Beyond Conventional Forensics: Structuring the Causal Causes of Institutional Failures in the 2023 Five Star Disasters, Augmented Research Through the Accimap Framework

The Osung Underpass disaster in South Korea in 2023 represents a catastrophic socio-technical system failure, where natural disasters intersect with systemic institutional vacuums. Although this disaster began as a natural disaster, it developed into a complex catastrophe of interconnected causes; Therefore, traditional investigative methodologies have encountered significant limitations in visualizing root causes from a governance perspective. To address these limitations, the present study presents the "Augmented Accimap Framework" shown in Figure 1, which includes four key methodological features.First, we systematized the institutional analysis by directly adding specific administrative guidelines (L-series codes) to the causal nodes. Secondly, the framework uses a standardized color-coded system—yellow for institutional factors and blue for non-systematic factors—to enhance the granularity of classification. Third, display an 'X' symbol on the cross-hierarchy arrow to visualize communication failures. Fourth, we clearly distinguished between "physical triggers" and "factors that increase human loss" and used red arrows to highlight important causal relationships.Applying this framework to the Five Star Disaster, we identified 8 systemic factors and 14 non-systemic factors at 5 hierarchical levels. In particular, major causal relationships have been identified at the level of local governments and relevant agencies. The analysis revealed that while the collapse of the levee was a physical trigger, the catastrophic scale of the loss of life was primarily triggered by institutional ambiguity (L01–L03) and communication breakdowns that paralyzed real-time decision-making. Ultimately, by providing a tool that provides visual clarity for causal structuring, this study serves as a solid framework for policymakers to identify potential systemic risks and contribute to the improved resilience of disaster management systems.