Haddon Matrix와 Bow-Tie 기법을 이용한 Root Cause Analysis에 관한 연구- 사회제도 및 구조적 사고원인을 중심으로 -

초록

In 2017, a fire explosion occurred during spray painting at Company A. Four employees of two-stage subcontractor Company D were killed in the accident. Therefore, Company A derived improvements to prevent recurrence of accidents. But It is difficult to judge that the social system and structural problems have been sufficiently improved. This is probably due to the fact that in the case of the existing accident investigation, the cause of the accident is derived only from the accident situation. Therefore, this study investigated through the Haddon Matrix how the cause of accident are connected. After that, reclassified the causes of accidents as direct, indirect, social system and structural causes. And The reclassified cause was expressed by Bow-Tie. Through the found accident cause by this study, it was confirmed that the accident investigation method applied in this study enables to derive from the cause of surface accident such as non - conformity of safety rules to social system and structural cause such as excessive subcontracting.

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