A Study on Legal and Institutional Improvement Measures for the Effective Implementation of SMS -Focusing on Aircraft Accident Investigation-

유경인 한국항공우주정책⋅법학회 2017 한국항공우주정책·법학회지 Vol.32 No.2

Even with the most advanced aviation technology benefits, aircraft accidents are constantly occurring while air passenger transportation volume is expected to double in the next 15 years. Since it is not possible to secure aviation safety only by the post aircraft accident safety action of accident investigations, it has been recognized and consensus has been formed that proactive and predictive prevention measures are necessary. In this sense, the aviation safety management system (SMS) was introduced in 2008 and has been carried out in earnest since 2011. SMS is a proactive and predictive aircraft accident preventive measure, which is a mechanism to eliminate the fundamental risk factors by approaching organizational factors beyond technological factors and human factors related to aviation safety. The methodology is to collect hazards in all the sites required for aircraft operations, to build a database, to analyze the risks, and through managing risks, to keep the risks acceptable or below. Therefore, the improper implementation of SMS indicates that the aircraft accident prevention is insufficient and it is to be directly connected with the aircraft accident. Reports of duty performance related hazards including their own errors are essential and most important in SMS. Under the policy of just culture for voluntary reporting, the guarantee of information providers' anonymity, non-punishment and non-blame should be basically secured, but to this end, under-reporting is stagnant due to lack of trust in their own organizations. It is necessary for the accountable executive(CEO) and senior management to take a leading role to foster the safety culture initiating from just culture with the safety consciousness, balancing between safety and profit for the organization. Though a Ministry of Land, Infrastructure and Transport’s order, “Guidance on SMS Implementation” states the training required for the accountable executive(CEO) and senior management, it is not legally binding. Thus it is suggested that the SMS training completion certificates of accountable executive(CEO) and senior management be included in SMS approval application form that is legally required by “Korea Aviation Safety Program” in addition to other required documents such as a copy of SMS manual. Also, SMS related items are missing in the aircraft accident investigation, so that organizational factors in association with safety culture and risk management are not being investigated. This hinders from preventing future accidents, as the root cause cannot be identified. The Aircraft Accident Investigation Manuals issued by ICAO contain the SMS investigation wheres it is not included in the final report form of Annex 13 to the Convention on International Civil Aviation. In addition, the US National Transportation Safety Board(NTSB) that has been a substantial example of the aircraft accident investigation for the other accident investigation agencies worldwide does not appear to expand the scope of investigation activities further to SMS. For these reasons, it is believed that investigation agencies conducting their investigations under Annex 13 do not include SMS in the investigation items, and the aircraft accident investigators are hardly exposed to SMS investigation methods or techniques. In this respect, it is necessary to include the SMS investigation in the organization and management information of the final report format of Annex 13. In Korea as well, in the same manner, SMS item should be added to the final report format of the Operating Regulation of the Aircraft and Railway Accident Investigation Board. If such legal and institutional improvement methods are complemented, SMS will serve the purpose of aircraft accident prevention effectively and contribute to the improvement of aviation safety in the future.

