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A systemic analysis of South Korea Sewol ferry accident – Striking a balance between learning and accountability

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Abstract

The South Korea Sewol ferry accident in April 2014 claimed the lives of over 300 passengers and led to criminal charges of 399 personnel concerned including imprisonment of 154 of them as of Oct 2014. Blame and punishment culture can be prevalent in a more hierarchical society like South Korea as shown in the aftermath of this disaster. This study aims to analyse the South Korea ferry accident using Rasmussen's risk management framework and the associated AcciMap technique and to propose recommendations drawn from an AcciMap-based focus group with systems safety experts. The data for the accident analysis were collected mainly from an interim investigation report by the Board of Audit and Inspection of Korea and major South Korean and foreign newspapers. The analysis showed that the accident was attributed to many contributing factors arising from front-line operators, management, regulators and government. It also showed how the multiple factors including economic, social and political pressures and individual workload contributed to the accident and how they affected each other. This AcciMap was presented to 27 safety researchers and experts at 'the legacy of Jens Rasmussen' symposium adjunct to ODAM2014. Their recommendations were captured through a focus group. The four main recommendations include forgive (no blame and punishment on individuals), analyse (socio-technical system-based), learn (from why things do not go wrong) and change (bottom-up safety culture and safety system management). The findings offer important insights into how this type of accident should be understood, analysed and the subsequent response.

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... STCW 1978 is related to the SPA and SA Korean laws. Rapid movement of the ship using the rudder at big angles [32,33,56,57], the lack of swift decision-making ability of the captain [33], an inappropriate response by the ship's crew during an emergency [32,56,58], and a lack of understanding of the structural constraints of the car carrier were identified as the causes of the accident [33]. These causes are related to the seafarers' ability and education. ...
... STCW 1978 is related to the SPA and SA Korean laws. Rapid movement of the ship using the rudder at big angles [32,33,56,57], the lack of swift decision-making ability of the captain [33], an inappropriate response by the ship's crew during an emergency [32,56,58], and a lack of understanding of the structural constraints of the car carrier were identified as the causes of the accident [33]. These causes are related to the seafarers' ability and education. ...
... The previous studies recognized the following as the causes of the accident: an inexperienced third officer's conning the vessel and helmsman's poor steering [32], cargo overloading [32][33][34]57], a lack of ballast water loading [32,34,56,57], poor cargo securing [32,33,56,57], an improper management system in the shipping company that violated regulations [32][33][34]56], structural problems in the vessel operation manager (VOM) resulting in superficial pre-departure checks [32][33][34]56], and lax SMS [32,56]. In other words, the accident was due to the negligence of safety management by the passenger transportation services provider (PTSP) and inherent problems in the overall coastal passenger ship SMS. ...
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... Similar to instances of terrorism increasing the American public's support of punitive policies, the Sewol Ferry Sinking on 16 April 2014, which occurred during the early stage of data collection for the present study, could have complicated the relationship between South Korean crime perception and attitudes towards the death penalty. A ferry carrying 476 people capsized and sank off the south-west coast of South Korea; the incident ended with over 300 people dead, missing, or injured (Kee, Jun, Waterson, & Haslam, 2017;Woo, Cho, Shim, Lee, & Song, 2015). The South Korean public watched the situation through live broadcasts and have been exposed to the scene of human errors and violations repeatedly (Kee et al., 2017;Woo et al., 2015). ...
... A ferry carrying 476 people capsized and sank off the south-west coast of South Korea; the incident ended with over 300 people dead, missing, or injured (Kee, Jun, Waterson, & Haslam, 2017;Woo, Cho, Shim, Lee, & Song, 2015). The South Korean public watched the situation through live broadcasts and have been exposed to the scene of human errors and violations repeatedly (Kee et al., 2017;Woo et al., 2015). The public blamed individuals who were directly responsible for the disaster as well as the South Korean government that showed overall weaknesses in crisis management (Kee et al., 2017;Yap, 2014). ...
... The South Korean public watched the situation through live broadcasts and have been exposed to the scene of human errors and violations repeatedly (Kee et al., 2017;Woo et al., 2015). The public blamed individuals who were directly responsible for the disaster as well as the South Korean government that showed overall weaknesses in crisis management (Kee et al., 2017;Yap, 2014). The lack of government success in times of past crises may have resulted in concerns for public safety and decreased the level of trust of government (Kee et al., 2017;Yap, 2014). ...
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As of this writing, South Korea (officially, the Republic of Korea) is an abolitionist-in-practice nation; capital punishment is legal, but no death sentences have been carried out since a moratorium was enacted in 1997. Public support for the death penalty has decreased over time; however, the factors that determine support for or opposition to the death penalty of the South Korean general public are largely unknown. Using survey data from a nationwide sample of 416 respondents, this study examined the potential predictors for public attitudes towards capital punishment support. A majority of survey respondents (83%) supported the death penalty, a higher percentage than recent surveys of the South Korean general public. The deterrence and retribution perspectives were positively related to death penalty support, while crime severity, neighbourhood safety, the brutalisation effect, and innocence were negatively related. This study provides the first multivariate analysis of factors associated with South Korean attitudes towards the death penalty.
... In cognitive engineering and safety science, Rasmussen's (1997) risk management framework has been applied in several in-depth analyses of large-scale accidents. They include such diverse events as the Walkerton E. Coli outbreak in Canada (Vicente & Christoffersen, 2006), the Flash Crash of May 6 2010 in US financial markets (Minotra & Burns, 2016), the alarming rate of mishaps in road freight transportation in the US (Newnam & Goode, 2015), the spread of beef contamination in the UK (Cassano-Piche, Vicente, & Jamieson, 2009), the Sewol ferry accident in South Korea (Kee, Jun, Waterson, & Haslam, 2017), and the police shooting of an innocent man in South London (Jenkins, Salmon, Stanton, & Walker, 2010). ...
... These generalizable findings can be used towards making decisions to prevent similar accidents from occurring. An associated technique, AcciMap, can be used in the analysis to display relationships in a diagram and communicate about the results of the analysis succinctly in a multidisciplinary team (Jenkins et al., 2010;Kee et al., 2017). However, accident analysts are sometimes interested in identifying accountable actors and their relationships in the context of the events leading to the accident. ...
... However, accident analysts are sometimes interested in identifying accountable actors and their relationships in the context of the events leading to the accident. According to a study by Kee et al. (2017) on the South Korean Sewol ferry accident that took the lives of over 300 passengers, Rasmussen's framework and the AcciMap technique provide a broader picture of an accident, balancing individual accountability with the systemic factors associated with systematic migrations in work practices over time. In the analysis of an accident with Rasmussen's framework, all levels in a sociotechnical system should be given attention. ...
Conference Paper
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Human-automated systems are becoming ubiquitous in our society, from the one-on-one interactions of a driver and their automated vehicle to large-scale interactions of managing a world-wide network of commercial aircraft. Realizing the importance of effectively governing these human-automated systems, there been a recent renaissance of legal-ethical analysis of robotics and artificial-intelligence-based systems. As cognitive engineers, we authored this paper to embrace our responsibility to support effective governance of these human-automated systems. We believe that there are unique synergies between the cognitive engineers who shape human-automated systems by designing the technology, training, and operations, and the lawyers who design the rules, laws, and governance structures of these systems. To show how cognitive engineering can provide a foundation for effective governance, we define and address five essential questions regarding human-automated systems: 1) Complexity: What makes human-automation systems complex? 2) Definitions: How should we define and classify different types of human-autonomous systems? 3) Transparency: How do we determine and achieve the right levels of transparency for operators and regulators? 4) Accountability: How should we determine responsibility for the actions of human-automation systems? 5) Safety: How do human-automated systems fail? Our answers, drawn from the diverse domains related to cognitive engineering, show that care should be taken when making assumptions about human-automated systems, that cognitive engineering can provide a strong foundation for legal-ethical regulations of human-automated systems, and that there is still much work to be done by lawyers, ethicists, and technologists together.
