• Title/Summary/Keyword: Root cause

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Root Cause Analysis of the Information Industry Ecosystem Problems (정보산업 생태계 문제의 근본원인 분석)

  • Kim, Sung Kun;Ahn, Nam Gyu
    • Journal of Information Technology Applications and Management
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    • v.24 no.4
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    • pp.71-92
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    • 2017
  • Finding a root cause is an essential step to solving a complex problem. Some previous studies have used the Delphi method for gathering opinions about root causes from geographically dispersed experts. However, we assert that complicated problems such as an industry ecosystem would make a general type of the Delphi method less practical because of too much psychological burden on study participants. In this study we present a preliminary list-based Delphi study method for identifying a root cause. This method was used to identify a root cause and draw a causal map for the information industry ecosystem problems.

Reliability Problem Solving Through Root Cause Analysis (근본원인분석을 이용한 신뢰성 문제 해결)

  • Jeong, Hai Sung
    • Journal of Applied Reliability
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    • v.16 no.1
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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.

Root Cause Analysis of Medical Accidents -Using Medical Accident Cases (의료사고의 근본원인 분석: 의료사고 판례문 이용)

  • KIM, Seon-Nyeo;Cho, Duk-Young
    • The Korean Journal of Health Service Management
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    • v.13 no.3
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    • pp.13-26
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    • 2019
  • Objectives: To investigate whether medical institutions can prevent accidents by analyzing the root cause of a medical accident and identifying the tendencies. Methods: A total of 345 medical cases were used for the RCA(Root Cause Analysis). The root causes were classified using the SHELL model. The suitability of the model was confirmed by SPSS's MDPREF and Euclidean distance. An SPSS20.0 hierarchical regression analysis was used as an influencing factor on the degree of injury resulting from medical accidents. Results: The SHELL model was suitable for classification. The rates of accident causes were LS49%, L34%, LL10.2%, LE3.7%, LH2.3%. The order in which the degree of a patient's injury was affected were: Risk Threshold (${\beta}=.180$), Time (${\beta}=.175$), Surgical stage (${\beta}=-.166$), Do not use procedure (${\beta}=.147$). Conclusions: Health care institutions should remove priorities through system improvement and training. For patients' safety, the five factors of the SHELL model should be managed in harmony.

Root Cause Analysis on the Steam Turbine Blade Damage of the Combined Cycle Power Plant (복합화력발전소 증기터빈 동익 손상 원인분석)

  • Kang, M.S.;Kim, K.Y.;Yun, W.N.;Lee, W.K.
    • Journal of Power System Engineering
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    • v.12 no.4
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    • pp.57-63
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    • 2008
  • The last stage blade of the low pressure steam turbine remarkably affects turbine plant performance and availability Turbine manufacturers are continuously developing the low pressure last stage blades using the latest technology in order to achieve higher reliability and improved efficiency. They tend to lengthen the last stage blade and apply shrouds at the blades to enhance turbine efficiency. The long blades increase the blade tip circumferential speed and water droplet erosion at shroud is anticipated. Parts of integral shrouds of the last stage 40 inch blades were cracked and liberated recently in a combined cycle power plant. In order to analyze the root cause of the last stage blades shroud cracks, we investigated operational history, heat balance diagram, damaged blades shape, fractured surface of damaged blades, microstructure examination and design data, etc. Root causes were analyzed as the improper material and design of the blade. Notches induced by erosion and blade shroud were failed eventually by high cycle fatigue. This paper describes the root cause analysis and countermeasures for the steam turbine last stage blade shroud cracks of the combined cycle power plant.

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A Study on Applying TRIZ to Logistics improvement (물류개선을 위한 트리즈 방법론 연구)

  • Jung, Soo-Hwan;Baek, Sung-Joon;Yu, Yen-Yoo
    • Journal of Digital Convergence
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    • v.12 no.8
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    • pp.77-84
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    • 2014
  • TRIZ was developed and refined in the Soviet Union between 1946 and 1985 by Genrich Altshuller. Its primary application has been for solving inventive problems in the areas of engineering. But, recently the elements of TRIZ began to be applied non-technical areas by Darrell Mann. TRIZ theroy was brought into South Korea in 1995 and it is used by the LG, SAMSUNG, POSCO. TRIZ is simply not the tool for technical problem solving, covering many areas of comprehensive approach is being recognized. TRIZ is a methodology for defining problem, finding root cause through RCA(Root cause analysis), defining technical contradiction and physical contradiction. TRIZ overcomes contradiction and purses problem solving method through innovation. TRIZ is a problem solving method in this study using the principles of non-technical fields applied to the improvement of the logistics area study. The method to overcome contradiction is 40 principles. It is possible to generate idea by using 40 principles. This study was applied to logistics field of non-technical area by using TRIZ principle.