항공사고 조사보고서의 증거능력

권창영 한국법학원 2023 저스티스 Vol.195 No.-

Aviation demand is steadily increasing due to the development of the aviation industry and the development of economy, and aircraft accidents are happening. Since aircraft accident investigation is a very specialized area, the International Civil Aviation Organization (ICAO) stipulates in detail the investigation of aircraft accidents in Annex 13 to the Chicago Convention. In Korea, the Aircraft Accident Investigation Committee intends to contribute to the prevention of aircraft accidents and safety of aircraft by accurately identifying the causes of accidents through independent and fair investigations. If the responsibility of the perpetrator is recognized as a result of the investigation, it will lead to civil lawsuits such as claims for damages to air carriers, administrative disputes on administrative measures against aviation operators or workers, and criminal penalties for violations of aviation safety laws. In above various litigation procedures, the court needs to investigate evidence by adopting aircraft accident final report managed by the committee as evidence in order to determine the cause of the aircraft accident and the responsibility of the perpetrator. However, the litigants often argue that the admissibility of evidence of final reports should be denied based on Annex 13 to the Chicago Convention and the Operation Regulation of the Aircraft and Railway Accident Investigation Committee (hereinafter referred to as the “Operation Regulation”). This article discusses the admissibility of evidence and credibility of aircraft accident final reports, focusing on the Chicago Convention and Annex, the trends of U.S. federal laws and cases on NTSB investigation reports, and Korean precedents and theories. First, the Chicago Convention and Annex 13 allows the disclosure or adoption of investigation records and final reports as evidence through balancing test. Regulations that denied the admissibility of evidence of investigation reports are not international standards but only non-binding recommendations. In addition, although U.S. federal law denies the admissibility of evidence in final reports (49 U.S.C. 1154(b)), many precedents recognize the admissibility of evidence of factual accident reports or the factual part of final report. Next, Korea has not notified that it excludes the application of 5.12 in Annex 13 to the Chicago Convention, but the admissibility of evidence of final reports is not denied even by the Chicago Convention and Annex; according to the Civil Procedure Act, the Administrative Procedure Act, and the Criminal Procedure Act, the admissibility of evidence of the investigation report is recognized. Article 34 (1) 2 (b) of the Operational Regulation allows the disclosure of investigation records when a judicial institution determines that disclosure of information in the court is more important for the public interest and the national interest than the effect on collecting information for accident investigation. In light of above points, it should be considered that the admissibility of evidence of final report is recognized. The Operating Regulation (Article 45 (1) and (2)), a directive, denies the admissibility of the final report and the opinions or analysis of employees, but it is difficult to recognize the legitimacy of the clauses because it violates the contents of the Constitution, Chicago Convention, Annexes, and various litigation laws and it is stipulating the matters to be stipulated in the law in directive without delegation. Therefore, I think it is reasonable to delete Article 45 (1) and (2) of the Operating Regulation in order to ensure the unity of the litigation laws and the laws of evidence in Korea.

자율주행차 사고조사제도의 법적 성격, 현황 분석 및 개선과제

황창근 ( Hwang Chang Geun ),이중기 ( Lee Choong-kee ) 홍익대학교 법학연구소 2022 홍익법학 Vol.23 No.2

자배법상 자율주행차 사고조사제도는 세계에서 최초로 시행하는 자율주행차 교통사고 전문 조사체계이다. 이를 규정한 것이 자배법, 동시행령, 국토부고시이다. 아직 자율주행차의 상용화도 이루어지지 않고, 그에 따라 교통사고가 발생된 사례도 많지 않아 어떤 방식의 조사가 적절할지 구성하기 쉽지 않다. 따라서 현행제도의 분석이 큰 의미가 없을 수도 있으나, 자율주행차의 상용화를 목전에 둔 상황에서 사고조사의 목적에 부합되고 한편 법치행정의 관점에서 분석하였다. 첫째, 자율주행차 사고조사의 대상인 자율주행차는 취지상 레벨3 이상을 염두해 둔 것인 만큼 이를 명문화하는 것이 필요하다. 둘째, 사고조사의 목적을 사법적 측면에서의 조사와 기술적 측면에서의 조사로 혼합하고 있는데, 이로써 기존의 경찰의 교통사고조사와의 관계가 모호해지는 점을 고려하여 이를 분명하게 정립할 필요가 있다. 셋째, 위원회의 사무의 위탁 근거 및 사무국의 위탁근거가 법령형식상 문제가 있으므로 재검토하여야 하고, 위원회 구성에 있어서도 상하법령간 위임의 범위, 정합성 등의 문제가 있으므로 전면적인 재검토가 있어야 한다. 또한 위원회의 전문성과 독립성을 보장하기 위하여 자문위원제, 상임위원제의 신설도 검토하여야 한다. 넷째, 사고조사의 방법과 수단에 대하여 보면 법령의 근거 없이 고시에서 정하는 등 법률유보원칙상 심각한 문제점을 가지고 있으므로 정비가 필요하다. 다섯째, 사고조사결과의 처리와 관련하여 현행법상 규정이 미비한바, 사고조사의 목적과 연관하여 관련 규정을 정비하여야 한다. 여섯째, 경찰조사와의 관계를 정립하는 것은 물론이고, 자동차관리법상 결함조사등을 통합하여 운영할 수 있는 방안을 마련하는 것도 중요하다. 일곱째, 현행 사고조사제도는 자배법을 근거로 하고 있는데, 사고조사제도의 취지나 목적에 부합되기 어렵고, 다양한 규율내용을 고려하여 별도의 법률 가칭 자율주행자동차 사고조사에 관한 법률의 제정이 필요하다고 할 것이다. 결론적으로 제도의 개선방향은 복잡한 자율주행차사고원인을 전문적이고 독립적으로 규명함으로써 피해의 신속한 구제에 도움이 되어야 하고, 이를 통한 자율주행차산업의 발전에 기여할 수 있도록 하여야 한다는 점이다. The automated vehicle accident investigation system is the world's first automated vehicle accident investigation system. It is not easy to establish an appropriate research system in a state where commercialization has not yet taken place. Nevertheless, the current system has many problems in that it will be implemented immediately when commercialization is achieved. As the autonomous vehicle, the subject of the self-driving car accident investigation, has Level 3 or higher in mind, it is necessary to stipulate it. Various problems related to the organization and operation of the committee and secretariat should be improved. The method of accident investigation must be faithfully rearranged in accordance with the Constitution. There should be legislative measures to resolve conflicts with the police investigation into traffic accidents. It is reasonable to transfer the legal basis of the investigation system from the current law to an independent law or the Automobile Management Act. In conclusion, the direction of improvement of the system is that by professionally and independently identifying the causes of complex autonomous vehicle accidents, damage can be promptly remedied and this should contribute to the development of the autonomous vehicle industry.

