Even t hough a response s ystem has been p repared to manage risks, why a re t he r isks n ot m anaged p roperly and major disasters repeated? We analyzed the fire disaster in Jecheon sports center using the Core System Model to see why. According to the analysis, problems such as building structure vulnerable to fire, perfunctory fire safety management and inspection of firefighting facilities, insufficient personnel and equipment, illegal parking vehicles, lax management of situations, neglect of relief duties and lack of professionalism were identified. The Jecheon fire disaster is a man-made disaster caused by a combination of factors, including a lack of safety awareness, lack of law and system, and lack of leadership by field commanders. Therefore, problems should be solved through a comprehensive, three-dimensional approach across the core system, not by one component. In particular, the role of local governments is important, such as the improvement of laws and systems, the support of budgets to expand manpower and equipment, and the establishment of a governance cooperative system based on citizens' participation.