• Radiation Oncology Journal
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• 제31권2호
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• pp.88-96
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• 2013

Purpose: This study identifies accident sequences from the past accidents in order to help the risk analysis application to the external radiotherapy. Materials and Methods: This study reviews 59 accidental cases in two retrospective safety analyses that have collected the incidents in the external radiotherapy extensively. Two accident analysis reports that accumulated past incidents are investigated to identify accident sequences including initiating events, failure of safety measures, and consequences. This study classifies the accidents by the treatments stages and sources of errors for initiating events, types of failures in the safety measures, and types of undesirable consequences and the number of affected patients. Then, the accident sequences are grouped into several categories on the basis of similarity of progression. As a result, these cases can be categorized into 14 groups of accident sequence. Results: The result indicates that risk analysis needs to pay attention to not only the planning stage, but also the calibration stage that is committed prior to the main treatment process. It also shows that human error is the largest contributor to initiating events as well as to the failure of safety measures. This study also illustrates an event tree analysis for an accident sequence initiated in the calibration. Conclusion: This study is expected to provide sights into the accident sequences for the prospective risk analysis through the review of experiences.

• 한국도로학회논문집
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• 제17권3호
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• pp.117-124
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• 2015

PURPOSES : The purpose of this study is to verify traffic accident injury severity factors for elderly drivers and the relative relationship of these factors. METHODS : To verify the complicated relationship among traffic accident injury severity factors, this study employed a structural equation model (SEM). To develop the SEM structure, only the severity of human injuries was considered; moreover, the observed variables were selected through confirmatory factor analysis (CFA). The number of fatalities, serious injuries, moderate injuries, and minor injuries were selected for observed variables of severity. For latent variables, the accident situation, environment, and vehicle and driver factors were respectively defined. Seven observed variables were selected among the latent variables. RESULTS : This study showed that the vehicle and driver factor was the most influential factor for accident severity among the latent factors. For the observed variable, the type of vehicle, type of accident, and status of day or night for each latent variable were the most relative observed variables for the accident severity factor. To verify the validity of the SEM, several model fitting methods, including ${\chi}^2/df$, GFI, AGFI, CFI, and others, were applied, and the model produced meaningful results. CONCLUSIONS : Based on an analysis of results of traffic accident injury severity for elderly drivers, the vehicle and driver factor was the most influential one for injury severity. Therefore, education tailored to elderly drivers is needed to improve driving behavior of elderly driver.

• 한국학교ㆍ지역보건교육학회지
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• 제12권1호
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• pp.71-89
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• 2011

Objectives: The purpose of this study is to identify risk behavior related to the school accident between male and female elementary school students. Methods: 838 School accident data provided by Seoul School Safety Council were analyzed by gender. Based on the results above, survey questionnaires on characteristics of school accident were developed. Self-reported data were collected from a sample population of 433 students in grade 5 to 6 students attending 4 elementary schools in Seoul. Results: The students who answered they experienced the accident in school for the past 1 year, accounts 60.5% of male and 39.5% of females students, which has statistically significant difference. The male's cases happened most around corridor/door, while female's cases happened most in the playground/gymnasium. As for the accident risk behavior, male students had the risk behavior by using the personal belongings/toys, while the female students had much risk behavior related to physical facility/playground. When classifying the characteristics of risk behaviors according to the accident causes, male students showed higher score in the accident risk behaviors related to play/fight than in those of the female students(p<0.05). Conclusions: Health care providers should develop school safety programs by characteristics of risk behavior between male and female elementary school students.

• 한국건축시공학회지
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• 제23권4호
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• pp.417-428
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• 2023

사고 원인에 대한 철저한 분석은 사고 재발 방지를 위한 필수적인 과정이다. 해체공사 사고의 원인을 살펴보면 작업자의 불안전한 행동, 불안전한 상태, 심리적·신체적 상태, 현장관리 원인 등 매우 다양하다. 현재 해체공사 사고통계는 지속적으로 조사·보고되고 있으나 사고 유형에 따른 보다 근본적인 원인 분류 정보가 필요하다. 본 연구에서는 하인리히의 도미노 이론을 바탕으로 해체공사 사고의 유형에 따라 사고원인(불안전한 행동, 불안전한 조건)과 휴먼에러(인적요인)를 분류하였다. 본 연구에서는 해체공사시 사고유형에 따라 사고원인을 체계적으로 분류하기 위해 QFD-FMEA(Quality Function Deployment - Failure Mode Effect Analysis) 3단계 모델을 사용하였다. 사고원인 분류 결과는 사고예방을 위한 안전지식 및 체크리스트로 활용할 수 있다.

