• 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.

• 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.

• 산업경영시스템학회지
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• 제36권3호
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• pp.34-42
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• 2013

In this study, we develop a method for analyzing business process based on the event-driven process chain (EPC) model. The method consists of five stages such as identifying abnormal events, finding causes for the abnormal events and problems caused by the abnormal events, making cause-and-effect chains, drawing root-cause map, and defining improvement areas. We illustrate how to apply the method with some examples for the domestic registered mail delivery process.

• 한국신재생에너지학회:학술대회논문집
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• 한국신재생에너지학회 2010년도 추계학술대회 초록집
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• pp.178.2-178.2
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• 2010

The wind turbine gearbox is important rotating part to transmit torque from turbine blade to generator. Generally, gear shaft which rotates causes vibration by influence of stiffness and mass with gear shaft. Root cause of this vibration source is well known to gear transmission error that is decided from gear tooth property. Transmission error excites a gear, and makes excitation force that is vibrated shaft. This vibration of shaft is transmitted to gearbox housing through gearbox bearing. If the resonance about which the natural frequency of the gearbox accords with shaft exciting frequency occurs, a wind turbine can lead to failure. The gearbox for wind turbine should be considered influence of vibration as well as the fatigue life and its performance by such reason. The cause to vibration should be closely examined to reduce influence of such vibration. In this paper, the cause of the vibration which occurs by a gearbox is closely examined and the method which can reduce the vibration which occurred is shown. It is compared with vibration test outcome of a 3MW gearbox for verification of the method shown by this paper.

• 산업경영시스템학회지
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• 제39권2호
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• pp.129-137
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• 2016

To identify the cause of the error and maintain the health of system, an administrator usually analyzes event log data since it contains useful information to infer the cause of the error. However, because today's systems are huge and complex, it is almost impossible for administrators to manually analyze event log files to identify the cause of an error. In particular, as OpenStack, which is being widely used as cloud management system, operates with various service modules being linked to multiple servers, it is hard to access each node and analyze event log messages for each service module in the case of an error. For this, in this paper, we propose a novel message-based log analysis method that enables the administrator to find the cause of an error quickly. Specifically, the proposed method 1) consolidates event log data generated from system level and application service level, 2) clusters the consolidated data based on messages, and 3) analyzes interrelations among message groups in order to promptly identify the cause of a system error. This study has great significance in the following three aspects. First, the root cause of the error can be identified by collecting event logs of both system level and application service level and analyzing interrelations among the logs. Second, administrators do not need to classify messages for training since unsupervised learning of event log messages is applied. Third, using Dynamic Time Warping, an algorithm for measuring similarity of dynamic patterns over time increases accuracy of analysis on patterns generated from distributed system in which time synchronization is not exactly consistent.

• 한국기계가공학회지
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• 제19권5호
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• pp.82-90
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• 2020

Due to the complicated shape of the spider, the production method was changed from cold to warm forging. Finite element analysis was performed to predict the forging load and shape using the enclosed hydraulic die set. As the forging load increases due to the spider die volume, die stress analyses were performed to optimize the die design in order to reduce the die stress in various conditions. Large deformation while producing the complicated forging parts induces high forging load, which is one of the main parameters of the forging surface defects. The forging process was analyzed to find out the root cause of the surface defects generated during the spider production for various parameters, thereby revealing that the radius of die in the defect zone influenced the air trap depth, being the root cause of the surface defect. It was verified that die life was increased and the surface defect was eliminated by changing the die design during the mass production test.

• 대한전자공학회:학술대회논문집
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• 대한전자공학회 2002년도 ITC-CSCC -1
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• pp.650-653
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• 2002

The increaseing speeds are accompanied by decreases in pulse rise and fall time in VLSI circuits. These accenturate the high frequency spectral contents of the signals and cause the frequency dependent loss of the conductors which interconnect the various sub-circuits composing of VLSI circuit. The lossy effect is approximated by the square root of frequency dependence of the per unit length resistance. In the practical applications, several problems may arise along with this approximation, so we extend our investigation of the lossy effect by numerical Laplace inversion method.

• 반도체디스플레이기술학회지
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• 제19권1호
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• pp.67-72
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• 2020

This study analyzes the method of adhesion and improvement between heat.er and RF filter in PE-CVD equipment through TRIZ method and proposes a solution. TRIZ Solution such as function analysis, 9-window matrix, ASIT, and Root cause analysis were used. The contact temperature between the heater and the RF filter was 20% and the surface temperature was lowered to 5.7℃, suggesting an improvement method for the thermal expansion of the PE-CVD equipment hot zone.

• Safety and Health at Work
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• 제1권1호
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• pp.43-50
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• 2010

Objectives: The objective of this study was to investigate the effect of chain installation condition on stress distribution that could eventually cause disastrous failure from sudden deformation and geometric rupture. Methods: Fractographic method used for the failed chain indicates that over-stress was considered as the root cause of failure. 3D modeling and finite element analysis for the chain, used in a crane hook, were performed with a three-dimensional interactive application program, CATIA, commercial finite element analysis and computational fluid dynamic software, ANSYS. Results: The results showed that the state of stress was changed depending on the initial position of the chain that was installed in the hook. Especially, the magnitude of the stress was strongly affected by the bending forces, which are 2.5 times greater (under the simulation condition currently investigated) than that from the plain tensile load. Also, it was noted that the change of load state is strongly related to the failure of parts. The chain can hold an ultimate load of about 8 tons with only the tensile load acting on it. Conclusion: The conclusions of this research clearly showed that a reduction of the loss from similar incidents can be achieved when an operator properly handles the installation of the chain.

• 반도체디스플레이기술학회지
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• 제20권4호
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• pp.146-150
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• 2021

Plasma information based virtual metrology (PI-VM) that predicts wafer-to-wafer etch rate variation after wet cleaning of plasma facing parts was developed. As input parameters, plasma information (PI) variables such as electron temperature, fluorine density and hydrogen density were extracted from optical emission spectroscopy (OES) data for etch plasma. The PI-VM model was trained by stepwise variable selection method and multi-linear regression method. The expected etch rate by PI-VM showed high correlation coefficient with measured etch rate from SEM image analysis. The PI-VM model revealed that the root cause of etch rate variation after the wet cleaning was desorption of hydrogen from the cleaned parts as hydrogen combined with fluorine and decreased etchant density and etch rate.