• Title/Summary/Keyword: human 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.

Conceptual Design of Information Displays Supporting Severe Accident Management in Nuclear Power Plants Based on Ecological Interface Design (EID) Framework (생태학적 인터페이스 디자인 프레임워크에 기반한 원전 중대사고 지원 정보디스플레이 개념설계)

  • Cho, Piljae;Ham, Dong-Han;Lee, Hyunchul
    • Journal of the Korea Safety Management & Science
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    • v.24 no.1
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    • pp.61-72
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    • 2022
  • This study aims to propose a conceptual design of information displays for supporting responsive actions under severe accidents in Nuclear Power Plants (NPPs). Severe accidents in NPPs can be defined as accident conditions that are more severe than a design basis accident and involving significant core degradation. Since the Fukushima accident in 2011, the management of severe accidents is increasing important in nuclear industry. Dealing with severe accidents involves several cognitively complex activities, such as situation assessment; accordingly, it is significant to provide human operators with appropriate knowledge support in their cognitive activities. Currently, severe accident management guidelines (SAMG) have been developed for this purpose. However, it is also inevitable to develop information displays for supporting the management of severe accidents, with which human operators can monitor, control, and diagnose the states of NPPs under severe accident situations. It has been reported that Ecological Interface Design (EID) framework can be a viable approach for developing information displays used in complex socio-technical systems such as NPPs. Considering the design principles underlying the EID, we can say that EID-based information displays can be useful for dealing with severe accidents effectively. This study developed a conceptual design of information displays to be used in severe accidents, following the stipulated design process and principles of the EID framework. We particularly attempted to develop a conceptual design to make visible the principle knowledge to be used for coping with dynamically changing situations of NPPs under severe accidents.

A Study on the Legal and Systemic Aspect of Aviation Accident Investigation Organization -Focusing on the Improvement Method- (항공사고조사기구(航空事故調査機構)에 관한 법적(法的) 제도적(制度的) 고찰(考察) -개선방안(改善方案)을 중심(中心)으로-)

  • Yoo, Kyung-In;Kim, Maeng-Sern
    • The Korean Journal of Air & Space Law and Policy
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    • v.19 no.1
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    • pp.109-139
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    • 2004
  • The first successful sustained powered flight by Wright Brothers was further extended to the rapid development of aviation technology, that led to transpacific flights, the invention of supersonic planes, and enabled hundreds of people to travel in the space, in addition to the fact that around 10 people had stepped on the moon, all of which were made possible within the very same century. However, on the back side of this most wondrous human technology, the vulnerableness to the aviation accident has been constantly accompanied with, right from the very beginning stage of the aircraft development. Moreover, the development of future aircraft is being focused on the aircraft performance, the increment of the number of passengers aboard and also its speed. In proportion to these phenomena of mega sizing the aircraft, the development of new technology and the increment of air traffic volume, the number of aviation accident is expected to augment, resulting in the enormous loss of human lives and properties. In order to prevent the disastrous aviation accident as such, it is essential to conduct the accident investigation in a specialized, systematic and scientific manner. In search for the method to attain the effective function of the aviation accident investigation organization, in this study, issues were examined as follows: The full-time Board Members and the establishment of an integrated investigation agency, The systematized security of status as an accident investigator, Inclusion of a human factors specialist in the investigator group organization, liability limit of an accident investigator Stipulation of the definition and the investigation scope of an accident and serious incident, along with the main body of conducting the investigation into the accident involving both civil and public aircraft, in the regulations related to the accident investigation.

