Earticle

According to the statistics, occupational fatal injuries by the fork lifts were about 30 per year in whole industrial. Fork lifts are widely used in various parts of industries to improve the efficiency of the work. In this study, the current regulations to be adequate in industrial site have to be renew in order to prevent the fatal injuries by the fork lifts. Fatal injury analysis were conducted with several accident cases by the fork lifts. For each accident, the causes of the injuries were examined and proper safety measures were proposed. In this study, the fork lift showed a high fatality rate in industrial accidents and no detailed cause analysis of fatal accidents was conducted in terms of unsafe acts or conditions. First, fork lifts were the highest of the machines caused the accidents. In order to prevent fatal injuries by the fork lifts, the tarket was manufacturing industry. Second, the order of the cause of cognitive engineering agenda in the manufacture industrial was visibility, responsibility and affordance, and revision of acts was proposed. Third, there was not a lots of different points of human error between occurrence types and business sizes. Forth, number of fatalities by the attacker was more than by the inducer.

지게차는 전동 포크를 이용해 화물을 적재하고 운반하는 용도로 사용되는 산업용 장비로, 지게차로 인한 산업재 해는 지속적으로 빈발하고 있다. 이러한 재해의 대다수는 작업자의 불안전한 행동에 기인하는 것으로 알려져 있으나, 지게차 작업에 초점을 두고 휴먼에러 관점에서 위험을 분석한 연구는 찾아보기 어렵다. 또한, 작업의 휴먼에러 위험을 파악하고 분석하기 위한 다양한 기법들이 개발되어 왔으나, 기법 간에 효과성이나 장단점을 직접적으로 비교한 연구는 드물다. 본 연구는 대표적인 휴먼에러 분석 기법인 SHERPA와 HE-HAZOP을 이용하여 지게차 작업에서의 불안전한 행동과 관련된 위험 요인을 분석하고 두 기법의 장단점을 비교한다. 지게차 작업 중 ‘하차작업’, ‘자재이동 및 적재작 업’, ‘상차작업’의 3가지 대표적 작업을 대상으로 분석을 수행한 결과, SHERPA에 의해 118건의 에러와 34건의 개선대 책이 도출되었으며 HE-HAZOP를 통해 139건의 에러와 54건의 개선대책이 도출되었다. 휴먼에러 위험 분석의 결과를 바탕으로 두 기법을 결과 건수, 접근방법, 원인분석, 위험성 평가, 개선방안 도출 방식 등 다양한 측면에서 비교하였다. 본 연구의 결과는 지게차를 사용하는 사업장에서 휴먼에러와 관련된 재해 위험을 줄이는 데 활용될 수 있다. 대상 작업 과 여건에 맞는 휴먼에러 분석 기법을 선정하기 위한 가이드를 제공하기 위해서는 향후 다양한 작업을 대상으로 보다 많은 휴먼에러 분석 기법에 대한 비교 연구가 필요할 것으로 보인다.

A forklift is an industrial vehicle with a power-operated fork for lifting and moving heavy loads over short distances. A significant number of accidents are caused by forklifts every year. Most of them are known to be caused by the unsafe acts of workers. However, only a few studies have focused on the risks of forklift work from the perspective of human error. In addition, various methods have been developed to analyze the risk of human error, while it is hard to find studies that directly compare the effectiveness or strengths/weaknesses of those methods. This study aims to analyze risk factors related to unsafe behavior in forklift operations using two representative human error analysis techniques, i.e., .SHERPA and HE-HAZOP, and compare their advantages and disadvantages. The analysis was performed on three main forklift operations (‘unloading from the truck', 'moving and loading into the storage', and 'loading on the truck'). As a result, 118 errors and 34 remedial measures were derived by SHERPA. Through HAZOP, 139 errors and 54 measures were derived. The two techniques were compared in terms of the number of results and the method of deriving errors and remedial measures, cause analysis, and risk assessment. This study might be used to reduce human error related disasters in workplaces using forklifts. In order to provide a guide for choosing an appropriate analysis method, more comparative studies on different techniques involving wide range of tasks are needed in the future.

