• Title/Summary/Keyword: critical incident

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The Effect of Frequent Change in Railway Driving Regulations on Human Error (철도운전관련규정의 잦은 변경이 휴먼에러에 미치는 영향)

  • Kim, Jin-Tae;Shin, Tack-Hyun
    • Journal of the Korea Safety Management & Science
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    • v.16 no.2
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    • pp.19-29
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    • 2014
  • Korean societal concern for the train accidents is fast and widely increasing with an ever-increasing demand and use for KTX. Most of these train accidents are inclined to be caused by human error. Experts used to attribute the causes of human error to the defects in various aspects such as technology, organizational system, practices, corporate culture, and/or human resource itself. Among the diverse causes of human error, an important one, even though it was rarely focused, may be the issue of impact of rule or procedure change on human error. Giving attention to the implicit importance of this issue, this study intends to highlight the theme of frequent procedure change in railway driving manual as a critical factor of human error. To attain this purpose mentioned above, dual methodologies were adopted. One is to qualitatively analyze the real cases of procedure change in relevant manuals followed by the incident case(passing the station scheduled to stop) happened lately. Another is to quantitatively perform statistical analysis based on questionnaires received from 224 train drivers. Results show that frequent changes in internal affairs procedure is or may be an important factor causing stress and human error from train drivers.

Design and Implementation of Information Security System to Prevent Leakage of Drawing Information (설계정보 유출방지를 위한 정보보안시스템 설계 및 구현)

  • Chang, H.B.;Lee, H.S.
    • Korean Journal of Computational Design and Engineering
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    • v.11 no.5
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    • pp.327-334
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    • 2006
  • Recently, security incidents are growing rapidly in which internal employees let the drawing leak out to competitors or other countries. This type of security incidents has a characteristic that it occurs less frequently than other types of security incidents such as network or server security incident, but the damage is a lot more serious. The existing information security technologies to prevent internal information from being leaked out are only applicable to general documents(office documents, web pages and image files in which data are encrypted one by one). However, architectural drawings made up of collection of files with various formats(extensions) have problems with the process speed of en(de) cryption and accuracy, so the developments of security technologies by new methods are required. In this study, we design and develop a security technology based on work area with which users can protect the leakage of critical information in the kernel level while maintaining their work environment when they have to use sharing information that cannot be managed by the unit of file. As a result, we developed the "Virtual Secure Disk" which allows only authorized users and applications to have an access to drawings, and have verified its security by applying it to the actual company.

An Estimation of RCS through Configuring Element Analysis (형상요소분석을 통한 레이더단면적의 추정)

  • Kwon, T.J.;Shin, Bo-Hyun
    • Journal of the Korea Institute of Military Science and Technology
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    • v.15 no.4
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    • pp.417-423
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    • 2012
  • Radar Cross Section(RCS) is a measure of how detectable an object is with a radar. A larger RCS indicates that an object is more easily detected. Informally, the RCS of an object is the cross-sectional area of a perfectly reflecting sphere that would produce the same amount of reflection strength as the object in question would. In order to estimate RCS of aircraft weapons the external surface is modeled as a collection of simple shape elements. And the overall RCS is estimated as a vector sum of configuring elements' cross-sections which are well known given by analytic formulae. A RCS estimation code is developed for a typical shape of Air-To-Surface bombs and missiles. Size of weapons and location of fins are implemented in the code in addition to the presence of canards. The ability to predict radar return from flying vehicles becomes a critical technology issue in the development of stealth configurations. This simplified method of RCS estimation is known to be fast and accurate enough in an optical region of high frequency incident radio wave.

