• Title/Summary/Keyword: Root cause analysis method

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Taxonomy of Performance Shaping Factors for Human Error Analysis of Railway Accidents (철도사고의 인적오류 분석을 위한 수행도 영향인자 분류)

  • Baek, Dong-Hyun;Koo, Lock-Jo;Lee, Kyung-Sun;Kim, Dong-San;Shin, Min-Ju;Yoon, Wan-Chul;Jung, Myung-Chul
    • Journal of Korean Society of Industrial and Systems Engineering
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    • v.31 no.1
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    • pp.41-48
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    • 2008
  • Enhanced machine reliability has dramatically reduced the rate and number of railway accidents but for further reduction human error should be considered together that accounts for about 20% of the accidents. Therefore, the objective of this study was to suggest a new taxonomy of performance shaping factors (PSFs) that could be utilized to identify the causes of a human error associated with railway accidents. Four categories of human factor, task factor, environment factor, and organization factor and 14 sub-categories of physical state, psychological state, knowledge/experience/ability, information/communication, regulation/procedure, specific character of task, infrastructure, device/MMI, working environment, external environment, education, direction/management, system/atmosphere, and welfare/opportunity along with 131 specific factors was suggested by carefully reviewing 8 representative published taxonomy of Casualty Analysis Methodology for Maritime Operations (CASMET), Cognitive Reliability and Error Analysis Method (CREAM), Human Factors Analysis and Classification System (HFACS), Integrated Safety Investigation Methodology (ISIM), Korea-Human Performance Enhancement System (K-HPES), Rail safety and Standards Board (RSSB), $TapRoot^{(R)}$, and Technique for Retrospective and Predictive Analysis of Cognitive Errors (TRACEr). Then these were applied to the case of the railway accident occurred between Komo and Kyungsan stations in 2003 for verification. Both cause decision chart and why-because tree were developed and modified to aid the analyst to find causal factors from the suggested taxonomy. The taxonomy was well suited so that eight causes were found to explain the driver's error in the accident. The taxonomy of PSFs suggested in this study could cover from latent factors to direct causes of human errors related with railway accidents with systematic categorization.

A Study on the Improvement of Brake Judder in Korean Light Tactical Vehicles (한국형 전술차량 제동 시 차체 떨림 개선에 관한 연구)

  • Kim, Sung-Gon;Kim, Seon-Jin;Shin, Cheol-Ho;Yun, Seong-Ho
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.21 no.6
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    • pp.432-439
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    • 2020
  • Brake judder has been identified in some operating military units of Korean Light Tactical Vehicles(KLTV) with In-board brake systems to improve braking performance. Severe vibration generated while driving the vehicle may reduce the KLTV's driving stability and further lead to accidents. For the prevention of this, this study analyzes the root cause through the failure analysis on the vehicles with the brake judder identified. Furthermore, the improvement factor was derived by identifying a vibration transmission path by analyzing the vibration transmission mechanism. The study analysis confirmed that the vibration of the frame during braking in the tactical vehicle is a cold judder phenomenon, which is caused by an increase in disk thickness variation due to rust and foreign substances under excessive brake disc's run-out. In addition, it was confirmed that such vibration can be reduced by improving the mounting structure. So, an improvement method for each factor was suggested and its effectiveness was verified by comparison test. Finally, it is expected that the improvement plans derived through this study can be used in the development of a next military vehicle.

A Study on the Development of Assessment Index for Catastrophic Incident Warning Sign at Refinery and Pertrochemical Plants (정유 및 석유화학플랜트 중대사고 전조신호 평가지표 개발에 관한 연구)

