• 한국안전학회지
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• 제36권2호
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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.

• 자동차안전학회지
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• 제13권4호
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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.

• 한국항공운항학회지
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• 제25권4호
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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.

• 한국철도학회:학술대회논문집
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• 한국철도학회 2009년도 춘계학술대회 논문집
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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.

• 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.

• 한국ITS학회 논문지
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• 제9권2호
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• pp.75-86
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• 2010

본 연구는 지역 교통사고 원인조사의 관리주체인 도로관리청에서 교통사고를 효율적이면서 효과적으로 관리하고 시행할 수 있는 교통사고 원인조사 기법 및 절차를 제시하였다. 또한, 시범도시를 선정하여 최근 3년간 교통사고 중 사망사고 자료를 바탕으로 사고형태지도, 구조분석표 및 사고도표의 작성, 사고누적지점 및 구간의 선정과 우선순위, 현장조사 및 개선시책의 결정, 기회비용의 추정, 모니터링 방안 등 향후 도로관리청의 교통사고 원인조사의 기술적, 조직적 및 행정적 프로세스를 적용하여 예상되는 사고감소효과에 대해 분석하였다.

• 한국ITS학회 논문지
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• 제8권3호
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• pp.34-41
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• 2009

최근 IT 첨단기술의 발전과 더불어 국민들의 정보화 수준이 지속적으로 향상되고 있는 가운데 교통 분야에 IT기술의 최신분야인 유비쿼터스 기술 및 모바일 기술 등 첨단기술을 접목하려는 시도가 늘어나고 있는 추세이다. 이러한 경향에 발맞춰 교통사고 조사를 신속하고 효율적으로 실시할 수 있는 PDA 조사 장치가 개발되었다. 본 논문에서는 교통사고 조사를 위해 개발된 PDA에 대해 평가방법론을 설정하고, 정성적 및 정량적 평가를 실시하였다. 평가 결과, PDA를 활용한 교통사고 조사는 수기조사에 비해 자료의 정확성 및 편리성, 그리고 조사시간 측면에서 비교 우위에 있는 것으로 평가되었다. 그리고 사고데이터를 입력하는 형식에 관한 일부 개선이 필요한 면도 파악되었다. 향후 이러한 문제점을 개선한다면 사고조사 분야에 큰 기여를 할 것으로 판단된다.

• 항공우주정책ㆍ법학회지
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• 제18권
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• pp.325-362
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• 2003

군항공기사고조사의 전문성과 독립성을 제고하기 위하여 상설사고조사기구를 신설하여야 한다. 상설조사기구를 신설함으로써 조사기구의 위상을 높이고 조사의 신뢰성을 확보할 수 있다. 민과 군이 모두 관련된 사고조사시 민과 군의 조사권한의 주제, 업무협조 등에 관한 규율이 부재하고 있으므로 이를 입법화해야 한다. 군과 관련된 민항공기 사고조사시 군의 전문가들이 참여함이 바람직하다. 조사의 실효성 보장을 위하여 항공사고에 대한 정보를 직접 수집하는 조사관의 활동을 보장하는 규정을 마련해야 한다. 또한, 사고조사의 목적은 오직 사고예방에만 있으므로 정보의 공개범위를 제한하고 조사결과를 형사절차나 징계절차에서 사용할 수 없도록 하여 조사의 객관성을 확보해야 할 것이다.

• 대한인간공학회지
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• 제35권3호
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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.

• 한국ITS학회 논문지
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• 제8권1호
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• pp.22-29
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• 2009

본 논문은 각종 교통사고에 대한 보다 효율적이고 신뢰성 있는 조사를 목적으로 PDA를 활용한 교통사고 조사 체계를 검토하고, 이를 구현하기 위하여 요구되는 교통사고 조사 장비를 개발하는 내용을 제시하였다. 이를 위하여 교통사고 조사 양식지와 전문가 설문을 통하여 32개 항목으로 구성된 교통사고 초동조사 양식지를 개발하였다. 이와 함께 도로 교통사고 조사를 위한 모바일 환경 및 GPS, GIS에 대한 PDA 단말기의 요구기능과 시스템 구축 프로세스를 제시하고 장비를 구현하였다. 이러한 연구결과를 반영하여 국내 교통사고 조사체계를 개선한다면 현재 보다 더욱 효율적이고 자동화된 관리가 가능하다고 판단된다.