• 제목/요약/키워드: Reporting system of a near accident

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원전 사고근접사례의 보고체계 현황 및 현안분석 (Analysis on Management Status and Issues for Near Miss Reporting in Nuclear Power Industry)

  • 정윤형;김동진
    • 한국안전학회지
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    • 제31권5호
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    • pp.177-186
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    • 2016
  • When an event is occurred in a nuclear power plant (NPP), the NPP operator reports it referred by the regulation on reporting and public announcement of accidents and incidents. Some of the events do not need to be reported because they are not included in the reporting criteria of the regulation. However, it is necessary that they should be managed effectively because the accident can be occurred by the recurrence of a lot of them as precursors. Among the events not included in the reporting criteria of the regulation, near miss is the event that is not occurred but can generate a significant consequence. This can provide the cause of the event which does not result an accident. So, it is able to offer insightful knowledges to prevent higher level events about the function and process of NPP. The objective of this study is to analyze the issues of near miss events, prepare the defence against the risk, and improve the management process of NPP. To achieve it, this study performed to analyze the management structure and status of near miss events as well as the accident reporting system of the domestic and foreign regulation bodies. In case of Korea, the status was analyzed by quantitative data, licensee event reports and procedures. Based on these, we could find the causes that near miss events were not managed effectively. Then, systematic alternatives that reflected the perspective of man, technology and organization were drawn.

Near Miss 사고 예방 활동과 환자안전관리 문화형성이 환자안전에 미치는 영향 (The Effects of Near Miss and Accident Prevention Activities and the Culture of Patient Safety Management for the Patient Safety)

  • 장호석;이귀원
    • 핵의학기술
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    • 제14권2호
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    • pp.138-144
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    • 2010
  • 급변하는 의료환경 속에서도 변함없이 의료기관들은 환자 안전관리 부분의 중요성을 인식하여 관리하고 있다. 하지만 현재 환자안전관리는 사후관리와 처벌이 강조된 프로세스들로 조직원들의 참여성이 결여된 문제를 보이고 있다. 본원 핵의학과 에서는 참여형 니어미스 사고예방 활동을 시행하여 환자안전사고에 사전관리를 시작하고 사고보고에 따른 불이익이 없는 시스템을 구축하여 니어미스 감소 와 환자안전사고 제로화를 목적으로 본 연구을 시작하였다. 또한 핵의학과만의 차별화된 환자안전관리System구축도 그 목적으로 하고 있다. 1. 팀원들의 과거 니어미스 및 현재 발생되고 있는 니어미스와 사고 사례수집(1차 자료수집). 2. 설문을 통해 중요도, 긴급도를 파악하고 니어미스 및 사고사례를 정량화(2차 자료수집). 3. 자료 분석을 통한 중요 접점 파악과 사고 사례 정량화. 4. 중요 접점 부분에 대한 매뉴얼 제작과 표준화, 오류방지를 위한 참여형 개선활동 시행. 5. 니어미스 보고체계 구축을 위한 웹 기반 커뮤니티 활동. 6. 설문과 FGI를 통해 활동 전후 평가 시행. 1) 비계량적이었던 핵의학과 내 안전사고 및 니어미스를 계량화(월 50여 회의 니어미스와 년 1건의 안전사고발생) 2) 계량화된 데이터를 통해 개선방안을 수립(0여건의 참여형 개선활동, 프로세스 개선, 표준화를 위한 약속 매뉴얼 제작) 3) 안전문화 시스템을 형성하고 팀원들의 높은 관여도를 형성.(보고체계구축, 체크리스트 제작, 안전문화 슬로건 제작, 평가 인덱스 구축) 4) 니어미스 및 사고 사례를 공유하고 반면교사로 삼기 위한 커뮤니티 개설. 5) 활동 전후 니어미스 발생률은 50% 감소 하였고 안전사고 제로. 핵의학과의 최고의 서비스는 환자안전이 보장된 양질의 검사와 치료를 제공하는 것이다. 참여형 개선활동으로 니어미스사고를 예방하고 안전문화를 형성하여 시스템을 구축함으로써 니어미스 발생 사례는 50% 줄었으며 안전사고는 발생하지 않았다. 이는 환자안전사고의 사전관리란 측면에서도 시사하는 바가 있다. 또한 불이익이 없는 사고보고체계도 마련하여 솔직하게 보고하고 인정하는 문화도 만든 계기가 되었다. 기본에 충실한 뛰어난 시스템은 환자에게 제공되는 최고의 서비스이며 형성된 안전문화 시스템은 결국 고객만족으로 이어질 것이다. 따라서 본원 핵의학과 에서는 마련된 시스템을 정착하고 안정시켜 차별화된 환자안전문화를 형성해 나가고자 한다.

