• Journal of the Korean Society for Railway
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• v.13 no.4
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• pp.455-461
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• 2010

We have identified which causes have influenced to accidents, case by case through a relational analysis on data of accidental case, root case, accident cause and hazard. The data on the accident of railway operation and system have been analyzed and the root cause, accident cause and hazard have been classified. This research has developed accident cause analysis system to build efficient railway safety policy which will be used to prevent railway accidents by government and railway operator.

• Journal of the Korean Institute of Gas
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• v.14 no.4
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• pp.6-11
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• 2010

The continuous fatal accidents like explosion or fire cause huge losses of both life and property in laboratories even though safety management system has been built and periodical checkups and safety diagnosis have been implementing in universities and enterprise-affiliated research institutes since Act on the Establishment of Safe Laboratory Environment was enacted in 2005 to prevent accidents in research laboratories. Cause analysis and safety management measures to prevent recurrence of accidents are urgently needed because accidents in research laboratories occur repeatedly with similar contents. This study will show results of analysis on incidents and accidents occurred in laboratories in universities and enterprise-affiliated research institutes using Root Cause Analysis Method and propose classified map of cause investigation and improvements so as to improve safety management in research laboratories.

• Journal of the Ergonomics Society of Korea
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• v.34 no.2
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• pp.103-113
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• 2015

Objective: This study proposes a systematic process to present the analysis methods and solutions of organizational root causes to human errors on the railroad. Background: In fact, organizational root cause such as organizational culture is an important factor in the safety concerns on human errors in the nuclear power plant, railroad and aircraft. Method: The proposed process is as follows: 1) define analysis boundary 2) select human error taxonomy 3) perform accident analysis 4) draw root causes with FGI 5) review root causes analysis with survey 6) chart analysis of root causes, and 7) propose alternatives and solutions. Results: As a result, root causes of the organizations like railroad and nuclear power plant came from the educational problems, violations, payoff system, safety culture and so forth. Conclusion: The proposed process does predict potential railroad accident through retrospect error analysis by building new human error taxonomies and problem solution. Application: This study would contribute to examination of the relationship between human error-based accidents and organizational root causes.

• Journal of Digital Convergence
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• v.12 no.8
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• pp.77-84
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• 2014

TRIZ was developed and refined in the Soviet Union between 1946 and 1985 by Genrich Altshuller. Its primary application has been for solving inventive problems in the areas of engineering. But, recently the elements of TRIZ began to be applied non-technical areas by Darrell Mann. TRIZ theroy was brought into South Korea in 1995 and it is used by the LG, SAMSUNG, POSCO. TRIZ is simply not the tool for technical problem solving, covering many areas of comprehensive approach is being recognized. TRIZ is a methodology for defining problem, finding root cause through RCA(Root cause analysis), defining technical contradiction and physical contradiction. TRIZ overcomes contradiction and purses problem solving method through innovation. TRIZ is a problem solving method in this study using the principles of non-technical fields applied to the improvement of the logistics area study. The method to overcome contradiction is 40 principles. It is possible to generate idea by using 40 principles. This study was applied to logistics field of non-technical area by using TRIZ principle.

• Journal of the Korean Institute of Gas
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• v.14 no.4
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• pp.1-5
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• 2010

Many sorts of fatal accidents like explosion or fire caused by gas leakage have become a social issue with the increasing use of harmful chemicals in laboratories in universities and enterprise-affiliated research institutes in Korea. Importance of safety management has been emphasized and it made Act on the Establishment of Safe Laboratory Environment enacted not only to protect lives and bodies of people working in laboratories in universities and enterprise-affiliated research institutes but also to make pleasant experimental atmosphere. Safety management system has been built and periodical checkups and safety diagnosis have been implementing in universities and enterprise-affiliated research institutes to prevent such accidents. However, in spite of those actions, continuous accidents make analysis of root cause essential. This study will show results of analysis on incidents and accidents occurred in laboratories in universities and enterprise-affiliated research institutes using Root Cause Analysis Method and propose the direction of safety management.

