• Title/Summary/Keyword: Accident Investigation Report

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A Study on the System of Aircraft Investigation (항공기(航空機) 사고조사제도(事故調査制度)에 관한 연구(硏究))

  • Kim, Doo-Hwan
    • The Korean Journal of Air & Space Law and Policy
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    • v.9
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    • pp.85-143
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    • 1997
  • The main purpose of the investigation of an accident caused by aircraft is to be prevented the sudden and casual accidents caused by wilful misconduct and fault from pilots, air traffic controllers, hijack, trouble of engine and machinery of aircraft, turbulence during the bad weather, collision between birds and aircraft, near miss flight by aircrafts etc. It is not the purpose of this activity to apportion blame or liability for offender of aircraft accidents. Accidents to aircraft, especially those involving the general public and their property, are a matter of great concern to the aviation community. The system of international regulation exists to improve safety and minimize, as far as possible, the risk of accidents but when they do occur there is a web of systems and procedures to investigate and respond to them. I would like to trace the general line of regulation from an international source in the Chicago Convention of 1944. Article 26 of the Convention lays down the basic principle for the investigation of the aircraft accident. Where there has been an accident to an aircraft of a contracting state which occurs in the territory of another contracting state and which involves death or serious injury or indicates serious technical defect in the aircraft or air navigation facilities, the state in which the accident occurs must institute an inquiry into the circumstances of the accident. That inquiry will be in accordance, in so far as its law permits, with the procedure which may be recommended from time to time by the International Civil Aviation Organization ICAO). There are very general provisions but they state two essential principles: first, in certain circumstances there must be an investigation, and second, who is to be responsible for undertaking that investigation. The latter is an important point to establish otherwise there could be at least two states claiming jurisdiction on the inquiry. The Chicago Convention also provides that the state where the aircraft is registered is to be given the opportunity to appoint observers to be present at the inquiry and the state holding the inquiry must communicate the report and findings in the matter to that other state. It is worth noting that the Chicago Convention (Article 25) also makes provision for assisting aircraft in distress. Each contracting state undertakes to provide such measures of assistance to aircraft in distress in its territory as it may find practicable and to permit (subject to control by its own authorities) the owner of the aircraft or authorities of the state in which the aircraft is registered, to provide such measures of assistance as may be necessitated by circumstances. Significantly, the undertaking can only be given by contracting state but the duty to provide assistance is not limited to aircraft registered in another contracting state, but presumably any aircraft in distress in the territory of the contracting state. Finally, the Convention envisages further regulations (normally to be produced under the auspices of ICAO). In this case the Convention provides that each contracting state, when undertaking a search for missing aircraft, will collaborate in co-ordinated measures which may be recommended from time to time pursuant to the Convention. Since 1944 further international regulations relating to safety and investigation of accidents have been made, both pursuant to Chicago Convention and, in particular, through the vehicle of the ICAO which has, for example, set up an accident and reporting system. By requiring the reporting of certain accidents and incidents it is building up an information service for the benefit of member states. However, Chicago Convention provides that each contracting state undertakes collaborate in securing the highest practicable degree of uniformity in regulations, standards, procedures and organization in relation to aircraft, personnel, airways and auxiliary services in all matters in which such uniformity will facilitate and improve air navigation. To this end, ICAO is to adopt and amend from time to time, as may be necessary, international standards and recommended practices and procedures dealing with, among other things, aircraft in distress and investigation of accidents. Standards and Recommended Practices for Aircraft Accident Injuries were first adopted by the ICAO Council on 11 April 1951 pursuant to Article 37 of the Chicago Convention on International Civil Aviation and were designated as Annex 13 to the Convention. The Standards Recommended Practices were based on Recommendations of the Accident Investigation Division at its first Session in February 1946 which were further developed at the Second Session of the Division in February 1947. The 2nd Edition (1966), 3rd Edition, (1973), 4th Edition (1976), 5th Edition (1979), 6th Edition (1981), 7th Edition (1988), 8th Edition (1992) of the Annex 13 (Aircraft Accident and Incident Investigation) of the Chicago Convention was amended eight times by the ICAO Council since 1966. Annex 13 sets out in detail the international standards and recommended practices to be adopted by contracting states in dealing with a serious accident to an aircraft of a contracting state occurring in the territory of another contracting state, known as the state of occurrence. It provides, principally, that the state in which the aircraft is registered is to be given the opportunity to appoint an accredited representative to be present at the inquiry conducted by the state in which the serious aircraft accident occurs. Article 26 of the Chicago Convention does not indicate what the accredited representative is to do but Annex 13 amplifies his rights and duties. In particular, the accredited representative participates in the inquiry by visiting the scene of the accident, examining the wreckage, questioning witnesses, having full access to all relevant evidence, receiving copies of all pertinent documents and making submissions in respect of the various elements of the inquiry. The main shortcomings of the present system for aircraft accident investigation are that some contracting sates are not applying Annex 13 within its express terms, although they are contracting states. Further, and much more important in practice, there are many countries which apply the letter of Annex 13 in such a way as to sterilise its spirit. This appears to be due to a number of causes often found in combination. Firstly, the requirements of the local law and of the local procedures are interpreted and applied so as preclude a more efficient investigation under Annex 13 in favour of a legalistic and sterile interpretation of its terms. Sometimes this results from a distrust of the motives of persons and bodies wishing to participate or from commercial or related to matters of liability and bodies. These may be political, commercial or related to matters of liability and insurance. Secondly, there is said to be a conscious desire to conduct the investigation in some contracting states in such a way as to absolve from any possibility of blame the authorities or nationals, whether manufacturers, operators or air traffic controllers, of the country in which the inquiry is held. The EEC has also had an input into accidents and investigations. In particular, a directive was issued in December 1980 encouraging the uniformity of standards within the EEC by means of joint co-operation of accident investigation. The sharing of and assisting with technical facilities and information was considered an important means of achieving these goals. It has since been proposed that a European accident investigation committee should be set up by the EEC (Council Directive 80/1266 of 1 December 1980). After I would like to introduce the summary of the legislation examples and system for aircraft accidents investigation of the United States, the United Kingdom, Canada, Germany, The Netherlands, Sweden, Swiss, New Zealand and Japan, and I am going to mention the present system, regulations and aviation act for the aircraft accident investigation in Korea. Furthermore I would like to point out the shortcomings of the present system and regulations and aviation act for the aircraft accident investigation and then I will suggest my personal opinion on the new and dramatic innovation on the system for aircraft accident investigation in Korea. I propose that it is necessary and desirable for us to make a new legislation or to revise the existing aviation act in order to establish the standing and independent Committee of Aircraft Accident Investigation under the Korean Government.

