• 한국건설관리학회:학술대회논문집
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• 한국건설관리학회 2006년도 정기학술발표대회 논문집
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• pp.131-136
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• 2006

작업의 지연을 줄이거나 예방하기 위해서는 작업지연상황을 지속적으로 확인하여 작업지연을 야기하는 원인을 찾아내고 대책을 세워야 한다. 건설 프로젝트는 동일한 조건하에서도 주변 환경에 따라 결과 값이 다르게 나타나는 일회성이 강한 분야 중에 하나이다. 그래서 지금까지 이루어진 선행연구들은 작업지연기간 산정방법 또는 작업지연의 클레임 사례에 관한 연구와 프로젝트 종료 후 결과에 의한 원인을 제시한 것이 대부분이다. 따라서 공사 진행 중에 발생하는 작업지연에 대해 체계적으로 활용할 수 있는 분석방법과 절차가 필요하다. 본 연구는 작업지연 원인분석 범위를 프로젝트내의 현장관리 분야로 국한하고 작업의 투입요소에 의한 분석과 VSM을 활용한 분석으로 나눴다. 건설업에 적합한 원인분석 방법을 제안하기 위해 기존에 활용되고 있는 분석방법의 특징을 분석하고 건설업의 특징을 분석하여 건설업에 활용이 적합한 방법을 도출하고 절차를 제안하였다.

• 한국의료질향상학회지
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• 제23권1호
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• pp.11-23
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• 2017

Root Cause Analysis (RCA) has been widely used as a structured approach to investigate patient safety incidents. RCA helps identify what, how, and why something happened, therefore preventing recurrence of incidents. Since many quality tools can be used during RCA, various formats of RCA exist. If RCAs are performed incorrectly or incompletely, they are likely to produce unusable results. To address this issue, RCA software has been developed. The use of RCA software in investigating patient safety incidents may offer several advantages, such as potential reduction in learning time, shortening of the analytic process, facilitation of collection, analysis, and presentation of data and production of meaningful RCA reports. We introduced six healthcare RCA software and compared characteristics. Results from this study will enable the RCA team to choose proper RCA software.

• 한국압력기기공학회 논문집
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• 제10권1호
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• pp.70-74
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• 2014

An Operating Experience Report(OER) has written about events and accidents happened at a Nuclear Power Plant(NPP). The purpose of publishing the OER is to prevent the similar event or accident repeatedly by spreading the experience of a single plant to other plants personnel. In this paper, it is analyses that the foreign NPPs' OERs on JIT published by the International Nuclear Agency(WANO, INPO, COG, BE). The analysis introduced in this paper is performed along with the various factors such as type of work, root-cause, and equipment. The root-cause analysis about the OERs shows that the Human-error is the major factor in foreign NPPs, but on the other hand equipment problem is the main part of the Domestic NPPs. The ratio of the foreign NPP's OERs on JIT according to the type of work was applied to KHNP-JIT developed nowadays for the first time in KOREA.

• 한국압력기기공학회 논문집
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• 제9권1호
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• pp.35-39
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• 2013

The Operating Experience Report(OER) has written about the event and accident happened at a Nuclear Power Plant(NPP). The purpose of publishing the OER is to prevent the similar event or accident repeatedly by spreading the experience of a single plant to other plants personnel. Before initiating the analysis mentioned in this paper, 2,298 review reports for the same number of OER published from 2007 to June 2012 have been written to achieve the correct and objective statistics. The analysis introduced in this paper is performed with the various factors such as year, plant type, equipment, type of work, root-cause. The root-cause analysis is showed that the equipment problem is the major factor in domestic NPPs, but on the other hand human-error is the main part of the foreign NPPs. Moreover, while the number of the man-made event is decreasing, the equipment-made event is rapidly increasing in domestic NPPs.

• 한국의료질향상학회지
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• 제24권1호
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• pp.9-22
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• 2018

Purpose: The purpose of this study is to develop the Korean root cause analysis (RCA) software that can be used to systematically investigate underlying causes for preventing or reducing recurrence of patient safety incidents. Methods: We reviewed the existing guidelines and literatures on the RCA in order to figure out the RCA process. Also we examined the existing RCA softwares for investigating patient safety incidents to design the contents and interface of the RCA software. Based on the results of reviewing literatures and softwares, we developed a draft version of the Korean RCA software that can be easily used in Korean hospital settings by RCA teams. Results: The Korean RCA software consisted of several modules, which are modules for identifying patient safety incidents, organizing RCA team, collecting and analysing data, determining contributory factors and root causes, developing the action plans, and guiding evaluation. Conclusion: The Korean RCA software included optimized RCA process and structured logic for cause analysis. Thus even beginners in RCA are expected to easily use this software for investigating patient safety incidents. As software has been developed with the public financial support, it will be distributed free of charge. We hope that it will contribute to facilitating patient safety improvement activities in Korea.

