• Journal of the Korean Society of Safety
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• v.36 no.4
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• pp.62-70
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• 2021

Representative systematic accident analysis methods proposed so far include AcciMap, STAMP, and FRAM. This study used these three techniques to analyze a fire accident case that occurred during routine manufacturing work in a domestic chemical plant and compared the results. The methods used different approaches to identify the cause of the accident, but they all highlighted similar causal factors. In addition to technical issues, the three accident analysis methods identified factors related to safety education, risk assessment, and the operation of the process safety management system, as well as management philosophy and company culture as problems. The AcciMap and STAMP models play complementary roles because they use hierarchical structures, while FRAM is more effective in analyses centered on human and organizational functions than in technical analyses.

• Journal of Navigation and Port Research
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• v.48 no.5
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• pp.384-391
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• 2024

The AcciMap technique has been a fundamental tool for examining accidents and their causal factors across complex socio-technical systems. This study utilized the AcciMap framework to evaluate ferry navigation accidents in the Mombasa Channel from 2011 to 2020. It categorized the identified causal factors into four primary levels of AcciMap: government, regulatory bodies, ferry operating companies, and ferry operators, including environmental and equipment conditions. The aim is to assess these factors to address systemic deficiencies in ferry operations within the channel. The findings highlight significant gaps in the ferry operation system by using a cause-and-effect analysis. Based on this assessment, the paper offers recommendations to rectify these deficiencies and improve safety in ferry operations. This research underscores the utility of system theory-based tools in uncovering complex, multifaceted causes of ferry accidents and providing a robust framework for enhancing maritime transportation safety.

• Journal of the Korean Society of Safety
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• v.38 no.3
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• pp.51-60
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• 2023

Investigation of the cause of the relatively recent building collapse accident in Gwangju revealed a lack of awareness about the safety of the dismantling construction system among stakeholders, in the form of issues such as illegal subcontracting, unauthorized design changes, and insufficient safety supervision. This study was conducted to analyze the safety interactions between the building dismantling construction system and the involved stakeholders and to propose ways to prevent accidents in related institutions and workplaces. AcciMap and STAMP-CAST analysis methods were used to evaluate safety interactions among the various stakeholders participating in building demolition work. Analysis results revealed that the collapse accident during the dismantling work was caused not only by structural causes occurring in the construction stage, but also by various causes throughout the system, such as the dismantling plan preparation stage and the construction permit stage. The results also revealed the need for proper implementation of safety control measures by various stakeholders to prevent collapse accidents during dismantling construction.

• Journal of the Korean Society of Safety
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• v.37 no.5
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• pp.42-55
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• 2022

In this study, an accident at an in-house maintenance subcontractor of a manufacturing company was analyzed using representative systemic analysis methods, and the results were compared to determine the socio-technical and organizational structure causal factors. Systemic accident analyses were performed using AcciMap, STAMP-CAST, and a method that utilizes work processing procedures. The causal factors derived from the three methods were classified according to HFACS classification criteria. AcciMap and STAMP-CAST analyses were able to derive legal problems and defects in organizational structure between the company and the subcontractors. The method that utilized the work processing procedures drew the most causal factors of the three methods but showed some limitations in deriving legal and facility-related problems. Most of the causal factors identified through the systemic methods could be classified according to the HFACS classification criteria, except for the legal and organizational structure matters. Socio-technical and organizational problems with a holistic perspective of the company and subcontractors could be found using systemic analysis methods. However, it is necessary to conduct analysis using various methods in order to derive more comprehensive measures to prevent accidents because each analysis method showed some limitations in the derivation or expression of some causal factors. The results of this study can be helpful in selecting and using an appropriate method for accident analysis.

• 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.