• 수산해양교육연구
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• 제27권3호
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• pp.706-717
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• 2015

Marine casualties and environmental pollution have increased recently. Especially, the rate of incident of Coastal tankers is higher, but the assessment tool for safety management system is lack in this fields. However Oil Major Vetting System being professional assessment tool for tanker is widely applied in ocean going tanker by the worldwide Oil Majors. According to the analysis of the marine tankers' incidents which applied Oil Major Vetting System, the incidents were reduced rapidly for recent about 5 years. Using Oil Major Vetting System is helped to improve safety management and to prevent marine incidents. Therefore if applying a parts of the Oil Major Vetting Systems to the coastal tankers' Safety Management System, the Coastal tankers incidents would be reduced and improved gradually.

• 한국방재학회 논문집
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• 제8권1호
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• pp.23-29
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• 2008

철도시스템은 전세계적으로 가장 안전한 교통수단으로 인식되고 있지만, 사고는 계속 발생되고 있다. 많은 하위부분으로 구성되어 있는 철도시스템의 특성상 사고위험을 완전히 방지하기는 어렵다. 철도사고는 다양한 원인이 복합적으로 작용하여 하나의 사건으로 표출되기 때문에 사고의 근원적 예방을 위해 사고사례의 사고모드를 분석하고, 사고모드에 영향을 미치는 인자들의 상관관계를 역 추적하는 시스템적인 접근은 매우 중요하다. 본 연구에서는 미국, 영국, 캐나다, 오스트레일리아의 국외사고사례분석을 수행하며 주요 위험인자를 도출하였다.

• 한국안전학회지
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• 제33권6호
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• pp.85-92
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• 2018

This study aimed to reduce of traps incident of metro train door by suggesting preventive actions throughout analyzing why railway drivers and passengers commit unsafe behaviors which are human factors making occurrence of the incidents. The incident cases were analyzed and Incident Tree was structured by brainstorming with safety experts. In addition, the questionnaire survey was conducted for comparison with the analysis results. As the result, this study suggested driver's factors, passenger's factors, and public relation plan for safe use of metro in order to reduce the frequency of the incidents. For driver's factors, implementing job-rotation systems between railway and non-railway drivers, installing Object Detection Sensors between the metro doors and PSD, and flexible operation of dwell time were suggested. For passenger's factors, placing a platform safety person, installing a safety fence in front of the stairs and the elevators, and country wide public relations through mass media were suggested.

• 중환자간호학회지
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• 제13권2호
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• pp.1-11
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• 2020

Purpose : The aim of this study was to compare shift satisfaction, sleep, fatigue, quality of life (QOL), and patient safety incidents between a newly implemented two-shift system and a traditional three-shift system. Methods : A total of 127 intensive care unit nurses (48 two-shift nurses and 79 three-shift nurses) working in a tertiary hospital in Seoul were recruited from January 1, 2017, to March 31, 2017. They completed a self-reported questionnaire about their work hours, shift satisfaction, sleep patterns, sleep quality, fatigue, QOL, and patient safety incidents in the past 2 weeks. Data were analyzed using SPSS version 23.0. Results : The two-shift group showed higher shift satisfaction scores compared with the three-shift group (6.93 vs. 4.37, p<.001). Sleep latency was shorter and sleep quality was better in the two-shift group compared with the three-shift group. There were no significant differences in other sleep parameters, fatigue, QOL, and patient safety incidents between the two groups. Conclusion : Although a two-shift system did not improve nurses' fatigue or QOL in this study, it may effectively serve as an alternative shift-work system that can increase sleep quality and shift satisfaction without increasing patient safety incidents.