Purpose: This study aims to analyze the occupational accidents of railway workers, with a particular focus on the human errors of track workers, and to propose effective countermeasures. Despite the comprehensive revision of the Occupational Safety and Health Act and the implementation of the Serious Accident Punishment Act, the railway industry remains structurally vulnerable to occupational accidents. Moreover, studies on the human errors of track workers are notably insufficient. This study systematically examines the causes of occupational fatalities among track workers and suggests preventive and mitigation measures. Methods: Data on occupational accidents from 2013 to 2022 were analyzed using Excel pivot tables, categorized by work processes and accident types. The HFACS (Human Factors Analysis and Classification System) framework was employed to identify root causes of accidents, while the Bow-Tie method was utilized to derive preventive and mitigation measures. Results: The analysis revealed that most accidents involving track workers occurred between July and September, particularly during rail and crossing replacement, track maintenance, and inspection activities. Collision accidents were the most frequent, followed by incidents of being struck and entrapment. Human error analysis showed that mistakes (36%) and violations (31%) were the primary contributors to these incidents. This indicates that accidents often stem from errors by inexperienced workers and violations committed by experienced personnel. Physical and technical factors, such as track infrastructure and safety equipment, were identified as significant contributors. Furthermore, a lack of safety awareness and inadequate safety management were highlighted as major underlying causes of these accidents. Conclusion: This study systematically identified the working environment, common accident types, and key human error causes among track workers. Based on these findings, preventive and mitigation measures were proposed to reduce occupational fatalities. Future research should focus on analyzing the interrelationships between the identified factors to provide more comprehensive and meaningful insights.

Since cranes are a kind of complex human-machine systems, it is almost impossible to completely secure safety with current technologies. Therefore, managerial interventions to prevent human errors are needed for safely operating a crane. The Occupational Safety and Health law states that cabin-type crane operators should have crane drivers’ licence and crane-related operators (e.g., pendent-type crane operators, slinging workers) should take a special safety training. However, statistics on industrial accidents showed that fatalities due to crane accidents (185 accidents occurred during 2013~2017) were the highest among hazardous machinery and equipment. To effectively control the crane-related accidents, voices of crane workers need to be analyzed to investigate the current status. This study surveyed perceived causes of crane accidents and status of special safety training for crane workers of 387. The survey revealed that 24.3% of the respondents experienced crane accidents and 31.4% eye-witnessed crane accidents. 79% of the respondents pointed human errors such as improper crane operation and improper slinging as the first cause. Lastly, only 16.7% of the respondents took a professional special safety training; but the rest took lecture-based or incomplete education. The findings of the present study can be applied to improve crane-related policies and special safety training systems.

Crane is an important equipment for the transport of heavy goods in industrial sites, but it is also known as one of the most fatal machines. In order to reduce crane accidents, it is necessary to minimize human errors during crane operations. To achieve this, ergonomic design principles are recommended to be reflected from the crane design stage. The study analyzed the safety certification standards for crane that should be fulfilled at the crane design and manufacturing stage. This study selected five representative ergonomic design principles (feedback, compatibility, consistency, full-proof, and fail-safe) by surveying heuristic evaluation principles that are widely used for usability evaluation in early design stage. Next, the principles were applied to the safety certification standards to identify insufficient clauses. This study identified 12 insufficient clauses out of 119 in the current safety certification standards for crane and discussed their improvement directions to comply the ergonomic principles. The analysis results of this study can help of improving the safety certification standards and the method used in this study can also be applied to identify insufficient clauses in the safety certification standards for other industrial machines such as press machine and lift.