• Journal of the Korean Society of Safety
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• v.36 no.5
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• pp.43-51
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• 2021

Incident investigation is one of the most important processes among various other safety management methods to prevent industrial accidents. Finding the root causes of accidents, eliminating hazards, and improving safety are the most important purposes of investigating accidents. During the investigation process, root cause analysis (RCA) techniques are used to effectively identify RCA. Over the past few decades, over 30 RCA methods have been developed. These techniques are being widely used in some industries, such as the nuclear and aircraft industries; however, most of the RCA techniques require professional knowledge and special training, making it difficult for safety managers in their respective fields to understand and apply them. Therefore, managers of general industrial sites are rarely present at the scene of actual accident investigations, and they cannot contribute much to the purpose and effectiveness of these investigations. In this study, to address these issues, we developed an RCA technique to facilitate root cause investigation of accidents in real-world industrial sites. To develop new techniques, Systematic Cause Analysis Technique (SCAT), one of the RCA techniques, was used to investigate incidents in the enterprise over three years. We also utilized feature analysis and other papers from existing RCA techniques. To verify its effectiveness, the technique proposed was also applied to the accident case. The technique developed can easily identify and analyze the root cause of an accident and help industrial managers. It can also identify the root cause category where accidents are concentrated and use this data to establish guidelines for preventing future accidents and, thus, focus on prioritizing improvement initiatives.

• 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.

• 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 korean journal of orthodontics
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• v.51 no.4
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• pp.241-249
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• 2021

Objective: This study aimed to evaluate the volume, amount, and localization of root resorption in the maxillary first premolars using micro-computed tomography (micro-CT) after expansion with four different rapid maxillary expansion (RME) appliances. Methods: In total, 20 patients who required RME and extraction of the maxillary first premolars were recruited for this study. The patients were divided into four groups according to the appliance used: mini-implant-supported hybrid RME appliance, hyrax RME appliance, acrylic-bonded RME appliance, and full-coverage RME appliance. The same activation protocol (one activation daily) was implemented in all groups. For each group, the left and right maxillary first premolars were scanned using micro-CT, and each root were divided into six regions. Resorption craters in the six regions were analyzed using special CTAn software for direct volumetric measurements. Data were statistically analyzed using Kruskal-Wallis one-way analysis of variance and Mann-Whitney U test with Bonferroni adjustment. Results: The hybrid expansion appliance resulted in the lowest volume of root resorption and the smallest number of craters (p < 0.001). In terms of overall root resorption, no significant difference was found among the other groups (p > 0.05). Resorption was greater on the buccal surface than on the lingual surface in all groups except the hybrid appliance group (p < 0.05). Conclusions: The findings of this study suggest that all expansion appliances cause root resorption, with resorption craters generally concentrated on the buccal surface. However, the mini-implant-supported hybrid RME appliance causes lesser root resorption than do other conventional appliances.

• The KSFM Journal of Fluid Machinery
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• v.3 no.4 s.9
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• pp.7-14
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• 2000

This paper provides integrity evaluation and root cause analysis for defects observed at volute tongue, or cutwater, of the operating centrifugal pump in power plant. The cause of the cracks are analyzed and reviewed from the viewpoint of the operation and maintenance of the pumps, and the sample obtained from the cracked volute tongue of the pump are examined. At first, in-situ hardness test and microstructure examination were performed to understand the cause of cracking at volute tongue. The evaluation of structural integrity and the possibility of the crack propagation is also evaluated. Cracks were typical intergranular cracking and propagated along with prior austenite grain boundary. At easing volute tongue, the hardness was higher than ASTM requirement and a large amount of intergranular Cr carbide was precipitated. These were due to high C content in material. P content was also higher than ASTM requirement. Therefore, Cr carbide precipitation and P segregation at grain boundary, caused by higher C and P content in material, resulted in intergranular cracking of casing volute tongue. This procedure for integrity evaluation and root cause analysis is used to guide, and support the pump designer and manufacturer's material selection and process design to avoid a costly, unplanned outage of plant.