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A Study on the Analysis of the Safety Management System of Korea-China Car Ferries

  • Park, Young-Soo;Jeon, Hea-Dong;Oh, Yong-Sik;Park, Sang-Won
    • 해양환경안전학회지
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    • 제23권3호
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    • pp.287-293
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    • 2017
  • The purpose of this study is to keep the safety of the car ferry passengers and vessels by investigating and analyzing vessel safety management systems in Korea and China. To this end, we investigated Korea-China car ferries and the current status and causes of global marine accidents corresponding to the sizes of the vessels from Korea and China. Furthermore, we investigated car ferries' crew management and safety management. As a result of the analysis of the ferry accident, the causes of human error and ship's age were the greatest, but the ship's companies showed a negative stance regarding the age restriction. It seems that it is necessary to utilize the near-miss accident reporting system and differentiate the management of ship's aging. Also, it was analyzed that both the ship company and the crew of the ship need to strengthen their awareness of safety management.

항공기(航空機) 사고조사제도(事故調査制度)에 관한 연구(硏究) (A Study on the System of Aircraft Investigation)

  • 김두환
    • 항공우주정책ㆍ법학회지
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    • 제9권
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    • pp.85-143
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    • 1997
  • The main purpose of the investigation of an accident caused by aircraft is to be prevented the sudden and casual accidents caused by wilful misconduct and fault from pilots, air traffic controllers, hijack, trouble of engine and machinery of aircraft, turbulence during the bad weather, collision between birds and aircraft, near miss flight by aircrafts etc. It is not the purpose of this activity to apportion blame or liability for offender of aircraft accidents. Accidents to aircraft, especially those involving the general public and their property, are a matter of great concern to the aviation community. The system of international regulation exists to improve safety and minimize, as far as possible, the risk of accidents but when they do occur there is a web of systems and procedures to investigate and respond to them. I would like to trace the general line of regulation from an international source in the Chicago Convention of 1944. Article 26 of the Convention lays down the basic principle for the investigation of the aircraft accident. Where there has been an accident to an aircraft of a contracting state which occurs in the territory of another contracting state and which involves death or serious injury or indicates serious technical defect in the aircraft or air navigation facilities, the state in which the accident occurs must institute an inquiry into the circumstances of the accident. That inquiry will be in accordance, in so far as its law permits, with the procedure which may be recommended from time to time by the International Civil Aviation Organization ICAO). There are very general provisions but they state two essential principles: first, in certain circumstances there must be an investigation, and second, who is to be responsible for undertaking that investigation. The latter is an important point to establish otherwise there could be at least two states claiming jurisdiction on the inquiry. The Chicago Convention also provides that the state where the aircraft is registered is to be given the opportunity to appoint observers to be present at the inquiry and the state holding the inquiry must communicate the report and findings in the matter to that other state. It is worth noting that the Chicago Convention (Article 25) also makes provision for assisting aircraft in distress. Each contracting state undertakes to provide such measures of assistance to aircraft in distress in its territory as it may find practicable and to permit (subject to control by its own authorities) the owner of the aircraft or authorities of the state in which the aircraft is registered, to provide such measures of assistance as may be necessitated by circumstances. Significantly, the undertaking can only be given by contracting state but the duty to provide assistance is not limited to aircraft registered in another contracting state, but presumably any aircraft in distress in the territory of the contracting state. Finally, the Convention envisages further regulations (normally to be produced under the auspices of ICAO). In this case the Convention provides that each contracting state, when undertaking a search for missing aircraft, will collaborate in co-ordinated measures which may be recommended from time to time pursuant to the Convention. Since 1944 further international regulations relating to safety and investigation of accidents have been made, both pursuant to Chicago Convention and, in particular, through the vehicle of the ICAO which has, for example, set