• 보건의료기술평가
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• 제5권1호
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• pp.31-41
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• 2017

Objectives: To explore prevalently used types of medication error and the types of medication error which would be appropriate to be used in Korea. Methods: In depth literature review was performed to explore the mostly used types of medication error in the United States, Canada, Europe, Australia, and Japan. We intended to examine experts' view on the suitability of the types of medication error to be used in Korea. The types of medicati0on error were classified by activity criteria, severity criteria, process criteria, and responsible person criteria based on literature reviews. Results: According to the result of literature review, activity criteria was the most commonly used type of medication error. Ten experts in the area of patient-safety and medication error responded and the top two types of medication error which were appropriate and suitable to be used in Korea were severity criteria and activity criteria. Conclusion: Severity criteria and activity criteria could be recommended to be used as the standard types of medication error in Korea although there are other types of criteria such as process criteria and responsible person criteria.

• 한국안전학회지
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• 제13권4호
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• pp.279-285
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• 1998

This study investigated human error characteristics of the 42 fatal industrial accidents reported by staff members of Korea Industrial Safety Corporation. Various types of human error were judged to be primary contributing factors in about 74 percent of the cases. Most of human error made by involved industrial operators resulted from two types of mistakes: (1) mistake in judgement of work situation, and (2) omission in daily check. It was concluded that preparation/observance for work procedure manuals, danger predication training and enforcement/Education of daily check routine would be effective preventive tools for these types of human error attributable to fatal industrial accidents.

• 컴퓨터교육학회논문지
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• 제17권5호
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• pp.43-51
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• 2014

본 연구는 중 고등학생들의 온라인 프로그래밍 과제 수행결과에서 발생한 오류를 파악하여, 오류유형과 오류내용을 분류하고, 프로그래밍 개념학습 성취수준에 따른 오류 빈도의 차이와 성취수준과 오류유형과의 상관관계를 분석하여 향후 프로그래밍 교육에 대한 방향과 인지수준에 따른 교육방법을 제시하였다. 연구를 위해 88명의 학생들의 프로그래밍 과제 수행 결과를 가지고 문법오류, 논리오류, 코딩오류로 오류유형과 오류내용을 분류하고 분석하였다. 분석결과, 세 오류유형 중 논리오류의 발생비율이 69.3%로 가장 높았으며, 성취수준에 따른 오류 빈도의 차이에서는 성취수준 상, 중, 하 세 집단 간에 유의한 차이가 있었다. 성취수준과 오류유형과의 상관관계 분석 결과에서는 논리오류와 코딩오류에서 부적 상관관계를 보여, 성취수준이 높을수록 논리오류와 코딩오류를 적게 범함을 알 수 있었다. 오류유형간의 상관관계에서는 문법오류와 코딩오류간의 정적상관관계를 보였다.

• 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.

• 대한인간공학회지
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• 제15권1호
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• pp.27-38
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• 1996

A total of 77 unanticipated trip cases induced by human errors in Korean nuclear power plants were collected from the nuclear power plant trip event reports and analyzed to investigate the areas of high priority for human error reduction. Prior to this analysis, a classification system was made on the four task-related categories including plant systems, work situations, task types, and error types. The erroneous actions affecting the unanticipated plant trips were indentified by reviewing carefully the description of trip events. Then, the events with erroneous action were analyzed by using the classification system. Based on the results for the individual cases, human error occurrences were counted for each of the four categories, also for the selected pairs of categories, to find out the relationships between the two categories in aspects of human errors. As a result, the plant systems, work situations, and task types, and error types which are dominant in human error occurrences were identified.

• Nuclear Engineering and Technology
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• 제40권7호
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• pp.615-624
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• 2008

In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1 %), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed.

• 한국학교수학회논문집
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• 제17권3호
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• pp.409-435
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• 2014

본 연구의 목적은 초등학교 5학년 학생들이 가장 어려워하는 연산 중 하나인 분수 연산관련 서술형 평가 문항에서 나타내는 연산 능력과 오류 유형을 살펴봄으로써 초등학교 현장에서의 분수 연산에 대한 시사점을 제공하고자 한다. 연구 결과, 연구참여자들은 분수의 덧셈과 뺄셈 연산 보다 분수의 곱셈 연산 능력이 낮게 나타났다. 또한 서술형 평가 문항에 다양한 오류 유형이 나타났는데, 연산 능력별 차이에서는 상 집단 학생들은 '풀이 과정의 비약', 중 집단과 하 집단에서는 모두 '문항 이해의 오류'로 나타났다. 분수의 덧셈과 뺄셈에 대한 연산 능력은 분수의 곱셈 연산 능력에 영향을 주는 것으로 나타났는데, '문항에 대한 이해'와 '풀이 과정에 대한 이해'에서 나타난 오류가 곱셈 연산 능력에 가장 큰 영향을 주는 것으로 나타났다.

• 한국콘텐츠학회논문지
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• 제21권6호
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• pp.19-34
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• 2021

본 연구는 챗봇의 오류의 유형과 오류 메시지의 구조화 여부에 따른 태도, 행동의도, 사용성의 차이를 검증하고자 하였다. 챗봇의 오류 유형은 마음지각 이론을 기반으로 기대수준이 서로 다른 경험요소 오류와 기능요소 오류로 나누었으며 오류 메시지는 오류 사실만을 명시하는 비구조화 조건과 사과 표현, 오류의 원인, 개선의지를 포함한 구조화된 조건으로 나누었다. 오류 유형에 따라 사용성 점수에 차이가 나타났으며, 구조화된 오류 메시지 조건에서 태도, 행동의도, 사용성 점수가 높게 나타났다. 경험요소 기대격차는 세 종속 변인을 예측하지 못했으나, 기능요소 기대격차는 세 종속 변인을 유의미하게 예측하였으며 기능요소 기대격차에 대하여 오류 유형과 오류 메시지 구조화 여부의 상호작용 경향성이 확인되었다. 본 연구는 구조화된 오류 메시지의 완충효과를 검증하였고 오류 유형에 따라 완충효과가 달라질 가능성을 확인하였다. 이 결과는 사용자 경험을 증진하는 오류대처전략설계에 적용가능할 것으로 기대한다.

• 한국안전학회지
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• 제22권4호
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• pp.66-71
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• 2007

Human error is one of the major contributors to the railway accidents or incidents. In order to develop an effective countermeasure to remove or reduce human errors, a systematic analysis should be preferentially performed to identify their causes, characteristics, and types of human error induced in accidents or incidents. This paper introduces a case study for human error analysis of the railway accidents and incidents. For the case study, more than 1,000 domestic railway accidents or incidents that happened during the year of 2004 have been investigated and a detailed error analysis was performed on the selected 90 cases, which were obviously caused by human error. This paper presents a classification structure for human error analysis, and summarizes the analysis results such as causes of the events, error modes and types, related worker, and task type.

• Nuclear Engineering and Technology
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• 제28권6호
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• pp.563-575
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• 1996

A total of 77 cases was identified to have human errors from a total of 255 trips occurred from 1978 to 1992 in Korean NPPs. The cases were analyzed to investigate how many human errors occurred on which work conditions to find out the areas of high priority for human error reduction. For the analysis of the 77 trip cases due to human errors, classifications were made for the following four categories ; plant systems, work situation, job types, and error types. Erroneous tasks critically influencing the plant trips were carefully identified and analyzed according to the classifications. Based on the results for the individual cases, the cases were counted for the classification items in each of the four categories, then also for the group of categories to investigate the relationships among the categories in aspects of human error occurrences. As results, the plant systems, work situations, and job types, and error types that are dominant in human errors related to the trips ore identified.