A COMPARATIVE ACCIDENT ANALYSIS MODEL ON

2013 GENTING HIGHLAND BUS CRASH AT GENTING

HIGHLAND – KUALA LUMPUR ROAD USING

SELECTED SYSTEMIC ACCIDENT MODELS

BY

MUHAMMAD SHAQIF BIN SYED JAMALUDIN

A thesis submitted in fulfilment of the requirement for the

degree of Masters of Health Sciences

Kulliyyah of Allied Health Sciences

International Islamic University Malaysia

SEPTEMBER 2018

ii

ABSTRACT

Road traffic accidents are increasingly recognised as a serious public health concern.

Each year road traffic accidents cause 1.2 million deaths worldwide and the number is

expected to increase by 65 percent in 20 years. One of the challenges to solving this

issue is that many accident investigation studies employed methods that gave less

emphasis on systemic factors of road traffic accidents such as enforcement and

government policies but rely on a direct cause-effect chain to analyse an accident

causation process. By contrast, more contemporary approaches of investigating

accidents are based on systemic accident models that can be used to analyse the

interactions between various components of a sociotechnical system. Different

systemic accident models, however, can lead to different analyses and subsequently

different conclusions. As such, this study sought to compare three different systemic

accident models, namely, the Driving Reliability and Error Analysis Method

(DREAM), System-Theoretic Accident Model and Process (STAMP), and AcciMap

in analysing the accident causation process of the 2013 Genting Highlands Bus Crash,

which was the deadliest road traffic accident in Malaysia. Using DREAM, this study

found that most of the contributing factors originated from maintenance errors and

road design issues. On the other hand, STAMP identified inadequate controls and

flaws within the road transportation system as contributing factors while AcciMap

indicated various direct and indirect factors across different levels within the system.

Findings of this study suggest that DREAM can present the accident factors in a

succinct graphical representation by using a classification system thus making it easy

to carry out and simple to understand. In addition, although both AcciMap and

STAMP analyse road traffic accident across different system levels, STAMP is more

comprehensive and flexible. However, because STAMP is time consuming and

complex, it is more suitable for analysing major road traffic accidents.

iii

خلاصة البحثABSTRACT IN ARABIC

عدد يبلغ حيث العالم أنحاء جميع في متزايد بصورة مةالعا الصحة على قلق مصدر المرور حوادث تعتبر .القادمة عامًا 20 خلال ٪65 بنسبة يزداد أن المتوقع ومن السنة، في نسمة مليون 1.2 حوالي الوفيات

العوامل لتحديد الدراسات من العديد محاولة هو المشكلة هذه حل في التحديات أحد فإن ذلك ومع بين التفاعل مثل المرور لحوادث النظامية العوامل ضمنها ضئيل،من باهتمام نولك المرور لحوادث الرئيسية

من مباشرة كسلسلة الحوادث تسبيب إلى تؤدي والت الحكومية، والسياسات القوانين وتطبيق الطريق بيئة بين التفاعل لتحليل المرور حوادث في للتحقيق حديث طريقة تطوير تم لذلك ونتيجة .والآثار الأسباب تحليل على القدرة لها الحديثة الطريقة هذه .التقني الاجتماعي النظام لهذا المتعددة المكونات مختلف

عوامل نفس تحدد الأوجه هذه كانت إذا ما لتحديد دراسات أجريت وقد مختلفة، أوجه من الحوادث باستخدام الكبير ةالمروري الحوادث تسبيب التي العمليات تحليل إلى الدراسة هذه سعت ولذلك .الحادث

الأخطاء وتحليل للقيادة الموثوقية الطريقة :وهي مختلفة نظامية لحوادث نماذج ثلاثة (DREAM)، للحوادث النظام نظريات وعملية نموذج (STAMP)، و ACCIMAP. الحالة دراسة كانت

المرورية دثالحوا أكثر يعد والذي ،2013 عام في جنتنج مرتفعات حافلة تحطم حادثة هي المستخدمةأن الدراسة ووجدت .ماليزيا في دموية DREAM المساهمة العوامل لتحديد تصنيف نظام تستخدم

حدد أخرى ناحية من .الطريق تصميم في ومشكلات الصيانة في أخطاء بسبب تنتج كالتي الحوادث في STAMP الحافلة حادثة في ساهمت كالتي البري النقل نظام داخل والعيوب السيطرة كفاية عدم.

