• 대한인간공학회지
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• 제34권2호
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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.

• 한국신뢰성학회지:신뢰성응용연구
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• 제16권1호
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• pp.71-77
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• 2016

Purpose: Root cause analysis (RCA) refers to any systematic process that identifies the causes that contribute to a focus event. The immediate cause of a focus event is often a symptom of underlying causes and may not truly identify the root causes that should be identified and addressed. Currently many RCA tools are available. Different investigators use different RCA tools on different issues. No standardized or commonly agreed way to analyse root causes exists. The purpose of this study is to propose the methodology of RCA process commonly useable for various issues. Methods: The methodology of RCA process is produced based on the hybrid RCA tools. The effectiveness assessment matrix of actions through the root cause candidates is presented. Results: No single RCA technique proposed has so far covered all necessary aspects. A hybrid approach which combines the best features of various techniques is proposed. The effectiveness assessment matrix helps us to identify the root cause to correct or eliminate system vulnerabilities effectively. Conclusion: This hybrid approach and effectiveness assessment matrix can provide guidance of RCA process across many industries and situations.

• 국제학술발표논문집
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• The 3th International Conference on Construction Engineering and Project Management
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• pp.184-189
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• 2009

In 2008 the total estimated failure costs in the Netherlands was estimated to be 11.4% of the industry's turnover compared to 7.7% seven years earlier. Failure costs can be the consequence of rework as a result of failure to conform to the product requirements and specifications or due to inefficient processes and bad management practices. Many construction companies however are unaware of the exact nature of these costs, their root causes or how to control them. This paper describes work carried out in the Netherlands to identify the different types of failure costs in construction and their root causes. The research described builds on previous findings by another research institution and expands it to include information collected from project cases and a survey of a number of project managers in the construction industry. The paper describes the analysis of the results from cases and the survey to identify the root causes of failure costs. Research shows, for example, that many failure costs are related to the client taking late decisions and making changes to the project requirements.

• Nuclear Engineering and Technology
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• 제51권3호
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• pp.709-718
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• 2019

The international nuclear industry has undergone a lot of changes since the Fukushima, Chernobyl and TMI nuclear power plant accidents. However, there are still large and small component deficiencies at nuclear power plants in the world. There are many causes of electrical equipment defects. There are also factors that cause component failures due to human errors. This paper analyzed the root causes of failure and types of human error in 300 cases of electrical component failures. We analyzed the operating experience of electrical components by methods of root causes in K-HPES (Korean-version of Human Performance Enhancement System) and by methods of human error types in HuRAM+ (Human error-Related event root cause Analysis Method Plus). As a result of analysis, the most electrical component failures appeared as circuit breakers and emergency generators. The major causes of failure showed deterioration and contact failure of electrical components by human error of operations management. The causes of direct failure were due to aged components. Types of human error affecting the causes of electrical equipment failure are as follows. The human error type group I showed that errors of commission (EOC) were 97%, the human error type group II showed that slip/lapse errors were 74%, and the human error type group III showed that latent errors were 95%. This paper is meaningful in that we have approached the causes of electrical equipment failures from a comprehensive human error perspective and found a countermeasure against the root cause. This study will help human performance enhancement in nuclear power plants. However, this paper has done a lot of research on improving human performance in the maintenance field rather than in the design and construction stages. In the future, continuous research on types of human error and prevention measures in the design and construction sector will be required.

• 한국위험물학회지
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• 제6권2호
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• pp.47-54
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• 2018

Mixed acid is very reactive and highly corrosive. it has been causing many accidents in a electronic industry, a steel industry, and a chemical industry. Therefore, it is required that the high safety level for the acid storage facilities. In this study, we investigated the accident causes for resent leak accidents with Root Cause Analysis (RCA). The root causes analysed by RCA were categorized as nine divisions by the their characteristics. Furthermore, each nine divisions causes was applied to the PDCA model which are using at OHSAS 18001. It is suggested that the nine division with the root causes can be the essential items for the development of the safety management manual. It is helpful to the safety improvement of the acid storage facility.

