• 제목/요약/키워드: Accident classification system

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의료사고의 근본원인 분석: 의료사고 판례문 이용 (Root Cause Analysis of Medical Accidents -Using Medical Accident Cases)

  • 김선녀;조덕영
    • 보건의료산업학회지
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    • 제13권3호
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    • pp.13-26
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    • 2019
  • Objectives: To investigate whether medical institutions can prevent accidents by analyzing the root cause of a medical accident and identifying the tendencies. Methods: A total of 345 medical cases were used for the RCA(Root Cause Analysis). The root causes were classified using the SHELL model. The suitability of the model was confirmed by SPSS's MDPREF and Euclidean distance. An SPSS20.0 hierarchical regression analysis was used as an influencing factor on the degree of injury resulting from medical accidents. Results: The SHELL model was suitable for classification. The rates of accident causes were LS49%, L34%, LL10.2%, LE3.7%, LH2.3%. The order in which the degree of a patient's injury was affected were: Risk Threshold (${\beta}=.180$), Time (${\beta}=.175$), Surgical stage (${\beta}=-.166$), Do not use procedure (${\beta}=.147$). Conclusions: Health care institutions should remove priorities through system improvement and training. For patients' safety, the five factors of the SHELL model should be managed in harmony.

열차 충돌/탈선사고 위험도 평가모델 개발 (Development of the Risk Assessment Model for Train Collision and Derailment)

  • 최돈범;왕종배;곽상록;박찬우;김민수
    • 한국철도학회:학술대회논문집
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    • 한국철도학회 2008년도 춘계학술대회 논문집
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    • pp.1518-1523
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    • 2008
  • Train collision and derailment are types of accident with low probability of occurrence, but they could lead to disastrous consequences including loss of lives and properties. The development of the risk assessment model has been called upon to predict and assess the risk for a long time. Nevertheless, the risk assessment model is recently introduced to the railway system in Korea. The classification of the hazardous events and causes is the commencement of the risk assessment model. In previous researches related to the classification, the hazardous events and causes were classified by centering the results. That classification was simple, but might not show the root cause of the hazardous events. This study has classified the train collision and derailment based on the relevant hazardous event including faults of the train related the accidents, and investigates the causes related to the hazardous events. For the risk assessment model, FTA (fault tree analysis) and ETA (event tree analysis) methods are introduced to assess the risk.

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조종사 비행훈련 성패예측모형 구축을 위한 중요변수 선정 (Selection of Important Variables in the Classification Model for Successful Flight Training)

  • 이상헌;이선두
    • 산업공학
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    • 제20권1호
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    • pp.41-48
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    • 2007
  • The main purpose of this paper is cost reduction in absurd pilot positive expense and human accident prevention which is caused by in the pilot selection process. We use classification models such as logistic regression, decision tree, and neural network based on aptitude test results of 505 ROK Air Force applicants in 2001~2004. First, we determine the reliability and propriety against the aptitude test system which has been improved. Based on this conference flight simulator test item was compared to the new aptitude test item in order to make additional yes or no decision from different models in terms of classification accuracy, ROC and Response Threshold side. Decision tree was selected as the most efficient for each sequential flight training result and the last flight training results predict excellent. Therefore, we propose that the standard of pilot selection be adopted by the decision tree and it presents in the aptitude test item which is new a conference flight simulator test.

조사 대상 부지 신규 분류 체계 제안 및 개황조사 강화를 통한 토양정밀조사 방법 개선 연구 (Improvement of Detailed Soil Survey Guidance through the New Site Classification System and Reinforcement of Exploratory Soil Survey)

  • 권지철;이군택;황상일;김태승;윤정기;김지인
    • 한국지하수토양환경학회지:지하수토양환경
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    • 제20권7호
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    • pp.53-60
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    • 2015
  • This study suggested the new site classification system according to land use, type of contamination and contaminants. Because the present site classification system can not cover all the areas, we changed the concept of land use to more detail one and enlarged the concept of other areas to cover all the areas not defined as certain land use. In case of the present industrial area, it was merged as other areas to avoid the confusion with oil and toxic material storage tank farm area. Accident area was separated from other areas and defined as only accident area caused by the mobile storage facility. In addition to classify the sites according to the basic land use, we classify the sites again in lower level according to the type of contamination and contaminants. With this classification system, we proposed different soil sampling strategy with the consideration of the origin of contamination and the interactions between soil and contaminants. We removed the surface soil sample (0~15 cm depth) around above storage tank because it was not a effective sample to assess whether that area contaminated or not. We also proposed to take the deeper soil samples at minimum three sampling points to confirm the depth of contamination in exploratory soil survey. We also proposed to remove the one point of 15 m depth sampling because it is not effective to confirm contaminated soil depth and needs the exhausted labor and cost. Instead of doing this, we added the continuous sampling to uncontaminated subsoil. Soil sampling points and depth in detailed soil survey is determined based on the results of exploratory soil survey. Therefore, effectiveness and reinforcements of exploratory soil survey would play an important role in improving the reliability of detailed soil survey.