أشار ذلك من النقيض على ACCIMAP مباشرة مختلفة عوامل بسبب تقع الحوادث أن أن إلى أن إلى الدراسة هذه نتائج تشير.النظام داخل مختلفة مستويات عبر مباشرة وغير DREAM قادر

.فهمه وبسّط تنفيذه سهّل مما تصنيف، نظام باستخدام موجز رسومي تمثيل في الحادث عوامل بيان علىمن كل قيام من فبالرغم فعلى على ذلك إلى بالإضافة ACCIMAP و STAMP بتحليل

كان النظام، من مختلفة مستويات على المرور حوادث STAMP اعتبر ذلك ومع .ومرونة شمولية أكثر STAMP طويلا وقتا وتستغرق معقدة لأنها الكبيرة المرورية الحوادث لتحليل أكثر مناسبا

iv

APPROVAL PAGE

I certify that I have supervised and read this study and that in my opinion, it conforms

to acceptable standards of scholarly presentation and is fully adequate, in scope and

quality, as a thesis for the degree of Master of Health Sciences

…………………………………..

Ibrahim Adham Taib

Supervisor

…………………………………..

Azir Saleh

Co-Supervisor

I certify that I have read this study and that in my opinion it conforms to acceptable

standards of scholarly presentation and is fully adequate, in scope and quality, as a

thesis for the degree of Master of Health Sciences

…………………………………..

Mohd Shukri Mohd Aris

Internal Examiner

…………………………………..

Shamsul Bahri Mohd Tamrin

External Examiner

This thesis was submitted to the Department of Biomedical Science and is accepted as

a fulfilment of the requirement for the degree of Master of Health Sciences

…………………………………..

Zaitunnatakhin Zamli

Head, Department of Biomedical

Science

This thesis was submitted to the Kulliyyah of Allied Health Sciences and is accepted

as a fulfilment of the requirement for the degree of Master of Health Sciences

…………………………………..

Suzanah Abdul Rahman

Dean, Kulliyyah of Allied Health

Sciences

v

DECLARATION

I hereby declare that this thesis is the result of my own investigations, except where

otherwise stated. I also declare that it has not been previously or concurrently

submitted as a whole for any other degrees at IIUM or other institutions.

Muhammad Shaqif bin Syed Jamaludin

Signature ........................................................... Date .........................................

vi

INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

DECLARATION OF COPYRIGHT AND AFFIRMATION OF

FAIR USE OF UNPUBLISHED RESEARCH

A COMPARATIVE ACCIDENT ANALYSIS MODEL ON 2013

GENTING HIGHLAND BUS CRASH AT GENTING HIGHLAND –

KUALA LUMPUR ROAD USING SELECTED SYSTEMIC

ACCIDENT MODELS

I declare that the copyright holders of this thesis are jointly owned by the student and

IIUM.

Copyright © 2018 Muhammad Shaqif bin Syed Jamaludin and International Islamic University

Malaysia. All rights reserved.

No part of this unpublished research may be reproduced, stored in a retrieval system,

or transmitted, in any form or by any means, electronic, mechanical, photocopying,

recording or otherwise without prior written permission of the copyright holder

except as provided below

1. Any material contained in or derived from this unpublished research may

be used by others in their writing with due acknowledgement.

2. IIUM or its library will have the right to make and transmit copies (print

or electronic) for institutional and academic purposes.

3. The IIUM library will have the right to make, store in a retrieved system

and supply copies of this unpublished research if requested by other

universities and research libraries.

By signing this form, I acknowledged that I have read and understand the IIUM

Intellectual Property Right and Commercialization policy.

Affirmed by Muhammad Shaqif bin Syed Jamaludin

……..…………………….. ………………………..

Signature Date

vii

ACKNOWLEDGEMENTS

Firstly, it is my utmost pleasure to dedicate this work to my dear parents and my

family, who granted me the gift of their unwavering belief in my ability to accomplish

this goal: thank you for your support and patience.

I wish to express my appreciation and thanks to those who provided their time,

effort and support for this project. To the members of my dissertation committee,

thank you for sticking with me.

