Needs for Changing Accident Investigation from Blaming to Systems Approach
Objective: The purposes of this study are to survey needs for changing accident investigation from blaming to systems approach and to briefly summarize systemsbased accident analysis techniques. Background: In modern complex socio technical systems, accidents are caused by a variety of contributing factors including human, technical, organizational, social factors, not by just a single violation or error of a specific actor, but accidents investigation used to be focused on the incorrect action of individuals. A new approach investigating causes of accidents as a symptom of a deficient system is required. Method: This study was mainly based on survey of literatures related to accidents, accidents investigation, which included academic journals, newspapers, etc. Results: This study showed that accidents investigation of Korea focusing on blaming is problematic. This was confirmed by two concepts of migration and hindsight bias frequently found in accident causation studies, and an attribute of accidents having varying causes. This was illustrated with an example of Sewol ferry capsizing accident. Representative systems based accident analysis models including Swiss cheese model, AcciMap, HFACS, FRAM and STAMP were briefly introduced, which can be used in systematic accidents investigations. Finally, this study proposed a procedure for establishing preventive measures of accidents, which was composed of two steps: public inquiry and devising preventive measures. Conclusion: A new approach considering how safety critical components such as technical and social elements, and their interactions lead to accidents is needed for preventing reoccurrence of similar accidents in complex socio technical systems. Application: The results would be used as a reference or guideline when the safety relevant governmental organizations investigate accidents.