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HFACS-K: A Method for Analyzing Human Error-Related Accidents in Manufacturing Systems: Development and Case Study (제조업의 인적오류 관련 사고분석을 위한 HFACS-K의 개발 및 사례연구)

  • Lim, Jae Geun;Choi, Joung Dock;Kang, Tae Won;Kim, Byung Chul;Ham, Dong-Han
    • Journal of the Korean Society of Safety
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    • v.35 no.4
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    • pp.64-73
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    • 2020
  • As Korean government and safety-related organizations make continuous efforts to reduce the number of industrial accidents, accident rate has steadily declined since 2010, thereby recording 0.48% in 2017. However, the number of fatalities due to industrial accidents was 1,987 in 2017, which means that more efforts should be made to reduce the number of industrial accidents. As an essential activity for enhancing the system safety, accident analysis can be effectively used for reducing the number of industrial accidents. Accident analysis aims to understand the process of an accident scenario and to identify the plausible causes of the accident. Accident analysis offers useful information for developing measures for preventing the recurrence of an accident or its similar accidents. However, it seems that the current practice of accident analysis in Korean manufacturing companies takes a simplistic accident model, which is based on a linear and deterministic cause-effect relation. Considering the actual complexities underlying accidents, this would be problematic; it could be more significant in the case of human error-related accidents. Accordingly, it is necessary to use a more elaborated accident model for addressing the complexity and nature of human-error related accidents more systematically. Regarding this, HFACS(Human Factors Analysis and Classification System) can be a viable accident analysis method. It is based on the Swiss cheese model and offers a range of causal factors of a human error-related accident, some of which can be judged as the plausible causes of an accident. HFACS has been widely used in several work domains(e.g. aviation and rail industry) and can be effectively used in Korean industries. However, as HFACS was originally developed in aviation industry, the taxonomy of causal factors may not be easily applied to accidents in Korean industries, particularly manufacturing companies. In addition, the typical characteristics of Korean industries need to be reflected as well. With this issue in mind, we developed HFACS-K as a method for analyzing accidents happening in Korean industries. This paper reports the process of developing HFACS-K, the structure and contents of HFACS-K, and a case study for demonstrating its usefulness.

A Study of Trends in Continuing Education Published in the Korean Nurse (간호협회지를 통해 본 보수교육의 역사적 경향 1962년 ~ 1995년)

  • Shin, Sung-Rae;Kim, Kyung-Sun;Lee, Sook
    • The Korean Nurse
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    • v.35 no.2
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    • pp.52-70
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    • 1996
  • This historical research was conducted to analyze and categorize the titles which were presented in the journal, The Korean Nurse, from August 1962 to October 1995. Titles which were published with the purpose of educating graduate nurses and to update 0 their nursing knowledge to improve professional practice were included. There were 348 articles published from the beginning of publication in August, 1962 to October, 1995. All of the journals were reviewed except nine missing journals which were not available in any library. According to the characteristics of the articles in the periodical, the articles were divided into three periods. In each of the three peroids there were five categories: Subject, Clinical Practice, Fundamentals of Nursing Science, Nursing Administration, Others. These categories were adopted from Kim's(1994) division system which was developed to analyze nurse's insurance education program. The special feature peroid was from August, 1962 to December, 1974. In this period the articles were presented in an unorganized manner in the area of special feature or main issue. The largest area was the subject category(44%). The second largest area wes the fundamental of nursing science category(31%). From May, 1975 to December, 1977, the articles with the educational purposes were published in a designated area called continuing education. This period was labelled as the continuing education period. Among the published articles in this period, 45% focused on the subject category and 45% on the fundamentals of nursing science category. In this period the articles were focusing on nurses 'work in specific areas such as industry, nurses' aid schools, and nursing administration, articles on physical assessment first started to appear. The written continuing education period was from January 1978 to October, 1995. All the educational articles published in this area were analyzed and categorized into five areas as for the other periods. 48% of the articles focused on the subject category. In the mid-eighties, the term nurse specialist first.appeared and ten years later in 1990, the titles were subdivided into more specific titles, such as, home nursing, industrial nursing, emergency nursing, 23% were in the fundamental nursing science category and they dealt with nursing process, nursing theories, theory development. For the content analysis, three articles, one from each period, dealing with cardiovscular diseases were selected for comparsion. First, the special feature period, the title of the article was on diet therapy for cardiovascular disease patients, but instead the content was about rest, hygiene, medication, observation. They recommended rings to prevent bed sores, which is now considered as a cause for bed sores. In the continuing education period, the content was more focused on rehabilitation rather than general nursing .care. It became more specific, systematic, and organized compared with the special feature period. In the written continuing education period, the focus was on rehabilitation, not broadly, but very specifically on exercise. The further research on the content analysis is recommended along with a comparison of the trends in the Journal of Nurses Academic Society.

