Journal of the Ergonomics Society of Korea (대한인간공학회지)

Ergonomics Society of Korea (대한인간공학회)
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Needs for Changing Accident Investigation from Blaming to Systems Approach

  • Kee, Dohyung (Department of Industrial and Management Engineering, Keimyung University)
  • Received : 2016.02.21
  • Accepted : 2016.05.04
  • Published : 2016.06.30
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Abstract

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.

Keywords

References

  1. Belmonte, F., Schoen, W., Heurley, L. and Capel, R., Interdisciplinary safety analysis of complex socio-technological systems based on the functional resonance accident model: An application to railway traffic supervision, Reliability Engineering & System Safety, 96(2), 237-249, 2011. https://doi.org/10.1016/j.ress.2010.09.006
  2. BAI (Board of Audit and inspection of Korea), Status on Audit progress, 2014.
  3. Bird, F., Management guide to loss control, Institute Press, Atlanta, GA, 1974.
  4. Branford, K., Seeing the big picture of mishaps: Applying the AcciMap approach to analyze system accidents, Aviation Psychology and Applied Human Factors, 1(1), 31-37, 2011. https://doi.org/10.1027/2192-0923/a00005
  5. Chosun-Ilbo(a), PM Chung resigned, http://news.chosun.com/site/data/html_dir/2014/04/28/2014042801155.html (retrieved February 15, 2016).
  6. Chosun-Ilbo(b), Critics saying that president should step down, http://news.chosun.com/site/data/html_dir/2014/04/29/2014042900055.html (retrieved February 15, 2016).
  7. Chosun-Ilbo(c), Do not forget, http://news.chosun.com/site/data/html_dir/2014/05/09/2014050903758.html (retrieved February 15, 2016).
  8. Chosun-Ilbo(d), National Intelligence Service intervened illegal Sewol expansion, http://news.chosun.com/site/data/html_dir/2014/07/25/2014072503031.html (retrieved February 15, 2016).
  9. Chosun-Ilbo(e), Parliamentary passage of Sewol special law, http://news.chosun.com/site/data/html_dir/2014/11/08/2014110800252.html (retrieved February 15, 2016).
  10. Chosun-Ilbo(f), Searching for missing of Sewol finished, http://news.chosun.com/site/data/html_dir/2014/11/11/2014111101158.html (retrieved February 15, 2016).
  11. Cook, R.I., Woods, D.D. and Miller, C., A tale of two stories: Contrasting views of patient safety, National Health Care Safety Council of National Patient Safety Foundation at the AMA, 1998.
  12. Donga-Ilbo, When reporting disaster, priority should be given to accuracy rather than speed, (retrieved February 15, 2016).
  13. Elliott, D., The failure of organizational learning from crisis - A matter of life and death?, Journal of Contingencies and Crisis Management, 17(3), 157-168, 2009. https://doi.org/10.1111/j.1468-5973.2009.00576.x
  14. Elliott, D. and Macpherson, A., Policy and practice: Recursive learning from crisis, Group & Organization Management, 35(5) 572-605, 2010. https://doi.org/10.1177/1059601110383406
  15. Elliott, D. and Smith, D., Cultural readjustment after crisis: Regulation and learning from crisis within the UK soccer industry, Journal of Management Studies, 43(2), 289-317, 2006. https://doi.org/10.1111/j.1467-6486.2006.00591.x
  16. Hollnagel, E., Barriers and accident prevention, Akdershot: Ashgate Publishing Limited, 2004.
  17. Hollnagel, E. and Goteman, O., The functional resonance accident model, In. Cognitive System Engineering in Process Control, 2004.
  18. Heinrich, H.W., Petersen, D. and Roos, N., Industrial accident prevention: A safety management approach (5th ed.), New York, McGraw-Hill, 1980.
  19. Herrera, I.A. and Woltjer, R., Comparing a multi-linear (STEP) and systemic (FRAM) method for accident analysis, Reliability Engineering & System Safety, 95(12), 1269-1275, 2010. https://doi.org/10.1016/j.ress.2010.06.003
