• Journal of the Korean Society for Aviation and Aeronautics
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• v.28 no.4
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• pp.21-31
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• 2020

There are two to three helicopter accidents every year in Korea, representing 5.7 deaths per 100,000 flights. In this study, an analysis was conducted on helicopter accidents that occurred in Korea from 2005 to 2017. The accident analysis was based on the aircraft accident and incident report published by the Aircraft and Railway Accident Investigation Board. This Research analyzed the characteristics of accidents occurring in Korea caused by human error by pilots. Accident analysis was done by classifying the organization, flight mission, aircraft class, flight stage, accident cause, etc. Pilot's huan error was classified as Skill-based error, decision error and perceptual error in accordance with the HFACS taxonomy. The accidents caused by pilot's human error were classified into five categories: powerlines collision, loss of control, fuel exhaustion, unstable approach to reservoir, and elimination of tail rotor.

• Nuclear Engineering and Technology
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• v.55 no.10
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• pp.3628-3638
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• 2023

This paper uses 135 Licensed Operator Event Reports (LOER) from Chinese nuclear plants to analyze how safety culture affects unsafe behaviors in nuclear power plants. On the basis of a modified human factors analysis and classification system (HFACS) framework, structural equation model (SEM) is used to explore the relationship between latent variables at various levels. Correlation tests such as chi-square test are used to analyze the path from safety culture to unsafe behaviors. The role of latent error is clarified. The results show that the ratio of latent errors to active errors is 3.4:1. The key path linking safety culture weaknesses to unsafe behaviors is Organizational Processes → Inadequate Supervision → Physical/Technical Environment → Skill-based Errors. The most influential factors on the latent variables at each level in the HFACS framework are Organizational Processes, Inadequate Supervision, Physical Environment, and Skill-based Errors.

• 한국항공운항학회:학술대회논문집
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• 2007.06a
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• pp.71-74
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• 2007

• Journal of the Korean Society of Safety
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• v.37 no.5
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• pp.42-55
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• 2022

In this study, an accident at an in-house maintenance subcontractor of a manufacturing company was analyzed using representative systemic analysis methods, and the results were compared to determine the socio-technical and organizational structure causal factors. Systemic accident analyses were performed using AcciMap, STAMP-CAST, and a method that utilizes work processing procedures. The causal factors derived from the three methods were classified according to HFACS classification criteria. AcciMap and STAMP-CAST analyses were able to derive legal problems and defects in organizational structure between the company and the subcontractors. The method that utilized the work processing procedures drew the most causal factors of the three methods but showed some limitations in deriving legal and facility-related problems. Most of the causal factors identified through the systemic methods could be classified according to the HFACS classification criteria, except for the legal and organizational structure matters. Socio-technical and organizational problems with a holistic perspective of the company and subcontractors could be found using systemic analysis methods. However, it is necessary to conduct analysis using various methods in order to derive more comprehensive measures to prevent accidents because each analysis method showed some limitations in the derivation or expression of some causal factors. The results of this study can be helpful in selecting and using an appropriate method for accident analysis.

• Journal of the Korean Society of Marine Environment & Safety
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• v.21 no.5
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• pp.515-523
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• 2015

This study reviewed 612 DP LOP(Loss of Position) incident reports which submitted to IMCA from 2001~2010 and identified 103 human error caused incidents and classified it through HFACS. And, this study analysis of conditional probability of human error on DP LOP incidents through application of bayesian network. As a result, all 103 human error related DP LOP incidents were caused by unsafe acts, and among unsafe acts 70 incidents(68.0 %) were related to skill based error which are the largest proportion of human error causes. Among skill based error, 60(58.3%) incidents were involved inadvertent use of controls and 8(7.8%) incidents were involved omitted step in procedure. Also, 21(20.8%) incidents were involved improper maneuver because of decision error. Also this study identified that unsafe supervision(68%) is effected as the largest latent causes of unsafe acts through application to bayesian network. As a results, it is identified that combined analysis of HFACS and bayesian network are useful tool for human error analysis. Based on these results, this study suggest 9 recommendations such as polices, interpersonal interaction, training etc. to prevent and mitigate human errors during DP operations.