Needs for Changing Accident Investigation from Blaming to Systems Approach

Dohyung Kee 대한인간공학회 2016 大韓人間工學會誌 Vol.35 No.3

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.

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

Dohyung Kee 대한인간공학회 2017 大韓人間工學會誌 Vol.36 No.5

Objective: This study aims to survey and compare three systemic accident investigation techniques of Accimap, STAMP and FRAM, based on the application studies of the Sewol ferry accident. Background: Traditional accident investigation methods such as domino models, FTA, etc. work well for losses caused by physical component failures or actions of human in relatively simple systems, but are unable to depict mechanisms generating errors and violations in the current complex socio-technical systems. For better understanding the structure and behavior of the socio-technical systems, systemic techniques have been developed and used. Method: This study was mainly based on survey of literatures through surfing webpages of ScienceDirect and Google, and ergonomics relevant journals. The key words of Sewol, Sewol ferry, Sewol ferry accident, etc. were used in the survey. Results: Three systemic accident investigation methods included similar actors in the Sewol ferry accident including government, Ministry of Ocean and Fisheries, Korean Coast Guard, Korean Register of Shipping, Korea Shipping Association, Chonghaejin Marine Company, crew members. The methods graphically represented each level"s failures or performance variabilities of relevant functions and relationships between them. It was shown that the systemic methods consider the entire system, ranging from the environment in which the accident occurred, to the role of government in shaping the system of work. Each method has its own comparative pros and cons, but the Accimap has advantages in terms of time of analysis, data required, model complexity and degree of comprehensiveness. Conclusion: This study reviewed and compared three systemic accident investigation methods, which showed that there are systemic characteristics and pros and cons in the methods. Application: The results would be used as a guideline when selecting accident investigation methods.

