• 한국항해항만학회:학술대회논문집
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• 한국항해항만학회 2003년도 춘계공동학술대회논문집
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• pp.42-50
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• 2003

우리나라의 해양안전심판원은 지난 40년동안 많은 업적을 남겼지만, 아직도 해양사고의 조사에 대한 법과 제도 및 매뉴얼 등에서 미흡한 점이 있다. 조사매뉴얼은 국제해사기구의 해양사고조사지침 등의 국제규정과 기준을 수용하지 못하고 심판지침과 함께 작성되어 있을 뿐만아니라 그 구성과 내용 및 조사기법 등이 매우 부실하다. 그리고, 조사제도는 심판원이 독립성을 가지지 못하고 재발방지를 위한 권고기능이 크게 위축되어 있는 실정이다. 또한, 해양사고의 원인판단지침이 없어 조사관이 항법적용을 혼동하거나 오류를 범하는 경우가 종종 발생하고 있고 초임 조사관 등의 사고원인판단의 기준으로 활용할 수 있는 교재도 없다. 이 연구에서는 영국, 미국, 네덜란드 및 일본의 조사매뉴얼과 조사제도를 비교ㆍ분석하여 개선안을 제안하고, 사고 종류별 질문조사기법을 제안한다.

• Journal of Advanced Marine Engineering and Technology
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• 제40권8호
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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.

• 대한인간공학회지
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• 제30권1호
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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.

• 한국항해항만학회지
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• 제27권4호
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• pp.367-373
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• 2003

우리나라의 해양안전심판원은 지난 40년동안 많은 업적을 남겼지만, 아직도 해양사고의 조사에 대한 법과 제도 및 매뉴얼 등의 내용 면에서 미흡한 점이 있다. 조사매뉴얼은 국제해사기구의 해양사고조사지침 등의 국제규정과 기준을 수용하지 못하고 심판지침과 함께 작성되어 있을 뿐만아니라 그 구성과 내용 및 조사기법 등이 매우 부실하다. 그리고, 조사제도는 심판원이 독립성을 가지지 못하고 재발방지를 위한 권고기능이 크게 위축되어 있는 실정이다. 또한, 해양사고의 원인판단지침이 없어 조사관이 항법을 적용하는데 있어 혼동하거나 오류를 범하는 경우가 종종 발생하고 있고 초임 조사관 등의 사고원인판단의 기준으로 활용할 수 있는 교재도 없다. 이 연구에서는 영국, 미국, 네덜란드 및 일본의 조사매뉴얼과 조사제도를 비교ㆍ분석하여 개선안을 제안하고, 사고 종류별 질문조사기법을 제안한다.

• 해양환경안전학회:학술대회논문집
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• 해양환경안전학회 2017년도 추계학술발표회
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• pp.78-78
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• 2017

• 한국항해항만학회지
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• 제41권5호
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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.

• 해양환경안전학회:학술대회논문집
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• 해양환경안전학회 2018년도 공동국제학술발표회
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• pp.120-120
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• 2018

• 대한인간공학회지
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• 제36권5호
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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.

• 한국항해항만학회지
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• 제34권2호
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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.

• 한국항해항만학회지
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• 제28권3호
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• pp.161-167
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• 2004

지금까지(1988∼2000년) 국내 해양안전심판원에서 재결한 선박충돌사고의 원인분류 통계데이터를 살펴보면 전체 2,290건의 인적과실(Human Error) 중에서 상대선박에 대한 경계의무소홀이 929건으로 약 40.6％나 되는 가장 많은 비중을 차지하고 있는 것으로 파악되고 있다. 선박충돌사고는 좌초사고와 더불어 인적과실로 기인한 수많은 인명피해와 재산피해 및 해양환경오염을 유발하는 심각한 해양사고로서 이에 대한 사고원인을 철저히 분석하고 그 예방대책 마련이 무엇보다 중요한 과제가 되고 있다. 따라서, 본 연구에서는 선박충돌사고의 인적과실을 분석하기 위한 목적으로 목포해양안전심판원에서 재결한 선박충돌사고(1990∼2002, 65건)에 대하여 상대선 경계의무소홀이나 동정감시 불충분으로 기인하여 발생한 충돌사고를 조사항목별로 분석하고, GEMS 동적모델을 이용하여 선박충돌사고의 인적과실 유형을 체계적으로 분류하였다.