up an accident and reporting system. By requiring the reporting of certain accidents and incidents it is building up an information service for the benefit of member states. However, Chicago Convention provides that each contracting state undertakes collaborate in securing the highest practicable degree of uniformity in regulations, standards, procedures and organization in relation to aircraft, personnel, airways and auxiliary services in all matters in which such uniformity will facilitate and improve air navigation. To this end, ICAO is to adopt and amend from time to time, as may be necessary, international standards and recommended practices and procedures dealing with, among other things, aircraft in distress and investigation of accidents. Standards and Recommended Practices for Aircraft Accident Injuries were first adopted by the ICAO Council on 11 April 1951 pursuant to Article 37 of the Chicago Convention on International Civil Aviation and were designated as Annex 13 to the Convention. The Standards Recommended Practices were based on Recommendations of the Accident Investigation Division at its first Session in February 1946 which were further developed at the Second Session of the Division in February 1947. The 2nd Edition (1966), 3rd Edition, (1973), 4th Edition (1976), 5th Edition (1979), 6th Edition (1981), 7th Edition (1988), 8th Edition (1992) of the Annex 13 (Aircraft Accident and Incident Investigation) of the Chicago Convention was amended eight times by the ICAO Council since 1966. Annex 13 sets out in detail the international standards and recommended practices to be adopted by contracting states in dealing with a serious accident to an aircraft of a contracting state occurring in the territory of another contracting state, known as the state of occurrence. It provides, principally, that the state in which the aircraft is registered is to be given the opportunity to appoint an accredited representative to be present at the inquiry conducted by the state in which the serious aircraft accident occurs. Article 26 of the Chicago Convention does not indicate what the accredited representative is to do but Annex 13 amplifies his rights and duties. In particular, the accredited representative participates in the inquiry by visiting the scene of the accident, examining the wreckage, questioning witnesses, having full access to all relevant evidence, receiving copies of all pertinent documents and making submissions in respect of the various elements of the inquiry. The main shortcomings of the present system for aircraft accident investigation are that some contracting sates are not applying Annex 13 within its express terms, although they are contracting states. Further, and much more important in practice, there are many countries which apply the letter of Annex 13 in such a way as to sterilise its spirit. This appears to be due to a number of causes often found in combination. Firstly, the requirements of the local law and of the local procedures are interpreted and applied so as preclude a more efficient investigation under Annex 13 in favour of a legalistic and sterile interpretation of its terms. Sometimes this results from a distrust of the motives of persons and bodies wishing to participate or from commercial or related to matters of liability and bodies. These may be political, commercial or related to matters of liability and insurance. Secondly, there is said to be a conscious desire to conduct the investigation in some contracting states in such a way as to absolve from any possibility of blame the authorities or nationals, whether manufacturers, operators or air traffic controllers, of the country in which the inquiry is held. The EEC has also had an input into accidents and investigations. In particular, a directive was issued in December 1980 encouraging the uniformity of standards within the EEC by means of joint co-operation of accident investigation. The sharing of and assisting with technical facilities and information was considered an important means of achieving these goals. It has since been proposed that a European accident investigation committee should be set up by the EEC (Council Directive 80/1266 of 1 December 1980). After I would like to introduce the summary of the legislation examples and system for aircraft accidents investigation of the United States, the United Kingdom, Canada, Germany, The Netherlands, Sweden, Swiss, New Zealand and Japan, and I am going to mention the present system, regulations and aviation act for the aircraft accident investigation in Korea. Furthermore I would like to point out the shortcomings of the present system and regulations and aviation act for the aircraft accident investigation and then I will suggest my personal opinion on the new and dramatic innovation on the system for aircraft accident investigation in Korea. I propose that it is necessary and desirable for us to make a new legislation or to revise the existing aviation act in order to establish the standing and independent Committee of Aircraft Accident Investigation under the Korean Government.

