• Journal of the Korean Society of Safety
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• v.36 no.2
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• pp.58-67
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• 2021

Incident investigation is regarded as a means to improve safety performance. For the prevention of industrial accidents, measures such as providing safety education, enhancing management interest and participation, establishing a safety management system, and conducting inspection of the work site are necessary. In particular, accident investigation activities, which are an important element of safety management, help to prevent similar accidents, thereby minimizing damage and enhancing work safety. They are critical for understanding business-related incidents and the vulnerabilities and opportunities associated with them. Therefore, it is clear that accident investigation activities are important for accident prevention. The primary focus of many incident investigation processes is on identifying the cause of an event. While considerable research has been conducted on potential accident investigation tools there has been little research on including the views and experiences of practitioners in the accident investigation process. In this study, a questionnaire survey was conducted among safety managers in the domestic manufacturing/construction industry to understand the practice of accident investigation. The investigation pertained to companies' accident investigation systems, the competence of investigators, and the identification and recommendations of the cause of accidents. From the analysis results of accident investigations, investigators' competence, the difficulty level of investigations, and the root causes of accidents were identified from the viewpoint of the participants of the accident investigations. In particular, the development of standardized and simple accident investigation methods and their dissemination to companies were found to be necessary for activating the root cause of accidents. Based on this, it can be used as basic data for the development of root cause analysis investigation techniques that are easily applicable to organizations.

• Journal of Auto-vehicle Safety Association
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• v.13 no.4
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• pp.66-72
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• 2021

This study was initiated to improve of the defect investigation method using event data recorders (EDR) and suggested a solution through the regulation and system analysis of EDR. The EDR data has been used for various purposes such as the vehicle defect investigation and the traffic accident investigation. However the EDR regulation has not been updated since the implementation in 2012. "Trigger Threshold" can be used to analyze a single accident such as the frontal crash, the side crash, and the rollover. In the case of a complex accident in which a rollover accident and a crash accident occur simultaneously, it is difficult to analyze a complex accident due to current "Trigger Threshold". This study proposed the method of separating the "Trigger Threshold" into a crash accident and a rollover accident so that accidents can be analyzed using the EDR data even when a complex accident occurs. In addition, it proposed the improvement method to quickly use the data of EDR in accident reconstruction software.

• 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.

• Proceedings of the KSR Conference
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• 2009.05a
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• pp.1360-1364
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• 2009

The basic concept of analysis of human error that induced railway accident is that errors are consequences, not causes. But in most cases, it is likely that direct causes of the accident could be concluded as real causes, which make it difficult to find out root causes. Design, training, staffing, culture and condition are general category applied to investigate human error. In order to examine how those approach could help accident analysis, this paper studied accident investigation reports of UK RAIB(Rail Accident Investigation Branch). Rather than consider specific investigation method, we focus investigation result on how to describe causal factors and how to indicate recommendations to prevent similar accident. The reports show that they try to find out causes more in organizational, environmental and job factors, which implies the necessity to improve investigation process of human error accident in Korea.

• 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.

• The Journal of The Korea Institute of Intelligent Transport Systems
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• v.9 no.2
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• pp.75-86
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• 2010

The objective of this study is to suggest the process and method of local accident investigation for local authorities with a view to efficient and effective managing traffic accidents. With a project city selected accident-type maps, accident lists, accident diagrams, priority of black-spots/-lengths, site visits, remedial measures, opportunity costs, monitoring etc. are taken into consideration, by using accident data in the last 3 years. Analyzed are accident savings to be expected when applying technical, organizational, and administrative processes attached to local accident investigation.

• The Journal of The Korea Institute of Intelligent Transport Systems
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• v.8 no.3
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• pp.34-41
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• 2009

Recently, information-Ievel of the people has been increased with growing IT cutting-edge technology. There is a trend to combine these achievements with information-technology, ubiquitous technology, and mobile technology in the field of transportation. Along with this trend, a PDA-based traffic accident investigation device was developed. This paper established the evaluation method of feasibility test on the PDA device, and performed qualitative and quantitative evaluation as compared with the current practice (manual investigation). Test results showed that traffic accident investigation using the PDA device was faster and more convenient than manual investigation. It is expected that the reliability of accident investigation will be improved by applying this tool with minor modifications.

• 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.

• Journal of the Ergonomics Society of Korea
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• v.35 no.3
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• pp.143-153
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• 2016

Objective: The purposes of this study are to survey needs for changing accident investigation from blaming to systems approach and to briefly summarize systems-based accident analysis techniques. Background: In modern complex socio-technical systems, accidents are caused by a variety of contributing factors including human, technical, organizational, social factors, not by just a single violation or error of a specific actor, but accidents investigation used to be focused on the incorrect action of individuals. A new approach investigating causes of accidents as a symptom of a deficient system is required. Method: This study was mainly based on survey of literatures related to accidents, accidents investigation, which included academic journals, newspapers, etc. Results: This study showed that accidents investigation of Korea focusing on blaming is problematic. This was confirmed by two concepts of migration and hindsight bias frequently found in accident causation studies, and an attribute of accidents having varying causes. This was illustrated with an example of Sewol ferry capsizing accident. Representative systems-based accident analysis models including Swiss cheese model, AcciMap, HFACS, FRAM and STAMP were briefly introduced, which can be used in systematic accidents investigations. Finally, this study proposed a procedure for establishing preventive measures of accidents, which was composed of two steps: public inquiry and devising preventive measures. Conclusion: A new approach considering how safety-critical components such as technical and social elements, and their interactions lead to accidents is needed for preventing reoccurrence of similar accidents in complex socio-technical systems. Application: The results would be used as a reference or guideline when the safety relevant governmental organizations investigate accidents.

• The Journal of The Korea Institute of Intelligent Transport Systems
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• v.8 no.1
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• pp.22-29
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• 2009

This paper suggests a PDA-based scientific traffic accident investigation system in order to improve the reliability and accuracy of a traffic accident investigation procedure. In order to fulfill this objective, a standard accident sheet with 32 elements to be used in the PDA system was developed through a reference review and an expert survey. Using this information, the required functionalities and realization procedure of the PDA system for traffic accident investigation were presented including mobile network environment and GPS/GIS design. A prototype of PDA system is presented and more improved and efficientmanagement is highly expected by applying the system developed in this paper.