• Title/Summary/Keyword: 근접사고

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Radiotherapy Incidents Analysis Based on ROSIS: Tendency and Frequency (ROSIS 자료 기반 방사선 사고 사례 분석 : 경향과 빈도)

  • Koo, Jihye;Yoon, MyongGeun;Chung, Won Kuu;Kim, Dong Wook
    • Progress in Medical Physics
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    • v.25 no.4
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    • pp.298-303
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    • 2014
  • In this study, we examine the trends and types of incidents frequently occur during radiation therapy by using the data from the radiation oncology safety information system (ROSIS), according to discovery method explores the development direction of future research accident cause factor control method. This study was carried out analysis of incident data in ROSIS nearly 1163 cases in last 11 years from 2003 to 2013. We categorized into treatment methods, found the time, discoverer of occupations and finding ways to analyze the data. Then, we calculate the percentage and the classification for each item. About 1163 cases of incident cases including the near miss cases, external radiation therapy, brachytherapy and other were 97%, 2% and 1%. In the case was improperly planned dose delivery was 44% (497 cases) which 429 cases (86%) was found before 3 fractions and 13 cases were found after 11 fractions. The investigation was found to be distributed in various a found times. Approximately 42% of found time was during treatment and 29% of patients were found the problem during inspection chart. Occupation to discover the most radiation accidents was the radiation therapist (53%) who works in treatment room. Among 1163 incidence cases, 24% cases were found the accident before the treatment, therefore most of accident were found after of during the treatment (70%, 813 cases). This trend is acquired through ROSIS analysis, is expected to be not significantly different in the case of Korea, so it is necessary more diverse and systematic research for the prevention and early detection by using the ROSIS data.

A Study on Development of Ship Collision Avoidance Support Program (선박충돌회피지원프로그램 개발에 관한 연구)

  • Yang Hyoung-Seon;Jeong Dae-Deuk
    • Proceedings of KOSOMES biannual meeting
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    • 2005.11a
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    • pp.15-20
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    • 2005
  • Recently, ship collision accidents account for $20\%\∼30\%$ of domestic marine accidents, also have increased continually. In this paper, therefore we propose the development of Ship Collision Avoidance Support program for decreasing ship collision accidents. This program has been developed on the basis of CCAS-Model. A CCAS-Model has ship's maneuvering performance and has studied for the propose of supporting to avoid ship collision in close quarters. Besides, the program will effectively support maneuvering for collision avoidance through displaying the feasible area and the method of collision avoidance using own ship's turning characteristic about action of target ship's keeping course and velocity in various encounter.

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A Study on the Reinforcement of the Soil Blocking Facilities Due to Water Pipe Rupture Accident (상수관 파열 사고로 인한 흙막이 가시설 보강사례 연구)

  • Woo, Jong-Tae
    • Proceedings of the Korean Society of Disaster Information Conference
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    • 2023.11a
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    • pp.241-243
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    • 2023
  • 아파트 신축공사 흙막이 가시설 현장에 근접 매설된 상수관의 누수 및 파열 사고로 터파기 공사 현장에 토사 유실 및 지반 함몰이 발생되었으며, 흙막이 가시설의 토류판이 파손되었다. 흙막이 가시설의 안정성 확보를 위해 벽체구간은 레이커로 보강하고 사보강재는 1단과 2단을 묶어 힘을 분산시키고 종방향으로 보강 및 토류판 보강을 시행하였다.

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Arc Flash Hazard Analysis (전력기술.정보 - 아크 플래시 위험 분석)