해운산업 전반에 걸쳐 안전문화의 중요성은 매우 크다. 해운은 가장 국제적인 산업인 동시에 매우 위험한 산업 중의 하나라고 일컬어진다. 해운에 있어서 비용 절감, 효율성 제고 등의 요인으로 인해 안전이 자칫 등한시될 소지가 있다. 위험한 산업을 지속시키기 위해서는 산업의 효율도 중요하지만 그 산업의 안전이 뒷받침되어야 한다. 해운은 선박 항행이 수반되는 산업 분야이고 바다 위를 항해하는 선박은 통상적으로 해상 고유의 위험에 노출되기 때문에 위험을 회피하거나 낮추는 등 해양 안전의 유지는 해운에 있어서 매우 중대한 사안이 되는 것이다. 해양안전의 중대성을 인식한 국제사회는 해양안전의 제고를 위해서 많은 노력을 경주해 왔다. 하지만 국제사회는 해양사고를 막기 위해 선박의 구조, 성능 등 기술적인 요소에 치중한 나머지 해양사고의 발생의 또 다른 축인 인적 과실을 예방하는 데는 소홀한 측면이 없지 않다. 기술적인 규정과 시스템을 만들어 통제하는 것만으로는 인적과실로부터 기인하는 해양사고를 줄일 수 없음이 통계로 나타난다. 따라서 인적 과실을 잘 다루어 해양안전의 향상을 꾀하는 것에 대한 논의는 아무리 강조해도 지나치지 않다. 이러한 점에 착안하여 이 논문은 해양안전 문화의 의미, 배경을 파악해 보고 이어 해양안전 문화와 관련된 국내외 논문을 분석하여 해양안전 문화의 제약 요인을 알아보고자 하였다. 그런 후 궁극적으로 해양안전 문화의 고양과 확산 방안에 관하여 검토하였다. 이 논문은 해양사고의 대부분이 이해당사자들의 안전의식 결여에서 기인하는 인적과실로부터 발생하고 있는 만큼 아래로부터의 해양안전을 실천하여 문화화하려는 노력이 필요함을 역설하고 있다. 이 논문에서는 해양안전문화가 범국민운동으로 확산되는데 매개체 역할을 할 수 있도록 해양안전문화 강사를 양성하여 해양안전문화의 국민교육 부분을 전담시켜야 한다고 제안하고 있다. 또한 해양안전문화의 향상은 현장에 그 해답을 찾아서 점차 상위의 관리부분으로 확산하는 것이 바람직하다는데 착안하여, 다중이용선박에서 잠재적인 해양안전 위험요인을 예지하여 해결할 수 있도록 보장하는 위험예지훈련 모델을 설계하여 비상훈련 시 적용하도록 제안하였다.

It is important for the shipping industry to deeply consider safety culture. This is because shipping is called one of the most international industries and also called one of the most dangerous industries. The shipping industry may not be able to see the importance of maritime safety culture as the first-policy due to the priority of cost-reduction and efficiency-first policies. However, safety is required for the sustainable development of dangerous industries. Shipping has the main factor of ship operations at sea and thus it is vital to keep maritime safety through evading or decreasing maritime risk factors in practice. The international community sees the importance of maritime safety and has made a lot of efforts to increase the safety, but it is true that it neglected the prevention of human error which is another main factor in maritime accidents. It is important to control safety matters by means of regulations and systems but statistics show that that is not perfect. Thus it goes without saying that maritime safety should be enhanced by properly dealing with human factors. Based on those points made above, this article attempts to study the concept of maritime safety culture and its background, and tries to find the vital factors of maritime safety culture by analysing domestic and international articles in the field of maritime safety. This is followed by the study of the enhancement and proliferation of maritime safety culture. This study argues that making efforts to culturalize maritime safety by practicing it from the bottom-up is very important since a large proportion of maritime accident results from the lack of safety culture of relevant stakeholders. This study sees that the maritime safety culture instructor, who is able to become a middle man for the proliferation of the national movement of maritime safety culture, needs to be raised and take up the role of the eduction of his or her nationals. In addition, based on the idea that it is desirable for maritime safety culture to be enhanced through finding the answer from the field to the top management, the study recommends that it is important to design the model of the risk identification and awareness drill, which is able to resolve the risk factors of potential maritime safety on board large passenger vessels through the identification of those risks in advance, and also to apply it to ships' emergency drills.

