• 제목/요약/키워드: Swiss cheese

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조종사와 항공교통관제사의 JCRM 필요성에 관한 연구 (A Study on Needs for JCRM with Pilot and Air Traffic Controllers)

  • 김진엽;조영진
    • 한국항행학회논문지
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    • 제27권3호
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    • pp.247-254
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    • 2023
  • 미국의 가인(GAIN)은 Pilot/Controller Collaboration Initiatives 보고서에서 "조종사와 항공교통관제사는 하루 종일 서로 이야기하지만 거의 의사소통하지 않는다."라고 기술하였다. 조종사-항공교통관제사 간의 안전 운항에 대한 인식과 문화, 또는 다른 요인에서 오는 차이점이 절차와 지시에 대하여 서로 간의 오해가 있는가라는 의문이 연구의 시발점이 되었다. 촉박한 시간 내에 해결해야 하는 많은 과정은 James Reason의 Swiss Cheese Theory와 같이 연쇄적인 위험요인을 거쳐 사고를 유발할 가능성을 높인다. 비행의 주체가 되는 조종사-항공교통관제사 간의 복합 요소가 상당 부분 차지하고 있는데 불구하고 두 집단 간의 안전 운항을 위한 통합적인 관리는 이루어지고 있지 않다. 본 연구는 조종사-항공교통관제사 간의 안전 운항을 위한 안전 및 교육의 통합적인 관리를 JCRM을 통해서 이루고자 기술하였다.

AIS 기반 관제의 문제점 보완 및 모니터 화면 개선을 통한 관제향상 방안

  • 김영신;하윤주;임표택;김유순
    • 한국항해항만학회:학술대회논문집
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    • 한국항해항만학회 2012년도 춘계학술대회
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    • pp.573-575
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    • 2012
  • 기존 RADAR 기반의 VTS에 AIS를 연계 집약하면서 예측 불가능한 데이터 전송률에도 동일선박으로부터의 AIS 및 RADAR 데이터는 상관관계를 유지하면서 물표에 대한 Tracking이 지속적으로 이루어져야 하지만 AIS 신호 Lost시 RADAR Tracking 자동 전환이 안 되는 경우가 많이 발생하고 있다. 또한 3개의 VTS 모니터 화면에 각각 다른 Scale과 다른 관제구역이 디스플레이 됨으로써 특히 모니터 가장자리 부근의 관제구역은 사각지대로 관제사의 집중도가 떨어질 수밖에 없다. 이러한 문제점들은 관제사의 Traffic Image구성 및 Situational Awareness를 방해하는 요소로 작용하며 사고의 개연성을 높이고 있다. 본 연구에서는 VTS 모니터상의 화면 재구성 방법을 통해서 관제사의 SA를 돕고, AIS-RADAR Tracking 알고리즘 보완을 통한 Target Tracking의 안정성을 확보하고, 교육 훈련을 통해서 AIS특성과 Error현상에 대한 관제사들이 충분히 이해하도록 하여 관제업무의 향상을 기하는 방안을 제시하였다.

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철도차량기지용 단권변압기의 전압강하에 대한 이론적 고찰 (A Theoretical Study on Voltage Drop of Auto-Transformer for Railway Vehicle Base)

  • 유기성;김재문
    • 전기학회논문지
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    • 제67권12호
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    • pp.1723-1728
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    • 2018
  • In order to investigate the voltage drop compensation effect of AT for domestic railway vehicle base, the parameters of AT voltage drop of railroad car base are Z3 (Impedance of feeder line), Xn ( Distance from railroad vehicle to AT to SS), and Dn (distance between both ATs of railway vehicle).In addition, when installed in a SSP for a railway vehicle base, there is no AT and feeder line in the railway vehicle base except for the SSP for the main line and the SSP for the railway vehicle base, so that if zero or ignored, the AC single-phase two- It can be confirmed that it becomes a form.

COVID-19 and Return-To-Work for the Construction Sector: Lessons From Singapore

  • Gan, Wee Hoe;Koh, David
    • Safety and Health at Work
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    • 제12권2호
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    • pp.277-281
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    • 2021
  • Singapore's construction sector employs more than 450,000 workers. During the height of the COVID-19 pandemic in Singapore from April to June 2020, migrant workers were disproportionately affected, including many working in the construction sector. Shared accommodation and construction worksites emerged as nexuses for COVID-19 transmission. Official government resources, including COVID-19 epidemiological data, 43 advisories and 19 circulars by Singapore's Ministries of Health and Manpower, were reviewed over 8 month period from March to October 2020. From a peak COVID-19 incidence of 1,424.6/100,000 workers in May 2020, the incidence declined to 3.7/100,000 workers by October 2020. Multilevel safe management measures were implemented to enable the phased reopening of construction worksites from July 2020. Using the Swiss cheese risk management model, the authors described the various governmental, industry, supervisory and worker-specific interventions to prevent, detect and contain COVID-19 for safe resumption of work for the construction sector.