  • Lee, Seong-U
    • Electric Engineers Magazine
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    • s.350
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    • pp.21-25
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    • 2011
  • 전기설비에 접근하여 활선작업을 수행하는 과정에서 "안전조치, 작업공구, 먼지, 분진, 쥐, 절연" 등의 문제로 기인하는 단락사고가 발생하면 플라즈마(plasma) 아크 형태의 전기적 방전이 일어나므로, 아크 플래시 위험에 노출된 작업자는 심각한 화상은 물론 생명에 위험을 초래할 수 있다. 이러한 위험으로부터 근로자를 보호하기 위하여 IEEE Std. 1584에 수행절차와 방법에 대하여 상세히 해설하고 있고, NFPA 70E는 보호기준 등을 규정하고 있다. 국내에서도 이 기준 등을 참고하여 산업안전기준에 관한 규칙에 의거, 활선작업 및 활선근접작업에 관한 기술지침(KOSHA CODE E-3G-2005)과 난연성 전기 작업복 선정에 관한 기술지침(KOSHA CODE E-32-2006을 규정하고 있다. 그러나 국내에서는 외국 기업 일부를 제외하고는 아크 플래시 위험분석 업무를 실무에 적용하는 사례를 찾아보기 어렵다. 또한 적용 범위에 있어서도 난연성 전기 작업복 선정에 관한 기술지침을 600V 이상의 활선작업 및 활선근접 작업시만 착용하도록 한정한 것은 아크 플래시 위험에 대한 보호가 충분하지 않은 것으로 판단된다. 오히려 고압보다도 저압회로 고장 지점의 최소 단락전류에서 차단기의 동작시간이 지연되는 경우, 사고에너지를 더 증가시키기 때문에 위험성과 빈도는 높아질 수 있다 이와 관련하여 본문에서는 "아크 플래시 위험" 분석 및 평가방법에 대하여 살펴보기로 한다.

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해상교통조사 기반 부산항 접근 해역의 선박 충돌 확률 산출에 관한 연구

  • Lee, Myeong-Gi;Park, Yeong-Su;Sin, Dae-Un;Park, Jin-Su
    • Proceedings of the Korean Institute of Navigation and Port Research Conference
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    • 2018.05a
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    • pp.108-109
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    • 2018
  • 국내 5년간의 해양사고 현황을 살펴보면 충돌사고가 가장 많은 비율을 차지하고 있으며, 사고 건수 또한 증가하는 주세이다. 우리나라에서는 해상교통안전진단 규정에 따라 통항 안전성 확보가 가능하다고 평가하는 기준을 근접도에 따른 충돌 확률 $10^{-4}$으로 정하고 있으나, 이 기준에는 해상교통흐름 및 교통량을 반영하고 있지 않은 실정이다. 따라서 본 연구에서는 해상교통조사를 기반으로 부산항 접근해 역의 선박 충돌 확률 산출을 목적으로 한다. 충돌 확률은 부산신항 $1.058{\times}10^{-4}$, 부산항 $0.830{\times}10^{-4}$으로 해상교통안전진단 기준인 $10^{-4}$과 근사한 값으로 산출되었으며, 최근 10년간 부산항 접근 해역의 해양사고 발생 위치와 비교해본 결과 충돌 확률이 높은 곳에서 실제 사고가 발생한 것을 확인하였다. 추후에 다양한 항만의 충돌확률 산출을 통하여 국내 해상교통량 기반의 충돌확률을 확립하는데 기초자료로 활용할 수 있을 것이다.

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Pre-service teachers' eliciting student thinking about a long division algorithm: Approximation of teaching via digital simulation (나눗셈 알고리즘에 대한 학생 사고를 예비교사가 도출하기 : 디지털 시뮬레이션을 통해 가르치는 것에 근접하기)

  • Kwon, Minsung;Pang, JeongSuk
    • The Mathematical Education
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    • v.59 no.3
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    • pp.271-294
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    • 2020
  • The purpose of this study was to explore the possibility of digital simulation by which pre-service teachers (PSTs) can approximate the core teaching practice of eliciting student thinking. This study examined PSTs' questions to elicit student thinking, their use of "pause" session and peer feedback, and their reflections on doing a digital simulation. We analyzed a two-hour digital simulation session with 13 PSTs who enrolled in the elementary mathematics methods course. The results showed that PSTs shifted their general questions to more content-specific questions throughout the simulation and made a quick transition to comparing students' strategies. The number of lead PST-initiated "pause" ranged one to four times for various reasons. Their peer-coaches did not voluntarily "pause" the simulation session but actively shared what they noticed from the student work samples and suggested the next teaching moves. Without utilizing the pause session, the dramatic improvement of questioning was not observed. Even though the PSTs felt overwhelmed with interacting with the student-avatars in real-time, they highlighted the benefits of simulations, appreciated the opportunity to learn the core teaching practice, and viewed this digital simulation as "real" and "authentic" experience. The findings of this study provide implications for re-designing a practice-based teacher education program.

