• Nuclear Engineering and Technology
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• v.55 no.12
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• pp.4408-4425
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• 2023

Alarm flood due to abnormality propagation is the most difficult alarm overloading problem in nuclear power plants (NPPs). Root-cause analysis is suggested to help operators in understand emergency events and plant status. Multilevel Flow Modeling (MFM) has been extensively applied in alarm management by virtue of the capability of explaining causal dependencies among alarms. However, there has never been a technique that can identify the actual root cause for complex alarm situations. This paper presents an automated root-cause analysis system based on MFM. The causal reasoning algorithm is first applied to identify several possible root causes that can lead to massive alarms. A novel root-cause ranking algorithm can subsequently be used to isolate the most likely faults from the other root-cause candidates. The proposed method is validated on a pressurized water reactor (PWR) simulator at HAMMLAB. The results show that the actual root cause is accurately identified for every tested operating scenario. The automation of root-cause identification and ranking affords the opportunity of real-time alarm analysis. It is believed that the study can further improve the situation awareness of operators in the alarm flooding situation.

• Journal of Information Technology Applications and Management
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• v.24 no.4
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• pp.71-92
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• 2017

Finding a root cause is an essential step to solving a complex problem. Some previous studies have used the Delphi method for gathering opinions about root causes from geographically dispersed experts. However, we assert that complicated problems such as an industry ecosystem would make a general type of the Delphi method less practical because of too much psychological burden on study participants. In this study we present a preliminary list-based Delphi study method for identifying a root cause. This method was used to identify a root cause and draw a causal map for the information industry ecosystem problems.

• Journal of Digital Convergence
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• v.12 no.8
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• pp.77-84
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• 2014

TRIZ was developed and refined in the Soviet Union between 1946 and 1985 by Genrich Altshuller. Its primary application has been for solving inventive problems in the areas of engineering. But, recently the elements of TRIZ began to be applied non-technical areas by Darrell Mann. TRIZ theroy was brought into South Korea in 1995 and it is used by the LG, SAMSUNG, POSCO. TRIZ is simply not the tool for technical problem solving, covering many areas of comprehensive approach is being recognized. TRIZ is a methodology for defining problem, finding root cause through RCA(Root cause analysis), defining technical contradiction and physical contradiction. TRIZ overcomes contradiction and purses problem solving method through innovation. TRIZ is a problem solving method in this study using the principles of non-technical fields applied to the improvement of the logistics area study. The method to overcome contradiction is 40 principles. It is possible to generate idea by using 40 principles. This study was applied to logistics field of non-technical area by using TRIZ principle.

• Proceedings of the Korean Institute Of Construction Engineering and Management
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• 2006.11a
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• pp.131-136
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• 2006

In constructing projects, there exist various kinds of work interferences, which cause a delay of the outset and completion of planned schedule because of some attributions, such as variability, uncertainty and complexity. and so schedule delay has been treated as a natural phenomenon. To reduce or prevent the schedule delay, a constant confirmation of schedule delay and a preparation of counter plans for finding out the cause structure of schedule delay should have been done. However, all this time the research has been mostly done on the calculation method or claim cases of schedule delay. Moreover, the analysis method did not consider the trait, which cause the schedule delay, in constructing projects. This paper restricts the range of the cause analysis of schedule delay to the field of site management in the projects and divides the cause structure of schedule delay into the cause objects and cause attributes of schedule delay according to the input elements. The system of classifying causes of schedule delay is examined by interviews with experts and questionnaire. Additionally, this paper analyzes the attributes of cause attributes and cause subjects and presents the analysis method and procedure of schedule delay with the application of VSM.

• Journal of the Ergonomics Society of Korea
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• v.34 no.2
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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.

• Journal of Korean Society of Industrial and Systems Engineering
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• v.38 no.1
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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.

• Journal of the Korean Institute of Gas
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• v.14 no.4
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• pp.1-5
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• 2010

Many sorts of fatal accidents like explosion or fire caused by gas leakage have become a social issue with the increasing use of harmful chemicals in laboratories in universities and enterprise-affiliated research institutes in Korea. Importance of safety management has been emphasized and it made Act on the Establishment of Safe Laboratory Environment enacted not only to protect lives and bodies of people working in laboratories in universities and enterprise-affiliated research institutes but also to make pleasant experimental atmosphere. Safety management system has been built and periodical checkups and safety diagnosis have been implementing in universities and enterprise-affiliated research institutes to prevent such accidents. However, in spite of those actions, continuous accidents make analysis of root cause essential. This study will show results of analysis on incidents and accidents occurred in laboratories in universities and enterprise-affiliated research institutes using Root Cause Analysis Method and propose the direction of safety management.

• Journal of the Korean Institute of Gas
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• v.14 no.4
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• pp.6-11
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• 2010

The continuous fatal accidents like explosion or fire cause huge losses of both life and property in laboratories even though safety management system has been built and periodical checkups and safety diagnosis have been implementing in universities and enterprise-affiliated research institutes since Act on the Establishment of Safe Laboratory Environment was enacted in 2005 to prevent accidents in research laboratories. Cause analysis and safety management measures to prevent recurrence of accidents are urgently needed because accidents in research laboratories occur repeatedly with similar contents. This study will show results of analysis on incidents and accidents occurred in laboratories in universities and enterprise-affiliated research institutes using Root Cause Analysis Method and propose classified map of cause investigation and improvements so as to improve safety management in research laboratories.

• Journal of the Korean Society of Safety
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• v.36 no.5
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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.

• Korean Journal of Construction Engineering and Management
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• v.7 no.5
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• pp.138-148
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• 2006

In constructing projects, there exist various kinds of work interferences, which cause a delay of the outset and completion of planned schedule because of some attributions, such as variability, uncertainty and complexity, and so schedule delay has been treated as a natural phenomenon. To reduce or prevent the schedule delay, a constant confirmation of schedule delay and a preparation of counter plans for finding out the cause structure of schedule delay should have been done. However, all this time the research has been mostly done on the calculation method or claim cases of schedule delay, and the range of analysis method of the cause structure of schedule delay has been multifarious from industrial views to views of specific work. Moreover, the classifying system and analysis method did not consider the trait, which cause the schedule delay, in constructing projects. For this reason, it is difficult to compare the cause of delay factors of the projects and to understand the effect of schedule delay by each factor. This paper restricts the range of the cause analysis of schedule delay to the field of site management in the projects and divides the cause structure of schedule delay into the cause objects and cause attributes of schedule delay according to the input elements. The system of classifying causes of schedule delay is examined by interviews with experts and questionnaire. Additionally, this paper analyzes the attributes of cause attributes and cause subjects and presents the analysis method and procedure of schedule delay with the application of VSM.