Finally, a special thanks to Associate Professor Dr. Ibrahim Adham bin Taib

for his continuous support, encouragement and leadership, and for that, I will be

forever grateful.

viii

TABLE OF CONTENTS

Abstract ....................................................................................................................... ii Abstract in Arabic ....................................................................................................... iii Approval page ............................................................................................................. iv Declaration .................................................................................................................. v

Copyright .................................................................................................................... vi Acknowledgements ..................................................................................................... vii Table of contents ......................................................................................................... viii

List of Tables .............................................................................................................. xii List of Figures ............................................................................................................. xiv

CHAPTER ONE: INTRODUCTION ....................................................................... 1

1.1 Background Of the Study .......................................................................... ..1 1.2 Statement Of the Problem .......................................................................... ..5 1.3 Purpose Of the Study ................................................................................. ..7 1.4 Research Objectives................................................................................... ..8

1.5 Research Questions .................................................................................... ..9 1.6 Theoretical Framework .............................................................................. ..9

1.6.1 Study Design ..................................................................................... 9 1.6.2 Driving Reliability and Error Analysis Method (DREAM) ............ 11

1.6.3 Systems-Theoretic Accident Model and Process (STAMP) ........... 11 1.6.4 AcciMap Analysis Model ............................................................... 12

1.7 Research Hypotheses ............................................................................... ..12 1.8 Significance of the Study ......................................................................... ..13 1.9 Limitations of the Study .......................................................................... ..14

1.10 Chapter Summary .................................................................................. ..14

CHAPTER TWO: LITERATURE REVIEW ........................................................ 16

2.1 Introduction.............................................................................................. ..16 2.2 Road Traffic Accident ............................................................................. ..16

2.2.1 Current Trend of Road Traffic Accident ......................................... 17 2.2.2 Cost of Road Traffic Accident ........................................................ 18

2.2.3 Causes of Road Traffic Accident .................................................... 19 2.2.4 Preventive Action to Reduce Road Traffic Accident ...................... 21

2.3 Accident Investigation Models ................................................................ ..23 2.3.1 Traditional Approach of Accident Investigation Model ................. 25

2.3.1.1 Event Based Accident Modelling ......................................... 25

2.3.1.2 Chain of Time-Ordered Events Model ................................. 27 2.3.2 Challenges of Traditional Accident Investigation Model ............... 29 2.3.3 Modern Approaches to Accident Investigation............................... 30

2.3.3.1 Swiss Cheese Model ............................................................. 32 2.3.3.2 Driving Reliability and Error Analysis Method (DREAM) . 35

2.3.3.3 Systems-Theoretic Accident Model and Process

(STAMP) ............................................................................. 37

2.3.3.4 AcciMap ............................................................................... 41

ix

2.4 Comparative Analysis Of Systemic Accident Analysis Models ............. ..47 2.5 The Use of Inquiry Report as Source Of Data ......................................... ..50

2.6 Accident Description of 2013 Genting Crash .......................................... ..51 2.7 Chapter Summary .................................................................................... ..54

CHAPTER THREE: APPLICATION OF DRIVING RELIABILITY AND

ERROR ANALYSIS METHOD (DREAM) ON 2013 GENTING CRASH ........ 55

3.1 Introduction.............................................................................................. ..55 3.2 Driving Reliability and Error Analysis Method (Dream) ........................ ..55

3.2.1 Stop Rules for Dream ...................................................................... 57 3.2.2 Coding of The Phenotype and Genotypes ....................................... 58 3.2.3 Driver, Vehicle, and Traffic Environment ...................................... 60

3.2.3.1 Description of the Bus Driver ............................................... 60 3.2.3.2 Description of the Bus .......................................................... 60

3.2.3.3 Description of the Traffic Environment ............................... 61 3.2.4 Step 4: Identifying the Critical Event (Phenotype) ......................... 61

3.2.4.1 Phenotype of the 2013 Genting Crash .................................. 63 3.2.5 Identifying the Contributing Factors (Genotypes) .......................... 64

3.2.5.1 Genotypes of the 2013 Genting Crash .................................. 64 3.2.6 Step 6: Graphical Representation of Road Traffic Accident

Using Dream Chart ......................................................................... 82 3.2.6.1 DREAM Chart of 2013 Genting Crash ................................ 84

3.3 Chapter Summary ...................................................................................... 85

CHAPTER FOUR: APPLICATION OF SYSTEMS-THEORETIC AND

ERROR ANALYSIS METHOD (STAMP) ON 2013 GENTING CRASH ......... 87 4.1 Introduction................................................................................................ 87

4.2 Causal Analysis Based on Stamp (Cast) .................................................... 88 4.2.1 Classification of the Control Flaws ................................................. 90

4.2.2 Step 1: Identify the Systems and Hazards Involved in the Loss ..... 91 4.2.2.1 Systems and Hazards Involved in the 2013 Genting Crash . 91

4.2.3 Step 2: Identify the Systems Safety Constraints and Systems

Requirements Associated with the Loss ......................................... 95 4.2.3.1 Systems Safety Constraints and Systems Requirements