Distribution and Content of Geometric Isomers of Conjugated Linoleic Acid in Dairy Foods from the Quebec Province of Canada

  • Park, Seung-Yong;Ahn, Jae-Eun;Kim, Geun-Bae;Jung, Mun-Yhung;Lee, Byong-H.
    • Food Science and Biotechnology
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    • 제17권1호
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    • pp.31-37
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    • 2008
  • The distributions and content of geometrical isomers of conjugated linoleic acids (CLA) in dairy foods such as milk, yogurt, and cheese, produced or being sold in the Quebec province of Canada, were investigated by gas chromatographic analysis. The mean contents of total CLA (mg/g fat) were $5.06{\pm}0.74$ in 4 low-fat milk samples, $14.14{\pm}4.95$ in 6 yogurt samples, and $18.22{\pm}7.89$ in 5 natural ripened cheeses. Among the yogurt samples, YY contained the highest content of total CLA ($20.68{\pm}5.17\;mg/g$ fat). Among the cheese samples, Gruyere contained the highest amount of total CLA ($29.86{\pm}0.62$) as well as c-9,t-11 ($22.03{\pm}0.36\;mg/g$ fat), followed by Jarlsberg ($22.76{\pm}0.14$), Provolone ($16.42{\pm}0.52$), Cheddar ($13.83{\pm}0.81$), and Swiss ($8.23{\pm}1.11$). Based on the distribution ratios of CLA isomers in these dairy foods, the c-9,t-11 isomer appeared to be the major CLA isomer in both the low-fat milk ($89.87{\pm}2.39%$) and yogurt ($90.98{\pm}4.42%$). In the cheeses, however, the ratio of c-9,t-11 ($54.86{\pm}13.06%$) was slightly higher than that of c-10,c-12 ($40.81{\pm}13.40%$).

Needs for Changing Accident Investigation from Blaming to Systems Approach

  • Kee, Dohyung
    • 대한인간공학회지
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    • 제35권3호
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    • pp.143-153
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    • 2016
  • Objective: The purposes of this study are to survey needs for changing accident investigation from blaming to systems approach and to briefly summarize systems-based accident analysis techniques. Background: In modern complex socio-technical systems, accidents are caused by a variety of contributing factors including human, technical, organizational, social factors, not by just a single violation or error of a specific actor, but accidents investigation used to be focused on the incorrect action of individuals. A new approach investigating causes of accidents as a symptom of a deficient system is required. Method: This study was mainly based on survey of literatures related to accidents, accidents investigation, which included academic journals, newspapers, etc. Results: This study showed that accidents investigation of Korea focusing on blaming is problematic. This was confirmed by two concepts of migration and hindsight bias frequently found in accident causation studies, and an attribute of accidents having varying causes. This was illustrated with an example of Sewol ferry capsizing accident. Representative systems-based accident analysis models including Swiss cheese model, AcciMap, HFACS, FRAM and STAMP were briefly introduced, which can be used in systematic accidents investigations. Finally, this study proposed a procedure for establishing preventive measures of accidents, which was composed of two steps: public inquiry and devising preventive measures. Conclusion: A new approach considering how safety-critical components such as technical and social elements, and their interactions lead to accidents is needed for preventing reoccurrence of similar accidents in complex socio-technical systems. Application: The results would be used as a reference or guideline when the safety relevant governmental organizations investigate accidents.

안전과학 패러다임의 전환과 환자안전의 개선 (What Will We Learn from the Paradigm Shift in Safety Science for Improving Patient Safety?)

  • 이상일
    • 한국의료질향상학회지
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    • 제27권1호
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    • pp.2-9
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    • 2021
  • Patient safety remains one of the most important health care issues in Korea. To improve patient safety, we have introduced concepts from the field of safety science such as the Swiss cheese model, and adopted several methodologies previously used in other industries, including incident reporting systems, root cause analysis, and failure mode and effects analysis. This approach has enabled substantial progress in patient safety to be made through undertaking patient safety improvement activities in hospitals that are systems-based, rather than individual-based. However, these methods have the shared limitation of focusing on negative consequences of patient safety. Therefore, the paradigm shift from Safety I to Safety-II in safety science becomes the focus of our discussion. We believe that Safety-II will complement, rather than replace, Safety-I in the discipline of patient safety. In order to continuously advance patient safety practices in Korea, it is necessary that Korea keeps abreast of the recent global trends and development in safety science. In addition, more focus should be placed on testing the feasibility of new patient safety approaches in real-world situations.