• 정보보호학회논문지
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• 제23권3호
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• pp.515-530
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• 2013

해양사고 조사의 결과는 원인규명은 물론 가해자 및 피해자의 과실여부와 과실정도를 판단하는 중요한 결정기준이 되고 있다. 그러나 해양사고는 해양이라는 특수한 환경에서 발생하기 때문에 사고현장의 보존, 사고 재연 및 목격자 확보 곤란 등 원인규명의 어려움이 있다. 이러한 해양사고의 특징으로 국제해사기구에서는 최근 발달된 전파통신 및 항해기술을 해상인명안전 협약에 도입하여 일정 규모 이상의 선박에 항해자료기록장치와 선박자동식별장치의 설치를 의무화하였고, 국제적으로 통일된 사고조사와 공조를 위해 발효한 새로운 해양사고 조사코드에서는 각 체약국에게 항해자료기록장치의 분석역량을 갖추도록 권고하고 있다. 이에 따라 본 논문에서는 선박용 블랙박스인 항해자료기록장치의 데이터 유형을 분석하고 디지털 포렌식 절차와 기법을 활용하여 사고원인을 효율적으로 조사할 수 있는 방법을 제시한다.

• 한국의료질향상학회지
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• 제24권1호
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• pp.9-22
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• 2018

Purpose: The purpose of this study is to develop the Korean root cause analysis (RCA) software that can be used to systematically investigate underlying causes for preventing or reducing recurrence of patient safety incidents. Methods: We reviewed the existing guidelines and literatures on the RCA in order to figure out the RCA process. Also we examined the existing RCA softwares for investigating patient safety incidents to design the contents and interface of the RCA software. Based on the results of reviewing literatures and softwares, we developed a draft version of the Korean RCA software that can be easily used in Korean hospital settings by RCA teams. Results: The Korean RCA software consisted of several modules, which are modules for identifying patient safety incidents, organizing RCA team, collecting and analysing data, determining contributory factors and root causes, developing the action plans, and guiding evaluation. Conclusion: The Korean RCA software included optimized RCA process and structured logic for cause analysis. Thus even beginners in RCA are expected to easily use this software for investigating patient safety incidents. As software has been developed with the public financial support, it will be distributed free of charge. We hope that it will contribute to facilitating patient safety improvement activities in Korea.

• 한국항공운항학회지
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• 제21권4호
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• pp.119-125
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• 2013

Since year 2001 to the present time, the aircraft accidents and serious incidents in our country have surpassed 150 occurrences. The Boeing has published the statistical summary of commercial jet airplane accidents annually for the past 10 years on the basis of the occurrence categories defined by the CICTT(CAST/ICAO Common Taxonomy Team), and the number of occurrences is in order of loss of control(LOC-I), controlled flight into terrain(CFIT) and runway excursion (RE). Like the NTSB and the EASA, when fatal and non-fatal accidents are aggregated, though fatality rate is low, abnormal runway contact(ARC), system/component failure(SCF-PP/NP), ground handling(RAMP) rank high in the CICTT occurrence categories. With the less occurrence frequency, it is difficult to statistically analyze the aircraft accidents in our country, thus customarily the accidents and the serious incidents on aggregate are consolidated, and the statistical analysis is performed. This study categorizes the accidents and serious incidents to the domestic transportation aircraft in the past 10 years according to the CICTT occurrence categories, that is compared with foreign practices, and the implications have been discussed. From years 2001 through 2010, the accidents to the domestic transportation aircraft occurred in order of system failure(SCF-NP), ARC and power plant failure(SCF-PP), and when the accidents and the serious incidents are consolidated and analyzed, it is verified that a distribution appears similar to the European accident occurrence categories defined from 300 accident occurrence data.