... The aim of the present study was to assess the reliability and validity of Accimap and STAMP based on four studies which analyzed the same accident. Two studies applied Accimap (Kee et al., 2016;Lee et al., 2016), while of the other two one applied STAMP (Kim et al., 2016;Kwon, 2016). Three studies were published in peer-reviewed journals (Kee et al., 2016;Kim et al., 2016;Lee et al., 2016) and the final one was an MSc dissertation (Kwon, 2016). ...
... Two studies applied Accimap (Kee et al., 2016;Lee et al., 2016), while of the other two one applied STAMP (Kim et al., 2016;Kwon, 2016). Three studies were published in peer-reviewed journals (Kee et al., 2016;Kim et al., 2016;Lee et al., 2016) and the final one was an MSc dissertation (Kwon, 2016). In order to compare the studies employed a categorization framework (section 2.1) in order to facilitate the analysis of reliability and validity. ...
... In nuclear, most of the documents at HF are published after the 2000s and the term HF more referred as a usability, human-machine interface, and system-design issue (IAEA, 2006), than as a theory or tool to renew overall safety culture. p0330 Not only practical needs and the stated normative basis but also statements by several scientists during several years has put pressure to rethink safety practices and the HF role in those (Waterson and Kolose, 2010;Dekker, 2015;Hollnagel et al., 2006;Hollnagel, 2014;Kee et al., 2016;Lee et al., 2017). p0335 These needs raised by scientists are listed with some modifications, as follows: o0050 1. ...
... p0645 A recommended way of using the HF Tool in NPPs would be also to make a preliminary investigation by some safety expert-or HF group, which then would be further evaluated by a wider focus group, that is, larger expert and operative group by plant operations, HR, occupational health and safety and line organization. This kind of "iterative investigation" was tested in Ferry Sewol accident as a practice case (Kee et al., 2016). s0090 2.3.3.4 ...
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Application of human factors (HF) into nuclear safety management is required already for a while. However, the conception of HF is often misunderstood as individual- and error-based actions, separated from its context and applied narrowly countering the original purpose of HF. Safety paradigm has shifted focus from risks to resources, but it can be questioned if the practical HF applications have been efficient for realizing the philosophy. This chapter gives a theoretical view of HF and practical tools for applying HF in nuclear power, by using HF Tool with a holistic, solution-based and participative view, aligning current safety thinking. HF application at strategic, tactical, and operative level of the organization is opened. The core intention is to give an overview of HF as a theoretical and practical way to give new perspective to nuclear safety management, by empowering people as a positive resource for improving safety.
... Kim, Nazir and Øvergå rd [21] analyzed this accident by the Systems-Theoretic Accident Model and Processes (STAMP) model. Kee, Jun, Waterson and Haslam [22] and Lee, Moh, Tabibzadeh and Meshkati [23] studied the accident by applying Rasmussen's risk management framework and associated AcciMap method. These papers investigated the causes of this accident systematically and made recommendations for further accident prevention, and highlighted the importance of establishing safety information systems of a major accident, which integrate piecemeal information, to assist decision making and continuous risk monitoring. ...
... From several studies of the accident [20][21][22][23]30] and accident investigation reports [28], the main causes of the capsizing includes the sharp turn, reduced inherent stability, overloaded cargo, unsecured cargo and discharged ballast water. When the investigations go deeper, it becomes clearer that information about these causes could have been identified and understood by different persons before the accident occurred. ...
Conference Paper
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The purpose of this paper is to investigate the possibilities of predicting conditions of accident through a study of MV Sewol accident. A capsizing accident model is developed and relevant information is investigated and connected to the accident model to evaluate whether if those indications were available before the accident, making it possible to foresee that the accident would happen. According to Turner's man-made disaster theory, there is an incubation period before an accident occurs. During this period, events accumulate and information spreads out to various places but stay unnoticed. This study is based on Turner's theory and has investigated relevant information, the information holders and the time when the information becomes available. Afterwards, the collected information is integrated into the developed accident model to see whether the accident could have been foreseen. Hence, this study will help in operational risk monitoring and support the concept of preventing accident by measuring, monitoring and controlling the conditions for accidents.
... The event chain is triggered by the first 'root cause' (e.g., unsafe human behavior and equipment failure) (Leveson 2004(Leveson , 2011Underwood, Waterson, and Braithwaite 2016;Zhang et al. 2016b). After an accident, the person with unsafe behaviors is often blamed and punished, while the factors at the system level are seldom investigated (Kee et al. 2017;Underwood, Waterson, and Braithwaite 2016). ...
... Previous pieces of evidence argue that accident investigation should not highlight the operators' unsafe behaviors that triggered the accident directly (Shappell and Wiegmann 2001), but on mechanisms that provide conditions for unsafe behaviors in the dynamic complex system (Kee et al. 2017). Several accident models, such as human factors analysis and classification system (HFACS) (Shappell and Wiegmann 2001), systems theoretic accident model and process (STAMP) (Leveson 2004(Leveson , 2011, and AcciMap (Rasmussen 1997), have been developed on the basis of systematic analysis and investigation of accidents in the past three decades (Goode et al. 2017;Kazaras, Kirytopoulos, and Rentizelas 2012;Kim, Nazir, and Øvergård 2016;Leveson 2013;Ouyang et al. 2010;Salmon, Cornelissen, and Trotter 2012;Underwood and Waterson 2014). ...
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The ‘8.12’ Tianjin Port fire and explosion are an extraordinarily major accident that involved hazardous chemicals, resulting in 165 fatalities, 798 injuries, and a direct economic loss of 6.866 billion yuan. This study introduced causal analysis based on systems theoretic accident model and process (STAMP) (CAST) to identify the key controllers in the control structure, and the control and feedback relationships among them. By using CAST, this study not only identified the traditional human and organizational factors within the physical company which are responsible for the operation process, but also identified the outside factors within the public political structure which are responsible for the public safety and security. In this study, the safety and security of hazardous chemical accident are integrated into a unified framework in which the key difference between safety and security in the intention of the actors is reframed as a general loss prevention problem. This study shows the applicability of the CAST approach in the analysis of hazardous chemical accidents and provides different perspectives and methods to develop safety and security interventions in a hazardous chemical accident.
... In particular, the sunken ferry Sewol accident was a VTS operator missing early detection. The VTS operators ignored the service regulation that two operators should be at work simultaneously; one has to monitor the coastal sea and the other to monitor the open sea [8,9]. Meanwhile, it was found that variables such as short and irregular meals and work overload due to lack of VTS operator staffing were correlated with job stress [10]. ...
... This leads to a problem that the current VTS operator may not prevent marine accidents due to failure to provide timely safety information. In addition, in the event of a marine accident during traffic congestion, the time to recognize the situation for the VTS operator may be long enough to delay the initial response [8,9]. ...
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Vessel traffic volume and vessel traffic service (VTS) operator workloads are increasing with the expansion of global maritime trade, contributing to marine accidents by causing difficulties in providing timely services. Therefore, it is essential to have sufficient VTS operators considering the vessel traffic volume and near-miss cases. However, no quantitative method for determining the optimal number of workstations, which is necessary for calculating the VTS operator staffing level, has yet been proposed. This paper proposes a new, microscopic approach for calculating the number of workstations from vessel trajectories and voice recording communication data between VTS operators and navigators. The vessel trajectory data are preprocessed to interpolate different intervals. The proposed method consists of three modules: Information services, navigational assistance services, and traffic organization service. The developed model was applied to the Yeosu VTS in Korea. Another workstation should be added to the current workstation based on the proposed method. The results showed that even without annual statistical data, a reasonable VTS operator staffing level could be calculated. The proposed approach helps prevent vessel accidents by providing timely services even if the vessel traffic is congested if VTS operators are deployed to a sufficient number of workstations.
