• 한국의료질향상학회지
• /
• 제19권2호
• /
• pp.50-64
• /
• 2013

Objectives : Suicide is a serious sentinel event in healthcare organization. Suicide and suicidal attempt are fatal and long lasting mental and physical damage to themselves, family, and medical staffs. To develope the system to prevent suicidal accident in hospital, we reviewed and analysed one case of suicidal sentinel event. Methods: The risks of suicidal sentinel event were evaluated and analysed through the root cause analysis and failure mode effects analysis. Result: We found several root causes such as initial assessment of oldest patient and security issues. Couple of action plans to fix the problems were done immediately. According to failure mode, we evaluate the risk priority number to modify the action plans. Conclusion: To reduce the risk of sentinel events, we reviewed the suicidal event and established the new system and action plan to prevent sentinel events.

• 한국가스학회지
• /
• 제27권1호
• /
• pp.57-62
• /
• 2023

정압기 EVENT는 각 지역정압기(이하 "정압기")에 설치된 원격감시장치가 보내는 신호로 당사 Client서버에서 직관적으로 확인할 수 있는 이상경보이다. 이는 정압기 이상발생 시 상황실에서 즉각적으로 출동명령 및 초동조치를 가능토록 하며 정압기 이상원인을 분석할 수 있는 중요한 Data이다. 최근 3년간 정압기 EVENT Data의 추이를 살펴보면 비점검 EVENT Data 증가 추세가 뚜렷하다. 비점검 EVENT(실제이상 또는 Noise EVENT)가 증가한다는 것은 첫째로 실제 정압기에 기계적 이상이나 압력이상 발생이 증가한다는 의미일 수도 있으며, 둘째로 실제 정압기엔 이상이 없지만 원격감시장치에서 발생한 통신오류, Reset오류, 센서오류, 전원오류(순간정전) 등에 의하여 정압기에 이상이 생긴 것처럼 EVENT Data가 형성될 수도 있다. 이중 본 연구에서는 최근 발생한 비점검 EVENT Data를 분석하여 Noise EVENT인 원격감시장치 오류 중 Critical Noise Event를 확인하고 이를 감소시켜 정압기 EVENT의 신뢰성을 높일 수 있는 방안에 대해 검토하였다.

• 한국안전학회지
• /
• 제34권1호
• /
• pp.14-20
• /
• 2019

This paper presents a safety assessment based approach for the safe operation for PCS(Power Conditioning System) of photovoltaic and energy storage systems, applying FTA. The approach established top events as power outage and a failure likely to cause the largest damage among the potential risks of PCS. Then the Minimal Cut Set (MCS) and the importance of basic events were analyzed for implementing risk assessment. To cope with the objects, the components and their functions of PCS were categorized. To calculate the MCS frequency based on IEEE J Photovolt 2013, IEEE Std. 493-2007 and RAC (EPRD, NPRD), the failure rate and failure mode were produced regarding the basic events. In order to analyze the top event of failure and power outage, it was assumed that failures occurred in DC breaker, AC breaker, SMPS, DC filter, Inverter, CT, PT, DSP board, HMI, AC reactor, MC and EMI filter and Fault Tree was drawn. It is expected that the MCS and the importance of basic event resulting from this study will help find and remove the causes of failure and power outage in PCS for efficient safety management.

• 한국운동역학회지
• /
• 제17권2호
• /
• pp.157-166
• /
• 2007

This study was to compare the major kinematic factors between the success and failure group on performing the back somersault motion in floor exercise. Three gymnasts(height : $167.3{\pm}2.88cm$, age : $22.0{\pm}1.0years$, body weight : $64.4{\pm}2.3kg$) were participated in this study. The kinematic data was recorded at 60Hz with four digital video camera. Two successful motions and failure motions for each subject were selected for three dimensional analysis. 1. Success Trail It was appear that success trail was larger than failure group in projection velocity, but success trail was smaller than failure trail in projection angle. Also it was appear that success trail was longer than failure group in the time required. Hand segment velocity and maximum velocity in success trail were larger than those in failure trail, and this result was increasing the projection velocity and finally increasing the vertical height of center of mass. At the take-off(event 2), flection amount of hip and knee joint angle was contributed to the optimal condition for the take-off and at the peak point, hip and knee joint angle was maximum flexed for reducing the moment of inertia. Also in this point, upper extremities of success trail extended more than those of failure trail. in this base, success trail in upward phase(p3) 2. Failure Trail It was appear that failure trail was smaller than success trail in projection velocity, but failure trail was larger than success trail in projection angle. Also it was appear that failure trail was more short than success trail in the time required. Hand segment velocity and maximum velocity in failure trail were smaller than those in success trail, and this result was reducing the projection velocity and finally reducing the vertical high of center of mass. At the take-off(event 2), flection amount of hip and knee joint angle wasn't contributed to the optimal condition for the take-off and at the peak point, hip and knee joint angle wasn't maximum flexed for reducing the moment of inertia. Also in this point, upper extremities of failure trail didn't extended more than those of success trail.