해양사고 조사방법 개선방안에 관한 연구

이명기,박영수,이은방,나송진 한국해양경찰학회 2019 한국해양경찰학회보 Vol.9 No.1

The purpose of this study is to propose a plan to improve marine accident investigation method which can identify the cause of marine accidents. For this purpose, the problems of domestic maritime accident investigation were identified by analyzing the contents of accident investigation of the Korean Maritime Safety Tribunal, Korea Coast Guard and the Transportation Safety Board of the United States and Japan. As a result, it was confirmed that the Korean maritime accident investigation lacks independence from the government, and the responsibility-oriented cause analysis for judging is being done. In addition, statistical, case-based, and technical analysis methods were applied to cases of domestic marine accidents in order to analyze the accident to find the cause. The statistical analysis method was applied to the cross-correlation analysis to identify the relationship between ship type and accident type. The M-SHELL model and the FTA technique were applied as case–based analysis method to identify the causes of direct and indirect accidents in ship sinking accidents. Also, the collision accident was analyzed by applying the PARK Model, which is a quantitative evaluation model that can represent the maritime traffic risk, to the ship collision accident by the technical analysis method. Based on this, it was derived the improvement plan for the construction of analysis model of the cause of marine accidents, the strengthening of visualization of the result of statistical analysis, and the introduction of technical investigation method of marine accidents. Improvements to the analysis method will enable accurate identification of the cause and provide fundamental and specific measures to prevent marine accidents. 본 연구에서는 해양사고 예방을 위하여 합목적인 원인규명이 가능한 해양사고 조사방법 개선방안을 제시하는 것을 목적으로 한다. 이를 위해 국내 해양안전심판원과해양경찰청 및 미국, 일본의 해양사고 조사기관의 사고조사 내용을 분석하여 국내해양사고조사의 문제점을 식별했으며, 그 결과 국내 해양사고 조사 기관은 독립성이부족하며 책임 지향형 사고 분석이 이루어지고 있음을 확인하였다. 그리고 원인 분석형 사고 분석을 위하여 국내 해양사고 사례에 통계적, 사례적, 기술적 분석 방법을적용하였다. 통계적 분석 방법으로 Cross 집계 분석을 적용하여 선종별-사고유형별 관계를 파악하였으며, 사례적 분석 방법으로 M-SHELL Model과 FTA기법을적용하여 선박 침몰사고의 직·간접적인 사고 원인을 규명하였다. 또한 기술적 분석 방법으로 선박 충돌사고에 대하여 해상 교통 위험을 나타낼 수 있는 정량적인평가 모델인 PARK Model을 적용하여 충돌사고를 분석하였다. 이를 기반으로 해양사고 조사·분석 방법에 대한 개선방안으로서 해양사고 원인 분석모델의 도출, 해양사고 통계분석 결과의 입체화·시각화 강화, 해양사고의 기술적 조사방법 도입을 도출하였다. 조사방법 개선을 통하여 정확한 원인 규명 및 근본적이고 구체적인 대책을 마련하고, 이에 대해 환류하여 해양사고를 예방할 수 있을 것이다.

경찰의 교통사고 처리비용 추계 개선방안에 관한 연구

강수철,조성근,심재익 한국교통연구원 2014 交通硏究 Vol.21 No.3

Traffic accidents incur serious personal injury and property damage, social cost, etc. Since 1992, the cost of traffic accidents has been used to prioritize investment of transportation safety projects and to advertise seriousness of traffic safety in policy data. The cost of traffic accidents includes the direct damage and accident processing cost for law enforcement and has been estimated as a social cost. However, the cost of accident processing by traffic police has various problems not addressed including the omitted cost of the first investigation and the segmentation of injury accidents. The total traffic accident process cost was fixed previously because of government budgets last year. In this study, a social improvement plan is devised and a new method for estimating accident processing costs for law enforcement is detailed. The traffic accidents processing cost for the police show 247.5 billion won for road traffic accidents. This is somewhat different with the 313.5 billion won derived by the conventional method in 2012. 39.3 billion won was missed in the record, as the first responders investigation and the traffic investigation cost is 208.2 billion won. 도로교통사고는 인적, 물적피해 등 심각한 사회적비용을 발생시킨다. 이로 인해 1992년부터 교통사고비용의 추계를 통해 교통안전사업의 투자우선순위 결정은 물론 교통안전의 심각성을 홍보하는 정책자료로 활용하여 왔다. 또한 교통사고비용에는 직접적인 피해와 더불어 경찰의 사고처리비용과 같은 간접적인 비용도 포함되며, 이를 사회기관비용으로 추계해 왔다. 그러나 기존의 교통경찰 사고처리비용에는 초동조사비용의 누락, 부상사고의 세분화가 이루어지지 않았던 점, 교통사고처리비용이 전년도 예산액에 의해 전체금액이 고정되어 있는 점 등의 문제점을 가지고 있었다. 따라서 본 연구에서는 이러한 문제점에 대한 개선방안을 도출하고 새로운 방법으로 경찰의 사고처리비용을 추계하여 제시하였다. 2012년 도로교통사고에 있어 경찰의 교통사고처리비용은 2,475억 2,124만 2,211원으로 나타나 기존 방법에 의해 도출한 3,134억 5,778만 4,924원과는 다소차이가 있었으며, 이를 세분화하면 기존의 연구에서 누락된 초동조사비용이 393억 3,926만 9,671원이었고, 사고조사비용이 2,081억 7,197만 2,540원이었다.

