• Title/Summary/Keyword: Accident Investigation Report

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An Investigation of the Car Accident in Kyongju (교통사고의 분석과 문제점 - 경주시 인왕동 사고를 중심으로 -)

  • 박외철
    • Journal of the Korean Society of Safety
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    • v.15 no.1
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    • pp.53-58
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    • 2000
  • In a car accident in Kyongju, each of the two occupants insisted that he was not driving the car. The accident was investigated to determine who the driver is through careful review of the collision report, the statements of accident and witness, photographs taken at the scene, and the expert report of the National Institute of Scientific Investigation. The accident was reconstructed based on the physical principles, injuries of occupants, damages of the involved vehicles and their final stops. A mistake was found in the expert report.

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Safety Measure Developed Through Analysis of Firefighters' 『Investigation Report on Accidents to On-Site Workers』

  • Jo, Chang-Hyun;Kong, Ha-Sung
    • International Journal of Advanced Culture Technology
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    • v.9 no.3
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    • pp.334-344
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    • 2021
  • The study has suggested a way to minimize safety accidents found in on-site firefighting activity by analyzing firefighters' [investigation report on accidents to on-sie workers]. The study result is described as follows. First, the result of [investigation report on on-site workers] shows that while accidents are found to most frequently have occurred to low-ranking firefighting officers such as Sobangsa and Sobanggyo and firefighting officers with career of less than 5 years, fire-extinguishing activity proved to be the most prone to accidents in the category of activity. Second, analysis performed to identify variance between injury extent and area based on cause of accident shows statistically significant variance. In addition, the result of verifying difference in cause of accident based on category of activity shows significant difference with 'falling over and sliding' being the highly likely cause of accident in fire containment and rescue activities and 'reckless move' being highly likely case of accident in emergency activities. Third, the result of verifying factors behind the extent of injury done to on-site workers shows that when accident is caused by 'incomplete behavior', it was found that the extent of injury is substantial. It was also found that rescue activity is accompanied by substantial extent of injury. As a solution to this, the study suggested ways to establish, extend and operate safety-specific curriculum for entrants, develop materials regarding risk prognosis training and explicate training-related regulations, set up safety management measure for a single squad team, upgrade performance of private protection equipment, institutionalize SOP by on-site activity stage, materialize and activate swift rescue team and increase objectivity and proficiency of safety accident investigation.

Accident Analysis & Lessons Learned of B737MAX JT610 from a Flight Control System Design Perspective (비행제어시스템 설계 관점의 B737MAX JT610편 사고분석과 교훈)

  • Moon, Jung-Ho;Cho, Hwankee
    • Journal of the Korean Society for Aviation and Aeronautics
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    • v.28 no.1
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    • pp.106-114
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    • 2020
  • The Lion Air JT610 accident in Indonesia in October 2018, along with the Ethiopian Airline ET302 accident in March 2019, is an significant aircraft accident that detects defects of the B737MAX aircraft. Shortly after the accident, the FAA prohibited operation of the aircraft. This action has affected the market environment of airlines and aircraft manufacturers around the world. In October 2019, Indonesian Traffic Safety Committee released an accident investigation report for Lion Air JT610, which concluded that the causes of the accident were MCAS design defects, lack of education and training, and errors in the repair process. This paper summarizes the flight control system of the B737MAX aircraft, the causes of the accident based on the final accident investigation report, and provides considerations for aircraft design and retrofit.

Suggestions for the Improvement of Aviation and Railway Accident Investigation Board in Korean (항공사고조사위원회의 업무개선에 대한 제언)

  • Han, KyoungKeun;Choi, YounChul
    • Journal of the Korean Society for Aviation and Aeronautics
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    • v.25 no.4
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    • pp.187-194
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    • 2017
  • ICAO Universal Safety Oversight Audit Programme is a comprehensive evaluation for aviation safety matters, including aircraft operation, licensing and aircraft incident/accident investigation. As this programme is measures aviation safety level of States, there is a need to meet international standards, especially in the field of aircraft incident/accident investigation. This research discusses points required to satisfy international standards, which are independence and autonomy of an accident investigation board, the lack of the enough number of investigators and efficient management of those personnel, the effective composition and use of an investigation report, an accident investigation itself to build big data and the creation of a cooperation system among States. This paper suggests various opinions in order to enhance aviation safety especially through aircraft accident investigations, using case studies from the US, UK and Japan.

