Sample records for complex safety critical

  1. Is Model-Based Development a Favorable Approach for Complex and Safety-Critical Computer Systems on Commercial Aircraft?

    NASA Technical Reports Server (NTRS)

    Torres-Pomales, Wilfredo

    2014-01-01

    A system is safety-critical if its failure can endanger human life or cause significant damage to property or the environment. State-of-the-art computer systems on commercial aircraft are highly complex, software-intensive, functionally integrated, and network-centric systems of systems. Ensuring that such systems are safe and comply with existing safety regulations is costly and time-consuming as the level of rigor in the development process, especially the validation and verification activities, is determined by considerations of system complexity and safety criticality. A significant degree of care and deep insight into the operational principles of these systems is required to ensure adequate coverage of all design implications relevant to system safety. Model-based development methodologies, methods, tools, and techniques facilitate collaboration and enable the use of common design artifacts among groups dealing with different aspects of the development of a system. This paper examines the application of model-based development to complex and safety-critical aircraft computer systems. Benefits and detriments are identified and an overall assessment of the approach is given.

  2. Time Factor in the Theory of Anthropogenic Risk Prediction in Complex Dynamic Systems

    NASA Astrophysics Data System (ADS)

    Ostreikovsky, V. A.; Shevchenko, Ye N.; Yurkov, N. K.; Kochegarov, I. I.; Grishko, A. K.

    2018-01-01

    The article overviews the anthropogenic risk models that take into consideration the development of different factors in time that influence the complex system. Three classes of mathematical models have been analyzed for the use in assessing the anthropogenic risk of complex dynamic systems. These models take into consideration time factor in determining the prospect of safety change of critical systems. The originality of the study is in the analysis of five time postulates in the theory of anthropogenic risk and the safety of highly important objects. It has to be stressed that the given postulates are still rarely used in practical assessment of equipment service life of critically important systems. That is why, the results of study presented in the article can be used in safety engineering and analysis of critically important complex technical systems.

  3. Cultural safety and the challenges of translating critically oriented knowledge in practice.

    PubMed

    Browne, Annette J; Varcoe, Colleen; Smye, Victoria; Reimer-Kirkham, Sheryl; Lynam, M Judith; Wong, Sabrina

    2009-07-01

    Cultural safety is a relatively new concept that has emerged in the New Zealand nursing context and is being taken up in various ways in Canadian health care discourses. Our research team has been exploring the relevance of cultural safety in the Canadian context, most recently in relation to a knowledge-translation study conducted with nurses practising in a large tertiary hospital. We were drawn to using cultural safety because we conceptualized it as being compatible with critical theoretical perspectives that foster a focus on power imbalances and inequitable social relationships in health care; the interrelated problems of culturalism and racialization; and a commitment to social justice as central to the social mandate of nursing. Engaging in this knowledge-translation study has provided new perspectives on the complexities, ambiguities and tensions that need to be considered when using the concept of cultural safety to draw attention to racialization, culturalism, and health and health care inequities. The philosophic analysis discussed in this paper represents an epistemological grounding for the concept of cultural safety that links directly to particular moral ends with social justice implications. Although cultural safety is a concept that we have firmly positioned within the paradigm of critical inquiry, ambiguities associated with the notions of 'culture', 'safety', and 'cultural safety' need to be anticipated and addressed if they are to be effectively used to draw attention to critical social justice issues in practice settings. Using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge, therefore, brings an added layer of complexity. To address these complexities, we propose that what may be required to effectively use cultural safety in the knowledge-translation process is a 'social justice curriculum for practice' that would foster a philosophical stance of critical inquiry at both the individual and institutional levels.

  4. Overview of Risk Mitigation for Safety-Critical Computer-Based Systems

    NASA Technical Reports Server (NTRS)

    Torres-Pomales, Wilfredo

    2015-01-01

    This report presents a high-level overview of a general strategy to mitigate the risks from threats to safety-critical computer-based systems. In this context, a safety threat is a process or phenomenon that can cause operational safety hazards in the form of computational system failures. This report is intended to provide insight into the safety-risk mitigation problem and the characteristics of potential solutions. The limitations of the general risk mitigation strategy are discussed and some options to overcome these limitations are provided. This work is part of an ongoing effort to enable well-founded assurance of safety-related properties of complex safety-critical computer-based aircraft systems by developing an effective capability to model and reason about the safety implications of system requirements and design.

  5. Aluminum Data Measurements and Evaluation for Criticality Safety Applications

    NASA Astrophysics Data System (ADS)

    Leal, L. C.; Guber, K. H.; Spencer, R. R.; Derrien, H.; Wright, R. Q.

    2002-12-01

    The Defense Nuclear Facility Safety Board (DNFSB) Recommendation 93-2 motivated the US Department of Energy (DOE) to develop a comprehensive criticality safety program to maintain and to predict the criticality of systems throughout the DOE complex. To implement the response to the DNFSB Recommendation 93-2, a Nuclear Criticality Safety Program (NCSP) was created including the following tasks: Critical Experiments, Criticality Benchmarks, Training, Analytical Methods, and Nuclear Data. The Nuclear Data portion of the NCSP consists of a variety of differential measurements performed at the Oak Ridge Electron Linear Accelerator (ORELA) at the Oak Ridge National Laboratory (ORNL), data analysis and evaluation using the generalized least-squares fitting code SAMMY in the resolved, unresolved, and high energy ranges, and the development and benchmark testing of complete evaluations for a nuclide for inclusion into the Evaluated Nuclear Data File (ENDF/B). This paper outlines the work performed at ORNL to measure, evaluate, and test the nuclear data for aluminum for applications in criticality safety problems.

  6. Nuclear Criticality Safety Data Book

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Hollenbach, D. F.

    The objective of this document is to support the revision of criticality safety process studies (CSPSs) for the Uranium Processing Facility (UPF) at the Y-12 National Security Complex (Y-12). This design analysis and calculation (DAC) document contains development and justification for generic inputs typically used in Nuclear Criticality Safety (NCS) DACs to model both normal and abnormal conditions of processes at UPF to support CSPSs. This will provide consistency between NCS DACs and efficiency in preparation and review of DACs, as frequently used data are provided in one reference source.

  7. Operating safely in surgery and critical care with perioperative automation.

    PubMed

    Grover, Christopher; Barney, Kate

    2004-01-01

    A study by the Institute of Medicine (IOM) found that as many as 98,000 Americans die each year from preventable medical errors. These findings, combined with a growing spate of negative publicity, have brought patient safety to its rightful place at the healthcare forefront. Nowhere are patient safety issues more critical than in the anesthesia, surgery and critical care environments. These high-acuity settings--with their fast pace, complex and rapidly changing care regimens and mountains of diverse clinical data-arguably pose the greatest patient safety risk in the hospital.

  8. Safety survey report EBR-II safety survey, ANL-west health protection, industrial safety and fire protection survey

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Dunbar, K.A.

    1972-01-10

    A safety survey covering the disciplines of Reactor Safety, Nuclear Criticality Safety, Health Protection and Industrial Safety and Fire Protection was conducted at the ANL-West EBR-II FEF Complex during the period January 10-18, 1972. In addition, the entire ANL-West site was surveyed for Health Protection and Industrial Safety and Fire Protection. The survey was conducted by members of the AEC Chicago Operations Office, a member of RDT-HQ and a member of the RDT-ID site office. Eighteen recommendations resulted from the survey, eleven in the area of Industrial Safety and Fire Protection, five in the area of Reactor Safety and twomore » in the area of Nuclear Criticality Safety.« less

  9. [Process design in high-reliability organizations].

    PubMed

    Sommer, K-J; Kranz, J; Steffens, J

    2014-05-01

    Modern medicine is a highly complex service industry in which individual care providers are linked in a complicated network. The complexity and interlinkedness is associated with risks concerning patient safety. Other highly complex industries like commercial aviation have succeeded in maintaining or even increasing its safety levels despite rapidly increasing passenger figures. Standard operating procedures (SOPs), crew resource management (CRM), as well as operational risk evaluation (ORE) are historically developed and trusted parts of a comprehensive and systemic safety program. If medicine wants to follow this quantum leap towards increased patient safety, it must intensively evaluate the results of other high-reliability industries and seek step-by-step implementation after a critical assessment.

  10. Analyzing Software Requirements Errors in Safety-Critical, Embedded Systems

    NASA Technical Reports Server (NTRS)

    Lutz, Robyn R.

    1993-01-01

    This paper analyzes the root causes of safety-related software errors in safety-critical, embedded systems. The results show that software errors identified as potentially hazardous to the system tend to be produced by different error mechanisms than non- safety-related software errors. Safety-related software errors are shown to arise most commonly from (1) discrepancies between the documented requirements specifications and the requirements needed for correct functioning of the system and (2) misunderstandings of the software's interface with the rest of the system. The paper uses these results to identify methods by which requirements errors can be prevented. The goal is to reduce safety-related software errors and to enhance the safety of complex, embedded systems.

  11. Principles and Benefits of Explicitly Designed Medical Device Safety Architecture.

    PubMed

    Larson, Brian R; Jones, Paul; Zhang, Yi; Hatcliff, John

    The complexity of medical devices and the processes by which they are developed pose considerable challenges to producing safe designs and regulatory submissions that are amenable to effective reviews. Designing an appropriate and clearly documented architecture can be an important step in addressing this complexity. Best practices in medical device design embrace the notion of a safety architecture organized around distinct operation and safety requirements. By explicitly separating many safety-related monitoring and mitigation functions from operational functionality, the aspects of a device most critical to safety can be localized into a smaller and simpler safety subsystem, thereby enabling easier verification and more effective reviews of claims that causes of hazardous situations are detected and handled properly. This article defines medical device safety architecture, describes its purpose and philosophy, and provides an example. Although many of the presented concepts may be familiar to those with experience in realization of safety-critical systems, this article aims to distill the essence of the approach and provide practical guidance that can potentially improve the quality of device designs and regulatory submissions.

  12. Validation and Verification of Future Integrated Safety-Critical Systems Operating under Off-Nominal Conditions

    NASA Technical Reports Server (NTRS)

    Belcastro, Christine M.

    2010-01-01

    Loss of control remains one of the largest contributors to aircraft fatal accidents worldwide. Aircraft loss-of-control accidents are highly complex in that they can result from numerous causal and contributing factors acting alone or (more often) in combination. Hence, there is no single intervention strategy to prevent these accidents and reducing them will require a holistic integrated intervention capability. Future onboard integrated system technologies developed for preventing loss of vehicle control accidents must be able to assure safe operation under the associated off-nominal conditions. The transition of these technologies into the commercial fleet will require their extensive validation and verification (V and V) and ultimate certification. The V and V of complex integrated systems poses major nontrivial technical challenges particularly for safety-critical operation under highly off-nominal conditions associated with aircraft loss-of-control events. This paper summarizes the V and V problem and presents a proposed process that could be applied to complex integrated safety-critical systems developed for preventing aircraft loss-of-control accidents. A summary of recent research accomplishments in this effort is also provided.

  13. Nuclear Data Activities in Support of the DOE Nuclear Criticality Safety Program

    NASA Astrophysics Data System (ADS)

    Westfall, R. M.; McKnight, R. D.

    2005-05-01

    The DOE Nuclear Criticality Safety Program (NCSP) provides the technical infrastructure maintenance for those technologies applied in the evaluation and performance of safe fissionable-material operations in the DOE complex. These technologies include an Analytical Methods element for neutron transport as well as the development of sensitivity/uncertainty methods, the performance of Critical Experiments, evaluation and qualification of experiments as Benchmarks, and a comprehensive Nuclear Data program coordinated by the NCSP Nuclear Data Advisory Group (NDAG). The NDAG gathers and evaluates differential and integral nuclear data, identifies deficiencies, and recommends priorities on meeting DOE criticality safety needs to the NCSP Criticality Safety Support Group (CSSG). Then the NDAG identifies the required resources and unique capabilities for meeting these needs, not only for performing measurements but also for data evaluation with nuclear model codes as well as for data processing for criticality safety applications. The NDAG coordinates effort with the leadership of the National Nuclear Data Center, the Cross Section Evaluation Working Group (CSEWG), and the Working Party on International Evaluation Cooperation (WPEC) of the OECD/NEA Nuclear Science Committee. The overall objective is to expedite the issuance of new data and methods to the DOE criticality safety user. This paper describes these activities in detail, with examples based upon special studies being performed in support of criticality safety for a variety of DOE operations.

  14. A performance improvement case study in aircraft maintenance and its implications for hazard identification.

    PubMed

    Ward, Marie; McDonald, Nick; Morrison, Rabea; Gaynor, Des; Nugent, Tony

    2010-02-01

    Aircraft maintenance is a highly regulated, safety critical, complex and competitive industry. There is a need to develop innovative solutions to address process efficiency without compromising safety and quality. This paper presents the case that in order to improve a highly complex system such as aircraft maintenance, it is necessary to develop a comprehensive and ecologically valid model of the operational system, which represents not just what is meant to happen, but what normally happens. This model then provides the backdrop against which to change or improve the system. A performance report, the Blocker Report, specific to aircraft maintenance and related to the model was developed gathering data on anything that 'blocks' task or check performance. A Blocker Resolution Process was designed to resolve blockers and improve the current check system. Significant results were obtained for the company in the first trial and implications for safety management systems and hazard identification are discussed. Statement of Relevance: Aircraft maintenance is a safety critical, complex, competitive industry with a need to develop innovative solutions to address process and safety efficiency. This research addresses this through the development of a comprehensive and ecologically valid model of the system linked with a performance reporting and resolution system.

  15. Brief history of patient safety culture and science.

    PubMed

    Ilan, Roy; Fowler, Robert

    2005-03-01

    The science of safety is well established in such disciplines as the automotive and aviation industry. In this brief history of safety science as it pertains to patient care, we review remote and recent publications that have guided the maturation of this field that has particular relevance to the complex structure of systems, personnel, and therapies involved in caring for the critically ill.

  16. Model Transformation for a System of Systems Dependability Safety Case

    NASA Technical Reports Server (NTRS)

    Murphy, Judy; Driskell, Stephen B.

    2010-01-01

    Software plays an increasingly larger role in all aspects of NASA's science missions. This has been extended to the identification, management and control of faults which affect safety-critical functions and by default, the overall success of the mission. Traditionally, the analysis of fault identification, management and control are hardware based. Due to the increasing complexity of system, there has been a corresponding increase in the complexity in fault management software. The NASA Independent Validation & Verification (IV&V) program is creating processes and procedures to identify, and incorporate safety-critical software requirements along with corresponding software faults so that potential hazards may be mitigated. This Specific to Generic ... A Case for Reuse paper describes the phases of a dependability and safety study which identifies a new, process to create a foundation for reusable assets. These assets support the identification and management of specific software faults and, their transformation from specific to generic software faults. This approach also has applications to other systems outside of the NASA environment. This paper addresses how a mission specific dependability and safety case is being transformed to a generic dependability and safety case which can be reused for any type of space mission with an emphasis on software fault conditions.

  17. Safety Metrics for Human-Computer Controlled Systems

    NASA Technical Reports Server (NTRS)

    Leveson, Nancy G; Hatanaka, Iwao

    2000-01-01

    The rapid growth of computer technology and innovation has played a significant role in the rise of computer automation of human tasks in modem production systems across all industries. Although the rationale for automation has been to eliminate "human error" or to relieve humans from manual repetitive tasks, various computer-related hazards and accidents have emerged as a direct result of increased system complexity attributed to computer automation. The risk assessment techniques utilized for electromechanical systems are not suitable for today's software-intensive systems or complex human-computer controlled systems.This thesis will propose a new systemic model-based framework for analyzing risk in safety-critical systems where both computers and humans are controlling safety-critical functions. A new systems accident model will be developed based upon modem systems theory and human cognitive processes to better characterize system accidents, the role of human operators, and the influence of software in its direct control of significant system functions Better risk assessments will then be achievable through the application of this new framework to complex human-computer controlled systems.

  18. [Risk management in anesthesia and critical care medicine].

    PubMed

    Eisold, C; Heller, A R

    2017-03-01

    Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. As a result, we do not always fully perceive the risks involved in our daily activity. A survey performed in Swiss hospitals identified a total of 169 hot spots which endanger patient safety. It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.

  19. Critical Incident Stress Management (CISM) in complex systems: cultural adaptation and safety impacts in healthcare.

    PubMed

    Müller-Leonhardt, Alice; Mitchell, Shannon G; Vogt, Joachim; Schürmann, Tim

    2014-07-01

    In complex systems, such as hospitals or air traffic control operations, critical incidents (CIs) are unavoidable. These incidents can not only become critical for victims but also for professionals working at the "sharp end" who may have to deal with critical incident stress (CIS) reactions that may be severe and impede emotional, physical, cognitive and social functioning. These CIS reactions may occur not only under exceptional conditions but also during every-day work and become an important safety issue. In contrast to air traffic management (ATM) operations in Europe, which have readily adopted critical incident stress management (CISM), most hospitals have not yet implemented comprehensive peer support programs. This survey was conducted in 2010 at the only European general hospital setting which implemented CISM program since 2004. The aim of the article is to describe possible contribution of CISM in hospital settings framed from the perspective of organizational safety and individual health for healthcare professionals. Findings affirm that daily work related incidents also can become critical for healthcare professionals. Program efficiency appears to be influenced by the professional culture, as well as organizational structure and policies. Overall, findings demonstrate that the adaptation of the CISM program in general hospitals takes time but, once established, it may serve as a mechanism for changing professional culture, thereby permitting the framing of even small incidents or near misses as an opportunity to provide valuable feedback to the system. Copyright © 2014 Elsevier Ltd. All rights reserved.

  20. System Guidelines for EMC Safety-Critical Circuits: Design, Selection, and Margin Demonstration

    NASA Technical Reports Server (NTRS)

    Lawton, R. M.

    1996-01-01

    Demonstration of required safety margins on critical electrical/electronic circuits in large complex systems has become an implementation and cost problem. These margins are the difference between the activation level of the circuit and the electrical noise on the circuit in the actual operating environment. This document discusses the origin of the requirement and gives a detailed process flow for the identification of the system electromagnetic compatibility (EMC) critical circuit list. The process flow discusses the roles of engineering disciplines such as systems engineering, safety, and EMC. Design and analysis guidelines are provided to assist the designer in assuring the system design has a high probability of meeting the margin requirements. Examples of approaches used on actual programs (Skylab and Space Shuttle Solid Rocket Booster) are provided to show how variations of the approach can be used successfully.

  1. A Possible Approach for Addressing Neglected Human Factors Issues of Systems Engineering

    NASA Technical Reports Server (NTRS)

    Johnson, Christopher W.; Holloway, C. Michael

    2011-01-01

    The increasing complexity of safety-critical applications has led to the introduction of decision support tools in the transportation and process industries. Automation has also been introduced to support operator intervention in safety-critical applications. These innovations help reduce overall operator workload, and filter application data to maximize the finite cognitive and perceptual resources of system operators. However, these benefits do not come without a cost. Increased computational support for the end-users of safety-critical applications leads to increased reliance on engineers to monitor and maintain automated systems and decision support tools. This paper argues that by focussing on the end-users of complex applications, previous research has tended to neglect the demands that are being placed on systems engineers. The argument is illustrated through discussing three recent accidents. The paper concludes by presenting a possible strategy for building and using highly automated systems based on increased attention by management and regulators, improvements in competency and training for technical staff, sustained support for engineering team resource management, and the development of incident reporting systems for infrastructure failures. This paper represents preliminary work, about which we seek comments and suggestions.

  2. TA 55 Reinvestment Project II Phase C Update Project Status May 23, 2017

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Giordano, Anthony P.

    The TA-55 Reinvestment Project (TRP) II Phase C is a critical infrastructure project focused on improving safety and reliability of the Los Alamos National Laboratory (LANL) TA-55 Complex. The Project recapitalizes and revitalizes aging and obsolete facility and safety systems providing a sustainable nuclear facility for National Security Missions.

  3. Bayesian Statistics and Uncertainty Quantification for Safety Boundary Analysis in Complex Systems

    NASA Technical Reports Server (NTRS)

    He, Yuning; Davies, Misty Dawn

    2014-01-01

    The analysis of a safety-critical system often requires detailed knowledge of safe regions and their highdimensional non-linear boundaries. We present a statistical approach to iteratively detect and characterize the boundaries, which are provided as parameterized shape candidates. Using methods from uncertainty quantification and active learning, we incrementally construct a statistical model from only few simulation runs and obtain statistically sound estimates of the shape parameters for safety boundaries.

  4. Some Challenges in the Design of Human-Automation Interaction for Safety-Critical Systems

    NASA Technical Reports Server (NTRS)

    Feary, Michael S.; Roth, Emilie

    2014-01-01

    Increasing amounts of automation are being introduced to safety-critical domains. While the introduction of automation has led to an overall increase in reliability and improved safety, it has also introduced a class of failure modes, and new challenges in risk assessment for the new systems, particularly in the assessment of rare events resulting from complex inter-related factors. Designing successful human-automation systems is challenging, and the challenges go beyond good interface development (e.g., Roth, Malin, & Schreckenghost 1997; Christoffersen & Woods, 2002). Human-automation design is particularly challenging when the underlying automation technology generates behavior that is difficult for the user to anticipate or understand. These challenges have been recognized in several safety-critical domains, and have resulted in increased efforts to develop training, procedures, regulations and guidance material (CAST, 2008, IAEA, 2001, FAA, 2013, ICAO, 2012). This paper points to the continuing need for new methods to describe and characterize the operational environment within which new automation concepts are being presented. We will describe challenges to the successful development and evaluation of human-automation systems in safety-critical domains, and describe some approaches that could be used to address these challenges. We will draw from experience with the aviation, spaceflight and nuclear power domains.

  5. Verification and Validation for Flight-Critical Systems (VVFCS)

    NASA Technical Reports Server (NTRS)

    Graves, Sharon S.; Jacobsen, Robert A.

    2010-01-01

    On March 31, 2009 a Request for Information (RFI) was issued by NASA s Aviation Safety Program to gather input on the subject of Verification and Validation (V & V) of Flight-Critical Systems. The responses were provided to NASA on or before April 24, 2009. The RFI asked for comments in three topic areas: Modeling and Validation of New Concepts for Vehicles and Operations; Verification of Complex Integrated and Distributed Systems; and Software Safety Assurance. There were a total of 34 responses to the RFI, representing a cross-section of academic (26%), small & large industry (47%) and government agency (27%).

  6. Safety Critical Mechanisms

    NASA Technical Reports Server (NTRS)

    Robertson, Brandan

    2008-01-01

    Spaceflight mechanisms have a reputation for being difficult to develop and operate successfully. This reputation is well earned. Many circumstances conspire to make this so: the environments in which the mechanisms are used are extremely severe, there is usually limited or no maintenance opportunity available during operation due to this environment, the environments are difficult to replicate accurately on the ground, the expense of the mechanism development makes it impractical to build and test many units for long periods of time before use, mechanisms tend to be highly specialized and not prone to interchangeability or off-the-shelf use, they can generate and store a lot of energy, and the nature of mechanisms themselves, as a combination of structures, electronics, etc. designed to accomplish specific dynamic performance, makes them very complex and subject to many unpredictable interactions of many types. In addition to their complexities, mechanism are often counted upon to provide critical vehicle functions that can result in catastrophic events should the functions not be performed. It is for this reason that mechanisms are frequently subjected to special scrutiny in safety processes. However, a failure tolerant approach, along with good design and development practices and detailed design reviews, can be developed to allow such notoriously troublesome mechanisms to be utilized confidently in safety-critical applications.

  7. Distracted Driving and Associated Crash Risks : Research Project Capsule

    DOT National Transportation Integrated Search

    2012-10-01

    Factors aff ecting the : cognitive tasks : associated with : driving are becoming : increasingly critical to : the overall roadway : safety performance. : Therefore, more research is needed in order to understand the complexity and : impact of distra...

  8. Creation of the Naturalistic Engagement in Secondary Tasks (NEST) distracted driving dataset.

    PubMed

    Owens, Justin M; Angell, Linda; Hankey, Jonathan M; Foley, James; Ebe, Kazutoshi

    2015-09-01

    Distracted driving has become a topic of critical importance to driving safety research over the past several decades. Naturalistic driving data offer a unique opportunity to study how drivers engage with secondary tasks in real-world driving; however, the complexities involved with identifying and coding relevant epochs of naturalistic data have limited its accessibility to the general research community. This project was developed to help address this problem by creating an accessible dataset of driver behavior and situational factors observed during distraction-related safety-critical events and baseline driving epochs, using the Strategic Highway Research Program 2 (SHRP2) naturalistic dataset. The new NEST (Naturalistic Engagement in Secondary Tasks) dataset was created using crashes and near-crashes from the SHRP2 dataset that were identified as including secondary task engagement as a potential contributing factor. Data coding included frame-by-frame video analysis of secondary task and hands-on-wheel activity, as well as summary event information. In addition, information about each secondary task engagement within the trip prior to the crash/near-crash was coded at a higher level. Data were also coded for four baseline epochs and trips per safety-critical event. 1,180 events and baseline epochs were coded, and a dataset was constructed. The project team is currently working to determine the most useful way to allow broad public access to the dataset. We anticipate that the NEST dataset will be extraordinarily useful in allowing qualified researchers access to timely, real-world data concerning how drivers interact with secondary tasks during safety-critical events and baseline driving. The coded dataset developed for this project will allow future researchers to have access to detailed data on driver secondary task engagement in the real world. It will be useful for standalone research, as well as for integration with additional SHRP2 data to enable the conduct of more complex research. Copyright © 2015 Elsevier Ltd and National Safety Council. All rights reserved.

  9. Problems and pitfalls in cardiac drug therapy.

    PubMed

    Stone, S M; Rai, N; Nei, J

    2001-01-01

    Medical errors in the care of patients may account for 44,000 to 98,000 deaths per year, and 7,000 deaths per year are attributed to medication errors alone. Increasing awareness among health care providers of potential errors is a critical step toward improving the safety of medical care. Because today's medications are increasingly complex, approved at an accelerated rate, and often have a narrow therapeutic window with only a small margin of safety, patient and provider education is critical in assuring optimal therapeutic outcomes. Providers can use electronic resources such as Web sites to keep informed on drug-drug, drug-food, and drug-nutritional supplements interactions.

  10. Threats to safety during sedation outside of the operating room and the death of Michael Jackson.

    PubMed

    Webster, Craig S; Mason, Keira P; Shafer, Steven L

    2016-03-01

    From an understanding of human psychology and the reliability of high-technology systems, this review considers critical threats to the safety of patients undergoing sedation outside of the operating room, and will stratify these threats along what we define as the 'Patient Risk Continuum'. We then consider interventions suitable for addressing identified risks. The technology, organization and delivery of healthcare continue to become more complex, highlighting the importance of maintaining the safety of patients. Sedation outside of the operating room is known to be associated with higher rates of adverse events. However, a number of recent safety initiatives have shown benefit in improving patient safety. The following threats to patients undergoing sedation, in increasing order of risk, are discussed: equipment and environmental factors, known patient risks, poor team performance, combinatorial problems and egregious violations. To address these threats, we discuss a number of approaches consistent with the systems approach to safety, namely: encouraging functions, forcing functions, cognitive safety nets, information sharing, recovery strategies and regulatory change. Demonstrating improvement with any safety initiative relies critically on quality data collected on the problem area in question.

  11. DOE Office of Scientific and Technical Information (OSTI.GOV)

    Eltoweissy, Mohamed Y.; Du, David H.C.; Gerla, Mario

    Mission-Critical Networking (MCN) refers to networking for application domains where life or livelihood may be at risk. Typical application domains for MCN include critical infrastructure protection and operation, emergency and crisis intervention, healthcare services, and military operations. Such networking is essential for safety, security and economic vitality in our complex world characterized by uncertainty, heterogeneity, emergent behaviors, and the need for reliable and timely response. MCN comprise networking technology, infrastructures and services that may alleviate the risk and directly enable and enhance connectivity for mission-critical information exchange among diverse, widely dispersed, mobile users.

  12. Validation and Verification (V&V) of Safety-Critical Systems Operating Under Off-Nominal Conditions

    NASA Technical Reports Server (NTRS)

    Belcastro, Christine M.

    2012-01-01

    Loss of control (LOC) remains one of the largest contributors to aircraft fatal accidents worldwide. Aircraft LOC accidents are highly complex in that they can result from numerous causal and contributing factors acting alone or more often in combination. Hence, there is no single intervention strategy to prevent these accidents. Research is underway at the National Aeronautics and Space Administration (NASA) in the development of advanced onboard system technologies for preventing or recovering from loss of vehicle control and for assuring safe operation under off-nominal conditions associated with aircraft LOC accidents. The transition of these technologies into the commercial fleet will require their extensive validation and verification (V&V) and ultimate certification. The V&V of complex integrated systems poses highly significant technical challenges and is the subject of a parallel research effort at NASA. This chapter summarizes the V&V problem and presents a proposed process that could be applied to complex integrated safety-critical systems developed for preventing aircraft LOC accidents. A summary of recent research accomplishments in this effort is referenced.

  13. A Model-based Framework for Risk Assessment in Human-Computer Controlled Systems

    NASA Technical Reports Server (NTRS)

    Hatanaka, Iwao

    2000-01-01

    The rapid growth of computer technology and innovation has played a significant role in the rise of computer automation of human tasks in modem production systems across all industries. Although the rationale for automation has been to eliminate "human error" or to relieve humans from manual repetitive tasks, various computer-related hazards and accidents have emerged as a direct result of increased system complexity attributed to computer automation. The risk assessment techniques utilized for electromechanical systems are not suitable for today's software-intensive systems or complex human-computer controlled systems. This thesis will propose a new systemic model-based framework for analyzing risk in safety-critical systems where both computers and humans are controlling safety-critical functions. A new systems accident model will be developed based upon modem systems theory and human cognitive processes to better characterize system accidents, the role of human operators, and the influence of software in its direct control of significant system functions. Better risk assessments will then be achievable through the application of this new framework to complex human-computer controlled systems.