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The Development of the Korean Life Change Unit Model for Accident Prevention - Focused on the Married Workers Living in the Middle Area - (재해방지를 위한 한국형 생활변화단위 모형의 개발 - 중부지역 거주 기혼 근로자를 중심으로 -)

  • Kang Young-Sig;Choi Man-Jin
    • Journal of the Korean Society of Safety
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    • v.19 no.3 s.67
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    • pp.118-123
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    • 2004
  • The more the lift environment eastern idea, culture, factory automation system and information technology complicates, the more the various human error brings about. It brings about all kind of accidents and occupational diseases. Also the death and sickness or injury by psychological stress among the human error has increased every year. Therefore this paper describes the Korean lift change unit model through statistical testing with the proposed life change unit factors on the married workers living the middle area. The proposed model can be simply used in order to minimize the industrial accident and human error in real fields. Finally, the result will be helpful for the better safety management.

A Study on Establishment of Discrimination Model of Big Traffic Accident (대형교통사고 판별모델 구축에 관한 연구)

  • 고상선;이원규;배기목;노유진
    • Journal of Korean Port Research
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    • v.13 no.1
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    • pp.101-112
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    • 1999
  • Traffic accidents increase with the increase of the vehicles in operation on the street. Especially big traffic accidents composed of over 3 killed or 20 injured accidents with the property damage become one of the serious problems to be solved in most of the cities. The purpose of this study is to build the discrimination model on big traffic accidents using the Quantification II theory for establishing the countermeasures to reduce the big traffic accidents. The results are summarized as follows. 1)The existing traffic accident related model could not explain the phenomena of the current traffic accident appropriately. 2) Based on the big traffic accident types vehicle-vehicle, vehicle-alone, vehicle-pedestrian and vehicle-train accident rates 73%, 20.5% 5.6% and two cases respectively. Based on the law violation types safety driving non-fulfillment center line invasion excess speed and signal disobedience were 48.8%, 38.1% 2.8% and 2.8% respectively. 3) Based on the law violation types major factors in big traffic accidents were road and environment, human, and vehicle in order. Those factors were vehicle, road and environment, and human in order based on types of injured driver’s death. 4) Based on the law violation types total hitting and correlation rates of the model were 53.57% and 0.97853. Based on the types of injured driver’s death total hitting and correlation rates of the model were also 71.4% and 0.59583.

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Research for the Mainly Cause of Safety-Management Sharp-type of Semiconductor Industry (To Center with Corporate Company) (반도체 산업의 안전관리 형태별에 따른 원인에 관한 연구 (협력업체 중심(中心)으로))

  • Yoon, Yong-Gu
    • Proceedings of the Safety Management and Science Conference
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    • 2008.04a
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    • pp.19-33
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    • 2008
  • The study on semiconductor industrial accident in korea has been focused on frequencies of each type, employee, characteristics, cause and un-safety condition, behaviour and so on. Those attributes of semiconductor industrial accidents were usually analyzed independently, so that it was hard to provides a well-process and systematic guide lines for efficient safety management. There fore, there were a few studies based on comprehensive survey in terms of sharp-type of safe management. The questionnaire survey carried out for the workers(284) who were responsible for safety management in to center with corporate company with semiconductor industry the factor analysis showed that there were three factor of safety management. They were 1) Investment and operation and management for accident prevention, 2) Unsafe, safety management 3) General human error and behavior the industries of respondents were correlative with three group. Three Groups showed a statistically significant differences on the number of cases. Actually, the group with the larger investment and the better unsafe cause, human error a of accident prevention had a smaller cause of accident cases.

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Framework of a Training Simulator for the Accident Response of Large-scale Facilities (대형 기계 설비의 사고 대응을 위한 훈련 시뮬레이터 프레임워크)

  • Cha, Moohyun;Huh, Young-Cheol;Mun, Duhwan
    • Korean Journal of Computational Design and Engineering
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    • v.19 no.4
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    • pp.423-433
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    • 2014
  • For the proper decision making and responsibility enhancement for an unexpected accident in large-scale facilities, it is important to train operators or first responders to minimize potential human errors and consequences resulted from them. Simulation technologies, including human-computer interaction and virtual reality, enables personnel to participate in simulated hazardous situations with a safe, interactive, repetitive way to perform these training activities. For the development of accident response training simulator, it is necessary to define components comprising the simulator and to integrate them for the given training purpose. In this paper, we analyze requirements of the training simulator, derive key components, and design the training simulator. Based on the design, we developed a prototype training simulator and verified the simulator through experiments.