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Stability Characteristics based on Crane Weight of Small Fishing Vessels Under Standard Loading Conditions: Investigation Report of the Capsize Accident at Goseong Port (크레인 교체에 따른 표준재화 상태에서의 소형 어선의 복원성 특성 - 고성항 전복 사고 재결서 중심 -)

  • Kang, Dae Kon;Lee, Gun Gyung;Lee, Jun Ho;Han, Seung Hun
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.26 no.1
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    • pp.22-30
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    • 2020
  • In March 2016, a 6.67-ton fishing boat capsized owing to the loss of stability during crane operations. Capsizing occurs when a boat or ship is flipped over (or turned upside down) for reason other than accidents caused by collisions, contact, stranding, fire or explosion. Over the past nine years (2010-2018), capsize accidents have accounted for 2.34 % of all marine accidents and are gradually increasing. The loss of stability from improper shipping is the main cause of most capsizes, especially for small fishing vessels weighing 10 tons. According to the Fishing Vessel Act, small fishing vessels weighing less than a ton are exempted from inspections on stability and load cranes. This study analyzes the issue cited as the reason for the capsizing of the small fishing boat in Goseong, namely, the reduction of restoring moment due to increased weight of the crane. Fishing boats with similar loading conditions were modeled on the basis of re-determination, and their stability before and after the accident was assumed. The fishing boats with heavier cranes were found to be at higher risk of capsizing owing to the reduction of the restoring moment and the angle of deck immersion. Under standard loading conditions, the stability moments of fishing vessels are lesser during fishing, compared to when they depart from or arrive at the port.

A Study on Legal Argument to the Overstorage Charge on the Long Storage Containers (장기체화 화물에 대한 경과보관료 적용에 관한 법률쟁점 - 부산지방법원 2011. 8. 18. 2009가합14442 판결 평석 -)

  • Ji, SangGyu
    • Journal of Korea Port Economic Association
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    • v.28 no.4
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    • pp.275-298
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    • 2012
  • Terminal operators have provided special services such as loading, discharging, stowage of cargo to the owner, and carriers of the sea, which contribute the domestic and international logistics. For smooth flow of logistics, container terminal should reserve spaces for inbound and outbound logistics. However, if it is unable to provide the spaces, which can be caused by labour strikes or terminal lockouts and so on, national logistic system and financial management of terminal operators can be seriously affected. In order to minimize these kinds of problems, terminal operators impose high rate of charges ("overstorage charge") to the accumulated cargoes and/or containers, which are stipulated in terminal service agreement. Nevertheless, if there is no terminal service agreement with an owner of cargo and/or container, any kind of charge can cause legal problems (conflict ??) between the cargo and terminal operator. In this regard, I would like to study on the definition of overstorage charge and the legal issue of it based on the Busan district court's judgment. In particular, I will propose a special right of commercial lien and public auction for terminal operators to settle accumulated cargoes in container terminal.

Design and Evaluation of a Reservation-Based Hybrid Disk Bandwidth Reduction Policy for Video Servers (비디오 서버를 위한 예약기반 하이브리드 디스크 대역폭 절감 정책의 설계 및 평가)

  • Oh, Sun-Jin;Lee, Kyung-Sook;Bae, Ihn-Han
    • The KIPS Transactions:PartB
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    • v.8B no.5
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    • pp.523-532
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    • 2001
  • A Critical issue in the performance of a video-on-demand system is the required I/O bandwidth of the Video server in order to satisfy clients requests, and it is the crucial resource that may cause delay increasingly. Several approaches such as batching and piggybacking are used to reduce the I/O demand on the video server through sharing. Bathing approach is to make single I/O request for storage server by grouping the requests for the same object. Piggybacking is th policy for altering display rates of requests in progress for the same object to merge their corresponding I/O streams into a single stream, and serve it as a group of merged requests. In this paper, we propose a reservation-based hybrid disk bandwidth reduction policy that dynamically reserves the I/O stream capacity of a video server for popular videos according to the loads of video server in order to schedule the requests for popular videos immediately. The performance of the proposed policy is evaluated through simulations, and is compared with that of bathing and piggybacking. As a result, we know that the reservation-based hybrid disk bandwidth reduction policy provides better probability of service, average waithing time and percentage of saving in frames than batching and piggybacking policy.