It is commonly recognized that railway is one of the representative transportation and it offers public service based on strategies for being rapid, automation, safety. Since the opening of high speed railway, 3-hundred-million people have used it and acknowledged its efficiency. However, derailed accident at Kwangmyeong station in February, 2011, frequent malfunction of KTX-Sancheon, and accidents by engineer's careless fault damaged on credibility of safety, Especially, spreaded accidents through social networking service by cell phones amplified anxiety of public, being criticized by the press. This study analyzed statistics of past accident and cases of passing-by accident, and surveyed 152 KTX captain engineers about their recognition of the accident by careless fault and experiences of possibility of occurrence for preventing engineer's careless fault and restoring trust According to the analysis, engineers worry about responsibility and disadvantages related to the accidents for the most, and they are nervous about malfunction for the second most. This study presents prevention methods regarding the result. First, it is required to improve mental stability and concentration on their work, secondly, advanced ability to cope with malfunction or error through repetitive education and training are required to increase confidence, and for the last, improvement of operational supporting system such as ATP, GPS to prevent errors by human factors. Improvement of the system is expected to lead engineers to prevent careless fault and regain the reputation of railway.

The Study lay Emphasised on to Investigate Human Related Causes of a Pointed End Equipment Accident and the Basic data for Analyzing Human-Error Prevention Program. Peter Son's Model of Human-Error Accident Causation and Cooper's Model of Safety Culture Were Applied to Analyze the Severe Cause of a Pointed End Equipment for Last 5 Years. Through to Analyzing the Cause of Equipment Accident of Human-Error, Expert's Opinion and Experience Theory Method was Reflected. The Analyses Showed What the Immature and Inexperient Error Were Major Causes of a Pointed and Equipment Accident. The Cause of Human-Error was Found with Respect to Human, Tasks, Acknowledge, Organization.

The Study lay Emphasised on to Investigate Human Related Causes of a Pointed End Equipment Accident and the Basic data for Analyzing Human-Error Prevention Program. Peter Son's Model of Human-Error Accident Causation and Cooper's Model of Safety Culture Were Applied to Analyze the Severe Cause of a Pointed End Equipment for Last 5 Years. Through to Analyzing the Cause of Equipment Accident of Human-Error, Expert's Opinion and Experience theory Method was Reflected. The Analyses Showed What the Immature and Inexperient Error Were Major Causes of a Pointed and Equipment Accident The Cause of Human-Error was Found with Respect to Human, Tasks, Acknowledge, Organization.

본 연구는 인천국제공항 엑스레이 검색 등급 시스템을 통해 도출된 실제 결과와 현장 관리자의 직관적 판단 간의 일치 정도를 분석했다. 데이터 분석은 45명의 관 리자를 대상으로 한 설문조사 결과와 1,034명의 보안검색요원의 성과평가를 기반으 로 진행했다. 분석결과, B등급을 제외한 대부분의 구간에서 예상 등급과 측정 등급 간에 상당한 불일치가 나타났다. B등급의 경우 예측값이 비교적 일관적이었다. 이러 한 불일치는 주관적인 평가에만 의존하는 것이 검색요원의 성과를 정확하게 평가하 는 데 충분하지 않을 수 있음을 시사한다. 이에 본 연구는 항공보안에서 절차적 일 관성을 강화하고 인적 오류를 줄이기 위해 교육, 평가, 인력 배치 기능을 연결하는 통합모델인 원툴 프로그램(OTP)을 제안하였다.

This research explored the degree of alignment between frontline managers’ intuitive judgments and the actual results generated by the X-Ray Screening Rating System at Incheon International Airport. Data analysis was based on the survey responses of 45 managers and performance ratings of 1,034 security screening personnel. The results indicated considerable mismatches between anticipated and measured grades in most rating levels, except for grade B, where the predictions were relatively consistent. These discrepancies suggest that relying solely on subjective evaluations may not be sufficient for accurately assessing screener performance. In response, the study proposes the One-Tool Program(OTP) an integrated model that links training, assessment, and staffing functions with the goal of enhancing procedural consistency and reducing human-related errors in aviation security.