• Nuclear Engineering and Technology
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• 제51권3호
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• pp.709-718
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• 2019

The international nuclear industry has undergone a lot of changes since the Fukushima, Chernobyl and TMI nuclear power plant accidents. However, there are still large and small component deficiencies at nuclear power plants in the world. There are many causes of electrical equipment defects. There are also factors that cause component failures due to human errors. This paper analyzed the root causes of failure and types of human error in 300 cases of electrical component failures. We analyzed the operating experience of electrical components by methods of root causes in K-HPES (Korean-version of Human Performance Enhancement System) and by methods of human error types in HuRAM+ (Human error-Related event root cause Analysis Method Plus). As a result of analysis, the most electrical component failures appeared as circuit breakers and emergency generators. The major causes of failure showed deterioration and contact failure of electrical components by human error of operations management. The causes of direct failure were due to aged components. Types of human error affecting the causes of electrical equipment failure are as follows. The human error type group I showed that errors of commission (EOC) were 97%, the human error type group II showed that slip/lapse errors were 74%, and the human error type group III showed that latent errors were 95%. This paper is meaningful in that we have approached the causes of electrical equipment failures from a comprehensive human error perspective and found a countermeasure against the root cause. This study will help human performance enhancement in nuclear power plants. However, this paper has done a lot of research on improving human performance in the maintenance field rather than in the design and construction stages. In the future, continuous research on types of human error and prevention measures in the design and construction sector will be required.

• 한국항공운항학회지
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• 제26권2호
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• pp.68-75
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• 2018

A flare from an Air Force fighter was abnormally dispensed during the landing. To determine the cause of the abnormal dispensing, fracture analysis, signal analysis and reproduction experiments based on physics of failures were performed. The primary cause of the failure was analyzed to be due to an intermittent fault of an internal circuit card in the AN/ALE-40 chaff/flare dispenser by a broken lid of a capacitor, and the root cause which had derived the primary cause was considered to be an improper handling during the domestic maintenance which were changed from the overseas maintenance due to the DMSMS problem. Therefore, the overall process of the maintenance capability development system was reviewed and alternative ways that considers maintenance error decision aid(MEDA) for system improvement were suggested to prevent further failures.

• 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.

• 한국안전학회지
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• 제36권2호
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• pp.58-67
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• 2021

Incident investigation is regarded as a means to improve safety performance. For the prevention of industrial accidents, measures such as providing safety education, enhancing management interest and participation, establishing a safety management system, and conducting inspection of the work site are necessary. In particular, accident investigation activities, which are an important element of safety management, help to prevent similar accidents, thereby minimizing damage and enhancing work safety. They are critical for understanding business-related incidents and the vulnerabilities and opportunities associated with them. Therefore, it is clear that accident investigation activities are important for accident prevention. The primary focus of many incident investigation processes is on identifying the cause of an event. While considerable research has been conducted on potential accident investigation tools there has been little research on including the views and experiences of practitioners in the accident investigation process. In this study, a questionnaire survey was conducted among safety managers in the domestic manufacturing/construction industry to understand the practice of accident investigation. The investigation pertained to companies' accident investigation systems, the competence of investigators, and the identification and recommendations of the cause of accidents. From the analysis results of accident investigations, investigators' competence, the difficulty level of investigations, and the root causes of accidents were identified from the viewpoint of the participants of the accident investigations. In particular, the development of standardized and simple accident investigation methods and their dissemination to companies were found to be necessary for activating the root cause of accidents. Based on this, it can be used as basic data for the development of root cause analysis investigation techniques that are easily applicable to organizations.

• ETRI Journal
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• 제36권6호
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• pp.1023-1031
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• 2014

Failure analysis is necessary to clarify the root cause of a failure, predict the next time a failure may occur, and improve the performance and reliability of a system. However, it is not an easy task to analyze and interpret failure data, especially for complex systems. Usually, these data are represented using many attributes, and sometimes they are inconsistent and ambiguous. In this paper, we present a scalable approach for the analysis and interpretation of failure data of high-performance computing systems. The approach employs rough sets theory (RST) for this task. The application of RST to a large publicly available set of failure data highlights the main attributes responsible for the root cause of a failure. In addition, it is used to analyze other failure characteristics, such as time between failures, repair times, workload running on a failed node, and failure category. Experimental results show the scalability of the presented approach and its ability to reveal dependencies among different failure characteristics.