The starter motor for military armored vehicles was known for its reliable quality, with less than one failure reported per year. However, this changed recently when a sudden wave of failures began to occur. The main issue was the “pinion gear teeth” snapping off during operation. When these teeth break, the metal fragments scatter and damage other internal parts, causing expensive repairs and leaving the vehicles unusable. Because it is vital for the military to keep these vehicles ready for action, solving this problem became a top priority. This paper provides a comprehensive investigation into the root causes of these pinion gear failures by examining the entire system from multiple perspectives. First, we conducted a detailed analysis of the individual component, including its material properties and the manufacturing process to identify any inconsistencies. Second, the study evaluates the gear meshing conditions and structural alignment with the mating components to ensure proper power transmission. Furthermore, we analyzed the electrical characteristics of the starter motor, such as current surges during ignition, which could impose excessive stress on the gear teeth. By integrating these findings, this paper discusses the comprehensive process of identifying the failure mechanism and proposes technical improvements to prevent future occurrences.

Purpose: The purpose of this study was to examine the effect of debriefing program applying patient safety analysis and comparison of knowledge and attitude toward patient safety. Method: A nested design of pretest-posttest control group was used with root cause analysis for debriefing. The participants were 58 undergraduate nursing students recruited from one university in Chungcheong province. They were assigned to either an experimental group (n=28 or a control group (n=30). A structured root cause analysis method for debriefing program offered to the experimental group whereas the control group did not receive any program. The data were analyzed using the PASW 23.0 program with χ2test, t-test, and ANOVA. Results: The participants who had participated in the root cause analysis in the debriefing showed significant difference (p < .001). Conclusion: The result of this study found that the root cause analysis method in the debriefing improved patient safety. Therefore, this program can be widely used in nursing curriculum because it leads to efficient debriefing and improves patient safety through root cause analysis.

Semiconductor is one of the biggest export items in Korea and one of future foods. In this study, the development of the product due to the repetition of the engineer mistakes repeatedly occurred due to the experience and habit of the individual in the semiconductor design process until now, resulting in an increase in the development period of the product and the economic loss of sales. As a result, the need for database of engineers' knowledge and know-how has emerged. This study investigate show to integrate and utilize data that is not managed on On/off-line for semiconductor knowledge and know-how. To do this, we intend to construct a RCT(RootCauseTracker) system that enables statistical analysis of the data on design failure accumulated over the previous year in any company.