... Secondly, the three accidents occurred in China, Korea, and Thailand, respectively, and they are all located in the Asian region with similar social contexts. After the capsizing of Eastern Star and Sewol, several scholars conducted detailed analysis on the accident causes [18][19][20][21]. However, few researchers conducted a comparative analysis on the causes of the three major maritime accidents. ...
... Furthermore, the three accidents verified the importance of safety training. Taking the Sewol accident for example, more than half of the crew members on the Sewol were informal workers, and the Cheonghaejin company did not provide adequate training for them [18]; thus, the crew on board did not provide immediate and accurate actions during emergency; additionally, the rescue workers provided poor initial rescue operation due to the lack of adequate training and climbing equipment [19]. In addition, violations in supervision were also key contributing factors in the three accidents, which increased the possibility of accidents to some extent. ...
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Maritime safety is a significant topic in the maritime industry since the numerous dangers at sea could lead to loss of property, environmental pollution, and even casualties. Existing research illustrates that human factors are the primary reasons of maritime accidents. Indeed, numerous maritime accidents can be classified into different types of human factors. In this context, the Human Factors Analysis and Classification System for Maritime Accidents (HFACS-MA) model is introduced in this paper. The HFACS-MA framework consists of five levels, complying with the core concepts of HFACS and the guiding principles of the International Maritime Organization (IMO). Based on the five levels of the framework, this research explores the underlying causes of Chinese Eastern Star, Korean Sewol, and Thai Phoenix accidents, and a comparative analysis is conducted. The analysis demonstrates the utility of applying the HFACS-MA model to the maritime industry, and the results emphasize the importance of the following categories: legislation gaps, organizational process, inadequate supervision, communication (ships and VTS), decision errors, and so on. Consequently, the research enables increased support for HFACS-MA and its application and provides valuable information for safety management and policy development in the maritime industry at different levels.
... Analyzing accidents from a global perspective and background can avoid unfair blame on frontline operators [46,47]. The AcciMap model usually consists of six levels: government policy, regulatory bodies and associations, company management, technical and operational management, processes and actor activities, and equipment and surroundings. ...
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The melting of Arctic Sea ice has significantly facilitated Arctic shipping. However, such increased shipping has brought about higher maritime accidents in Arctic waters, especially for grounding and fire/explosion accidents. The paper presents a framework for quantitative analysis of the causation of grounding accidents in Arctic shipping by developing an accident map (AcciMap) - Bayesian network (BN) model. First, the potential risk factors for grounding accidents in the Arctic shipping were identified according to 322 maritime accident investigation reports (MAIRs) - 299 global MAIRs of grounding accidents (including 5 in Arctic waters) and 23 MAIRs (except grounding accidents) in Arctic waters and related literature. Consequently, an AcciMap model is developed for describing the evolution of grounding accident scenarios and reflecting the interdependency of the identified risk factors. Then, a probabilistic model is proposed to evaluate the probability and severity of the grounding accident for presenting a convincing justification for risk control options (RCOs). The framework is applied for the quantitative analysis of a cruise ship grounding accident in Arctic waters. Results demonstrate (1) improved understanding of cruise ship grounding risk factors related to government supervision, shipping company management, technical and operational management, unsafe incidents and behaviors, and environmental conditions; (2) quantitative analysis of the evolution of grounding accident and better identification of the critical risk factors; (3) determination of RCOs for risk management in Arctic shipping.
... A system-theoretic, holistic insight has originally been developed to address safety issues regardless organizational levels to which they relate, from top management through individual operators or actuators. By that, control over hazards in each point of the systemʹs structure would be ensured (Kee et al. 2017;Leveson 2011). Within this approach, known as System-Theoretic Accident Model and Process (STAMP), it is not unreliability of particular components of the system in question but inadequacy of interactions between them that leads to accidents. ...
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While a system‐theoretic approach to the safety analysis of innovative socio‐technical systems gains a growing acceptance among academia, safety issues of Maritime Autonomous Surface Ships (MASS) remain largely unexplored. Therefore, we applied a System‐Theoretic Process Analysis to develop and analyze a preliminary model of the unmanned shipping system in order to elaborate safety recommendations for future developers of the actual system. Results indicate that certain advancements shall be undertaken in relation to MASS’ software solutions in particular.
... 1 Many dramatic maritime disasters happened in recent years (e.g. the capsizing of the Princess of Stars in 2008). Some of them have been characterised by the desertion of the ship by the captain before the end of the evacuation process; in 2014 the captain of the Sewol left the ship without issuing an evacuation order, hindering the formal start of the evacuation (Kee et al., 2017). Most of these events were characterised by the captain's inability to manage the emergency and by ineffective decisions; for example, during the emergency of the Oceanos the cruise director reported that many of the officers left the ship before the emergency was over, leaving the passengers without any information about what to do (Allen, 1994). ...
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Despite the increase in regulation and codes, there is a relatively small body of scientific literature on maritime disasters management, especially in terms of human factors that affect the success of the evacuation and safety procedures. This paper provides an analysis of passengers’ behaviour during the Costa Concordia disaster of 2012, in which 32 people died. We use 49 passengers’ witness statements to understand how the evacuation occurred. We examine whether the main factor in reducing the effectiveness of the evacuation procedure was the lack of effective management or the behaviours among evacuees, or a combination of the two. Results of the analysis suggest that passengers reacted with solidarity, helped each other and that such spontaneous and pro-social behaviour possibly contributed to reduce the number of casualties. By contrast, competitive behaviours happened only in relation to specific environmental constraints and were limited to the proximity of safety boats. The deficiencies in command in the Costa Concordia evacuation highlights the need to increase the skills of personnel called to manage an emergency at sea and the need to create ad hoc training programs that consider also unexpected scenarios. Understanding how people (both staff and public) deal with an emergency and the factors that affect their decision is pivotal to help planners to review their strategy, anticipate similar events, and consider all the factors in future plans and regulations. While human error is always a big factor in maritime disaster, its impact can be considered and mitigated with specific procedures and adaptable plans.
... No entanto, a literatura científica internacional apresenta a aplicação do Accimap para investigar acidentes ocorridos nessa atividade. Como exemplo, citamse Lee et al. (2016) e Kee et al. (2016), que aplicaram esse método para investigar um acidente envolvendo um Ferry ocorrido na Coreia do Sul. ...
Article
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This article presents the result of a maritime accident investigation where the systemic approach was used, in which the system as a whole is considered and the accident described as resulting from an uncontrolled relation of its constituent parts. For this, Accimap investigation method was used. The accident occurred in the state of Bahia, when a ship known as Cavalo Marinho I, which carried passengers between the maritime terminals of Salvador and Mar Grande, on the Island of Itaparica, sank and resulted in the deaths of 19 people. Being considered the worst tragedy involving shipping in the state. In the data collection phase, the crew and the owner of the ship were interviewed. There were also analyzes of documents and inspections at the maritime terminals and in vessels similar to those reported. In addition, a crossing was made between the terminals with the commander of Cavalo Marinho I. A map of the accident was constructed, containing 13 contributing factors and the interrelationship between them. Recommendations were presented with the aim of improving the safety of the maritime transport system, such as dredging of the maritime access channel to Mar Grande Beach. It is concluded that the systemic approach allowed to develop a complete picture of how and why the accident occurred and to recommend appropriate measures to prevent that similar accident occurs again.