  • Yun, Yong Jin;Park, Dal Jae
    • Korean Chemical Engineering Research
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    • v.57 no.5
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    • pp.637-651
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    • 2019
  • In the event of a major accident such as an explosion in a refinery or a petrochemical plant, it has caused a serious loss of life and property and has had a great impact on the insurance market. In the case of catastrophic incidents occurring in process industries such as refinery and petrochemical plants, only the proximate causes of loss have been drawn and studied from inspectors or claims adjustors responsible for claims of property insurers, incident cause investigators, and national forensic service workers. However, it has not been done well for conducting root cause analysis (RCA) and identifying the factors that contributed to the failure and establishing preventive measures before leading to chemical plant's catastrophic incidents. In this study, the criteria of warning signs on CCPS catastrophic incident waning sign self-assessment tool which was derived through the RCA method and the contribution factor analysis method using the swiss cheese model principle has been reviewed first. Secondly, in order to determine the major incident warning signs in an actual chemical plant, 614 recommendations which have been issued during last the 17 years by loss control engineers of global reinsurers were analyzed. Finally, in order to facilitate the assessment index for catastrophic incident warning signs, the criteria for the catastrophic incident warning sign index at chemical plants were grouped by type and classified into upper category and lower category. Then, a catastrophic incident warning sign index for a chemical plant was developed using the weighted values of each category derived by applying the analytic hierarchy process (pairwise comparison method) through a questionnaire answered by relevant experts of the chemical plant. It is expected that the final 'assessment index for catastrophic incident warning signs' can be utilized by the refinery and petrochemical plant's internal as well as external auditors to assess vulnerability levels related to incident warning signs, and identify the elements of incident warning signs that need to be tracked and managed to prevent the occurrence of serious incidents in the future.

Reduction of Fall Incidence through Operation of the Staff Nurse-Centered Peer Review Group (낙상 peer review group 운영을 통한 낙상발생률 감소)

  • Sung, Il Soon;Song, Mi Ra;Kim, Hee Sun;Kim, Eun Sook;Jung, Mi A;Lee, Su Mi;Sung, Young Hee;Ha, Kook Hee;Kim, Seong Hwa;Lee, Hye Ran;An, Kyoung Jin;Shim, Mi Ok;Kim, Nag Hee;Sung, Young Hee
    • Quality Improvement in Health Care
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    • v.14 no.1
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    • pp.49-54
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    • 2008
  • Background : This study was to reduce incidence of falls by analyzing actual problem and drawing out improvement plan applicable to the clinical practice through operation of the staff nurses-centered fall peer review group. Method : The fall peer review group was composed of 8 nurses having patient nursing experience for over 5 years, and each of fall cases was reviewed and the root cause was analyzed. As a result, it was found that the patients and their families did not fully understandthe content of the education, and the staff nurses did not completely inspect the risk factors of falls and perform immediate intervention when patient's condition changed. Based on the above-mentioned results, improvement activity was conducted for the purposes of consolidating patients education method and supplementing computerized system to support nurses' decision making as well as devices and facilities. Result : As a result of conducting improvement activity in the aspects of education for patients, support of nurse's decision-making, and devices and facilities through operation of the staff nurses-centered fall peer review group, falls decreased by 9.5% compared to before improvement activity. Conclusion : It is concluded that operation of the clinical nurses-centered fall peer review group played a role of promoter to draw out practical and applicable improvement plan to the clinical practice and apply directions of the field-centered, and increased nurses' interest in falls and ultimately, reduced incidence of falls. Therefore the Center will continue to operate the staff nurses-centered peer review group, and recommends participation of nurses who actually take the charge of nursing patients in further analysis of patients' safety accidents.

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Fault Localization for Self-Managing Based on Bayesian Network (베이지안 네트워크 기반에 자가관리를 위한 결함 지역화)

  • Piao, Shun-Shan;Park, Jeong-Min;Lee, Eun-Seok
    • The KIPS Transactions:PartB
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    • v.15B no.2
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    • pp.137-146
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    • 2008
  • Fault localization plays a significant role in enormous distributed system because it can identify root cause of observed faults automatically, supporting self-managing which remains an open topic in managing and controlling complex distributed systems to improve system reliability. Although many Artificial Intelligent techniques have been introduced in support of fault localization in recent research especially in increasing complex ubiquitous environment, the provided functions such as diagnosis and prediction are limited. In this paper, we propose fault localization for self-managing in performance evaluation in order to improve system reliability via learning and analyzing real-time streams of system performance events. We use probabilistic reasoning functions based on the basic Bayes' rule to provide effective mechanism for managing and evaluating system performance parameters automatically, and hence the system reliability is improved. Moreover, due to large number of considered factors in diverse and complex fault reasoning domains, we develop an efficient method which extracts relevant parameters having high relationships with observing problems and ranks them orderly. The selected node ordering lists will be used in network modeling, and hence improving learning efficiency. Using the approach enables us to diagnose the most probable causal factor with responsibility for the underlying performance problems and predict system situation to avoid potential abnormities via posting treatments or pretreatments respectively. The experimental application of system performance analysis by using the proposed approach and various estimations on efficiency and accuracy show that the availability of the proposed approach in performance evaluation domain is optimistic.

