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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.
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.
목차
1. Introduction
2. Systemic Techniques
3. Method
4. Results
5. Discussion
6. Conclusions
References
참고문헌 (22)
참고문헌 신청
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.
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.
FRAM, A brief instruction to the FRAM, http://functionalresonance.com/brief-introduction-to-fram/index.html (retrieved August 15, 2017).
Hollnagel, E., Barriers and Accident Prevention, Ashgate, Aldershot, UK, 2004.
Hollnagel, E. and Goteman, O., The functional resonance accident model. In Cognitive System Engineering in Process Control 2004, CSEPC, 155-161, 2004.
Hollnagel, E. and Goteman, O., The functional resonance accident model. In Cognitive System Engineering in Process Control 2004, CSEPC, 155-161, 2004.
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