Growth Characteristics of Bacteriocin-Producing Lactococcus lactis subsp. hordniae JNU533 in a Glucose-Containing Skim Milk Medium

  • Jiho Shin;Subin Kim;Sejong Oh
    • Journal of Dairy Science and Biotechnology
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    • 제41권3호
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    • pp.138-148
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    • 2023
  • In this study, Lactococcus lactis subsp. hordniae JNU533 (JNU533) was isolated from Swiss-type cheese, and the bacteriocin produced by this strain was characterized. The spot-on-lawn assay was used to determine the antimicrobial spectrum and characteristics of the JNU533-derived bacteriocin. Results confirmed that the JNU533-derived bacteriocin inhibited the growth of lactic acid bacteria. The size of the bacteriocin was approximately 4.9 kDa, and it was heat- and pH-stable under various temperature and pH conditions. Furthermore, the possibility of using JNU533 as a starter culture in the manufacturing of fermented dairy products was assessed. A single colony of JNU533 was inoculated into 10% skim milk containing 0.5% glucose to investigate its characteristics in milk culture. The decrease in the pH was similar to that elicited by Lactobacillus delbrueckii subsp. bulgaricus. Furthermore, the results confirmed that JNU533 inhibited the growth of various bacteria and could be used as a milk fermentation starter. This study highlights the characteristics of the bacteriocin produced by JNU533 and the growth features of this strain in a skim milk medium.

비골골절 정복술 후 커진 지방육아종의 치험례 (Enlarged Lipogranuloma after Closed Reduction of Nasal Bone Fracture: A Case Report)

  • 이지원;최재일;하원;양완석;김선영
    • 대한두개안면성형외과학회지
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    • 제13권1호
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    • pp.63-67
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    • 2012
  • Purpose: Lipogranuloma is the reaction of adipose tissue to various oils, paraffin, and other hydrocarbons injected into subcutaneous tissue for cosmetic or other reasons. The authors experienced a case of sclerosing lipogranuloma on the nasal dorsum. Methods: A 42-year-old female, without a history of the injection of any foreign materials, was admitted on our hospital for a painless, irregular, and firm mass located on her nasal dorsum with step-off deformity. It was considered that the mass had developed after augmentation rhinoplasty. The size of mass had been increased after closed reduction of nasal bone fracture. On April 2011, under general anesthesia, the mass was removed by open rhinoplasty technique. In addition, a pathologic examination was performed. After the mass extirpation, dermofat graft was performed for the correction of depression deformity. Results: The histopathological findings demonstrated a Swiss cheese pattern with variably-sized vacuoles, which corresponded to lipid removed with tissue processing, and variable foreign body giant cell reaction, fat necrosis, and hyalinized fibrous tissue. The pathologic diagnosis is lipogranuloma replacing nasalis muscle. It has been considered that sclerosing lipogranuloma is caused by nerve injury during augmentation rhinoplasty and the ointment used after the closed reduction of nasal bone fracture, which infiltrated through the injured mucosa. Conclusion: During the treatment of rhinoplasty or nasal bone fracture, the nerve injury or the ointment use can lead to lipogranuloma. Therefore, careful dissection for avoidance of the nerve injury and limited use of ointment seems to be helpful in decreasing incidence of lipogranuloma.

제조업의 인적오류 관련 사고분석을 위한 HFACS-K의 개발 및 사례연구 (HFACS-K: A Method for Analyzing Human Error-Related Accidents in Manufacturing Systems: Development and Case Study)

  • 임재근;최종덕;강태원;김병철;함동한
    • 한국안전학회지
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    • 제35권4호
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    • pp.64-73
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    • 2020
  • As Korean government and safety-related organizations make continuous efforts to reduce the number of industrial accidents, accident rate has steadily declined since 2010, thereby recording 0.48% in 2017. However, the number of fatalities due to industrial accidents was 1,987 in 2017, which means that more efforts should be made to reduce the number of industrial accidents. As an essential activity for enhancing the system safety, accident analysis can be effectively used for reducing the number of industrial accidents. Accident analysis aims to understand the process of an accident scenario and to identify the plausible causes of the accident. Accident analysis offers useful information for developing measures for preventing the recurrence of an accident or its similar accidents. However, it seems that the current practice of accident analysis in Korean manufacturing companies takes a simplistic accident model, which is based on a linear and deterministic cause-effect relation. Considering the actual complexities underlying accidents, this would be problematic; it could be more significant in the case of human error-related accidents. Accordingly, it is necessary to use a more elaborated accident model for addressing the complexity and nature of human-error related accidents more systematically. Regarding this, HFACS(Human Factors Analysis and Classification System) can be a viable accident analysis method. It is based on the Swiss cheese model and offers a range of causal factors of a human error-related accident, some of which can be judged as the plausible causes of an accident. HFACS has been widely used in several work domains(e.g. aviation and rail industry) and can be effectively used in Korean industries. However, as HFACS was originally developed in aviation industry, the taxonomy of causal factors may not be easily applied to accidents in Korean industries, particularly manufacturing companies. In addition, the typical characteristics of Korean industries need to be reflected as well. With this issue in mind, we developed HFACS-K as a method for analyzing accidents happening in Korean industries. This paper reports the process of developing HFACS-K, the structure and contents of HFACS-K, and a case study for demonstrating its usefulness.