• Proceedings of the Korean Institute of Navigation and Port Research Conference
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• 2003.05a
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• pp.42-50
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• 2003

The marine accident investigation of Korea Marine Safety Tribunal does not keep up with the international rule and guideline. Also there is no proper investigation manual. This study analyzed the investigation system and manual of Korea. USA and Japan etc., and proposed the newly investigation system and manual of KMST including the classfication guideline of marine accident investigation and analysis.

• Journal of Advanced Marine Engineering and Technology
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• v.40 no.8
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• pp.721-725
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• 2016

This paper reviews the analysis of a given scenario according to the Hybrid Model, and why accident causation models are necessary in casualty investigations. The given scenario has been analyzed according to the Hybrid Model using its main five components, fallible decisions, line management, psychological precursors to unsafe acts, unsafe acts, and inadequate defenses. In addition, the differences between the SHEL and the Hybrid Model, and the importance of a safety barrier during an accident investigation, are shown in this paper. One unit of SHEL can be linked with another unit of SHEL. However, it cannot be used for the analysis of an accident. Therefore, we must use an accident causation model, which can be a Hybrid Model. This can explain the "How" and "Why" of accident, so it is a suitable model for analyzing them. During an accident investigation, the reason we focus on a safety barrier is to create another safety barrier or to change an existing safety barrier if that barrier fails. Hence, the paper shows how a sea accident can be investigated, and we propose a preventive way of avoiding the accident through combining the methods of different models for the future.

• Journal of the Ergonomics Society of Korea
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• v.30 no.1
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• pp.137-150
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• 2011

Nationally and internationally reported statistics on marine accidents show that 80% or more of all marine accidents are caused fully or in part by human error. According to the statistics of marine accident causes from Korean Maritime Safety Tribunal(KMST), operating errors are implicated in 78.7% of all marine accidents that occurred from 2002 to 2006. In the case of the collision accidents, about 95% of all collision accidents are caused by operating errors, and those human error related collision accidents are mostly caused by failure of maintaining proper lookout and breach of the regulations for preventing collision. One way of reducing the probability of occurrence of the human error related marine accidents effectively is by investigating and understanding the role of the human elements in accident causation. In this paper, causal factors/root causes classification systems for marine accident investigation were reviewed and some typical human error analysis methods used in shipping industry were described in detail. This paper also proposed a human error analysis method that contains a cognitive process model, a human error analysis technique(Maritime HFACS) and a marine accident causal chains, and then its application to the actual marine accident was provided as a case study in order to demonstrate the framework of the method.

• Journal of Navigation and Port Research
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• v.27 no.4
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• pp.367-373
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• 2003

The marine accident investigation of Korean Marine Safety Tribunal does not keep up with the international rule and guideline. Also there is no manual for a proper investigation into the marine accident. This study analyzed the investigation system and manual of Korea. USA and Japan etc., and proposed the new investigation system and manual of KMST including the inquiry guideline according to the type of marine accident.

• Proceedings of KOSOMES biannual meeting
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• 2017.11a
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• pp.78-78
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• 2017

• 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.

• Proceedings of KOSOMES biannual meeting
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• 2018.06a
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• pp.120-120
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• 2018

• 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 Navigation and Port Research
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• v.34 no.2
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• pp.145-152
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• 2010

The management of safety at sea is based on a set of internationally accepted regulations and codes, governing or guiding the design and operation of ships. The regulations most directly concerned with human safety and protection of the environment are, in general, agreed internationally through the International Maritime Organization(IMO). IMO has continuously dealt with safety problems and, recognized that the human element is a key factor in both safety and pollution prevention issues(IMO, 2010). This paper proposes a human error analysis methodology which is based on the human error taxonomy and theories (SHELL model, GEMS model and etc.) that were discussed in the IMO guidelines for the investigation of human factors in marine casualties and incidents. In this paper, a cognitive process model, a human error analysis technique and a marine accident causal chains focused on human factors are discussed, and towing vessel collision accidents are analyzed as a case study in order to examine the applicability of the human error analysis technique to marine accidents. Also human errors related to those towing vessel collision accidents and their underlying factors are discussed in detail.

• Journal of Navigation and Port Research
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• v.28 no.3
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• pp.161-167
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• 2004

Maritime safety and marine environmental protection are the most important topic in marine society. But, so many marine accidents have been occurred with the development of marine transportation industry. On the other side, ship is being operated under a highly dynamic environment and many factors are related with ship's collision Nowadays, the increasing tendency to the human errors of ship's collision is remarkable, and the investigation of the human errors has been heavily concentrated. This study analysed on the human errors of ship's collision related to the negligence of lookout and classified basic error type using GEMS(Generic Error Modeling System) dynamic model.