Study on Aircraft Accident Investigation (군항공기사고조사에 관한 연구)

  • Kim, Hae-Ma-Joong;Ha, Hong-Young;Hong, Sang-Beom
    • The Korean Journal of Air & Space Law and Policy
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    • v.18
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    • pp.325-362
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    • 2003
  • In an effort to enhance the independence of and expertise in military aircraft accident investigation, a permanent accident investigation board should be established. Establishing permanent accident investigation board would render the military accident investigation more reliable and would increase its public esteem. Because there is no provision governing the responsibilities of the investigation and cooperation between civil and military authority in case that both civil and military aircraft are involved, it is necessary to fill this gap by enacting appropriate laws. In case of civil aircraft accident investigation involving a military issue, it would be better to allow military authority to be involved in the investigation. For the betterment of investigation, it is also necessary to provide a field investigator an authority to directly collect relevant information. Since the sole purpose of accident investigation is to prevent the recurrence of aircraft accidents, the scope of information disclosure should be limited and the investigation report shall be used for neither criminal procedure nor disciplinary procedure so that the objectivity of the investigation should be ensured.

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Case Study on the Time Zero (T0) of Event Data Recorder (사고기록장치의 기록 시점에 대한 사례연구)

  • Jongjin Park;Jeongman Park;Jungwoo Park;Byungdeok In
    • Journal of Auto-vehicle Safety Association
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    • v.15 no.2
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    • pp.35-41
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    • 2023
  • On December 19, 2015, as Article 29-3 (Installation of Accident Recording Devices and Provision of Information) of Motor Vehicle Management Act came into force, In Korea, the EDR (Event Data Recorder) reports are often used for the analysis of various traffic accident cases such as multiple collisions, traffic insurance crimes, and sudden unintended acceleration (SUA), and the others. So many investigators have analyzed the driver's behavior and vehicle situation by comparing the time zero in the EDR report to the actual crash time in dash-cam (or CCTV). Time zero (T0) is defined as the reference time for the record interval or time interval when recording an accident in Article 56-2, Enforcement rule of Performance and Standard for Automobile and Automotive parts. Also in the EDR report, time zero (T0) is defined as whichever of the following occurs first; 1. "wake-up" by an air-bag control system, 2. Continuously running algorithms (by monitoring of longitudinal or lateral delta-V), 3. Deployment of a non-reversible deployment restraint. We have already proposed the "Flowchart & Checklist" to adopt the EDR report for traffic accident investigation and the necessity of specialized institutions or courses to systematically educate or analyze the EDR data. Therefore, in this paper, we report to traffic accident investigators notable points and analysis methods based on some real-world traffic accidents that can be misjudged in specifying time zero (T0).

Cause Analysis and Measure for Accident of Door Detachment in Elevator Platform (승강장 도어이탈 안전사고에 대한 원인분석 및 대책)

  • Kim, Eui-Soo;Kim, Sang-Hyeon;Kim, Dong-Hwan;Park, Nam-Kyu
    • Journal of the Korean Society of Safety
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    • v.22 no.6
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    • pp.1-6
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    • 2007
  • A Recently elevator accidents were occurred and increased due to carelessness of user and violent behavior. The accident of door detachment in elevator platform by electronic motor scooter show a example of safety concerns and insensibility for safety awareness. In this report, we review the cause of accident of door detachment in elevator platform by electronic motor scooter, and show some suggestions of preventing from the safety concerns about this case.

Study on Adopting EDR Report for Traffic Accident Analysis (교통사고분석에서 EDR 기록정보의 채택에 관한 고찰)

  • Park, Jongjin;Park, Jeongman;Lee, Yeonsub
    • Journal of Auto-vehicle Safety Association
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    • v.12 no.3
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    • pp.52-60
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    • 2020
  • Usage of EDR(Event Data Recorder) report for traffic accident analysis is currently increasing due to government regulation of EDR data release. Nevertheless, a lot of investigators simply adopt by comparing the number of ignition cycles(crash) at event to the number of ignition cycles(download) without an exact judgment whether event data occurred by this accident or not. In the EDR report, besides ignition cycles, there are many factors such as event record type, algorithm active(rear/rollover/side/frontal), time between events, event severity status(rollover/rear/right side/reft side/frontal), belt switch circuit status, driver/passenger pretensioner/air-bag deployment, PDOF(Principal Direction of Force) by ΔV to be able to decide whether or not to adopt. also the event data is considered enough to vehicle damaged state, accident situation at the scene of the accident. and there is described in "all data should be examined in conjunction with other available physical evidence from the vehicle and scene" in the CDR(Crash Data Retrieval) report. Therefore many investigators have to decide whether or not to adopt after they consider sufficiently to above factors when they are the traffic accident analysis and investigate the causes of a accident on the adopted event data. In this paper, we report to traffic accident investigators notable points and analysis methods on the basis of thousands of cases and the results of one's own experiment in NFS(National Forensic Service).