Evaluation and Test Method Characterization for Mechanical and Electrical Properties in BGA Package (BGA 패키지의 기계적${\cdot}$전기적 특성 평가 및 평가법)

  • Koo Ja-Myeong;Kim Jong-Woong;Kim Dae-Gon;Yoon Jeong-Won;Lee Chang-Yong;Jung Seung-Boo
    • Journal of the Microelectronics and Packaging Society
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    • v.12 no.4 s.37
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    • pp.289-299
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    • 2005
  • The ball shear force was investigated in terms of test parameters, i.e. displacement rate and probe height, with an experimental and non-linear finite element analysis for evaluation of the solder joint integrity in area array packages. The increase in the displacement rate and the decrease in the probe height led to the increase in the shear force. Excessive probe height could cause some detrimental effects on the test results such as unexpected high standard deviation and probe sliding from the solder ball surface. The low shear height conditions were favorable for assessing the mechanical integrity of the solder joints. The mechanical and electrical properties of the Sn-37Pb/Cu and Sn-3.5Ag/Cu BGA solder joints were also investigated with the number of reflows. The total thickness of the intermetallic compound (IMC) layers, consisting of Cu6Sn5 and Cu3Sn, was increased as a function of cubic root of reflow time. The shear force was increased up to 3 or 4 reflows, and then was decreased with the number of reflows. The fracture occurred along the bulk solder, in irrespective of the number of reflows. The electrical resistivity was increased with increasing the number of reflows.

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Diversity and Pathogenic Characteristics of Fusarium Species isolated from Wilted Soybeans in Korea (콩 시들음병에 관여하는 Fusarium균의 다양성 및 병원학적 특성)

  • Choi, Hyo-Won;Kim, Seungnoh;Hong, Sung Kee
    • The Korean Journal of Mycology
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    • v.48 no.3
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    • pp.297-312
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    • 2020
  • Wilted soybean plants were collected from soybeans cultivation fields in Korea from 2014 to 2016. Fusarium spp., Colletotrichum spp., Rhizoctonia spp., Macrophomina sp., Phytophthora spp., and Calonectria ilicicola were obtained from the infected samples. Out of these, Fusarium spp. were the dominant species (79.1%). In total, 53 isolates were identified as F. solani species complex, F. oxysporum species complex, F. graminearum species complex, and F. fujikuroi species complex based on mycological characteristics. Sequence typing analysis was conducted using translation elongation factor 1 alpha (TEF) to confirm the identification of isolates. All isolates were identified as F. solani, F. oxysporum, F. commune, F. asiaticum, and F. fujikuroi based on phylogenetic analysis of TEF sequences. Pathogenicity of 44 isolates was tested on three cultivars of soybean using the root dip inoculation method. Out of 5 Fusarium species, only F. asiaticum could not cause the symptoms or be weak. Ten isolates were selected based on pathogenic characters and species identification to investigate the host range and screen soybean cultivars for resistance. Fusarium solani, F. oxysporum, and F. commune were aggressive only to soybean, and F. fujikuroi was aggressive to kidney bean, yellow cowpea, black cowpea, adzuki bean as well as soybean. All 13 Korean soybean cultivars were susceptible to F. commune and F. fujikuroi. Out of 13 cultivars, cv. Janggi, cv. Poongsannamul, and cv. Socheongja were resistant to Fusarium wilt, while cv. Hwanggeumol and Chamol were susceptible to Fusarium wilt.

