• Journal of Korean Society of Occupational and Environmental Hygiene
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• v.33 no.2
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• pp.188-205
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• 2023

Objectives: Methanol poisoning accidents in smartphone parts manufacturing facilities were analyzed using a systemic accident analysis method, and the necessity and possibility of the application of this systemic method in the field of occupational health were reviewed. Methods: A STAMP model for accident analysis was created based on the previously published literature. CAST analysis was performed to find the causal factors of the components and between the components. Results: The STAMP model visually showed the abstract and complex system control structure. The CAST analysis results could include all the causal factors from the previously published literature, and presented them holistically. Additional causal factors that were not presented in the literature were found. Conclusions: The holistic accident analysis results in this study will be helpful to establish comprehensive measures to prevent methanol or other chemical poisoning accidents. Therefore, it will be necessary to use systemic accident analysis methods in the field of occupational health.

• Journal of the Ergonomics Society of Korea
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• v.36 no.5
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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.

• 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 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.

• Journal of the Korean Society of Safety
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• v.36 no.4
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• pp.88-98
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• 2021

Korean industry has achieved dramatic growth in a short time through continuous technical innovations. However, safety consciousness and management have not kept pace with industry growth. The characteristics of industrial accidents in socio-technical systems have become so complicated that it has been challenging for safety professionals to implement effective preventive measures because it is difficult to determine what is happening in the complex workplace. Thus far, they have focused on technical improvements and the requirements of OSH regulations to avoid legal responsibility. Accordingly, this study has used the systemic analysis method to explain the emergence of something unexpected in complex and multi-layered business structures, which is usually related to the variabilities of humans and organizations. This study chose a shipyard where a few fatal accidents had occurred because the shipbuilding industry includes numerous variabilities, including obtaining orders, manpower supply, procurement, etc. Systemic analysis progressed using FRAM based on two accident cases related to the truss platform used in LNG vessels. The outcome shows that each function within the system has its variabilities and has become coupled or dependent on other functions, increasing the possibility of accidents. This analysis method can provide OSH professionals with practical techniques for explaining what is happening in a complex socio-technical system and how to take proper measures.

• Korea Journal of Hospital Management
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• v.26 no.1
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• pp.17-25
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• 2021

This study aimed to analysis factors related to in-hospital death of injured patients by patient safety accident. A total of 1,529 inpatients were selected from Korea Centers for Disease Control and Prevention database(2013-2017). Frequency, Fisher's exact test, t-test, ANOVA, logistic regression analyses by using STATA 12.0 were performed. Analysis results show that the mortality rate was lower for female than male but the mortality rate was higher for the older age, the higher the CCI, head (or neck), multiple, systemic damage sites, internal and others, metropolitan cities based on Seoul and 300-499 based on the bed size of 100-299. Based on these findings, the possibility of using the in-depth investigation of discharge damage from the Korea Centers for Disease Control and Prevention as a data source for the patient safety survey conducted to understand the actual status of patient safety accident types, frequency, and trends should be reviewed. Also, it is necessary to prevent injury and minimize death by identifying factors that affect death after injury by patient safety accident.

• Journal of Wellbeing Management and Applied Psychology
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• v.7 no.1
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• pp.27-33
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• 2024

Purpose: This study investigates human error accidents in the Korean railway sector, emphasizing the need for systematic management to prevent such incidents, which can have fatal consequences, especially in driving-related jobs. Research design, data and methodology: This paper analyzed data from the Aviation and Railway Accident Investigation Board and the Korea Transportation Safety Authority, examining 240 human error accidents that occurred over the last five years (2018-2022). The analysis focused on accidents in the driving, facility, electric, and control fields. Results: The findings indicate that the majority of human error accidents stem from negligence in confirmation checks, issues with work methods, and oversight in facility maintenance. In the driving field, errors such as signal check neglect and braking failures are prevalent, while in the facility and electric fields, the main issues are maintenance delays and neglect of safety measures. Conclusions: The paper concludes that human error accidents are complex and multifaceted, often resulting from a high workload on engineers and systemic issues within the railway system. Future research should delve into the causal relationships of these accidents and develop targeted prevention strategies through improved work processes, education, and training.

• Journal of the Korean Society of Safety
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• v.16 no.2
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• pp.69-74
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• 2001

In this study, we analyzed the accident scenarios of chemical plants through the analysis of lots of chemical accidents and using experts knowledge, and looked into the method of prevention and response. Moreover, we developed a systemic and actual Emergency Response Plan Software(ERPS) that could prevent, prepare and respond totally for the chemical industry facilities using the data from the accident effect estimation from the local society and the geographic information of a chemical plant. The ERPS consists of the information for the plant and process, the consequence analysis and the ERPTA(Emergency Response Plan Tree Analysis). In conclusion, the program developed in this study could help effectively all the chemical industry facilities to prevent and respond to possible accidents.

• Proceedings of the KSR Conference
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• 2005.11a
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• pp.599-604
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• 2005

As a public transportation possible to convey a large quantity, the railway is safe and keeps time, but it has hazards to cause a disaster if the accidents such as collision, derailment, and fire occur. So advanced countries carry out System Safety Plan with various program activities which have connected orders to maintain or improve safety level by finding hazards, evaluation, taking measures and practice, and improving problems. Especially they systematically manage hazards to cause railway accidents and the factors which possibly threat safety, using national classification of risk and causes with analysis of the related data such as establishing accident/incident data and safety regulations/standards. As executing railway safety regulations, domestic railway is currently trying to improve railway safety management system. The research of classification system of accidents/incidents is one thing to make railway safety management systems better. In this research, we reviewed hazardous factors of railway systems and classification of the causes as the beginning of system safety management, and we conducted study on development of railway accident classification based on findings of this research. The results are able to be used in identifying hazards and activities of systemic safety management at the step of railway accident report and investigation.

• 시스템엔지니어링워크숍
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• s.4
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• pp.151-154
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• 2004

This paper presents the general system theory and its applications to the safety analysis method that is a recent trend over the traditional event-driven model. This new model is known as STAMP(Systems Theory Accident Modeling and Process)proposed by Nancy G. Leveson in MIT. The new model has benefits of systemic approaches concerning the system safety as a whole including the context it is in, its stimulants and outcomes, and its parts as well as the relationships among them in a holistic manner. The method consists of a hierarchical control structure, a process model, and the safety constraints governing the control. This paper demonstrates an example the contrasts the differences between the approaches of STAMP and the traditional safety models.