• 한국가스학회지
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• 제14권4호
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• pp.6-11
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• 2010

연구실험실 사고 방지를 위하여 2005년 연구실 안전환경조성에 관한 법률이 법제화되어 국내 대학 또는 국공립출연연구소나 기업부설 연구소 실험실에서는 안전관리시스템을 구축하고, 안전점검과 정밀안전진단을 실시하고 있음에도 불구하고 폭발, 화재 등 각종 대형 사고가 지속적으로 발생하여 연구 활동 종사자의 인명 피해와 재산 손실이 상당한 수준에 이르고 있다. 또한 연구실험실에서 발생하는 사고는 유사한 내용으로 반복적으로 발생되고 있으므로 이러한 사고의 원인분석과 재발 방지를 위한 안전관리 대책이 시급하다. 따라서 본 논문에서는 국내 해외 대학 또는 국공립출연 연구소나 기업 부설 연구소 실험실에서 발생한 사건 사고에 대해 Root Cause Analysis 기법을 이용하여 사고원인 조사 결과를 보여주고, 이에 따른 실험실 사고원인 조사 분류 Map과 개선사항을 제시하여 연구실험실의 안전관리를 향상시키고자 한다.

• 대한인간공학회지
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• 제34권2호
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• pp.103-113
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• 2015

Objective: This study proposes a systematic process to present the analysis methods and solutions of organizational root causes to human errors on the railroad. Background: In fact, organizational root cause such as organizational culture is an important factor in the safety concerns on human errors in the nuclear power plant, railroad and aircraft. Method: The proposed process is as follows: 1) define analysis boundary 2) select human error taxonomy 3) perform accident analysis 4) draw root causes with FGI 5) review root causes analysis with survey 6) chart analysis of root causes, and 7) propose alternatives and solutions. Results: As a result, root causes of the organizations like railroad and nuclear power plant came from the educational problems, violations, payoff system, safety culture and so forth. Conclusion: The proposed process does predict potential railroad accident through retrospect error analysis by building new human error taxonomies and problem solution. Application: This study would contribute to examination of the relationship between human error-based accidents and organizational root causes.

• 디지털융복합연구
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• 제12권8호
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• pp.77-84
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• 2014

TRIZ는 원래 러시아인인 알트슐러에 의해 개발되어 기술 분야의 문제 해결에 활용 되어 왔지만, 최근에는 Darrell Mann에 의해 비 기술 영역에도 적용이 되기 시작하였다. 국내에는 1995년 LG전자에서 최초로 도입하여 현재는 삼성, 포스코 등 많은 기업들이 문제 해결도구로 사용하고 있다. TRIZ 문제 해결 방법은 문제를 정의하고, RCA(Root Cause Analysis)를 통해 근본원인을 찾아내어 기술적 모순과 물리적 모순을 정의 하고 있다. TRIZ는 모순을 극복하는 것이 문제를 해결하는 것이다. 본 연구는 문제 해결 방법인 TRIZ 원리를 이용하여 비기술 분야인 물류 영역의 개선에 적용하고자 하였다. 실제 "L" 기업의 물류 재작업이라는 물류 운영 개선을 하기 위해 TRIZ 방법론 중 RCA(Root Cause Analysis)분석, 모순 정의, 40가지 발명원리를 사용하여 문제 해결을 위한 아이디어 도출 및 적용 하였다. 본 연구는 TRIZ를 비기술 분야에 활용하고자 하는 향후 연구자들에게 도움이 되고자 하였다.

• 한국가스학회지
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• 제14권4호
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• pp.1-5
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• 2010

국내 대학 또는 기업 부설 연구소 실험실에서 유해화학 물질 사용 증가에 따라 가스누출 등으로 인한 폭발 화재 등 각종 대형 사고가 발생하여 사회적 이슈로 관심이 집중되었고, 실험실에서 안전관리에 대한 중요성이 강조되어 국내 대학 또는 기업 부설 연구소에서 연구 실험하는 연구 활동종사자의 생명과 신체를 보호하고, 쾌적한 실험 환경 조성을 위하여 연구실 안전환경조성에 관한 법률이 제정되었다. 국내 대학 또는 기업 부설 연구소에서는 이러한 사고 방지를 위하여 실험실 안전관리체계를 구축하고 안전점검과 정밀안전진단 등을 실시하고 있다. 이러한 조치에도 불구하고 국내 실험실에서는 사고가 지속적으로 발생하여 사고에 대한 근본원인분석이 필요한 실정이다. 이 논문에서는 국내 대학 또는 기업 부설 연구소 실험실에서 발생한 사건 사고에 대해 근본원인분석(Root Cause Analysis) 기법을 활용하여 사고 원인에 대해 분석한 결과를 보여주고, 국내 실험실의 안전관리방향을 제시 하고자 한다.

• 한국안전학회지
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• 제36권5호
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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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• 제12권1호
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• pp.42-50
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• 2021

Introduction: Despite huge investments in new technology and transportation infrastructure, terrible accidents still remain a reality of traffic. Methods: Severe traffic accidents were analyzed from four prevailing modes of today's transportations: sea, air, railway, and road. Main root causes of all four accidents were defined with implementation of the approach, based on Flanagan's critical incident technique. In accordance with Molan's Availability Humanization model (AH model), possible preventive or humanization interventions were defined with the focus on technology, environment, organization, and human factors. Results: According to our analyses, there are significant similarities between accidents. Root causes of accidents, human behavioral patterns, and possible humanization measures were presented with rooted graphs. It is possible to create a generalized model graph, which is similar to rooted graphs, for identification of possible humanization measures, intended to prevent similar accidents in the future. Majority of proposed humanization interventions are focused on organization. Organizational interventions are effective in assurance of adequate and safe behavior. Conclusions: Formalization of root cause analysis with rooted graphs in a model offers possibility for implementation of presented methods in analysis of particular events. Implementation of proposed humanization measures in a particular analyzed situation is the basis for creation of safety culture.