  14. Understanding Risk Tolerance and Building an Effective Safety Culture

    NASA Technical Reports Server (NTRS)

    Loyd, David

    2018-01-01

    Estimates range from 65-90 percent of catastrophic mishaps are due to human error. NASA's human factors-related mishaps causes are estimated at approximately 75 percent. As much as we'd like to error-proof our work environment, even the most automated and complex technical endeavors require human interaction... and are vulnerable to human frailty. Industry and government are focusing not only on human factors integration into hazardous work environments, but also looking for practical approaches to cultivating a strong Safety Culture that diminishes risk. Industry and government organizations have recognized the value of monitoring leading indicators to identify potential risk vulnerabilities. NASA has adapted this approach to assess risk controls associated with hazardous, critical, and complex facilities. NASA's facility risk assessments integrate commercial loss control, OSHA (Occupational Safety and Health Administration) Process Safety, API (American Petroleum Institute) Performance Indicator Standard, and NASA Operational Readiness Inspection concepts to identify risk control vulnerabilities.

  15. Reliability/safety analysis of a fly-by-wire system

    NASA Technical Reports Server (NTRS)

    Brock, L. D.; Goddman, H. A.

    1980-01-01

    An analysis technique has been developed to estimate the reliability of a very complex, safety-critical system by constructing a diagram of the reliability equations for the total system. This diagram has many of the characteristics of a fault-tree or success-path diagram, but is much easier to construct for complex redundant systems. The diagram provides insight into system failure characteristics and identifies the most likely failure modes. A computer program aids in the construction of the diagram and the computation of reliability. Analysis of the NASA F-8 Digital Fly-by-Wire Flight Control System is used to illustrate the technique.

  16. Deriving Safety Cases from Machine-Generated Proofs

    NASA Technical Reports Server (NTRS)

    Basir, Nurlida; Fischer, Bernd; Denney, Ewen

    2009-01-01

    Proofs provide detailed justification for the validity of claims and are widely used in formal software development methods. However, they are often complex and difficult to understand, because they use machine-oriented formalisms; they may also be based on assumptions that are not justified. This causes concerns about the trustworthiness of using formal proofs as arguments in safety-critical applications. Here, we present an approach to develop safety cases that correspond to formal proofs found by automated theorem provers and reveal the underlying argumentation structure and top-level assumptions. We concentrate on natural deduction proofs and show how to construct the safety cases by covering the proof tree with corresponding safety case fragments.

  17. Modernization at the Y-12 National Security Complex: A Case for Additional Experimental Benchmarks

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Thornbury, M. L.; Juarez, C.; Krass, A. W.

    Efforts are underway at the Y-12 National Security Complex (Y-12) to modernize the recovery, purification, and consolidation of un-irradiated, highly enriched uranium metal. Successful integration of advanced technology such as Electrorefining (ER) eliminates many of the intermediate chemistry systems and processes that are the current and historical basis of the nuclear fuel cycle at Y-12. The cost of operations, the inventory of hazardous chemicals, and the volume of waste are significantly reduced by ER. It also introduces unique material forms and compositions related to the chemistry of chloride salts for further consideration in safety analysis and engineering. The work hereinmore » briefly describes recent investigations of nuclear criticality for 235UO2Cl2 (uranyl chloride) and 6LiCl (lithium chloride) in aqueous solution. Of particular interest is the minimum critical mass of highly enriched uranium as a function of the molar ratio of 6Li to 235U. The work herein also briefly describes recent investigations of nuclear criticality for 235U metal reflected by salt mixtures of 6LiCl or 7LiCl (lithium chloride), KCl (potassium chloride), and 235UCl3 or 238UCl3 (uranium tri-chloride). Computational methods for analysis of nuclear criticality safety and published nuclear data are employed in the absence of directly relevant experimental criticality benchmarks.« less

  18. Critical issues in sensor science to aid food and water safety.

    PubMed

    Farahi, R H; Passian, A; Tetard, L; Thundat, T

    2012-06-26

    The stability of food and water supplies is widely recognized as a global issue of fundamental importance. Sensor development for food and water safety by nonconventional assays continues to overcome technological challenges. The delicate balance between attaining adequate limits of detection, chemical fingerprinting of the target species, dealing with the complex food matrix, and operating in difficult environments are still the focus of current efforts. While the traditional pursuit of robust recognition methods remains important, emerging engineered nanomaterials and nanotechnology promise better sensor performance but also bring about new challenges. Both advanced receptor-based sensors and emerging non-receptor-based physical sensors are evaluated for their critical challenges toward out-of-laboratory applications.

  19. A new technology perspective and engineering tools approach for large, complex and distributed mission and safety critical systems components

    NASA Technical Reports Server (NTRS)

    Carrio, Miguel A., Jr.

    1988-01-01

    Rapidly emerging technology and methodologies have out-paced the systems development processes' ability to use them effectively, if at all. At the same time, the tools used to build systems are becoming obsolescent themselves as a consequence of the same technology lag that plagues systems development. The net result is that systems development activities have not been able to take advantage of available technology and have become equally dependent on aging and ineffective computer-aided engineering tools. New methods and tools approaches are essential if the demands of non-stop and Mission and Safety Critical (MASC) components are to be met.

  20. Review of battery powered embedded systems design for mission-critical low-power applications

    NASA Astrophysics Data System (ADS)

    Malewski, Matthew; Cowell, David M. J.; Freear, Steven

    2018-06-01

    The applications and uses of embedded systems is increasingly pervasive. Mission and safety critical systems relying on embedded systems pose specific challenges. Embedded systems is a multi-disciplinary domain, involving both hardware and software. Systems need to be designed in a holistic manner so that they are able to provide the desired reliability and minimise unnecessary complexity. The large problem landscape means that there is no one solution that fits all applications of embedded systems. With the primary focus of these mission and safety critical systems being functionality and reliability, there can be conflicts with business needs, and this can introduce pressures to reduce cost at the expense of reliability and functionality. This paper examines the challenges faced by battery powered systems, and then explores at more general problems, and several real-world embedded systems.

  1. Definition and Measurement of Complexity in the Context of Safety Assurance

    DTIC Science & Technology

    2016-11-01

    design for each sys- tem and on a larger design from a NASA report. The complexity measurement must be matched to available review time to determine...ARP4754A to Flight Critical Systems.” NASA , 2015. http://ntrs.nasa.gov/search.jsp?R=20160001634 [Rayner 2016] Rayner, Keith; Schotter, Elizabeth R...systems. We tested it on a second design for each system and on a larger design from a NASA report. The complexity measurement must be matched to

  2. Application of SAE ARP4754A to Flight Critical Systems

    NASA Technical Reports Server (NTRS)

    Peterson, Eric M.

    2015-01-01

    This report documents applications of ARP4754A to the development of modern computer-based (i.e., digital electronics, software and network-based) aircraft systems. This study is to offer insight and provide educational value relative to the guidelines in ARP4754A and provide an assessment of the current state-of-the- practice within industry and regulatory bodies relative to development assurance for complex and safety-critical computer-based aircraft systems.

  3. Napping during breaks on night shift: critical care nurse managers' perceptions.

    PubMed

    Edwards, Marie P; McMillan, Diana E; Fallis, Wendy M

    2013-01-01

    Fatigue associated with shiftwork can threaten the safety and health of nurses and the patients in their care. Napping during night shift breaks has been shown to be an effective strategy to decrease fatigue and enhance performance in a variety of work environments, but appears to have mixed support within health care. The purpose of this study was to explore critical care unit managers'perceptions of and experiences with their nursing staff's napping practices on night shift, including their perceptions of the benefits and barriers to napping/not napping in terms of patient safety and nurses'personal health and safety. A survey design was used. Forty-seven Canadian critical care unit managers who were members of the Canadian Association of Critical Care Nurses responded to the web-based survey. Data analysis involved calculation of frequencies and percentages for demographic data, use of the Friedman rank test for comparison of managers' perceptions, and content analysis for responses to open-ended questions. The findings of this study offer valuable insights into the complexities and conflicts perceived by managers with respect to napping on night shift breaks by nursing staff Staff and patient health and safety issues, work and break expectations and experiences, and strengths and deficits related to organizational napping resources and policy are considerations that will be instrumental in the development of effective napping strategies and guidelines.

  4. The road ahead: comprehensive and innovative approaches for improving safety and preventing child maltreatment fatalities.

    PubMed

    Chahine, Zeinab; Sanders, David

    2013-01-01

    This article presents a high-level overview of the complex issues, opportunities, and challenges involved in improving child safety and preventing child maltreatment fatalities. It emphasizes that improving measurement and classification is critical to understanding and preventing child maltreatment fatalities. It also stresses the need to reframe child maltreatment interventions from a public health perspective. The article draws on the lessons learned from state-of-the-art safety engineering innovations, research, and other expert recommendations presented in this special issue that can inform future policy and practice direction in this important area.

  5. Future Data Communication Architectures for Safety Critical Aircraft Cabin Systems

    NASA Astrophysics Data System (ADS)

    Berkhahn, Sven-Olaf

    2012-05-01

    The cabin of modern aircraft is subject to increasing demands for fast reconfiguration and hence flexibility. These demands require studies for new network architectures and technologies of the electronic cabin systems, which consider also weight and cost reductions as well as safety constraints. Two major approaches are in consideration to reduce the complex and heavy wiring harness: the usage of a so called hybrid data bus technology, which enables the common usage of the same data bus for several electronic cabin systems with different safety and security requirements and the application of wireless data transfer technologies for electronic cabin systems.

  6. Reductions in invasive device use and care costs after institution of a daily safety checklist in a pediatric critical care unit.

    PubMed

    Tarrago, Rod; Nowak, Jeffrey E; Leonard, Christopher S; Payne, Nathaniel R

    2014-06-01

    In the critical care unit, complexity of care can contribute to both medical errors and increased costs, particularly when clinicians are forced to rely on memory. Checklists can be used to improve safety and reduce cost. A number of omission-related adverse events in 2010 prompted the development of a checklist to reduce the possibility of similar future events. The PICU Safety Checklist was implemented in the pediatric ICU (PICU) at Children's Hospitals and Clinics of Minnesota. During a 21-month period, the checklist was used to prompt the care team to address quality and safety items during rounds. The initial checklist was paper, with two subsequent versions being incorporated into the electronic medical record (EMR). The daily safety checklist was successfully implemented in the PICU. Work-flow improvements based on regular multidisciplinary feedback led to more consistent use of the checklist. Improvements on all quality and safety metrics were identified, including invasive device use, medication costs, antibiotic and laboratory test use, and compliance with standards of care. Staff satisfaction rates were > 80% for safety, communication, and collaboration. By using a daily safety checklist in the pediatric critical care unit, we improved quality and safety, as well as the collaborative culture among all clinicians. Incorporating the checklist into the EMR improved compliance and accountability, ensuring its application to all patients. Clinicians now often individually address many checklist items outside the formal rounding process, indicating that the checklist content has become part of their usual practice. A successful implementation showing tangible clinical improvements can lead to interest and adoption in other clinical areas within the institution.

  7. An Improved Method to Control the Critical Parameters of a Multivariable Control System

    NASA Astrophysics Data System (ADS)

    Subha Hency Jims, P.; Dharmalingam, S.; Wessley, G. Jims John

    2017-10-01

    The role of control systems is to cope with the process deficiencies and the undesirable effect of the external disturbances. Most of the multivariable processes are highly iterative and complex in nature. Aircraft systems, Modern Power Plants, Refineries, Robotic systems are few such complex systems that involve numerous critical parameters that need to be monitored and controlled. Control of these important parameters is not only tedious and cumbersome but also is crucial from environmental, safety and quality perspective. In this paper, one such multivariable system, namely, a utility boiler has been considered. A modern power plant is a complex arrangement of pipework and machineries with numerous interacting control loops and support systems. In this paper, the calculation of controller parameters based on classical tuning concepts has been presented. The controller parameters thus obtained and employed has controlled the critical parameters of a boiler during fuel switching disturbances. The proposed method can be applied to control the critical parameters like elevator, aileron, rudder, elevator trim rudder and aileron trim, flap control systems of aircraft systems.

  8. New health and safety initiatives at the Department of Energy (DOE)

    NASA Technical Reports Server (NTRS)

    Ziemer, Paul L.

    1993-01-01

    This document touches on some of the more important lessons learned and the more noteworthy initiatives DOE has put into motion in the last three years to protect the health and safety of our contractor employees. What we have learned in the process should come as no surprise to those of you who have been working in the field: (1) that management commitment to safety and health is critical to a successful program; (2) that meaningful employee participation in all aspects of the program enhances its effectiveness at every level; and (3) that the dedication and expertise of medical and occupational safety and health professionals are needed if the challenging problems presented by the complex and technologically advanced environment at DOE facilities are to be overcome. I believe that we have made a good beginning in the long and arduous task of building an Occupational Safety and Health Program that will serve as a model for others, and I can assure you that we intend to continue our efforts to protect every worker within the complex from occupational injury and disease.

  9. Model-based safety analysis of human-robot interactions: the MIRAS walking assistance robot.

    PubMed

    Guiochet, Jérémie; Hoang, Quynh Anh Do; Kaaniche, Mohamed; Powell, David

    2013-06-01

    Robotic systems have to cope with various execution environments while guaranteeing safety, and in particular when they interact with humans during rehabilitation tasks. These systems are often critical since their failure can lead to human injury or even death. However, such systems are difficult to validate due to their high complexity and the fact that they operate within complex, variable and uncertain environments (including users), in which it is difficult to foresee all possible system behaviors. Because of the complexity of human-robot interactions, rigorous and systematic approaches are needed to assist the developers in the identification of significant threats and the implementation of efficient protection mechanisms, and in the elaboration of a sound argumentation to justify the level of safety that can be achieved by the system. For threat identification, we propose a method called HAZOP-UML based on a risk analysis technique adapted to system description models, focusing on human-robot interaction models. The output of this step is then injected in a structured safety argumentation using the GSN graphical notation. Those approaches have been successfully applied to the development of a walking assistant robot which is now in clinical validation.

  10. Data systems and computer science: Software Engineering Program

    NASA Technical Reports Server (NTRS)

    Zygielbaum, Arthur I.

    1991-01-01

    An external review of the Integrated Technology Plan for the Civil Space Program is presented. This review is specifically concerned with the Software Engineering Program. The goals of the Software Engineering Program are as follows: (1) improve NASA's ability to manage development, operation, and maintenance of complex software systems; (2) decrease NASA's cost and risk in engineering complex software systems; and (3) provide technology to assure safety and reliability of software in mission critical applications.

  11. A Toolset for Supporting Iterative Human Automation: Interaction in Design

    NASA Technical Reports Server (NTRS)

    Feary, Michael S.

    2010-01-01

    The addition of automation has greatly extended humans' capability to accomplish tasks, including those that are difficult, complex and safety critical. The majority of Human - Automation Interacton (HAl) results in more efficient and safe operations, ho,,:,ever ertain unpected atomatlon behaviors or "automation surprises" can be frustrating and, In certain safety critical operations (e.g. transporttion, manufacturing control, medicine), may result in injuries or. the loss of life.. (Mellor, 1994; Leveson, 1995; FAA, 1995; BASI, 1998; Sheridan, 2002). This papr describes he development of a design tool that enables on the rapid development and evaluation. of automaton prototypes. The ultimate goal of the work is to provide a design platform upon which automation surprise vulnerability analyses can be integrated.

  12. Complexity analysis of the Next Gen Air Traffic Management System: trajectory based operations.

    PubMed

    Lyons, Rhonda

    2012-01-01

    According to Federal Aviation Administration traffic predictions currently our Air Traffic Management (ATM) system is operating at 150 percent capacity; forecasting that within the next two decades, the traffic with increase to a staggering 250 percent [17]. This will require a major redesign of our system. Today's ATM system is complex. It is designed to safely, economically, and efficiently provide air traffic services through the cost-effective provision of facilities and seamless services in collaboration with multiple agents however, contrary the vision, the system is loosely integrated and is suffering tremendously from antiquated equipment and saturated airways. The new Next Generation (Next Gen) ATM system is designed to transform the current system into an agile, robust and responsive set of operations that are designed to safely manage the growing needs of the projected increasingly complex, diverse set of air transportation system users and massive projected worldwide traffic rates. This new revolutionary technology-centric system is dynamically complex and is much more sophisticated than it's soon to be predecessor. ATM system failures could yield large scale catastrophic consequences as it is a safety critical system. This work will attempt to describe complexity and the complex nature of the NextGen ATM system and Trajectory Based Operational. Complex human factors interactions within Next Gen will be analyzed using a proposed dual experimental approach designed to identify hazards, gaps and elicit emergent hazards that would not be visible if conducted in isolation. Suggestions will be made along with a proposal for future human factors research in the TBO safety critical Next Gen environment.

  13. Nuclear criticality safety: 5-day training course

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Schlesser, J.A.

    1992-11-01

    This compilation of notes is presented as a source reference for the criticality safety course. It represents the contributions of many people, particularly Tom McLaughlin, the course's primary instructor. At the completion of this training course, the attendee will: be able to define terms commonly used in nuclear criticality safety; be able to appreciate the fundamentals of nuclear criticality safety; be able to identify factors which affect nuclear criticality safety; be able to identify examples of criticality controls as used at Los Alamos; be able to identify examples of circumstances present during criticality accidents; be able to identify examples ofmore » computer codes used by the nuclear criticality safety specialist; be able to identify examples of safety consciousness required in nuclear criticality safety.« less

  14. Qualitative Future Safety Risk Identification an Update

    NASA Technical Reports Server (NTRS)

    Barr, Lawrence C.

    2017-01-01

    The purpose of this report is to document the results of a high-level qualitative study that was conducted to identify future aviation safety risks and to assess the potential impacts to the National Airspace System (NAS) of NASA Aviation Safety research on these risks. Multiple external sources (for example, the National Transportation Safety Board, the Flight Safety Foundation, the National Research Council, and the Joint Planning and Development Office) were used to develop a compilation of future safety issues risks, also referred to as future tall poles. The primary criterion used to identify the most critical future safety risk issues was that the issue must be cited in several of these sources as a safety area of concern. The tall poles in future safety risk, in no particular order of importance, are as follows: Runway Safety, Loss of Control In Flight, Icing Ice Detection, Loss of Separation, Near Midair Collision Human Fatigue, Increasing Complexity and Reliance on Automation, Vulnerability Discovery, Data Sharing and Dissemination, and Enhanced Survivability in the Event of an Accident.

  15. 2011 Annual Criticality Safety Program Performance Summary

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Andrea Hoffman

    The 2011 review of the INL Criticality Safety Program has determined that the program is robust and effective. The review was prepared for, and fulfills Contract Data Requirements List (CDRL) item H.20, 'Annual Criticality Safety Program performance summary that includes the status of assessments, issues, corrective actions, infractions, requirements management, training, and programmatic support.' This performance summary addresses the status of these important elements of the INL Criticality Safety Program. Assessments - Assessments in 2011 were planned and scheduled. The scheduled assessments included a Criticality Safety Program Effectiveness Review, Criticality Control Area Inspections, a Protection of Controlled Unclassified Information Inspection,more » an Assessment of Criticality Safety SQA, and this management assessment of the Criticality Safety Program. All of the assessments were completed with the exception of the 'Effectiveness Review' for SSPSF, which was delayed due to emerging work. Although minor issues were identified in the assessments, no issues or combination of issues indicated that the INL Criticality Safety Program was ineffective. The identification of issues demonstrates the importance of an assessment program to the overall health and effectiveness of the INL Criticality Safety Program. Issues and Corrective Actions - There are relatively few criticality safety related issues in the Laboratory ICAMS system. Most were identified by Criticality Safety Program assessments. No issues indicate ineffectiveness in the INL Criticality Safety Program. All of the issues are being worked and there are no imminent criticality concerns. Infractions - There was one criticality safety related violation in 2011. On January 18, 2011, it was discovered that a fuel plate bundle in the Nuclear Materials Inspection and Storage (NMIS) facility exceeded the fissionable mass limit, resulting in a technical safety requirement (TSR) violation. The TSR limits fuel plate bundles to 1085 grams U-235, which is the maximum loading of an ATR fuel element. The overloaded fuel plate bundle contained 1097 grams U-235 and was assembled under an 1100 gram U-235 limit in 1982. In 2003, the limit was reduced to 1085 grams citing a new criticality safety evaluation for ATR fuel elements. The fuel plate bundle inventories were not checked for compliance prior to implementing the reduced limit. A subsequent review of the NMIS inventory did not identify further violations. Requirements Management - The INL Criticality Safety program is organized and well documented. The source requirements for the INL Criticality Safety Program are from 10 CFR 830.204, DOE Order 420.1B, Chapter III, 'Nuclear Criticality Safety,' ANSI/ANS 8-series Industry Standards, and DOE Standards. These source requirements are documented in LRD-18001, 'INL Criticality Safety Program Requirements Manual.' The majority of the criticality safety source requirements are contained in DOE Order 420.1B because it invokes all of the ANSI/ANS 8-Series Standards. DOE Order 420.1B also invokes several DOE Standards, including DOE-STD-3007, 'Guidelines for Preparing Criticality Safety Evaluations at Department of Energy Non-Reactor Nuclear Facilities.' DOE Order 420.1B contains requirements for DOE 'Heads of Field Elements' to approve the criticality safety program and specific elements of the program, namely, the qualification of criticality staff and the method for preparing criticality safety evaluations. This was accomplished by the approval of SAR-400, 'INL Standardized Nuclear Safety Basis Manual,' Chapter 6, 'Prevention of Inadvertent Criticality.' Chapter 6 of SAR-400 contains sufficient detail and/or reference to the specific DOE and contractor documents that adequately describe the INL Criticality Safety Program per the elements specified in DOE Order 420.1B. The Safety Evaluation Report for SAR-400 specifically recognizes that the approval of SAR-400 approves the INL Criticality Safety Program. No new source requirements were released in 2011. A revision to LRD-18001 is planned for 2012 to clarify design requirements for criticality alarms. Training - Criticality Safety Engineering has developed training and provides training for many employee positions, including fissionable material handlers, facility managers, criticality safety officers, firefighters, and criticality safety engineers. Criticality safety training at the INL is a program strength. A revision to the training module developed in 2010 to supplement MFC certified fissionable material handlers (operators) training was prepared and presented in August of 2011. This training, 'Applied Science of Criticality Safety,' builds upon existing training and gives operators a better understanding of how their criticality controls are derived. Improvements to 00INL189, 'INL Criticality Safety Principles' are planned for 2012 to strengthen fissionable material handler training.« less

  16. CDS Re Mix

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    None

    CDS (Change Detection Systems) is a mechanism for rapid visual analysis using complex image alignment algorithms. CDS is controlled with a simple interface that has been designed for use for anyone that can operate a digital camera. A challenge of complex industrial systems like nuclear power plants is to accurately identify changes in systems, structures and components that may critically impact the operation of the facility. CDS can provide a means of early intervention before the issues evolve into safety and production challenges.

  17. Hoisting and Rigging (Formerly Hoisting and Rigging Manual)

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    NONE

    1995-06-01

    This standard is intended as a reference document to be used by supervisors, line managers, safety personnel, equipment operators, and any other personnel responsible for safety of hoisting and rigging operations at DOE sites. It quotes or paraphrases the US OSHA and ANSI requirements. It also encompasses, under one cover,hoisting and rigging requirements, codes, standards, and regulations, eliminating the need to maintain extensive (and often incomplete) libraries of hoisting and rigging standards throughout DOE. The standard occasionally goes beyond the minimum general industry standards established by OSHA and ANSI, and also delineates the more stringent requirements necessary to accomplish themore » complex, diversified, critical, and often hazardous hoisting and rigging work found with the DOE complex.« less

  18. Certification Processes for Safety-Critical and Mission-Critical Aerospace Software

    NASA Technical Reports Server (NTRS)

    Nelson, Stacy

    2003-01-01

    This document is a quick reference guide with an overview of the processes required to certify safety-critical and mission-critical flight software at selected NASA centers and the FAA. Researchers and software developers can use this guide to jumpstart their understanding of how to get new or enhanced software onboard an aircraft or spacecraft. The introduction contains aerospace industry definitions of safety and safety-critical software, as well as, the current rationale for certification of safety-critical software. The Standards for Safety-Critical Aerospace Software section lists and describes current standards including NASA standards and RTCA DO-178B. The Mission-Critical versus Safety-Critical software section explains the difference between two important classes of software: safety-critical software involving the potential for loss of life due to software failure and mission-critical software involving the potential for aborting a mission due to software failure. The DO-178B Safety-critical Certification Requirements section describes special processes and methods required to obtain a safety-critical certification for aerospace software flying on vehicles under auspices of the FAA. The final two sections give an overview of the certification process used at Dryden Flight Research Center and the approval process at the Jet Propulsion Lab (JPL).

  19. Less is (sometimes) more in cognitive engineering: the role of automation technology in improving patient safety

    PubMed Central

    Vicente, K

    2003-01-01

    

 There is a tendency to assume that medical error can be stamped out by automation. Technology may improve patient safety, but cognitive engineering research findings in several complex safety critical systems, including both aviation and health care, show that more is not always better. Less sophisticated technological systems can sometimes lead to better performance than more sophisticated systems. This "less is more" effect arises because safety critical systems are open systems where unanticipated events are bound to occur. In these contexts, decision support provided by a technological aid will be less than perfect because there will always be situations that the technology cannot accommodate. Designing sophisticated automation that suggests an uncertain course of action seems to encourage people to accept the imperfect advice, even though information to decide independently on a better course of action is available. It may be preferable to create more modest designs that merely provide feedback about the current state of affairs or that critique human generated solutions than to rush to automate by creating sophisticated technological systems that recommend (fallible) courses of action. PMID:12897363

  20. Proceedings of the Sixth NASA Langley Formal Methods (LFM) Workshop

    NASA Technical Reports Server (NTRS)

    Rozier, Kristin Yvonne (Editor)

    2008-01-01

    Today's verification techniques are hard-pressed to scale with the ever-increasing complexity of safety critical systems. Within the field of aeronautics alone, we find the need for verification of algorithms for separation assurance, air traffic control, auto-pilot, Unmanned Aerial Vehicles (UAVs), adaptive avionics, automated decision authority, and much more. Recent advances in formal methods have made verifying more of these problems realistic. Thus we need to continually re-assess what we can solve now and identify the next barriers to overcome. Only through an exchange of ideas between theoreticians and practitioners from academia to industry can we extend formal methods for the verification of ever more challenging problem domains. This volume contains the extended abstracts of the talks presented at LFM 2008: The Sixth NASA Langley Formal Methods Workshop held on April 30 - May 2, 2008 in Newport News, Virginia, USA. The topics of interest that were listed in the call for abstracts were: advances in formal verification techniques; formal models of distributed computing; planning and scheduling; automated air traffic management; fault tolerance; hybrid systems/hybrid automata; embedded systems; safety critical applications; safety cases; accident/safety analysis.

  1. Understanding Teamwork in Trauma Resuscitation through Analysis of Team Errors

    ERIC Educational Resources Information Center

    Sarcevic, Aleksandra

    2009-01-01

    An analysis of human errors in complex work settings can lead to important insights into the workspace design. This type of analysis is particularly relevant to safety-critical, socio-technical systems that are highly dynamic, stressful and time-constrained, and where failures can result in catastrophic societal, economic or environmental…

  2. Using Immersive Virtual Environments for Certification

    NASA Technical Reports Server (NTRS)

    Lutz, R.; Cruz-Neira, C.

    1998-01-01

    Immersive virtual environments (VEs) technology has matured to the point where it can be utilized as a scientific and engineering problem solving tool. In particular, VEs are starting to be used to design and evaluate safety-critical systems that involve human operators, such as flight and driving simulators, complex machinery training, and emergency rescue strategies.

  3. Design of Low Complexity Model Reference Adaptive Controllers

    NASA Technical Reports Server (NTRS)

    Hanson, Curt; Schaefer, Jacob; Johnson, Marcus; Nguyen, Nhan

    2012-01-01

    Flight research experiments have demonstrated that adaptive flight controls can be an effective technology for improving aircraft safety in the event of failures or damage. However, the nonlinear, timevarying nature of adaptive algorithms continues to challenge traditional methods for the verification and validation testing of safety-critical flight control systems. Increasingly complex adaptive control theories and designs are emerging, but only make testing challenges more difficult. A potential first step toward the acceptance of adaptive flight controllers by aircraft manufacturers, operators, and certification authorities is a very simple design that operates as an augmentation to a non-adaptive baseline controller. Three such controllers were developed as part of a National Aeronautics and Space Administration flight research experiment to determine the appropriate level of complexity required to restore acceptable handling qualities to an aircraft that has suffered failures or damage. The controllers consist of the same basic design, but incorporate incrementally-increasing levels of complexity. Derivations of the controllers and their adaptive parameter update laws are presented along with details of the controllers implementations.

  4. Software Reliability Issues Concerning Large and Safety Critical Software Systems

    NASA Technical Reports Server (NTRS)

    Kamel, Khaled; Brown, Barbara

    1996-01-01

    This research was undertaken to provide NASA with a survey of state-of-the-art techniques using in industrial and academia to provide safe, reliable, and maintainable software to drive large systems. Such systems must match the complexity and strict safety requirements of NASA's shuttle system. In particular, the Launch Processing System (LPS) is being considered for replacement. The LPS is responsible for monitoring and commanding the shuttle during test, repair, and launch phases. NASA built this system in the 1970's using mostly hardware techniques to provide for increased reliability, but it did so often using custom-built equipment, which has not been able to keep up with current technologies. This report surveys the major techniques used in industry and academia to ensure reliability in large and critical computer systems.

  5. How does information congruence influence diagnosis performance?

    PubMed

    Chen, Kejin; Li, Zhizhong

    2015-01-01

    Diagnosis performance is critical for the safety of high-consequence industrial systems. It depends highly on the information provided, perceived, interpreted and integrated by operators. This article examines the influence of information congruence (congruent information vs. conflicting information vs. missing information) and its interaction with time pressure (high vs. low) on diagnosis performance on a simulated platform. The experimental results reveal that the participants confronted with conflicting information spent significantly more time generating correct hypotheses and rated the results with lower probability values than when confronted with the other two levels of information congruence and were more prone to arrive at a wrong diagnosis result than when they were provided with congruent information. This finding stresses the importance of the proper processing of non-congruent information in safety-critical systems. Time pressure significantly influenced display switching frequency and completion time. This result indicates the decisive role of time pressure. Practitioner Summary: This article examines the influence of information congruence and its interaction with time pressure on human diagnosis performance on a simulated platform. For complex systems in the process control industry, the results stress the importance of the proper processing of non-congruent information in safety-critical systems.

