Page 91 - Demo

%ud55c%ud3b8, James Reason(1997)%uc740 %u201c%uc548%uc804%ubb38%ud654%ub294 %uc815%ubcf4%uc5d0 %uc785%uac01%ud55c %ubb38%ud6543)%u201d%ub77c%uace0 %uc815%uc758%ud558%uc600%ub2e4. %uc774%ub294, %uc2dc%uc2a4%ud15c%uc758 %uc815%uae30%uc801 %u00b7 %uc120%uc81c%uc801 %uc810%uac80, %uc0ac%uace0(incident) %ubc0f %uc544%ucc28 %uc0ac%uace0(near miss)%ub85c%ubd80%ud130 %uc815%ubcf4%ub97c %uc218%uc9d1%ud558%uace0 %ubd84%uc11d%ud574 %uad6c%uc131%uc6d0%ub4e4%uc5d0%uac8c %uad00%ub828 %uc815%ubcf4%ub97c %uacf5%uc720%ud558%ub294 %uc548%uc804%uc815%ubcf4%uc2dc%uc2a4%ud15c %uad6c%ucd95%uc758 %ud544%uc694%ud568%uc744 %uac15%uc870%ud55c %uac83%uc774%ub2e4. %uc989, %uc548%uc804%uc815%ubcf4%uc2dc%uc2a4%ud15c %uad6c%ucd95%uc740 %uc548%uc804%uc758 %uac00%uce58, %ub9ac%ub354%uc2ed, %uc2e4%ud589%ub825, %uc804%ubb38%uc131, %uc18c%ud1b5 %ub4f1 %uc548%uc804%ubb38%ud654%uc758 %uad6c%uc131%uc694%uc18c%ub97c %uad6c%ucd95%ud558%uae30 %uc704%ud574 %uad00%ub828 %uc815%ubcf4%ub97c %uad00%ub9ac%ud558%uace0 %uacf5%uc720%ud560 %uc218 %uc788%uac8c %ud558%ub294 %uc870%uc9c1 %ucc28%uc6d0%uc758 %uae30%ubc18 %uc2dc%uc2a4%ud15c%uc774%ub2e4.%ud55c%ud3b8, %uc548%uc804%ubb38%ud654%ub294 %ud559%uc2b5%uc744 %ud1b5%ud574 %ubcc0%ud654%ud558%uace0 %uc131%uc7a5%ud560 %uc218 %uc788%ub294%ub370, %ud559%uc2b5%uc740 %uc815%ubcf4%ub97c %uae30%ubc18%uc73c%ub85c %uc774%ub8e8%uc5b4%uc9c0%uae30 %ub54c%ubb38%uc5d0 %uc548%uc804 %uad00%ub828 %uc815%ubcf4%uc758 %ud6a8%uacfc%uc801%uc774%uace0 %ud6a8%uc728%uc801%uc778 %uad00%ub9ac%uac00 %ud544%uc694%ud55c%ub370, %uc774%ub7ec%ud55c %ud544%uc694%ub97c %ucda9%uc871%uc2dc%ud0a4%ub294 %uc548%uc804%uc815%ubcf4%uc2dc%uc2a4%ud15c %uad6c%ucd95%uc740 %uc548%uc804%ubb38%ud654%uc758 %uc870%uc131%uc744 %uc704%ud55c %uc804%uc81c%uc870%uac74%uc774%ub77c%uace0%ub3c4 %ud560 %uc218 %uc788%ub2e4. %uc774%ub7ec%ud55c %uad00%uc810%uc5d0%uc11c James Reason(1997)%uc740 %uc870%uc9c1 %ucc28%uc6d0%uc758 %uc548%uc804%uc815%ubcf4%uc2dc%uc2a4%ud15c %uad6c%ucd95%uc5d0 %ud544%uc694%ud55c %uc548%uc804%ubb38%ud654 %uc870%uc131%uc744 %uc704%ud55c 4%uac00%uc9c0 %uc138%ubd80 %ubb38%ud654%ub97c [%ud45c 1]%uacfc %uac19%uc774 %uaddc%uc815%ud558%uc600%ub2e4.