at the component level within the entire system of ships, and they are systematically used for accident prevention and risk evaluation as well as simple accident analysis.