  6. Cockpit emergency safety system

    NASA Astrophysics Data System (ADS)

    Keller, Leo

    2000-06-01

    A comprehensive safety concept is proposed for aircraft's experiencing an incident to the development of fire and smoke in the cockpit. Fire or excessive heat development caused by malfunctioning electrical appliance may produce toxic smoke, may reduce the clear vision to the instrument panel and may cause health-critical respiration conditions. Immediate reaction of the crew, safe respiration conditions and a clear undisturbed view to critical flight information data can be assumed to be the prerequisites for a safe emergency landing. The personal safety equipment of the aircraft has to be effective in supporting the crew to divert the aircraft to an alternate airport in the shortest possible amount of time. Many other elements in the cause-and-effect context of the emergence of fire, such as fire prevention, fire detection, the fire extinguishing concept, systematic redundancy, the wiring concept, the design of the power supplying system and concise emergency checklist procedures are briefly reviewed, because only a comprehensive and complete approach will avoid fatal accidents of complex aircraft in the future.

  7. NASA's Software Safety Standard

    NASA Technical Reports Server (NTRS)

    Ramsay, Christopher M.

    2007-01-01

    NASA relies more and more on software to control, monitor, and verify its safety critical systems, facilities and operations. Since the 1960's there has hardly been a spacecraft launched that does not have a computer on board that will provide command and control services. There have been recent incidents where software has played a role in high-profile mission failures and hazardous incidents. For example, the Mars Orbiter, Mars Polar Lander, the DART (Demonstration of Autonomous Rendezvous Technology), and MER (Mars Exploration Rover) Spirit anomalies were all caused or contributed to by software. The Mission Control Centers for the Shuttle, ISS, and unmanned programs are highly dependant on software for data displays, analysis, and mission planning. Despite this growing dependence on software control and monitoring, there has been little to no consistent application of software safety practices and methodology to NASA's projects with safety critical software. Meanwhile, academia and private industry have been stepping forward with procedures and standards for safety critical systems and software, for example Dr. Nancy Leveson's book Safeware: System Safety and Computers. The NASA Software Safety Standard, originally published in 1997, was widely ignored due to its complexity and poor organization. It also focused on concepts rather than definite procedural requirements organized around a software project lifecycle. Led by NASA Headquarters Office of Safety and Mission Assurance, the NASA Software Safety Standard has recently undergone a significant update. This new standard provides the procedures and guidelines for evaluating a project for safety criticality and then lays out the minimum project lifecycle requirements to assure the software is created, operated, and maintained in the safest possible manner. This update of the standard clearly delineates the minimum set of software safety requirements for a project without detailing the implementation for those requirements. This allows the projects leeway to meet these requirements in many forms that best suit a particular project's needs and safety risk. In other words, it tells the project what to do, not how to do it. This update also incorporated advances in the state of the practice of software safety from academia and private industry. It addresses some of the more common issues now facing software developers in the NASA environment such as the use of Commercial-Off-the-Shelf Software (COTS), Modified OTS (MOTS), Government OTS (GOTS), and reused software. A team from across NASA developed the update and it has had both NASA-wide internal reviews by software engineering, quality, safety, and project management. It has also had expert external review. This presentation and paper will discuss the new NASA Software Safety Standard, its organization, and key features. It will start with a brief discussion of some NASA mission failures and incidents that had software as one of their root causes. It will then give a brief overview of the NASA Software Safety Process. This will include an overview of the key personnel responsibilities and functions that must be performed for safety-critical software.

  8. Energy, climate, food and health.

    PubMed

    Erwin, Patricia J

    2008-01-01

    On June 3-5, 2008, international organizations and heads of state met in Rome to discuss the critical situation in global food supplies and prices during the World Food Crisis Summit. The intent of this column is to provide approaches to identifying the complex issues that impact public health, public safety, and nutrition on a global basis. The Web sites selected provide a background for the complex issues involved (energy, climate and environment, agriculture, and politics) and reveal controversial and competing agendas with many far-reaching implications.

  9. Nursing care plans versus concept maps in the enhancement of critical thinking skills in nursing students enrolled in a baccalaureate nursing program.

    PubMed

    Sinatra-Wilhelm, Tina

    2012-01-01

    Appropriate and effective critical thinking and problem solving is necessary for all nurses in order to make complex decisions that improve patient outcomes, safety, and quality of nursing care. With the current emphasis on quality improvement, critical thinking ability is a noteworthy concern within the nursing profession. An in-depth review of literature related to critical thinking was performed. The use of nursing care plans and concept mapping to improve critical thinking skills was among the recommendations identified. This study compares the use of nursing care plans and concept mapping as a teaching strategy for the enhancement of critical thinking skills in baccalaureate level nursing students. The California Critical Thinking Skills Test was used as a method of comparison and evaluation. Results indicate that concept mapping enhances critical thinking skills in baccalaureate nursing students.

  10. Meeting the global demand of sports safety: the intersection of science and policy in sports safety.

    PubMed

    Timpka, Toomas; Finch, Caroline F; Goulet, Claude; Noakes, Tim; Yammine, Kaissar

    2008-01-01

    Sports and physical activity are transforming, and being transformed by, the societies in which they are practised. From the perspectives of both competitive and non-competitive sports, the complexity of their integration into today's society has led to neither sports federations nor governments being able to manage the safety problem alone. In other words, these agencies, whilst promoting sport and physical activity, deliver policy and practices in an uncoordinated way that largely ignores the need for a concurrent overall policy for sports safety. This article reviews and analyses the possibility of developing an overall sports safety policy from a global viewpoint. Firstly, we describe the role of sports in today's societies and the context within which much sport is delivered. We then discuss global issues related to injury prevention and safety in sports, with practical relevance to this important sector, including an analysis of critical policy issues necessary for the future development of the area and significant safety gains for all. We argue that there is a need to establish the sports injury problem as a critical component of general global health policy agendas, and to introduce sports safety as a mandatory component of all sustainable sports organizations. We conclude that the establishment of an explicit intersection between science and policy making is necessary for the future development of sports and the necessary safety gains required for all participants around the world. The Safe Sports International safety promotion programme is outlined as an example of an international organization active within this arena.

  11. Quantitative safety assessment of air traffic control systems through system control capacity

    NASA Astrophysics Data System (ADS)

    Guo, Jingjing

    Quantitative Safety Assessments (QSA) are essential to safety benefit verification and regulations of developmental changes in safety critical systems like the Air Traffic Control (ATC) systems. Effectiveness of the assessments is particularly desirable today in the safe implementations of revolutionary ATC overhauls like NextGen and SESAR. QSA of ATC systems are however challenged by system complexity and lack of accident data. Extending from the idea "safety is a control problem" in the literature, this research proposes to assess system safety from the control perspective, through quantifying a system's "control capacity". A system's safety performance correlates to this "control capacity" in the control of "safety critical processes". To examine this idea in QSA of the ATC systems, a Control-capacity Based Safety Assessment Framework (CBSAF) is developed which includes two control capacity metrics and a procedural method. The two metrics are Probabilistic System Control-capacity (PSC) and Temporal System Control-capacity (TSC); each addresses an aspect of a system's control capacity. And the procedural method consists three general stages: I) identification of safety critical processes, II) development of system control models and III) evaluation of system control capacity. The CBSAF was tested in two case studies. The first one assesses an en-route collision avoidance scenario and compares three hypothetical configurations. The CBSAF was able to capture the uncoordinated behavior between two means of control, as was observed in a historic midair collision accident. The second case study compares CBSAF with an existing risk based QSA method in assessing the safety benefits of introducing a runway incursion alert system. Similar conclusions are reached between the two methods, while the CBSAF has the advantage of simplicity and provides a new control-based perspective and interpretation to the assessments. The case studies are intended to investigate the potential and demonstrate the utilities of CBSAF and are not intended for thorough studies of collision avoidance and runway incursions safety, which are extremely challenging problems. Further development and thorough validations are required to allow CBSAF to reach implementation phases, e.g. addressing the issues of limited scalability and subjectivity.

  12. Autonomy Software: V&V Challenges and Characteristics

    NASA Technical Reports Server (NTRS)

    Schumann, Johann; Visser, Willem

    2006-01-01

    The successful operation of unmanned air vehicles requires software with a high degree of autonomy. Only if high level functions can be carried out without human control and intervention, complex missions in a changing and potentially unknown environment can be carried out successfully. Autonomy software is highly mission and safety critical: failures, caused by flaws in the software cannot only jeopardize the mission, but could also endanger human life (e.g., a crash of an UAV in a densely populated area). Due to its large size, high complexity, and use of specialized algorithms (planner, constraint-solver, etc.), autonomy software poses specific challenges for its verification, validation, and certification. -- - we have carried out a survey among researchers aid scientists at NASA to study these issues. In this paper, we will present major results of this study, discussing the broad spectrum. of notions and characteristics of autonomy software and its challenges for design and development. A main focus of this survey was to evaluate verification and validation (V&V) issues and challenges, compared to the development of "traditional" safety-critical software. We will discuss important issues in V&V of autonomous software and advanced V&V tools which can help to mitigate software risks. Results of this survey will help to identify and understand safety concerns in autonomy software and will lead to improved strategies for mitigation of these risks.

  13. Medical innovation versus stem cell tourism.

    PubMed

    Lindvall, Olle; Hyun, Insoo

    2009-06-26

    Stem cell tourism is criticized on grounds of consumer fraud, blatant lack of scientific justification, and patient safety. However, the issues are complex because they invoke questions concerning the limits of acceptable medical innovation and medical travel. Here we discuss these issues and articulate conditions under which "unproven" therapies may be offered to patients outside of regular clinical trials.

  14. Nuclear criticality safety staff training and qualifications at Los Alamos National Laboratory

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Monahan, S.P.; McLaughlin, T.P.

    1997-05-01

    Operations involving significant quantities of fissile material have been conducted at Los Alamos National Laboratory continuously since 1943. Until the advent of the Laboratory`s Nuclear Criticality Safety Committee (NCSC) in 1957, line management had sole responsibility for controlling criticality risks. From 1957 until 1961, the NCSC was the Laboratory body which promulgated policy guidance as well as some technical guidance for specific operations. In 1961 the Laboratory created the position of Nuclear Criticality Safety Office (in addition to the NCSC). In 1980, Laboratory management moved the Criticality Safety Officer (and one other LACEF staff member who, by that time, wasmore » also working nearly full-time on criticality safety issues) into the Health Division office. Later that same year the Criticality Safety Group, H-6 (at that time) was created within H-Division, and staffed by these two individuals. The training and education of these individuals in the art of criticality safety was almost entirely self-regulated, depending heavily on technical interactions between each other, as well as NCSC, LACEF, operations, other facility, and broader criticality safety community personnel. Although the Los Alamos criticality safety group has grown both in size and formality of operations since 1980, the basic philosophy that a criticality specialist must be developed through mentoring and self motivation remains the same. Formally, this philosophy has been captured in an internal policy, document ``Conduct of Business in the Nuclear Criticality Safety Group.`` There are no short cuts or substitutes in the development of a criticality safety specialist. A person must have a self-motivated personality, excellent communications skills, a thorough understanding of the principals of neutron physics, a safety-conscious and helpful attitude, a good perspective of real risk, as well as a detailed understanding of process operations and credible upsets.« less

  15. 76 FR 52138 - Defense Federal Acquisition Regulation Supplement; Identification of Critical Safety Items (DFARS...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-19

    ...; or (iii) An uncommanded engine shutdown that jeopardizes safety. Design control activity. (i) With... aviation critical safety item is to be used; and (ii) With respect to a ship critical safety item, means...-AG92 Defense Federal Acquisition Regulation Supplement; Identification of Critical Safety Items (DFARS...

  16. Safety I-II, resilience and antifragility engineering: a debate explained through an accident occurring on a mobile elevating work platform.

    PubMed

    Martinetti, Alberto; Chatzimichailidou, Maria Mikela; Maida, Luisa; van Dongen, Leo

    2018-04-24

    Occupational health and safety (OHS) represents an important field of exploration for the research community: in spite of the growth of technological innovations, the increasing complexity of systems involves critical issues in terms of degradation of the safety levels. In such a situation, new safety management approaches are now mandatory in order to face the safety implications of the current technological evolutions. Along these lines, performing risk-based analysis alone seems not to be enough anymore. The evaluation of robustness, antifragility and resilience of a socio-technical system is now indispensable in order to face unforeseen events. This article will briefly introduce the topics of Safety I and Safety II, resilience engineering and antifragility engineering, explaining correlations, overlapping aspects and synergies. Secondly, the article will discuss the applications of those paradigms to a real accident, highlighting how they can challenge, stimulate and inspire research for improving OHS conditions.

  17. Researching safety culture: deliberative dialogue with a restorative lens.

    PubMed

    Lorenzini, Elisiane; Oelke, Nelly D; Marck, Patricia Beryl; Dall'agnol, Clarice Maria

    2017-10-01

    Safety culture is a key component of patient safety. Many patient safety strategies in health care have been adapted from high-reliability organizations (HRO) such as aviation. However, to date, attempts to transform the cultures of health care settings through HRO approaches have had mixed results. We propose a methodological approach for safety culture research, which integrates the theory and practice of restoration science with the principles and methods of deliberative dialogue to support active engagement in critical reflection and collective debate. Our aim is to describe how these two innovative approaches in health services research can be used together to provide a comprehensive effective method to study and implement change in safety culture. Restorative research in health care integrates socio-ecological theory of complex adaptive systems concepts with collaborative, place-sensitive study of local practice contexts. Deliberative dialogue brings together all stakeholders to collectively develop solutions on an issue to facilitate change. Together these approaches can be used to actively engage people in the study of safety culture to gain a better understanding of its elements. More importantly, we argue that the synergistic use of these approaches offers enhanced potential to move health care professionals towards actionable strategies to improve patient safety within today's complex health care systems. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  18. Human behaviours in evacuation crowd dynamics: From modelling to "big data" toward crisis management

    NASA Astrophysics Data System (ADS)

    Bellomo, N.; Clarke, D.; Gibelli, L.; Townsend, P.; Vreugdenhil, B. J.

    2016-09-01

    This paper proposes an essay concerning the understanding of human behaviours and crisis management of crowds in extreme situations, such as evacuation through complex venues. The first part focuses on the understanding of the main features of the crowd viewed as a living, hence complex system. The main concepts are subsequently addressed, in the second part, to a critical analysis of mathematical models suitable to capture them, as far as it is possible. Then, the third part focuses on the use, toward safety problems, of a model derived by the methods of the mathematical kinetic theory and theoretical tools of evolutionary game theory. It is shown how this model can depict critical situations and how these can be managed with the aim of minimizing the risk of catastrophic events.

  19. The Department of Energy Nuclear Criticality Safety Program

    NASA Astrophysics Data System (ADS)

    Felty, James R.

    2005-05-01

    This paper broadly covers key events and activities from which the Department of Energy Nuclear Criticality Safety Program (NCSP) evolved. The NCSP maintains fundamental infrastructure that supports operational criticality safety programs. This infrastructure includes continued development and maintenance of key calculational tools, differential and integral data measurements, benchmark compilation, development of training resources, hands-on training, and web-based systems to enhance information preservation and dissemination. The NCSP was initiated in response to Defense Nuclear Facilities Safety Board Recommendation 97-2, Criticality Safety, and evolved from a predecessor program, the Nuclear Criticality Predictability Program, that was initiated in response to Defense Nuclear Facilities Safety Board Recommendation 93-2, The Need for Critical Experiment Capability. This paper also discusses the role Dr. Sol Pearlstein played in helping the Department of Energy lay the foundation for a robust and enduring criticality safety infrastructure.

  20. Disruption of Radiologist Workflow.

    PubMed

    Kansagra, Akash P; Liu, Kevin; Yu, John-Paul J

    2016-01-01

    The effect of disruptions has been studied extensively in surgery and emergency medicine, and a number of solutions-such as preoperative checklists-have been implemented to enforce the integrity of critical safety-related workflows. Disruptions of the highly complex and cognitively demanding workflow of modern clinical radiology have only recently attracted attention as a potential safety hazard. In this article, we describe the variety of disruptions that arise in the reading room environment, review approaches that other specialties have taken to mitigate workflow disruption, and suggest possible solutions for workflow improvement in radiology. Copyright © 2015 Mosby, Inc. All rights reserved.

  1. A systems-based food safety evaluation: an experimental approach.

    PubMed

    Higgins, Charles L; Hartfield, Barry S

    2004-11-01

    Food establishments are complex systems with inputs, subsystems, underlying forces that affect the system, outputs, and feedback. Building on past exploration of the hazard analysis critical control point concept and Ludwig von Bertalanffy General Systems Theory, the National Park Service (NPS) is attempting to translate these ideas into a realistic field assessment of food service establishments and to use information gathered by these methods in efforts to improve food safety. Over the course of the last two years, an experimental systems-based methodology has been drafted, developed, and tested by the NPS Public Health Program. This methodology is described in this paper.

  2. Representing and Enacting Movement: The Body as an Instructional Resource in a Simulator-Based Environment

    ERIC Educational Resources Information Center

    Sellberg, Charlott

    2017-01-01

    Simulators are used to practice in a safe setting before training in a safety-critical environment. Since the nature of situations encountered in high-risk domains is complex and dynamic, it is considered important for the simulation to resemble conditions of real world tasks. For this reason, simulation-based training is often discussed in terms…

  3. Regulatory Compliance in Multi-Tier Supplier Networks

    NASA Technical Reports Server (NTRS)

    Goossen, Emray R.; Buster, Duke A.

    2014-01-01

    Over the years, avionics systems have increased in complexity to the point where 1st tier suppliers to an aircraft OEM find it financially beneficial to outsource designs of subsystems to 2nd tier and at times to 3rd tier suppliers. Combined with challenging schedule and budgetary pressures, the environment in which safety-critical systems are being developed introduces new hurdles for regulatory agencies and industry. This new environment of both complex systems and tiered development has raised concerns in the ability of the designers to ensure safety considerations are fully addressed throughout the tier levels. This has also raised questions about the sufficiency of current regulatory guidance to ensure: proper flow down of safety awareness, avionics application understanding at the lower tiers, OEM and 1st tier oversight practices, and capabilities of lower tier suppliers. Therefore, NASA established a research project to address Regulatory Compliance in a Multi-tier Supplier Network. This research was divided into three major study efforts: 1. Describe Modern Multi-tier Avionics Development 2. Identify Current Issues in Achieving Safety and Regulatory Compliance 3. Short-term/Long-term Recommendations Toward Higher Assurance Confidence This report presents our findings of the risks, weaknesses, and our recommendations. It also includes a collection of industry-identified risks, an assessment of guideline weaknesses related to multi-tier development of complex avionics systems, and a postulation of potential modifications to guidelines to close the identified risks and weaknesses.

  4. Deriving Safety Cases from Automatically Constructed Proofs

    NASA Technical Reports Server (NTRS)

    Basir, Nurlida; Denney, Ewen; Fischer, Bernd

    2009-01-01

    Formal proofs provide detailed justification for the validity of claims and are widely used in formal software development methods. However, they are often complex and difficult to understand, because the formalism in which they are constructed and encoded is usually machine-oriented, and they may also be based on assumptions that are not justified. This causes concerns about the trustworthiness of using formal proofs as arguments in safety-critical applications. Here, we present an approach to develop safety cases that correspond to formal proofs found by automated theorem provers and reveal the underlying argumentation structure and top-level assumptions. We concentrate on natural deduction style proofs, which are closer to human reasoning than resolution proofs, and show how to construct the safety cases by covering the natural deduction proof tree with corresponding safety case fragments. We also abstract away logical book-keeping steps, which reduces the size of the constructed safety cases. We show how the approach can be applied to the proofs found by the Muscadet prover.

  5. Criticality Safety Evaluation for the TACS at DAF

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Percher, C. M.; Heinrichs, D. P.

    2011-06-10

    Hands-on experimental training in the physical behavior of multiplying systems is one of ten key areas of training required for practitioners to become qualified in the discipline of criticality safety as identified in DOE-STD-1135-99, Guidance for Nuclear Criticality Safety Engineer Training and Qualification. This document is a criticality safety evaluation of the training activities and operations associated with HS-3201-P, Nuclear Criticality 4-Day Training Course (Practical). This course was designed to also address the training needs of nuclear criticality safety professionals under the auspices of the NNSA Nuclear Criticality Safety Program1. The hands-on, or laboratory, portion of the course will utilizemore » the Training Assembly for Criticality Safety (TACS) and will be conducted in the Device Assembly Facility (DAF) at the Nevada Nuclear Security Site (NNSS). The training activities will be conducted by Lawrence Livermore National Laboratory following the requirements of an Integrated Work Sheet (IWS) and associated Safety Plan. Students will be allowed to handle the fissile material under the supervision of an LLNL Certified Fissile Material Handler.« less

  6. The science of laboratory and project management in regulated bioanalysis.

    PubMed

    Unger, Steve; Lloyd, Thomas; Tan, Melvin; Hou, Jingguo; Wells, Edward

    2014-05-01

    Pharmaceutical drug development is a complex and lengthy process, requiring excellent project and laboratory management skills. Bioanalysis anchors drug safety and efficacy with systemic and site of action exposures. Development of scientific talent and a willingness to innovate or adopt new technology is essential. Taking unnecessary risks, however, should be avoided. Scientists must strategically assess all risks and find means to minimize or negate them. Laboratory Managers must keep abreast of ever-changing technology. Investments in instrumentation and laboratory design are critical catalysts to efficiency and safety. Matrix management requires regular communication between Project Managers and Laboratory Managers. When properly executed, it aligns the best resources at the right times for a successful outcome. Attention to detail is a critical aspect that separates excellent laboratories. Each assay is unique and requires attention in its development, validation and execution. Methods, training and facilities are the foundation of a bioanalytical laboratory.

  7. Proceedings of the Nuclear Criticality Technology Safety Workshop

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Rene G. Sanchez

    1998-04-01

    This document contains summaries of most of the papers presented at the 1995 Nuclear Criticality Technology Safety Project (NCTSP) meeting, which was held May 16 and 17 at San Diego, Ca. The meeting was broken up into seven sessions, which covered the following topics: (1) Criticality Safety of Project Sapphire; (2) Relevant Experiments For Criticality Safety; (3) Interactions with the Former Soviet Union; (4) Misapplications and Limitations of Monte Carlo Methods Directed Toward Criticality Safety Analyses; (5) Monte Carlo Vulnerabilities of Execution and Interpretation; (6) Monte Carlo Vulnerabilities of Representation; and (7) Benchmark Comparisons.

  8. Patient safety goals for the proposed Federal Health Information Technology Safety Center.

    PubMed

    Sittig, Dean F; Classen, David C; Singh, Hardeep

    2015-03-01

    The Office of the National Coordinator for Health Information Technology is expected to oversee creation of a Health Information Technology (HIT) Safety Center. While its functions are still being defined, the center is envisioned as a public-private entity focusing on promotion of HIT related patient safety. We propose that the HIT Safety Center leverages its unique position to work with key administrative and policy stakeholders, healthcare organizations (HCOs), and HIT vendors to achieve four goals: (1) facilitate creation of a nationwide 'post-marketing' surveillance system to monitor HIT related safety events; (2) develop methods and governance structures to support investigation of major HIT related safety events; (3) create the infrastructure and methods needed to carry out random assessments of HIT related safety in complex HCOs; and (4) advocate for HIT safety with government and private entities. The convening ability of a federally supported HIT Safety Center could be critically important to our transformation to a safe and effective HIT enabled healthcare system. © The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  9. URBAN-NET: A Network-based Infrastructure Monitoring and Analysis System for Emergency Management and Public Safety

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Lee, Sangkeun; Chen, Liangzhe; Duan, Sisi

    Abstract Critical Infrastructures (CIs) such as energy, water, and transportation are complex networks that are crucial for sustaining day-to-day commodity flows vital to national security, economic stability, and public safety. The nature of these CIs is such that failures caused by an extreme weather event or a man-made incident can trigger widespread cascading failures, sending ripple effects at regional or even national scales. To minimize such effects, it is critical for emergency responders to identify existing or potential vulnerabilities within CIs during such stressor events in a systematic and quantifiable manner and take appropriate mitigating actions. We present here amore » novel critical infrastructure monitoring and analysis system named URBAN-NET. The system includes a software stack and tools for monitoring CIs, pre-processing data, interconnecting multiple CI datasets as a heterogeneous network, identifying vulnerabilities through graph-based topological analysis, and predicting consequences based on what-if simulations along with visualization. As a proof-of-concept, we present several case studies to show the capabilities of our system. We also discuss remaining challenges and future work.« less

  10. Resilience Engineering in Critical Long Term Aerospace Software Systems: A New Approach to Spacecraft Software Safety

    NASA Astrophysics Data System (ADS)

    Dulo, D. A.

    Safety critical software systems permeate spacecraft, and in a long term venture like a starship would be pervasive in every system of the spacecraft. Yet software failure today continues to plague both the systems and the organizations that develop them resulting in the loss of life, time, money, and valuable system platforms. A starship cannot afford this type of software failure in long journeys away from home. A single software failure could have catastrophic results for the spaceship and the crew onboard. This paper will offer a new approach to developing safe reliable software systems through focusing not on the traditional safety/reliability engineering paradigms but rather by focusing on a new paradigm: Resilience and Failure Obviation Engineering. The foremost objective of this approach is the obviation of failure, coupled with the ability of a software system to prevent or adapt to complex changing conditions in real time as a safety valve should failure occur to ensure safe system continuity. Through this approach, safety is ensured through foresight to anticipate failure and to adapt to risk in real time before failure occurs. In a starship, this type of software engineering is vital. Through software developed in a resilient manner, a starship would have reduced or eliminated software failure, and would have the ability to rapidly adapt should a software system become unstable or unsafe. As a result, long term software safety, reliability, and resilience would be present for a successful long term starship mission.

  11. Rethinking critical reflection on care: late modern uncertainty and the implications for care ethics.

    PubMed

    Vosman, Frans; Niemeijer, Alistair

    2017-12-01

    Care ethics as initiated by Gilligan, Held, Tronto and others (in the nineteen eighties and nineties) has from its onset been critical towards ethical concepts established in modernity, like 'autonomy', alternatively proposing to think from within relationships and to pay attention to power. In this article the question is raised whether renewal in this same critical vein is necessary and possible as late modern circumstances require rethinking the care ethical inquiry. Two late modern realities that invite to rethink care ethics are complexity and precariousness. Late modern organizations, like the general hospital, codetermined by various (control-, information-, safety-, accountability-) systems are characterized by complexity and the need for complexity reduction, both permeating care practices. By means of a heuristic use of the concept of precariousness, taken as the installment of uncertainty, it is shown that relations and power in late modern care organizations have changed, precluding the use of a straightforward domination idea of power. In the final section a proposition is made how to rethink the care ethical inquiry in order to take late modern circumstances into account: inquiry should always be related to the concerns of people and practitioners from within care practices.

  12. Orion Launch from UCS-3

    NASA Image and Video Library

    2014-12-05

    A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system.

  13. Orion Launch

    NASA Image and Video Library

    2014-12-05

    A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system.

  14. Rethinking healthcare as a safety--critical industry.

    PubMed

    Lwears, Robert

    2012-01-01

    The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy (eg, 15% of US gross domestic product) and has been associated with large volumes of potentially preventable morbidity and mortality, has heretofore not been viewed as a safety-critical industry. This paper proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries.

  15. Traceability of Software Safety Requirements in Legacy Safety Critical Systems

    NASA Technical Reports Server (NTRS)

    Hill, Janice L.

    2007-01-01

    How can traceability of software safety requirements be created for legacy safety critical systems? Requirements in safety standards are imposed most times during contract negotiations. On the other hand, there are instances where safety standards are levied on legacy safety critical systems, some of which may be considered for reuse for new applications. Safety standards often specify that software development documentation include process-oriented and technical safety requirements, and also require that system and software safety analyses are performed supporting technical safety requirements implementation. So what can be done if the requisite documents for establishing and maintaining safety requirements traceability are not available?

  16. Systemic Analysis Approaches for Air Transportation

    NASA Technical Reports Server (NTRS)

    Conway, Sheila

    2005-01-01

    Air transportation system designers have had only limited success using traditional operations research and parametric modeling approaches in their analyses of innovations. They need a systemic methodology for modeling of safety-critical infrastructure that is comprehensive, objective, and sufficiently concrete, yet simple enough to be used with reasonable investment. The methodology must also be amenable to quantitative analysis so issues of system safety and stability can be rigorously addressed. However, air transportation has proven itself an extensive, complex system whose behavior is difficult to describe, no less predict. There is a wide range of system analysis techniques available, but some are more appropriate for certain applications than others. Specifically in the area of complex system analysis, the literature suggests that both agent-based models and network analysis techniques may be useful. This paper discusses the theoretical basis for each approach in these applications, and explores their historic and potential further use for air transportation analysis.

  17. A primer on criticality safety

    DOE PAGES

    Costa, David A.; Cournoyer, Michael E.; Merhege, James F.; ...

    2017-05-01

    Criticality is the state of a nuclear chain reacting medium when the chain reaction is just self-sustaining (or critical). Criticality is dependent on nine interrelated parameters. Moreover, we design criticality safety controls in order to constrain these parameters to minimize fissions and maximize neutron leakage and absorption in other materials, which makes criticality more difficult or impossible to achieve. We present the consequences of criticality accidents are discussed, the nine interrelated parameters that combine to affect criticality are described, and criticality safety controls used to minimize the likelihood of a criticality accident are presented.

  18. ZPR-6 assembly 7 high {sup 240} PU core : a cylindrical assemby with mixed (PU, U)-oxide fuel and a central high {sup 240} PU zone.

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Lell, R. M.; Schaefer, R. W.; McKnight, R. D.