• 디지털융복합연구
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• 제17권9호
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• pp.79-88
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• 2019

본 연구에서는 데이터 마이닝 기법을 활용하여 항공기 사고와 준사고로 인한 사망 발생 요인들과 패턴들을 분석하고자 한다. 이를 위해, 항공기 사고와 준사고 데이터를 보유하고 있는 미국연방교통안전위원회(NTSB)와 미국연방항공청(FAA)의 데이터를 사용하였다. 다음으로 의사결정나무 알고리즘을 사용하여 항공기 사고 및 준사고에 따른 사망여부 예측모형들을 구축하였고 이를 토대로 사망 발생에 영향을 주는 주요 요인들과 패턴들을 도출하였다. NTSB 데이터의 경우 항공기가 완파되거나 고기동 또는 고위험 임무를 수행할 때 주로 사망이 발생하는 것을 알 수 있었다. FAA 데이터의 경우 항공기가 일부 파괴된 경우 조종사의 숙련도가 저조하거나 미인가 조종사의 경우 사망이 발생하였으며, 고공낙하점프와 지상운용단계에서 발생되는 다양한 사망관련 패턴들도 발견되었다. 또한 도출된 패턴들을 활용하여 사망 사고 예방을 위한 실용적인 방안들을 제시한 점에서 연구의 의의를 찾을 수 있다.

• 한국안전학회지
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• 제34권1호
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• pp.62-69
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• 2019

Korean shipbuilding companies have taken many efforts for safety over the years by developing Health, Safety & Environment (HSE) Management Systems, Procedures, Training, and studying Programs for prevention of incidents. As a result, the shipbuilding industry has succeeded in reducing overall injury rates. Nevertheless, the industry also noticed that incident rates are still not at zero and more importantly, serious injuries and fatalities are still occurring. One factor that may be attributing to this is the lack of managing potential severity during incident investigations, most incident investigations are implemented based on the actual result. Generally, each shipbuilding company develops their customized incident investigation programs and these are also commonly being focused on actual result. This study aimed to develop a shift in strategy toward safety to classify the criteria of potential severity from any incidents and manage that to prevent any recurrence or causing any serious injuries or fatalities in the shipbuilding industry. Several global energy companies have already developed potential severity management tools and applied them in their incident investigations. In order to verify the necessity of improvement for current systems, a case study and comparative analysis between a domestic shipbuilding company and several global energy companies from foreign countries was implemented and comparison of two incident investigation cases from specific offshore projects was conducted to measure the value of a potential severity system. Also, a checklist was established from the data of fatalities and serious injuries in recent 5 years that occurred in Korea shipbuilding industry and a proposal to verify high potential incidents in the incident investigation process and comparative analysis between the assessment by appling proposed checklist and the assessment from a global energy company by using their own system was implemented. As a measure to prevent any incidents, it is required to focus on potential severity assessment during the incident investigation rather than to only control actual result. Hence, this study aims to propose a realistic plan which enables to improve the existing practices of incident investigation and control in the shipbuilding industry.

• 기록학연구
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• 제62호
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• pp.185-224
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• 2019

최근 사회적 약자를 향한 혐오로 인하여 거듭 발생하는 동시대 사건들은 아키비스트의 사회적 역할과 책임을 끊임없이 상기시키고 있다. 이에 본 연구는 사회적 약자들이 주요 행위자로 개입한 동시대 사건의 기록화 방법론으로서 도큐멘테이션 전략에 주목하며, L코믹스 사태를 중심으로 동시대 사건 기록화를 위한 도큐멘테이션 전략 방안을 제안하는 것을 목적으로 하였다. 이를 위해 본 연구는 동시대 사건 기록화와 도큐멘테이션 전략의 개념과 의의 등을 이론적으로 고찰하며, L코믹스 사태의 개요, 특징, 전개 과정과 핵심 사건, 초점 그룹 분석으로 사건의 맥락을 파악하고 온라인상에서 확인되는 관련 기록을 조사하였다. 이와 함께 사건 이해관계자 및 기록전문가와의 면담을 통해 L코믹스 사태의 기록화와 동시대 사건의 도큐멘테이션 전략에 관한 의견을 수집하였다. 결론에 이르러 본 연구는 L코믹스 사태의 기록화 목표와 방향, 원칙, 범주, 주체 그리고 고려사항을 차례로 논하며 L코믹스 사태 도큐멘테이션 전략 방안을 제안하였다.