Associated with 2013 Genting Crash................................... 96

4.2.4 Step 3: Documenting the Control Structure in Place to Control

the Hazard and Enforce the Safety Constraints ............................ 100

4.2.4.1 The Control Structure in place to control the Hazard and

enforce the System Safety Constraints In 2013 Genting

Crash .................................................................................. 100 4.2.5 Step 5: Analyse Loss at Physical System Level............................ 105

4.2.5.1 Loss of the Physical System Level in 2013 Genting Crash 107 4.2.5.2 Analysis of the bus driver on 2013 Genting Crash. ............ 110

4.2.6 Step 6: Analyse the Higher Levels of the Control Structure ......... 112

4.2.6.1 Lower Level Management .................................................. 113 4.2.6.2 Higher Level Management ................................................. 132

4.2.7 Step 7: Overall Coordination and Communication Contributors

Leading to the Loss ....................................................................... 147

x

4.2.7.1 Overall Coordination and Communication Contributors

Leading to The Loss .......................................................... 148

4.2.8 Step 8: Dynamic and Changes to The System and Its Control

Structure Over Time ..................................................................... 151 4.2.8.1 Dynamic and Changes to the System and its Control

Structure over time in the 2013 Genting Crash ................. 153 4.3 Chapter Summary .................................................................................... 156

CHAPTER FIVE: APPLICATION OF ACCIMAP ON 2013 GENTING

CRASH ..................................................................................................................... 158 5.1 Introduction.............................................................................................. 158 5.2 Accimap Analysis .................................................................................... 158

5.2.1 Step 1: Identify the Outcome of the Accident ............................... 161 5.2.1.1 The Outcome of 2013 Genting Crash ................................. 162

5.2.2 Step 2: Identify the Causal Factors of the Accident ...................... 163 5.2.2.1 Physical or Actor Events, Processes and Conditions

Level ................................................................................. 164 5.2.2.2 Organisation Level ............................................................. 165

5.2.2.3 External Level .................................................................... 167 5.2.3 Step 3: Create the Causal Links Between Causal Factors and the

Outcome ........................................................................................ 169 5.2.4 Step 4: Generate the AcciMap Diagram ....................................... 170

5.2.4.1 AcciMap Diagram of 2013 Genting Crash ......................... 170

5.3 Chapter Summary .................................................................................... 174

CHAPTER SIX: COMPARISON OF SYSTEMIC ACCIDENT ANALYSIS

MODEL ON 2013 GENTING CRASH ................................................................. 175

6.1 Introduction.............................................................................................. 175 6.2 Graphical Presentation ............................................................................. 175

6.2.1 Comparison of Graphical Presentation on DREAM, STAMP,

and AcciMap ................................................................................. 176 6.3 Sequence Of Accident ............................................................................. 179

6.3.1 Comparison of Accident Sequences on DREAM, STAMP, and

AcciMap ....................................................................................... 180 6.4 Domain Of Use ........................................................................................ 181

6.4.1 Comparison of Domain of Use on DREAM, STAMP, and

AcciMap ....................................................................................... 182

6.5 Level Of Details And Level Of Analysis ................................................ 183 6.5.1 Accessibility of the Information on 2013 Genting Crash ............. 184

6.5.2 Accessibility to the Hierarchy of Work Level on 2013 Genting

Crash ............................................................................................. 186 6.6 Usability Of The Systemic Accident Analysis Model ............................. 188

6.6.1 Availability of Guidelines to use the Systemic Accident

Analysis Model ............................................................................. 189

6.6.2 Level of Knowledge to Use the Systemic Accident Analysis

Model ............................................................................................ 192 6.6.3 Difficulties of Learning the Systemic Accident Analysis Model . 195 6.6.4 Difficulties of Applying the Systemic Accident Analysis Model . 198

6.6.4.1 Difficulties of applying DREAM ....................................... 198

xi

6.6.4.2 Difficulties of applying STAMP ........................................ 199 6.6.4.3 Difficulties of applying AcciMap ....................................... 202

6.6.4.4 Difficulties comparison of applying DREAM, STAMP,

and AcciMap ...................................................................... 203 6.7 Chapter Summary .................................................................................... 204

CHAPTER SEVEN: DISCUSSION AND CONCLUSION ................................ 205

7.1 Introduction.............................................................................................. 205 7.2 Complexity Of The Road Traffic Accident In Malaysia ......................... 205 7.3 Application Of Systemic Accident Analysis Model On Road Traffic

Accident In Malaysia ............................................................................. 208 7.4 Future Works To Improve Road Safety System In Malaysia .................. 213

7.5 Conclusion ............................................................................................... 219

REFERENCES ....................................................................................................... 222

APPENDIX A ......................................................................................................... 233

xii

LIST OF TABLES

Table No. Page No.

