Development of Disaster Profiling Technique for Case-based Cause Analysis, Mi-Ran LEE

6th
International Disaster and Risk Conference IDRC 2016
‘Integrative Risk Management – Towards Resilient Cities‘ • 28 Aug – 1 Sept 2016 • Davos • Switzerland
www.grforum.org
Development of Disaster Profiling Technique
for Case-based Cause Analysis
Mi-Ran LEE·Chang-Geon YEO·Bo-Young SEO·Hyun-Ju KIM
National Disaster Management Research Institute, Korea
August 29, 2016

6th
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Contents
1. Need for case-based Cause Analysis
2. What is DSI?
3. Disaster Profiling for Root Cause Analysis
4. Case Study
▷ Hydrofluoric Acid Leak in Gumi
▷ Collapse of the Resort’s Gymnasium in Gyeongju
5. Conclusion
1
2
3
4
5

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Need for case-based Cause Analysis
The Paradigm shift of Disaster Management
Collapse of the Resort’s Gymnasium in Gyeongju
(2014.2.17)
The Sewol ferry sinking disaster(2014.4.16)
Complex &
Massive
disaster
Similar accidents
(20 year cycle)

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What is DSI?

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What is DSI?
* Central Governmental Disaster Investigation Team

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Disaster Profiling for Root Cause Analysis
The Basic Procedure
STEP1
STEP2
STEP3
STEP4
STEP5
Similar Cases
Analysis
Collection of Evidence
(Meteorological and
Spatial Information of
Field)
Scientific Field
Investigation
Root Cause
Analysis
Improvement
Measures
Feedback and
Assessment
Cause & Result
(Past case analysis
and Statistical data
research)
Causal relationship
model, Numerical &
Empirical experiments
(the process to find the
main causal factors)
Policy Improvement
& Feedback
(policy development,
implementation and
assessment, etc.)
“establishing
countermeasures to
mitigate the root
causes as a means to
reduce the
reoccurrences of
similar disaster”

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Disaster Profiling for Root Cause Analysis
Development of Analyzing Techniques for Finding Causes of Disaster
Cause Analysis Tree Diagram
• Treediagramofcausesofdisasters
• (Merits)Allows stakeholders to set
priorities for improvements based
on the type of disaster
• (Demerits)Cannotdeterminethe
relationshipbetweenthecausalfactors
• (Use)Priorityreviewchecklistduringfield
investigations
Cause Analysis Matrix
• Taxonomic analysis of an accident
• (Merits) Easy to see the principal
cause of each accident
• (Demerits) Cannot track the
development of the situation over
time or track the connection between
causes
• (Use) Derivation of the principal cause
of a disaster or accident
GOAL
To establish techniques for analyzing information on the causes of
disasters based on a case analysis
Cause Classification System
• Comprehensive disaster cause
information & cause Classification
• (Characteristics) Causal factors
- (Level1) Man-made, Management,
Environmental, Economic, Physical,
Political, Social
- (Level2, 3) Detailed Information
related to 7 causal factors
• (Use)Checklist for Fieldinvestigation,
Analysisofrootcause
Causal Loop Diagram
• Two-dimensionaldiagramforeachcausal
factor(explainthedynamicsofthecause-
effect relationships)
• (Characteristics)Understandtheinter-
connections betweenpoliciesand
decisionmakingprocessesandtheir
impactonthesystemgrowthand
stability
• (Use)eliminatethelinksinadvance

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Case Study : Hydrofluoric Acid Leak in Gumi(2012)
Overview

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Cause Analysis Tree Diagram(Chemical Accidents)
Man-made
Managemental
Environmental
Economic
Physical
Politic
Social

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Cause Analysis Tree Diagram(Chemical Accidents)
Man-made
Management
Environmental
Economic
Physical
Politic
Social
Hydrofluoric
acid leak in
Gumi

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Cause Analysis Sheet(Hydrofluoric Acid Leak in Gumi)
Category Description
Direct Factor Artificial Man-made Negligence Carelessness of workers
Indirect
Factors
Artificial Managemental Management
system
Dispersed laws and institutions regarding chemical material
management
Lack of inter-departmental collaboration system
Failure to perform regular inspections
Political Relevant laws Blind spots in disasters
Insufficient inspection and management regulations in relation to
regular safety education
Accident
manual
Lack of early response manuals
Social Disaster
preventionsystem
Insufficient safety education and promotion to the employees of
subcontractors and local residents
Aggravation
Factors
Natural Environmental Wind Strong winds blowing at a velocity of 1.7m/s~2.0m/s
Changes in the wind direction(SW->NE->N)
Artificial Technical Response
equipment
Inadequacy or failure to use personal protective equipment by
field workers during early response
Managemental Organization
activities
Confusion/miscommunication among the Gov. Depts. And
inadequate sharing of information
Inadequate analysis of residue contamination
Political Relevant laws Insufficient standards for field measures
(emergencywarning,evacuation/returnofresidents,Trafficcontroletc.)

