• Journal of the Korean Society of Marine Environment & Safety
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• v.27 no.1
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• pp.1-12
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• 2021

The International Maritime Organization (IMO) is promoting the introduction of e-Navigation that prevents maritime accidents by fusion of Information & Communication Technology (ICT) with ship operation technology. In Korea, Korean e-Navigation is also being developed for fishing vessels and small vessels sailing offshore, which are vulnerable to maritime accidents. However, for the successful development of Korean e-Navigation, it is necessary to develop an indicator that can evaluate the development performance so that the development performance that has been progressed so far can be evaluated and the development direction can be re-established. Therefore, this study attempted to develop an evaluation index tailored to the development goal of e-Navigation service centering on the collision accident, which is a major maritime accident. In this study, a collision accident evaluation index for e-Navigation service was developed by deriving and quantifying the root cause of maritime collision accidents using Root cause analysis(RCA) and fault tree analysis (FTA) techniques. This indicator is considered to be helpful in reducing maritime accidents as it is used as a development indicator for e-Navigation and an indicator for maritime collision accident analysis.

• Journal of Digital Convergence
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• v.15 no.8
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• pp.69-83
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• 2017

This study aims to analyze the causes of a new product failure by using system safety methods, focusing on the case of Samsung Galaxy Note7. However, when analyzing the causes of a product failure, if only technical problems are too emphasized, it is likely to miss other more meaningful causes of a failure. Thus, we claim that the root causes of a product failure should be identified in a broad perspective of integrated systems that include non-technical as well as technical elements. With this viewpoint, we investigated the failure of Samsung Galaxy Note7, by using Root Cause Analysis(RCA) and Fault Tree Analysis (FTA). The results showed that it is necessary to address not only the technical issues but also other non-technical issues, such as a very impetuous launch of a new product due to a very tough competition in the market. Additionally, we also found that RCA and FTA could be a useful tool for analyzing the causes of a new product failure from the viewpoint of an integrated system comprising technical and management elements.

• Quality Improvement in Health Care
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• v.19 no.2
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• pp.50-64
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• 2013

Objectives : Suicide is a serious sentinel event in healthcare organization. Suicide and suicidal attempt are fatal and long lasting mental and physical damage to themselves, family, and medical staffs. To develope the system to prevent suicidal accident in hospital, we reviewed and analysed one case of suicidal sentinel event. Methods: The risks of suicidal sentinel event were evaluated and analysed through the root cause analysis and failure mode effects analysis. Result: We found several root causes such as initial assessment of oldest patient and security issues. Couple of action plans to fix the problems were done immediately. According to failure mode, we evaluate the risk priority number to modify the action plans. Conclusion: To reduce the risk of sentinel events, we reviewed the suicidal event and established the new system and action plan to prevent sentinel events.

• Journal of Auto-vehicle Safety Association
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• v.13 no.3
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• pp.32-40
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• 2021

Composite material is very attractive because it has excellent mechanical property and is possible to lightweight due to the low density. However, composite material is less used compared to other systems in the chassis system because it is very hard to solve NVH problem when composite material is applied to vehicle. Especially, reducing squeal noise of composite brake system is essential to apply it to vehicle successfully. In this paper, we present a new solution to reduce squeal noise of composite brake system. To achieve this goal, we analyze main causes of noise using RCA (Root Cause Analysis), CA (Contradiction Analysis) and sequentially get IFR (Ideal Final Result) to solve the problem. Next, we define the function of composite brake system and derive control factors and noise factors. A variety of tests for factors like chamfer, slot, damping shim, underlayer of brake pad are done. In addition, we analyze level of contribution for control factors theoretically. Finally, we get the effective solution for reducing squeal noise.

• The Journal of Korean Institute for Practical Engineering Education
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• v.5 no.1
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• pp.66-72
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• 2013

An Education-Industrial cooperative system is a systematic effort that industrial body and educational body cooperate with each other in order to achieve two different purposes. This paper suggested an education-industrial cooperative system model based on the experiential learning through cooperating with the industry. SEARIM, the research activities company is received the guideline for the improvement and management of quality regarding products by using TRIZ/6-sigma. Also, we evaluated and analyzed the product of this study result based on the result a survey.

• Korean Chemical Engineering Research
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• v.57 no.5
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• pp.637-651
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• 2019

In the event of a major accident such as an explosion in a refinery or a petrochemical plant, it has caused a serious loss of life and property and has had a great impact on the insurance market. In the case of catastrophic incidents occurring in process industries such as refinery and petrochemical plants, only the proximate causes of loss have been drawn and studied from inspectors or claims adjustors responsible for claims of property insurers, incident cause investigators, and national forensic service workers. However, it has not been done well for conducting root cause analysis (RCA) and identifying the factors that contributed to the failure and establishing preventive measures before leading to chemical plant's catastrophic incidents. In this study, the criteria of warning signs on CCPS catastrophic incident waning sign self-assessment tool which was derived through the RCA method and the contribution factor analysis method using the swiss cheese model principle has been reviewed first. Secondly, in order to determine the major incident warning signs in an actual chemical plant, 614 recommendations which have been issued during last the 17 years by loss control engineers of global reinsurers were analyzed. Finally, in order to facilitate the assessment index for catastrophic incident warning signs, the criteria for the catastrophic incident warning sign index at chemical plants were grouped by type and classified into upper category and lower category. Then, a catastrophic incident warning sign index for a chemical plant was developed using the weighted values of each category derived by applying the analytic hierarchy process (pairwise comparison method) through a questionnaire answered by relevant experts of the chemical plant. It is expected that the final 'assessment index for catastrophic incident warning signs' can be utilized by the refinery and petrochemical plant's internal as well as external auditors to assess vulnerability levels related to incident warning signs, and identify the elements of incident warning signs that need to be tracked and managed to prevent the occurrence of serious incidents in the future.