3.1 List of phenotypes from DREAM (Warner et al., 2008) 62

3.2 Extract of linking table between Phenotype (A) and its associated

Genotype (B-Q). Only part of the Genotype (B-Q) is shown. 65

3.3 Extract of linking table between Interpretation Genotype (C) and

Vehicle Equipment Failure (I), and its associated Antecedents

Genotype (B-Q). Only part of the Genotype (B-Q) is shown. 68

3.4 Extract of linking table between Interpretation Genotype (C) and

Vehicle Equipment Failure (I), and its associated Antecedents

Genotype (B-Q). Only part of the Genotype (B-Q) is shown. 70

3.5 Extract of linking table between Consequent Genotype (M) and its

associated Antecedents Genotype (B-Q). Only part of the

information is shown. 72

3.6 Extract of linking table between State of Road Genotype (L) and

its associated Antecedents Genotype (B-Q). Only part of the

information is shown. 76

3.7 Extract of linking table between Maintenance Genotype (O) and

Road Design Genotype (Q), and its associated Antecedents

Genotype (B-Q). Only part of the information is shown. 78

3.8 Extract of linking table between Vehicle Equipment Failure

Genotype (I) and its associated Antecedents Genotype (B-Q). Only

part of the information is shown. 79

3.9 Extract of linking table between Maintenance Genotype (O) and

Vehicle Design Genotype (P), and its associated Antecedents

Genotype (B-Q). Only part of the information is shown. 82

4.1 System and system hazard identified on 2013 Genting Crash based

on 2013 Genting Report 95

4.2 System constraints and system requirements on 2013

Genting Crash 99

5.1 Outcome of 2013 Genting Crash 162

5.2 Causal factors of 2013 Genting Crash at Physical or Actor Events,

Processes and Conditions Level. 165

xiii

5.3 Causal factors for 2013 Genting Crash at Organisational level. 166

5.4 Causal factors for 2013 Genting Crash at External level. 168

xiv

LIST OF FIGURES

Figure No. Page No.