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COATED PARTICLE FUEL FOR HIGH TEMPERATURE GAS COOLED REACTORS

  • Verfondern, Karl;Nabielek, Heinz;Kendall, James M.
    • Nuclear Engineering and Technology
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    • 제39권5호
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    • pp.603-616
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    • 2007
  • Roy Huddle, having invented the coated particle in Harwell 1957, stated in the early 1970s that we know now everything about particles and coatings and should be going over to deal with other problems. This was on the occasion of the Dragon fuel performance information meeting London 1973: How wrong a genius be! It took until 1978 that really good particles were made in Germany, then during the Japanese HTTR production in the 1990s and finally the Chinese 2000-2001 campaign for HTR-10. Here, we present a review of history and present status. Today, good fuel is measured by different standards from the seventies: where $9*10^{-4}$ initial free heavy metal fraction was typical for early AVR carbide fuel and $3*10^{-4}$ initial free heavy metal fraction was acceptable for oxide fuel in THTR, we insist on values more than an order of magnitude below this value today. Half a percent of particle failure at the end-of-irradiation, another ancient standard, is not even acceptable today, even for the most severe accidents. While legislation and licensing has not changed, one of the reasons we insist on these improvements is the preference for passive systems rather than active controls of earlier times. After renewed HTGR interest, we are reporting about the start of new or reactivated coated particle work in several parts of the world, considering the aspects of designs/ traditional and new materials, manufacturing technologies/ quality control quality assurance, irradiation and accident performance, modeling and performance predictions, and fuel cycle aspects and spent fuel treatment. In very general terms, the coated particle should be strong, reliable, retentive, and affordable. These properties have to be quantified and will be eventually optimized for a specific application system. Results obtained so far indicate that the same particle can be used for steam cycle applications with $700-750^{\circ}C$ helium coolant gas exit, for gas turbine applications at $850-900^{\circ}C$ and for process heat/hydrogen generation applications with $950^{\circ}C$ outlet temperatures. There is a clear set of standards for modem high quality fuel in terms of low levels of heavy metal contamination, manufacture-induced particle defects during fuel body and fuel element making, irradiation/accident induced particle failures and limits on fission product release from intact particles. While gas-cooled reactor design is still open-ended with blocks for the prismatic and spherical fuel elements for the pebble-bed design, there is near worldwide agreement on high quality fuel: a $500{\mu}m$ diameter $UO_2$ kernel of 10% enrichment is surrounded by a $100{\mu}m$ thick sacrificial buffer layer to be followed by a dense inner pyrocarbon layer, a high quality silicon carbide layer of $35{\mu}m$ thickness and theoretical density and another outer pyrocarbon layer. Good performance has been demonstrated both under operational and under accident conditions, i.e. to 10% FIMA and maximum $1600^{\circ}C$ afterwards. And it is the wide-ranging demonstration experience that makes this particle superior. Recommendations are made for further work: 1. Generation of data for presently manufactured materials, e.g. SiC strength and strength distribution, PyC creep and shrinkage and many more material data sets. 2. Renewed start of irradiation and accident testing of modem coated particle fuel. 3. Analysis of existing and newly created data with a view to demonstrate satisfactory performance at burnups beyond 10% FIMA and complete fission product retention even in accidents that go beyond $1600^{\circ}C$ for a short period of time. This work should proceed at both national and international level.