• Title/Summary/Keyword: The Root-Cause Analysis

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Latest passenger vehicle fire trend and case study based on field investigation data (차량화재 사고경향 및 사례분석)

  • Shin, Junho;Won, Eugene;Hong, Ilmin
    • Journal of Auto-vehicle Safety Association
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    • v.6 no.2
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    • pp.67-71
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    • 2014
  • Based on the analysis of the actual passenger vehicle fire cases for recent four years (2010~2013), the passenger vehicle fire is increasing annually. Main root cause was analyzed as an electric problem as a 39%. Vehicle fire case by electric problem was mainly caused by use of Non-genuine part. Vehicle fire case by mechanical problem was mainly caused by various oil system maintenance. Vehicle fire case by smoking material was mainly caused by cigarette and disposal lighter. And external fire transition issue and towing mistake fire cases was also confirmed.

Root cause analysis of sticking in hydraulically actuated multi-disc friction clutch for ship propulsion (선박 추진용 유압작동식 다판 마찰클러치 고착현상 고장탐구)

  • Jeong, Sang-Hu;Kim, Jeong-Ryeol;Shin, Jae-Won
    • Journal of Advanced Marine Engineering and Technology
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    • v.41 no.4
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    • pp.330-336
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    • 2017
  • This study performs a root cause analysis of the sticking that occurs in the hydraulically actuated wet type multi-disc friction clutch in a ship's diesel engine propulsion system that uses rubber elastic coupling. The fishbone method was used to study the sticking through dismantling investigation of the reduction gear and clutch, investigation of the components, and onboard system tests including nondestructive testing. The friction plate sticking is caused by the slip due to friction heat resulting from the leakage of control oil through cracks in the assembled hollow shaft. The friction plate cooling oil also leaks simultaneously through the crack, and partial sticking occurs due to the hot spots in the friction plates. These are caused by insufficient amount of cooling oil due to oil leakage.

Root Causes and Characteristics of Occupational Incidents by Cause Investigation - Focusing on Maintenance and Repair Work - (사고 원인조사를 통한 농작업 안전사고 특성 연구 - 유지, 보수 작업을 중심으로 -)

  • Yongseok Shin;Hyocher Kim;Kyungsu Kim;Dongeok Kim
    • Journal of Agricultural Extension & Community Development
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    • v.30 no.2
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    • pp.119-129
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    • 2023
  • This study aims to identify the types of safety accidents that occur during maintenance and repair operations and analyze the root causes. We used the logic tree diagramming to extract the root causes of 65 safety incidents specifically related to maintenance and repair work out of a total of 1,024 agricultural safety incidents that occurred between 2007 and 2020 collected by investigation with interviews. The extracted root causes were analyzed by categorizing them into six different safety system classifications. The results of the analysis and suggestions are as follows. Incidents related to maintenance and repair work, which can lead to irreversible safety hazards, have occurred frequently. These incidents were found to be occurring due to the overlapping of various safety system errors such as personal protective system and safety operation procedure. In the short term, it is necessary to emphasize compliance with the use of personal protective equipment, and enhancement of maintenance training. In the long term, it is necessary to establish a legal distinction for maintenance and repair work and clarify the responsible parties. Introducing a maintenance system is also crucial to prevent occupational injuries during maintenance and repair in agriculture.

A Study on the Cause Analysis of Human Error Accidents by Railway Job

  • Byeoung-Soo YUM;Tae-Yoon KIM;Sun-Haeng CHOI;Won-Mo GAL
    • Journal of Wellbeing Management and Applied Psychology
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    • v.7 no.1
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    • pp.27-33
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    • 2024
  • Purpose: This study investigates human error accidents in the Korean railway sector, emphasizing the need for systematic management to prevent such incidents, which can have fatal consequences, especially in driving-related jobs. Research design, data and methodology: This paper analyzed data from the Aviation and Railway Accident Investigation Board and the Korea Transportation Safety Authority, examining 240 human error accidents that occurred over the last five years (2018-2022). The analysis focused on accidents in the driving, facility, electric, and control fields. Results: The findings indicate that the majority of human error accidents stem from negligence in confirmation checks, issues with work methods, and oversight in facility maintenance. In the driving field, errors such as signal check neglect and braking failures are prevalent, while in the facility and electric fields, the main issues are maintenance delays and neglect of safety measures. Conclusions: The paper concludes that human error accidents are complex and multifaceted, often resulting from a high workload on engineers and systemic issues within the railway system. Future research should delve into the causal relationships of these accidents and develop targeted prevention strategies through improved work processes, education, and training.