[%ud45c 1. James Reason(1997)%uc758 %uc548%uc804%ubb38%ud654 %uc870%uc131%uc744 %uc704%ud55c 4%uac00%uc9c0 %uc138%ubd80 %ubb38%ud654][%ud45c 1]%uc5d0 %uc815%ub9ac%ud55c %uc138%ubd80 %ubb38%ud654%uc758 %uad6c%ucd95%uc744 %uc704%ud55c %uc870%uc9c1 %ucc28%uc6d0%uc758 %uc911%uc694 %ud3ec%uc778%ud2b8%ub97c %uc81c%uc548%ud558%uba74 %ub2e4%uc74c%uacfc %uac19%ub2e4. %uccab%uc9f8, %ubcf4%uace0%ud558%ub294 %ubb38%ud654%ub294 %u201c%uc2e0%ub8b0 %ubd84%uc704%uae30%uc758 %uc870%uc131, %ubcf4%uace0%uc758 %ub3d9%uae30%ubd80%uc5ec, %uc9d5%uacc4%ucc98%ubd84 %uba74%ucc45, %ube44%ubc00%ubcf4%uc7a5%u201d%uc744 %ud1b5%ud574 %uad6c%ucd95%ud560 %uc218 %uc788%ub294%ub370, %ubcf4%uace0%uc758 %uc218%uc9d1 %u00b7 %ubd84%uc11d %u00b7 %uc81c%uc7ac %ub4f1 %uad00%ub828 %uc5c5%ubb34%ub97c %ub2f4%ub2f9%ud558%ub294 %ubd80%uc11c%ub97c %ubd84%ub9ac%ud558%ub294 %uac83%ub3c4 %uace0%ub824%ud574%uc57c %ud560 %uc911%uc694 %ud3ec%uc778%ud2b8%uc774%ub2e4. %ub458%uc9f8, %uacf5%uc815%uc758 %ubb38%ud654 %uad6c%ucd95%uc744 %uc704%ud574%uc11c%ub294 %u201c%ubd88%uc548%uc804%ud55c %ud589%ub3d9 %ub610%ub294 %uc0c1%ud0dc%u201d%uc758 %ubc1c%uc0dd %uc0ac%uc720%uc758 %ud655%uc778%uacfc %uc6d0%uc778 %ubd84%uc11d%uc774 %uac1d%uad00%uc801%uc73c%ub85c %uc774%ub8e8%uc5b4%uc838%uc57c %ud55c%ub2e4. %ub354%ubd88%uc5b4 %uc548%uc804%ud55c %uc791%uc5c5%uc5d0 %ub300%ud55c %ubcf4%uc0c1%uacfc %uc704%ubc18%uc5d0 %ub300%ud55c %uc6d0%uce59%uacfc %uae30%uc900%uc5d0 %ub530%ub978 %uc81c%uc7ac %ub610%ub294 %uc9d5%uacc4%uac00 %uc6b0%uc120%ub418%uc5b4%uc57c %ud55c%ub2e4.3) J. Reason, Managing the Risk of Organization Accidents, Ashgate, 1997, pp. 195-196.%u3000%uc138%ubd80 %ubb38%ud654 %uc0c1%uc138 %ub0b4%uc6a9%ubcf4%uace0%ud558%ub294 %ubb38%ud654- %uad6c%uc131%uc6d0%uc740 %ubcf4%uace0 %uc2dc %uc9d5%uacc4%ucc98%ubd84%uc758 %uac71%uc815 %uc5c6%uc774, - %uc2a4%uc2a4%ub85c %uc5d0%ub7ec, %uc544%ucc28%uc0ac%uace0%ub97c %ubcf4%uace0%ud560 %uc218 %uc788%uc5b4%uc57c %ud55c%ub2e4. - %ubcf4%uace0%uc790%uc758 %ube44%ubc00%uc131 %ub610%ub294 %uc775%uba85%uc131%uc774 %ubcf4%uc7a5%ub418%uc5b4%uc57c %ud558%uace0, - %ubcf4%uace0%uc5d0 %ub300%ud55c %uc870%uce58 %uacb0%uacfc%ub97c %ubcf4%uace0%uc790%uc5d0%uac8c %uc2e0%uc18d%ud558%uac8c %ud53c%ub4dc%ubc31%ud574%uc57c %ud55c%ub2e4.