... Rasmussen's AcciMap is a domain-generic approach and can be easily modified to suit the needs of studies in different context (Scott-Parker et al. 2015). It has been applied to analyze accidents in different domains, such as aerospace (Johnson and Almeida 2008), aviation (Debrincat et al. 2013), agribusiness (Salmon et al. 2014), railway (Salmon et al. 2014, Underwood and Waterson 2014, road transport (Newnam and Goode 2015), and marines (Kee et al. 2016). In the hazardous chemical safety domain, a holistic understanding of hazardous chemical accident can be shown in the following parts. ...
Article
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The aim of this paper is to make a systemic analysis of the China-Tianjin Port Fire and Explosion, the most serious chemicals accident in Chinese history, and reveal the human, organizational, and external factors and their interactions. AcciMap, one of the most popular systems-based accident models, is constructed in this study. A dialed case study of China-Tianjin Port Fire and Explosion was carried out to identify the actors in the accident and the interactions among them. Contributory factors and their interactions which led to the China-Tianjin Port Fire and Explosion directly or indirectly are identified and depicted in six levels from a system perspective. Measures and suggestions from a system perspective were proposed to improve and optimize the performance of the hazardous chemical accident response system. This paper highlights the importance of analyzing accidents from a system perspective and presents a case study in which AcciMap model was applied into the analysis of China-Tianjin Port fire and explosion.
... Most authors categorized the barriers and evaluated the importance of each one in sample of companies from several economic sectors or check the gains from interventions in the technical or technological regime. However, studies of the socio-technical regime for EEI in the industrial sector are scarce, mostly are focused on the households [15][16][17][18], and the interventions on behavioral change, due to methodological issues, have been ineffective [19]. ...
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Generalized renewable energy use and the implementation of energy efficiency are two promising solutions to face global environmental challenges and achieve sustainable development. Government and large enterprises are making efforts in this direction; however, there are bottlenecks to start energy efficiency projects especially in non-intensive energy enterprises (NIEs). The aim of this work is to discuss energy efficiency improvement (EEI) initiatives and analyses a framework proposal to improve the energy efficiency implementation in (NIEs). It was applied the theory of Barrier Model to Energy Efficiency to understand the gap between the levels of opportunities implemented, and what theoretically the industrial sector could achieve. It was found that behavior barriers are relevant to understand the efficiency gap and it is necessary to have an action plan to address them. The analysis has been carried out in the fertilizer industry and the preliminary results demonstrate the advantageous reduction of energy losses.
... This provides elements to review the reliability of the analyses executed in the design method, focusing on obtaining arguments for an inter-subjective agreement of the outcome of these. This is a key issue previously pointed out in the implementation STAMP in Sharples (2017) and Kee et al. (2017). The study points out that in the analyses of the Sewol accident presented in Kwon (2016) and Kim et al. (2016), both analyses utilized STAMP and these have produced two different control structures for ensuring safety within the same context. ...
Article
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Designing maritime safety management systems commonly follows basic processes which focus on fulfilling the demands of the regulations in the industry. This provokes designing systems with limited application which are not capable to efficiently use the guidance contained in regulatory demands, and more importantly, creating systems which are not capable of representing, evaluating, and improving the dynamic management of safety-critical organizations. This article proposes a safety system engineering process for designing maritime safety management systems which is based on the Systems-Theoretic Accident Modelling and Processes (STAMP). This process is applied for sketching the safety management of the Vessel Traffic Services in Finland. The aim is to systematically represent the function of the utilized controls for ensuring the internal VTS safety management and the safety of navigation in Finnish sea areas. The outcome of this study provides a descriptive process of analysis for designing maritime safety management systems. In this process, two other concrete elements are included for supporting the functioning of the safety management system to be designed. First, the adaptation of an identification process for determining key performance indicators for planning, monitoring and evaluating the functioning of the safety management system. Second, the constitution of a performance monitoring tool capable of executing the monitoring, measuring, and updating of the determined key performance indicators and the general functioning of the designed safety management system.
... The two STAMP studies, for example, set out partly to examine the feasibility and appropriateness of using the method in the maritime domain. By contrast, the two Accimap studies were less oriented around the method, but focused more on wider, systemic aspects of the accident and how these contrasted with prevalent ways of viewing accidents in terms of 'blame' (Study 2 - Lee et al., 2017) and the relationship between organisational learning and accountability (study 2 - Kee et al., 2017). Again, it is difficult to be precise about how preconceptions, theoretical preferences and other possible sources of bias may have crept into the four studies, but it is possible that a variation of what Lundberg et al. (2009) called the 'What-you-look-for-iswhat you-find' principle may have been in operation such as the availability of different source data. ...
... For example, the Sewol ferry disaster, which occurred on April 16, 2014, involved a tragic incident in which 304 out of 476 passengers on the ferry drowned. 15,16 Following the 2014 Sewol ferry incident, an amendment to the law assigned responsibility for the control of disaster responses to the Ministry of Public Safety and Security (MPSS). South Korea is divided into 17 regional autonomies and 226 local autonomies. ...
Article
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Objective: The purpose of this study was to determine the key components of Korean disaster psychiatric assistant teams (K-DPATs), to set up new mental health service providing system for the disaster victims. Methods: We conducted an analytic hierarchy process (AHP) involving disaster mental health experts, using a pairwise comparison questionnaire to compare the relative importance of the key components of the Korean disaster mental health response system. In total, 41 experts completed the first online survey; of these, 36 completed the second survey. Ten experts participated in panel meetings and discussed the results of the survey and AHP process. Results: It was agreed that K-DPATs should be independent of the existing mental health system (70.1%), funding for K-DPATs should be provided by the Ministry of Public Safety, and the system should be managed by the Ministry of Health (65.8%). Experts shared the view that K-DPAT leaders would be suitable key decision makers for all types of disaster, with the exception of those involving infectious diseases. Conclusion: K-DPAT, a new model for disaster mental health response systems could improve the insufficiency of the current system, address problems such as fragmentation, and fulfill disaster victims' unmet need for early professional intervention.
... A systemic insight has been proposed so as to address the safety issue on higher organisational levels including operational practices and management policies ensuring that hazards are controlled in each point of the system's structure (Kee et al., 2017;Leveson, 2011;Salmon et al., 2015). In this approach, referred to as System-Theoretic Accident Model and Process (STAMP), it is inadequate interactions between a system's components that lead to accidents. ...
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Unmanned merchant vessels' prototypes are expected to come into operation within a few years. This revolutionary shift in the shipping industry is feared to negatively impact the safety of maritime transportation. Therefore, in order to support future designers of remotely operated merchant vessels system, we applied System-Theoretic Process Analysis (STPA), identifying the most likely safety control structure of the analysed system and investigating it. The aim was to suggest potential ways of increasing the system's safety and to assess the effectiveness of such measures. Results indicate that the implementation of remotely-controlled merchant vessels and, in a wider sense, unmanned ships, and ensuring their safety shall consist of executing various controls on regulatory, organisational and technical plains. Potential effectiveness is evaluated and some recommendations are given on how to ensure the safety of such systems.
... Monthly basis road accident is measured to store the time series data for revealing the future trend. This will help to identify the dissimilar regions of road accidents for providing the trend analysis [12]. This analysis contains 11 leading cities in India for using the dataset. ...
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Road traffic accidents are a ‘global tragedy’ that generates unpredictable chunks of data having heterogeneity. To avoid this heterogeneous tragedy, we need to fraternize and categorize the datasets. This can be done with the help of clustering and association rule mining techniques. As the trend of accidents is increasing throughout the year, agglomerative hierarchical clustering approach is proposed for time series big data for trend analysis. This clustering approach segments the time sequence data into different clusters after normalizing the discrete time sequence data. Agglomerative hierarchical clustering takes the objects with similar properties and groups them together to form the group of clusters. The paradigmatic time sequence (PTS) data for each cluster with the help of dynamic time warping are identified that calculate the closest time sequence. The PTS analyzes various zone details and forms a cluster to report the data. This approach is more useful and optimal than the traditional statistical techniques.