Factor Analysis on Outbreak of Musculoskeletal Disorders (근골격계질환 증상 요인 분석)

  • Choi, Yo-Han;Leem, Young-Moon
    • Proceedings of the Safety Management and Science Conference
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    • 2008.04a
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    • pp.149-156
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    • 2008
  • The main objective of this study is to find factors and typical characteristics on outbreak of musculoskeletal disorders in small sized companies which are located at eastern area in Kangwon-Do. Musculoskeletal disorders are becoming a serious problem in various industrial fields. Many researches have been focused on the analysis on outbreak of musculoskeletal disorders in order to reduce and prevent them. As a similar endeavor, this paper provides factor analysis on outbreak of musculoskeletal disorders. Questionnaire surveys regarding musculoskeletal disorders were conducted for the total number of 250 field workers. For the purpose of this study, seven independent variables(gender, age, career, housework, accident, trouble, and pain) are taken from questionnaires. The provided analysis result will be helpful as a starting point for root cause analysis and reduction of musculoskeletal disorders and also for establishment of safe work environments.

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Crack analysis of reinforced concrete members with and without crack queuing algorithm

  • Ng, P.L.;Ma, F.J.;Kwan, A.K.H.
    • Structural Engineering and Mechanics
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    • v.70 no.1
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    • pp.43-54
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    • 2019
  • Due to various numerical problems, crack analysis of reinforced concrete members using the finite element method is confronting with substantial difficulties, rendering the prediction of crack patterns and crack widths a formidable task. The root cause is that the conventional analysis methods are not capable of tracking the crack sequence and accounting for the stress relief and re-distribution during cracking. To address this deficiency, the crack queuing algorithm has been proposed. Basically, at each load increment, iterations are carried out and within each iteration step, only the most critical concrete element is allowed to crack and the stress re-distribution is captured in subsequent iteration by re-formulating the cracked concrete element and re-analysing the whole concrete structure. To demonstrate the effectiveness of the crack queuing algorithm, crack analysis of concrete members tested in the literature is performed with and without the crack queuing algorithm incorporated.

Involvement of Growth-Promoting Rhizobacterium Paenibacillus polymyxa in Root Rot of Stored Korean Ginseng

  • Jeon, Yong-Ho;Chang, Sung-Pae;Hwang, In-Gyu;Kim, Young-Ho
    • Journal of Microbiology and Biotechnology
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    • v.13 no.6
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    • pp.881-891
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    • 2003
  • Paenibacillus polymyxa is a plant growth-promoting rhizobacterium (PGPR) which can be used for biological control of plant diseases. Several bacterial strains were isolated from rotten roots of Korean ginseng (Panax ginseng C. A. Meyer) that were in storage. These strains were identified as P. polymyxa, based on a RAPD analysis using a P. polymyxa-specific primer, cultural and physiological characteristics, an analysis utilizing the Biolog system, gas chromatography of fatty acid methyl esters (GC-FAME), and the 16S rDNA sequence analysis. These strains were found to cause the rot in stored ginseng roots. Twenty-six P. polymyxa strains, including twenty GBR strains, were phylogenetically classified into two groups according to the ERIC and BOX-PCR analyses and 16S rDNA sequencing, and the resulting groupings systematized to the degrees of virulence of each strain in causing root rot. In particular, highly virulent GBR strains clustered together, and this group may be considered as subspecies or biovar. The virulence of the strains seemed to be related to their starch hydrolysis enzyme activity, but not their cellulase or hemicellulase activity, since strains with reduced or no starch-hydrolytic activity showed little or no virulence. Artificial inoculation of the highly virulent strain GBR-1 onto the root surfaces of Korean ginseng resulted in small brown lesions which were sunken and confined to the outer portion of the root. Ginseng root discs inoculated in vitro or two-year-old roots grown in soil drenched with the inoculum developed significant rot only when the inoculum density was $10^{6}-10^{7}$ or more colony-forming units (CFU) per ml. These results suggest that P. polymyxa might induce ginseng root rot if their population levels are high. Based on these results, it is recommended that the concentration of P. polymyxa should be monitored, when it is used as a biocontrol agent of ginseng, especially in the treatment of stored roots.

