• 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.

• 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.

• 동력기계공학회지
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• 제9권1호
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• pp.57-63
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• 2005

In the calendar and the advertising catalog, the surface is usually coated by coating polypropylene film. The delamination failure of coating film depends on surface roughness and quality of the substrate paper. In this paper, the mechanisms of delamination failure between the coating film and the paper is investigated by using the root cause analysis as one of techniques of reliability evaluation. The papers used in failure analysis are three kind products made by two domestic and one foreign companies. It found that the main causes of delamination failure between the coating film and the paper were the creation of microvoids caused by shape of filler and their growth caused by contraction of paper.

• 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.

• 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.

• 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.

• 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.

• 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.

• 산업경영시스템학회지
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• 제38권1호
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• pp.101-109
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• 2015

This paper suggests a procedure to define business process improvement (BPI) projects with analysis results based on the cause-and-effect chain. The procedure developed in this paper focuses on eliminating root causes of business problems resulted from abnormal events occurred in business process executions. First, we develop three criteria used to make clusters of the root causes where a cluster of root causes will be eliminated together by a BPI project defined based on the cluster. Second, we develop a method to formulate desired expectations from the BPI project. Also, we suggest a method to calculate the relative importance of the BPI projects that help a BPI organization determine priorities of them. We illustrate the procedure and the methods with some examples for the domestic mail delivery process in the postal service industry.

• 대한건축학회논문집:구조계
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• 제35권8호
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• pp.157-168
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• 2019

Modular Construction is regarded as having enhanced safety compared to traditional construction since most of modular manufacturing process in plants. Unlike general consideration for safety in modular construction, several industrial accident data and studies have pointed out that the accident rate of modular construction is not enough less as much as the practitioners have expected. It means that there is a clear need for improvement of safety management in modular construction. To enhance safety, it is necessary to identify the type and cause of accident through accident cases in order to prevent safety accident in advance. In this consideration, this study analyzed the types and causes of accidents through root cause analysis procedure with accident cases of U.S. OSHA. The classification was carried out in the order of process type, accident type and cause of accident. By following the classification criteria in this study, the causal factor was derived and the root cause map was created. Based on the analysis results, cross-analysis was conducted and it is shown that activity characteristics of modular construction are related to safety accidents. In addition, prevention methods to reduce safety accident by major activity are presented in terms of organizational, educational and technical aspects. This study contributes that the result can be used as the basic safety management in the manufacturing and construction process of modular construction.