The Effects of the Export Insurance on the Exports of Big and Small-Medium Businesses (수출보험의 대기업 및 중소기업 수출지원에 대한 효과분석)

  • Lee, Seo-Young
    • International Commerce and Information Review
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    • v.13 no.3
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    • pp.377-401
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    • 2011
  • Under the WTO system, direct export support system that provides financial and tax related support is altogether prohibited. This presented an obstacle in strengthening competitiveness of Korean export business and in increasing exports continuously. One of the methods used to solve this problem was to actively leverage export insurance. In Korea, export insurance services have been conducted by the Korea Trade Insurance Corporation (k-sure) to promote export. Korea has been among the world's active users of the export insurance system. Given this situation, this paper examines the effectiveness of the Korea export insurance system in the promotion of export. In particular, this study analyzed about discriminating effects of the export insurance on the export of big and small-medium business. In order to analyze, We introduce a Export Supply Function model. In this paper, We construct two model. The one is about big business, the other is small-medium business. For empirical analysis, unit-root test was conducted to understand the safety of time series. The results show that all variables are not I(0) time series. Instead, they are I(1) time series. To this, cointegration verification was conducted based on the use of Johansen verification method to define the existence (or non-existence) of long-term balance relationship among variables. The results come out as follows. The export insurance of big business has a stronger effect on export than that of small-medium business. The cause of these results is due to the distinct structure of Korea industries. In view of the fact that the insurance can make the risk decreased. We can say that the export insurance affects the export of a high-risk country.

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Study on the Sea Level Pressure Prediction of Typhoon Period in South Coast of the Korean Peninsula Using the Neural Networks (신경망 모형을 이용한 태풍시기의 남해안 기압예측 연구)

  • Park, Jong-Kil;Kim, Byung-Soo;Jung, Woo-Sik;Seo, Jang-Won;Shon, Yong-Hee;Lee, Dae-Geun;Kim, Eun-Byul
    • Atmosphere
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    • v.16 no.1
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    • pp.19-31
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    • 2006
  • The purpose of this study is to develop the statistical model to predict sea level pressure of typhoon period in south coast of the Korean Peninsula. Seven typhoons, which struck south coast of the Korean Peninsula, are selected for this study, and the data for analysis include the central pressure and location of typhoon, and sea level pressure and location of 19 observing site. Models employed in this study are the first order regression, the second order regression and the neural network. The dependent variable of each model is a 3-hr interval sea level pressure at each station. The cause variables are the central pressure of typhoon, distance between typhoon center and observing site, and sea level pressure of 3 hrs before, whereas the indicative variable reveals whether it is before or after typhoon passing. The data are classified into two groups - one is the full data obtained during typhoon period and the other is the data that sea level pressure is less than 1000 hPa. The stepwise selection method is used in the regression model while the node number is selected in the neural network by the Schwarz's Bayesian Criterion. The performance of each model is compared in terms of the root-mean square error. It turns out that the neural network shows better performance than other models, and the case using the full data produces similar or better results than the case using the other data.

The effects of aqueous extracts of plant roots on germination of seeds and growth of seedings (식물근의 추출물질이 종자발아 및 유식물의 생장에 미치는 영향)