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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.

Domestic Helicopter Accident Analysis using HFACS & Dirty Dozen

  • Kim, Su-Ro;Cho, Young-Jin;Song, Byung-Heym
    • International Journal of Internet, Broadcasting and Communication
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    • v.12 no.4
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    • pp.1-10
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    • 2020
  • Safety can be defined as being maintained or reduced to a level below which the possibility of human or physical harm can be tolerated through continuous identification of risks and safety risk management. FAA, EASA, IATA and Boeing, major organizations that conduct research and analysis for aviation safety around the world, report that about 70 percent of aviation accidents are caused by human factors, which have led to a surge in interest in human factors-induced accident prevention activities around the world. As part of this purpose, the FAA in the U.S. is raising awareness among aviation workers by publicizing the 12 human errors (Boeing, 2016), which account for the largest part of aviation accidents under the theme of Dirty Dozen, to prevent aviation accidents. Therefore, based on the domestic helicopter accidents reported to the Air Railroad Accident Investigation Committee from 2007 until recently, this study aims to use HFACS to extract human factors for the six recent helicopter accidents in Korea, analyze the extracted human factors in conjunction with the Dirty Dozen concept, and then present measures to prevent accidents by item.

A Study on Cause Analysis of the Crash for the Ski Lift (스키 리프트 기계안전사고 원인분석에 관한 연구)

  • Kim, Eui-Soo
    • Journal of the Korean Society of Safety
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    • v.24 no.2
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    • pp.13-16
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    • 2009
  • A ski lifter for winter sports is one of the necessary and familiar facilities. But recently safety concern about ski lifter has been built. The ski lifter crash in Pocheon happened recently showed an example of safety concern and frigidity for safety awareness. In this report, the cause of the ski lifter crash in Pocheon was reviewed, and some suggestions were made to prevent a similar accident base on this review.

Discussions on the Cause of Mixed Gas Cylinder Rupture (혼합가스용기폭발 원인에 대한 고찰)

  • Yoon, Jae-Kun
    • Journal of the Korean Institute of Gas
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    • v.15 no.6
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    • pp.51-56
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    • 2011
  • Mixed gas cylinder(80% Ar, 20% $O_2$) exploded three years ago. But the cause of cylinder rupture was not identified and the case was finished. This paper is the discussions on the cause of cylinder explosion with the investigation report by the police and the similar accident cases. The cause of explosion is the chemical reaction in the cylinder. This accident is similar with the explosion of pressurized oxygen cylinder.