    Over a period of 30 years more than a hundred Zero Power Reactor (ZPR) critical assemblies were constructed at Argonne National Laboratory. The ZPR facilities, ZPR-3, ZPR-6, ZPR-9 and ZPPR, were all fast critical assembly facilities. The ZPR critical assemblies were constructed to support fast reactor development, but data from some of these assemblies are also well suited to form the basis for criticality safety benchmarks. Of the three classes of ZPR assemblies, engineering mockups, engineering benchmarks and physics benchmarks, the last group tends to be most useful for criticality safety. Because physics benchmarks were designed to test fast reactormore » physics data and methods, they were as simple as possible in geometry and composition. The principal fissile species was {sup 235}U or {sup 239}Pu. Fuel enrichments ranged from 9% to 95%. Often there were only one or two main core diluent materials, such as aluminum, graphite, iron, sodium or stainless steel. The cores were reflected (and insulated from room return effects) by one or two layers of materials such as depleted uranium, lead or stainless steel. Despite their more complex nature, a small number of assemblies from the other two classes would make useful criticality safety benchmarks because they have features related to criticality safety issues, such as reflection by soil-like material. The term 'benchmark' in a ZPR program connotes a particularly simple loading aimed at gaining basic reactor physics insight, as opposed to studying a reactor design. In fact, the ZPR-6/7 Benchmark Assembly (Reference 1) had a very simple core unit cell assembled from plates of depleted uranium, sodium, iron oxide, U3O8, and plutonium. The ZPR-6/7 core cell-average composition is typical of the interior region of liquid-metal fast breeder reactors (LMFBRs) of the era. It was one part of the Demonstration Reactor Benchmark Program,a which provided integral experiments characterizing the important features of demonstration-size LMFBRs. As a benchmark, ZPR-6/7 was devoid of many 'real' reactor features, such as simulated control rods and multiple enrichment zones, in its reference form. Those kinds of features were investigated experimentally in variants of the reference ZPR-6/7 or in other critical assemblies in the Demonstration Reactor Benchmark Program.« less

  19. [How patient safety programmes can be successfully implemented - an example from Switzerland].

    PubMed

    Kobler, Irene; Mascherek, Anna; Bezzola, Paula

    2015-01-01

    Internationally, the implementation of patient safety programmes poses a major challenge. In the first part, we will demonstrate that various measures have been found to be effective in the literature but that they often do not reach the patient because their implementation proves difficult. Difficulties arise from both the complexity of the interventions themselves and from different organisational settings in individual hospitals. The second part specifically describes the implementation of patient safety improvement programmes in Switzerland and discusses measures intended to bridge the gap between the theory and practice of implementation in Switzerland. Then, the national pilot programme to improve patient safety in surgery is presented, which was launched by the federal Swiss government and has been implemented by the patient safety foundation. Procedures, challenges and highlights in implementing the programme in Switzerland on a national level are outlined. Finally, first (preliminary) results are presented and critically discussed. Copyright © 2015. Published by Elsevier GmbH.

  20. CRITICALITY SAFETY CONTROLS AND THE SAFETY BASIS AT PFP

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Kessler, S

    2009-04-21

    With the implementation of DOE Order 420.1B, Facility Safety, and DOE-STD-3007-2007, 'Guidelines for Preparing Criticality Safety Evaluations at Department of Energy Non-Reactor Nuclear Facilities', a new requirement was imposed that all criticality safety controls be evaluated for inclusion in the facility Documented Safety Analysis (DSA) and that the evaluation process be documented in the site Criticality Safety Program Description Document (CSPDD). At the Hanford site in Washington State the CSPDD, HNF-31695, 'General Description of the FH Criticality Safety Program', requires each facility develop a linking document called a Criticality Control Review (CCR) to document performance of these evaluations. Chapter 5,more » Appendix 5B of HNF-7098, Criticality Safety Program, provided an example of a format for a CCR that could be used in lieu of each facility developing its own CCR. Since the Plutonium Finishing Plant (PFP) is presently undergoing Deactivation and Decommissioning (D&D), new procedures are being developed for cleanout of equipment and systems that have not been operated in years. Existing Criticality Safety Evaluations (CSE) are revised, or new ones written, to develop the controls required to support D&D activities. Other Hanford facilities, including PFP, had difficulty using the basic CCR out of HNF-7098 when first implemented. Interpretation of the new guidelines indicated that many of the controls needed to be elevated to TSR level controls. Criterion 2 of the standard, requiring that the consequence of a criticality be examined for establishing the classification of a control, was not addressed. Upon in-depth review by PFP Criticality Safety staff, it was not clear that the programmatic interpretation of criterion 8C could be applied at PFP. Therefore, the PFP Criticality Safety staff decided to write their own CCR. The PFP CCR provides additional guidance for the evaluation team to use by clarifying the evaluation criteria in DOE-STD-3007-2007. In reviewing documents used in classifying controls for Nuclear Safety, it was noted that DOE-HDBK-1188, 'Glossary of Environment, Health, and Safety Terms', defines an Administrative Control (AC) in terms that are different than typically used in Criticality Safety. As part of this CCR, a new term, Criticality Administrative Control (CAC) was defined to clarify the difference between an AC used for criticality safety and an AC used for nuclear safety. In Nuclear Safety terms, an AC is a provision relating to organization and management, procedures, recordkeeping, assessment, and reporting necessary to ensure safe operation of a facility. A CAC was defined as an administrative control derived in a criticality safety analysis that is implemented to ensure double contingency. According to criterion 2 of Section IV, 'Linkage to the Documented Safety Analysis', of DOESTD-3007-2007, the consequence of a criticality should be examined for the purposes of classifying the significance of a control or component. HNF-PRO-700, 'Safety Basis Development', provides control selection criteria based on consequence and risk that may be used in the development of a Criticality Safety Evaluation (CSE) to establish the classification of a component as a design feature, as safety class or safety significant, i.e., an Engineered Safety Feature (ESF), or as equipment important to safety; or merely provides defense-in-depth. Similar logic is applied to the CACs. Criterion 8C of DOE-STD-3007-2007, as written, added to the confusion of using the basic CCR from HNF-7098. The PFP CCR attempts to clarify this criterion by revising it to say 'Programmatic commitments or general references to control philosophy (e.g., mass control or spacing control or concentration control as an overall control strategy for the process without specific quantification of individual limits) is included in the PFP DSA'. Table 1 shows the PFP methodology for evaluating CACs. This evaluation process has been in use since February of 2008 and has proven to be simple and effective. Each control identified in the applicable new/revised CSE is evaluated via the table. The results of this evaluation are documented in tables attached to the CCR as an appendix, for each CSE, to the base document.« less

  1. Nurse Project Consultant: Critical Care Nurses Move Beyond the Bedside to Affect Quality and Safety.

    PubMed

    Mackinson, Lynn G; Corey, Juliann; Kelly, Veronica; O'Reilly, Kristin P; Stevens, Jennifer P; Desanto-Madeya, Susan; Williams, Donna; O'Donoghue, Sharon C; Foley, Jane

    2018-06-01

    A nurse project consultant role empowered 3 critical care nurses to expand their scope of practice beyond the bedside and engage within complex health care delivery systems to reduce harms in the intensive care unit. As members of an interdisciplinary team, the nurse project consultants contributed their clinical expertise and systems knowledge to develop innovations that optimize care provided in the intensive care unit. This article discusses the formal development of and institutional support for the nurse project consultant role. The nurse project consultants' responsibilities within a group of quality improvement initiatives are described and their challenges and lessons learned discussed. The nurse project consultant role is a new model of engaging critical care nurses as leaders in health care redesign. ©2018 American Association of Critical-Care Nurses.

  2. Software-Based Safety Systems in Space - Learning from other Domains

    NASA Astrophysics Data System (ADS)

    Klicker, M.; Putzer, H.

    2012-01-01

    Increasing complexity and new emerging capabilities for manned and unmanned missions have been the hallmark of the past decades of space exploration. One of the drivers in this process was the ever increasing use of software and software-intensive systems to implement system functions necessary to the capabilities needed. The course of technological evolution suggests that this development will continue well into the future with a number of challenges for the safety community some of which shall be discussed in this paper. The current state of the art reveals a number of problems with developing and assessing safety critical software which explains the reluctance of the space community to rely on software-based safety measures to mitigate hazards. Among others, usually lack of trustworthy evidence of software integrity in all foreseeable situations and the difficulties to integrate software in the traditional safety analysis framework are cited. Experience from other domains and recent developments in modern software development methodologies and verification techniques are analysed for the suitability for space systems and an avionics architectural framework (see STANAG 4626) for the implementation of safety critical software is proposed. This is shown to create among other features the possibility of numerous degradation modes enhancing overall system safety and interoperability of computerized space systems. It also potentially simplifies international cooperation on a technical level by introducing a higher degree of compatibility. As software safety cannot be tested or argued into a system in hindsight, the development process and especially the architecture chosen are essential to establish safety properties for the software used to implement safety functions. The core of the safety argument revolves around the separation of different functions and software modules from each other by minimal coupling of functions and credible separation mechanisms in the architecture combined with rigorous development methodologies for the software itself.

  3. Collegiate Aviation Research and Education Solutions to Critical Safety Issues. UNO Aviation Monograph Series. UNOAI Report.

    ERIC Educational Resources Information Center

    Bowen, Brent, Ed.

    This document contains four papers concerning collegiate aviation research and education solutions to critical safety issues. "Panel Proposal Titled Collegiate Aviation Research and Education Solutions to Critical Safety Issues for the Tim Forte Collegiate Aviation Safety Symposium" (Brent Bowen) presents proposals for panels on the…

  4. Orion EFT-1 Launch from NASA Causeway

    NASA Image and Video Library

    2014-12-05

    A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system.

  5. Orion Launch from UCS-3

    NASA Image and Video Library

    2014-12-05

    A Delta IV Heavy rocket soars after liftoff from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system.

  6. Reference Materials: Critical Importance to the Infant Formula Industry.

    PubMed

    Wargo, Wayne F

    2017-09-01

    Infant formula is one of the most regulated foods in the world. It has advanced in complexity over the years as a result of numerous research innovations. To ensure product safety and quality, analytical technologies have also had to advance to keep pace. Given the rigorous performance demands expected of these methods and the ever-growing array of complex matrixes, there is the potential for gaps to exist in current Official MethodsSM and other recognized international methods for infant formula and adult nutritionals. Food safety concerns, particularly for infants, drive the need for extensive testing by manufacturers and regulators. The net effect is the potential for an increase in time- and resource-consuming regulatory disputes. In an effort to mitigate such costly activities, AOAC INTERNATIONAL, under the direction of the Infant Formula Council of America-a trade association of manufacturers and marketers of formulated nutritional products-agreed to establish voluntary consensus Standard Method Performance Requirements, and, ultimately, to identify and publish globally recognized, fit-for-purpose standard methods. To accomplish this task, nutritional reference materials (RMs), representing all major commercially available nutritional formulations, were (and continue to be) a critical necessity. In this paper, various types of RMs will be defined, followed by review and discussion of their importance to the infant formula industry.

  7. Software Safety Risk in Legacy Safety-Critical Computer Systems

    NASA Technical Reports Server (NTRS)

    Hill, Janice; Baggs, Rhoda

    2007-01-01

    Safety-critical computer systems must be engineered to meet system and software safety requirements. For legacy safety-critical computer systems, software safety requirements may not have been formally specified during development. When process-oriented software safety requirements are levied on a legacy system after the fact, where software development artifacts don't exist or are incomplete, the question becomes 'how can this be done?' The risks associated with only meeting certain software safety requirements in a legacy safety-critical computer system must be addressed should such systems be selected as candidates for reuse. This paper proposes a method for ascertaining formally, a software safety risk assessment, that provides measurements for software safety for legacy systems which may or may not have a suite of software engineering documentation that is now normally required. It relies upon the NASA Software Safety Standard, risk assessment methods based upon the Taxonomy-Based Questionnaire, and the application of reverse engineering CASE tools to produce original design documents for legacy systems.

  8. Scheduling Software for Complex Scenarios

    NASA Technical Reports Server (NTRS)

    2006-01-01

    Preparing a vehicle and its payload for a single launch is a complex process that involves thousands of operations. Because the equipment and facilities required to carry out these operations are extremely expensive and limited in number, optimal assignment and efficient use are critically important. Overlapping missions that compete for the same resources, ground rules, safety requirements, and the unique needs of processing vehicles and payloads destined for space impose numerous constraints that, when combined, require advanced scheduling. Traditional scheduling systems use simple algorithms and criteria when selecting activities and assigning resources and times to each activity. Schedules generated by these simple decision rules are, however, frequently far from optimal. To resolve mission-critical scheduling issues and predict possible problem areas, NASA historically relied upon expert human schedulers who used their judgment and experience to determine where things should happen, whether they will happen on time, and whether the requested resources are truly necessary.

  9. State of science: mental workload in ergonomics.

    PubMed

    Young, Mark S; Brookhuis, Karel A; Wickens, Christopher D; Hancock, Peter A

    2015-01-01

    Mental workload (MWL) is one of the most widely used concepts in ergonomics and human factors and represents a topic of increasing importance. Since modern technology in many working environments imposes ever more cognitive demands upon operators while physical demands diminish, understanding how MWL impinges on performance is increasingly critical. Yet, MWL is also one of the most nebulous concepts, with numerous definitions and dimensions associated with it. Moreover, MWL research has had a tendency to focus on complex, often safety-critical systems (e.g. transport, process control). Here we provide a general overview of the current state of affairs regarding the understanding, measurement and application of MWL in the design of complex systems over the last three decades. We conclude by discussing contemporary challenges for applied research, such as the interaction between cognitive workload and physical workload, and the quantification of workload 'redlines' which specify when operators are approaching or exceeding their performance tolerances.

  10. DOE standard 3009 - a reasoned, practical approach to integrating criticality safety into SARs

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Vessard, S.G.

    1995-12-31

    In the past there have been efforts by the U.S. Department of Energy (DOE) to provide guidance on those elements that should be included in a facility`s safety analysis report (SAR). In particular, there are two DOE Orders (5480.23, {open_quotes}Nuclear Safety Analysis Reports,{close_quotes} and 5480.24, {open_quotes}Nuclear Criticality Safety{close_quotes}), an interpretive guidance document (NE-70, Interpretive Guidance for DOE Order 5480.24, {open_quotes}Nuclear Criticality Safety{close_quotes}), and DOE Standard DOE-STD-3009-94 {open_quotes}Preparation Guide for U.S. Department of Energy Nonreactor Nuclear Facility Safety Analysis Reports.{close_quotes} Of these, the most practical and useful (pertaining to the application of criticality safety) is DOE-STD-3009-94. This paper is a reviewmore » of Chapters 3, 4, and 6 of this standard and how they provide very clear, helpful, and reasoned criticality safety guidance.« less

  11. Providing Nuclear Criticality Safety Analysis Education through Benchmark Experiment Evaluation

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    John D. Bess; J. Blair Briggs; David W. Nigg

    2009-11-01

    One of the challenges that today's new workforce of nuclear criticality safety engineers face is the opportunity to provide assessment of nuclear systems and establish safety guidelines without having received significant experience or hands-on training prior to graduation. Participation in the International Criticality Safety Benchmark Evaluation Project (ICSBEP) and/or the International Reactor Physics Experiment Evaluation Project (IRPhEP) provides students and young professionals the opportunity to gain experience and enhance critical engineering skills.

  12. Verification and Validation of Flight-Critical Systems

    NASA Technical Reports Server (NTRS)

    Brat, Guillaume

    2010-01-01

    For the first time in many years, the NASA budget presented to congress calls for a focused effort on the verification and validation (V&V) of complex systems. This is mostly motivated by the results of the VVFCS (V&V of Flight-Critical Systems) study, which should materialize as a a concrete effort under the Aviation Safety program. This talk will present the results of the study, from requirements coming out of discussions with the FAA and the Joint Planning and Development Office (JPDO) to technical plan addressing the issue, and its proposed current and future V&V research agenda, which will be addressed by NASA Ames, Langley, and Dryden as well as external partners through NASA Research Announcements (NRA) calls. This agenda calls for pushing V&V earlier in the life cycle and take advantage of formal methods to increase safety and reduce cost of V&V. I will present the on-going research work (especially the four main technical areas: Safety Assurance, Distributed Systems, Authority and Autonomy, and Software-Intensive Systems), possible extensions, and how VVFCS plans on grounding the research in realistic examples, including an intended V&V test-bench based on an Integrated Modular Avionics (IMA) architecture and hosted by Dryden.

  13. Optimizing the Design of Preprinted Orders for Ambulatory Chemotherapy: Combining Oncology, Human Factors, and Graphic Design

    PubMed Central

    Jeon, Jennifer; White, Rachel E.; Hunt, Richard G.; Cassano-Piché, Andrea L.; Easty, Anthony C.

    2012-01-01

    Purpose: To establish a set of guidelines for developing ambulatory chemotherapy preprinted orders. Methods: Multiple methods were used to develop the preprinted order guidelines. These included (A) a comprehensive literature review and an environmental scan; (B) analyses of field study observations and incident reports; (C) critical review of evidence from the literature and the field study observation analyses; (D) review of the draft guidelines by a clinical advisory group; and (E) collaboration with graphic designers to develop sample preprinted orders, refine the design guidelines, and format the resulting content. Results: The Guidelines for Developing Ambulatory Chemotherapy Preprinted Orders, which consist of guidance on the design process, content, and graphic design elements of ambulatory chemotherapy preprinted orders, have been established. Conclusion: Health care is a safety critical, dynamic, and complex sociotechnical system. Identifying safety risks in such a system and effectively addressing them often require the expertise of multiple disciplines. This study illustrates how human factors professionals, clinicians, and designers can leverage each other's expertise to uncover commonly overlooked patient safety hazards and to provide health care professionals with innovative, practical, and user-centered tools to minimize those hazards. PMID:23077436

  14. Optimizing the design of preprinted orders for ambulatory chemotherapy: combining oncology, human factors, and graphic design.

    PubMed

    Jeon, Jennifer; White, Rachel E; Hunt, Richard G; Cassano-Piché, Andrea L; Easty, Anthony C

    2012-03-01

    To establish a set of guidelines for developing ambulatory chemotherapy preprinted orders. Multiple methods were used to develop the preprinted order guidelines. These included (A) a comprehensive literature review and an environmental scan; (B) analyses of field study observations and incident reports; (C) critical review of evidence from the literature and the field study observation analyses; (D) review of the draft guidelines by a clinical advisory group; and (E) collaboration with graphic designers to develop sample preprinted orders, refine the design guidelines, and format the resulting content. The Guidelines for Developing Ambulatory Chemotherapy Preprinted Orders, which consist of guidance on the design process, content, and graphic design elements of ambulatory chemotherapy preprinted orders, have been established. Health care is a safety critical, dynamic, and complex sociotechnical system. Identifying safety risks in such a system and effectively addressing them often require the expertise of multiple disciplines. This study illustrates how human factors professionals, clinicians, and designers can leverage each other's expertise to uncover commonly overlooked patient safety hazards and to provide health care professionals with innovative, practical, and user-centered tools to minimize those hazards.

  15. From Invention to Innovation: Risk Analysis to Integrate One Health Technology in the Dairy Farm

    PubMed Central

    Lombardo, Andrea; Boselli, Carlo; Amatiste, Simonetta; Ninci, Simone; Frazzoli, Chiara; Dragone, Roberto; De Rossi, Alberto; Grasso, Gerardo; Mantovani, Alberto; Brajon, Giovanni

    2017-01-01

    Current Hazard Analysis Critical Control Points (HACCP) approaches mainly fit for food industry, while their application in primary food production is still rudimentary. The European food safety framework calls for science-based support to the primary producers’ mandate for legal, scientific, and ethical responsibility in food supply. The multidisciplinary and interdisciplinary project ALERT pivots on the development of the technological invention (BEST platform) and application of its measurable (bio)markers—as well as scientific advances in risk analysis—at strategic points of the milk chain for time and cost-effective early identification of unwanted and/or unexpected events of both microbiological and toxicological nature. Health-oriented innovation is complex and subject to multiple variables. Through field activities in a dairy farm in central Italy, we explored individual components of the dairy farm system to overcome concrete challenges for the application of translational science in real life and (veterinary) public health. Based on an HACCP-like approach in animal production, the farm characterization focused on points of particular attention (POPAs) and critical control points to draw a farm management decision tree under the One Health view (environment, animal health, food safety). The analysis was based on the integrated use of checklists (environment; agricultural and zootechnical practices; animal health and welfare) and laboratory analyses of well water, feed and silage, individual fecal samples, and bulk milk. The understanding of complex systems is a condition to accomplish true innovation through new technologies. BEST is a detection and monitoring system in support of production security, quality and safety: a grid of its (bio)markers can find direct application in critical points for early identification of potential hazards or anomalies. The HACCP-like self-monitoring in primary production is feasible, as well as the biomonitoring of live food producing animals as sentinel population for One Health. PMID:29218304

  16. From Invention to Innovation: Risk Analysis to Integrate One Health Technology in the Dairy Farm.

    PubMed

    Lombardo, Andrea; Boselli, Carlo; Amatiste, Simonetta; Ninci, Simone; Frazzoli, Chiara; Dragone, Roberto; De Rossi, Alberto; Grasso, Gerardo; Mantovani, Alberto; Brajon, Giovanni

    2017-01-01

    Current Hazard Analysis Critical Control Points (HACCP) approaches mainly fit for food industry, while their application in primary food production is still rudimentary. The European food safety framework calls for science-based support to the primary producers' mandate for legal, scientific, and ethical responsibility in food supply. The multidisciplinary and interdisciplinary project ALERT pivots on the development of the technological invention (BEST platform) and application of its measurable (bio)markers-as well as scientific advances in risk analysis-at strategic points of the milk chain for time and cost-effective early identification of unwanted and/or unexpected events of both microbiological and toxicological nature. Health-oriented innovation is complex and subject to multiple variables. Through field activities in a dairy farm in central Italy, we explored individual components of the dairy farm system to overcome concrete challenges for the application of translational science in real life and (veterinary) public health. Based on an HACCP-like approach in animal production, the farm characterization focused on points of particular attention (POPAs) and critical control points to draw a farm management decision tree under the One Health view (environment, animal health, food safety). The analysis was based on the integrated use of checklists (environment; agricultural and zootechnical practices; animal health and welfare) and laboratory analyses of well water, feed and silage, individual fecal samples, and bulk milk. The understanding of complex systems is a condition to accomplish true innovation through new technologies. BEST is a detection and monitoring system in support of production security, quality and safety: a grid of its (bio)markers can find direct application in critical points for early identification of potential hazards or anomalies. The HACCP-like self-monitoring in primary production is feasible, as well as the biomonitoring of live food producing animals as sentinel population for One Health.

  17. 48 CFR 209.270 - Aviation and ship critical safety items.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 48 Federal Acquisition Regulations System 3 2012-10-01 2012-10-01 false Aviation and ship critical safety items. 209.270 Section 209.270 Federal Acquisition Regulations System DEFENSE ACQUISITION... Requirements 209.270 Aviation and ship critical safety items. ...

  18. 48 CFR 209.270 - Aviation and ship critical safety items.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 48 Federal Acquisition Regulations System 3 2011-10-01 2011-10-01 false Aviation and ship critical safety items. 209.270 Section 209.270 Federal Acquisition Regulations System DEFENSE ACQUISITION... Requirements 209.270 Aviation and ship critical safety items. ...

  19. 48 CFR 209.270 - Aviation and ship critical safety items.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 48 Federal Acquisition Regulations System 3 2013-10-01 2013-10-01 false Aviation and ship critical safety items. 209.270 Section 209.270 Federal Acquisition Regulations System DEFENSE ACQUISITION... Requirements 209.270 Aviation and ship critical safety items. ...

  20. 48 CFR 209.270 - Aviation and ship critical safety items.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 48 Federal Acquisition Regulations System 3 2014-10-01 2014-10-01 false Aviation and ship critical safety items. 209.270 Section 209.270 Federal Acquisition Regulations System DEFENSE ACQUISITION... Requirements 209.270 Aviation and ship critical safety items. ...

  1. 48 CFR 209.270 - Aviation and ship critical safety items.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Requirements 209.270 Aviation and ship critical safety items. ... 48 Federal Acquisition Regulations System 3 2010-10-01 2010-10-01 false Aviation and ship critical safety items. 209.270 Section 209.270 Federal Acquisition Regulations System DEFENSE ACQUISITION...

  2. Criticality Safety Evaluation of the LLNL Inherently Safe Subcritical Assembly (ISSA)

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Percher, Catherine

    2012-06-19

    The LLNL Nuclear Criticality Safety Division has developed a training center to illustrate criticality safety and reactor physics concepts through hands-on experimental training. The experimental assembly, the Inherently Safe Subcritical Assembly (ISSA), uses surplus highly enriched research reactor fuel configured in a water tank. The training activities will be conducted by LLNL following the requirements of an Integration Work Sheet (IWS) and associated Safety Plan. Students will be allowed to handle the fissile material under the supervision of LLNL instructors. This report provides the technical criticality safety basis for instructional operations with the ISSA experimental assembly.

  3. A method for identifying EMI critical circuits during development of a large C3

    NASA Astrophysics Data System (ADS)

    Barr, Douglas H.

    The circuit analysis methods and process Boeing Aerospace used on a large, ground-based military command, control, and communications (C3) system are described. This analysis was designed to help identify electromagnetic interference (EMI) critical circuits. The methodology used the MIL-E-6051 equipment criticality categories as the basis for defining critical circuits, relational database technology to help sort through and account for all of the approximately 5000 system signal cables, and Macintosh Plus personal computers to predict critical circuits based on safety margin analysis. The EMI circuit analysis process systematically examined all system circuits to identify which ones were likely to be EMI critical. The process used two separate, sequential safety margin analyses to identify critical circuits (conservative safety margin analysis, and detailed safety margin analysis). These analyses used field-to-wire and wire-to-wire coupling models using both worst-case and detailed circuit parameters (physical and electrical) to predict circuit safety margins. This process identified the predicted critical circuits that could then be verified by test.

  4. Software Safety Progress in NASA

    NASA Technical Reports Server (NTRS)

    Radley, Charles F.

    1995-01-01

    NASA has developed guidelines for development and analysis of safety-critical software. These guidelines have been documented in a Guidebook for Safety Critical Software Development and Analysis. The guidelines represent a practical 'how to' approach, to assist software developers and safety analysts in cost effective methods for software safety. They provide guidance in the implementation of the recent NASA Software Safety Standard NSS-1740.13 which was released as 'Interim' version in June 1994, scheduled for formal adoption late 1995. This paper is a survey of the methods in general use, resulting in the NASA guidelines for safety critical software development and analysis.

  5. Activities of the DOE Nuclear Criticality Safety Program (NCSP) at the Oak Ridge Electron Linear Accelerator (ORELA)

    NASA Astrophysics Data System (ADS)

    Valentine, Timothy E.; Leal, Luiz C.; Guber, Klaus H.

    2002-12-01

    The Department of Energy established the Nuclear Criticality Safety Program (NCSP) in response to the Recommendation 97-2 by the Defense Nuclear Facilities Safety Board. The NCSP consists of seven elements of which nuclear data measurements and evaluations is a key component. The intent of the nuclear data activities is to provide high resolution nuclear data measurements that are evaluated, validated, and formatted for use by the nuclear criticality safety community to provide improved and reliable calculations for nuclear criticality safety evaluations. High resolution capture, fission, and transmission measurements are performed at the Oak Ridge Electron Linear Accelerator (ORELA) to address the needs of the criticality safety community and to address known deficiencies in nuclear data evaluations. The activities at ORELA include measurements on both light and heavy nuclei and have been used to identify improvements in measurement techniques that greatly improve the measurement of small capture cross sections. The measurement activities at ORELA provide precise and reliable high-resolution nuclear data for the nuclear criticality safety community.

  6. Test Facilities and Experience on Space Nuclear System Developments at the Kurchatov Institute

    NASA Astrophysics Data System (ADS)

    Ponomarev-Stepnoi, Nikolai N.; Garin, Vladimir P.; Glushkov, Evgeny S.; Kompaniets, George V.; Kukharkin, Nikolai E.; Madeev, Vicktor G.; Papin, Vladimir K.; Polyakov, Dmitry N.; Stepennov, Boris S.; Tchuniyaev, Yevgeny I.; Tikhonov, Lev Ya.; Uksusov, Yevgeny I.

    2004-02-01

    The complexity of space fission systems and rigidity of requirement on minimization of weight and dimension characteristics along with the wish to decrease expenditures on their development demand implementation of experimental works which results shall be used in designing, safety substantiation, and licensing procedures. Experimental facilities are intended to solve the following tasks: obtainment of benchmark data for computer code validations, substantiation of design solutions when computational efforts are too expensive, quality control in a production process, and ``iron'' substantiation of criticality safety design solutions for licensing and public relations. The NARCISS and ISKRA critical facilities and unique ORM facility on shielding investigations at the operating OR nuclear research reactor were created in the Kurchatov Institute to solve the mentioned tasks. The range of activities performed at these facilities within the implementation of the previous Russian nuclear power system programs is briefly described in the paper. This experience shall be analyzed in terms of methodological approach to development of future space nuclear systems (this analysis is beyond this paper). Because of the availability of these facilities for experiments, the brief description of their critical assemblies and characteristics is given in this paper.

  7. Accidents in Malaysian construction industry: statistical data and court cases.

    PubMed

    Chong, Heap Yih; Low, Thuan Siang

    2014-01-01

    Safety and health issues remain critical to the construction industry due to its working environment and the complexity of working practises. This research attempts to adopt 2 research approaches using statistical data and court cases to address and identify the causes and behavior underlying construction safety and health issues in Malaysia. Factual data on the period of 2000-2009 were retrieved to identify the causes and agents that contributed to health issues. Moreover, court cases were tabulated and analyzed to identify legal patterns of parties involved in construction site accidents. Approaches of this research produced consistent results and highlighted a significant reduction in the rate of accidents per construction project in Malaysia.

