• Safety and Health at Work
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• v.12 no.1
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• pp.42-50
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• 2021

Introduction: Despite huge investments in new technology and transportation infrastructure, terrible accidents still remain a reality of traffic. Methods: Severe traffic accidents were analyzed from four prevailing modes of today's transportations: sea, air, railway, and road. Main root causes of all four accidents were defined with implementation of the approach, based on Flanagan's critical incident technique. In accordance with Molan's Availability Humanization model (AH model), possible preventive or humanization interventions were defined with the focus on technology, environment, organization, and human factors. Results: According to our analyses, there are significant similarities between accidents. Root causes of accidents, human behavioral patterns, and possible humanization measures were presented with rooted graphs. It is possible to create a generalized model graph, which is similar to rooted graphs, for identification of possible humanization measures, intended to prevent similar accidents in the future. Majority of proposed humanization interventions are focused on organization. Organizational interventions are effective in assurance of adequate and safe behavior. Conclusions: Formalization of root cause analysis with rooted graphs in a model offers possibility for implementation of presented methods in analysis of particular events. Implementation of proposed humanization measures in a particular analyzed situation is the basis for creation of safety culture.

• The Korean Journal of Health Service Management
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• v.13 no.3
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• pp.13-26
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• 2019

Objectives: To investigate whether medical institutions can prevent accidents by analyzing the root cause of a medical accident and identifying the tendencies. Methods: A total of 345 medical cases were used for the RCA(Root Cause Analysis). The root causes were classified using the SHELL model. The suitability of the model was confirmed by SPSS's MDPREF and Euclidean distance. An SPSS20.0 hierarchical regression analysis was used as an influencing factor on the degree of injury resulting from medical accidents. Results: The SHELL model was suitable for classification. The rates of accident causes were LS49%, L34%, LL10.2%, LE3.7%, LH2.3%. The order in which the degree of a patient's injury was affected were: Risk Threshold (${\beta}=.180$), Time (${\beta}=.175$), Surgical stage (${\beta}=-.166$), Do not use procedure (${\beta}=.147$). Conclusions: Health care institutions should remove priorities through system improvement and training. For patients' safety, the five factors of the SHELL model should be managed in harmony.

• KOREAN JOURNAL OF CROP SCIENCE
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• v.30 no.2
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• pp.180-183
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• 1985

Percent dormant root and percent missing root were investigated in ginseng (Panax ginseng) plantations and correlated with soil chemical characteristics. Percent dormant root showed no consistency with root age and significant positive correlation with percent missing root in many cases. Percent dormant root showed significant positive correlation with available phosphorus and phosphorus-moisture ratio in soils. Percent missing root showed significant negative correlation with moisture and calcium in soil and positive one with phosphorus - moisture ratio. Above results strongly suggest that excess phosphorus and water stress are the common causes of dormancy and missing of root.

• Industrial Engineering and Management Systems
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• v.9 no.3
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• pp.251-261
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• 2010

This article demonstrated the application of the Fuzzy Data Envelopment Analytical Hierarchy Process (FDEAHP) to evaluate the root causes of critical defect problems occurring in the production of liquid medicine. The methodology of the research began by collecting the defect data by using Check Sheets, and ranking the significant problems by using a Pareto Diagram. Two types of major problems were found to occur, including glass fragments in the medicine and damaged lid threads. The causes of each problem were then analyzed by using Cause and Effect Diagrams. The significant causes were ranked by FDEAHP under three criteria, Severity (S), Occurrence (O) and Detection (D), followed by the framework of the FMEA Technique. Two causes with the highest Final Weight (FW) of each problem were selected to be improved, such as installing auxiliary equipment, using the Poka-Yoke system, setting the scale of the shaft and lathing the bushes of each bottle size. The results demonstrated a reduction in defects from 3.209% to 1.669% and showed that improving a few significant root causes, identified by an experienced decision maker, was sufficient to reduce the defect rate.

• Journal of Navigation and Port Research
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• v.46 no.5
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• pp.400-408
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• 2022

Maritime transportation is one of the most complicated and hazardous business fileds. Maritime accidents still occur despite several precautions since maritime is exposed to natural factors more than any other industries. In this harsh environment as a part of their job, marine pilots often embark/disembark to/ from vessels and confront life-endangering personal accidents. In the maritime field, several risk assessments are applied. However, all of them could not evaluate occupational accident risk for maritime pilot specifically. This paper performs specific risk analysis using the bow-tie method based on past accident records. This paper aims to qualify root causes and quantify root causes by importance level according to occurrence probability. As a result of analysis, occupational accident occurrence probability is found to be 14%, indicating that accident occurrence rate is significantly high. Hence, the probability of root causes triggering accidents and accident occurrence probability can be ascertained so that preventive measurements can be implemented. Besides theoretical achievement, this paper provides safety awareness to marine pilots, Marine Pilot Organizations, and ship crew who play a key role during marine pilots' transfer.