Development of a Human Factors Investigation and Analysis Model for Use in Maritime Accidents: A Case Study of Collision Accident Investigation

Kim, Hong-Tae,Na, Seong Korean Institute of Navigation and Port Research 2017 한국항해항만학회지 Vol.41 No.5

In the shipping industry, it is well known that around 80 % or more of all marine accidents are caused fully or at least in part by human error. In this regard, the International Maritime Organization (IMO) stated that the study of human factors would be important for improving maritime safety. Consequently, the IMO adopted the Casualty Investigation Code, including guidelines to assist investigators in the implementation of the Code, to prevent similar accidents occurring again in the future. In this paper, a process of the human factors investigation is proposed to provide investigators with a guide for determining the occurrence sequence of marine accidents, to identify and classify human error-inducing underlying factors, and to develop safety actions that can manage the risk of marine accidents. Also, an application of these investigation procedures to a collision accident is provided as a case study This is done to verify the applicability of the proposed human factors investigation procedures. The proposed human factors investigation process provides a systematic approach and consists of 3 steps: 'Step 1: collect data & determine occurrence sequence' using the SHEL model and the cognitive process model; 'Step 2: identify and classify underlying human factors' using the Maritime-Human Factor Analysis and Classification System (M-HFACS) model; and 'Step 3: develop safety actions,' using the causal chains. The case study shows that the proposed human factors investigation process is capable of identifying the underlying factors and indeveloping safety actions to prevent similar accidents from occurring.

Analysis of Fukushima Accident in Resilience Engineering Perspective Using the FRAM (Functional Resonance Analysis Method)

Dong Yeon Lee,Hyun-Chul Lee 대한인간공학회 2018 大韓人間工學會誌 Vol.37 No.3

Objective: The aim of this study is to investigate the combination of function variability that has affected the development of the Fukushima accident and to identify potential risks of the emergency response system that directly related the Fukushima accident using the functional resonance analysis method. Background: From a traditional perspective (safety-1), safety management is implemented in a way that finds and solves the direct cause of the accident. In the Resilience engineering (safety-2), perspective, accidents or adverse outcomes are considered to emergent from the variability of performance rather than a linear causal relationship. The FRAM is a method of modeling system functions and finding potential risks in the system. Method: This study used the FRAM to analyze the accident response of the Fukushima case. In order to identify the accident response system of the Fukushima, we investigated the existing Fukushima accident reports and analyzed the nuclear power plant structure report. Based on these results, we modeled the accident response system of Fukushima accident. Through the FRAM model, we analyzed the variability of the system functions and identified the risks that the combinations of variability might cause. Results: Through the retrospective analysis, we identified the effect of the combinations of variability of system functions on the accident development process. In this study, we present two instantiations. In addition, we conducted the prospective analysis to identify the potential risks of accident response system of the Fukushima that were not reported in actual Fukushima accident. Conclusion: This study suggested that how the variability of the functions of system connected and contributed to the expansion of the accident. The FRAM can be used to reduce the risk of system-wide hazards through analyzing the combination of variability of system functions, identifying the potential risks related to safety. Application: The FRAM will be a systematic method of analysis for in-depth risk management.

Development of a Human Factors Investigation and Analysis Model for Use in Maritime Accidents: A Case Study of Collision Accident Investigation

Hong-Tae Kim,Seong Na 한국항해항만학회 2017 한국항해항만학회지 Vol.41 No.5

In the shipping industry, it is well known that around 80 % or more of all marine accidents are caused fully or at least in part by human error. In this regard, the International Maritime Organization (IMO) stated that the study of human factors would be important for improving maritime safety. Consequently, the IMO adopted the Casualty Investigation Code, including guidelines to assist investigators in the implementation of the Code, to prevent similar accidents occurring again in the future. In this paper, a process of the human factors investigation is proposed to provide investigators with a guide for determining the occurrence sequence of marine accidents, to identify and classify human error-inducing underlying factors, and to develop safety actions that can manage the risk of marine accidents. Also, an application of these investigation procedures to a collision accident is provided as a case study This is done to verify the applicability of the proposed human factors investigation procedures. The proposed human factors investigation process provides a systematic approach and consists of 3 steps: ‘Step 1: collect data & determine occurrence sequence’ using the SHEL model and the cognitive process model; ‘Step 2: identify and classify underlying human factors’ using the Maritime-Human Factor Analysis and Classification System (M-HFACS) model; and ‘Step 3: develop safety actions,’ using the causal chains. The case study shows that the proposed human factors investigation process is capable of identifying the underlying factors and indeveloping safety actions to prevent similar accidents from occurring.