시스템사고로 본 궁평2 지하차도 침수 재난발생의 인과순환구조 분석 = Analysis of the Circular Causal Structures of the Gungpyeong 2 Underpass Flood Disaster: A Systems Thinking Approach

다국어 초록 (Multilingual Abstract)

This study analyzes the causal mechanisms of the Osong Gungpyeong 2 Underpass flooding disaster using a systems thinking approach. Specifically, it aims to identify the circular causal feedback loops underlying the systemic 23 failures observed during the disaster and the subsequent response. By integrating conventional accident causation theories—including Heinrich's Law, the Swiss Cheese Model, and AcciMap—with systems thinking, this paper establishes a robust analytical framework to elucidate the structural dynamics of the disaster. The analysis reveals that the failure to seize 23 distinct opportunities for disaster prevention was not a result of isolated incidents. Instead, these failures stemmed from self-reinforcing feedback loops driven by critical factors such as pervasive organizational safety insensitivity, deficits in inter-organizational communication, responsibility shifting, a lack of situational awareness, and compounded human errors.