• Journal of the Korean Institute of Gas
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• v.18 no.4
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• pp.86-94
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• 2014

To develop a Root Cause Analysis Map which determines the cause of the accident in chemical laboratory, The Root Cause Analysis(RCA) Map for the laboratory areas was sketched from Phase 1 of the accident element to Phase 3 of the accident element, based on the RCA Map which is applied in the petrochemical industry. On the basis of laboratory RCA Map which was classified by using such method. The root causes of the 211 accident cases in laboratories were classified from Phase 4 to Phase 5 by the Cause Factor Charting technique and The cause of the accident data were inputted to EXCEL program. After that, The causes of the accident data were sorted and classified by type and each step. So 'Approximate Primary RCA Map Draft' was written. In addition, it was reaffirmed whether the root causes of 211 accidents of laboratory were appropriate to 'Primary RCA Map Draft'. By complementing the cause which was expected to cause future accidents, the RCA Map for chemical laboratories was developed. Based on 'RCA Map' proposed in this study, the causes of accidents were analysed management systems 35%, monitoring 12.2%, Human Factor Eng. 15.1% and education training 12.1% by the size of the frequency from Phase 1 to Phase 5.

• The Journal of the Korean dental association
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• v.55 no.3
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• pp.230-239
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• 2017

Root coverage can be an efficacious treatment not only in aspect of dental symptoms like root caries and hypersensitivity, but also in aspect of esthetic problem. There are several predictable methods for gaining a connective tissue attachment to an exposed root surface. Among them, this case report will deal with three cases using enamel matrix derivative and connective tissue graft to recover esthetic and physiological periodontal environment and its form. This case report deals with three patients with gingival recession which has occurred by different causes. They were treated with de-epithelialized graft accompanied by application of enamel matrix derivative. 6-12 months later, all three patients showed considerable root coverage and clinically stable condition of healing. In conclusion, within the limitation of this study, de-epithelialized connective tissue graft accompanied by application of enamel matrix derivative shows stable and clinical acceptable results in aspect of root coverage.

• Journal of Information Technology Applications and Management
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• v.24 no.4
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• pp.71-92
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• 2017

Finding a root cause is an essential step to solving a complex problem. Some previous studies have used the Delphi method for gathering opinions about root causes from geographically dispersed experts. However, we assert that complicated problems such as an industry ecosystem would make a general type of the Delphi method less practical because of too much psychological burden on study participants. In this study we present a preliminary list-based Delphi study method for identifying a root cause. This method was used to identify a root cause and draw a causal map for the information industry ecosystem problems.

• International Journal of Industrial Entomology and Biomaterials
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• v.16 no.2
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• pp.49-56
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• 2008

A preliminary survey on the incidence and intensity of root disease complex (association of Meloidogyne incognita and root rot pathogens) was carried out in the sericultural areas of Karnataka. A total of 280 mulberry gardens were surveyed in 14 districts of Karnataka belonging to different types of soil (red sandy, red loamy and black cotton), farming systems (irrigated and rainfed), varieties (V-1, K-2, Local and S-13) and age of the plants (0-5, 5-10 and 10-15 years). It was observed that the association of M. incognita with Botryodiplodia theobromae and Fusarium solani causes the root disease complex in mulberry. Of the 280 gardens visited, 94 were infested with the disease complex and incidence was recorded as 33.6%. The higher intensity of root disease complex was observed when the root system had more than 100 galls/plant with infection of mixed population of B. theobromae and F. solani in sandy soil under irrigated farming. The 5-10 years old mulberry plantation with V-I variety was found to be most susceptible to root disease complex. Districts like Mysore, Kolar, Mandya, Tumkur, Chitradurga and Bangalore were observed as sensitive areas. Further, the wounds caused by M. incognita in mulberry roots favour the easy entry of root rot pathogens, which increased the severity of the disease very fast.

• Nuclear Engineering and Technology
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• v.55 no.12
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• pp.4408-4425
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• 2023

Alarm flood due to abnormality propagation is the most difficult alarm overloading problem in nuclear power plants (NPPs). Root-cause analysis is suggested to help operators in understand emergency events and plant status. Multilevel Flow Modeling (MFM) has been extensively applied in alarm management by virtue of the capability of explaining causal dependencies among alarms. However, there has never been a technique that can identify the actual root cause for complex alarm situations. This paper presents an automated root-cause analysis system based on MFM. The causal reasoning algorithm is first applied to identify several possible root causes that can lead to massive alarms. A novel root-cause ranking algorithm can subsequently be used to isolate the most likely faults from the other root-cause candidates. The proposed method is validated on a pressurized water reactor (PWR) simulator at HAMMLAB. The results show that the actual root cause is accurately identified for every tested operating scenario. The automation of root-cause identification and ranking affords the opportunity of real-time alarm analysis. It is believed that the study can further improve the situation awareness of operators in the alarm flooding situation.