Fraunhofer Diffraction Pattern of a Periodic Hologram When the Input Beam Size is Similar to the Period of the Hologram (주기적인 홀로그램에 입사하는 레이저빔의 크기가 주기와 유사할 때의 프라운호퍼 회절 패턴에 대한 연구)

  • Go, Chun Soo;Lim, Sungwoo;Oh, Yong Ho
    • Journal of the Korean Institute of Electrical and Electronic Material Engineers
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    • v.31 no.4
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    • pp.193-197
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    • 2018
  • The ratio of the period of a diffractive element to the input beam size is a critical parameter in a diffractive beam shaper. We measured and calculated the Fraunhofer diffraction patterns of a periodic hologram with an input beam size similar to the period of the hologram. The measured intensities show very complicated patterns and are strongly dependent upon the center position of the laser beam relative to the hologram. Using a diffraction formula for a periodic hologram, we calculated the diffracted light intensities and fit them to the measured ones. The measured and calculated intensities are in good agreement even when the beam diameter of the incident laser is similar to the period of the hologram. We can therefore use this formula to estimate the output of a periodic beam shaper even under such an extreme condition.

A Study on the Fire Hazards of Puzzle Mats in Group Day Care Home (놀이방 퍼즐매트의 화재위험성에 관한 연구)

  • Park, Hyung-Ju
    • Journal of the Korean Society of Safety
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    • v.23 no.5
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    • pp.73-78
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    • 2008
  • The fire hazards and combustion heat of puzzle mats in group day care home were analysed using variable external irradiation level. The fire hazards such as ignition time, ignition temperature, mass loss rate, and flame temperature profile were measured. Incident heat fluxes of $15kW/m^2$, $20kW/m^2$, $25kW/m^2$, $35kW/m^2$, $50kW/m^2$ and $75kW/m^2$ were selected for these experiments. All samples were tested in the horizontal orientation and were wrapped in a single layer of aluminium foil. Each sample was nominally 20mm thick and 100mm square. Five samples of puzzle mat were tested in the study : Type A, B, C, D and E. Type A, B and C are all general grades whereas Type D and E are both Flame retardant grades. As results, Type E of FR-grade showed the best characteristics in safety of the early fire from ignition time, critical heat flux, and ignition and flame temperature data of this study. All specimen of G-grade(Type A, B and C), however, showed the weak in safety of fire.

'AMADEUS' Software for ion Beam Nano Patterning and Characteristics of Nano Fabrication ('아마데우스' 이온빔 나노 패터닝 소프트웨어와 나노 가공 특성)

  • Kim H.B.;Hobler G.;Lugstein A.;Bertagonolli E.
    • Proceedings of the Korean Society of Precision Engineering Conference
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    • 2005.10a
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    • pp.322-325
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    • 2005
  • The shrinking critical dimensions of modern technology place a heavy requirement on optimizing feature shapes at the micro- and nano scale. In addition, the use of ion beams in the nano-scale world is greatly increased by technology development. Especially, Focused ion Beam (FIB) has a great potential to fabricate the device in nano-scale. Nevertheless, FIB has several limitations, surface swelling in low ion dose regime, precipitation of incident ions, and the re-deposition effect due to the sputtered atoms. In recent years, many approaches and research results show that the re-deposition effect is the most outstanding effect to overcome or reduce in fabrication of micro and nano devices. A 2D string based simulation software AMADEUS-2D $(\underline{A}dvanced\;\underline{M}odeling\;and\;\underline{D}esign\;\underline{E}nvironment\;for\;\underline{S}putter\;Processes)$ for ion milling and FIB direct fabrication has been developed. It is capable of simulating ion beam sputtering and re-deposition. In this paper, the 2D FIB simulation is demonstrated and the characteristics of ion beam induced direct fabrication is analyzed according to various parameters. Several examples, single pixel, multi scan box region, and re-deposited sidewall formation, are given.

