A STAMP-Based Causal Analysis of the Korean Sewol Ferry Accident

The increased complexity of socio-technical systems has revealed the limited contributions of existing event-based accident analysis methods on sustainable safety improvements. Systems-Theoretic Accident Model and Processes (STAMP) – constructed upon Systems Theory – deploys a holistic approach to safety and provides broad insights into accident causality via the integration of the analysis from both direct and indirect factors involved. A dedicated STAMP-based analysis is conducted in this paper by taking the recent Sewol ferry tragedy as an example, to illustrate the utility of applying the STAMP-Model to the maritime transportation domain and to stimulate a broader view of accident mechanisms that expands casual analysis beyond immediate physical failures to a systemic view. Some recommendations are developed for continuous improvements and corrective actions to prevent such catastrophic accident from future occurrences.

[1]  Zahid H. Qureshi,et al.  A review of accident modelling approaches for complex socio-technical systems , 2007 .

[2]  Sidney Dekker,et al.  The Field Guide to Understanding 'Human Error' , 2014 .

[3]  Su Zhang,et al.  Analysis of South Korea Sewol Sunken Ferry Accident Based on Behavioral Safety , 2015 .

[4]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[5]  Erik Hollnagel,et al.  Risk + barriers = safety? , 2008 .

[6]  Erik Hollnagel,et al.  From Titanic to Costa Concordia—a century of lessons not learned , 2012 .

[7]  Denis Besnard,et al.  I want to believe: some myths about the management of industrial safety , 2012, Cognition, Technology & Work.

[8]  Jos A. Rijpma,et al.  From Deadlock to Dead End: The Normal Accidents‐ High Reliability Debate Revisited , 2003 .

[9]  Kathryn Mearns,et al.  Safety in shipping: the human element. , 2006, Journal of safety research.

[10]  Jens Rasmussen,et al.  Risk management in a dynamic society: a modelling problem , 1997 .

[11]  Ian I. Mitroff,et al.  The Challenge of the 21st Century: Managing Technology and Ourselves in a Shrinking World , 1994 .

[12]  Liu Hong,et al.  STAMP-based analysis on the railway accident and accident spreading: Taking the China-Jiaoji railway accident for example , 2010 .

[13]  Patrick Waterson,et al.  Systemic accident analysis: examining the gap between research and practice. , 2013, Accident; analysis and prevention.

[14]  David Woods,et al.  Behind human error : cognitive systems, computers, and hindsight : state-of-the-art report , 1994 .

[15]  Patrick Waterson,et al.  Systems thinking, the Swiss Cheese Model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models. , 2014, Accident; analysis and prevention.

[16]  Joseph R. Laracy A Systems Theoretic Accident Model Applied to Biodefense , 2006 .

[17]  Guy H. Walker,et al.  Broken components versus broken systems: why it is systems not people that lose situation awareness , 2015, Cognition, Technology & Work.

[18]  Seok Yoon,et al.  A Note on the Marine Policy of the Ferry Sewol-Ho Disaster in Korea , 2015 .

[19]  Nicolas Dulac,et al.  A framework for dynamic safety and risk management modeling in complex engineering systems , 2007 .

[20]  Nancy G. Leveson,et al.  A new accident model for engineering safer systems , 2004 .

[21]  Paul S. Nelson,et al.  A STAMP ANALYSIS OF THE LEX COMAIR 5191 ACCIDENT , 2008 .

[22]  René Amalberti,et al.  The paradoxes of almost totally safe transportation systems , 2001 .

[23]  D. L. Simms,et al.  Normal Accidents: Living with High-Risk Technologies , 1986 .

[24]  Kwang Il Hwang Comparative Study on Predictions of Passengers` Evacuation Performances Before and After the Remodelling of MV SEWOL , 2015 .

[25]  Bruno Fabiano,et al.  An Approach to Risk Evaluation in Connection with Fire Scenarios from a Cruise Ship , 2015 .

[26]  Nancy G. Leveson,et al.  Engineering a Safer World: Systems Thinking Applied to Safety , 2012 .