1.1 Theoretical framework for analysing the 2013 Genting Crash 11

2.1 Domino Theory by Heinrich. Adapted from Qureshi (2007) 26

2.2 Chains of Time-Ordered Event models. Adapted from

Qureshi (2007) 27

2.3 Firefighter burning incident using MES. Adapted from

Munson (2010) 28

2.4 Accident Causation Swiss Cheese Model. Adapted from

Reason, (2008) 33

2.5 Classification scheme of DREAM. Adapted from

Warner et al. (2008). 36

2.6 Accident causation model of DREAM. Adapted from

Ljung, (2002) 37

2.7 Risk management framework. Adapted from

Rasmussen (1997). 43

2.8 Diagram of AcciMap Analysis Method (Rasmussen, 1997;

Branford et al., 2009) 46

2.9 Location of the 2013 Genting Crash at Genting road

(Google Maps, 2017) 51

2.10 Accident scenario of 2013 Genting Crash 52

2.11 Chronology of 2013 Genting Crash on 21st August 53

3.1 Step by step process of DREAM. Adapted from

Warner et al., (2008) 57

3.2 General and Specific Phenotype for 2013 Genting Crash 63

3.3 Phenotype and Genotypes for 2013 Genting Crash. 66

3.4 Antecedent genotype Habitually stretching rules and

recommendations (F4) 69

3.5 Second antecedent genotype for consequent genotype

Misjudgment of situation (C2) 71

xv

3.6 Antecedent genotype for consequent genotype

Inadequate transmission 73

3.7 Antecedent genotype Insufficient guidance (L1) for

consequent genotype 74

3.8 Antecedent genotypes for consequent genotype

Insufficient guidance (L1). 77

3.9 Antecedent genotypes for consequent genotype

Equipment failure (I1). 81

3.10 Standard DREAM chart for road traffic accident analysis 83

3.11 DREAM-chart for 2013 Genting Crash 84

4.1 The general process and stages of CAST approach

(Leveson, 2012). 89

4.2 Classification of control flaws. Adapted from

(Leveson, 2004) 90

4.3 The Hierarchical control structure of bus transportation

safety in Malaysia prior to Genting Crash 102

4.4 Physical system level of Bus Operating Process 108

4.5 Analysis of the bus driver in the accident 110

4.6 Analysis of the bus operating company 114

4.7 Analysis of the private road owner 116

4.8 Analysis of the Private Road Owner and Bus Driver on

Genting Road 118

4.9 Analysis of Land Public Transport Commission and Automotive 120

4.10 Analysis of PUSPAKOM on vehicle inspection towards the crash

bus 123

4.11 Vehicle inspection, approval, and permit renewal by the

organisation 125

4.12 Blacklisting system between RTD and RMP 127

4.13 The analysis of coach building companies as bus coach builder 128

4.14 Analysis of documented technical requirement on vehicle

specification with several organisations 130

4.15 Analysis of DOSH and Bus Operating Company 134

xvi

4.16 Analysis of PWD on the Genting Road 137

4.17 Analysis of RTD on several transportation issues in 2013

Genting Crash 140

4.18 Ministry of Transport in road safety in Malaysia 145

4.19 Three components of the system dynamic model. 152

4.20 System Dynamics Model for 2013 Genting Crash 154

5.1 The general process of AcciMap analysis model

(Branford et al., 2009) 159

5.2 Diagram of AcciMap Diagram by Branford et al., (2009).

Adapted from Branford et al., (2009) 160

5.3 AcciMap diagram for 2013 Genting Crash based on the AcciMap

version by Branford et al., (2009). 171

1

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Concern on the road traffic accident dates many decades since the early invention of

motorised cars as a mode of transportation. The first recorded road traffic accident

was tracked back to 1771 in France which involve a steam-powered vehicle (Vivoda

and Eby, 2011). Though no one was injured or killed, it set up the issues of road

traffic accident. Decades after, road traffic accident found its first road traffic fatality

in 1869 at Irish Midland. This time, a respected astronomer and microscopist, Mary

Ward fall off from the vehicle when the steam vehicle took a turn on a street corner

(Fallon and O’Neill, 2005). Since then, the numbers of road traffic accident increase,

whether in terms of the severity of the accident, number of passengers involved, and

in the numbers of vehicles involved with crash from hundred to millions in numbers

(World Health Organisation [WHO], 2015). In addition, the current state of the road

traffic accident become worsen as it is estimated that 50 million people are injured due

to road traffic accident with 1.2 million deaths per year are associated with road traffic

accidents (Peden et al., 2004). The numbers are not going to stop; it is estimated that

by 2020, half of the global injuries and deaths are causes by road traffic accident

(WHO, 2015).

The increasing trend in road traffic accident are found probably to be

associated with the increasing advancement of technology on the transportation sector.

While the earlier mode of transportation for human civilisation were simple by using

animal-powered transport, it has now become motorised, replacing the traditional

2

animal transportation method (Eckermann, 2001). The technology advancement on

motorised vehicle at the moment does not showing any sign that it is going to stop.

Although the advancement of technology in transportation sector is going to help

human to reach farther destination in short period of time, the task of driving however

required various input of information and understanding. This information and

understanding not only limited to the interaction between driver and the vehicle but

also consider the surrounding environment as well (Regan et al., 2008). For example,

a driver may need to aware with the weather condition, road condition, traffic

conditions, and the activity of other road users while at the same time have to remain a

safe driving process. Considering that driving is a both physical and mental process

(Anstey et al., 2005), this create a complexity in the driving process as more elements

need to be considered while driving. Thus, due to this complexity, there is more

factors of road traffic accident being exposed to the driver, hence increasing the risk

of road traffic accident (Larsson et al., 2010).

Hence, under those circumstances, road traffic accident at the modern world

has no longer associated with the simple cause and effect as seen with first recorded

road traffic accident. In the accident, the first ever motorised vehicle was speeding at

recorded 2 miles per hour before it hit a wall. It was believed that the cause of the

crash is due to speeding (Vivoda and Eby, 2011). Although, the speeding was

considered as too slow for the current speed standard of the modern wold, the accident

still occurs and damaging the vehicle. This show that road traffic accident can happen

anytime and at any moment, even though some factors seems to be illogical for the

road traffic accident to occur.

3

The causes of the road traffic accident were later then varied as seen in the case

of Mary Ward. The speed is not a cause in this road traffic accident, but rather the

jolted vehicle when turning around the corner is what cause the accident (Fallon and

O’Neill, 2005). Returning to the modern world, speed and road corner incident are

still associated with the causes of road traffic accident, but the causes has become

more diverse and no longer associated with only the vehicle and the road condition.