Use of In-Situ Optical Emission Spectroscopy for Leak Fault Detection and Classification in Plasma Etching

  • Lee, Ho Jae;Seo, Dong-Sun;May, Gary S.;Hong, Sang Jeen
    • JSTS:Journal of Semiconductor Technology and Science
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    • v.13 no.4
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    • pp.395-401
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    • 2013
  • In-situ optical emission spectroscopy (OES) is employed for leak detection in plasma etching system. A misprocessing is reported for significantly reduced silicon etch rate with chlorine gas, and OES is used as a supplementary sensor to analyze the gas phase species that reside in the process chamber. Potential cause of misprocessing reaches to chamber O-ring wear out, MFC leaks, and/or leak at gas delivery line, and experiments are performed to funnel down the potential of the cause. While monitoring the plasma chemistry of the process chamber using OES, the emission trace for nitrogen species is observed at the chlorine gas supply. No trace of nitrogen species is found in other than chlorine gas supply, and we found that the amount of chlorine gas is slightly fluctuating. We successfully found the root cause of the reported misprocessing which may jeopardize the quality of thin film processing. Based on a quantitative analysis of the amount of nitrogen observed in the chamber, we conclude that the source of the leak is the fitting of the chlorine mass flow controller with the amount of around 2-5 sccm.

Retrospective Analysis of Incisor Root Resorption Associated with Impacted Maxillary Canines (매복된 상악 견치에 의한 전치의 치근 흡수에 대한 후향적 연구)

  • Jung, Seo-Hyun;Song, Ji-Soo;Shin, Teo Jeon;Hyun, Hong-Keun;Kim, Young-Jae;Kim, Jung-Wook;Lee, Sang-Hoon;Jang, Ki-Taeg
    • Journal of the korean academy of Pediatric Dentistry
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    • v.45 no.2
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    • pp.203-214
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    • 2018
  • Root resorption of the permanent maxillary incisors can occur due to ectopic eruption of the permanent canines. Severe root resorption threatens the long-term survival of the affected incisors. The aim of the present study was to identify risk factors for root resorption of the maxillary incisors associated with impacted maxillary canines. In the present study, we retrospectively analyzed the Cone-Beam Computed Tomography (CBCT) scans of 65 children and adolescents with ectopically erupting maxillary canines (total of 88 impacted canines). Root resorption of central incisors was significantly associated with the mesiodistal position and root development of the adjacent canine. Root resorption of lateral incisors was significantly associated with sex, age, and the buccolingual and vertical position of the adjacent canine. However, enlargement of the dental follicle was not significantly associated with root resorption of adjacent incisors. Although incisor resorption is difficult to diagnose and predict, our findings suggest that changes in the dental follicles of the erupting maxillary canines do not cause resorption of the adjacent permanent incisors. CBCT should be utilized to ensure early diagnosis of impacted canines and precise evaluation of incisor root resorption.

Stress Corrosion Cracking Lifetime Prediction of Spring Screw (스프링 체결나사의 응력부식균열 수명예측)

  • Koh, S.K.;Ryu, C.H.
    • Proceedings of the KSME Conference
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    • 2004.11a
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    • pp.7-12
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    • 2004
  • A lifetime prediction of holddown spring screw in nuclear fuel assembly was performed using fracture mechanics approach. The spring screw was designed such that it was capable of sustaining the loads imposed by the initial tensile preload and operational loads. In order to investigate the cause of failure and to predict the stress corrosion cracking life of the screw, a stress analysis of the top nozzle spring assembly was done using finite element analysis. The elastic-plastic finite element analysis showed that the local stresses at the critical regions of head-shank fillet and thread root significantly exceeded than the yield strength of the screw material, resulting in local plastic deformation. Normalized stress intensity factors for PWSCC life prediction was proposed. Primary water stress corrosion cracking life of the Inconel 600 screw was predicted by using integration of the Scott model and resulted in 1.78 years, which was fairly close to the actual service life of the holddown spring screw.

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