• 한국정밀공학회:학술대회논문집
• /
• 한국정밀공학회 2001년도 춘계학술대회 논문집
• /
• pp.594-597
• /
• 2001

As many industrial systems become more complex, they become extremely difficult to diagnose the cause of failures. The subject of this paper is ECCS(Emergency Core Cooling System) part of PWR(Pressurized Water Reactor). This paper presents modeling and diagnoser construction of ECCS based on discrete event system theory. Also, this paper presents that the ECCS system is diagnosible in our approach.

• Journal of Acupuncture Research
• /
• 제25권4호
• /
• pp.117-125
• /
• 2008

Objectives : Analyze according to types of event causing the adverse outcome due to acupotomy, and discuss problems and safety reqirements to using this therapy in Korea. Methods : Based upon the indication, contraindication, treatment procedures, clinical obsevations, acupotomy-related adverse outcome case reports, the factors of damaging event were classified. Results : The main factors of adverse outcome by acupotomy were anatomical ignorance, contamination of device or hospital staff, failure to notice preexisting disease(cardiovascular disease, hypertension, renal failure, hemophilia, chronic Liver Disease, etc.), unskilled treatment procedures(massive bleeding) and techniques(nerve injury, hepatic and splenic injury, Pneumothorax). Conclusions : It is mandatory to prepare adequate sterilie aseptic technique. The clinician should ensure understand genernal health state of patient and anatomical direction.

• Nuclear Engineering and Technology
• /
• 제44권5호
• /
• pp.437-452
• /
• 2012

The Tohoku earthquake (Mw9.0) occurred on March 11, 2011 and caused a large tsunami. The Fukushima Dai-ichi NPP (F1-NPP) were overwhelmed by the tsunami and core damage occurred. This paper describes the overview of F1-NPP accident and the usability of tsunami PRA at Tohoku earthquake. The paper makes reference to the following current issues: influence on seismic hazard of gigantic aftershocks and triggered earthquakes, concepts for evaluating core damage frequency considering common cause failure with correlation coefficient against seismic event at multi units and sites, and concepts of "seismic-tsunami PSA" considering a combination of seismic motion and tsunami effects.

• Nuclear Engineering and Technology
• /
• 제46권2호
• /
• pp.207-216
• /
• 2014

This paper revisits the Fukushima accident to draw lessons in the aspect of nuclear safety considering the fact that the Fukushima accident resulted in core damage for three nuclear power plants simultaneously and that there is a high possibility of a failure of the integrity of reactor vessel and primary containment vessel. A brief review on the accident progression at Fukushima nuclear power plants is discussed to highlight the nature and characteristic of the event. As the severe accident management measures at the Fukushima Daiich nuclear power plants seem to be not fully effective, limitations of current severe accident management strategy are discussed to identify the areas for the potential improvements including core cooling strategy, containment venting, hydrogen control, depressurization of primary system, and proper indication of event progression. The gap between the Fukushima accident event progression and current understanding of severe accident phenomenology including the core damage, reactor vessel failure, containment failure, and hydrogen explosion are discussed. Adequacy of current safety goals are also discussed in view of the socio-economic impact of the Fukushima accident. As a conclusion, it is suggested that an investigation on a coherent integrated safety principle for the severe accident and development of innovative mitigation features is necessary for robust and resilient nuclear power system.

• 한국산업정보학회논문지
• /
• 제17권4호
• /
• pp.71-85
• /
• 2012

본 논문은 운항중인 선박에서 기록되어지는 운항정보 및 엔진 가동정보 등을 실시간으로 모니터링하고, 문제 발생 시에 그 근본원인을 찾아내어 민첩하게 대응할 수 있는 일련의 결함원인 분석 및 예방시스템 개발을 목적으로 한다. 결함분석을 위해서는 선박엔진의 주요기관에 부착된 센서들로부터 장기간 수집된 정보를 사용하게 되는데, 이 양이 매우 방대하며, 잡음 및 중복정보(Redundancy)가 너무 많이 포함되어, 수집된 센서 데이터를 바로 고장분석에 사용하기에는 어려움이 있다. 따라서 본 논문에서는 방대한 양의 데이터 중, 정보의 손실을 최소화하고 중요한 정보만을 추출하기 위해 'Equal-frequency binning'과 'Entropy' 기반의 데이터 필터링 방법에 관해 연구하였다. 실제로 시험운용 중인 선박엔진 데이터를 개발된 선박엔진 고장분석 소프트웨어를 이용하여 결함분석을 수행하여, 제안된 방법의 효용성을 검증한다.

• 한국정밀공학회:학술대회논문집
• /
• 한국정밀공학회 2001년도 춘계학술대회 논문집
• /
• pp.570-573
• /
• 2001

Safety is very important to operate nuclear power plant. To have the safety, nuclear power plant should be run without trouble. This paper presents the application of a failure diagnosis approach based on discrete event system theory to the Main Feedwater System for Safe Integral Reactor.