  8. Verification Failures: What to Do When Things Go Wrong

    NASA Astrophysics Data System (ADS)

    Bertacco, Valeria

    Every integrated circuit is released with latent bugs. The damage and risk implied by an escaped bug ranges from almost imperceptible to potential tragedy; unfortunately it is impossible to discern within this range before a bug has been exposed and analyzed. While the past few decades have witnessed significant efforts to improve verification methodology for hardware systems, these efforts have been far outstripped by the massive complexity of modern digital designs, leading to product releases for which an always smaller fraction of system's states has been verified. The news of escaped bugs in large market designs and/or safety critical domains is alarming because of safety and cost implications (due to replacements, lawsuits, etc.).

  9. KSC-2014-4729

    NASA Image and Video Library

    2014-12-05

    CAPE CANAVERAL, Fla. -- A Delta IV Heavy rocket soars after liftoff from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system. Photo credit: NASA/George Roberts

  10. Clinical risk management and patient safety education for nurses: a critique.

    PubMed

    Johnstone, Megan-Jane; Kanitsaki, Olga

    2007-04-01

    Nurses have a pivotal role to play in clinical risk management (CRM) and promoting patient safety in health care domains. Accordingly, nurses need to be prepared educationally to manage clinical risk effectively when delivering patient care. Just what form the CRM and safety education of nurses should take, however, remains an open question. A recent search of the literature has revealed a surprising lack of evidence substantiating models of effective CRM and safety education for nurses. In this paper, a critical discussion is advanced on the question of CRM and safety education for nurses and the need for nurse education in this area to be reviewed and systematically researched as a strategic priority, nationally and internationally. It is a key contention of this paper that without 'good' safety education research it will not be possible to ensure that the educational programs that are being offered to nurses in this area are evidence-based and designed in a manner that will enable nurses to develop the capabilities they need to respond effectively to the multifaceted and complex demands that are inherent in their ethical and professional responsibilities to promote and protect patient safety and quality care in health care domains.

  11. Expressions of cultural safety in public health nursing practice.

    PubMed

    Richardson, Anna; Yarwood, Judy; Richardson, Sandra

    2017-01-01

    Cultural safety is an essential concept within New Zealand nursing that is formally linked to registration and competency-based practice certification. Despite its centrality to New Zealand nursing philosophies and the stated expectation of cultural safety as a practice element, there is limited evidence of its application in the literature. This research presents insight into public health nurse's (PHN) experiences, demonstrating the integration of cultural safety principles into practice. These findings emerged following secondary analysis of data from a collaborative, educative research project where PHNs explored the use of family assessment tools. In particular, the 15-minute interview tool was introduced and used by the PHNs when working with families. Critical analysis of transcribed data from PHN interviews, utilising a cultural safety lens, illuminated practical ways in which cultural safety concepts infused PHN practice with families. The themes that emerged reflected the interweaving of the principles of cultural safety with the application of the five components of the 15-minute interview. This highlights elements of PHN work with individuals and families not previously acknowledged. Examples of culturally safe nursing practice resonated throughout the PHN conversations as they grappled with the increasing complexity of working with a diverse range of families. © 2016 John Wiley & Sons Ltd.

  12. Physics of reactor safety. Quarterly report, January--March 1977. [LMFBR

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    None

    1977-06-01

    This report summarizes work done on reactor safety, Monte Carlo analysis of safety-related critical assembly experiments, and planning of DEMI safety-related critical experiments. Work on reactor core thermal-hydraulics is also included.

  13. Experimental Fuels Facility Re-categorization Based on Facility Segmentation

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Reiss, Troy P.; Andrus, Jason

    The Experimental Fuels Facility (EFF) (MFC-794) at the Materials and Fuels Complex (MFC) located on the Idaho National Laboratory (INL) Site was originally constructed to provide controlled-access, indoor storage for radiological contaminated equipment. Use of the facility was expanded to provide a controlled environment for repairing contaminated equipment and characterizing, repackaging, and treating waste. The EFF facility is also used for research and development services, including fuel fabrication. EFF was originally categorized as a LTHC-3 radiological facility based on facility operations and facility radiological inventories. Newly planned program activities identified the need to receive quantities of fissionable materials in excessmore » of the single parameter subcritical limit in ANSI/ANS-8.1, “Nuclear Criticality Safety in Operations with Fissionable Materials Outside Reactors” (identified as “criticality list” quantities in DOE-STD-1027-92, “Hazard Categorization and Accident Analysis Techniques for Compliance with DOE Order 5480.23, Nuclear Safety Analysis Reports,” Attachment 1, Table A.1). Since the proposed inventory of fissionable materials inside EFF may be greater than the single parameter sub-critical limit of 700 g of U-235 equivalent, the initial re-categorization is Hazard Category (HC) 2 based upon a potential criticality hazard. This paper details the facility hazard categorization performed for the EFF. The categorization was necessary to determine (a) the need for further safety analysis in accordance with LWP-10802, “INL Facility Categorization,” and (b) compliance with 10 Code of Federal Regulations (CFR) 830, Subpart B, “Safety Basis Requirements.” Based on the segmentation argument presented in this paper, the final hazard categorization for the facility is LTHC-3. Department of Energy Idaho (DOE-ID) approval of the final hazard categorization determined by this hazard assessment document (HAD) was required per the DOE-ID Supplemental Guidance for DOE-STD-1027-92 based on the proposed downgrade of the initial facility categorization of Hazard Category 2.« less

  14. Tank waste remediation system nuclear criticality safety program management review

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    BRADY RAAP, M.C.

    1999-06-24

    This document provides the results of an internal management review of the Tank Waste Remediation System (TWRS) criticality safety program, performed in advance of the DOE/RL assessment for closure of the TWRS Nuclear Criticality Safety Issue, March 1994. Resolution of the safety issue was identified as Hanford Federal Facility Agreement and Consent Order (Tri-Party Agreement) Milestone M-40-12, due September 1999.

  15. Y-12 PLANT NUCLEAR SAFETY HANDBOOK

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Wachter, J.W. ed.; Bailey, M.L.; Cagle, T.J.

    1963-03-27

    Information needed to solve nuclear safety problems is condensed into a reference book for use by persons familiar with the field. Included are a glossary of terms; useful tables; nuclear constants; criticality calculations; basic nuclear safety limits; solution geometries and critical values; metal critical values; criticality values for intermediate, heterogeneous, and interacting systems; miscellaneous and related information; and report number, author, and subject indexes. (C.H.)

  16. Developing the practice context to enable more effective pain management with older people: an action research approach

    PubMed Central

    2011-01-01

    Background This paper, which draws upon an Emancipatory Action Research (EAR) approach, unearths how the complexities of context influence the realities of nursing practice. While the intention of the project was to identify and change factors in the practice context that inhibit effective person-centred pain management practices with older people (65 years or older), reflective critical engagement with the findings identified that enhancing pain management practices with older people was dependent on cultural change in the unit as a whole. Methods An EAR approach was utilised. The project was undertaken in a surgical unit that conducted complex abdominal surgery. Eighty-five percent (n = 48) of nursing staff participated in the two-year project (05/NIR02/107). Data were obtained through the use of facilitated critical reflection with nursing staff. Results Three key themes (psychological safety, leadership, oppression) and four subthemes (power, horizontal violence, distorted perceptions, autonomy) were found to influence the way in which effective nursing practice was realised. Within the theme of 'context,' effective leadership and the creation of a psychologically safe environment were key elements in the enhancement of all aspects of nursing practice. Conclusions Whilst other research has identified the importance of 'practice context' and models and frameworks are emerging to address this issue, the theme of 'psychological safety' has been given little attention in the knowledge translation/implementation literature. Within the principles of EAR, facilitated reflective sessions were found to create 'psychologically safe spaces' that supported practitioners to develop effective person-centred nursing practices in complex clinical environments. PMID:21284857

  17. Criticality Safety Evaluations on the Use of 200-gram Pu Mass Limit for RHWM Waste Storage Operations

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Chou, P

    This work establishes the criticality safety technical basis to increase the fissile mass limit from 120 grams to 200 grams for Type A 55-gallon drums and their equivalents. Current RHWM fissile mass limit is 120 grams Pu for Type A 55-gallon containers and their equivalent. In order to increase the Type A 55-gallon drum limit to 200 grams, a few additional criticality safety control requirements are needed on moderators, reflectors, and array controls to ensure that the 200-gram Pu drums remain criticality safe with inadvertent criticality remains incredible. The purpose of this work is to analyze the use of 200-grammore » Pu drum mass limit for waste storage operations in Radioactive and Hazardous Waste Management (RHWM) Facilities. In this evaluation, the criticality safety controls associated with the 200-gram Pu drums are established for the RHWM waste storage operations. With the implementation of these criticality safety controls, the 200-gram Pu waste drum storage operations are demonstrated to be criticality safe and meet the double-contingency-principle requirement per DOE O 420.1.« less

  18. 75 FR 8239 - School Food Safety Program Based on Hazard Analysis and Critical Control Point Principles (HACCP...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-24

    ... 0584-AD65 School Food Safety Program Based on Hazard Analysis and Critical Control Point Principles... Safety Program Based on Hazard Analysis and Critical Control Point Principles (HACCP) was published on... of Management and Budget (OMB) cleared the associated information collection requirements (ICR) on...

  19. 76 FR 14641 - Defense Federal Acquisition Regulation Supplement; Identification of Critical Safety Items (DFARS...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-17

    ... Federal Acquisition Regulation Supplement; Identification of Critical Safety Items (DFARS Case 2010-D022... contract clause that clearly identifies any items being purchased that are critical safety items so that.... SUPPLEMENTARY INFORMATION: I. Background This DFARS case was initiated at the request of the Defense Contract...

  20. Cannabis for therapeutic purposes and public health and safety: a systematic and critical review.

    PubMed

    Sznitman, Sharon R; Zolotov, Yuval

    2015-01-01

    The use of Cannabis for Therapeutic Purposes (CTP) has recently become legal in many places. These policy and legal modifications may be related to changes in cannabis perceptions, availability and use and in the way cannabis is grown and sold. This may in turn have effects on public health and safety. To better understand the potential effects of CTP legalization on public health and safety, the current paper synthesizes and critically discusses the relevant literature. Twenty-eight studies were identified by a comprehensive search strategy, and their characteristics and main findings were systematically reviewed according to the following content themes: CTP and illegal cannabis use; CTP and other public health issues; CTP, crime and neighbourhood disadvantage. The research field is currently limited by a lack of theoretical and methodological rigorous studies. The review shows that the most prevalent theme of investigation so far has been the relation between CTP and illegal cannabis use. In addition, the literature review shows that there is an absence of evidence to support many common concerns related to detrimental public health and safety effects of CTP legalization. Although lack of evidence provides some reassurance that CTP legalization may not have posed a substantial threat to public health and safety, this conclusion needs to be examined in light of the limitations of studies conducted so far. Furthermore, as CTP policy continues to evolve, including incorporation of greater commercialization, it is possible that the full effects of CTP legalization have yet to take place. Ensuring study quality will allow future research to better investigate the complex role that CTP plays in relation to society at large, and public health and safety in particular. Copyright © 2014 Elsevier B.V. All rights reserved.

  1. Optimizing Automatic Deployment Using Non-functional Requirement Annotations

    NASA Astrophysics Data System (ADS)

    Kugele, Stefan; Haberl, Wolfgang; Tautschnig, Michael; Wechs, Martin

    Model-driven development has become common practice in design of safety-critical real-time systems. High-level modeling constructs help to reduce the overall system complexity apparent to developers. This abstraction caters for fewer implementation errors in the resulting systems. In order to retain correctness of the model down to the software executed on a concrete platform, human faults during implementation must be avoided. This calls for an automatic, unattended deployment process including allocation, scheduling, and platform configuration.

  2. Interpretation of Simultaneous Mechanical-Electrical-Thermal Failure in a Lithium-Ion Battery Module: Preprint

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Zhang, Chao; Santhanagopalan, Shriram; Stock, Mark J.

    Lithium-ion batteries are currently the state-of- the-art power sources for electric vehicles, and their safety behavior when subjected to abuse, such as a mechanical impact, is of critical concern. A coupled mechanical-electrical-thermal model for simulating the behavior of a lithium-ion battery under a mechanical crush has been developed. We present a series of production-quality visualizations to illustrate the complex mechanical and electrical interactions in this model.

  3. Fuzzy-logic-based network for complex systems risk assessment: application to ship performance analysis.

    PubMed

    Abou, Seraphin C

    2012-03-01

    In this paper, a new interpretation of intuitionistic fuzzy sets in the advanced framework of the Dempster-Shafer theory of evidence is extended to monitor safety-critical systems' performance. Not only is the proposed approach more effective, but it also takes into account the fuzzy rules that deal with imperfect knowledge/information and, therefore, is different from the classical Takagi-Sugeno fuzzy system, which assumes that the rule (the knowledge) is perfect. We provide an analytical solution to the practical and important problem of the conceptual probabilistic approach for formal ship safety assessment using the fuzzy set theory that involves uncertainties associated with the reliability input data. Thus, the overall safety of the ship engine is investigated as an object of risk analysis using the fuzzy mapping structure, which considers uncertainty and partial truth in the input-output mapping. The proposed method integrates direct evidence of the frame of discernment and is demonstrated through references to examples where fuzzy set models are informative. These simple applications illustrate how to assess the conflict of sensor information fusion for a sufficient cooling power system of vessels under extreme operation conditions. It was found that propulsion engine safety systems are not only a function of many environmental and operation profiles but are also dynamic and complex. Copyright © 2011 Elsevier Ltd. All rights reserved.

  4. Building Safer Systems With SpecTRM

    NASA Technical Reports Server (NTRS)

    2003-01-01

    System safety, an integral component in software development, often poses a challenge to engineers designing computer-based systems. While the relaxed constraints on software design allow for increased power and flexibility, this flexibility introduces more possibilities for error. As a result, system engineers must identify the design constraints necessary to maintain safety and ensure that the system and software design enforces them. Safeware Engineering Corporation, of Seattle, Washington, provides the information, tools, and techniques to accomplish this task with its Specification Tools and Requirements Methodology (SpecTRM). NASA assisted in developing this engineering toolset by awarding the company several Small Business Innovation Research (SBIR) contracts with Ames Research Center and Langley Research Center. The technology benefits NASA through its applications for Space Station rendezvous and docking. SpecTRM aids system and software engineers in developing specifications for large, complex safety critical systems. The product enables engineers to find errors early in development so that they can be fixed with the lowest cost and impact on the system design. SpecTRM traces both the requirements and design rationale (including safety constraints) throughout the system design and documentation, allowing engineers to build required system properties into the design from the beginning, rather than emphasizing assessment at the end of the development process when changes are limited and costly.System safety, an integral component in software development, often poses a challenge to engineers designing computer-based systems. While the relaxed constraints on software design allow for increased power and flexibility, this flexibility introduces more possibilities for error. As a result, system engineers must identify the design constraints necessary to maintain safety and ensure that the system and software design enforces them. Safeware Engineering Corporation, of Seattle, Washington, provides the information, tools, and techniques to accomplish this task with its Specification Tools and Requirements Methodology (SpecTRM). NASA assisted in developing this engineering toolset by awarding the company several Small Business Innovation Research (SBIR) contracts with Ames Research Center and Langley Research Center. The technology benefits NASA through its applications for Space Station rendezvous and docking. SpecTRM aids system and software engineers in developing specifications for large, complex safety critical systems. The product enables engineers to find errors early in development so that they can be fixed with the lowest cost and impact on the system design. SpecTRM traces both the requirements and design rationale (including safety constraints) throughout the system design and documentation, allowing engineers to build required system properties into the design from the beginning, rather than emphasizing assessment at the end of the development process when changes are limited and costly.

  5. 49 CFR 236.911 - Exclusions.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... system technology. However, a subsystem or component of an office system must comply with the requirements of this subpart if it performs safety-critical functions within, or affects the safety performance... this subpart if they result in a degradation of safety or a material increase in safety-critical...

  6. 49 CFR 236.911 - Exclusions.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... system technology. However, a subsystem or component of an office system must comply with the requirements of this subpart if it performs safety-critical functions within, or affects the safety performance... this subpart if they result in a degradation of safety or a material increase in safety-critical...

  7. 49 CFR 236.911 - Exclusions.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... system technology. However, a subsystem or component of an office system must comply with the requirements of this subpart if it performs safety-critical functions within, or affects the safety performance... this subpart if they result in a degradation of safety or a material increase in safety-critical...

  8. 49 CFR 236.911 - Exclusions.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... system technology. However, a subsystem or component of an office system must comply with the requirements of this subpart if it performs safety-critical functions within, or affects the safety performance... this subpart if they result in a degradation of safety or a material increase in safety-critical...

  9. 49 CFR 236.911 - Exclusions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... system technology. However, a subsystem or component of an office system must comply with the requirements of this subpart if it performs safety-critical functions within, or affects the safety performance... this subpart if they result in a degradation of safety or a material increase in safety-critical...

  10. Critical Characteristics of Radiation Detection System Components to be Dedicated for use in Safety Class and Safety Significant System

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    DAVIS, S.J.

    2000-05-25

    This document identifies critical characteristics of components to be dedicated for use in Safety Class (SC) or Safety Significant (SS) Systems, Structures, or Components (SSCs). This document identifies the requirements for the components of the common radiation area monitor alarm in the WESF pool cell. These are procured as Commercial Grade Items (CGI), with the qualification testing and formal dedication to be performed at the Waste Encapsulation Storage Facility (WESF), in safety class, safety significant systems. System modifications are to be performed in accordance with the instructions provided on ECN 658230. Components for this change are commercially available and interchangeablemore » with the existing alarm configuration This document focuses on the operational requirements for alarm, declaration of the safety classification, identification of critical characteristics, and interpretation of requirements for procurement. Critical characteristics are identified herein and must be verified, followed by formal dedication, prior to the components being used in safety related applications.« less

  11. Additional nuclear criticality safety calculations for small-diameter containers

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Hone, M.J.

    This report documents additional criticality safety analysis calculations for small diameter containers, which were originally documented in Reference 1. The results in Reference 1 indicated that some of the small diameter containers did not meet the criteria established for criticality safety at the Portsmouth facility (K{sub eff} +2{sigma}<.95) when modeled under various contingency assumptions of reflection and moderation. The calculations performed in this report reexamine those cases which did not meet the criticality safety criteria. In some cases, unnecessary conservatism is removed, and in other cases mass or assay limits are established for use with the respective containers.

  12. Role of champions in the implementation of patient safety practice change.

    PubMed

    Soo, Stephanie; Berta, Whitney; Baker, G Ross

    2009-01-01

    Practitioners of patient safety practice change agree that champions are central to the success of implementation. The clinical champion role is a concept that has been widely promoted yet empirically underdeveloped in health services literature. Questions remain as to who these champions are, what roles they play in patient safety practice change and what contexts serve to facilitate their efforts. This investigation used a multiple-case study design to critically examine the role of champions in the implementation of rapid response teams (RRTs), an innovative complex patient safety intervention, in two large urban acute care facilities. An analysis of interviews with key individuals involved in the RRT implementation process revealed a typology of the patient safety practice champion that extended beyond clinical personnel to include managerial and executive staff. Champions engaged to a varying extent in a number of core activities, including education, advocacy, relationship building and boundary spanning. Individuals became champions both through informal emergence and a combination of formal appointment and informal emergence. By identifying and elaborating upon specific features of the champion role, this study aims to expand the dialogue about champions for patient safety practice change.

  13. Parallel computation of multigroup reactivity coefficient using iterative method

    NASA Astrophysics Data System (ADS)

    Susmikanti, Mike; Dewayatna, Winter

    2013-09-01

    One of the research activities to support the commercial radioisotope production program is a safety research target irradiation FPM (Fission Product Molybdenum). FPM targets form a tube made of stainless steel in which the nuclear degrees of superimposed high-enriched uranium. FPM irradiation tube is intended to obtain fission. The fission material widely used in the form of kits in the world of nuclear medicine. Irradiation FPM tube reactor core would interfere with performance. One of the disorders comes from changes in flux or reactivity. It is necessary to study a method for calculating safety terrace ongoing configuration changes during the life of the reactor, making the code faster became an absolute necessity. Neutron safety margin for the research reactor can be reused without modification to the calculation of the reactivity of the reactor, so that is an advantage of using perturbation method. The criticality and flux in multigroup diffusion model was calculate at various irradiation positions in some uranium content. This model has a complex computation. Several parallel algorithms with iterative method have been developed for the sparse and big matrix solution. The Black-Red Gauss Seidel Iteration and the power iteration parallel method can be used to solve multigroup diffusion equation system and calculated the criticality and reactivity coeficient. This research was developed code for reactivity calculation which used one of safety analysis with parallel processing. It can be done more quickly and efficiently by utilizing the parallel processing in the multicore computer. This code was applied for the safety limits calculation of irradiated targets FPM with increment Uranium.

  14. Integrated Systems Health Management for Space Exploration

    NASA Technical Reports Server (NTRS)

    Uckun, Serdar

    2005-01-01

    Integrated Systems Health Management (ISHM) is a system engineering discipline that addresses the design, development, operation, and lifecycle management of components, subsystems, vehicles, and other operational systems with the purpose of maintaining nominal system behavior and function and assuring mission safety and effectiveness under off-nominal conditions. NASA missions are often conducted in extreme, unfamiliar environments of space, using unique experimental spacecraft. In these environments, off-nominal conditions can develop with the potential to rapidly escalate into mission- or life-threatening situations. Further, the high visibility of NASA missions means they are always characterized by extraordinary attention to safety. ISHM is a critical element of risk mitigation, mission safety, and mission assurance for exploration. ISHM enables: In-space maintenance and repair; a) Autonomous (and automated) launch abort and crew escape capability; b) Efficient testing and checkout of ground and flight systems; c) Monitoring and trending of ground and flight system operations and performance; d) Enhanced situational awareness and control for ground personnel and crew; e) Vehicle autonomy (self-sufficiency) in responding to off-nominal conditions during long-duration and distant exploration missions; f) In-space maintenance and repair; and g) Efficient ground processing of reusable systems. ISHM concepts and technologies may be applied to any complex engineered system such as transportation systems, orbital or planetary habitats, observatories, command and control systems, life support systems, safety-critical software, and even the health of flight crews. As an overarching design and operational principle implemented at the system-of-systems level, ISHM holds substantial promise in terms of affordability, safety, reliability, and effectiveness of space exploration missions.

  15. Evaluation of human exposure to complex waveform magnetic fields generated by arc-welding equipment according to European safety standards.

    PubMed

    Zoppetti, Nicola; Bogi, Andrea; Pinto, Iole; Andreuccetti, Daniele

    2015-02-01

    In this paper, a procedure is described for the assessment of human exposure to magnetic fields with complex waveforms generated by arc-welding equipment. The work moves from the analysis of relevant guidelines and technical standards, underlining their strengths and their limits. Then, the procedure is described with particular attention to the techniques used to treat complex waveform fields. Finally, the procedure is applied to concrete cases encountered in the workplace. The discussion of the results highlights the critical points in the procedure, as well as those related to the evolution of the technical and exposure standards. © The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  16. A Wicked Problem: Early Childhood Safety in the Dynamic, Interactive Environment of Home

    PubMed Central

    Simpson, Jean; Fougere, Geoff; McGee, Rob

    2013-01-01

    Young children being injured at home is a perennial problem. When parents of young children and family workers discussed what influenced parents’ perceptions and responses to child injury risk at home, both “upstream” and “downstream” causal factors were identified. Among the former, complex and interactive facets of society and contemporary living emerged as potentially critical features. The “wicked problems” model arose from the need to find resolutions for complex problems in multidimensional environments and it proved a useful analogy for child injury. Designing dynamic strategies to provide resolutions to childhood injury, may address our over-dependence on ‘tame solutions’ that only deal with physical cause-and-effect relationships and which cannot address the complex interactive contexts in which young children are often injured. PMID:23615453

  17. Planning the Unplanned Experiment: Assessing the Efficacy of Standards for Safety Critical Software

    NASA Technical Reports Server (NTRS)

    Graydon, Patrick J.; Holloway, C. Michael

    2015-01-01

    We need well-founded means of determining whether software is t for use in safety-critical applications. While software in industries such as aviation has an excellent safety record, the fact that software aws have contributed to deaths illustrates the need for justi ably high con dence in software. It is often argued that software is t for safety-critical use because it conforms to a standard for software in safety-critical systems. But little is known about whether such standards `work.' Reliance upon a standard without knowing whether it works is an experiment; without collecting data to assess the standard, this experiment is unplanned. This paper reports on a workshop intended to explore how standards could practicably be assessed. Planning the Unplanned Experiment: Assessing the Ecacy of Standards for Safety Critical Software (AESSCS) was held on 13 May 2014 in conjunction with the European Dependable Computing Conference (EDCC). We summarize and elaborate on the workshop's discussion of the topic, including both the presented positions and the dialogue that ensued.

  18. Safety Hazards During Intrahospital Transport: A Prospective Observational Study.

    PubMed

    Bergman, Lina M; Pettersson, Monica E; Chaboyer, Wendy P; Carlström, Eric D; Ringdal, Mona L

    2017-10-01

    To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. The study was undertaken at two ICUs in one university hospital. Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. None. Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4-10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety.

  19. Criticality Safety Basics for INL FMHs and CSOs

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    V. L. Putman

    2012-04-01

    Nuclear power is a valuable and efficient energy alternative in our energy-intensive society. However, material that can generate nuclear power has properties that require this material be handled with caution. If improperly handled, a criticality accident could result, which could severely harm workers. This document is a modular self-study guide about Criticality Safety Principles. This guide's purpose it to help you work safely in areas where fissionable nuclear materials may be present, avoiding the severe radiological and programmatic impacts of a criticality accident. It is designed to stress the fundamental physical concepts behind criticality controls and the importance of criticalitymore » safety when handling fissionable materials outside nuclear reactors. This study guide was developed for fissionable-material-handler and criticality-safety-officer candidates to use with related web-based course 00INL189, BEA Criticality Safety Principles, and to help prepare for the course exams. These individuals must understand basic information presented here. This guide may also be useful to other Idaho National Laboratory personnel who must know criticality safety basics to perform their assignments safely or to design critically safe equipment or operations. This guide also includes additional information that will not be included in 00INL189 tests. The additional information is in appendices and paragraphs with headings that begin with 'Did you know,' or with, 'Been there Done that'. Fissionable-material-handler and criticality-safety-officer candidates may review additional information at their own discretion. This guide is revised as needed to reflect program changes, user requests, and better information. Issued in 2006, Revision 0 established the basic text and integrated various programs from former contractors. Revision 1 incorporates operation and program changes implemented since 2006. It also incorporates suggestions, clarifications, and additional information from readers and from personnel who took course 00INL189. Revision 1 also completely reorganized the training to better emphasize physical concepts behind the criticality controls that fissionable material handlers and criticality safety officers must understand. The reorganization is based on and consistent with changes made to course 00INL189 due to a review of course exam results and to discussions with personnel who conduct area-specific training.« less

  20. Challenges of postgraduate critical care nursing program in Iran.

    PubMed

    Dehghan Nayeri, Nahid; Shariat, Esmaeil; Tayebi, Zahra; Ghorbanzadeh, Majid

    2017-01-01

    Background: The main philosophy of postgraduate preparation for working in critical care units is to ensure the safety and quality of patients' care. Increasing the complexity of technology, decision-making challenges and the high demand for advanced communication skills necessitate the need to educate learners. Within this aim, a master's degree in critical care nursing has been established in Iran. Current study was designed to collect critical care nursing students' experiences as well as their feedback to the field critical care nursing. Methods: This study used qualitative content analysis through in-depth semi-structured interviews. Graneheim and Lundman method was used for data analysis. Results: The results of the total 15 interviews were classified in the following domains: The vision of hope and illusion; shades of grey attitude; inefficient program and planning; inadequacy to run the program; and multiple outcomes: Far from the effectiveness. Overall findings indicated the necessity to review the curriculum and the way the program is implemented. Conclusion: The findings of this study provided valuable information to improve the critical care-nursing program. It also facilitated the next review of the program by the authorities.

  1. The new interactive CESAR

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Fox, P.B.; Yatabe, M.

    1987-01-01

    In this report the Nuclear Criticality Safety Analytical Methods Resource Center describes a new interactive version of CESAR, a critical experiments storage and retrieval program available on the Nuclear Criticality Information System (NCIS) database at Lawrence Livermore National Laboratory. The original version of CESAR did not include interactive search capabilities. The CESAR database was developed to provide a convenient, readily accessible means of storing and retrieving code input data for the SCALE Criticality Safety Analytical Sequences and the codes comprising those sequences. The database includes data for both cross section preparation and criticality safety calculations. 3 refs., 1 tab.

  2. New interactive CESAR

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Fox, P.B.; Yatabe, M.

    1987-01-01

    The Nuclear Criticality Safety Analytical Methods Resource Center announces the availability of a new interactive version of CESAR, a critical experiments storage and retrieval program available on the Nuclear Criticality Information System (NCIS) data base at Lawrence Livermore National Laboratory. The original version of CESAR did not include interactive search capabilities. The CESAR data base was developed to provide a convenient, readily accessible means of storing and retrieving code input data for the SCALE criticality safety analytical sequences and the codes comprising those sequences. The data base includes data for both cross-section preparation and criticality safety calculations.

  3. Promoting correct car seat use in parents of young children: challenges, recommendations, and implications for health communication.

    PubMed

    Weaver, Nancy L; Brixey, Suzanne N; Williams, Janice; Nansel, Tonja R

    2013-03-01

    Injuries involving motor vehicles continue to be the biggest threat to the safety of children. Although child safety seats (CSS) have been established as a central countermeasure in decreasing injury risk, the majority of parents do not use the correct car seat correctly. There are many challenges in promoting correct car seat use, which itself is a complex behavior. To advance this critical protective behavior, the public health community would benefit from clarifying CSS messaging, communicating clearly, and addressing the conflicting recommendations of product use. In this article, we present current challenges in promoting CSS use and draw on health communication and other fields to offer recommendations for future work in this area.

  4. Nuclear criticality safety evaluation of the passage of decontaminated salt solution from the ITP filters into tank 50H for interim storage

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Hobbs, D.T.; Davis, J.R.