The chemical factory deals with dangerous element and more advance, human-error analyzes and becomes effective research for the country and region. This paper analysis the form of work-miss on human-error according to a safety accident for domestic chemical factory from 1999-2002. It include the present contents and raise issues human knowledge, behavior, judgment, sensibility as an important counter plan that makes the safety solution of work miss. For the point of view of human knowledge, it takes color standard for works to be effective in work place. For behavior, the test has been for risk Point of work place and infra worker movement, also the workers performed professional work as classify according to work. For judgement, the valuation sheet is reflected to minimize the human-error and the 3rd supervisor does a cross-check audit beforehand. For sensibility, it is applicable for human relations, information, communication by program to the consciousness and an attitude of worker-supervisor.

The chemical factory deals with dangerous element and more advance, human-error analyzes and becomes effective research for the country and region, this paper analyes the form of work-miss on human-error according to a safety accident for domestic chemical factory from 1999-2002. It include the present contents and raise issues human knowledge, behavior, judgment, sensibility as an important counterplan that makes the safety solution of work miss. For the point of view of human knowledge, it takes color standard for works to be effective in work place. for behavior, the test has been for risk point of work place and infra worker movement, also the workers performed professional work as classify according to work. for judgement, the valuation sheet is reflected to minimize the human -error and the 3rd supervisor does a cross-check audit beforehand. For sensibility, it is applicable for human relations, information, communication by program to the consciousness and an attitude of worker-supervisor.

The use of intravenous catheters are occasionally complicated by intravascular fragments and swelling of the catheter fragments. We present a patient in whom an intravenous catheter fragments was retrieved from the dorsal metacarpal vein following its incidental CT examination detection. The case of demonstrates the utility of microscopy and multi‐detector CT in localizing small of subtle intravenous catheter fragments as a human error. A case of IV catheter fragments in the metacarpal vein, in which reproducible and microscopy data allowed complete localization of a missing fragments and guided surgery with respect to the optimal incision site for fragments removal. These reproducible studies may help to determine the best course of action and treatment for the patient who presents with such a case.

여가생활 활동수단으로 자전거 이용이 증가하는 추세이다. 최근에는 자전거 운전자의 과실로 인한 자전거 사고가 증가하고 있어, 이에 대한 예방방안을 마련해야 한다. 이를 위해 본 연구는 도로교통 관리공단 교통사고분석시스템(TAAS)에서 최근 5년간(2014-2018) 자전거 운전자가 교통사고의 원인 을 제공한(제1당사자) 사고 데이터를 수집하여, 자전거 사고의 위험도를 분석하였다. 사고전개 시나 리오를 활용하여 1, 2차 세부적인 사고유형을 분류하였으며, 인명피해는 사망자뿐만 아니라 부상자 를 고려하여 분석하였다. 자전거 사고는 1차적으로 자전거대차(일부 원동기 및 자전거 포함), 2차 분류에서 측면충돌이 가장 높은 확률을 나타내고 있었다. 반면 1건당 인명피해는 자전거 단독 사고 중 도로이탈이 가장 치명적인 것으로 나타나, 인체손상의 심각도를 보여주었다. 이러한 자전거 사고 는 대부분 안전수칙 미준수로 인하여 발생되는 것으로 확인된다. 그러므로 개개인은 방향전환 시 수신호, 안전모 착용과 같은 기본적인 안전수칙을 지켜야 한다. 지자체와 정부는 인적오류를 개선할 수 있는 교육 프로그램과 홍보, 단속을 적극적으로 펼쳐야 할 것이다.

Bicycle riding becomes more popular as a leisure activity and bicycle accidents by human error have recently increased. To provide safety measure for the accidents, this study performed a risk analysis of bicycle accidents in South Korea. We collected the statistical data of bicycle accidents due to driver’s negligence during 5 years (2014-2018) from Koroad TAAS (Traffic Accidents Analysis System). Bicycle accident types were identified in the 1st and 2nd detailed classifications, and human casualty was weight calculated including fatalities and injuries. The results show that side collision by an automobile is most frequent and driving off the road is the most severe in fatality rate. Considering that most of the bicycle accidents occurred by human error, local and central government should improve road safety education and campaign and enforce safety regulation.