• 한국원자력학회:학술대회논문집
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• 한국원자력학회 2004년도 추계학술발표회 발표논문집
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• pp.491-492
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• 2004

• 대한인간공학회지
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• 제30권1호
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• pp.151-160
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• 2011

There have been many efforts to prevent accidents in Korea for the last 25 years. Many measures in the area of hardware sciences including electrical, mechanical, chemical engineering, etc. were applied to eliminate or at least reduce causes of accidents. However, the accidents rate has not been reduced much despite of these measures. This research aimed to find real causes of these accidents and to suggest a comprehensive model that can mainly be applied to industrial fields to find potential or existence of human errors during the pre-installation stage or after an accident. We tried to explain sequences of an operator's information process that might cause human errors on one hand, and life cycle stages of facilities involved when human errors occur on the other hand. With this comprehensive model presented in this research, one can follow up the sequence of human errors caused by operators. Further, errors made at the design stage which could be a main cause of accidents can be tracked. It is recommended that this comprehensive model should be used to prevent human errors in industrial fields since safety personnel can easily find out errors or error potentials through the life cycle stages of manmachine facilities.

• 대한인간공학회지
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• 제30권1호
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• pp.29-39
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• 2011

Safety management paradigm which against human errors in aviation industry is now changing from the follow-up measures after accident in the past to systematic approach that a forecast the hazards and improve the working system of the group to prevent accidents. As human factors are based on the man's specific psychological traits, it takes much time and efforts to prepare the preventive measures. That's why aviation industry is interested in the accident-prevent measurements against human errors. In this thesis, therefore, we are going to introduce the efforts that aviation organizations have tried and recommend management systems and discuss the suggestive facts. At first, we discussed introduction of HFACS which is the systematic accidents-classification system related to human errors in the aviation organization and countermeasure in the aspects of management, technology/engineering, education training. We described about FOQA, LOSA, CRM/TEM, aviation safety information DB in the aspect of management, and explained safety technologies that prevent human errors or avoid technologically when emergency occurs in the aspect of technology/engineering. In the aspect of education training, we explained the application plan about safety programs(LOFT/Simulator use, CRM/TEM application etc).

• 한국가스학회지
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• 제7권2호
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• pp.42-47
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• 2003

화학공정산업에서 화재, 폭발, 독성물질 누출의 대형사고로 인한 막대한 인적 물적 손실을 효과적으로 방지하기 위하여 기계적 오류와 연계하여 사람의 행동을 동적으로 제어하는 것이 필요하다. 석유화학공단을 비롯한 에너지산업시설에서의 대형사고는 기계적인 결함과 더불어 사람의 행동과 관련되어 있음에도 불구하고, 대부분의 연구는 시스템의 위험을 감소시키기 위하여 안전장치의 결함과 인간의 행동에 대하여 서로 연계를 지우지 않고 독립적으로 연구를 수행하여 왔다 본 연구에서는 화학공정산업의 안전을 향상시키기 위한 방법을 제시하기 위하여 기계적 고장과 인적오류를 동시에 고려하여 인적오류를 제어하고, 중요한 수행영향인자에 대하여 고찰하였다.

• 대한인간공학회지
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• 제32권6호
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• pp.535-540
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• 2013

Objective: The aim of this study is to evaluate the effectiveness and efficiency of causal links between various error causes in human error analysis. Background: As finding root causes of human error in safety-critical systems is often a cognitively demanding and time-consuming task, it is particularly necessary to develop a method for improving both the quality and efficiency of the task. Although a few methods such as CREAM have suggested causal linking between error causes as a means to enhance the quality and efficiency of human error analysis, no published research to date has evaluated the performance of the causal links. Method: The performance of the CREAM links between error causes were evaluated with 80 railway accident investigation reports from the UK. From each report, errorneous actions of operators were derived, and for each error, candidate causes were found by following the predefined links. Two measures, coverage and selectivity, were used to evaluate the effectiveness and efficiency of the links, respectively. Results: On average, 96% of error causes actually included in the accident reports were found by following the causal links, and among the total of 121 possible error causes, the number of error causes to be examined further was reduced to one-tenth on average. As an additional result of this work, frequent error causes and frequently used links are provided. Conclusion: This result implies that the predefined causal links between error causes can significantly reduce the time and effort required to find the multiple levels of error causes and their causal relations without losing the quality of the results. Application: The CREAM links can be applied to human error analysis in any industry with minor modifications.

• 대한안전경영과학회지
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• 제26권2호
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• pp.1-10
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• 2024

Human stampedes were a major hazard that could occur during mass gatherings, but they have received limited attention in korea. However, after the 10.29 Itaewon disaster, this atmosphere has turned around. The cause of such an accident and how to prevent it should be considered. The main aim of this study is to identify the reason why did the accident happen at that time, the root cause, and the triggering cause with Delphi-AHP survey method. In addition, various preventive measures were investigated by experts to prevent accidents similar to 10.29 Itaewon disaster. Problems and solutions were presented by collecting expert opinions on the causes and preventive measures of the 10.29 Itaewon disaster. However, the opinion of the experienced peoples who experienced the risk at the Itaewon was not included, so further investigation is considered necessary.