    This report assesses the nuclear criticality safety associated with the decontaminated salt solution after passing through the In-Tank Precipitation (ITP) filters, through the stripper columns and into Tank 50H for interim storage until transfer to the Saltstone facility. The criticality safety basis for the ITP process is documented. Criticality safety in the ITP filtrate has been analyzed under normal and process upset conditions. This report evaluates the potential for criticality due to the precipitation or crystallization of fissionable material from solution and an ITP process filter failure in which insoluble material carryover from salt dissolution is present. It is concludedmore » that no single inadvertent error will cause criticality and that the process will remain subcritical under normal and credible abnormal conditions.« less

  5. Managing Complex IT Security Processes with Value Based Measures

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Abercrombie, Robert K; Sheldon, Frederick T; Mili, Ali

    2009-01-01

    Current trends indicate that IT security measures will need to greatly expand to counter the ever increasingly sophisticated, well-funded and/or economically motivated threat space. Traditional risk management approaches provide an effective method for guiding courses of action for assessment, and mitigation investments. However, such approaches no matter how popular demand very detailed knowledge about the IT security domain and the enterprise/cyber architectural context. Typically, the critical nature and/or high stakes require careful consideration and adaptation of a balanced approach that provides reliable and consistent methods for rating vulnerabilities. As reported in earlier works, the Cyberspace Security Econometrics System provides amore » comprehensive measure of reliability, security and safety of a system that accounts for the criticality of each requirement as a function of one or more stakeholders interests in that requirement. This paper advocates a dependability measure that acknowledges the aggregate structure of complex system specifications, and accounts for variations by stakeholder, by specification components, and by verification and validation impact.« less

  6. AANA Journal course: update for nurse anesthetists--ERR WATCH: anesthesia crisis resource management from the nurse anesthetist's perspective.

    PubMed

    Fletcher, J L

    1998-12-01

    Anesthesia crisis resource management (ACRM) was developed by David Gaba, MD, and colleagues at Stanford University in the early 1990s. Derived from cockpit resource management of the aviation industry, ACRM addresses the issues of human performance and patient safety in anesthesia. Due to the inherent complexity of our dynamic work environment, we are frequently faced with situations that could escalate into critical incidents. ACRM explains the role of personal and environmental factors that can contribute to the evolution of critical incidents and provides the practitioner with some behavioral and intellectual guidelines to manage the risks more effectively. ERR WATCH is an acronym I developed to interpret the principles of ACRM from the nurse anesthetist's perspective. It provides a quick review of the major principles of ACRM, which are Environment, Resources, Reevaluation, Workload, Attention, Teamwork, Communication, and Help. Used together with good clinical management, these principles may provide an edge in solving complex problems and improving performance.

  7. Semantic Annotation of Complex Text Structures in Problem Reports

    NASA Technical Reports Server (NTRS)

    Malin, Jane T.; Throop, David R.; Fleming, Land D.

    2011-01-01

    Text analysis is important for effective information retrieval from databases where the critical information is embedded in text fields. Aerospace safety depends on effective retrieval of relevant and related problem reports for the purpose of trend analysis. The complex text syntax in problem descriptions has limited statistical text mining of problem reports. The presentation describes an intelligent tagging approach that applies syntactic and then semantic analysis to overcome this problem. The tags identify types of problems and equipment that are embedded in the text descriptions. The power of these tags is illustrated in a faceted searching and browsing interface for problem report trending that combines automatically generated tags with database code fields and temporal information.

  8. Critical attributes of transdermal drug delivery system (TDDS)--a generic product development review.

    PubMed

    Ruby, P K; Pathak, Shriram M; Aggarwal, Deepika

    2014-11-01

    Bioequivalence testing of transdermal drug delivery systems (TDDS) has always been a subject of high concern for generic companies due to the formulation complexity and the fact that they are subtle to even minor manufacturing differences and hence should be clearly qualified in terms of quality, safety and efficacy. In recent times bioequivalence testing of transdermal patches has gained a global attention and many regulatory authorities worldwide have issued recommendations to set specific framework for demonstrating equivalence between two products. These current regulatory procedures demand a complete characterization of the generic formulation in terms of its physicochemical sameness, pharmacokinetics disposition, residual content and/or skin irritation/sensitization testing with respect to the reference formulation. This paper intends to highlight critical in vitro tests in assessing the therapeutic equivalence of products and also outlines their valuable applications in generic product success. Understanding these critical in vitro parameters can probably help to decode the complex bioequivalence outcomes, directing the generic companies to optimize the formulation design in reduced time intervals. It is difficult to summarize a common platform which covers all possible transdermal products; hence few case studies based on this approach has been presented in this review.

  9. KSC-2014-4711

    NASA Image and Video Library

    2014-12-05

    CAPE CANAVERAL, Fla. -- A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system. For more information, visit www.nasa.gov/orion Photo credit: NASA/Jim Grossman

  10. KSC-2014-4742

    NASA Image and Video Library

    2014-12-05

    CAPE CANAVERAL, Fla. -- A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system. For more information, visit www.nasa.gov/orion Photo credit: NASA/Sandra Joseph

  11. KSC-2014-4710

    NASA Image and Video Library

    2014-12-05

    CAPE CANAVERAL, Fla. -- A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system. For more information, visit www.nasa.gov/orion Photo credit: NASA/Jim Grossman

  12. KSC-2014-4733

    NASA Image and Video Library

    2014-12-05

    CAPE CANAVERAL, Fla. -- A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system. For more information, visit www.nasa.gov/orion Photo credit: NASA/Tim Terry

  13. KSC-2014-4738

    NASA Image and Video Library

    2014-12-05

    CAPE CANAVERAL, Fla. -- A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system. For more information, visit www.nasa.gov/orion Photo credit: NASA/Sandra Joseph

  14. KSC-2014-4730

    NASA Image and Video Library

    2014-12-05

    CAPE CANAVERAL, Fla. -- A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system. For more information, visit www.nasa.gov/orion Photo credit: NASA/Tim Terry

  15. KSC-2014-4708

    NASA Image and Video Library

    2014-12-05

    CAPE CANAVERAL, Fla. -- A Delta IV Heavy rocket lifts off from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida carrying NASA's Orion spacecraft on an unpiloted flight test to Earth orbit. Liftoff was at 7:05 a.m. EST. During the two-orbit, four-and-a-half hour mission, engineers will evaluate the systems critical to crew safety, the launch abort system, the heat shield and the parachute system. For more information, visit www.nasa.gov/orion Photo credit: NASA/Jim Grossman

  16. International Space Station Materials: Selected Lessons Learned

    NASA Technical Reports Server (NTRS)

    Golden, Johnny L.

    2007-01-01

    The International Space Station (ISS) program is of such complexity and scale that there have been numerous issues addressed regarding safety of materials: from design to manufacturing, test, launch, assembly on-orbit, and operations. A selection of lessons learned from the ISS materials perspective will be provided. Topics of discussion are: flammability evaluation of materials with connection to on-orbit operations; toxicity findings for foams; compatibility testing for materials in fluid systems; and contamination control in precision clean systems and critical space vehicle surfaces.

  17. Challenges in High-Assurance Runtime Verification

    NASA Technical Reports Server (NTRS)

    Goodloe, Alwyn E.

    2016-01-01

    Safety-critical systems are growing more complex and becoming increasingly autonomous. Runtime Verification (RV) has the potential to provide protections when a system cannot be assured by conventional means, but only if the RV itself can be trusted. In this paper, we proffer a number of challenges to realizing high-assurance RV and illustrate how we have addressed them in our research. We argue that high-assurance RV provides a rich target for automated verification tools in hope of fostering closer collaboration among the communities.

  18. Using a Theory-Driven Approach to Manage the Relocation of an Intensive Care Unit: An Exemplar.

    PubMed

    Lin, Frances; Marshall, Andrea; Hervey, Lucy; Foster, Michelle; Hancock, Jane; Chaboyer, Wendy

    Proactive planning and managing moving from old to newly built hospitals, and the relocation process of patients for complex specialized units such as intensive care units, are necessary for both patient safety and staff well-being. This article provides an exemplar for how theory can be used to facilitate a positive relocation experience. Using change management theory, a systematic approach to cocreate implementation strategy among researchers and clinicians was critical to the success of this project.

  19. DOE Office of Scientific and Technical Information (OSTI.GOV)

    Costa, David A.; Cournoyer, Michael E.; Merhege, James F.

    Criticality is the state of a nuclear chain reacting medium when the chain reaction is just self-sustaining (or critical). Criticality is dependent on nine interrelated parameters. Moreover, we design criticality safety controls in order to constrain these parameters to minimize fissions and maximize neutron leakage and absorption in other materials, which makes criticality more difficult or impossible to achieve. We present the consequences of criticality accidents are discussed, the nine interrelated parameters that combine to affect criticality are described, and criticality safety controls used to minimize the likelihood of a criticality accident are presented.

  20. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting.

    PubMed

    Clarke, Christina M; Persaud, Drepaul David

    2011-03-01

    Many contemporary acute care facilities lack safe and effective clinical handover practices resulting in patient transitions that are vulnerable to discontinuities in care, medical errors, and adverse patient safety events. This article is intended to supplement existing handover improvement literature by providing practical guidance for leaders and managers who are seeking to improve the safety and the effectiveness of clinical handovers in the acute care setting. A 4-stage change model has been applied to guide the application of strategies for handover improvement. Change management and quality improvement principles, as well as concepts drawn from safety science and high-reliability organizations, were applied to inform strategies. A model for handover improvement respecting handover complexity is presented. Strategies targeted to stages of change include the following: 1. Enhancing awareness of handover problems and opportunities with the support of strategic directions, accountability, end user involvement, and problem complexity recognition. 2. Identifying solutions by applying and adapting best practices in local contexts. 3. Implementing locally adapted best practices supported by communication, documentation, and training. 4. Institutionalizing practice changes through integration, monitoring, and active dissemination. Finally, continued evaluation at every stage is essential. Although gaps in handover process and function knowledge remain, efforts to improve handover safety and effectiveness are still possible. Continued evaluation is critical in building this understanding and to ensure that practice changes lead to improvements in patient safety, organizational effectiveness, and patient and provider satisfaction. Through handover knowledge building, fundamental changes in handover policies and practices may be possible.

  1. Using Machine Learning to Predict MCNP Bias

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Grechanuk, Pavel Aleksandrovi

    For many real-world applications in radiation transport where simulations are compared to experimental measurements, like in nuclear criticality safety, the bias (simulated - experimental k eff) in the calculation is an extremely important quantity used for code validation. The objective of this project is to accurately predict the bias of MCNP6 [1] criticality calculations using machine learning (ML) algorithms, with the intention of creating a tool that can complement the current nuclear criticality safety methods. In the latest release of MCNP6, the Whisper tool is available for criticality safety analysts and includes a large catalogue of experimental benchmarks, sensitivity profiles,more » and nuclear data covariance matrices. This data, coming from 1100+ benchmark cases, is used in this study of ML algorithms for criticality safety bias predictions.« less

  2. Recognising safety critical events: can automatic video processing improve naturalistic data analyses?

    PubMed

    Dozza, Marco; González, Nieves Pañeda

    2013-11-01

    New trends in research on traffic accidents include Naturalistic Driving Studies (NDS). NDS are based on large scale data collection of driver, vehicle, and environment information in real world. NDS data sets have proven to be extremely valuable for the analysis of safety critical events such as crashes and near crashes. However, finding safety critical events in NDS data is often difficult and time consuming. Safety critical events are currently identified using kinematic triggers, for instance searching for deceleration below a certain threshold signifying harsh braking. Due to the low sensitivity and specificity of this filtering procedure, manual review of video data is currently necessary to decide whether the events identified by the triggers are actually safety critical. Such reviewing procedure is based on subjective decisions, is expensive and time consuming, and often tedious for the analysts. Furthermore, since NDS data is exponentially growing over time, this reviewing procedure may not be viable anymore in the very near future. This study tested the hypothesis that automatic processing of driver video information could increase the correct classification of safety critical events from kinematic triggers in naturalistic driving data. Review of about 400 video sequences recorded from the events, collected by 100 Volvo cars in the euroFOT project, suggested that drivers' individual reaction may be the key to recognize safety critical events. In fact, whether an event is safety critical or not often depends on the individual driver. A few algorithms, able to automatically classify driver reaction from video data, have been compared. The results presented in this paper show that the state of the art subjective review procedures to identify safety critical events from NDS can benefit from automated objective video processing. In addition, this paper discusses the major challenges in making such video analysis viable for future NDS and new potential applications for NDS video processing. As new NDS such as SHRP2 are now providing the equivalent of five years of one vehicle data each day, the development of new methods, such as the one proposed in this paper, seems necessary to guarantee that these data can actually be analysed. Copyright © 2013 Elsevier Ltd. All rights reserved.

  3. Taking ownership of safety. What are the active ingredients of safety coaching and how do they impact safety outcomes in critical offshore working environments?

    PubMed

    Krauesslar, Victoria; Avery, Rachel E; Passmore, Jonathan

    2015-01-01

    Safety coaching interventions have become a common feature in the safety critical offshore working environments of the North Sea. Whilst the beneficial impact of coaching as an organizational tool has been evidenced, there remains a question specifically over the use of safety coaching and its impact on behavioural change and producing safe working practices. A series of 24 semi-structured interviews were conducted with three groups of experts in the offshore industry: safety coaches, offshore managers and HSE directors. Using a thematic analysis approach, several significant themes were identified across the three expert groups including connecting with and creating safety ownership in the individual, personal significance and humanisation, ingraining safety and assessing and measuring a safety coach's competence. Results suggest clear utility of safety coaching when applied by safety coaches with appropriate coach training and understanding of safety issues in an offshore environment. The current work has found that the use of safety coaching in the safety critical offshore oil and gas industry is a powerful tool in managing and promoting a culture of safety and care.

  4. Investigation of criticality safety control infraction data at a nuclear facility

    DOE PAGES

    Cournoyer, Michael E.; Merhege, James F.; Costa, David A.; ...

    2014-10-27

    Chemical and metallurgical operations involving plutonium and other nuclear materials account for most activities performed at the LANL's Plutonium Facility (PF-4). The presence of large quantities of fissile materials in numerous forms at PF-4 makes it necessary to maintain an active criticality safety program. The LANL Nuclear Criticality Safety (NCS) Program provides guidance to enable efficient operations while ensuring prevention of criticality accidents in the handling, storing, processing and transportation of fissionable material at PF-4. In order to achieve and sustain lower criticality safety control infraction (CSCI) rates, PF-4 operations are continuously improved, through the use of Lean Manufacturing andmore » Six Sigma (LSS) business practices. Employing LSS, statistically significant variations (trends) can be identified in PF-4 CSCI reports. In this study, trends have been identified in the NCS Program using the NCS Database. An output metric has been developed that measures ADPSM Management progress toward meeting its NCS objectives and goals. Using a Pareto Chart, the primary CSCI attributes have been determined in order of those requiring the most management support. Data generated from analysis of CSCI data help identify and reduce number of corresponding attributes. In-field monitoring of CSCI's contribute to an organization's scientific and technological excellence by providing information that can be used to improve criticality safety operation safety. This increases technical knowledge and augments operational safety.« less

  5. Identifying behaviour patterns of construction safety using system archetypes.

    PubMed

    Guo, Brian H W; Yiu, Tak Wing; González, Vicente A

    2015-07-01

    Construction safety management involves complex issues (e.g., different trades, multi-organizational project structure, constantly changing work environment, and transient workforce). Systems thinking is widely considered as an effective approach to understanding and managing the complexity. This paper aims to better understand dynamic complexity of construction safety management by exploring archetypes of construction safety. To achieve this, this paper adopted the ground theory method (GTM) and 22 interviews were conducted with participants in various positions (government safety inspector, client, health and safety manager, safety consultant, safety auditor, and safety researcher). Eight archetypes were emerged from the collected data: (1) safety regulations, (2) incentive programs, (3) procurement and safety, (4) safety management in small businesses (5) production and safety, (6) workers' conflicting goals, (7) blame on workers, and (8) reactive and proactive learning. These archetypes capture the interactions between a wide range of factors within various hierarchical levels and subsystems. As a free-standing tool, they advance the understanding of dynamic complexity of construction safety management and provide systemic insights into dealing with the complexity. They also can facilitate system dynamics modelling of construction safety process. Copyright © 2015 Elsevier Ltd. All rights reserved.

  6. Novel Hybrid Scheduling Technique for Sensor Nodes with Mixed Criticality Tasks.

    PubMed

    Micea, Mihai-Victor; Stangaciu, Cristina-Sorina; Stangaciu, Valentin; Curiac, Daniel-Ioan

    2017-06-26

    Sensor networks become increasingly a key technology for complex control applications. Their potential use in safety- and time-critical domains has raised the need for task scheduling mechanisms specially adapted to sensor node specific requirements, often materialized in predictable jitter-less execution of tasks characterized by different criticality levels. This paper offers an efficient scheduling solution, named Hybrid Hard Real-Time Scheduling (H²RTS), which combines a static, clock driven method with a dynamic, event driven scheduling technique, in order to provide high execution predictability, while keeping a high node Central Processing Unit (CPU) utilization factor. From the detailed, integrated schedulability analysis of the H²RTS, a set of sufficiency tests are introduced and demonstrated based on the processor demand and linear upper bound metrics. The performance and correct behavior of the proposed hybrid scheduling technique have been extensively evaluated and validated both on a simulator and on a sensor mote equipped with ARM7 microcontroller.

  7. Brazed Joints Design and Allowables: Discuss Margins of Safety in Critical Brazed Structures

    NASA Technical Reports Server (NTRS)

    FLom, Yury

    2009-01-01

    This slide presentation tutorial discusses margins of safety in critical brazed structures. It reviews: (1) the present situation (2) definition of strength (3) margins of safety (4) design allowables (5) mechanical testing (6) failure criteria (7) design flowchart (8) braze gap (9) residual stresses and (10) delayed failures. This presentation addresses the strength of the brazed joints, the methods of mechanical testing, and our ability to evaluate the margins of safety of the brazed joints as it applies to the design of critical and expensive brazed assemblies.

  8. 49 CFR 229.309 - Safety-critical changes and failures.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 49 Transportation 4 2013-10-01 2013-10-01 false Safety-critical changes and failures. 229.309 Section 229.309 Transportation Other Regulations Relating to Transportation (Continued) FEDERAL RAILROAD ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD LOCOMOTIVE SAFETY STANDARDS Locomotive Electronics § 229...

  9. 49 CFR 229.309 - Safety-critical changes and failures.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 49 Transportation 4 2012-10-01 2012-10-01 false Safety-critical changes and failures. 229.309 Section 229.309 Transportation Other Regulations Relating to Transportation (Continued) FEDERAL RAILROAD ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD LOCOMOTIVE SAFETY STANDARDS Locomotive Electronics § 229...

  10. 49 CFR 229.309 - Safety-critical changes and failures.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 49 Transportation 4 2014-10-01 2014-10-01 false Safety-critical changes and failures. 229.309 Section 229.309 Transportation Other Regulations Relating to Transportation (Continued) FEDERAL RAILROAD ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD LOCOMOTIVE SAFETY STANDARDS Locomotive Electronics § 229...

  11. Putting Safety in the Software

    NASA Technical Reports Server (NTRS)

    Wetherholt, Martha S.; Berens, Kalynnda M.; Hardy, Sandra (Technical Monitor)

    2001-01-01

    Software is a vital component of nearly every piece of modern technology. It is not a 'sub-system', able to be separated out from the system as a whole, but a 'co-system' that controls, manipulates, or interacts with the hardware and with the end user. Software has its fingers into all the pieces of the pie. If that 'pie', the system, can lead to injury, death, loss of major equipment, or impact your business bottom line, then software safety becomes vitally important. Learning to think about software from a safety perspective is the focus of this paper. We want you to think of software as part of the safety critical system, a major part. This requires 'system thinking' - being able to grasp the whole picture. Software's contribution to modern technology is both good and potentially bad. Software allows more complex and useful devices to be built. It can also contribute to plane crashes and power outages. We want you to see software in a whole new light, see it as a contributor to system hazards, and also as a possible fix or mitigation to some of those hazards.

  12. Beat-the-wave evacuation mapping for tsunami hazards in Seaside, Oregon, USA

    USGS Publications Warehouse

    Priest, George R.; Stimely, Laura; Wood, Nathan J.; Madin, Ian; Watzig, Rudie

    2016-01-01

    Previous pedestrian evacuation modeling for tsunamis has not considered variable wave arrival times or critical junctures (e.g., bridges), nor does it effectively communicate multiple evacuee travel speeds. We summarize an approach that identifies evacuation corridors, recognizes variable wave arrival times, and produces a map of minimum pedestrian travel speeds to reach safety, termed a “beat-the-wave” (BTW) evacuation analysis. We demonstrate the improved approach by evaluating difficulty of pedestrian evacuation of Seaside, Oregon, for a local tsunami generated by a Cascadia subduction zone earthquake. We establish evacuation paths by calculating the least cost distance (LCD) to safety for every grid cell in a tsunami-hazard zone using geospatial, anisotropic path distance algorithms. Minimum BTW speed to safety on LCD paths is calculated for every grid cell by dividing surface distance from that cell to safety by the tsunami arrival time at safety. We evaluated three scenarios of evacuation difficulty: (1) all bridges are intact with a 5-minute evacuation delay from the start of earthquake, (2) only retrofitted bridges are considered intact with a 5-minute delay, and (3) only retrofitted bridges are considered intact with a 10-minute delay. BTW maps also take into account critical evacuation points along complex shorelines (e.g., peninsulas, bridges over shore-parallel estuaries) where evacuees could be caught by tsunami waves. The BTW map is able to communicate multiple pedestrian travel speeds, which are typically visualized by multiple maps with current LCD-based mapping practices. Results demonstrate that evacuation of Seaside is problematic seaward of the shore-parallel waterways for those with any limitations on mobility. Tsunami vertical-evacuation refuges or additional pedestrian bridges may be effective ways of reducing loss of life seaward of these waterways.

  13. [Patient safety and errors in medicine: development, prevention and analyses of incidents].

    PubMed

    Rall, M; Manser, T; Guggenberger, H; Gaba, D M; Unertl, K

    2001-06-01

    "Patient safety" and "errors in medicine" are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a "systems" approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology--within which realistic simulators were developed--is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of "culture" throughout the entire health care system. The "culture of blame" focused on individuals should be replaced by a "safety culture", that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a "preventive and proactive safety culture" should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient safety must have the highest priority in the goals of the institution: "Primum nihil nocere"--"First, do not harm".

  14. Verification and Validation Challenges for Adaptive Flight Control of Complex Autonomous Systems

    NASA Technical Reports Server (NTRS)

    Nguyen, Nhan T.

    2018-01-01

    Autonomy of aerospace systems requires the ability for flight control systems to be able to adapt to complex uncertain dynamic environment. In spite of the five decades of research in adaptive control, the fact still remains that currently no adaptive control system has ever been deployed on any safety-critical or human-rated production systems such as passenger transport aircraft. The problem lies in the difficulty with the certification of adaptive control systems since existing certification methods cannot readily be used for nonlinear adaptive control systems. Research to address the notion of metrics for adaptive control began to appear in the recent years. These metrics, if accepted, could pave a path towards certification that would potentially lead to the adoption of adaptive control as a future control technology for safety-critical and human-rated production systems. Development of certifiable adaptive control systems represents a major challenge to overcome. Adaptive control systems with learning algorithms will never become part of the future unless it can be proven that they are highly safe and reliable. Rigorous methods for adaptive control software verification and validation must therefore be developed to ensure that adaptive control system software failures will not occur, to verify that the adaptive control system functions as required, to eliminate unintended functionality, and to demonstrate that certification requirements imposed by regulatory bodies such as the Federal Aviation Administration (FAA) can be satisfied. This presentation will discuss some of the technical issues with adaptive flight control and related V&V challenges.

  15. The Dangers of Failure Masking in Fault-Tolerant Software: Aspects of a Recent In-Flight Upset Event

    NASA Technical Reports Server (NTRS)

    Johnson, C. W.; Holloway, C. M.

    2007-01-01

    On 1 August 2005, a Boeing Company 777-200 aircraft, operating on an international passenger flight from Australia to Malaysia, was involved in a significant upset event while flying on autopilot. The Australian Transport Safety Bureau's investigation into the event discovered that an anomaly existed in the component software hierarchy that allowed inputs from a known faulty accelerometer to be processed by the air data inertial reference unit (ADIRU) and used by the primary flight computer, autopilot and other aircraft systems. This anomaly had existed in original ADIRU software, and had not been detected in the testing and certification process for the unit. This paper describes the software aspects of the incident in detail, and suggests possible implications concerning complex, safety-critical, fault-tolerant software.

  16. Critical Characteristics of Radiation Detection System Components to be Dedicated for use in Safety Class and Safety Significant System

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    DAVIS, S.J.

    2000-12-28

    This document identifies critical characteristics of components to be dedicated for use in Safety Significant (SS) Systems, Structures, or Components (SSCs). This document identifies the requirements for the components of the common, radiation area, monitor alarm in the WESF pool cell. These are procured as Commercial Grade Items (CGI), with the qualification testing and formal dedication to be performed at the Waste Encapsulation Storage Facility (WESF) for use in safety significant systems. System modifications are to be performed in accordance with the approved design. Components for this change are commercially available and interchangeable with the existing alarm configuration This documentmore » focuses on the operational requirements for alarm, declaration of the safety classification, identification of critical characteristics, and interpretation of requirements for procurement. Critical characteristics are identified herein and must be verified, followed by formal dedication, prior to the components being used in safety related applications.« less

  17. Product Engineering Class in the Software Safety Risk Taxonomy for Building Safety-Critical Systems

    NASA Technical Reports Server (NTRS)

    Hill, Janice; Victor, Daniel

    2008-01-01

    When software safety requirements are imposed on legacy safety-critical systems, retrospective safety cases need to be formulated as part of recertifying the systems for further use and risks must be documented and managed to give confidence for reusing the systems. The SEJ Software Development Risk Taxonomy [4] focuses on general software development issues. It does not, however, cover all the safety risks. The Software Safety Risk Taxonomy [8] was developed which provides a construct for eliciting and categorizing software safety risks in a straightforward manner. In this paper, we present extended work on the taxonomy for safety that incorporates the additional issues inherent in the development and maintenance of safety-critical systems with software. An instrument called a Software Safety Risk Taxonomy Based Questionnaire (TBQ) is generated containing questions addressing each safety attribute in the Software Safety Risk Taxonomy. Software safety risks are surfaced using the new TBQ and then analyzed. In this paper we give the definitions for the specialized Product Engineering Class within the Software Safety Risk Taxonomy. At the end of the paper, we present the tool known as the 'Legacy Systems Risk Database Tool' that is used to collect and analyze the data required to show traceability to a particular safety standard

  18. 48 CFR 252.209-7010 - Critical Safety Items.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... personal injury or loss of life; or (iii) An uncommanded engine shutdown that jeopardizes safety. Design... personal injury or loss of life. (b) Identification of critical safety items. One or more of the items... control activity: (Insert additional lines as necessary) (c) Heightened quality assurance surveillance...

  19. 48 CFR 252.209-7010 - Critical Safety Items.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... personal injury or loss of life; or (iii) An uncommanded engine shutdown that jeopardizes safety. Design... personal injury or loss of life. (b) Identification of critical safety items. One or more of the items... control activity: (Insert additional lines as necessary) (c) Heightened quality assurance surveillance...

  20. 48 CFR 252.209-7010 - Critical Safety Items.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... personal injury or loss of life; or (iii) An uncommanded engine shutdown that jeopardizes safety. Design... personal injury or loss of life. (b) Identification of critical safety items. One or more of the items... control activity: (Insert additional lines as necessary) (c) Heightened quality assurance surveillance...

  1. 48 CFR 252.209-7010 - Critical Safety Items.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... personal injury or loss of life; or (iii) An uncommanded engine shutdown that jeopardizes safety. Design... personal injury or loss of life. (b) Identification of critical safety items. One or more of the items... control activity: (Insert additional lines as necessary) (c) Heightened quality assurance surveillance...

  2. Training and qualification of health and safety technicians at a national laboratory

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Egbert, W.F.; Trinoskey, P.A.

    1994-10-01

    Over the last 30 years, Lawrence Livermore National Laboratory (LLNL) has successfully implemented the concept of a multi-disciplined technician. LLNL Health and Safety Technicians have responsibilities in industrial hygiene, industrial safety, health physics, as well as fire, explosive, and criticality safety. One of the major benefits to this approach is the cost-effective use of workers who display an ownership of health and safety issues which is sometimes lacking when responsibilities are divided. Although LLNL has always promoted the concept of a multi-discipline technician, this concept is gaining interest within the Department of Energy (DOE) community. In November 1992, individuals frommore » Oak Ridge Institute of Science and Education (ORISE) and RUST Geotech, joined by LLNL established a committee to address the issues of Health and Safety Technicians. In 1993, the DOE Office of Environmental, Safety and Health, in response to the Defense Nuclear Facility Safety Board Recommendation 91-6, stated DOE projects, particularly environmental restoration, typically present hazards other than radiation such as chemicals, explosives, complex construction activities, etc., which require additional expertise by Radiological Control Technicians. They followed with a commitment that a training guide would be issued. The trend in the last two decades has been toward greater specialization in the areas of health and safety. In contrast, the LLNL has moved toward a generalist approach integrating the once separate functions of the industrial hygiene and health physics technician into one function.« less

  3. SRTC criticality safety technical review: Nuclear Criticality Safety Evaluation 93-04 enriched uranium receipt

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Rathbun, R.

    Review of NMP-NCS-930087, {open_quotes}Nuclear Criticality Safety Evaluation 93-04 Enriched Uranium Receipt (U), July 30, 1993, {close_quotes} was requested of SRTC (Savannah River Technology Center) Applied Physics Group. The NCSE is a criticality assessment to determine the mass limit for Engineered Low Level Trench (ELLT) waste uranium burial. The intent is to bury uranium in pits that would be separated by a specified amount of undisturbed soil. The scope of the technical review, documented in this report, consisted of (1) an independent check of the methods and models employed, (2) independent HRXN/KENO-V.a calculations of alternate configurations, (3) application of ANSI/ANS 8.1,more » and (4) verification of WSRC Nuclear Criticality Safety Manual procedures. The NCSE under review concludes that a 500 gram limit per burial position is acceptable to ensure the burial site remains in a critically safe configuration for all normal and single credible abnormal conditions. This reviewer agrees with that conclusion.« less

  4. [Communication on health and safety risk control in contemporary society: an interdisciplinary approach].