Analysis of Injury Types in Korean Disaster (우리나라 인적재해 유형별 손상 분석)

  • Shin, Dong-Min;Lee, In-Soo;Baek, Mi-Lye
    • The Korean Journal of Emergency Medical Services
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    • v.8 no.1
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    • pp.179-187
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    • 2004
  • The purpose of the study was to injury types in Daegu subway fire accident, Sampung department store collapse, Mokpo airport civil aircraft accident, and Buan sunken ship disaster. The conclusion obtained from these analyses are as following. 1. The total of victims were Sampung department store collapse(l440 people). Buan sunken ship disaster(355 people), Daegu subway fire accident(340 people), and Mokpo airport civil aircraft accident(110 people). 2. The total of dead people were Sampung department store collapse(502 people), Buan sunken ship disaster(287 people), Daegu subway fire accident(192 people), and Mokpa airport civil aircraft accident(66 people). 3. The total of injured people were Sampung department store collapse(938 people), Daegu subway fire accident(148 people), Mokpo airport civil aircraft accident(84 people), and Buan sunken ship disaster(67 people). 4. The major types of victims presented smoke inhalation such as coughing, dyspnea, and sore throat in Daegu subway fire accident. 5. The major types of victims presented crushing(multiple fractures), vertebral, and soft tissues injuries in Sampung department store collapse. 6. The major types of victims presented multiple fractures. In addition to, a lot of people showed vertebral injuries and shock symptoms in Mokpo airport civil aircraft accident. 7. The major types of victims presented drowning as well lots of hypothermia patients in Buan sunken ship disaster. There were a wide variety of types in human disaster. Therefore, the most important disaster training program need to each disaster aspect in the local emergency medical services system. Moreover, the emergency medical services personnel should be understand and training for injury types of each human disaster.

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Development of an Objective Judgement Procedure for Determining Involvement of Violation-Type Unsafe Acts caused Industrial Accidents (사고 유발 불안전행동의 위반 여부에 대한 객관적 판단절차 개발)

  • Lim, Hyeon Kyo;Ham, Seung Eon;Bak, Geon Yeong;Lee, Yong Hee
    • Journal of the Korean Society of Safety
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    • v.37 no.2
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    • pp.35-42
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    • 2022
  • When an accident occurs, the associated human activity is typically regarded as a "human error," or a temporal deviation. On the other hand, if the accident results in a serious loss or if it evokes a social issue, the person determined to be responsible may be punished with a "violation" of related laws or regulations. However, as Heinrich stated, it is neither appropriate nor reasonable in terms of probability theory and cognitive science to distinguish whether it is a "human error" or a "violation" with a criterion of resultant accident severity. Nonetheless, some in society get on the social climate to strengthen regulations on workers who have caused accidents, especially violations. This response can present a social issue due to the lack of systematic judgment procedure which distinguishes violations from human errors. The purpose of this study was to develop an objective and systematic procedure to assess whether workers' activities which induced industrial accidents should be categorized as violations rather than human errors. Various analysis techniques for the determination of violation procedure were investigated and compared using an analysis approach method. An appropriate technique was not found, however, for judging the culpability of intentional violations. As an alternative, this study developed the process of creating violations, based on cognitive procedure, as well as the criteria to determine and categorize an activity as a violation. In addition, the developed procedure was applied to cases of industrial accidents and nuclear power plant issues to test its practical applicability. The study demonstrated that the proposed model could be used to determine the existence of a violation even in the case of multiple workers who work simultaneously.

Development of a Human Factors Investigation and Analysis Model for Use in Maritime Accidents: A Case Study of Collision Accident Investigation

  • Kim, Hong-Tae;Na, Seong
    • 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.