외상후 스트레스 장애는 임상적 수준의 유의미한 고통뿐 아니라, 사회적·직업적 기능 수행 및 적응에 있어서도 장기간에 걸쳐 어려움을 나타내는 것으로 알려져 있다. 외상경험에 대한 심리적 반응들은 외상사건의 종류 또는 피해를 경험한 개인들의 특성에 따라 다양하게 나타날 수 있기 때문에 외상사건에 노출된 개인의 특성과 외상경험 자체의 특수성을 고려한 보호요인을 찾는 것이 중요하다. 이에, 본 연구에서는 공군 전투기 조종사의 비행사고 관련 외상사건 노출이 외상후 스트레스 장애 증상에 미치는 영향을 살펴보고, 조종사들의 주된 특성이라 할 수 있는 인지적 유연성의 조절효과를 검증하였다. 이를 위해 남성 공군 전투기 조종사 64명을 대상으로 설문조사가 실시되었다. 연구결과, 인적요인 관련 비행사고에 노출된 조종사 집단에서 그러한 경험이 없는 집단에 비해 외상후 스트레스 증상이 높게 나타나는 경향이있었다. 또한 인적요소에 의한 비행사고 노출과 외상후 스트레스 증상 간의 관계에서 인지적 유연성이 조절효과를 나타냈다. 이러한 결과는 조종사의 비행임무 수행 중 외상사건 노출이 외상후 스트레스 증상과 유의미하게 연관될 수 있으며 높은 수준의 인지적 유연성은 외상경험이 외상후 스트레스 증상으로 이어지는 것에 대한 보호요인으로 작용할 수 있음을 의미한다. 이러한 결과를 바탕으로 본 연구의 의의및 후속연구의 필요성에 대하여 논의하였다.

Posttraumatic stress disorder is characterized by not only significant psychological distress but also long-term difficulties in social and occupational functioning and adjustment. Psychological response to exposure to trauma can vary depending on the type of traumatic incident or factors related to the individual exposed to trauma. As such, it is important to investigate the potential protective factors that consider individual characteristics and the particular nature of the trauma. The present study thus examined the effect of exposure to human error-related aircraft accident in air force pilots on posttraumatic stress symptoms. Secondly, the moderation effect of cognitive flexibility was tested. A total of 64 male air force pilots participated in the study. The results indicated that air force pilots exposed to human error-related aircraft accident evidenced more posttraumatic stress symptoms than pilots with no prior exposure to human error-related aircraft accident. Furthermore, cognitive flexibility moderated the relationship between flight-related trauma secondary to human error and posttraumatic stress symptoms. The findings indicate that exposure to traumatic events during flight missions may be significantly associated with posttraumatic stress symptoms and that high degree of cognitive flexibility may serve as a protective factor. The implications and suggestions for future research are discussed.

Through so that accident of semiconductor industry deduces unsafe factor of the person center on unsafe behaviour that incident history and questionnaire and I made starting point that extract very important factor. It served as a momentum that make up base that analyzes factors that happen based on factor that extract factor cause classification for the first factor, the second factor and the third factor and presents model of human error. Factor for whole defines factor component for human factor and to cause analysis 1 stage in human factor and step that wish to do access of problem and it do analysis cause of data of 1 step. Also, see significant difference that analyzes interrelation between leading persons about human mistake in semiconductor industry and connect interrelation of mistake by this. Continuously, dictionary road map to human error theoretical background to basis traditional accidental cause model and modern accident cause model and leading persons. I wish to present model and new model in semiconductor industry by backbone that leading persons of existing scholars who present model of existent human error deduce relation. Finally, I wish to deduce backbone of model of pre-suppression about accident leading person of the person center.

Presses are very widely used in industrial and commercial companies and are often the source of serious accidents occurring during operation. In Korea, the press holds the first place in the industrial hazard machines for frequency of accidents. Most of the press accidents are due to the human error. Continuous recordings of eye and hand movements that included operating errors of five experienced subjects were made during the press operation. The results showed that significant differences were observed on eye fixation time, hand fixation time, and lead departure time between the operations that has errors and no errors. The result could be used as basic data to establish a guideline for preventing the accidents.