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An Outcome-Based Approach in Medical Curriculum Development (성과중심교육과정 개발절차에 대한 고찰)

  • Ahn, Jae Hee;Yang, Eunbae B.
    • Korean Medical Education Review
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    • v.15 no.1
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    • pp.9-18
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    • 2013
  • An outcome-based curriculum is perceived to be one alternative educational approach in medical education. Nonetheless, it is difficult for curriculum developers to convert from traditional curriculum to an outcome-based curriculum because research documenting its development process is rare. Therefore, this study aims to introduce the development process and method of outcome-based curriculum. For the purpose of this study, we used diverse data analyses, such as an existing literature search, development model analysis, and case analysis. We identified five phases from the analysis. First, the curriculum developers analyze the physician's job or a high performer in a medical situation. Second, curriculum developers extract outcomes and competencies through developing a curriculum, affinity diagraming, and critical incident interviews. Third, curriculum developers determine the proficiency levels of each outcome and competency evaluation methods. Fourth, curriculum developers conduct curriculum mapping with outcomes and competencies. Fifth, curriculum developers develop an educational system. Also, it is important to develop an assessment system for the curriculum implementation in the process of developing the outcome-based curriculum. An outcome-based curriculum influences all the people concerned with education in a medical school including the professors, students, and administrative staff members. Therefore, curriculum developers should consider not only performance assessment tools for the students but also assessment indicators for checking curriculum implementation and managing curriculum quality.

Nanofluid flow and heat transfer from heated square cylinder in the presence of upstream rectangular cylinder under Couette-Poiseuille flow

  • Sharma, Swati;Maiti, Dilip K.;Alam, Md. Mahbub;Sharma, Bhupendra K.
    • Wind and Structures
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    • v.29 no.1
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    • pp.65-75
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    • 2019
  • A heated square cylinder (with height $A^*$) is kept parallel to the cold wall at a fixed gap height $0.5A^*$ from the wall. Another adiabatic rectangular cylinder (of same height $A^*$ and width $0.5A^*$) is placed upstream in an inline tandem arrangement. The spacing between the two cylinders is fixed at $3.0A^*$. The inlet flow is taken as Couette-Poiseuille flow based non-linear velocity profile. The conventional fluid (also known as base fluid) is chosen as water (W) whereas the nanoparticle material is selected as $Al_2O_3$. Numerical simulations are performed by using SIMPLE algorithm based Finite Volume approach with staggered grid arrangement. The dependencies of hydrodynamic and heat transfer characteristics of the cylinder on non-dimensional parameters governing the nanofluids and the fluid flow are explored here. A critical discussion is made on the mechanism of improvement/reduction (due to the presence of the upstream cylinder) of heat transfer and drag coefficient, in comparison to those of an isolated cylinder. It is observed that the heat transfer increases with the increase in the non-linearity in the incident velocity profile at the inlet. For the present range studied, particle concentration has a negligible effect on heat transfer.

Fatigue analysis on the mooring chain of a spread moored FPSO considering the OPB and IPB

  • Kim, Yooil;Kim, Min-Suk;Park, Myong-Jin
    • International Journal of Naval Architecture and Ocean Engineering
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    • v.11 no.1
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    • pp.178-201
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    • 2019
  • The appropriate design of a mooring system to maintain the position of an offshore structure in deep sea under various environmental loads is important. Fatigue design of the mooring line considering OPB/IPB(out-of-plane bending/in-plane bending) became an essential factor after the incident of premature fatigue failure of the mooring chain due to OPB/IPB in the Girassol region in West Africa. In this study, mooring line fatigue analysis was performed considering the OPB/IPB of a spread moored FPSO in deep sea. The tension of the mooring line was derived by hydrodynamic analysis using the de-coupled analysis method. The floater motion time histories were calculated under the assumption that the mooring line behaves in quasi-static manner. Additional time domain analysis was carried out by prescribing the obtained motions on top of the selected critical mooring line, which was determined based on spectral fatigue analysis. In addition, nonlinear finite element analysis was performed considering the material nonlinearities, and both the interlink stiffness and stress concentration factors were derived. The fatigue damage to the chain surface was estimated by combining both the hydrodynamic and stress analysis results.

Theoretical Model for Accident Prevention Based on Root Cause Analysis With Graph Theory

  • Molan, Gregor;Molan, Marija
    • 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.