    PubMed

    Rangel-S, Maria Ligia

    2007-01-01

    This paper discusses communication as a technology for risk control with health and safety protection and promotion, within the context of a "risk society". As a component of Risk Analysis, risk communication is a technology that appears in risk literature, with well defined objectives, principles and models. These aspects are described and the difficulties are stressed, taking into consideration the multiple rationales related to risks in the culture and the many different aspects of risk regulation and control in the so-called "late modernity". Consideration is also given to the complexity of the communications process, guided by theoretical and methodological discussions in the field. In order to understand the true value of the communications field for risk control with health and safety protection and promotion, this paper also offers an overview of communication theories that support discussions of this matter, proposing a critical approach to models that include the dimensions of power and culture in the context of a capitalist society.

  5. Researching Reflexively With Patients and Families: Two Studies Using Video-Reflexive Ethnography to Collaborate With Patients and Families in Patient Safety Research.

    PubMed

    Collier, Aileen; Wyer, Mary

    2016-06-01

    Patient safety research has to date offered few opportunities for patients and families to be actively involved in the research process. This article describes our collaboration with patients and families in two separate studies, involving end-of-life care and infection control in acute care. We used the collaborative methodology of video-reflexive ethnography, which has been primarily used with clinicians, to involve patients and families as active participants and collaborators in our research. The purpose of this article is to share our experiences and findings that iterative researcher reflexivity in the field was critical to the progress and success of each study. We present and analyze the complexities of reflexivity-in-the-field through a framework of multilayered reflexivity. We share our lessons here for other researchers seeking to actively involve patients and families in patient safety research using collaborative visual methods. © The Author(s) 2015.

  6. Parametric Criticality Safety Calculations for Arrays of TRU Waste Containers

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Gough, Sean T.

    The Nuclear Criticality Safety Division (NCSD) has performed criticality safety calculations for finite and infinite arrays of transuranic (TRU) waste containers. The results of these analyses may be applied in any technical area onsite (e.g., TA-54, TA-55, etc.), as long as the assumptions herein are met. These calculations are designed to update the existing reference calculations for waste arrays documented in Reference 1, in order to meet current guidance on calculational methodology.

  7. Building effective critical care teams

    PubMed Central

    2011-01-01

    Critical care is formulated and delivered by a team. Accordingly, behavioral scientific principles relevant to teams, namely psychological safety, transactive memory and leadership, apply to critical care teams. Two experts in behavioral sciences review the impact of psychological safety, transactive memory and leadership on medical team outcomes. A clinician then applies those principles to two routine critical care paradigms: daily rounds and resuscitations. Since critical care is a team endeavor, methods to maximize teamwork should be learned and mastered by critical care team members, and especially leaders. PMID:21884639

  8. NASA's Software Safety Standard

    NASA Technical Reports Server (NTRS)

    Ramsay, Christopher M.

    2005-01-01

    NASA (National Aeronautics and Space Administration) relies more and more on software to control, monitor, and verify its safety critical systems, facilities and operations. Since the 1960's there has hardly been a spacecraft (manned or unmanned) launched that did not have a computer on board that provided vital command and control services. Despite this growing dependence on software control and monitoring, there has been no consistent application of software safety practices and methodology to NASA's projects with safety critical software. Led by the NASA Headquarters Office of Safety and Mission Assurance, the NASA Software Safety Standard (STD-18l9.13B) has recently undergone a significant update in an attempt to provide that consistency. This paper will discuss the key features of the new NASA Software Safety Standard. It will start with a brief history of the use and development of software in safety critical applications at NASA. It will then give a brief overview of the NASA Software Working Group and the approach it took to revise the software engineering process across the Agency.

  9. Software Safety Risk in Legacy Safety-Critical Computer Systems

    NASA Technical Reports Server (NTRS)

    Hill, Janice L.; Baggs, Rhoda

    2007-01-01

    Safety Standards contain technical and process-oriented safety requirements. Technical requirements are those such as "must work" and "must not work" functions in the system. Process-Oriented requirements are software engineering and safety management process requirements. Address the system perspective and some cover just software in the system > NASA-STD-8719.13B Software Safety Standard is the current standard of interest. NASA programs/projects will have their own set of safety requirements derived from the standard. Safety Cases: a) Documented demonstration that a system complies with the specified safety requirements. b) Evidence is gathered on the integrity of the system and put forward as an argued case. [Gardener (ed.)] c) Problems occur when trying to meet safety standards, and thus make retrospective safety cases, in legacy safety-critical computer systems.

  10. Orion Splashdown Recovery

    NASA Image and Video Library

    2014-12-05

    NASA's Orion spacecraft splashed down in the Pacific Ocean after its first flight test atop a Delta IV Heavy rocket from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida. U.S. Navy divers in Zodiac boats prepare to recover Orion and tow her in to the well deck of the USS Anchorage. NASA's Orion spacecraft completed a two-orbit, four-and-a-half hour mission to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. The Ground Systems Development and Operations Program is leading the recovery efforts.

  11. Nurse Leadership and Informatics Competencies: Shaping Transformation of Professional Practice.

    PubMed

    Kennedy, Margaret Ann; Moen, Anne

    2017-01-01

    Nurse leaders must demonstrate capacities and develop specific informatics competencies in order to provide meaningful leadership and support ongoing transformation of the healthcare system. Concurrently, staff informatics competencies must be planned and fostered to support critical principles of transformation and patient safety in practice, advance evidence-informed practice, and enable nursing to flourish in complex digital environments across the healthcare continuum. In addition to nurse leader competencies, two key aspects of leadership and informatics competencies will be addressed in this chapter - namely, the transformation of health care and preparation of the nursing workforce.

  12. Underwater Sound Propagation from Marine Pile Driving.

    PubMed

    Reyff, James A

    2016-01-01

    Pile driving occurs in a variety of nearshore environments that typically have very shallow-water depths. The propagation of pile-driving sound in water is complex, where sound is directly radiated from the pile as well as through the ground substrate. Piles driven in the ground near water bodies can produce considerable underwater sound energy. This paper presents examples of sound propagation through shallow-water environments. Some of these examples illustrate the substantial variation in sound amplitude over time that can be critical to understand when computing an acoustic-based safety zone for aquatic species.

  13. Aircraft Loss-of-Control: Analysis and Requirements for Future Safety-Critical Systems and Their Validation

    NASA Technical Reports Server (NTRS)

    Belcastro, Christine M.

    2011-01-01

    Loss of control remains one of the largest contributors to fatal aircraft accidents worldwide. Aircraft loss-of-control accidents are complex, resulting from numerous causal and contributing factors acting alone or more often in combination. Hence, there is no single intervention strategy to prevent these accidents. This paper summarizes recent analysis results in identifying worst-case combinations of loss-of-control accident precursors and their time sequences, a holistic approach to preventing loss-of-control accidents in the future, and key requirements for validating the associated technologies.

  14. RICIS research

    NASA Technical Reports Server (NTRS)

    Mckay, Charles W.; Feagin, Terry; Bishop, Peter C.; Hallum, Cecil R.; Freedman, Glenn B.

    1987-01-01

    The principle focus of one of the RICIS (Research Institute for Computing and Information Systems) components is computer systems and software engineering in-the-large of the lifecycle of large, complex, distributed systems which: (1) evolve incrementally over a long time; (2) contain non-stop components; and (3) must simultaneously satisfy a prioritized balance of mission and safety critical requirements at run time. This focus is extremely important because of the contribution of the scaling direction problem to the current software crisis. The Computer Systems and Software Engineering (CSSE) component addresses the lifestyle issues of three environments: host, integration, and target.

  15. Cardiac catheterization laboratory management: the fundamentals.

    PubMed

    Newell, Amy

    2012-01-01

    Increasingly, imaging administrators are gaining oversight for the cardiac cath lab as part of imaging services. Significant daily challenges include physician and staff demands, as well as patients who in many cases require higher acuity care. Along with strategic program driven responsibilities, the management role is complex. Critical elements that are the major impacts on cath lab management, as well as the overall success of a cardiac and vascular program, include program quality, patient safety, operational efficiency including inventory management, and customer service. It is critically important to have a well-qualified cath lab manager who acts as a leader by example, a mentor and motivator of the team, and an expert in the organization's processes and procedures. Such qualities will result in a streamlined cath lab with outstanding results.

  16. MISSION: Mission and Safety Critical Support Environment. Executive overview

    NASA Technical Reports Server (NTRS)

    Mckay, Charles; Atkinson, Colin

    1992-01-01

    For mission and safety critical systems it is necessary to: improve definition, evolution and sustenance techniques; lower development and maintenance costs; support safe, timely and affordable system modifications; and support fault tolerance and survivability. The goal of the MISSION project is to lay the foundation for a new generation of integrated systems software providing a unified infrastructure for mission and safety critical applications and systems. This will involve the definition of a common, modular target architecture and a supporting infrastructure.

  17. Risk maps for navigation in liver surgery

    NASA Astrophysics Data System (ADS)

    Hansen, C.; Zidowitz, S.; Schenk, A.; Oldhafer, K.-J.; Lang, H.; Peitgen, H.-O.

    2010-02-01

    The optimal transfer of preoperative planning data and risk evaluations to the operative site is challenging. A common practice is to use preoperative 3D planning models as a printout or as a presentation on a display. One important aspect is that these models were not developed to provide information in complex workspaces like the operating room. Our aim is to reduce the visual complexity of 3D planning models by mapping surgically relevant information onto a risk map. Therefore, we present methods for the identification and classification of critical anatomical structures in the proximity of a preoperatively planned resection surface. Shadow-like distance indicators are introduced to encode the distance from the resection surface to these critical structures on the risk map. In addition, contour lines are used to accentuate shape and spatial depth. The resulting visualization is clear and intuitive, allowing for a fast mental mapping of the current resection surface to the risk map. Preliminary evaluations by liver surgeons indicate that damage to risk structures may be prevented and patient safety may be enhanced using the proposed methods.

  18. NASA Software Safety Standard

    NASA Technical Reports Server (NTRS)

    Rosenberg, Linda

    1997-01-01

    If software is a critical element in a safety critical system, it is imperative to implement a systematic approach to software safety as an integral part of the overall system safety programs. The NASA-STD-8719.13A, "NASA Software Safety Standard", describes the activities necessary to ensure that safety is designed into software that is acquired or developed by NASA, and that safety is maintained throughout the software life cycle. A PDF version, is available on the WWW from Lewis. A Guidebook that will assist in the implementation of the requirements in the Safety Standard is under development at the Lewis Research Center (LeRC). After completion, it will also be available on the WWW from Lewis.

  19. Modeling and Analysis of Mixed Synchronous/Asynchronous Systems

    NASA Technical Reports Server (NTRS)

    Driscoll, Kevin R.; Madl. Gabor; Hall, Brendan

    2012-01-01

    Practical safety-critical distributed systems must integrate safety critical and non-critical data in a common platform. Safety critical systems almost always consist of isochronous components that have synchronous or asynchronous interface with other components. Many of these systems also support a mix of synchronous and asynchronous interfaces. This report presents a study on the modeling and analysis of asynchronous, synchronous, and mixed synchronous/asynchronous systems. We build on the SAE Architecture Analysis and Design Language (AADL) to capture architectures for analysis. We present preliminary work targeted to capture mixed low- and high-criticality data, as well as real-time properties in a common Model of Computation (MoC). An abstract, but representative, test specimen system was created as the system to be modeled.

  20. Software-safety and software quality assurance in real-time applications Part 2: Real-time structures and languages

    NASA Astrophysics Data System (ADS)

    Schoitsch, Erwin

    1988-07-01

    Our society is depending more and more on the reliability of embedded (real-time) computer systems even in every-day life. Considering the complexity of the real world, this might become a severe threat. Real-time programming is a discipline important not only in process control and data acquisition systems, but also in fields like communication, office automation, interactive databases, interactive graphics and operating systems development. General concepts of concurrent programming and constructs for process-synchronization are discussed in detail. Tasking and synchronization concepts, methods of process communication, interrupt- and timeout handling in systems based on semaphores, signals, conditional critical regions or on real-time languages like Concurrent PASCAL, MODULA, CHILL and ADA are explained and compared with each other and with respect to their potential to quality and safety.

  1. Update on FMT 2015: Indications, Methodologies, Mechanisms and Outlook

    PubMed Central

    Kelly, Colleen R.; Kahn, Stacy; Kashyap, Purna; Laine, Loren; Rubin, David; Atreja, Ashish; Moore, Thomas; Wu, Gary

    2016-01-01

    The community of microorganisms within the human gut (or microbiota) is critical to health and functions with a level of complexity comparable to an organ system. Alterations of this ecology (or dysbiosis) has been implicated in a number of disease states, the prototypical example being Clostridium difficile infection (CDI). Fecal microbiota transplantation (FMT) has been demonstrated to durably alter the gut microbiota of the recipient and has shown efficacy in the treatment of recurrent CDI. There is hope that FMT may eventually prove beneficial for treatment of other disease associated with alterations in gut microbiota, such as inflammatory bowel disease, irritable bowel syndrome and the metabolic syndrome, to name a few. Although the basic principles that underlie the mechanisms by which FMT demonstrates therapeutic efficacy in CDI are becoming apparent, further research is needed to understand the possible role of FMT in these other conditions. Though relatively simple to perform, questions regarding both short- and long-term safety, as well as the complex and rapidly evolving regulatory landscape has limited widespread utilization. Future work will focus on establishing best practices and more robust safety data than exist currently, as well as refining FMT beyond current “whole stool” transplants to increase safety and tolerability. Encapsulated formulations, full spectrum stool-based products and defined microbial consortia are all in the immediate future. PMID:25982290

  2. Lecture Notes on Criticality Safety Validation Using MCNP & Whisper

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Brown, Forrest B.; Rising, Michael Evan; Alwin, Jennifer Louise

    Training classes for nuclear criticality safety, MCNP documentation. The need for, and problems surrounding, validation of computer codes and data area considered first. Then some background for MCNP & Whisper is given--best practices for Monte Carlo criticality calculations, neutron spectra, S(α,β) thermal neutron scattering data, nuclear data sensitivities, covariance data, and correlation coefficients. Whisper is computational software designed to assist the nuclear criticality safety analyst with validation studies with the Monte Carlo radiation transport package MCNP. Whisper's methodology (benchmark selection – C k's, weights; extreme value theory – bias, bias uncertainty; MOS for nuclear data uncertainty – GLLS) and usagemore » are discussed.« less

  3. A Human Reliability Based Usability Evaluation Method for Safety-Critical Software

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Phillippe Palanque; Regina Bernhaupt; Ronald Boring

    2006-04-01

    Recent years have seen an increasing use of sophisticated interaction techniques including in the field of safety critical interactive software [8]. The use of such techniques has been required in order to increase the bandwidth between the users and systems and thus to help them deal efficiently with increasingly complex systems. These techniques come from research and innovation done in the field of humancomputer interaction (HCI). A significant effort is currently being undertaken by the HCI community in order to apply and extend current usability evaluation techniques to these new kinds of interaction techniques. However, very little has been donemore » to improve the reliability of software offering these kinds of interaction techniques. Even testing basic graphical user interfaces remains a challenge that has rarely been addressed in the field of software engineering [9]. However, the non reliability of interactive software can jeopardize usability evaluation by showing unexpected or undesired behaviors. The aim of this SIG is to provide a forum for both researchers and practitioners interested in testing interactive software. Our goal is to define a roadmap of activities to cross fertilize usability and reliability testing of these kinds of systems to minimize duplicate efforts in both communities.« less

  4. Structural empowerment and patient safety culture among registered nurses working in adult critical care units.

    PubMed

    Armellino, Donna; Quinn Griffin, Mary T; Fitzpatrick, Joyce J

    2010-10-01

    The aim of the present study was to examine the relationship between structural empowerment and patient safety culture among staff level Registered Nurses (RNs) within adult critical care units (ACCU). There is literature to support the value of RNs' structurally empowered work environments and emerging literature towards patient safety culture; the link between empowerment and patient safety culture is being discovered. A sample of 257 RNs, working within adult critical care of a tertiary hospital in the United States, was surveyed. Instruments included a background data sheet, the Conditions of Workplace Effectiveness and the Hospital Survey on Patient Safety Culture. Structural empowerment and patient safety culture were significantly correlated. As structural empowerment increased so did the RNs' perception of patient safety culture. To foster patient safety culture, nurse leaders should consider providing structurally empowering work environments for RNs. This study contributes to the body of knowledge linking structural empowerment and patient safety culture. Results link structurally empowered RNs and increased patient safety culture, essential elements in delivering efficient, competent, quality care. They inform nursing management of key factors in the nurses' environment that promote safe patient care environments. © 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd.

  5. Tactile display landing safety and precision improvements for the Space Shuttle

    NASA Astrophysics Data System (ADS)

    Olson, John M.

    A tactile display belt using 24 electro-mechanical tactile transducers (tactors) was used to determine if a modified tactile display system, known as the Tactile Situation Awareness System (TSAS) improved the safety and precision of a complex spacecraft (i.e. the Space Shuttle Orbiter) in guided precision approaches and landings. The goal was to determine if tactile cues enhance safety and mission performance through reduced workload, increased situational awareness (SA), and an improved operational capability by increasing secondary cognitive workload capacity and human-machine interface efficiency and effectiveness. Using both qualitative and quantitative measures such as NASA's Justiz Numerical Measure and Synwork1 scores, an Overall Workload (OW) measure, the Cooper-Harper rating scale, and the China Lake Situational Awareness scale, plus Pre- and Post-Flight Surveys, the data show that tactile displays decrease OW, improve SA, counteract fatigue, and provide superior warning and monitoring capacity for dynamic, off-nominal, high concurrent workload scenarios involving complex, cognitive, and multi-sensory critical scenarios. Use of TSAS for maintaining guided precision approaches and landings was generally intuitive, reduced training times, and improved task learning effects. Ultimately, the use of a homogeneous, experienced, and statistically robust population of test pilots demonstrated that the use of tactile displays for Space Shuttle approaches and landings with degraded vehicle systems, weather, and environmental conditions produced substantial improvements in safety, consistency, reliability, and ease of operations under demanding conditions. Recommendations for further analysis and study are provided in order to leverage the results from this research and further explore the potential to reduce the risk of spaceflight and aerospace operations in general.

  6. Seniors managing multiple medications: using mixed methods to view the home care safety lens.

    PubMed

    Lang, Ariella; Macdonald, Marilyn; Marck, Patricia; Toon, Lynn; Griffin, Melissa; Easty, Tony; Fraser, Kimberly; MacKinnon, Neil; Mitchell, Jonathan; Lang, Eddy; Goodwin, Sharon

    2015-12-12

    Patient safety is a national and international priority with medication safety earmarked as both a prevalent and high-risk area of concern. To date, medication safety research has focused overwhelmingly on institutional based care provided by paid healthcare professionals, which often has little applicability to the home care setting. This critical gap in our current understanding of medication safety in the home care sector is particularly evident with the elderly who often manage more than one chronic illness and a complex palette of medications, along with other care needs. This study addresses the medication management issues faced by seniors with chronic illnesses, their family, caregivers, and paid providers within Canadian publicly funded home care programs in Alberta (AB), Ontario (ON), Quebec (QC) and Nova Scotia (NS). Informed by a socio-ecological perspective, this study utilized Interpretive Description (ID) methodology and participatory photographic methods to capture and analyze a range of visual and textual data. Three successive phases of data collection and analysis were conducted in a concurrent, iterative fashion in eight urban and/or rural households in each province. A total of 94 participants (i.e., seniors receiving home care services, their family/caregivers, and paid providers) were interviewed individually. In addition, 69 providers took part in focus groups. Analysis was iterative and concurrent with data collection in that each interview was compared with subsequent interviews for converging as well as diverging patterns. Six patterns were identified that provide a rich portrayal of the complexity of medication management safety in home care: vulnerabilities that impact the safe management and storage of medication, sustaining adequate supports, degrees of shared accountability for care, systems of variable effectiveness, poly-literacy required to navigate the system, and systemic challenges to maintaining medication safety in the home. There is a need for policy makers, health system leaders, care providers, researchers, and educators to work with home care clients and caregivers on three key messages for improvement: adapt care delivery models to the home care landscape; develop a palette of user-centered tools to support medication safety in the home; and strengthen health systems integration.

  7. Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies.

    PubMed

    Jones, Christian E L; Phipps, Denham L; Ashcroft, Darren M

    2018-06-01

    Procedural violations are known to occur in a range of work settings, and are an important topic of interest with regard to safety management. A Safety-I perspective sees violations as undesirable digressions from standardised procedures, while a Safety-II perspective sees violations as adaptations to a complex work system. This study aimed to apply both perspectives to the examination of violations in community pharmacies. Twenty-four participants (13 pharmacists and 11 pharmacy support staff) were purposively sampled to participate in semi-structured interviews using the critical incident technique. Participants described violations they made during the course of their work. Interviews were digitally recorded, transcribed verbatim and analysed using template analysis. Community pharmacies located in England and Wales. 31 procedural violations were described during the interviews revealing multiple reasons for violations in this setting. Our findings suggest that from a Safety-II perspective, staff violated to adapt to situations and to manage safety. However, participants also violated procedures in order to maintain productivity which was found to increase risk in some, but not all situations. Procedural violations often relied on the context in which staff were working, resulting in the violation being deemed rational to the individual making the violation, yet the behaviour may be difficult to justify from an outside perspective. Combining Safety-I and Safety-II perspectives provided a detailed understanding of the underlying reasons for procedural violations. Our findings identify aspects of practice that could benefit from targeted interventions to help support staff in providing safe patient care.

  8. Ending on a positive: Examining the role of safety leadership decisions, behaviours and actions in a safety critical situation.

    PubMed

    Donovan, Sarah-Louise; Salmon, Paul M; Horberry, Timothy; Lenné, Michael G

    2018-01-01

    Safety leadership is an important factor in supporting safe performance in the workplace. The present case study examined the role of safety leadership during the Bingham Canyon Mine high-wall failure, a significant mining incident in which no fatalities or injuries were incurred. The Critical Decision Method (CDM) was used in conjunction with a self-reporting approach to examine safety leadership in terms of decisions, behaviours and actions that contributed to the incidents' safe outcome. Mapping the analysis onto Rasmussen's Risk Management Framework (Rasmussen, 1997), the findings demonstrate clear links between safety leadership decisions, and emergent behaviours and actions across the work system. Communication and engagement based decisions featured most prominently, and were linked to different leadership practices across the work system. Further, a core sub-set of CDM decision elements were linked to the open flow and exchange of information across the work system, which was critical to supporting the safe outcome. The findings provide practical implications for the development of safety leadership capability to support safety within the mining industry. Copyright © 2017 Elsevier Ltd. All rights reserved.

  9. Design, Development, and Testing of a UAV Hardware-in-the-Loop Testbed for Aviation and Airspace Prognostics Research

    NASA Technical Reports Server (NTRS)

    Kulkarni, Chetan; Teubert, Chris; Gorospe, George; Burgett, Drew; Quach, Cuong C.; Hogge, Edward

    2016-01-01

    The airspace is becoming more and more complicated, and will continue to do so in the future with the integration of Unmanned Aerial Vehicles (UAVs), autonomy, spacecraft, other forms of aviation technology into the airspace. The new technology and complexity increases the importance and difficulty of safety assurance. Additionally, testing new technologies on complex aviation systems & systems of systems can be very difficult, expensive, and sometimes unsafe in real life scenarios. Prognostic methodology provides an estimate of the health and risks of a component, vehicle, or airspace and knowledge of how that will change over time. That measure is especially useful in safety determination, mission planning, and maintenance scheduling. The developed testbed will be used to validate prediction algorithms for the real-time safety monitoring of the National Airspace System (NAS) and the prediction of unsafe events. The framework injects flight related anomalies related to ground systems, routing, airport congestion, etc. to test and verify algorithms for NAS safety. In our research work, we develop a live, distributed, hardware-in-the-loop testbed for aviation and airspace prognostics along with exploring further research possibilities to verify and validate future algorithms for NAS safety. The testbed integrates virtual aircraft using the X-Plane simulator and X-PlaneConnect toolbox, UAVs using onboard sensors and cellular communications, and hardware in the loop components. In addition, the testbed includes an additional research framework to support and simplify future research activities. It enables safe, accurate, and inexpensive experimentation and research into airspace and vehicle prognosis that would not have been possible otherwise. This paper describes the design, development, and testing of this system. Software reliability, safety and latency are some of the critical design considerations in development of the testbed. Integration of HITL elements in the development phases and veri cation/ validation are key elements to this report.

  10. Health information technology and hospital patient safety: a conceptual model to guide research.

    PubMed

    Paez, Kathryn; Roper, Rebecca A; Andrews, Roxanne M

    2013-09-01

    The literature indicates that health information technology (IT) use may lead to some gains in the quality and safety of care in some situations but provides little insight into this variability in the results that has been found. The inconsistent findings point to the need for a conceptual model that will guide research in sorting out the complex relationships between health IT and the quality and safety of care. A conceptual model was developed that describes how specific health IT functions could affect different types of inpatient safety errors and that include contextual factors that influence successful health IT implementation. The model was applied to a readily available patient safety measure and nationwide data (2009 AHA Annual Survey Information Technology Supplement and 2009 Healthcare Cost and Utilization Project State Inpatient Databases). The model was difficult to operationalize because (1) available health IT adoption data did not characterize health IT features and extent of usage, and (2) patient safety measures did not elucidate the process failures leading to safety-related outcomes. The sample patient safety measure--Postoperative Physiologic and Metabolic Derangement Rate--was not significantly related to self-reported health IT capabilities when adjusted for hospital structural characteristics. These findings illustrate the critical need for collecting data that are germane to health IT and the possible mechanisms by which health IT may affect inpatient safety. Well-defined and sufficiently granular measures of provider's correct use of health IT functions, the contextual factors surrounding health IT use, and patient safety errors leading to health care-associated conditions are needed to illuminate the impact of health IT on patient safety.

  11. The peer review system (PRS) for quality assurance and treatment improvement in radiation therapy

    NASA Astrophysics Data System (ADS)

    Le, Anh H. T.; Kapoor, Rishabh; Palta, Jatinder R.

    2012-02-01

    Peer reviews are needed across all disciplines of medicine to address complex medical challenges in disease care, medical safety, insurance coverage handling, and public safety. Radiation therapy utilizes technologically advanced imaging for treatment planning, often with excellent efficacy. Since planning data requirements are substantial, patients are at risk for repeat diagnostic procedures or suboptimal therapeutic intervention due to a lack of knowledge regarding previous treatments. The Peer Review System (PRS) will make this critical radiation therapy information readily available on demand via Web technology. The PRS system has been developed with current Web technology, .NET framework, and in-house DICOM library. With the advantages of Web server-client architecture, including IIS web server, SOAP Web Services and Silverlight for the client side, the patient data can be visualized through web browser and distributed across multiple locations by the local area network and Internet. This PRS will significantly improve the quality, safety, and accessibility, of treatment plans in cancer therapy. Furthermore, the secure Web-based PRS with DICOM-RT compliance will provide flexible utilities for organization, sorting, and retrieval of imaging studies and treatment plans to optimize the patient treatment and ultimately improve patient safety and treatment quality.

  12. Cardiac-Activity Measures for Assessing Airport Ramp-Tower Controller's Workload

    NASA Technical Reports Server (NTRS)

    Hayashi, Miwa; Dulchinos, Victoria

    2016-01-01

    Heart rate (HR) and heart rate variability (HRV) potentially offer objective, continuous, and non-intrusive measures of human-operators mental workload. Such measurement capability is attractive for workload assessment in complex laboratory simulations or safety-critical field testing. The present study compares mean HR and HRV data with self-reported subjective workload ratings collected during a high-fidelity human-in-the-loop simulation of airport ramp traffic control operations, which involve complex cognitive and coordination tasks. Mean HR was found to be weakly sensitive to the workload ratings, while HRV was not sensitive or even contradictory to the assumptions. Until more knowledge on stress response mechanisms of the autonomic nervous system is obtained, it is recommended that these cardiac-activity measures be used with other workload assessment tools, such as subjective measures.

  13. Cardiac-Activity Measures for Assessing Airport Ramp-Tower Controller's Workload

    NASA Technical Reports Server (NTRS)

    Hayashi, Miwa; Dulchinos, Victoria L.

    2016-01-01

    Heart rate (HR) and heart rate variability (HRV) potentially offer objective, continuous, and non-intrusive measures of human-operator's mental workload. Such measurement capability is attractive for workload assessment in complex laboratory simulations or safety-critical field testing. The present study compares mean HR and HRV data with self-reported subjective workload ratings collected during a high-fidelity human-in-the-loop simulation of airport ramp traffic control operations, which involve complex cognitive and coordination tasks. Mean HR was found to be weakly sensitive to the workload ratings, while HRV was not sensitive or even contradictory to the assumptions. Until more knowledge on stress response mechanisms of the autonomic nervous system is obtained, it is recommended that these cardiac-activity measures be used with other workload assessment tools, such as subjective measures.