... A variety of SAA methods have been developed since the 1990s include, but are not limited to, Accimap (Rasmussen, 1997), STAMP (Leveson, 2004) and FRAM (Hollnagel, 2004). These methods have been used across a wide variety of industries including: aviation and aerospace industries (Johnson and de Almeida, 2008); led outdoor activities (Salmon et al., 2014); transport (Underwood and Waterson, 2014); patient safety (Waterson, 2009;Canham et al., 2018); the process industries (Tabibzadeh and Meshkhati, 2015); and, marine transportation (Kee et al., 2016;Kim et al., 2016;Lee at al., 2016). ...
Conference Paper
The present study has two main aims: To develop a contributing factor classification framework to support systemic accident investigation in the construction sector and to carry out an assessment of the validity and reliability of the contributing factor classification framework in order to assess its suitability for accident analysis in construction. The classification framework was developed in three phases. The phase 1 involved generating a list of contributing factors from literature review and accident reports. In total 26 articles were reviewed, and 532 accident reports were analysed. Contributing factors were elicited from each. In phase 2, Accimap was selected as framework as well as a set of contributing factors by five experts with more than ten years’ experience with accident investigations in construction domain as federal inspectors. Then each of them was located by the experts into each six levels of the classification framework (government, regulatory body, organisations, technical and operational management, physical process, and equipment, surround and physical environment). Validity and reliability test were carried out in phase 3. In order to do this, five practitioners in construction sector applied classification framework to three real accident that occurred in construction industry. Validity was evaluated comparing to result against those of the expert. Both Inter-rater and intra-rater reliability are assessed. The classification framework presented acceptable validity and reliability evaluation. It has 51 contributing factors distributed across the six level.
... However, in the few cases where an underlying cause was given, the failure to prioritise safety and ethics was the outcome of forces outside an organisation's control, including societal or national norms (e.g. neoliberalism; Behling et al. 2019;Kee et al. 2017), privatisation (Dien et al. 2004), and legislation (Behling et al. 2019). ...
Article
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Organisational culture is assumed to be a key factor in large-scale and avoidable institutional failures (e.g. accidents, corruption). Whilst models such as “ethical culture” and “safety culture” have been used to explain such failures, minimal research has investigated their ability to do so, and a single and unified model of the role of culture in institutional failures is lacking. To address this, we systematically identified case study articles investigating the relationship between culture and institutional failures relating to ethics and risk management (n = 74). A content analysis of the cultural factors leading to failures found 23 common factors and a common sequential pattern. First, culture is described as causing practices that develop into institutional failure (e.g. poor prioritisation, ineffective management, inadequate training). Second, and usually sequentially related to causal culture, culture is also used to describe the problems of correction: how people, in most cases, had the opportunity to correct a problem and avert failure, but did not take appropriate action (e.g. listening and responding to employee concerns). It was established that most of the cultural factors identified in the case studies were consistent with survey-based models of safety culture and ethical culture. Failures of safety and ethics also largely involve the same causal and corrective factors of culture, although some aspects of culture more frequently precede certain outcome types (e.g. management not listening to warnings more commonly precedes a loss of human life). We propose that the distinction between causal and corrective culture can form the basis of a unified (combining both ethical and safety culture literatures) and generalisable model of organisational failure.
... This framework offers serious predictions regarding performance and safety in complex socio-technical systems [46]. AcciMap has been applied by various studies in different industries, such as aerospace [21], aviation [10], agribusiness [46], marine [2,24], railway [46,54], and road transport [35]. ...
Article
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China-Tianjin Port fire and explosion on August 12, 2015, was a major accident that involved hazardous chemicals and resulted in 165 fatalities and 798 injuries. Three-system-based accident models, human factor analysis and classification system (HFACS), AcciMap, and system theoretic accident modeling and process (STAMP), were applied to identify contributory factors and relationships in the accident. The analysis outputs and usage of the three techniques were compared. The three-system accident models show several differences in terms of the emphasis on the models, system structure, classification of contributory factors, and interactions between system components. An important advantage of HFACS is the taxonomic nature, which can be easily applied in practical application. AcciMap provides a clear graphic representation of the causal flow of accidents, which is suitable for academic research. STAMP is suitable for both academic research and practical applications.
... Johnson and De Almeida, 2008;Debrincat et al 2013;Salmon et al 2014;Underwood and Waterson, 2014;Newnam and Goode, 2015;Kee et al 2017;Zhang et al 2018).Fig. 5shows a graphical representation of the AcciMap method. ...
Article
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In an attempt to incorporate human factors into technical failures as accident causal factors, researchers have promoted the concept of human factor analysis. Human factor analysis models seek to identify latent conditions within the system that influence the operator's action to trigger an accident. For an effective application of human factor analysis models, a domain-specific model is recommended. Most existing models are developed with category/subcategory peculiar to a particular domain. This presents challenges and hinders effective application outside the domain developed for. This paper sought to propose a human factor analysis framework for Ghana's mining industry. A comparative study was carried out between three dominated accident causation models and investigation methods in literature; AcciMap, HFACS, and STAMP. The comparative assessment showed that HFACS is suitable for incident data analysis based on the following reason; ease of learning and use, suitability for multiple incident analysis and statistical quantification of trends and patterns, and high inter and intra-coder reliability. A thorough study was done on HFACS and its derivative. Based on recommendations and research findings on HFACS from literature, Human Factor Analysis, and Classification System-Ghana Mining Industry (HFACS-GMI) was proposed. The HFACS-GMI has 4 tiers, namely; External influence/factor, Organisational factor, Local Workplace/Individual Condition and, Unsafe Act. A partial list of causal factors under each tier was generated to serve as a guide during incident coding and investigation. The HFACS-GMI consists of 18 subcategories and these have been discussed. The HFACS-GMI is specific to the Ghanaian Mines and could potentially help in identifying causal and contributing factors of an accident during an incident investigation and data analysis.
... A variety of SAA methods have been developed since the 1990s include, but are not limited to, Accimap (Rasmussen, 1997), STAMP (Leveson, 2004) and FRAM (Hollnagel, 2004). These methods have been used across a wide variety of industries including: aviation and aerospace industries (Johnson and de Almeida, 2008); led outdoor activities (Salmon et al., 2014); transport (Underwood and Waterson, 2014); patient safety (Waterson, 2009;Canham et al., 2018); the process industries (Tabibzadeh and Meshkhati, 2015); and, marine transportation (Kee et al., 2016;Kim et al., 2016;Lee at al., 2016). ...
Article
Construction industry is still one of the most dangerous industries and its fatal work injuries is almost three times higher than the average across all sectors. Previous researchers have attempted to apply more systemic models and methods to improve accident analysis in construction, but few studies have fully encompassed upstream factors such as decisions and actions at the level of the government and regulator in accident analysis. More importantly, no previous study has evaluated the validity and reliability of systemic accident analysis methods in construction. The present study, therefore, has two main aims: to develop a contributing factor classification framework to support systemic accident investigation in construction and to carry out an assessment of its validity and reliability. The classification framework was developed and assessed in two phases. The phase one involved generating a list of contributing factors from the review of 26 articles and the analysis of 532 construction accident reports. Five federal inspectors with expertise in accident investigation were involved in refining the list into 61 contributing factors and categorizing them into six levels of the Accimap framework. The phase two involved in assessing the validity and reliability of the framework with five practitioners in construction sector using three real construction accidents. This study contributes to the development of a contributing factors classification system framework for construction with acceptable validity and reliability.
