A STAMP-based causal analysis of the Korean Sewol ferry accident

Kim, Tae-eun; Nazir, Salman; Øvergård, Kjell Ivar

doi:10.1016/j.ssci.2015.11.014

Cited by 94 publications

(48 citation statements)

References 16 publications

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“…The authors concluded that limiting blame to the Sewol's captain and its crewmembers was unfair, and the disaster was a result of a series of safety issues across different levels of the company, government and regulatory bodies. The CAST has also been applied to the same accident, resulting with analogous conclusions (Kim et al, 2016a).…”

Section: Related Workmentioning

confidence: 93%

“…The adopted methodology rests on the accident analysis approach CAST that allows examining the entire sociotechnical system, taking into account both separate variables and systemic causal factors (Leveson, 2011;Leveson et al, 2003). The CAST has been applied to individual railway, aviation and maritime accidents (Kim et al, 2016b;Song et al, 2012;Wong, 2004); comparisons also exist with other accident analysis methods (Salmon et al, 2012;Underwood and Waterson, 2014). In contrast to other systemic models, STAMP better embodies systems thinking (Underwood and Waterson, 2014) and it is the most frequently cited (Underwood and Waterson, 2012).…”

Section: Methodsmentioning

confidence: 99%

“…Such evidence, for instance, points to systemic factors that insidiously degraded safety barriers, acting as their common cause failure and making the defence-in-depth ineffective. For instance, Kim et al describe the accident with passenger ferry MV Sewol where commercial pressures and lax regulatory control had disabled vital organisational and technical barriers, making the accident imminent (Kim et al, 2016a). According to the systems approach, accidents are a result of poor functioning of the safety control system as a whole, i.e.…”

Section: Introductionmentioning

confidence: 99%

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Unravelling causal factors of maritime incidents and accidents

et al. 2018

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Lessons from maritime accidents are conventionally used to inform safety improvements in design and operation of ships. However, this process is only as good as the core understanding derived from accident analysis is. The current explanation of accidents is limited to direct and contributing causal factors, whereas the role of a wider socio-technical context that has given rise to causal mechanisms behind major maritime accidents in recent years is left unexplained. The paper describes analysis results of maritime incidents and accidents occurred over the last decade with passenger ships, with the purpose to illuminate the prevailing causal factors, not least the systemic ones. The results show where the weak links in maritime safety control are (e.g., interactions between ship operators and equipment manufacturers), what their role in accident causation is, and how they can be strengthened. The study seeks to provide valuable input for enhancements in overall maritime safety control and proactive safety management at the ship and shipping company levels.

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Section: Related Workmentioning

confidence: 93%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Unravelling causal factors of maritime incidents and accidents

et al. 2018

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“…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 a 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.…”

Section: Study Aimmentioning

confidence: 99%

Human factors and human reliability

Čepin¹,

Briš²

2017

Safety and Reliability. Theory and Applications

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Four studies, two methods and one accident another look at the reliability and validity of STAMP and Accimap for systemic accident analysis his item ws sumitted to voughorough niversity9s snstitutionl epository y theGn uthorF Citation: psvryD eFFqFD txD qFF nd eiyxD FD PHIUF pour studE iesD two methodsD one ident"nother look t the reliility nd vlidity of eimp nd ew for systemi ident nlysisF sxX gepinD wF nd frisD F @edsFA roeedings of the iuropen fety nd eliility gonferene @iE iv PHIUAD ortoro § zD loveniD tune IVEPPndF fo tonD pvX gg ressD ppFUSEVPF Additional Information:• his is n eepted wnusript of pper pulished y gg ress in fety nd eliilityF heory nd epplitions on PS wy PHIUD vilE le onlineX httpsXGGwwwFrpressFomGfetyEndEeliilityEheoryE ndEepplitionsGgepinEfrisGpGookGWUVIIQVTPWQUHF INTRODUTIONThe types of methods for accident analysis and investigation that have developed since the 1990's reflect the increasing complexity of socio-technical systems, across a range of domains, including nuclear power production, rail and marine transportation (Waterson et al., 2015;2017). Socalled 'Systemic Accident Analysis' (SAA) draws on sociotechnical systems theory, (e.g., AccimapRasmussen, 1997) and control and resilience engineering (e.g., STAMP -Leveson, 2004; FRAMHollnagel, 2004) in order to illustrate the diversity of causal factors contributing to accident across different levels of the systems, interactions between them and the role played by external influences such as political, cultural, financial, and technological circumstances (Branford, 2011). Systemic Accident Analysis (SAA): validity and reliabilityAlthough SAA are underpinned by sociotechnical systems theory, there are significant differences between them in terms of their theoretical assumptions, the type of causal representation and the outputs they produce. The extent to which methods for systemic accident analysis produce outcomes which are valid (e.g., the degree to which the Accimap and STAMP analysis successfully identifies the causes of an accident) and reliable (e.g., the degree to which accident analysts produce similar causal representations) are often viewed as an important criteria for judging their appropriateness for accident analysis ( Human Factors and Complex Systems Research Group, Loughborough Design School, Loughborough UniversityABSTRACT: The aim of this study was to assess the validity and reliability of two accident analysis methods. We identified four studies which analysed the same accident (the South Korea Sewol Ferry accident). Studies 1 and 2 used Accimap whilst Studies 3 and 4 applied STAMP. The four studies were compared in terms of analysis procedure taken, granularity of analysis, causal factors identified and recommendations suggested. The results indicate that the reliability between two STAMP studies (61%) is higher than two Accimap studies (31%) in terms of contributing factor identification. It was found that the recommendations made from each study reflect the focus and knowledge of the analyst.

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“…In 2013, corruption among regulatory officials led to nationwide power shortages after components in Korean nuclear power plants were found to have forged reliability documentation [35]. In 2014, the national tragedy of a ferry capsizing and killing 295 people (mostly children) [36] triggered the reorganization of the entire Korean emergency management industry to centralize crisis coordination efforts into a single agency [37]. In 2016, a city-wide blackout in Jeonggwan New City was exacerbated by a failure to deploy backup infrastructure stored on the other side of the country.…”

Section: Introductionmentioning

confidence: 99%

Sociotechnical Network Analysis for Power Grid Resilience in South Korea

2017

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International efforts to improve power grid resilience mostly focus on technological solutions to reduce the probability of losses by designing hardened, automated, redundant, and smart systems. However, how well a system recovers from failures depends on policies and protocols for human and organizational coordination that must be considered alongside technological analyses. In this work, we develop a sociotechnical network analysis that considers technological and human systems together to support improved blackout response. We construct corresponding infrastructure and social network models for the Korean power grid and analyze them with betweenness to identify critical infrastructures and emergency management organizations. Power grid network analysis reveals important power companies and emergency management headquarters for responding to infrastructure losses, where social network analysis reveals how information-sharing and decision-making authority shifts among these organizations. We find that separate analyses provide relevant yet incomplete recommendations for improving blackout management protocols. In contrast, combined results recommend explicit ways to improve response by connecting key owner, operator, and emergency management organizations with the Ministry of Trade, Industry, and Energy. Findings demonstrate that both technological and social analyses provide important information for power grid resilience, and their combination is necessary to avoid unintended consequences for future blackout events.

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A STAMP-based causal analysis of the Korean Sewol ferry accident

Cited by 94 publications

References 16 publications

Unravelling causal factors of maritime incidents and accidents

Unravelling causal factors of maritime incidents and accidents

Human factors and human reliability

Sociotechnical Network Analysis for Power Grid Resilience in South Korea

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