• Journal of the Ergonomics Society of Korea
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• v.30 no.1
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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.

• Journal of the Ergonomics Society of Korea
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• v.30 no.1
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• pp.29-39
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• 2011

Safety management paradigm which against human errors in aviation industry is now changing from the follow-up measures after accident in the past to systematic approach that a forecast the hazards and improve the working system of the group to prevent accidents. As human factors are based on the man's specific psychological traits, it takes much time and efforts to prepare the preventive measures. That's why aviation industry is interested in the accident-prevent measurements against human errors. In this thesis, therefore, we are going to introduce the efforts that aviation organizations have tried and recommend management systems and discuss the suggestive facts. At first, we discussed introduction of HFACS which is the systematic accidents-classification system related to human errors in the aviation organization and countermeasure in the aspects of management, technology/engineering, education training. We described about FOQA, LOSA, CRM/TEM, aviation safety information DB in the aspect of management, and explained safety technologies that prevent human errors or avoid technologically when emergency occurs in the aspect of technology/engineering. In the aspect of education training, we explained the application plan about safety programs(LOFT/Simulator use, CRM/TEM application etc).

• Proceedings of the Korean Institute of Navigation and Port Research Conference
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• 2019.05a
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• pp.96-97
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• 2019

동적위치제어선박의 위치손실사고는 해양플랜트 운영에 있어서 치명적인 결과를 초래할 수 있음에도 불구하고 이러한 사고의 원인 및 대응방안에 대한 연구는 매우 드물다. 이 연구에서는 2011년부터 2016년까지 6년간의 위치손실사고에 대한 분석을 수행하고 그 결과를 기존에 있었던 분석 결과와 비교 검토하였으며, 이를 기반으로 DPO교육훈련의 개선방안을 제시하였다.

• Journal of Navigation and Port Research
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• v.41 no.5
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• pp.303-318
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• 2017

In the shipping industry, it is well known that around 80 % or more of all marine accidents are caused fully or at least in part by human error. In this regard, the International Maritime Organization (IMO) stated that the study of human factors would be important for improving maritime safety. Consequently, the IMO adopted the Casualty Investigation Code, including guidelines to assist investigators in the implementation of the Code, to prevent similar accidents occurring again in the future. In this paper, a process of the human factors investigation is proposed to provide investigators with a guide for determining the occurrence sequence of marine accidents, to identify and classify human error-inducing underlying factors, and to develop safety actions that can manage the risk of marine accidents. Also, an application of these investigation procedures to a collision accident is provided as a case study This is done to verify the applicability of the proposed human factors investigation procedures. The proposed human factors investigation process provides a systematic approach and consists of 3 steps: 'Step 1: collect data & determine occurrence sequence' using the SHEL model and the cognitive process model; 'Step 2: identify and classify underlying human factors' using the Maritime-Human Factor Analysis and Classification System (M-HFACS) model; and 'Step 3: develop safety actions,' using the causal chains. The case study shows that the proposed human factors investigation process is capable of identifying the underlying factors and indeveloping safety actions to prevent similar accidents from occurring.

• Journal of the Korean Society for Aviation and Aeronautics
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• v.10 no.1
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• pp.9-20
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• 2002

In aviation, it is important to analyse and classify human error in detail. Because human error has been implicated in 70 or 80% of aviation accidents in literature review. But, there is little detailed classification and research of human error. In this study, Objectives are to establish human error model by classifying types of human error in detail and also to analyse human factors by using the established model. Analysis of the data uses Korea Aviation Incidents Reporting System(GYRO). The resulting from actual analysis, there is a some difference between flight steps for human error occurrence and types of human error are different according to the aviation personnel(pilot, ATC controller).