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Cause Analysis Matrix(the Hydrofluoric Acid Leak in Gumi)

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Case Study : Hydrofluoric acid leak in Gumi(2012)
Cause Loop Diagram(the Hydrofluoric Acid Leak in Gumi)

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Case Study : Hydrofluoric acid leak in Gumi(2012)
After the accidentBefore the accident
Responsible Gov.
Scope of safety
management
Dedicated
organization
for safety
management
Integrated management
by the Ministry of Environment
Absence
Ministry of Environment
The National Institute of Chemical Safety
within the Ministry of Environment
Business establishment
management oriented
toward safety inspections Introduction of
the Off-premises impact assessment system
(Former) National Emergency
Management Agency
Ministry of Employment and Labor
Improve Measurements

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Overview
Case Study : Collapse of the Mauna Ocean
Resort’s Gymnasium in Gyeongju(2014)

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Cause Analysis Tree Diagram

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CauseAnalysisSheet(CollapseoftheResortGymnasiuminGyeongju)
Category Description
Direct Factor Artificial Physical Technical No pre-inspection of structural analysis and design by official experts
Poor Construction Supervision
Managemental Management
system
NOT following the formal approval process
Organization
activities
No Snow-removing work of roof
Indirect
Factors
Natural Environmental weather Increased snowfall Wet snowfall
Artificial Politic Relevant laws Inadequate Design Code
Managemental Organization
activities NOT included in the Specific official objective facility
Aggravation
Factors
Artificial Managemental Management
system
Inadequate control for response at the accident scene
Organization
activities Confusions of patient classification and transportation

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CauseAnalysisMatrix(CollapseoftheResortGymnasiuminGyeongju)

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CausalLoopDiagram(CollapseoftheResortGymnasiuminGyeongju)
Difficulty in
ordering field
command
Impossible to
count non-local
manpower
Non-local
manpower
Inadequate command system
of the emergency rescue &
control group
Can not Control
press/media agency
Steep slope of the access road
Dispatch of rescue team
Dispatch of
rescue team
Command
System
Traffic
situation
Rescue
Activity
Patient
Transport
System
Casualties
& Deaths
Government
response
Relevant
standards
Soundness of
the enacted·
amended laws
Insufficient
equipment
Insufficient rescue
personnel
Ambulance entry
not possible
Tight
construction
schedule
Negative Press/
Media opinion
Failure to consider
the structural specific
characteristics Failure
to check
structural safety
Building
Construction Construction
Supervision
Collapse
Climate Change
Inadequate safety
management
Heavy Snow
Faulty design
Non-compliance
with approval
procedures
safety inspections
exception
Absence of P.E.B.
design standards
Absence of
design criterion
on wet/snow
loads
Can not determine
casualties & deaths
Delays in patient
classification and transport

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Direct
Technique
No pre-inspection of structural analysis
and design by official experts
Poor Construction Supervision
[Revision] Framework Act on Building Article 67
Management
NOT following the formal approval
process
No Snow-removing work of roof [Revision] Countermeasures against Natural Disaster Act Article 26
Indirect
Meteorology Increased snowfall Wet snowfall [Revision] Korean Building Code Article 3
Policy Inadequate Design Code
[Enactment] Framework Act on Building Article/Korean Building
Code
Management
NOT included in the Specific official
objective facility
[Revision] Guideline for Designation and Management of the
Specific official objective facility Article 4
Aggravating Management
Inadequate control for response at the
accident scene
[Revision] Framework Act on the management for disasters and
safety Article 16
Confusions of patient classification and
transportation
[Revision] Guideline for Emergency Response Activities Article 20
Improvement measures

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Conclusions
‘Learn the disaster from the past disaster”
Past
Present
Future
Forensic Investigation of Disaster
Disaster Profiling Technique for Cause identification
Training of Disaster Profiler
Innovation of Disaster Management Feedback System

6th
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Questions? Comments?
Mi-Ran, LEE
Senior Researcher/Professional Engineer
National Disaster Management Research Institute
Ministry of Public Safety and Security
Homepage: www.ndmi.go.kr
E-mail: merang75@gmail.com, mrlee75@korea.kr

Development of Disaster Profiling Technique for Case-based Cause Analysis, Mi-Ran LEE

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