... However the most tragic accident strictly related to a rapid turn was the disaster of Sewol ferry in 2014 with the death toll stood at 294 (Kee et al., 2017). ...
Conference Paper
The only formal stability-related requirement referring to a turning maneuver of a ship results from the IS Code and its application is limited to passenger ships only. The goal of the adopted criterion is to prevent an excessive angle of heel in turn. Likewise, the remaining prescriptive criteria, this one is simply based on the concept of a threshold that must not be exceeded. In this case, the angle of heel should remain below 10 degrees. The heel evaluation is based on a straightforward static moments balance model, which is obtained with the use of GZ curve, without consideration of any dynamic effects. At the same time, according to COLREG convention, a ship collision evasive action typically consists of the turn to starboard, occasionally even quite hard turn, if necessary. Thus, the ship heel in turns is unavoidable and the dynamics-related component adds up to the static one, potentially resulting in excessive asymmetric dynamic heeling. Such a maneuver, if undertaken rapidly, may be risky since its aftermath might be serious which is revealed by accidents evidence, e.g., the disaster of Sewol ferry in 2014 with the death toll stood at 294. Inspired by the SGISC philosophy we conducted the first stage of investigation on determination of the dynamic angle of heel in turns, with the view on a potential future extension of the list of stability failures covered by the SGISC. A series of ship motion simulations was carried out in order to identify whether the simple GZ-based criterion may be found adequate. The simulations accounted for both the maneuverability and stability characteristics of a sample ship. The up-to-date 6DoF ship dynamics model was utilized to enable covering major deficiencies of the possibly oversimplified static approach. The contemporary IS Code recommended criterion outcome for a large passenger ship was compared to the results of numerous simulations performed for turns in calm water. A proposal of the criterion modification that has been submitted in 2013 in the document SDC 1/14/1 was included for the comparison as well. The main intended objective of this article is to initiate a discussion on the possible future modification of the stability during turning criterion. This issue is pretty much in line with the ship design process but all the more relevant to day-today navigation since collision avoidance, and thus turning at high speed, is unavoidable in the course of a routine operation.
... Though the annual number of ships and boats involved in maritime accidents-ranging from 818 to 1,197 had never shown any significant decrease from 2009 to 2013, for example, the KCG allocated only 1.86 percent of its total annual budget in 2014 and only 8.7 percent of its newly added personnel during the 2006-2014 period for the purpose of rescue operations, not to mention its provision of insufficient rescue tools and devices, including the failure to provide a helicopter devoted to rescue activities (Lim, 2014). Furthermore, the KCG has never implemented organization-wide rescue drills and exercises for improving its skills for rescue operations in emergency situationsits annual drills were mostly dedicated to strengthening its maritime security and policing activities (Kee, Gyuchan, Patrick, & Haslam, 2017). ...
Article
The Sewol ferry accident, occurring in the ocean in South Korea on April 16, 2014, resulted in the loss of 304 lives. Some argue that one of the primary reasons for such an excessive death toll was because the post-disaster rescue operations led by the Korea Coast Guard (KCG) were neither timely nor efficient and effective. In this study, we attempt to understand whether there was any systemic cause behind such an unsuccessful disaster response on the part of the KCG. In doing so, we analyze the KCG's aptitudes, attitudes, and behaviors vis-à-vis its rescue operations in the broader context of Sewol ferry disaster management, while utilizing the classic theories of bureaucratic accountability. We conclude this research by arguing that the KCG was more concerned about hierarchical, political, and legal accountability than professional accountability in the midst of the accident, and discuss theoretical and practical ramifications of our findings. © 2017 Policy Studies Organization.
... With the Sewol ferry disaster in 2014, problems related to social disasters and corruption became social issues. Studies have been conducted in various fields on the Sewol ferry disaster and social disasters, but no in-depth analysis through literary works has been conducted (Huh et al. 2017;Chae et al. 2018;Kee et al. 2017). ...
Article
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The main purpose of this study is to clarify the difference in disaster resilience between survivors and victims’ families by analyzing the language used in popular literature on disaster cases. The results showed that there were differences in emotions, behaviors, attitudes, role perceptions, etc., between survivors and victims’ families in dealing with a disaster. In particular, survivors remember and think about the situation that occurred at the time of the disaster, which creates resilience to the incident, while victims’ families attempt to establish resilience to the incident by investigating the facts and government countermeasures. While survivors were focused on building their own resilience, victims’ families were more focused on improving government countermeasures to prevent such accidents from recurring. This can be considered as social or national resilience. Based on this comparative analysis, it is necessary to prepare various theoretical foundations for disaster preparedness and resilience, while further elaborating the theory.
... AcciMap has been applied to a number of studies in a broad range of fields: recent case studies have been carried out in the maritime (Kee et al., 2016;Lee et al., 2016), aviation (Debrincat et al., 2013), railway (Underwood and Waterson, 2014), and food industries (Nayak and Waterson, 2016), in outdoor recreation (Salmon et al., 2012) and emergency response services (Salmon et al., 2014). Waterson et al. (2016) have also written a review. ...
Article
Aim Nuclear regulations demand that human contribution is included in the reporting and analysis of operational events (OE), but this topic is not actively studied. We studied current human factor (HF) procedures in nuclear OE reporting and analysis, and tested a new HF tool for OE analysis. Methods We modified an HF tool for nuclear purposes. Safety experts (n = 8) from two nuclear power companies (NPC) tested the HF tool in a workshop investigating three OEs. We interviewed the safety experts and managers (n = 20) of the two NPCs, to evaluate the current HF practices and the output of the OE analysis with the new HF tool. We also analysed the documentation. Results The study revealed that currently, the reporting and analysis of OE focuses mainly on technical and risk aspects, and HF is not very concrete. The new HF tool offered a more accurate picture of the analysed OEs and HFs affecting OEs including the successes, than current OE analysis methods. The users found the HF tool clear and easy to use, useful for investigation, training and self-evaluation, and for monitoring safety trends. Discussion NPCs are aware of the need and usefulness of HF thinking, but HFs in OE reporting and analysis still need to be concretized. Development needs include further modification and validation of the tool, and planning of future implementation at NPCs and in the nuclear industry. Conclusions HF competence and implementation has to be improved, as stressed in the nuclear safety regulation.
... Overall, AcciMap was used in studies with six hierarchical levels developed based on Rasmussen's (1997) framework. A few works used the five levels of AcciMap and one depicted the contributing factors in the outcome level [81][82][83]. Table A1 outlines the details of these works (Appendix A). ...
Article
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Accident models are mental models that make it possible to understand the causality of adverse events. This research was conducted based on five major objectives: (i) to systematically review the relevant literature about AcciMap, STAMP, and FRAM models and synthesize the theoretical and experimental findings, as well as the main research flows; (ii) to examine the standalone and hybrid applications for modeling the leading factors of the accident and the behavior of sociotechnical systems; (iii) to highlight the strengths and weaknesses of exploring the research opportunities; (iv) to describe the safety and accident models in terms of safety-I-II-III; and finally, to investigate the impact of the systemic models’ applications in enhancing the system’s sustainability. The systematic models can identify contributory factors, functions, and relationships in different system levels which helps to increase the awareness of systems and enhance the sustainability of safety management. Furthermore, their hybrid extensions can significantly overcome the limitations of these models and provide more reliable information. Applying the safety II and III concepts and their approaches in the system can also progress their safety levels. Finally, the ethical control of sophisticated systems suggests that further research utilizing these methodologies should be conducted to enhance system analysis and safety evaluations.
