• 한국철도학회:학술대회논문집
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• 한국철도학회 2007년도 추계학술대회 논문집
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• pp.859-864
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• 2007

The rolling stock which is used the most frequently by public transportation has to secure reliability and safety. In these, vibration is the important factor which causes of serious problem of rolling stock. By the way, rolling stocks vibration test specific activity that is using translating JIS standard is serious mistake, but it is actuality that is used until present more than ten years. Study wishes to analyze problem of standard of domestic rolling stocks and present countermeasure.

• 산업경영시스템학회지
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• 제2권2호
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• pp.105-110
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• 1979

The purpose of this study is to find the problems of I.E, and solve the problems. Compared with other parts, production-control's theory and practice do not always go hand in hand. But, we must rectify these mistake. In order to grasp the situation, this paper inquire the real condition centering around the Busan's 117 enterprises.

• 한국안전학회지
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• 제15권1호
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• pp.53-58
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• 2000

In a car accident in Kyongju, each of the two occupants insisted that he was not driving the car. The accident was investigated to determine who the driver is through careful review of the collision report, the statements of accident and witness, photographs taken at the scene, and the expert report of the National Institute of Scientific Investigation. The accident was reconstructed based on the physical principles, injuries of occupants, damages of the involved vehicles and their final stops. A mistake was found in the expert report.

• 대한안전경영과학회지
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• 제8권2호
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• pp.39-49
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• 2006

Forklift achieves transportation of freight and continues loading and unloading work repeatedly long for hours in industry spot. Therefore, drivers feel tired make a mistake for wrong operation of vehicle caused by continuous work. These components are resulted in CTDs, some industrial accident. That is the forklift need to ergonomics access. So, in this paper, requirements of forklift user were abstracted using questionnaire, produced important design factor for pedal and lever using QFD(Quality Function Deployment), and then suggested ergonomic considerations for industrial accident prevention.

• 한국재난정보학회 논문집
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• 제8권1호
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• pp.93-99
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• 2012

본 연구는 문헌연구를 기초로 기계경비서비스의 공급자인 기계경비업체의 서비스 담당자와 인터뷰를 실시하여 그 결과를 분석하여 오경보 관리방안을 제시하였다. 고객의 실수로 인한 오경보를 줄이기 위해 고객 시설의 특성에 맞는 교육도구의 제공이 필요하며, 고객의 실수에 의해 불필요한 출동이 이루어 졌을 경우 일정한 금액의 출동수수료를 고객에게 부과할 수 있는 제도적 합의를 도출할 필요가 있다. 기기의 결함 및 설치 등으로 인해 발생하는 오경보 문제를 개선하기 위하여 기기의 기술기준과 설치기준을 표준화 하는 것이 필요하며, 오경보에 영향을 많이 주는 열선감지기의 성능을 개선하기 위한 새로운 형태의 감지기 개발이 필요하다. 오경보에 대한 용어의 정의와 사용자에 대한 오경보 방지 교육내용을 보다 전문적이고 세부적인 가이드라인 형태로 규정화 하는 것이 필요하다.

• 한국전통조경학회지
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• 제33권2호
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• pp.58-66
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• 2015

본 연구는 고려시대 및 조선시대 고문헌에 출현한 녹나무의 기록을 고찰한 논문이다. 녹나무의 한자 표기인 '장(樟)' 자를 바탕으로 녹나무의 정의와 용도를 살펴보았고, 현대적 개념과의 오류 사례를 분석하여 다음과 같은 가능성을 제시하고자하였다. 첫째, 녹나무에 대한 정의와 사례를 분석한 결과, 현재 녹나무로 해석되는 남(枏) 남(楠) 예(豫) 장(樟) 가운데, '장(樟)'이 현대적인 개념의 녹나무에 가장 부합한 것으로 나타났다. 둘째, 과거의 기록에서 녹나무가 생육 불가능한 지역에 출현하는 모습을 확인하였는데, 녹나무는 대표적인 남부수종이니 녹나무가 아닌 다른 나무를 녹나무라 지칭한 오류로 사료된다. 셋째, 다른 수종과 오인한 사례들을 추적하여 기록을 고찰한 결과, 이규경의 "오주연문장전산고" 중 "침뇌변증설"에서 모감주나무와 혼동했을 가능성이 확인되었다. 이상 본 연구에서 살펴본 녹나무의 경우 외에도 여타 문헌에 나타난 오류 사례의 검증이 요구된다. 또한 현대의 성상별 기준과 문헌의 대조를 통해 선별하는 과정을 병행하여, 녹나무에 대한 새로운 가능성을 도출할 후속연구를 기대하는 바이다.