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A Revisit to the Recent Human Error Events in Nuclear Power Plants Focused to the Organizational and Safety Culture

  • Lee, Yong-Hee
    • Journal of the Ergonomics Society of Korea
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    • v.32 no.1
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    • pp.117-124
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    • 2013
  • Objective: This paper presents additional considerations related to organization and safety culture extracted from recent human error incidents in Korea, such as station blackout(i.e., SBO) in Kori#1. Background: Safety culture has been already highlighted as a major cause of human errors after 1986 Chernobyl accident. After Fukushima accident in Japan, the public acceptance for nuclear energy has taken its toll. Organizational characteristics and culture became elucidated as a major contributor again. Therefore many nuclear countries are re-evaluating their safety culture, and discussing any preparedness and its improvement. On top of that, there was an SBO in 2012 in the Kori#1. Korean public feels frustrated due to the similar human errors causing to a catastrophe like Fukushima accident. Method: This paper reassesses Japan's incidents, and revisits Korea's recent incidents. It focuses on the analysis of the hazards rather than the causes of human errors, the derivation of countermeasures, and their implementation. The preceding incidents and conclusions from Japanese experience are also re-analyzed. The Fukushima accident was an SBO due to the natural disaster such as earthquakes and a successive tsunami. Unlike the Fukushima accident, the Kori#1 incident itself was simple and restored without any loss and radioactive release. However, the fact that the incident was deliberately concealed led to massive distrust. Moreover, the continued violation of rules and organized concealment of the accident are serious signs of a new distorted type of human errors, blatantly revealing the cultural and fundamental weakness of the current organization. Result: We should learn from Japanese experiences who had taken pride in its safety technology and fairly high confidence in safety culture. Japan's first criticality accident in JCO facility splashed cold water on that confidence. It has turned out to be a typical case revealing the problems in the organization and safety culture. Since Japan has failed to gain lessons and countermeasure, the issue persists to the Fukushima incident. Conclusion: Safety culture is not a specific independent element, which makes it difficult to either evaluate it properly or establish countermeasures from the lessons. It may continue to expose similar human errors such as concealment of incident and manipulation of bad data. Application: Not only will this work establish the course of research for organization and safety culture, but this work will also contribute to the revitalization of Korea's nuclear industry from the disappointment after the export contract to UAE.

An Efficient Weight Signaling Method for BCW in VVC (VVC의 화면간 가중 양예측(BCW)을 위한 효율적인 가중치 시그널링 기법)

  • Park, Dohyeon;Yoon, Yong-Uk;Lee, Jinho;Kang, Jungwon;Kim, Jae-Gon
    • Journal of Broadcast Engineering
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    • v.25 no.3
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    • pp.346-352
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    • 2020
  • Versatile Video Coding (VVC), a next-generation video coding standard that is in the final stage of standardization, has adopted various techniques to achieve more than twice the compression performance of HEVC (High-Efficiency Video Coding). VVC adopted Bi-prediction with CU-level Weight (BCW), which generates the final prediction signal with the weighted combination of bi-predictions with various weights, to enhance the performance of the bi-predictive inter prediction. The syntax element of the BCW index is adaptively coded according to the value of NoBackwardPredFlag which indicates if there is no future picture in the display order among the reference pictures. Such syntax structure for signaling the BCW index could violate the flexibility of video codec and cause the dependency issue at the stage of bitstream parsing. To address these issues, this paper proposes an efficient BCW weight signaling method which enables all weights and parsing without any condition check. The performance of the proposed method was evaluated with various weight searching methods in the encoder. The experimental results show that the proposed method gives negligible BD-rate losses and minor gains for 3 weights searching and 5 weights searching, respectively, while resolving the issues.

