• Journal of Advanced Navigation Technology
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• v.22 no.3
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• pp.198-204
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• 2018

In this paper, It proposed the development of integrated data management's prototype system for aviation accident and incident system. With the recent development of the aviation accident investigation equipment, accident investigation system should collect and manage the various types of jpg, avi, and wav data files. However, the ECCAIRS system does not have a separate database for managing the various generated data during the accident investigation. And the Korea aviation accident management system also has the same problem. Therefore, in this paper, we analyze the aviation accident report system of major foreign countries and prepare a method to apply it to the domestic environment. Through the prototype of the integrated data management system, we confirmed the performance through inputting the existing data and the recently investigated data. We will use this result as basic data for completion of final integrated data management system.

• Journal of the Korean Society for Aviation and Aeronautics
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• v.8 no.1
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• pp.41-56
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• 2000

In the Aircraft Incident Reporting System(AIRS), It is important to collect and gather date about aircraft incidents by means of systemic methods and make it materials for study in the view point of aircraft accident in the future. Especially, the development of such effective tools can be one of main factors determining whether the investigation of potential accident factors succeeds or fails. For such a reason and the purpose of aircraft accident prevention, the AIRS compatible to each county has been developed early and been adopting now in several countries involving USA. First this study examine the actual condition about investigation method tools of potential accident factors used in several countries and investigation and analyze them, finally present the method which can improve more acceptable forms to flight crew used at the KAIRS(Korean AIRS).

• Journal of the Korean Society for Aviation and Aeronautics
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• v.28 no.2
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• pp.63-70
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• 2020

Many organizations apply reactive safety management to prevent the same or similar types of accidents by through investigation and analysis of the accident cases. Although research on investigation techniques has contributed a lot to the objective results of safety accidents and the preparation of countermeasures, many accident investigation techniques currently in use treat accidents from a linear perspective, revealing limitations in reflecting current systems dominated by complexity and uncertainty. In order to overcome these limitations, this study will review recent studies and concepts from a system safety perspective and predict future research trends through a case analysis of aviation accident. The models used in the analysis are STAMP, HFACS, and FRAM, and the characteristics of each technique are presented so that analysts who perform related tasks in the field can refer to them.

• Journal of Advanced Navigation Technology
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• v.28 no.1
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• pp.77-86
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• 2024

'UAS flight recording system' is a system that is mounted on an unmanned aircraft system consisting of various components and records flight-related data. The data recorded by this system should be used for aviation accident and incident investigations to prevent similar accidents. In particular, for the category of UAS with high operating risk, safety devices close to that of manned aircraft are required, and it is urgent to develop flight recording systems reflecting the characteristics of the UAS to secure airworthiness. This paper highlights the need for UAS flight recording systems for aviation accident and incident investigations and seek a method to derive flight recording system parameters for 'Certified Category' with high operational risk. To this end, Inter-City UAM was used as a concrete use case, and the process of approaching system parameters was devised by assuming accident occurrences and hazards from mission profiles and scenarios. As a result of the study, it was confirmed that parameters could be derived through this process.

• The Korean Journal of Air & Space Law and Policy
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• v.19 no.1
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• pp.109-139
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• 2004

The first successful sustained powered flight by Wright Brothers was further extended to the rapid development of aviation technology, that led to transpacific flights, the invention of supersonic planes, and enabled hundreds of people to travel in the space, in addition to the fact that around 10 people had stepped on the moon, all of which were made possible within the very same century. However, on the back side of this most wondrous human technology, the vulnerableness to the aviation accident has been constantly accompanied with, right from the very beginning stage of the aircraft development. Moreover, the development of future aircraft is being focused on the aircraft performance, the increment of the number of passengers aboard and also its speed. In proportion to these phenomena of mega sizing the aircraft, the development of new technology and the increment of air traffic volume, the number of aviation accident is expected to augment, resulting in the enormous loss of human lives and properties. In order to prevent the disastrous aviation accident as such, it is essential to conduct the accident investigation in a specialized, systematic and scientific manner. In search for the method to attain the effective function of the aviation accident investigation organization, in this study, issues were examined as follows: The full-time Board Members and the establishment of an integrated investigation agency, The systematized security of status as an accident investigator, Inclusion of a human factors specialist in the investigator group organization, liability limit of an accident investigator Stipulation of the definition and the investigation scope of an accident and serious incident, along with the main body of conducting the investigation into the accident involving both civil and public aircraft, in the regulations related to the accident investigation.

• Journal of the Korean Society of Safety
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• v.36 no.5
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• pp.43-51
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• 2021

Incident investigation is one of the most important processes among various other safety management methods to prevent industrial accidents. Finding the root causes of accidents, eliminating hazards, and improving safety are the most important purposes of investigating accidents. During the investigation process, root cause analysis (RCA) techniques are used to effectively identify RCA. Over the past few decades, over 30 RCA methods have been developed. These techniques are being widely used in some industries, such as the nuclear and aircraft industries; however, most of the RCA techniques require professional knowledge and special training, making it difficult for safety managers in their respective fields to understand and apply them. Therefore, managers of general industrial sites are rarely present at the scene of actual accident investigations, and they cannot contribute much to the purpose and effectiveness of these investigations. In this study, to address these issues, we developed an RCA technique to facilitate root cause investigation of accidents in real-world industrial sites. To develop new techniques, Systematic Cause Analysis Technique (SCAT), one of the RCA techniques, was used to investigate incidents in the enterprise over three years. We also utilized feature analysis and other papers from existing RCA techniques. To verify its effectiveness, the technique proposed was also applied to the accident case. The technique developed can easily identify and analyze the root cause of an accident and help industrial managers. It can also identify the root cause category where accidents are concentrated and use this data to establish guidelines for preventing future accidents and, thus, focus on prioritizing improvement initiatives.

• Safety and Health at Work
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• v.15 no.1
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• pp.24-32
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• 2024

Background: Learning from incidents for accident prevention is a two-stage process, involving the investigation of past accidents to identify the causal factors, followed by the identification and implementation of remedial measures to address the identified causal factors. The focus of past research has been on the identification of causal factors, with limited focus on the identification and implementation of remedial measures. This research begins to contribute to this gap. The motivation for the research is twofold. First, previous analyses show the recurring nature of accidents within the Ghanaian mining industry, and the causal factors also remain the same. This raises questions on the nature and effectiveness of remedial measures identified to address the causes of past accidents. Secondly, without identifying and implementing remedial measures, the full benefits of accident investigations will not be achieved. Hence, this study aims to assess the nature of remedial measures proposed to address investigation causal factors. Method: The study adopted SMARTER from business studies with the addition of HMW (H - Hierarchical, M - Mapping, and W - Weighting of causal factors) to analyse the recommendations from 500 individual investigation reports across seven different mines in Ghana. Results: The individual and the work environment (79%) were mostly the focused during the search for causes, with limited focus on organisational factors (21%). Forty eight percentage of the recommendations were administrative, focussing on fixing the problem in the immediate affected area or department of the victim(s). Most recommendations (70.4%) were support activities that only enhance the effectiveness of control but do not prevent/mitigate the failure directly. Across all the mines, there was no focus on evaluating the performance of remedial measures after their implementation. Conclusion: Identifying sharp-end causes leads to proposing weak recommendations which fail to address latent organisational conditions. The study proposed a guide for effective planning and implementation of remedial actions.

• 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.