An Investigation of Human Error Analysis Techniques in Various Industries with Implications for the Korean Railway Industry

인적오류 분석기법의 국내외 활용 현황 및 국내 철도 산업에의 적용 방안

  • 백동현 (한양대학교 안산캠퍼스 경영학부) ;
  • 윤완철 (한국과학기술원 산업공학과) ;
  • 김동산 (한국과학기술원 산업공학과)
  • Published : 2007.02.28

Abstract

Since human errors are being recognized as one of the primary issues in railway safety, there is a definite need for human error analysis techniques that can identify the types of errors and their causes and derive effective countermeasures to help reduce their future probability. But, for some reasons, there are not yet systematic procedures or techniques for analyzing human errors in the Korean railway industry. This paper introduces several techniques that have been developed and utilized for analyzing human errors in Korean and overseas nuclear power aviation railway, offshore oil industry, etc., and summarizes the strengths and weaknesses of each technique. Based on the Investigation of the techniques, the paper also discusses the implications for the development of a human error analysis system for the Korean railway industry.

Keywords

References

  1. 건설교통부 (2006), '철도안전종합계획: 제1차 (2006-2010 )'. 2006년 2월
  2. Wiegmann, D.A., Shappell, S.A. (2003), A Human Error Approach to Aviation Accident Analysis: The Human Factors Analysis and Classification System, Aldershot, UK, Ashgate Publishing Company
  3. Thomas, M.J.W., Petrilli, R.M. & Dawson, D. (2004), 'An exploratory study of error detection processes during normal line operations', Proceedings of 26th Conference of the European Association for Aviation Psychology
  4. Reason, J. (1990), Human Error, New York: Cambridge University Press
  5. 이정운, 이용희, 박근옥 (1996), '국내 원자력발전소의 인적오류사례의 추이 분석', 대한인간공학회지, 제 15권, 제 1호, pp.27-38
  6. 김두환 (1998), '화학 공장의 Human Error 방지 당면 과제에 관한 연구', 대한산업공학회 인지공학연구회 공동하계 Workshop 발표논문집, pp.147-157
  7. Woods, D.D., Johannesen, L.J., Cook, R.I. & Sarter, N.B. (1994), Behind human error: cognitive systems, computers, and hindsight, Columbus, Ohio: CSERIAC
  8. 건설교통부 (2006), '철도사고보고 및 조사에 관한 지침(안)', 건설교통부 고시 제2006-3호
  9. Reinach, S. & Viale, A. (2006), 'Application of a human error framework to conduct train accident/incident investigations', Accident Analysis and Prevention, 38, pp.396-406 https://doi.org/10.1016/j.aap.2005.10.013
  10. RSSB (2005), 'Rail-specific HRA technique for driving tasks', Final Report
  11. Reason, J., Free, R., Havard, S., Benson, M. & van Oijen, P. (1994), 'Railway Accident Investigation Tool (RAIT): A step by step Guide for New Users', Department of Psychology, University of Manchester
  12. INPO, (1990), 'Human Performance Enhancement System', INPO 90-005, Atlanta: Institute of Nuclear Power Operations
  13. 한국전력공사 기술연구원 (1994), '원자력발전소 인적행위 개선 시스템(K-HPES) 개발 (I)', 최종보고서
  14. 한국전력공사 전력연구원 (1998), '원자력발전소 인적행위 개선 시스템 (K-HPES) 개발 (II)', 최종보고서
  15. 한국수력원자력(주) 환경기술원 (2004), '사고근접 사례 분석 절차 개발 및 K-HPES 개선(I)', 최종보고서
  16. Paradies, M., Unger, L., Haas, P. & Terranova, M. (1993), 'Development of the NRC's Human Performance Investigation Process (HPIP)', NUREG/CR-5455, SI-92-01, Vol. 1, Washington, DC: US Nuclear Regulatory Commission
  17. NRC (2001), 'The Human Performance Evaluation Process: A Resource for reviewing the identification and resolution of human performance problems', NUREC/CR-6751, Washington, DC: U.S. Nuclear Regulatory Commission
  18. Shappell, S.A. & Wiegmann, D.A. (2000), 'The Human Factors Analysis and Classification System (HFACS)', Report Number DOT/FAA/AM-00/7, Washington, DC: Federal Aviation Administration
  19. Shorrock, S.T. & Kirwan, B. (2000), 'Development and application of a human error identification tool for air traffic control', Applied Ergonomics, 33, pp.319-336 https://doi.org/10.1016/S0003-6870(02)00010-8
  20. Paradies, M. & Unger, L. (2000), $TapRooT{\circledR}$: The system for root cause analysis, problem investigation, and proactive improvement, System Improvements, Inc
  21. Hollnagel, E. (1998), Cognitive Reliability and Error Analysis Method, Oxford: Elsevier
  22. Hendrick, K. & Benner, L. (1987), Investigating Accidents with Sequentially Timed and Events Plotting (STEP), New York.: Marcel Dekker
  23. Gordon, R., Flin, R. & Mearns, K. (2005), 'Designing and evaluating a human factors investigation tool(HFIT) for accident analysis', Safety Science, 43, pp.147-171 https://doi.org/10.1016/j.ssci.2005.02.002
  24. SIEP (2004), 'Managing rule-breaking The Toolkit', Rijsvijk, Netherlands: Shell International Exploration and Production B.V