A Study on Analysis of Laboratory Accident with Root Cause Analysis (근본원인분석 기법을 활용한 실험실 사고 분석에 관한 연구)

  • Eom, Seok-Hwa;Lee, Su-Kyung
    • Journal of the Korean Institute of Gas
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    • v.14 no.4
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    • pp.1-5
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    • 2010
  • Many sorts of fatal accidents like explosion or fire caused by gas leakage have become a social issue with the increasing use of harmful chemicals in laboratories in universities and enterprise-affiliated research institutes in Korea. Importance of safety management has been emphasized and it made Act on the Establishment of Safe Laboratory Environment enacted not only to protect lives and bodies of people working in laboratories in universities and enterprise-affiliated research institutes but also to make pleasant experimental atmosphere. Safety management system has been built and periodical checkups and safety diagnosis have been implementing in universities and enterprise-affiliated research institutes to prevent such accidents. However, in spite of those actions, continuous accidents make analysis of root cause essential. This study will show results of analysis on incidents and accidents occurred in laboratories in universities and enterprise-affiliated research institutes using Root Cause Analysis Method and propose the direction of safety management.

A Study on Developing a Knowledge-based Database Program for Gas Facility Accident Analysis (가스시설 사고원인 해석을 위한 지식 데이터베이스 프로그램 개발)

  • Kim Min Seop;Im Cha Soon;Lee Jin Han;Park Kyo Shik;Ko Jae Wook
    • Journal of the Korean Institute of Gas
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    • v.4 no.4
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    • pp.65-70
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    • 2000
  • We develop the database program for accident cause analysis which can help to increase domestic safety custom and prevent recurrence of gas accident and analyze accidents easily The program developed in this study consists of two parts. one part uses accident case database applied if than rule, so it finds root causes by inference of some input values. The other uses Root Cause Analysis Map which divided human errors and equipment difficulties and so we get general root cause by reply some proper questions.

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Guidelines for Performing Root Cause Analysis (근본원인분석 수행을 위한 지침)

  • Lee, Hyeon-Jeong;Choi, Eun-Young;Ock, Min-Su;Lee, Sang-Il
    • Quality Improvement in Health Care
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    • v.23 no.1
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    • pp.25-38
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    • 2017
  • Root cause analysis (RCA) is systematic process for identifying contributing factors and root causes. It detects system-level vulnerabilities and prevents them from occurring in the future. In many countries, RCA guidelines have been developed and used for these purposes, and various practical tools are suggested according to stages of RCA implementation. In Korea, adverse events occur in 7.2-8.3 percent of inpatients according to studies conducted in hospitals. However, frontline staffs are suffering from lack of knowledge about RCA implementation. This study introduces RCA guidelines that may be used in hospitals to improve the quality of medical care and patient safety.

Prediction Methodology for Reliability of Semiconductor Packages

  • Kim, Jin-Young
    • Proceedings of the International Microelectronics And Packaging Society Conference
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    • pp.79-94
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    • 2002
  • Root cause -Thermal expansion coefficient mismatch -Tape warpage -Initial die crack (die roughness) Guideline for failure prevention -Optimized tape/Substrate design for minimizing the warpage -Fine surface of die backside Root cause -Thermal expansion coefficient mismatch - Repetitive bending of a signal trace during TC cycle - Solder mask damage Guideline for failure prevention - Increase of trace width - Don't make signal trace passing the die edge - Proper material selection with thick substrate core Root cause -Thermal expansion coefficient mismatch -Creep deformation of solder joint(shear/normal) -Material degradation Guideline for failure Prevention -Increase of solder ball size -Proper selection of the PCB/Substrate thickness -Optimal design of the ball array -Solder mask opening type : NSMD -In some case, LGA type is better

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Root Cause Analysis on Delamination Failure between Coating Film and Paper (코팅지 박리파손에 대한 근본원인분석)

  • Lee, D.B.
    • Journal of Power System Engineering
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    • v.9 no.1
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    • pp.57-63
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    • 2005
  • In the calendar and the advertising catalog, the surface is usually coated by coating polypropylene film. The delamination failure of coating film depends on surface roughness and quality of the substrate paper. In this paper, the mechanisms of delamination failure between the coating film and the paper is investigated by using the root cause analysis as one of techniques of reliability evaluation. The papers used in failure analysis are three kind products made by two domestic and one foreign companies. It found that the main causes of delamination failure between the coating film and the paper were the creation of microvoids caused by shape of filler and their growth caused by contraction of paper.

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