For example, causes of the road traffic accident has now been associated with the

factors from pedestrian, human factors, environment factors, time factors, distraction

while driving, and driving under influence of drugs and alcoholic drinks (Beshah and

Hill, 2010; Mishra et al., 2010; Zhang et al., 2013; WHO, 2015).

Interestingly, there is also evidence that technology, organisation factors, and

inadequate enforcement of regulations and guidelines contribute to the road traffic

accidents (Salmon and Lenne, 2009; Habibovic et al., 2013; Thomas et al., 2013;

WHO, 2013; WHO, 2015). With this in mind, it reflects on how the transportation

sector of had changed throughout time since the first road traffic accident in 1771

France where there are many factors that are associated with either contributing to

road traffic accident or minimise the impact, depending on how it was used (Vivoda

and Eby, 2011). For example, a normal driver will have to handle out the vehicle user

interface, pressing and depressing the pedal to drive or brake, and gear shifting. At the

same time, a driver would also require a legal driving license in order to drive the

vehicle where various road safety regulations, including road signs, road conditions

that are needed to be understood. Occasionally, certain driver will need assistant from

the Global Positioning System (GPS) which are made available from smartphone

technology (Jensen et al., 2010). Considering all this, multiples activities were

incorporated to the driving activities in order to aid the driving process of the driver.

4

All these, will increase the number of factors associated with road traffic accident

(Peden et al., 2004). Technology and modernisation is to help people in their daily

life, but the risks and factors of road traffic accident also rises in parallel.

Although extensive research has been carried out to solve the issues with road

traffic accident, identifying the root cause remain the focus of solving the road traffic

accident. The purpose of identifying the root cause for road traffic is to eliminate the

cause in hope that the similar road traffic accident would not occur in the future

(Thomas et al., 2013). However, this may cause other factors to be overlooked.

Instead, the outcome of the investigated road traffic accident will justify that the root

cause identified is the main cause of the road traffic accident. Because of that, this

create an oversimplification of the accident factors thus lead to blaming culture

(Leveson, 2011). This will often, lead the person, or the group of people involved with

the road traffic accident being put into blame. Issues of hindsight bias could also

influence the finding for the cause of road traffic accident (Leveson, 2012). For this

reason, to solve the problems with the road traffic accident, the accident should be

perceived to be originated from multiple interaction of factors for road traffic accident

(Qureshi, 2007). By using this concept, analysing the accident, the road traffic

accident will able to present that it does not occur from a single cause, thus the right

approach to prevent similar road traffic accident could be achieved.

Considering that the factors of road traffic accident had become diverse, it is

also worth to note that the number of road user had increased too. There are two types

of road user that are associated with the road traffic accidents. The first is the non-

motorised vehicle road user such as cyclist and the pedestrians. The second is the

motorised vehicle road users. The second types could be classified into private

motorised transport such as personal car and personal motorcycle while the second is

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and the public motorised transport (Eckermann, 2001). such as buses and taxis.

Despite the essentiality of these motorised transport to make transportation easier,

road traffic accident involving with these transport cause a great accident cost such as

the medical costs, legal costs, and the property costs eventhough the private transport

cause a lesser cost than private transport (Jakob et al., 2006).However, this is only

applicable to high-income countries as low and middle income countries frequently

surround with various problems even though the public transport was considered as

very safe and a better approach to reduce road traffic accident (Peden et al., 2004;

Chimba et al., 2010; WHO, 2013). Poor regulations, poor law enforcement, and

struggle with economic funding to provide a safe public motorised transport is always

issues to these countries (WHO, 2013).

1.2 STATEMENT OF THE PROBLEM

Bus, one of the public motorised transport always found as a preferred choice of

transport despite any inefficiencies for instance, bus may experience poor service

quality particularly on the system configurations and the engineering services

(Govender, 2014). In addition, due to this, road traffic accident involving bus such as

side-swipe accident, rear end bus accident, bus-to-bus accident and roll-over accident

are found to be common particularly due to the weakness of the roof strengths and the

structural integrity of the bus body (Rahman et al., 2011; Li et al., 2012; Goh et al.,

2014). Considering that bus carry more passengers for land public transport than any

other motorised transport, any accident involving bus would cause more injuries and

fatalities (Kareem, 2003; Chu, 2014). As previously mentioned, the problem with

public motorised transport are often found on low and middle-income countries

(Peden et al., 2004). As a middle-income country, the same issues were also faced by