%uacf5%uc815%uc758 %ubb38%ud654- %ubcf4%uc0c1%uc774 %ud544%uc694%ud560 %ub54c %ubcf4%uc0c1%ub418%ub294 %uc2e0%ub8b0 %ubd84%uc704%uae30 %uc870%uc131%uc774 %ud544%uc694%ud558%uace0, - %uc758%ub3c4%uce58 %uc54a%uc740 %ubd88%uc548%uc804%ud55c %ud589%ub3d9%uc740 %uc9d5%uacc4%ud558%uc9c0 %uc54a%uc73c%uba70, - %uc758%ub3c4%uc801%uc778 %uc704%ubc18 %ud589%uc704, %uc911%uacfc%uc2e4%uc5d0 %ub300%ud574%uc11c%ub294 %uc9d5%uacc4%uac00 %ud544%uc694%ud558%ub2e4. - %ubcf4%uc0c1%uacfc %uc9d5%uacc4%uc758 %ud310%ub2e8%uc774 %uae30%uc900%uacfc %uc6d0%uce59%uc5d0 %ub530%ub77c %uacf5%uc815%ud574%uc57c %ud55c%ub2e4.%uc720%uc5f0%ud55c %ubb38%ud654- %uae34%uae09 %uc0c1%ud669%uc5d0 %uc870%uc9c1%uc740 %uc218%uc9c1%uc801 %uccb4%uacc4%uc5d0%uc11c %uc218%ud3c9%uc801 %uccb4%uacc4%ub85c %uc804%ud658%uc774 %uac00%ub2a5%ud55c %uc870%uc9c1%uc758 %uc720%uc5f0%uc131%uc744 %uc758%ubbf8%ud568. - %ud604%uc5c5 %uc804%ubb38%uac00(%uc608. %uad00%ub9ac%uac10%ub3c5%uc790)%uc758 %uacbd%ud5d8, %ub2a5%ub825%uc758 %uc874%uc911%uc774 %ud544%uc218%uc801%uc774%uba70, - %uad6c%uc131%uc6d0%uc758 %uc5ed%ub7c9 %ud5a5%uc0c1%uc744 %uc704%ud55c %uad50%uc721 %u00b7 %ud6c8%ub828%uc5d0 %ub300%ud55c %ud22c%uc790%uac00 %ud544%uc694%ud558%ub2e4.%ud559%uc2b5%ud558%ub294 %ubb38%ud654- %uc0ac%ub0b4 %u00b7 %uc678 %uc0ac%uace0 %ub610%ub294 %uc7ac%ud574 %uc0ac%ub840%ub85c%ubd80%ud130 %ubc30%uc6b0%uace0, - %uc720%uc0ac %u00b7 %ub3d9%uc885 %uc0ac%uace0 %ub610%ub294 %uc7ac%ud574 %uc608%ubc29%ub300%ucc45%uc744 %uc218%ub9bd%ud558%uba70, - %uad6c%uc131%uc6d0%uc740 %ud68c%uc0ac%uc758 %uc548%uc804%uae30%uc900%uacfc %uc791%uc5c5%uae30%uc900%uc744 %ubc30%uc6cc, - %uc548%uc804%ud55c %uc791%uc5c5%uc744 %uc720%uc9c0%ud558%ub294 %uc870%uc9c1%uc801 %uc6c0%uc9c1%uc784%uc744 %uc758%ubbf8%ud568.91KOHA %uc548%uc804