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Comparison of Systemic Accident Investigation Techniques Based on the Sewol Ferry Capsizing

  • Kee, Dohyung (Department of Industrial and Management Engineering, Keimyung University)
  • Received : 2017.08.22
  • Accepted : 2017.09.16
  • Published : 2017.10.31

Abstract

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.

Keywords

References

  1. Branford, K., Seeing the big picture of mishaps: applying the AcciMap approach to analyze system accidents, Aviation Psychology and Applied Human Factors, 1(1), 31-33, 2011. https://doi.org/10.1027/2192-0923/a00005
  2. Cassano-Piche, A.L., Vicente, K.J. and Jamieson, G.A., A test of Rasmussen's risk management framework in the food safety domain:BSE in the UK, Theoretical Issues in Ergonomics Science, 10(4), 283-304, 2009. https://doi.org/10.1080/14639220802059232
  3. FRAM, A brief instruction to the FRAM, http://functionalresonance.com/brief-introduction-to-fram/index.html (retrieved August 15, 2017).
  4. Hollnagel, E., Barriers and Accident Prevention, Ashgate, Aldershot, UK, 2004.
  5. Hollnagel, E. and Goteman, O., The functional resonance accident model. In Cognitive System Engineering in Process Control 2004, CSEPC, 155-161, 2004.
  6. Ka, D.H., Application of functional resonance analysis method for analyzing combined system accidents, unpublished master thesis, KAIST, 2017.
  7. Kee, D., Needs for changing accident investigation from blaming to systems approach, Journal of the Ergonomics Society of Korea, 34(1), 45-62, 2106. https://doi.org/10.5143/JESK.2015.34.1.45
  8. Kee, D., Jun, G.T., Waterson, P. and Haslam, R., A systemic analysis of South Korea Sewol ferry accident: Striking a balance between learning and accountability, Applied Ergonomics, 59, 504-516, 2017. https://doi.org/10.1016/j.apergo.2016.07.014
  9. Kim, T-E., Nazir, S. and Overgard, K.I., A STAMP-based causal analysis of the Korean Sewol ferry accident, Safety Science, 83, 93-101, 2016. https://doi.org/10.1016/j.ssci.2015.11.014
  10. Korean Maritime Safety Tribunal (KMST), Safety Investigation Report, Korean Maritime Safety Tribunal, 2014.
  11. Kwon, Y., System theoretic safety analysis of the Sewol-Ho ferry accident in South Korea, unpublished doctoral thesis, MIT, 2016.
  12. Lee, S., Moh, Y.B., Tabizadeh, M. and Meshkati, N., Applying the AcciMap methodology to investigate the tragic Sewol Ferry accident in South Korea, Applied Ergoonmics, 59, 517-525, 2017. https://doi.org/10.1016/j.apergo.2016.07.013
  13. 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
  14. Leveson, N.G., Engineering a Safer World: Systems Thinking Applied to Safety, MIT Press, USA, 2011.
  15. Rasmussen, J., Risk management in a dynamic society: a modelling problem, Safety Science, 27(2-3), 183-213, 1997. https://doi.org/10.1016/S0925-7535(97)00052-0
  16. Rasmussen, J. and Svedung, I., Proactive Risk Management in a Dynamic Society, first ed. Raddningsverket, Risk and Environmental Department. Swedish Rescue Services Agency, Karlstad, Sweden, 2000.
  17. Salmon, P.N., 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
  18. Salmon, P.N., Lenne, W.M., Mitsopoulos-Rubens, E. and Rudin-Brown, C.M., Systems-based analysis in the led outdoor activity domain: application of a risk management framework, Ergonomics, 53(8), 927-939, 2010. https://doi.org/10.1080/00140139.2010.489966
  19. Svedung, I. 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
  20. Underwood, P. and Waterson, P., Accident analysis models and methods: Guidance for safety professionals, Loughborough University, 2013a.
  21. Underwood, P. and Waterson, P., Systemic accident analysis: Examining the gap between research and practice, Accident Analysis and Prevention, 55, 154-164, 2013b. https://doi.org/10.1016/j.aap.2013.02.041
  22. Victor, P. and Carvalho, R.D., The use of Functional Resonance Analysis Method (FRAM) in a mid-air collision to understand some characteristics of the air traffic management system resilience, Reliability Engineering and System Safety, 96, 1482-1498, 2011. https://doi.org/10.1016/j.ress.2011.05.009