독일의 사례를 통해 본 농업인재해 보장체계 구축 방안 (A Scheme of Compensation System for Farmers' Accidents through the Example of Germany)

  • 민병욱;김효철;이경숙
    • 농촌지도와개발
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    • 제18권3호
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    • pp.351-384
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    • 2011
  • The purpose of this study is to look at the case of the German compensation system for farmers' accidents and to build a basic scheme in our country's compensation system for farmers' accidents. When you view examples of Germany, the social insurance scheme for farmers accidents in korea should be design as an independent institution from the existing industrial accident insurance, and it comes to relationships with other social insurance system, preferably with complementary personalities. A general rule of the compensation system applies to all farmers in principle but the coverage limits part-time farmers. Financial burden consists of the mix of insurance premium and state aid. The type and level of benefits is similar to the current industrial accident insurance, which give priority to places on economic security for keeping farmworks, such as cost for using temporary farmers, rather than income loss. In terms of financial system, pay-as-you-go system would be better because of immediate payment with the introduction of the compensation system. The compensation system might be managed and administrated by the existing nationwide organization. Of course, for operating of system review and further research on the technical details such as premium issues and funding problems of government support, the exact classification of the target coverage, premiums based on estimated income for the farmers' estimation, the exact statistical data on the accumulation of agricultural disaster is needed.

요인 및 군집분석을 이용한 유해화학물질 사고 잠재적 피해에 대한 도시 유형 분류 및 특성 분석 (The Analysis and Classification of Urban Types for Potential Damage from Hazardous Chemical Accidents Using Factor and Cluster Analysis)

  • 이승훈;유영은;김규리;백종인;김호현;반영운
    • 한국환경보건학회지
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    • 제46권6호
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    • pp.726-734
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    • 2020
  • Objectives: The aim of this study was to analyze and classify the characteristics of potential damage from hazardous chemical accidents in 229 administrative units in South Korea by reflecting the social and environmental characteristics of areas where chemical accidents can occur. Methods: A number of indicators were selected through preceding studies. Factor analysis was performed on selected indicators to derive factors, and cluster analysis was performed based on the factor scores. Results: As a result of the cluster analysis, 229 administrative units were divided into three clusters, and it was confirmed that each cluster had its own characteristics. Conclusions: The first cluster, "areas at risk of accident occurrence and spread of damage" was a type with a high potential for accident damage and a high density of hazardous facilities. The second cluster, "Urban infrastructure damage hazard areas" appeared to be a cluster with high urban development characteristics. Finally, the third cluster 'Urban and environmental damage hazard areas' appeared to be a cluster with an excellent natural environment. This study went further from the qualitative discussion related to existing chemical accidents to identify and respond to accident damage by reflecting the social and environmental characteristics of the region. Distinct from the previous studies related to the causes of accidents and the response system, it is meaningful to conduct empirical research focusing on the affected areas by analyzing the possibility of accident damage in reflection of the social and environmental characteristics of the community.

국내 민간 무인항공기 사고조사 HFACS 적용중점 (Applicable Focal Points of HFACS to Investigate Domestic Civil Unmanned Aerial Vehicle Accidents)

  • 이건희;김현덕
    • 한국항행학회논문지
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    • 제25권3호
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    • pp.256-266
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    • 2021
  • 국내외 연구들은 무인항공기 사고의 주원인으로 인적요인을 지목하고 있고, 이러한 인적요인을 효과적으로 분석하는 기법으로 HFACS를 소개하고 있다. 현재까지는 HFACS를 이용해 무인항공기 사고의 인적요인을 분석했던 국내외 사례는 주로 군용 무인항공기가 대상이었는데, 항공사고를 유발하는 인적요인 정보를 분석하여 객관적 원인 규명과 유사 사고 예방 도구로 사용할 수 있는 HFACS가 국내 민간 무인항공기 분야에서도 활용이 필요한 시점이다. 특히, 국내 민간 무인항공기의 성능과 운용 여건을 고려한 HFACS 적용중점을 식별한다면 사고 발생 시 원인 규명과 재발 방지에 큰 도움이 될 것으로 예상된다. 본 연구는 HFACS version 7.0을 근간으로 우리나라 항공철도사고조사위원회가 수행했던 사고조사 결과보고서 자료를 분석하여 국내 민간 무인항공기 사고조사에 활용할 수 있는 HFACS 적용중점을 식별하였다.