  • Chan-Ho Park
    • KOREAN JOURNAL OF CROP SCIENCE
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    • v.4 no.1
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    • pp.1-23
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    • 1968
  • This study aimed at contributing to the improvement of cropping systems after finding out the effects of excrements and components of crop root influence on other crops as well as themselves. The following forage crops suitable for our country were selected for the present study. Aqueous extracts of fresh roots, aqueous extracts of rotting roots and aqueous solutions of excrements of red clover, orchard grass and brome grass were studied for the effects influencing the germination and growth of seedlings of red clover, ladino clover, lespedeza, soybean, orchard grass, Italian ryegrass, brome grass, barley, wheat, sorghum, corn and Hog-millet. In view of the possibility that the organic acid might be closely related to the excrements and components of crop root connected with soil sickness, the acid components of three species of roots were analysed by paper chromatography and gas chromatography method. The following results were obtained: 1. Effects of Aqueous Extracts of Fresh Roots : Aqueous extracts of red clover: The extracts inhibited the growth of seedlings of the ladino clover and lespedeza and also inhibited the development of most crops except that of sorghum among the Graminaceae. Aqueous extracts of orchard grass: The extracts promoted the seedlings growth of red clover and soybean, while it inhibited the germination and growth of orchard grass. There were no noticeable effects influencing other crops while it inhibited the growth of barley and Hog-millet. Aqueous extracts of brome grass: There was no effect on Italian ryegrass but there was an inhibiting effect on the other crops. 2. Effects of Aqueous Extracts of Rotting Roots : Aqueous extracts of red clover: The extracts promoted the seedling growth of red clover. But it reflected the inhibiting effects on other crops except sorghum. Aqueous extracts of orchard grass: The extracts promoted the growth of red clover, ladino clover, soybean and sorghun, while it inhibited the germination and rooting of barley and Hog-millet. Aqueous extracts of brome grass: The extracts gave the promotive effects to the growth of red clover, soybean and sorghum, but caused inhibiting effects on orchard grass, brome grass, barley and Hog-millet. 3. Effects of Aqueous Solutions of Excrements : The aqueous solution of excrements of red clover reflected the inhibition effects to the growth of Graminaceae, while the aqueous solutions of excrements of orchard grass and Italian ryegrass caused the promotive effects on the growth of red clover. 4. Results of Organic Acid Analysis : The oxalic acid, citric acid, tartaric acid, malonic acid, malic acid and succinic acid were included in the roots of red clover as unvolatile organic acid, and in the orchard grass and brome grass there were included the oxalic acid, citric acid, tartaric acid and malic acid. And formic acid was confirmed in the red clover, orchard grass and brome grass as volatile organic acid. In consideration of the results mentioned in above the effects of excrements and components of roots found in this studies may be summarized as follows. 1) The red clover generally gave a disadvantageous effect on the Graminaceae. Such trend was considered chiefly caused by the presence of many organic acids, namely oxalic, citric, tartaric, malonic, malic, succinic and formic acid. 2) The orchard grass generally gave an advantageous effect on the Leguminosae. This may be due to a few kinds of organic acid contained in the root, namely oxalic, citric, tartaric, malic and formic acid. Furthermore a certain of promotive materials for growth was noted. 3) As long as the root of brome grass are not rotten, it gave a disadvantageous effect on the Leguminosae and Graminaceae. This may be due to the fact that several unidentified volatile organic acid were also included besides the confirmed organic acid, namely oxalic, citric, tartaric, malic and formic acid. 5. Effects of Components in Roots to the Soil Sickness : 1) It was considered that the cause of alleged red clover's soil sickness did not result from the toxic components of the roots. 2) It was recognized that the toxic components of roots might be the cause of soil sickness in case the orchard grass and brome grass were put into the long-term single cropping. 6. Effects of Rooted Components to the Companion Crops in the Cropping System : a) In case of aqueous extracts of fresh roots and aqueous excrements (Inter cropping and mixed cropping) : 1) Advantageous combinations : Orchard grass->Red clover, Soybean, Italian ryegrass->Red clover, 2) Disadvantageous combinations : Red clover->Ladino clover, Lespedeza, Orchard grass, Italian ryegrass, Fescue Ky-31, Brome grass, Barley, Wheat, Corn and Hog.millet, Orchard grass->Lespedeza, Orchard grass, Barley and Hog-millet, Brome grass->Red clover, Ladino clover, Lespedeza, Soybean, Orchard grass, Brome grass, Barley, Wheat, Sorghum, Corn and Hog-millet, 3) Harmless combinations : Red clover->Red clover, Soybean and Sorghum, Orchard grass->Ladino clover, Italian ryegrass, Brome grass, Wheat, Sorghum and Corn, Brome grass->Italian ryegrass, b) In case of aquecus extracts of rotting roots(After cropping) : 1) Advantageous combinations : Red clover->Red clover and Sorghum, Orchard grass->Red clover, Ladino clover, Soybean, Sorghum, and Corn, Brome grass->Red clover, Soybean and Sorghum, 2) Disadvantageous combinations : Red clover->Lespedeza, Orchard grass, Italian ryegrass, Brome grass, Barley, Wheat, and Hog-millet Orchard grass->Barley and Hog-millet, Brome grass->Orchard grass, Brome grass, Barley and Hog-millet, 3) Harmless combinations : Red clover->Ladino clover, Soybean and Corn, Orchard grass->Lespedeza, Orchard grass, Italian ryegrass, Brome grass and Wheat Brome gass->Ladino clover, Lespedeza, Italian ryegrass and Wheat.

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