  20. Jenkins, D.P., Salmon, P.M., Stanton, N.A. and Walker, G.H., A systemic approach to accident analysis: A case study of the Stockwell shooting, Ergonomics, 53(1), 1-17, 2010. https://doi.org/10.1080/00140130903311625
  21. Johnson, C.W. and Muniz de Almeida, I., Extending the borders of accident investigation: applying novel analysis techniques to the loss of the Brazilian space launch vehicle VLS-1 V03, Safety Science, 46(1), 38-53, 2008. https://doi.org/10.1016/j.ssci.2006.05.007
  22. Johnson, C.W. and Holloway, C.M., The ESA/NASA SOHO mission interruption: Using the STAMP accident analysis technique for a software related 'mishap', Software: Practice and Experience 33(12), 1177-1198, 2003. https://doi.org/10.1002/spe.544
  23. Leveson, N., A new accident model for engineering safer systems, Safety Science, 42(4), 237-270, 2004. https://doi.org/10.1016/S0925-7535(03)00047-X
  24. Monthly Chosun, 10th anniversary of Daegu Subway fire disaster, http://monthly.chosun.com/client/news/viw.asp?ctcd=C&nNewsNumb=201302100027 (retrieved February 15, 2016).
  25. Murray, S., A proposed technique to identify human and organisational factors in accident investigations in the marine industry, unpublished Master Thesis, School of the Built Environment, Heriot-Watt University, 2013.
  26. Rasmussen, J., Risk management in a dynamic society: A modelling problem, Safety Science, 27, 183-213, 1997. https://doi.org/10.1016/S0925-7535(97)00052-0
  27. Rasmussen, J. and Svedung, I., Proactive risk management in a dynamic society Karlstad, Sweden, Swedish Rescue Services Agency, 2000.
  28. Reason, J., Human error, New York, Cambridge University Press, 1990.
  29. Reason, J., A systems approach to organizational error, Ergonomics, 38, 1708-1721, 1995. https://doi.org/10.1080/00140139508925221
  30. Roed-Larson, S., Valvisto, T., Harms-Ringdahl, L. and Kirchsteiger, C., Accident investigation practices in Europe-main responses from a recent study of accidents in industry and transport, Journal of Hazardous Materials, 111, 7-12, 2004. https://doi.org/10.1016/j.jhazmat.2004.02.008
  31. Salmon, P., Williamson, A., Lenne, M., Mitsopoulos-Rubens, E. and Rudin-Brown, CM., Systems-based accident analysis in the led outdoor activity domain: application and evaluation of a risk management framework, Ergonomics, 53(8), 927-939, 2010. https://doi.org/10.1080/00140139.2010.489966
  32. Salmon, P.M., Cornelissen, M. and Trotter, M.J., Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP, Safety Science, 50, 1158-1170, 2012. https://doi.org/10.1016/j.ssci.2011.11.009
  33. Shappell, S.A. and Wiegmann, D.A., The human factors analysis and classification system-HFACS, U.S. Department of Transportation, Federal Aviation Administration, 2000.
  34. Svedung, J. and Rasmussen, J., Graphic representation of accident scenarios: mapping system structure and the causation of accidents, Safety Science, 40, 397-417, 2002. https://doi.org/10.1016/S0925-7535(00)00036-9
  35. Turner, B.A., Man-made disasters, Wykeham Publications, London, 1978.
  36. Vicente, K.J. and Christoffersen, K., The Walkerton E. coli outbreak: A test of Rasmussen's framework for risk management in a dynamic society, Theoretical Issues in Ergonomics Science, 7(2), 93-112, 2006. https://doi.org/10.1080/14639220500078153
  37. Waterson, P., A systems ergonomics analysis of the Maidstone and Tunbridge Wells infection outbreaks, Applied Ergonomics, 52(10), 1196-1205, 2009. https://doi.org/10.1080/00140130903045629
  38. Wikipedia homepage, hindsight bias, https://en.wikipedia.org/wiki/Hindsight_bias (retrieved February 16, 2016).
  39. Woo, D.M. and Vicente, K.J., Sociotechnical systems, risk management, and public health: Comparing the North Battleford and Walterton outbreaks, Reliability Engineering and System Safety, 80, 253-269, 2003. https://doi.org/10.1016/S0951-8320(03)00052-8