소비자안전을 위한 RAP 및 군집분석을 통한 제품안전 관리대상 유형분류 연구 (Classification of Product Safety Management Target by RAP and Cluster Analysis for Consumer Safety)

  • 서정대
    • 한국안전학회지
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    • 제33권6호
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    • pp.128-135
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    • 2018
  • Currently, the government selects products that are likely to cause harm to consumers as safety management targets and classifies them into three types: safety certification, safety confirmation, and supplier conformity verification. In addition, the government conducts safety surveys on products in circulation or accident products, and recalls products that are of great concern to consumer risks. In this paper, we have developed RAP (Risk Assessment method based on Probability), which is a probability based product risk assessment method, for the classification of safety management type of product and safety investigation, and have shown an application example. In this process, information is used for the CISS (Consumer Injury Surveillance System) of the Korean Consumer Agency. In addition, we apply the cluster analysis to classify the current supervised children products into three groups. Then, we confirm the effectiveness of RAP by comparing the result of RAP application, cluster analysis result and current safety management classification type. Also, we recognize the need to review the current safety management classification criteria for classifying products into three types.

DEVELOPMENT OF AN OPERATION STRATEGY FOR A HYBRID SAFETY INJECTION TANK WITH AN ACTIVE SYSTEM

  • JEON, IN SEOP;KANG, HYUN GOOK
    • Nuclear Engineering and Technology
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    • 제47권4호
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    • pp.443-453
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    • 2015
  • A hybrid safety injection tank (H-SIT) can enhance the capability of an advanced power reactor plus (APR+) during a station black out (SBO) that is accompanied by a severe accident. It may a useful alternative to an electric motor. The operations strategy of the H-SIT has to be investigated to achieve maximum utilization of its function. In this study, the master logic diagram (i.e., an analysis for identifying the differences between an H-SIT and a safety injection pump) and an accident case classification were used to determine the parameters of the H-SIT operation. The conditions that require the use of an H-SIT were determined using a decision-making process. The proper timing for using an H-SIT was also analyzed by using the Multi-dimensional Analysis of Reactor Safety (MARS) 1.3 code (Korea Atomic Energy Research Institute, Daejeon, South Korea). The operation strategy analysis indicates that a H-SIT can mitigate five types of failure: (1) failure of the safety injection pump, (2) failure of the passive auxiliary feedwater system, (3) failure of the depressurization system, (4) failure of the shutdown cooling pump (SCP), and (5) failure of the recirculation system. The results of the MARS code demonstrate that the time allowed for recovery can be extended when using an H-SIT, compared with the same situation in which an H-SIT is not used. Based on the results, the use of an H-SIT is recommended, especially after the pilot-operated safety relief valve (POSRV) is opened.

도시철도 사상사고 유형·원인 분류 및 표준화 방안 (Classification and Standardized Coding for Urban Railway Casuality Accident Types and Causes)

  • 모천석;김시곤;권영종;강갑생
    • 대한토목학회논문집
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    • 제35권5호
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    • pp.1173-1177
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    • 2015
  • 본 논문에서는 도시철도역사 내 철도안전사상사고의 사고유형과 원인분류를 표준화하는 방안을 제시하였다. 이를 위하여 도시철도 운영기관 (서울메트로, 서울도시철도공사)의 4,086건 철도안전사상 사고를 분석하여 표준화 코드를 작성하였다. 사고유형의 표준화는 사상자유형, 사고대상, 사고 위치, 사고형태로 구분하여 분류하고 이를 포함한 4자리의 표준화코드를 제시하였다. 사고원인의 표준화는 원인제공자, 음주여부, 1차 원인, 2차 원인을 포함한 4자리의 표준화코드를 제시하였다. 이러한 표준화코드는 도시철도 역사 내 철도안전사상사고의 체계적인 비상관리 및 긴급대응에 기본이 되는 역할을 담당할 것이라 판단된다.