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Malaysia on the public motorised transport involving bus (Rahman et al., 2011; The

World Bank, 2017). Despite the number of registered bus and number of accident

related to bus was considered as low in Malaysia, the severity of the road traffic

accident should not be neglected (Rahman et al., 2011; WHO, 2013). Often, road

traffic accident in Malaysia involving busses will become a public attention due to its

rare occurrence but with severe impact (Solah et al., 2013). For many years, road

traffic accident involving bus in Malaysia always associated with many injuries and

fatalities such as the 1996 Genting Highland Bus Crash with 17 casualties (Aini et al.,

2001), 2007 Bus Accident with 22 casualties, 2011 Genting Bus Disaster (Aini and

Fakhru’l, 2013), 2013 Genting Bus Crash (Ministry of Transport, 2014), 2016 Genting

-Kl Bus Crash (Channel News Asia, 2016), and 2016 Pagoh Bus Crash (Astro Awani,

2016). Interestingly, based on the previously mentioned cases, express bus service was

mostly associated with the bus accident in Malaysia. In addition, bus accident with

high number of casualties often occurs at the Genting Highland road. At the moment,

the highest number of causalities regarding bus accident was recorded in the 2013

Genting Highland Bus Crash (referred as 2013 Genting Crash afterwards) with 37

passengers are dead including the driver. 16 passengers were badly injured. The bus

itself fall into the ravine on the scene of the accident. It was considered as the worst

ever road traffic accident involving bus in Malaysia to date (Ministry of Transport,

2014). The finding of the accident reveal various factors of the accident with speeding

was selected as the main cause. The finding, however, present each of the factors as an

individual outcome rather than considering it as a system entity. Thus, the causal

relationship between the factors and the system component of the 2013 Genting Crash

could not be established hence limited the explanation of non-linear complexity of the

socio-technical system of the road traffic accident (Underwood and Waterson, 2013).

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In addition, this miss out the opportunity to learn important lesson from the system

safety point of view of road traffic accident as interactions between the system

component were not considered.

1.3 PURPOSE OF THE STUDY

This research sought to identify the causes of the road traffic accident from the

concept of systems theory by using the systemic accident analysis model. The system

theory is defined as the laws, principles, and model that are in need in order for the

complex interactions and the interdependencies of the system component to work in a

complex system (Fan et al., 2015). Hence, a better approach that can consider all this

to describe the accident causation process using this concept is by using the systemic

accident analysis model. The study focused on analysing the accident of the 2013

Genting Bus Crash. The crash attracts a lot of public attention and cause an inquiry is

made to investigate in depth the cause of the accident (Ministry of Transport, 2014).

The official inquiry report makes details on the reason for the 2013 Genting Crash, but

lack of emphasis was given on how the factors of the accident interact with each other

and cause the accident. Indeed, the factors and causes of the accident are presented in

the report, however systemic accident analysis model will able to present the accident

in a systematic approach and able to provide alternate recommendation option to

prevent similar occurrence of accident in the future. In this study, three different

systemic accident analysis models are used to analyse the accident. The systemic

accident analysis model used in this study are Driving Reliability and Error Analysis

Model (DREAM), Systems-Theoretic Accident Model and Process (STAMP), and

AcciMap (Warner et al., 2008; Leveson, 2012; Branford et al., 2009). Each of the

systemic accident analysis model being used in this study will focus on different

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aspect of the accident, thus providing different recommendations (Katsakiori et al.,

2009) particularly on the system safety for improving the road safety in Malaysia.

1.4 RESEARCH OBJECTIVES

The study aimed to achieve the following objectives:

1- To analyse the causes of the 2013 Genting Crash through the systemic

accident analysis models known as DREAM by analysing the accident on

the causal relationship between the critical events and the contributing

factors of the accident.

2- To analyse the causes of the 2013 Genting Crash through the systemic

accident analysis model known as STAMP by analysing the accident on

the violation of system safety constraints and the inadequate controls

enforce on the sociotechnical system of the road safety domain.

3- To analyse the causes of the 2013 Genting Crash through the systemic

accident analysis model known as AcciMap by analysing the accident on

the combination of causal factors of the accident across the organisational

work level of the road safety system.

4- To compare the outcome of DREAM, STAMP, and AcciMap on the 2013

Genting Crash by comparing certain characteristic of the systemic

accident analysis models including the graphical presentation, the

sequences of accident, the domain of use, the levels of detail and analysis,

and the usability of the systemic accident analysis model.