철도사고의 인적오류 분석을 위한 수행도 영향인자 분류

【Enhanced machine reliability has dramatically reduced the rate and number of railway accidents but for further reduction human error should be considered together that accounts for about 20% of the accidents. Therefore, the objective of this study was to suggest a new taxonomy of performance shaping factors (PSFs) that could be utilized to identify the causes of a human error associated with railway accidents. Four categories of human factor, task factor, environment factor, and organization factor and 14 sub-categories of physical state, psychological state, knowledge/experience/ability, information/communication, regulation/procedure, specific character of task, infrastructure, device/MMI, working environment, external environment, education, direction/management, system/atmosphere, and welfare/opportunity along with 131 specific factors was suggested by carefully reviewing 8 representative published taxonomy of Casualty Analysis Methodology for Maritime Operations (CASMET), Cognitive Reliability and Error Analysis Method (CREAM), Human Factors Analysis and Classification System (HFACS), Integrated Safety Investigation Methodology (ISIM), Korea-Human Performance Enhancement System (K-HPES), Rail safety and Standards Board (RSSB), $TapRoot^{(R)}$ , and Technique for Retrospective and Predictive Analysis of Cognitive Errors (TRACEr). Then these were applied to the case of the railway accident occurred between Komo and Kyungsan stations in 2003 for verification. Both cause decision chart and why-because tree were developed and modified to aid the analyst to find causal factors from the suggested taxonomy. The taxonomy was well suited so that eight causes were found to explain the driver's error in the accident. The taxonomy of PSFs suggested in this study could cover from latent factors to direct causes of human errors related with railway accidents with systematic categorization.】