Development of Integrated Data Management Prototype System for Aviation Accident and Incident Investigation (국내 항공사고조사를 위한 항공사고 통합 데이터 관리시스템의 프로토 타입 개발)

  • Kim, Do-Hyun;Hong, Seung-Beom
    • Journal of Advanced Navigation Technology
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    • v.22 no.3
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    • pp.198-204
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    • 2018
  • In this paper, It proposed the development of integrated data management's prototype system for aviation accident and incident system. With the recent development of the aviation accident investigation equipment, accident investigation system should collect and manage the various types of jpg, avi, and wav data files. However, the ECCAIRS system does not have a separate database for managing the various generated data during the accident investigation. And the Korea aviation accident management system also has the same problem. Therefore, in this paper, we analyze the aviation accident report system of major foreign countries and prepare a method to apply it to the domestic environment. Through the prototype of the integrated data management system, we confirmed the performance through inputting the existing data and the recently investigated data. We will use this result as basic data for completion of final integrated data management system.

A Study on Legal and Institutional Improvement Measures for the Effective Implementation of SMS -Focusing on Aircraft Accident Investigation-

  • Yoo, Kyung-In
    • The Korean Journal of Air & Space Law and Policy
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    • v.32 no.2
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    • pp.101-127
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    • 2017
  • Even with the most advanced aviation technology benefits, aircraft accidents are constantly occurring while air passenger transportation volume is expected to double in the next 15 years. Since it is not possible to secure aviation safety only by the post aircraft accident safety action of accident investigations, it has been recognized and consensus has been formed that proactive and predictive prevention measures are necessary. In this sense, the aviation safety management system (SMS) was introduced in 2008 and has been carried out in earnest since 2011. SMS is a proactive and predictive aircraft accident preventive measure, which is a mechanism to eliminate the fundamental risk factors by approaching organizational factors beyond technological factors and human factors related to aviation safety. The methodology is to collect hazards in all the sites required for aircraft operations, to build a database, to analyze the risks, and through managing risks, to keep the risks acceptable or below. Therefore, the improper implementation of SMS indicates that the aircraft accident prevention is insufficient and it is to be directly connected with the aircraft accident. Reports of duty performance related hazards including their own errors are essential and most important in SMS. Under the policy of just culture for voluntary reporting, the guarantee of information providers' anonymity, non-punishment and non-blame should be basically secured, but to this end, under-reporting is stagnant due to lack of trust in their own organizations. It is necessary for the accountable executive(CEO) and senior management to take a leading role to foster the safety culture initiating from just culture with the safety consciousness, balancing between safety and profit for the organization. Though a Ministry of Land, Infrastructure and Transport's order, "Guidance on SMS Implementation" states the training required for the accountable executive(CEO) and senior management, it is not legally binding. Thus it is suggested that the SMS training completion certificates of accountable executive(CEO) and senior management be included in SMS approval application form that is legally required by "Korea Aviation Safety Program" in addition to other required documents such as a copy of SMS manual. Also, SMS related items are missing in the aircraft accident investigation, so that organizational factors in association with safety culture and risk management are not being investigated. This hinders from preventing future accidents, as the root cause cannot be identified. The Aircraft Accident Investigation Manuals issued by ICAO contain the SMS investigation wheres it is not included in the final report form of Annex 13 to the Convention on International Civil Aviation. In addition, the US National Transportation Safety Board(NTSB) that has been a substantial example of the aircraft accident investigation for the other accident investigation agencies worldwide does not appear to expand the scope of investigation activities further to SMS. For these reasons, it is believed that investigation agencies conducting their investigations under Annex 13 do not include SMS in the investigation items, and the aircraft accident investigators are hardly exposed to SMS investigation methods or techniques. In this respect, it is necessary to include the SMS investigation in the organization and management information of the final report format of Annex 13. In Korea as well, in the same manner, SMS item should be added to the final report format of the Operating Regulation of the Aircraft and Railway Accident Investigation Board. If such legal and institutional improvement methods are complemented, SMS will serve the purpose of aircraft accident prevention effectively and contribute to the improvement of aviation safety in the future.

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