Cause Analysis and Improvement Suggestion for Flood Accident in Dorimcheon - Focused on the Tripping and Isolation Accidents (도림천에서 발생한 고립 및 실족사고의 원인분석을 통한 개선방안 도출에 관한 연구)

  • Lee, Kyung-Su;Jeon, Jong-Hyeong;Kim, Tai-Hoon;Kim, Hyunju
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.22 no.4
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    • pp.25-36
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    • 2021
  • This study analyzed the causes of flood accidents, such as isolation and lost footing accidents in Dorimcheon, to provide legal and institutional improvements. For cause analysis, Field Investigation, Stakeholder Interview, Report, manual, Law et al. Review, Analysis of water level change characteristics, automatic alarm issuance standard level analysis, and evacuation time according to river control were evaluated. Dorimcheon has the characteristics of a typical urban river, which is disadvantageous in terms of water control. In addition, the risk of flood accidents is high because the section where fatal accidents occur forms sharply curved channels. Tripping and isolation accidents occur in the floodplain watch and evacuation stage, which is the stage before the flood watch and warning is issued. Because floodplain evacuation is issued only when the water level rises to the floodplain, an immediate response according to the rainfall forecast is essential. Furthermore, considering that the rate of water level rise is up to 2.62 cm/min in Sillimgyo 3 and Gwanakdorimgyo, sufficient evacuation time is not secured after the floodplain watch is issued. Considering that fatal accidents occurred 0.46 m below the standard water level for the flood watch, complete control is very important, such as blocking the entry of rivers to prevent accidents. Based on these results, four improvement measures were suggested, and it is expected to contribute to the prevention of Tripping and Isolation Accidents occurring in rivers.

A Study on the Risk Reduction of Distribution Line through Analysis of Electric Shock Accident (감전재해 분석을 통한 배전선로의 위험성 저감에 관한 연구)

  • Byeon, Junghwan;Choi, Sang-won
    • Journal of the Korean Society of Safety
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    • v.33 no.2
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    • pp.14-20
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    • 2018
  • In this study, we analyze the current status of major disasters in distribution works and propose safety measures through the distribution live-line work method and electric shock risk assessment. The result of analyzing the ratio of electric shocks to the occurrence of industrial accidents in the recent 13 years shows that the death rate is higher than other industries, especially the construction industry occupying most of the disaster, and it is higher than the collapse disaster. We analyze statistic data of 101 victims selected as core words of live work, distribution line, pole and 22.9 kV in the investigation report of major accident of electric shock fatal from 2001 to 2014. The safety measure was established through the risk assessment of the distribution method using the standard model of the risk assessment based on the results of electric shock analysis on the distribution line. In order to prevent the electric shock accident which is recently being discussed, the risk assessment procedure were carried out in the above-mentioned 22.9kV special high voltage live-line operation method. We derived the risk reduction plan for the distribution line from the results of the major accidents statistic and demonstration of the line works.

A Study on the Analysis and Classification of Types and Causes of Railway Accidents (철도사고 위험분류 및 원인분석에 관한 연구)

  • Park Chan-Woo;Park Joo-Nam;Wang Jong-Bae;Cho Yun-ok
    • 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.

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Characteristics Analysis of Accident Factors of UK Civil Unmanned Aircraft Using SHELL Model and HFACS (SHELL 모델과 HFACS를 활용한 영국 민간 무인 항공기 사고 요인 특징 분석)

  • Do Yun Kim;Jo Won Chang
    • Journal of the Korean Society for Aviation and Aeronautics
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    • v.32 no.1
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    • pp.1-9
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    • 2024
  • The unmanned aerial vehicle industry has developed a lot, but the possibility of accidents is increasing due to potential risks. In this study, SHELL models and HFACS were used to analyze unmanned aerial vehicle accidents in the UK and to identify the main causes and characteristics of accidents. The main cause analyzed by the SHELL model was identified as an abnormality in the alarm system. The main cause of the accident analyzed by HFACS was identified as the technical environment. The common cause identified by the SHELL model and HFACS was identified as a mechanical problem of unmanned aerial vehicles. This is due to the lack of accurate information or functionality of the alarm system in the operator interface, which often prevents the operator from responding to sensitive information. Therefore, in order to prevent civil UAV accidents, the stability and reliability of the system must be secured through regular inspections of the UAV system and continuous software updates. In addition, an ergonomic approach considering human interfaces is needed when developing technologies.

A Study on the Improvement of Hazardous Materials Accident Report for Chemical Safety Management (화학물질 안전관리를 위한 위험물 사고 발생보고서 개선연구)

  • Goh, Moon-Soo;Jang, Hyeon-Jun;Seong, Chun-Mo;Lee, Hunggi;Lee, Bong-Woo;Shin, Dong-il
    • Journal of the Korean Institute of Gas
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    • v.26 no.1
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    • pp.41-49
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    • 2022
  • Chemicals are widely used throughout society, and usage is expected to increase in the future. As a result, various accidents related to chemicals and dangerous substances are occurring, and the frequency of occurrence is expected to continue to increase. Thus, it is expected that this study will present problems and improvement directions through analysis of each associated agency's accident report and management system, and improve the research input system to increase efficiency in collecting and statistical calculation of chemical and hazardous accident.