... Difficulties in applying the phases of CWA, and especially Work Domain Analysis (WDA) were reported by Hilliard and Jamieson (2016) as they developed information systems for energy efficiency monitoring and targeting. Two Accimap analyses of the South Korea Sewol Ferry accident produced somewhat different outputs (Kee et al., 2016;Lee et al., 2016;Sharples, 2016) and Salmon et al. (2016) noted the difficulties of conveying the philosophy underlying Accimaps to potential domain end-users. ...
Article
In this special issue, many of the papers focus on Rasmussen's analytic contributions to the understanding of work in complex sociotechnical systems. Work is analysed for the purpose of developing new designs that can improve the nature of that work. The evaluation of such designs was a key part of Rasmussen's program, yet he was often sceptical of the claims made for the generalizability of empirical studies. To tackle this problem, he extended his work analysis framework to provide a way of thinking about empirical evaluation. As authors of this paper, we come from two different backgrounds—systems engineering in the case of Burns, and engineering psychology in the case of Sanderson—and over the decades of our respective research programs, we have both performed many empirical investigations: field investigations, simulation studies, and behavioural laboratory experiments. Rasmussen's scepticism—and his writings on the issue—have stimulated and shaped our own research. In this brief paper we present our interpretation of Rasmussen's perspective, we provide examples how our research sits within Rasmussen's framework of constraints defining boundary conditions for experiments, and we draw conclusions for the future.
... Quite frequently, the studies that applied systemic methods relied largely on the information contained in accident reports (Goncalves Filho et al., 2019;O. O. Igene & Johnson, 2020;Kee et al., 2017;Salmon et al., 2012) which was not our case. ...
Conference Paper
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Using a systemic and human-centered approach to analyze quality deficiencies in complex manual assemblies can help to shift the focus towards the role of systems failures instead of focusing on the operators' actions. This paper features the Human Factors Analysis and Classification System (HFACS) framework, to identify several contributing factors to quality deficiencies in a manufacturing environment. Overall, 34 factors were identified. Some 56% were associated with the human operator and operating environment, while 44% were related to organizational influences and supervisory factors. The latter included inadequate design/update of working instructions, variability in production demands, high complexity of product design, and lack of guidelines on shift scheduling and overtime allocation best practices. Although HFACS was able to provide a "big picture" of the situation analyzed, it requires that the user possess a good understanding of the operational aspects of the system and have ample access to data and information. Particularly for latent conditions, which are not so easy to detect.
... The AcciMap approach, as a systemic accident analysis tool originally proposed by Rasmussen (1997), is becoming increasingly prominent in accident systems analysis approach Goode et al., 2017). It has been applied to learn accident causation in various domains such as the led outdoor activity sector Salmon et al., 2010), railway (Salmon et al., 2012;Underwood and Waterson, 2014), aviation (Debrincat et al., 2013), public department , marine industry (Akyuz, 2015;Kee et al., 2017), food production plant (Nayak and Waterson, 2016) and roadway (Stevens and Salmon, 2016). Although the AcciMap approach has been widely utilized in numerous domains, it still possesses some limitations in assessing contributory factors of potential systemic accidents : (i) the hierarchy levels of accident contributory factors are not considered from the perspective of accident causation, (ii) the interaction relationships among the contributory factors are not appreciated, and (iii) the most dominant contributory factors of an accident cannot be identified. ...
Article
The Rasmussen's AcciMap approach is an important system thinking method widely used to guide accident analysis and assess potential contributory factors. However, the AcciMap approach cannot quantify interaction relationships among contributory factors and the hierarchical representation of these factors, and it also cannot identify the dominant contributory factors in potential systemic accident. These limitations influence applications of the AcciMap method. The purpose of this paper is to propose a new AcciMap approach combining fuzzy Interpretive Structural Modeling (fuzzy ISM) and Matrix of Cross Impact Multiplications Applied to Classification (MICMAC) to overcome the limitations of current AcciMap approach. Firstly, the fuzzy ISM method is adopted to determine the interaction relationships among contributory factors and the hierarchical representation of these factors. Secondly, the MICMAC method integrated with fuzzy ISM is applied to classify the contributory factors into different categories on the basis of their driving and dependence power values. Then, the degree of a vertex is introduced into the MICMAC approach to determine the dominant contributory factors in potential systemic accident. Finally, the proposed extended AcciMap approach is applied to a ship grounding accident to demonstrate its feasibility, and then a sensitivity analysis is also performed to validate the effectiveness of the new AcciMap approach.
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Di era modern ini, Korea Selatan dikenal sebagai negara liberal dengan industri hiburan yang mendunia. Akan tetapi menelisik kurang dari 20 tahun kebelakang, Pemerintahan Korea dibawah Presiden kesebelas Park Geun-hye menghadapi banyak kecaman, baik dari masyarakat domestik dan dari dunia internasional. Praktik korupsi, kolusi, dan nepotisme (KKN) berlangsung secara masif di berbagai tingkat pemerintahan. Pemerintah Korea Selatan juga dianggap tidak siap dalam menghadapi permasalahan karamnya kapal feri MV Sewol yang dianggap bisa diselesaikan dengan cepat dan relatif mudah. Selain bobroknya birokrasi pemerintahan dalam penanganan masalah ini, ketidaksiapan dan kurangnya pengalaman dan komunikasi dari penjaga pantai Korea Selatan yang berpartisipasi di operasi evakuasi kapal feri ini juga turut menjadi alasan mengapa kejadian ini berdampak lebih besar dari seharusnya. Dengan menulis tulisan ini, penulis berharap bisa menjelaskan lebih dalam mengenai langkah-langkah yang diambil, baik sebelum maupun sesudah kejadian ini, oleh Pemerintahan Korea Selatan, Penjaga Pantai Korea Selatan, dan Chonghaejin Marine selaku pemilik dan operator kapal ferry MV Sewol. Penulis juga berusaha menganalisis kejadian ini dari kacamata perspektif realisme dalam hubungan internasional, karena dalam proses evakuasi dan investigasi kejadian ini melibatkan pihak-pihak internasional. Penulis juga berusaha menjelaskan dampak dari kejadian ini, baik terhadap korban dan keluarga korban, kru kapal feri MV Sewol, dan pihak terkait lainnya.
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Introduction: This systematic review examines and reports on peer reviewed studies that have applied systems thinking accident analysis methods to better understand the cause of accidents in a diverse range of sociotechnical systems contexts. Methods: Four databases (PubMed, ScienceDirect, Scopus, Web of Science) were searched for published articles during the dates 01 January 1990 to 31 July 2018, inclusive, for original peer reviewed journal articles. Eligible studies applied AcciMap, the Human Factors Analysis and Classification System (HFACS), the Systems Theoretic Accident Model and Processes (STAMP) method, including Causal Analysis based on STAMP (CAST), and the Functional Resonance Analysis Method (FRAM). Outcomes included accidents ranging from major events to minor incidents. Results: A total of 73 articles were included. There were 20, 43, six, and four studies in the AcciMap, HFACS, STAMP-CAST, and FRAM methods categories, respectively. The most common accident contexts were aviation, maritime, rail, public health, and mining. A greater number of contributory factors were found at the lower end of the sociotechnical systems analysed, including the equipment/technology, human/staff, and operating processes levels. A majority of studies used supplementary approaches to enhance the analytical capacity of base applications. Conclusions: Systems thinking accident analysis methods have been popular for close to two decades and have been applied in a diverse range of sociotechnical systems contexts. A number of research-based recommendations are proposed, including the need to upgrade incident reporting systems and further explore opportunities around the development of novel accident analysis approaches.