• 한국가스학회지
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• 제18권4호
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• pp.86-94
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• 2014

화학실험실 사고의 근본원인분석 Map을 개발하기 위하여 석유화학 사고 근본원인분석 Map을 참고하여 3단계 사고 요인 트리(Tree)로 구성된 Map을 작성하였다. 원인 인자 도표(Cause Factor Charting) 방식을 적용하여 실험실 사건 사고 211건을 1~5단계까지 사고 원인을 조사하고, 그 사고의 원인을 EXCEL 프로그램에 입력하였다. 그 후, 그 사고요인들을 유형과 각 단계별로 분류하여, 근본원인분석 Map 초안(draft)을 작성하였다. 또한, 연구실 사건 사고 211건의 근본원인이 근본원인분석 Map초안에 적절한지 재확인하였다. 향후 실험실에서 발생할 수 있는 사고의 원인들을 보완함으로써, 화학실험실에 관한 RCA Map이 개발되었다. 본 연구에서 제시한 근본원인분석 Map을 기반으로 발생빈도를 고려하여 사고 원인을 1~5단계로 나누어 분석한 결과, 3단계 원인은 관리시스템 35.%, 모니터링 12.2%, Human Factor Eng. 15.1%, 교육훈련 12.1% 등의 순으로 나타났다.

• 대한치과교정학회지
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• 제51권4호
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• pp.241-249
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• 2021

Objective: This study aimed to evaluate the volume, amount, and localization of root resorption in the maxillary first premolars using micro-computed tomography (micro-CT) after expansion with four different rapid maxillary expansion (RME) appliances. Methods: In total, 20 patients who required RME and extraction of the maxillary first premolars were recruited for this study. The patients were divided into four groups according to the appliance used: mini-implant-supported hybrid RME appliance, hyrax RME appliance, acrylic-bonded RME appliance, and full-coverage RME appliance. The same activation protocol (one activation daily) was implemented in all groups. For each group, the left and right maxillary first premolars were scanned using micro-CT, and each root were divided into six regions. Resorption craters in the six regions were analyzed using special CTAn software for direct volumetric measurements. Data were statistically analyzed using Kruskal-Wallis one-way analysis of variance and Mann-Whitney U test with Bonferroni adjustment. Results: The hybrid expansion appliance resulted in the lowest volume of root resorption and the smallest number of craters (p < 0.001). In terms of overall root resorption, no significant difference was found among the other groups (p > 0.05). Resorption was greater on the buccal surface than on the lingual surface in all groups except the hybrid appliance group (p < 0.05). Conclusions: The findings of this study suggest that all expansion appliances cause root resorption, with resorption craters generally concentrated on the buccal surface. However, the mini-implant-supported hybrid RME appliance causes lesser root resorption than do other conventional appliances.

• 한국유체기계학회 논문집
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• 제3권4호
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• pp.7-14
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• 2000

This paper provides integrity evaluation and root cause analysis for defects observed at volute tongue, or cutwater, of the operating centrifugal pump in power plant. The cause of the cracks are analyzed and reviewed from the viewpoint of the operation and maintenance of the pumps, and the sample obtained from the cracked volute tongue of the pump are examined. At first, in-situ hardness test and microstructure examination were performed to understand the cause of cracking at volute tongue. The evaluation of structural integrity and the possibility of the crack propagation is also evaluated. Cracks were typical intergranular cracking and propagated along with prior austenite grain boundary. At easing volute tongue, the hardness was higher than ASTM requirement and a large amount of intergranular Cr carbide was precipitated. These were due to high C content in material. P content was also higher than ASTM requirement. Therefore, Cr carbide precipitation and P segregation at grain boundary, caused by higher C and P content in material, resulted in intergranular cracking of casing volute tongue. This procedure for integrity evaluation and root cause analysis is used to guide, and support the pump designer and manufacturer's material selection and process design to avoid a costly, unplanned outage of plant.

• 한국마이크로전자및패키징학회:학술대회논문집
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• 한국마이크로전자및패키징학회 2002년도 International Symposium
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• pp.79-94
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• 2002

Root cause -Thermal expansion coefficient mismatch -Tape warpage -Initial die crack (die roughness) Guideline for failure prevention -Optimized tape/Substrate design for minimizing the warpage -Fine surface of die backside Root cause -Thermal expansion coefficient mismatch - Repetitive bending of a signal trace during TC cycle - Solder mask damage Guideline for failure prevention - Increase of trace width - Don't make signal trace passing the die edge - Proper material selection with thick substrate core Root cause -Thermal expansion coefficient mismatch -Creep deformation of solder joint(shear/normal) -Material degradation Guideline for failure Prevention -Increase of solder ball size -Proper selection of the PCB/Substrate thickness -Optimal design of the ball array -Solder mask opening type : NSMD -In some case, LGA type is better