• 전자공학회논문지SC
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• 제37권4호
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• pp.42-48
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• 2000

일반적으로 시술자가 환자에게 마취를 할 때에는 매우 주의하여야 한다. 만약 잘못 시행 될 때는 환자는 매우 위험한 상황에 빠지게 된다. 본 논문에서는 잘못 시술이 발생 될 수 있는 몇몇 위험요소들을 사전에 예방하기 위하여 시스템의 정밀성과 사용자의 편리성을 고려하여 구현하는 것을 목표로 하였다. 특히 시스템에서 전자적인 부분은 스위치와 엔코더를 이용하여 사용자 인터페이스에서 조작을 편리하게 하고, 그래픽 액정화면 표시기를 이용하여 환자의 기도압과 이산화탄소 파형을 실시간 모니터링 기능을 구현하였다. 또한 설정값의 정밀한 제어를 위해 기계적인 부분에서 유량 제어 밸브와 유량 센서를 이용하여 피드백 유량 제어 시스템을 구현하였다. 이러한 기술을 개발함으로써 시술자에게 설정치 조작의 편리성과 정확성을 가져다줄 뿐만 아니라 환자의 상태와 여러 가지 변수들의 허용 범위를 넘을 경우 정확하고 신속하게 정보를 알려줌으로서 마취기용 인공 호흡기의 안정성과 신뢰성이 확보될 수 있음을 알 수 있었다.

• 대한인간공학회지
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• 제32권1호
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• pp.9-16
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• 2013

Objective: The aim of this study is to investigate a trend of human error types observed in a series of verification and validation experiments for an Advanced Control Room(ACR) equipped with Lager Display Panel(LDP), Work Station Flat Panel Display(WS FPD), list type Alarm System(AS), Soft Control(SC) and Computerized Procedure System(CPS). Background: Operator behaviors in a fully computerized control room are quite different from those in a traditional hard-wired control room. Operators in an ACR all together monitor plant status and variables through their own interface system such as LDP and WS FPD, are notified of abnormal plant status through their own list type AS, control the plant through their own SC, and follow the structured procedure through their own CPS whereas operators in a traditional control room only separately do their duty directed by their supervisor. Especially the secondary task such as manipulating the user interface of ACR can be an extra burden to all the operators including the supervisor. Method: The Reason's human error classification method was applied to operators' behavioral data collected from a series of verification and validation experiments where operators showed their plant operational behaviors under a couple of harsh scenarios using the ACR simulator. Results: As operators accustomed to the new ACR system, knowledge or rule based mistakes appearing frequently in the early series of experiments decreased drastically in the latest stage of the series. Slip and lapse types of errors were observed throughout the series of experiments. Conclusion: Education and training can be one of the most important factors for the operators accustomed to the traditional control room to be adapted to the new system and to run the ACR successfully. Application: The results of this study implied that knowledge or rule based mistakes can be reduced by training and education but that lapse type errors might be reduced only through innovative improvement in human-system interface design or teamwork culture design including a new leadership style suitable for ACR.

• 한국의학물리학회:학술대회논문집
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• 한국의학물리학회 2002년도 Proceedings
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• pp.11-12
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• 2002

Accidental overexposures by radiotherapy have gathered attention recently in Japan. The widely publicized accidents have occurred at the government official benefit society hospital and at the hospital affiliated to a medical school. The accident at the government official benefit society hospital occurred when one of two existing accelerators was renewed. A radiotherapy planning system was also introduced at that time. Then treatment planning for the old and the new linear accelerator was performed using the system. There were variations in wedge factors for the 30 degrees wedge filter between the old and the new linear accelerator. That is, the difference in the structure of the wedge filter (30 degrees) resulted in variations of the wedge factors between both accelerators. In order to keep strength, a lead board was backed to the lead wedge filter for the new linear accelerator, whereas the wedge filter for the old one was made of the iron. The X-ray attenuation of the iron wedge filter is smaller than that of the lead wedge filter. The basic beam data of the old linear accelerator, however, wasn't delivered properly between the user and the maker. Then, the accident took place because the same wedge factor was used for the old and the new linear accelerator. On the other hand, the accident which occurred at the university hospital was brought about by the input mistake in initialization of the computer system when a linear accelerator was introduced. The input mistake was found when the software of the system was updated. If the dose had been measured and confirmed adequately, the accidents could have been prevented in both cases.

• 의료법학
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• 제15권2호
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• pp.435-459
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• 2014

Supreme Court of Korea has been mitigating the burden of proof on the malpractice and causal relation by a patient in accordance with the practical transfer of such burden of proof on causal relation as well as relieving a doctor's burden of proof on mistake in the civil damage claim suits on the malpractice. However, a prosecutor shall strictly prove the causal relation between malpractice and unfavorable results as well as a doctor's mistake in the criminal cases for making a doctor accept the professional negligence resulting in death or injury in accordance with In Dubio Pro Reo principles. Furthermore, it shall not be allowed to relieve the burden of proof on malpractice and causal relation which has been frequently applied in the civil proceedings. Nevertheless, it was widely known that the front-line courts accepted the malpractice and causal relation by quoting the legal principles on relieving the burden of proof on malpractice and causal relation applied in the civil cases even in criminal cases with no or insufficient proof on malpractice or causal relation. However, the latest precedents in Supreme Court explicitly declared the opinion that there was no reason to apply the legal principle to relieve the burden of proof on the malpractice and causal relation in the criminal cases requiring the proof 'which doesn't cause any reasonable doubt' on malpractice and causal relation in accordance with the legal principles 'favorable judgment for a defendant in case of any doubt' on the basis of the strict principle of 'nulla poena sine lege.' Accordingly, Supreme court definitely clarified that there would be no reason to relieve the burden of proof on malpractice and causal relation in criminal cases by reversing several original judgments accepting malpractice and causal relation even though there were no strict evidence.