Article
Jens Rasmussen developed a risk management framework that is extensive and multi-faceted. This framework is generally regarded as normative largely because the numerous citations of his work relate to isolated elements of that framework. There are, however, neglected elements to Rasmussen’s framework, such as functional-relational modelling, work domain analysis, and development of ecological information systems, that mark it as formative. In this article, I lay out Rasmussen’s risk management framework as gleaned from several of his publications. Rather than evaluation, the intent is to describe, and where necessary, explain his ideas. I follow with a review of AcciMap research that has been inspired by Rasmussen’s ideas. Based on that review, I conclude that Rasmussen’s formative strategy contains ideas that do not have a high profile within our current discourse on risk management. Given the limitations of a normative approach to risk management, coupled with the catastrophic potential of many of our contemporary sociotechnical systems, serious assessment of those neglected aspects of Rasmussen’s risk management framework seems warranted.
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As AcciMap is now arguably the most popular accident analysis method in the peer-reviewed literature, there are key learnings to be taken from reviewing and synthesising published AcciMap analyses. In particular, the extent to which the network of contributory factors underpinning accidents is consistent across safety critical domains. This study reviewed and synthesised 23 AcciMap analyses published in the peer-reviewed literature. Contributory factors and relationships were extracted and thematically coded to form a single multi-domain, multi-incident AcciMap. The resulting AcciMap contains 5587 contributory factors spanning seventy-nine distinct contributory factor types. The findings reveal a set of generic contributory factors that consistently play a role in major accidents regardless of domain. Additionally, contributory factors previously only associated with sharp-end human operators are, in fact, prevalent across multiple levels of accident systems. The implications of these findings for accident theory and accident analysis and prevention activities are discussed. For future AcciMap analyses it is recommended that the contributory factor classification scheme developed in the present study is used to support the identification and classification of contributory factors. In addition, further education for analysts on the systems thinking perspective on accident causation is recommended.
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To assess the collision risk of ferries in the Yangtze River during crossing, the collision risk modeling is conducted based on AIS data. Risk Influencing Factors (RIFs) including Distance to Closest Point of Approach (DCPA), Time to Closest Point of Approach (TCPA), distance and relative velocity are involved. First, the historical multi-ship encounter scenarios involved ferry during crossing are identified from AIS data. Then, the value of RIFs is calculated according to their cumulative distribution, and their corresponding weights are determined using entropy theory. Next, the Collision Risk Index of Ferry (CRIF) is proposed considering the behavior of ferry and multiple target ships, which makes it possible to assess real-time collision risk during crossing and to integrate collision risk of each voyage based on historical encounter scenarios. The performance of the proposed model is evaluated according to the analysis on several encounter scenarios with different collision risk. Furthermore, the areas with higher collision risk are identified. The results bring some new insights to enhancing navigation safety of ferries.
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By using a structured analytic technique, this paper reviews the development of research on maritime accidents involving human factors (HFs). First, a clear framework is generated for consolidating the main viewpoints on diverse topics; it is structured in terms of focus, perspective, and methodology. In particular, research focus is further classified into factor identification, interaction investigation, and regulative intervention. Second, most generic HF-related accident models employed in the maritime domain are specialized for specific maritime situations: the HF analysis and classification system (HFACS) is the most commonly used model in factor identification studies; the few intervention-related studies only propose intervention measures; and studies on maritime HF-related accidents are more qualitative and retrospective than quantitative and prospective. Third, the following research gaps are identified: i) inadequate fundamental exploration of nonlinear interaction and intervening mechanisms, ii) lack of application-based conceptualization of maritime-specific analytical frameworks, and iii) methodological limitations regarding data collection and quantitative analysis. Finally, suggestions for future research are proposed, including establishing an “interlink net” rather than only a linear chain to explore interactions among causal factors; objectively investigating the effect of an intervention; constructing maritime-specific integrated models concerning the accident cause, interlinkage, and intervention; applying specific methods in data collection in accordance with the “potential” and “heterogeneity” of HFs.
Chapter
Based on research on recent disasters from around the world, this chapter identifies lessons and strategies for strengthening the resilience of transportation systems. It argues that transportation is essential to the resilience of other systems, which support disaster response and recovery. There are three reasons to focus on international perspectives on transportation resilience. First, in both developed and developing countries across the world, there are useful ideas, policies, and practices supporting transportation resilience. Second, a broad spatial and temporal perspective provides insight into not just different hazards and threats but also effective transportation strategies related to response, recovery, mitigation, and preparedness for disasters. Third, many threats and hazards faced by those managing transportation systems including climate change, sea-level rise, and other global problems and require plans, actions, and interventions of public and private actors at different scales including neighborhood, city, regional, national, and global. International perspectives are useful for comparative analysis and for the development of collective actions to reduce stressors and increase resilience. Urbanization, globalization, and new technologies affect not just the quality of transportation services, but also the longer term performance and resilience of these systems. There are important lessons to be distilled from international cases in terms of exposure to future threats and hazards and in understanding coping mechanisms, adaptation strategies, and transportation resilience.
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Complexity in marine operations requires a robust and dynamic framework for human error assessment to aid safety-based decision making under uncertainty. The current study presents a dynamic Human Factors Analysis and Classification System for Maritime Accident. The model is used for human factor assessment in critical maritime operations, considering the influential factors of dynamic cognitive human behavior and complex interactions among core risk factors. The HFACS-MA structure consists of five levels of human factors based on the International Maritime Organization (IMO) guiding principles and the Human Factor Analysis and Classification System (HFACS) concept. Based on three accident case studies, the study explores five levels of human role to develop a robust model structure for critical maritime operations. The developed structure is translated into a novel Bayesian network (BN) structure, capturing the dependencies among the risk influencing factors for the three accident scenarios. The developed model framework for the accident scenarios emphasizes the changing characteristics of human performance influential factors and the dynamic operating environment. The demonstrated case studies further confirm the model adaptiveness in human factor assessment, considering the dynamic decision-making influential factors and operational uncertainty.
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In sectors such as aerospace manufacturing, human errors in the assembly of complex products can negatively impact quality, productivity, and safety. Until now, the analysis of assembly errors has focused more on the immediate human‐system interface and less on broader organizational factors. This article presents a case study‐based analysis of assembly errors in the aeronautical industry using the systemic methods AcciMap and Systems‐Theoretic Accident Model and Processes (STAMP). We seek to provide the company with elements to build a quality improvement strategy that considers human factors and ergonomics from a systemic perspective. The data and information necessary to conduct the analysis came from a project carried out at an aerospace manufacturing facility over a period of 12 months. The team had direct and recurrent access to primary data sources and communication with various stakeholders. A total of 31 influencing factors were identified with AcciMap at different levels within the manufacturing system. STAMP made it possible to model the sociotechnical control structure of the assembly process and identify several control flaws leading to hazards. The analysis shows that systemic methods require a high level of understanding of the manufacturing system and access to relatively high amounts of data and information. Therefore, direct contact with the field and stakeholders is crucial. Training quality specialists on systemic methods could support its use and help to close the gap between theory and practice. Globally, the field of quality in manufacturing could benefit from using systemic methods when deemed necessary.
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The application of concepts, theories and methods from systems ergonomics within patient safety has proved to be an expanding area of research and application in the last decade. This paper aims to take a step back and examine what types of research have been conducted so far and use the results to suggest new ways forward. An analysis of a selection of the patient safety literature suggests that research has so far focused on human error, frameworks for safety and risk and incident reporting. The majority of studies have addressed system concerns at an individual level of analysis with only a few analysing systems across multiple system boundaries. Based on the findings, it is argued that future research needs to move away from a concentration on errors and towards an examination of the connections between systems levels. Examples of how this could be achieved are described in the paper. The outcomes from the review of the systems approach within patient safety provide practitioners and researchers within health care (e.g. the UK National Health Service) with a picture of what types of research are currently being investigated, gaps in understanding and possible future ways forward.