• 농촌지도와개발
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• 제30권2호
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• pp.119-129
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• 2023

This study aims to identify the types of safety accidents that occur during maintenance and repair operations and analyze the root causes. We used the logic tree diagramming to extract the root causes of 65 safety incidents specifically related to maintenance and repair work out of a total of 1,024 agricultural safety incidents that occurred between 2007 and 2020 collected by investigation with interviews. The extracted root causes were analyzed by categorizing them into six different safety system classifications. The results of the analysis and suggestions are as follows. Incidents related to maintenance and repair work, which can lead to irreversible safety hazards, have occurred frequently. These incidents were found to be occurring due to the overlapping of various safety system errors such as personal protective system and safety operation procedure. In the short term, it is necessary to emphasize compliance with the use of personal protective equipment, and enhancement of maintenance training. In the long term, it is necessary to establish a legal distinction for maintenance and repair work and clarify the responsible parties. Introducing a maintenance system is also crucial to prevent occupational injuries during maintenance and repair in agriculture.

• 산업경영시스템학회지
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• 제38권1호
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• pp.101-109
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• 2015

This paper suggests a procedure to define business process improvement (BPI) projects with analysis results based on the cause-and-effect chain. The procedure developed in this paper focuses on eliminating root causes of business problems resulted from abnormal events occurred in business process executions. First, we develop three criteria used to make clusters of the root causes where a cluster of root causes will be eliminated together by a BPI project defined based on the cluster. Second, we develop a method to formulate desired expectations from the BPI project. Also, we suggest a method to calculate the relative importance of the BPI projects that help a BPI organization determine priorities of them. We illustrate the procedure and the methods with some examples for the domestic mail delivery process in the postal service industry.

• Safety and Health at Work
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• 제12권4호
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• pp.505-510
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• 2021

Background: Factors related to root causes can cause commonly occurring accidents such as falls, slips, and jammed injuries. An important means of reducing the frequency of occupational accidents in small- to medium-sized enterprises (SMSEs) of South Korea is to perform intensity analysis of the root cause factors for accident prevention in the cause and effect model like decision models, epidemiological models, system models, human factors models, LCU (life change unit) models, and the domino theory. Especially intensity analysis in a robot system and smart technology as Industry 4.0 is very important in order to minimize the occupational accidents and fatal accident because of the complexity of accident factors. Methods: We have developed the modern cause and effect model that includes factors of root cause through statistical testing to minimize commonly occurring accidents and fatal accidents in SMSEs of South Korea and systematically proposed educational policies for accident prevention. Results: As a result, the consciousness factors among factors of root cause such as unconsciousness, disregard, ignorance, recklessness, and misjudgment had strong relationships with occupational accidents in South Korean SMSEs. Conclusion: We conclude that the educational policies necessary for minimizing these consciousness factors include continuous training procedures followed by periodic hands-on experience, along with perceptual and cognitive education related to occupational health and safety.

• 국제학술발표논문집
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• The 6th International Conference on Construction Engineering and Project Management
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• pp.627-628
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• 2015

Construction defect which can causes economic damage such as schedule delay, cost overrun is a considerably important factor in construction industry. In general, a construction defect features a difficulty to find out causes precisely because it occurs when several interrelated causes combine. Yet, studies have tried to understand the interrelationships between factors are limited. In addition, despite of a tremendous amount of construction data, it's not still enough to analyze them, but tends to depend on experience or know-how of practitioners. Thus, it is necessary to identify underlying causes in influential factors by utilizing related data. This paper analyses Interrelationships between causal factors using Association Rule Mining to discover root causes of construction defects. Confidence and Lift that can be used for presenting the interrelationships of the causes were extracted from 1241 cases in 30 projects in Korea. It is expected that this paper allows the construction managers to discover key factors and make right decisions to reduce occurrence of construction defects. Furthermore, analysis of interrelationships can improve understanding of structural patterns of construction defects.

• 한국건설관리학회:학술대회논문집
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• 한국건설관리학회 2007년도 정기학술발표대회 논문집
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• pp.473-478
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• 2007

여러조직과 많은 사람이 참여하는 건설프로젝트는 갈등이 발생할 수 있다. 이러한 건설참여자들 사이의 갈등은 건설프로젝트 건설프로젝트의 커다란 관심거리로서 이의원인에 대한 연구는 대단히 중요하다. 본 연구의 목적은 건설산업에서 분쟁의 근본적 원인을 조사하고자 현장의 건설전문가들(발주자, 컨설턴트, 시공사)로부터 설문자료를 이용하여 자료수집 하였고 이 조사 자료를 통계적 분석을 통하여 건설갈등의 근본원인인 재정적 요인 등 10가지를 도출하였고 이를 (i) 프로젝트 리더쉽의 부족, (ii) 부실기공사의 선정, (iii) 부실한 프로젝트 관리 경영, (iv)프로젝트 전문가의 태도의 4가지로 분류하였다.