A Study on Development of Ship Collision Avoidance Support Program (선박충돌회피지원프로그램 개발에 관한 연구)

  • Yang Hyoung-Seon;Jeong Dae-Deuk
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.12 no.1 s.24
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    • pp.47-52
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    • 2006
  • Recently, ship collision accidents account for $20%{\sim}34%$ of domestic marine accidents, also have increased continually. In this paper, therefore we propose the development of Ship Collision A voidance Support program for decreasing ship collision accidents. This program has been developed on the basis of CCAS-Model. A CCAS-Model has ship's maneuvering performance and has been studied for the propose of supporting to avoid ship collision in close quarters. Besides. the program will effectively support maneuvering for collision avoidance through display of the feasible area and the method of collision avoidance using own ship's turning characteristic about action of target ship's keeping course and velocity in various encounter.

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Study of Failure Mode and Effect Analysis in Brachytherapy (근접방사선치료에 관한 사고유형과 영향분석 연구)

  • Lee, Soon Sung;Park, Dong Wook;Shin, Dong Oh;Kim, Dong Wook;Kim, Kum Bae;Oh, Yoon-Jin;Kim, Juhye;Kwon, Na Hye;Kim, Kyeong Min;Choi, Sang Hyoun
    • Journal of the Korean Society of Radiology
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    • v.11 no.7
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    • pp.627-635
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    • 2017
  • Brachytherapy is generally performed in conjunction with external radiation therapy, and the treatment course is very complicated, which can lead to radiation accidents. In order to solve this problem, we designed the process map by applying the failure mode and effects analysis (FMEA) method to the Brachytherapy and scored the risk priority number (RPN) for each treatment course based on this process map. The process map consisted of five steps, Patient consulting", "Brachytherapy simulation", "CT simulation", "Brachytherapy treatment planning" and "Treatment". In order to calculate the RPN, doctor, medical physicist, dose planners, therapist, and nurse participated in the study and evaluated occurrence, severity, and lack of detectability at each detail step. Overall, the process map is preceded by a patient identification procedure at each treatment stage, which can be mistaken for another patient, and a different treatment plan may be established to cause a radiation accident. As a result of evaluating the RPN for the detailed steps based on the process map, overall "Patient consulting" and "Brachytherapy treatment planning" step were evaluated as high risk. The nurses showed a tendency to be different from each other, and the nurses had a risk of 55 points or more for all the procedures except "Treatment", and the "Brachytherapy simulation" step was the highest with 88.8 points. Since the treatment stage differs somewhat for each medical institution performing radiotherapy, it is thought that the risk management should be performed intensively by preparing the process map for each institution and calculating the risk RPN.

A Study on the Monitoring Case of the Soil Blocking Facilities Due to Water Pipe Rupture Accident (상수관 파열 사고로 인한 흙막이 가시설 계측사례 연구)

  • Woo, Jong-Tae
    • Proceedings of the Korean Society of Disaster Information Conference
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    • 2023.11a
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    • pp.244-246
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    • 2023
  • 아파트 신축공사 흙막이 가시설 현장에 근접 매설된 상수관의 누수 및 파열 사고로 인접 건물이 공사현장 방향으로 58~188mm 기울어졌으며, 지중수평경사계 계측결과 21.07.20일 22.64mm가 21.10.18.일 101.46mm로 급격하게 78.82mm의 큰 수평 변위가 발생되었으며, 이로 인해 흙막이 가시설의 사보강재가 변형되고 토류판 일부가 파손되었다.

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Ship Collision Avoidance Support Model in Close Quarters Situation( I ) (근접상황 선박충돌회피지원모델에 관한 연구( I ))

  • Yang Hyoung-Seon;Yea Byeong-Deok
    • Journal of Navigation and Port Research
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    • v.28 no.10 s.96
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    • pp.827-832
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    • 2004
  • Up to now a lot of the study on ship collision avoidance systems have proceeded actively. However the rate of ship collision accidents hasn't decreased yet. If there is collision risk in close quarters situation in spite of maneuvering ship for collision avoidance according to the system, only use of TCP A and DCP A as input factor for collision risk decision is not useful to avoiding collision action. For the recent 5 years by the analysis of first observation distance about approaching ship in domestic collision accidents, nearly $45\%$ of accidents is close first observation less than 2 miles. Therefore it is essential part for safety navigations to study for collision avoidance action in close encounter. In this paper, as a fundamental study of supporting collision avoidance maneuvering for navigators, we proposed ship collision avoidance support model in close quarters situation through analysis qf collision accidents to effectively get rid of the causes.