• 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.

• 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.

• 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.

• Journal of Ginseng Research
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• 제19권1호
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• pp.77-83
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• 1995

This study was conducted to investigate the chemical components of rusty root for seeking the cause of rust. Na, Fe contents were higher in various tissues of six-year-old rusty root than healthy root. Contents of total sugar in epidermis of rusty root was low but crude lignin and suborn contents were high. Crude lipid content increased with the rate of rusty symptoms in each part of root respectively. Pentadecanoic, stearic, oleic, lignoseric acid contents increased in cortex of tap root with the rate of rusty symptoms but decreased in pith. Total ginsenoside and crude saponin contents increased , in pith and cortex of tap root with the rate of rusty symptoms but decreased in lateral and fine root.

• 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.

• 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.

• 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.

• Imaging Science in Dentistry
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• 제44권4호
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• pp.315-320
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• 2014

Root resorption is loss of dental hard tissue as a result of clastic activities. The dental hard tissue of permanent teeth does not normally undergo resorption, except in cases of inflammation or trauma. However, there are rare cases of tooth resorption of an unknown cause, known as "idiopathic root resorption". This report would discuss a rare case of multiple idiopathic resorption in the permanent maxillary and mandibular teeth of an otherwise healthy 36-year-old male patient. In addition to a clinical examination, the patient was imaged using conventional radiography and cone-beam computed tomography (CBCT). The examinations revealed multiple external and internal resorption of the teeth in all four quadrants of the jaws with an unknown cause. Multiple root resorption is a rare clinical phenomenon that should be examined using different radiographic modalities. Cross-sectional CBCT is useful in the diagnosis and examination of such lesions.

• The Plant Pathology Journal
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• 제39권6호
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• pp.575-583
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• 2023

Fusarium root rot is an increasingly severe problem in soybean cultivation. Although several Fusarium species have been reported to infect soybean roots in Heilongjiang province, their frequency and aggressiveness have not been systematically quantified in the region. This study aimed to investigate the diversity and distribution of Fusarium species that cause soybean root rot in Heilongjiang province over two years. A total of 485 isolates belonging to nine Fusarium species were identified, with F. oxysporum and F. solani being the most prevalent. Pot experiments were conducted to examine the relative aggressiveness of different Fusarium species on soybean roots, revealing that F. oxysporum and F. solani were the most aggressive pathogens, causing the most severe root rot symptoms. The study also assessed the susceptibility of different soybean cultivars to Fusarium root rot caused by F. oxysporum and F. solani. The results indicated that the soybean cultivar DN51 exhibited the most resistance to both pathogens, indicating that it may possess genetic traits that make it less susceptible to Fusarium root rot. These findings provide valuable insights into the diversity and distribution of Fusarium species that cause soybean root rot and could facilitate the development of effective management strategies for this disease.

• 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.