Accident Investigation based on the Systems Theoretic Accident Model and Processes: a Case Study in the Car Industry

摘要

In industry and developed societies, annual work accidents can bring about huge losses. By proper analysis of these events, the development of controlling measures can be the most important action to prevent similar events and enhance the health of the society. Hence, the current study aimed at analyzing a case of occupational accidents leading to death in one of the car industries. This qualitative case study was conducted in spring, 2018. With the implementation of Systems Theoretic Accident Model and Processes (STAMP), the incident statement had been described accurately and, then, a safety control structure has been designed to determine inadequate effective safety control actions in the event of an accident. In the analysis of the incident, various factors were involved at different levels of incident hierarchy where the various components of socio-technical systems interact with each other; the inadequate control action of the safety unit was more prominent. In STAMP technique, unlike traditional methods, does not consider the cause of the accident just a component of failure or malfunction of the system. Therefore, it can be used as a useful tool in incident analysis, especially in complicated and sensitive systems.