A Study on Cooling Performance and Exergy Analysis of Desiccant Cooling System in Various Regeneration Temperature and Outdoor Air Conditions (재생온도와 외기조건 변화에 따른 제습 냉방시스템의 냉방 성능 및 엑서지 해석에 관한 연구)

  • Lee, Jang Il;Hong, Seok Min;Byun, Jae Ki;Choi, Young Don;Lee, Dae Young
    • Transactions of the Korean Society of Mechanical Engineers B
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    • v.38 no.5
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    • pp.413-421
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    • 2014
  • Desiccant cooling system is an air conditioning system that uses evaporative cooler to cool air and it can perform cooling by using heat energy only without electrically charged cooler. Thus, it can solve many problems of present cooling system including the destruction of ozone layer due to the use of CFC[chloro fluoro carbon] affiliated refrigerants and increase of peak power during summer season. In this study, cooling performance and exergy analysis was conducted in order to increase efficiency of desiccant cooling system. Especially, using exergy analysis based on the second law of thermodynamics can resolve the issue related to system efficiency in a more fundamental way by analyzing the cause of exergy destruction both in whole system and each component. The purpose of this study is to evaluate COP[coefficient of performance], cooling capacity and exergy performance of desiccant cooling system incorporating a regenerative evaporative cooler in various regeneration temperature and outdoor air conditions.

DNDC Modeling for Greenhouse Gases Emission in Rice Paddy of South Korea and the Effect of Flooding Management Change and RCP 8.5 Scenario (RCP 8.5 시나리오와 관수 기법의 변화에 따른 논에서의 온실가스 배출 변화의 DNDC 모델을 통한 모의)

  • Min, Hyungi;Kim, Min-Suk;Kim, Jeong-Gyu;Hwang, Wonjae
    • Ecology and Resilient Infrastructure
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    • v.5 no.3
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    • pp.189-198
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    • 2018
  • In 21th century, climate change is one of the fundamental issue. Greenhouses gases are pointed as the main cause of climate change. Soil play a vital role of carbon sink and also can be a huge source of greenhouse gases defense on the management. Flux of greenhouse gases is not the only factor can be changed by climate change. Climate change can alter proper management. Temperature change will modify crop planting and harvesting date. Other management skills like fertilizer, manure, irrigation, tillage can also be changed with climate change. In this study, greenhouse gases emission in rice paddy in South Korea is simulated with DNDC model from 2011 - 2100 years. Climate for future is simulated with RCP 8.5 scenario for understanding the effect of climate change to greenhouse gases emission. Various rice paddy flooding techniques were applied to find proper management for future management. With conventional flooding technique, climate change increase greenhouse gases emission highly. Marginal flooding can decrease large amount of greenhouse gases emission and even it still increases with climate change, it has the smallest increasing ratio. If we suppose the flooding technique will change for best grain yield, dominant flooding technique will be different from conventional flooding to marginal flooding. The management change will reduce greenhouse gases emission. The result of study shows the possibility to increase greenhouse gases emission with climate change and climate change adaptation can show apposite result compared without the adaptation.

Research Review on Turfgrass Disease in Korea (한국의 잔디병해 연구사)

  • Shim, Gyu Yul;Lee, Jung Han
    • Weed & Turfgrass Science
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    • v.7 no.2
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    • pp.87-97
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    • 2018
  • Turfgrass provides various beneficial effects to our societies such as recreation, aesthetic components, and other public service. Diseases in turfgrass is the major issue, which cause quality problems in golf courses, playgrounds, parks and cultivation areas, and tremendous cost is required to prevent the diseases. Research activity and investigation for turfgrass disease remain to be further attributed when compared to other crops in Korea. In this study, we present previously reported turfgrass diseases researches, especially caused by fungal pathogens, and review the history of turfgrass research activity in Korea to contribute future turfgrass research direction. Research papers were searched and analyzed using Korea Educational and Research Information Service (www.riss.kr). More than eighty papers presented turfgrass diseases and among the papers, 50% were published in Korean Journal of Turfgrass. Half of the papers reported turfgrass diseases control. Research articles about large patch disease were the majority (36%), followed dollar spot (18%), Pythium blight (10%) and Typhular blight (8%). Number of the first disease reports in Korea were total fifteen. Total 542 fungicides have been registered in Korea to prevent turfgrass diseases and most of the fungicides were for brown patch, rust, yellow patch, dollar spot, snow mold, summer patch, anthracnose, Pythium blight, powdery mildew and algae. And we will also need to conduct ecological studies on turf diseases and to develop control methods with improved efficacy and environmentally-friend sound. Researches on epidemiology of turfgrass diseases which deals with the incidence, distribution, and interactions with other factors will be also greatly favored for precise control prescription, timing of control and use of less pesticides.