  14. The synergy of the whole: building a global system for clinical trials to accelerate medicines development.

    PubMed

    Koski, Greg; Tobin, Mary F; Whalen, Matthew

    2014-10-01

    The pharmaceutical industry, once highly respected, productive, and profitable, is in the throes of major change driven by many forces, including economics, science, regulation, and ethics. A variety of initiatives and partnerships have been launched to improve efficiency and productivity but without significant effect because they have failed to consider the process as a system. Addressing the challenges facing this complex endeavor requires more than modifications of individual processes; it requires a fully integrated application of systems thinking and an understanding of the desired goals and complex interactions among essential components and stakeholders of the whole. A multistakeholder collaborative effort, led by the Alliance for Clinical Research Excellence and Safety (ACRES), a global nonprofit organization operating in the public interest, is now under way to build a shared global system for clinical research. Its systems approach focuses on the interconnection of stakeholders at critical points of interaction within 4 operational domains: site development and support, quality management, information technology, and safety. The ACRES initiatives, Site Accreditation and Standards, Product Safety Culture, Global Ethical Review and Regulatory Innovation, and Quality Assurance and Safety, focus on building and implementing systems solutions. Underpinning these initiatives is an open, shared, integrated technology (site and optics and quality informatics initiative). We describe the rationale, challenges, progress, and successes of this effort to date and lessons learned. The complexity and fragmentation of the intensely proprietary ecosystem of drug development, challenging regulatory climate, and magnitude of the endeavor itself pose significant challenges, but the economic, social, and scientific rewards will more than justify the effort. An effective alliance model requires a willingness of multiple stakeholders to work together to build a shared system within a noncompetitive space that will have major benefits for all, including better access to medicines, better health, and more productive lives. Copyright © 2014 Elsevier HS Journals, Inc. All rights reserved.

  15. Risk-Significant Adverse Condition Awareness Strengthens Assurance of Fault Management Systems

    NASA Technical Reports Server (NTRS)

    Fitz, Rhonda

    2017-01-01

    As spaceflight systems increase in complexity, Fault Management (FM) systems are ranked high in risk-based assessment of software criticality, emphasizing the importance of establishing highly competent domain expertise to provide assurance. Adverse conditions (ACs) and specific vulnerabilities encountered by safety- and mission-critical software systems have been identified through efforts to reduce the risk posture of software-intensive NASA missions. Acknowledgement of potential off-nominal conditions and analysis to determine software system resiliency are important aspects of hazard analysis and FM. A key component of assuring FM is an assessment of how well software addresses susceptibility to failure through consideration of ACs. Focus on significant risk predicted through experienced analysis conducted at the NASA Independent Verification & Validation (IV&V) Program enables the scoping of effective assurance strategies with regard to overall asset protection of complex spaceflight as well as ground systems. Research efforts sponsored by NASAs Office of Safety and Mission Assurance (OSMA) defined terminology, categorized data fields, and designed a baseline repository that centralizes and compiles a comprehensive listing of ACs and correlated data relevant across many NASA missions. This prototype tool helps projects improve analysis by tracking ACs and allowing queries based on project, mission type, domain/component, causal fault, and other key characteristics. Vulnerability in off-nominal situations, architectural design weaknesses, and unexpected or undesirable system behaviors in reaction to faults are curtailed with the awareness of ACs and risk-significant scenarios modeled for analysts through this database. Integration within the Enterprise Architecture at NASA IV&V enables interfacing with other tools and datasets, technical support, and accessibility across the Agency. This paper discusses the development of an improved workflow process utilizing this database for adaptive, risk-informed FM assurance that critical software systems will safely and securely protect against faults and respond to ACs in order to achieve successful missions.

  16. Risk-Significant Adverse Condition Awareness Strengthens Assurance of Fault Management Systems

    NASA Technical Reports Server (NTRS)

    Fitz, Rhonda

    2017-01-01

    As spaceflight systems increase in complexity, Fault Management (FM) systems are ranked high in risk-based assessment of software criticality, emphasizing the importance of establishing highly competent domain expertise to provide assurance. Adverse conditions (ACs) and specific vulnerabilities encountered by safety- and mission-critical software systems have been identified through efforts to reduce the risk posture of software-intensive NASA missions. Acknowledgement of potential off-nominal conditions and analysis to determine software system resiliency are important aspects of hazard analysis and FM. A key component of assuring FM is an assessment of how well software addresses susceptibility to failure through consideration of ACs. Focus on significant risk predicted through experienced analysis conducted at the NASA Independent Verification Validation (IVV) Program enables the scoping of effective assurance strategies with regard to overall asset protection of complex spaceflight as well as ground systems. Research efforts sponsored by NASA's Office of Safety and Mission Assurance defined terminology, categorized data fields, and designed a baseline repository that centralizes and compiles a comprehensive listing of ACs and correlated data relevant across many NASA missions. This prototype tool helps projects improve analysis by tracking ACs and allowing queries based on project, mission type, domaincomponent, causal fault, and other key characteristics. Vulnerability in off-nominal situations, architectural design weaknesses, and unexpected or undesirable system behaviors in reaction to faults are curtailed with the awareness of ACs and risk-significant scenarios modeled for analysts through this database. Integration within the Enterprise Architecture at NASA IVV enables interfacing with other tools and datasets, technical support, and accessibility across the Agency. This paper discusses the development of an improved workflow process utilizing this database for adaptive, risk-informed FM assurance that critical software systems will safely and securely protect against faults and respond to ACs in order to achieve successful missions.

  17. Novel Hybrid Scheduling Technique for Sensor Nodes with Mixed Criticality Tasks

    PubMed Central

    Micea, Mihai-Victor; Stangaciu, Cristina-Sorina; Stangaciu, Valentin; Curiac, Daniel-Ioan

    2017-01-01

    Sensor networks become increasingly a key technology for complex control applications. Their potential use in safety- and time-critical domains has raised the need for task scheduling mechanisms specially adapted to sensor node specific requirements, often materialized in predictable jitter-less execution of tasks characterized by different criticality levels. This paper offers an efficient scheduling solution, named Hybrid Hard Real-Time Scheduling (H2RTS), which combines a static, clock driven method with a dynamic, event driven scheduling technique, in order to provide high execution predictability, while keeping a high node Central Processing Unit (CPU) utilization factor. From the detailed, integrated schedulability analysis of the H2RTS, a set of sufficiency tests are introduced and demonstrated based on the processor demand and linear upper bound metrics. The performance and correct behavior of the proposed hybrid scheduling technique have been extensively evaluated and validated both on a simulator and on a sensor mote equipped with ARM7 microcontroller. PMID:28672856

  18. Inter-organisational response to disasters.

    PubMed

    Paturas, James L; Smith, Stewart R; Albanese, Joseph; Waite, Geraldine

    2016-01-01

    Inter-organisational communication failures during times of real-world disasters impede the collaborative response of agencies responsible for ensuring the public's health and safety. In the best of circumstances, communications across jurisdictional boundaries are ineffective. In times of crisis, when communities are grappling with the impact of a disaster, communications become critically important and more complex. Important factors for improving inter-organisational communications are critical thinking and problem-solving skills; inter-organisational relationships; as well as strategic, tactical and operational communications. Improving communication, critical thinking, problem-solving and decision-making requires a review of leadership skills. This discussion begins with an analysis of the existing disaster management research and moves to an examination of the importance of inter-organisational working relationships. Before a successful resolution of a disaster by multiple levels of first responders, the group of organisations must have a foundation of trust, collegiality, flexibility, expertise, openness, relational networking and effective communications. Leaders must also be prepared to improve leadership skills through continual development in each of these foundational areas.

  19. PRELIMINARY NUCLEAR CRITICALITY NUCLEAR SAFETY EVLAUATION FOR THE CONTAINER SURVEILLANCE AND STORAGE CAPABILITY PROJECT

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Low, M; Matthew02 Miller, M; Thomas Reilly, T

    2007-04-30

    Washington Safety Management Solutions (WSMS) provides criticality safety services to Washington Savannah River Company (WSRC) at the Savannah River Site. One activity at SRS is the Container Surveillance and Storage Capability (CSSC) Project, which will perform surveillances on 3013 containers (hereafter referred to as 3013s) to verify that they meet the Department of Energy (DOE) Standard (STD) 3013 for plutonium storage. The project will handle quantities of material that are greater than ANS/ANSI-8.1 single parameter mass limits, and thus required a Nuclear Criticality Safety Evaluation (NCSE). The WSMS methodology for conducting an NCSE is outlined in the WSMS methods manual.more » The WSMS methods manual currently follows the requirements of DOE-O-420.1B, DOE-STD-3007-2007, and the Washington Savannah River Company (WSRC) SCD-3 manual. DOE-STD-3007-2007 describes how a NCSE should be performed, while DOE-O-420.1B outlines the requirements for a Criticality Safety Program (CSP). The WSRC SCD-3 manual implements DOE requirements and ANS standards. NCSEs do not address the Nuclear Criticality Safety (NCS) of non-reactor nuclear facilities that may be affected by overt or covert activities of sabotage, espionage, terrorism or other security malevolence. Events which are beyond the Design Basis Accidents (DBAs) are outside the scope of a double contingency analysis.« less

  20. Social Security: Strengthening a Vital Safety Net for Latinos

    ERIC Educational Resources Information Center

    Cruz, Jeff

    2012-01-01

    Since 1935, Social Security has provided a vital safety net for millions of Americans who cannot work because of age or disability. This safety net has been especially critical for Americans of Latino decent, who number more than 50 million or nearly one out of every six Americans. Social Security is critical to Latinos because it is much more…

  1. Ensuring the validity of calculated subcritical limits

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Clark, H.K.

    1977-01-01

    The care taken at the Savannah River Laboratory and Plant to ensure the validity of calculated subcritical limits is described. Close attention is given to ANSI N16.1-1975, ''Validation of Calculational Methods for Nuclear Criticality Safety.'' The computer codes used for criticality safety computations, which are listed and are briefly described, have been placed in the SRL JOSHUA system to facilitate calculation and to reduce input errors. A driver module, KOKO, simplifies and standardizes input and links the codes together in various ways. For any criticality safety evaluation, correlations of the calculational methods are made with experiment to establish bias. Occasionallymore » subcritical experiments are performed expressly to provide benchmarks. Calculated subcritical limits contain an adequate but not excessive margin to allow for uncertainty in the bias. The final step in any criticality safety evaluation is the writing of a report describing the calculations and justifying the margin.« less

  2. Prospective Safety Analysis and the Complex Aviation System

    NASA Technical Reports Server (NTRS)

    Smith, Brian E.

    2013-01-01

    Fatal accident rates in commercial passenger aviation are at historic lows yet have plateaued and are not showing evidence of further safety advances. Modern aircraft accidents reflect both historic causal factors and new unexpected "Black Swan" events. The ever-increasing complexity of the aviation system, along with its associated technology and organizational relationships, provides fertile ground for fresh problems. It is important to take a proactive approach to aviation safety by working to identify novel causation mechanisms for future aviation accidents before they happen. Progress has been made in using of historic data to identify the telltale signals preceding aviation accidents and incidents, using the large repositories of discrete and continuous data on aircraft and air traffic control performance and information reported by front-line personnel. Nevertheless, the aviation community is increasingly embracing predictive approaches to aviation safety. The "prospective workshop" early assessment tool described in this paper represents an approach toward this prospective mindset-one that attempts to identify the future vectors of aviation and asks the question: "What haven't we considered in our current safety assessments?" New causation mechanisms threatening aviation safety will arise in the future because new (or revised) systems and procedures will have to be used under future contextual conditions that have not been properly anticipated. Many simulation models exist for demonstrating the safety cases of new operational concepts and technologies. However the results from such models can only be as valid as the accuracy and completeness of assumptions made about the future context in which the new operational concepts and/or technologies will be immersed. Of course that future has not happened yet. What is needed is a reasonably high-confidence description of the future operational context, capturing critical contextual characteristics that modulate both the likelihood of occurrence of hazards, and the likelihood that those hazards will lead to negative safety events. Heuristics extracted from scenarios, questionnaires, and observed trends from scanning the aviation horizon may be helpful in capturing those future changes in a way conducive to safety assessment. What is also needed is a checklist of potential sources of emerging risk that arise from organizational features that are frequently overlooked. The ultimate goal is to develop a pragmatic, workable method for using descriptions of the future aviation context, to generate valid predictions of safety risks.

  3. The breakdown of coordinated decision making in distributed systems.

    PubMed

    Bearman, Christopher; Paletz, Susannah B F; Orasanu, Judith; Thomas, Matthew J W

    2010-04-01

    This article aims to explore the nature and resolution of breakdowns in coordinated decision making in distributed safety-critical systems. In safety-critical domains, people with different roles and responsibilities often must work together to make coordinated decisions while geographically distributed. Although there is likely to be a large degree of overlap in the shared mental models of these people on the basis of procedures and experience, subtle differences may exist. Study 1 involves using Aviation Safety Reporting System reports to explore the ways in which coordinated decision making breaks down between pilots and air traffic controllers and the way in which the breakdowns are resolved. Study 2 replicates and extends those findings with the use of transcripts from the Apollo 13 National Aeronautics and Space Administration space mission. Across both studies, breakdowns were caused in part by different types of lower-level breakdowns (or disconnects), which are labeled as operational, informational, or evaluative. Evaluative disconnects were found to be significantly harder to resolve than other types of disconnects. Considering breakdowns according to the type of disconnect involved appears to capture useful information that should assist accident and incident investigators. The current trend in aviation of shifting responsibilities and providing increasingly more information to pilots may have a hidden cost of increasing evaluative disconnects. The proposed taxonomy facilitates the investigation of breakdowns in coordinated decision making and draws attention to the importance of considering subtle differences between participants' mental models when considering complex distributed systems.

  4. Understanding safety-critical interactions with a home medical device through Distributed Cognition.

    PubMed

    Rajkomar, Atish; Mayer, Astrid; Blandford, Ann

    2015-08-01

    As healthcare shifts from the hospital to the home, it is becoming increasingly important to understand how patients interact with home medical devices, to inform the safe and patient-friendly design of these devices. Distributed Cognition (DCog) has been a useful theoretical framework for understanding situated interactions in the healthcare domain. However, it has not previously been applied to study interactions with home medical devices. In this study, DCog was applied to understand renal patients' interactions with Home Hemodialysis Technology (HHT), as an example of a home medical device. Data was gathered through ethnographic observations and interviews with 19 renal patients and interviews with seven professionals. Data was analyzed through the principles summarized in the Distributed Cognition for Teamwork methodology. In this paper we focus on the analysis of system activities, information flows, social structures, physical layouts, and artefacts. By explicitly considering different ways in which cognitive processes are distributed, the DCog approach helped to understand patients' interaction strategies, and pointed to design opportunities that could improve patients' experiences of using HHT. The findings highlight the need to design HHT taking into consideration likely scenarios of use in the home and of the broader home context. A setting such as home hemodialysis has the characteristics of a complex and safety-critical socio-technical system, and a DCog approach effectively helps to understand how safety is achieved or compromised in such a system. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

  5. Synthetic depth data creation for sensor setup planning and evaluation of multi-camera multi-person trackers

    NASA Astrophysics Data System (ADS)

    Pattke, Marco; Martin, Manuel; Voit, Michael

    2017-05-01

    Tracking people with cameras in public areas is common today. However with an increasing number of cameras it becomes harder and harder to view the data manually. Especially in safety critical areas automatic image exploitation could help to solve this problem. Setting up such a system can however be difficult because of its increased complexity. Sensor placement is critical to ensure that people are detected and tracked reliably. We try to solve this problem using a simulation framework that is able to simulate different camera setups in the desired environment including animated characters. We combine this framework with our self developed distributed and scalable system for people tracking to test its effectiveness and can show the results of the tracking system in real time in the simulated environment.

  6. Bus operator safety : critical issues examination and model practices.

    DOT National Transportation Integrated Search

    2014-01-01

    In this study, researchers at the National Center for Transit Research performed a multi-topic comprehensive : examination of bus operator-related critical safety and personal security issues. The goals of this research : effort were to: : 1. Identif...

  7. 75 FR 4305 - Regulatory Guidance Concerning the Applicability of the Federal Motor Carrier Safety Regulations...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-27

    ... of drivers conducting real-world revenue operations. \\1\\ This report is available at FMCSA's Research... odds ratio of 23.2. This means that the odds of being involved in a safety-critical event is 23.2 times... preceding a safety-critical event. At 55 mph (or 80.7 feet per second), this equates to a driver traveling...

  8. Measuring quality in anatomic pathology.

    PubMed

    Raab, Stephen S; Grzybicki, Dana Marie

    2008-06-01

    This article focuses mainly on diagnostic accuracy in measuring quality in anatomic pathology, noting that measuring any quality metric is complex and demanding. The authors discuss standardization and its variability within and across areas of care delivery and efforts involving defining and measuring error to achieve pathology quality and patient safety. They propose that data linking error to patient outcome are critical for developing quality improvement initiatives targeting errors that cause patient harm in addition to using methods of root cause analysis, beyond those traditionally used in cytologic-histologic correlation, to assist in the development of error reduction and quality improvement plans.

  9. Capabilities overview of the MORET 5 Monte Carlo code

    NASA Astrophysics Data System (ADS)

    Cochet, B.; Jinaphanh, A.; Heulers, L.; Jacquet, O.

    2014-06-01

    The MORET code is a simulation tool that solves the transport equation for neutrons using the Monte Carlo method. It allows users to model complex three-dimensional geometrical configurations, describe the materials, define their own tallies in order to analyse the results. The MORET code has been initially designed to perform calculations for criticality safety assessments. New features has been introduced in the MORET 5 code to expand its use for reactor applications. This paper presents an overview of the MORET 5 code capabilities, going through the description of materials, the geometry modelling, the transport simulation and the definition of the outputs.

  10. [Error prevention through management of complications in urology: standard operating procedures from commercial aviation as a model].

    PubMed

    Kranz, J; Sommer, K-J; Steffens, J

    2014-05-01

    Patient safety and risk/complication management rank among the current megatrends in modern medicine, which has undoubtedly become more complex. In time-critical, error-prone and difficult situations, which often occur repeatedly in everyday clinical practice, guidelines are inappropriate for acting rapidly and intelligently. With the establishment and consistent use of standard operating procedures like in commercial aviation, a possible strategic approach is available. These medical aids to decision-making - quick reference cards - are short, optimized instructions that enable a standardized procedure in case of medical claims.

  11. Comments on the "Byzantine Self-Stabilizing Pulse Synchronization" Protocol: Counter-examples

    NASA Technical Reports Server (NTRS)

    Malekpour, Mahyar R.; Siminiceanu, Radu

    2006-01-01

    Embedded distributed systems have become an integral part of many safety-critical applications. There have been many attempts to solve the self-stabilization problem of clocks across a distributed system. An analysis of one such protocol called the Byzantine Self-Stabilizing Pulse Synchronization (BSS-Pulse-Synch) protocol from a paper entitled "Linear Time Byzantine Self-Stabilizing Clock Synchronization" by Daliot, et al., is presented in this report. This report also includes a discussion of the complexity and pitfalls of designing self-stabilizing protocols and provides counter-examples for the claims of the above protocol.

  12. Bayesian Software Health Management for Aircraft Guidance, Navigation, and Control

    NASA Technical Reports Server (NTRS)

    Schumann, Johann; Mbaya, Timmy; Menghoel, Ole

    2011-01-01

    Modern aircraft, both piloted fly-by-wire commercial aircraft as well as UAVs, more and more depend on highly complex safety critical software systems with many sensors and computer-controlled actuators. Despite careful design and V&V of the software, severe incidents have happened due to malfunctioning software. In this paper, we discuss the use of Bayesian networks (BNs) to monitor the health of the on-board software and sensor system, and to perform advanced on-board diagnostic reasoning. We will focus on the approach to develop reliable and robust health models for the combined software and sensor systems.

  13. DOE Office of Scientific and Technical Information (OSTI.GOV)

    Hopper, Calvin Mitchell

    In May 1973 the University of New Mexico conducted the first nationwide criticality safety training and education week-long short course for nuclear criticality safety engineers. Subsequent to that course, the Los Alamos Critical Experiments Facility (LACEF) developed very successful 'hands-on' subcritical and critical training programs for operators, supervisors, and engineering staff. Since the inception of the US Department of Energy (DOE) Nuclear Criticality Technology and Safety Project (NCT&SP) in 1983, the DOE has stimulated contractor facilities and laboratories to collaborate in the furthering of nuclear criticality as a discipline. That effort included the education and training of nuclear criticality safetymore » engineers (NCSEs). In 1985 a textbook was written that established a path toward formalizing education and training for NCSEs. Though the NCT&SP went through a brief hiatus from 1990 to 1992, other DOE-supported programs were evolving to the benefit of NCSE training and education. In 1993 the DOE established a Nuclear Criticality Safety Program (NCSP) and undertook a comprehensive development effort to expand the extant LACEF 'hands-on' course specifically for the education and training of NCSEs. That successful education and training was interrupted in 2006 for the closing of the LACEF and the accompanying movement of materials and critical experiment machines to the Nevada Test Site. Prior to that closing, the Lawrence Livermore National Laboratory (LLNL) was commissioned by the US DOE NCSP to establish an independent hands-on NCSE subcritical education and training course. The course provided an interim transition for the establishment of a reinvigorated and expanded two-week NCSE education and training program in 2011. The 2011 piloted two-week course was coordinated by the Oak Ridge National Laboratory (ORNL) and jointly conducted by the Los Alamos National Laboratory (LANL) classroom education and facility training, the Sandia National Laboratory (SNL) hands-on criticality experiments training, and the US DOE National Criticality Experiment Research Center (NCERC) hands-on criticality experiments training that is jointly supported by LLNL and LANL and located at the Nevada National Security Site (NNSS) This paper provides the description of the bases, content, and conduct of the piloted, and future US DOE NCSP Criticality Safety Engineer Training and Education Project.« less

  14. Aviation occupant survival factors: an empirical study of the SQ006 accident.

    PubMed

    Chang, Yu-Hern; Yang, Hui-Hua

    2010-03-01

    We present an empirical study of Singapore Airline (SIA) flight SQ006 to illustrate the critical factors that influence airplane occupant survivability. The Fuzzy Delphi Method was used to identify and rank the survival factors that may reduce injury and fatality in potentially survivable accidents. This is the first attempt by a group from both the public and private sectors in Taiwan to focus on cabin-safety issues related to survival factors. We designed a comprehensive survey based on our discussions with aviation safety experts. We next designed an array of important cabin-safety dimensions and then investigated and selected the critical survival factors for each dimension. Our findings reveal important cabin safety and survivability information that should provide a valuable reference for developing and evaluating aviation safety programs. We also believe that the results will be practical for designing cabin-safety education material for air travelers. Finally, the major contribution of this research is that it has identified 47 critical factors that influence accident survivability; therefore, it may encourage improvements that will promote more successful cabin-safety management. Copyright 2009 Elsevier Ltd. All rights reserved.

  15. Developing a proactive research agenda to advance nail salon worker health, safety, and rights.

    PubMed

    Quach, Thu; Liou, Julia; Fu, Lisa; Mendiratta, Anuja; Tong, My; Reynolds, Peggy

    2012-01-01

    Nail salons represent a burgeoning industry with Vietnamese immigrant workers making up the majority. Workers routinely handle cosmetic products containing hazardous compounds, with implications for their health. This paper describes how a collaborative of multiple organizations and community members collectively developed a proactive research agenda for salon worker health, safety, and rights during a pivotal multistakeholder convening, and advanced on such recommendations, including creating groundbreaking policy changes. Key recommendations included (1) creating a multidisciplinary research advisory committee, (2) conducting research on workplace exposures and long-term health impacts, (3) advocating for better governmental oversight of product manufacturers, and (4) identifying safer product alternatives via green chemistry, albeit with cost considerations to salon businesses. The participation of diverse stakeholders in the discussions allowed for cross-dialogue on a complex issue, helped to align different stakeholders as allies, and identified critical resources to addressing research gaps.

  16. 76 FR 67020 - Railroad Safety Advisory Committee; Notice of Meeting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-28

    ... Device Distraction, Critical Incident, Track Safety Standards, Dark Territory, Passenger Safety, and... railroad safety matters. The RSAC is composed of 54 voting representatives from 31 member organizations...

  17. Comparing safety climate for nurses working in operating theatres, critical care and ward areas in the UK: a mixed methods study

    PubMed Central

    Tarling, Maggie; Jones, Anne; Murrells, Trevor; McCutcheon, Helen

    2017-01-01

    Objectives The main aim of the study was to explore the potential sources of variation and understand the meaning of safety climate for nursing practice in acute hospital settings in the UK. Design A sequential mixed methods design included a cross-sectional survey using the Safety Climate Questionnaire (SCQ) and thematic analysis of focus group discussions. Confirmatory factor analysis (CFA) was used to validate the factor structure of the SCQ. Factor scores were compared between nurses working in operating theatres, critical care and ward areas. Results from the survey and the thematic analysis were then compared and synthesised. Setting A London University. Participants 319 registered nurses working in acute hospital settings completed the SCQ and a further 23 nurses participated in focus groups. Results CFA indicated that there was a good model fit on some criteria (χ2=1683.699, df=824, p<0.001; χ2/df=2.04; root mean square error of approximation=0.058) but a less acceptable fit on comparative fit index which is 0.804. There was a statistically significant difference between clinical specialisms in management commitment (F (4,266)=4.66, p=0.001). Nurses working in operating theatres had lower scores compared with ward areas and they also reported negative perceptions about management in their focus group. There was significant variation in scores for communication across clinical specialism (F (4,266)=2.62, p=0.035) but none of the pairwise comparisons achieved statistical significance. Thematic analysis identified themes of human factors, clinical management and protecting patients. The system and the human side of caring was identified as a meta-theme. Conclusions The results suggest that the SCQ has some utility but requires further exploration. The findings indicate that safety in nursing practice is a complex interaction between safety systems and the social and interpersonal aspects of clinical practice. PMID:29084793

  18. Parallel computation safety analysis irradiation targets fission product molybdenum in neutronic aspect using the successive over-relaxation algorithm

    NASA Astrophysics Data System (ADS)

    Susmikanti, Mike; Dewayatna, Winter; Sulistyo, Yos

    2014-09-01

    One of the research activities in support of commercial radioisotope production program is a safety research on target FPM (Fission Product Molybdenum) irradiation. FPM targets form a tube made of stainless steel which contains nuclear-grade high-enrichment uranium. The FPM irradiation tube is intended to obtain fission products. Fission materials such as Mo99 used widely the form of kits in the medical world. The neutronics problem is solved using first-order perturbation theory derived from the diffusion equation for four groups. In contrast, Mo isotopes have longer half-lives, about 3 days (66 hours), so the delivery of radioisotopes to consumer centers and storage is possible though still limited. The production of this isotope potentially gives significant economic value. The criticality and flux in multigroup diffusion model was calculated for various irradiation positions and uranium contents. This model involves complex computation, with large and sparse matrix system. Several parallel algorithms have been developed for the sparse and large matrix solution. In this paper, a successive over-relaxation (SOR) algorithm was implemented for the calculation of reactivity coefficients which can be done in parallel. Previous works performed reactivity calculations serially with Gauss-Seidel iteratives. The parallel method can be used to solve multigroup diffusion equation system and calculate the criticality and reactivity coefficients. In this research a computer code was developed to exploit parallel processing to perform reactivity calculations which were to be used in safety analysis. The parallel processing in the multicore computer system allows the calculation to be performed more quickly. This code was applied for the safety limits calculation of irradiated FPM targets containing highly enriched uranium. The results of calculations neutron show that for uranium contents of 1.7676 g and 6.1866 g (× 106 cm-1) in a tube, their delta reactivities are the still within safety limits; however, for 7.9542 g and 8.838 g (× 106 cm-1) the limits were exceeded.

  19. Evaluation of an active learning module to teach hazard and risk in Hazard Analysis and Critical Control Points (HACCP) classes.

    PubMed

    Oyarzabal, Omar A; Rowe, Ellen

    2017-04-01

    The terms hazard and risk are significant building blocks for the organization of risk-based food safety plans. Unfortunately, these terms are not clear for some personnel working in food manufacturing facilities. In addition, there are few examples of active learning modules for teaching adult participants the principles of hazard analysis and critical control points (HACCP). In this study, we evaluated the effectiveness of an active learning module to teach hazard and risk to participants of HACCP classes provided by the University of Vermont Extension in 2015 and 2016. This interactive module is comprised of a questionnaire; group playing of a dice game that we have previously introduced in the teaching of HACCP; the discussion of the terms hazard and risk; and a self-assessment questionnaire to evaluate the teaching of hazard and risk. From 71 adult participants that completed this module, 40 participants (56%) provided the most appropriate definition of hazard, 19 participants (27%) provided the most appropriate definition of risk, 14 participants (20%) provided the most appropriate definitions of both hazard and risk, and 23 participants (32%) did not provide an appropriate definition for hazard or risk. Self-assessment data showed an improvement in the understanding of these terms (P < 0.05). Thirty participants (42%) stated that the most valuable thing they learned with this interactive module was the difference between hazard and risk, and 40 participants (65%) responded that they did not attend similar presentations in the past. The fact that less than one third of the participants answered properly to the definitions of hazard and risk at baseline is not surprising. However, these results highlight the need for the incorporation of modules to discuss these important food safety terms and include more active learning modules to teach food safety classes. This study suggests that active learning helps food personnel better understand important food safety terms that serve as building blocks for the understanding of more complex food safety topics.

  20. A Practical Risk Assessment Methodology for Safety-Critical Train Control Systems

    DOT National Transportation Integrated Search

    2009-07-01

    This project proposes a Practical Risk Assessment Methodology (PRAM) for analyzing railroad accident data and assessing the risk and benefit of safety-critical train control systems. This report documents in simple steps the algorithms and data input...

  1. 49 CFR 533.6 - Measurement and calculation procedures.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... the technology is related to crash-avoidance technologies, safety critical systems or systems affecting safety-critical functions, or technologies designed for the purpose of reducing the frequency of... improvements related to air conditioning efficiency, off-cycle technologies, and hybridization and other...

  2. System Guidelines for EMC Safety-Critical Circuits: Design, Selection, and Margin Demonstration

    NASA Technical Reports Server (NTRS)

    Lawton, R. M.

    1996-01-01

    Demonstration of safety margins for critical points (circuits) has traditionally been required since it first became a part of systems-level Electromagnetic Compatibility (EMC) requirements of MIL-E-6051C. The goal of this document is to present cost-effective guidelines for ensuring adequate Electromagnetic Effects (EME) safety margins on spacecraft critical circuits. It is for the use of NASA and other government agencies and their contractors to prevent loss of life, loss of spacecraft, or unacceptable degradation. This document provides practical definition and treatment guidance to contain costs within affordable limits.

  3. [The INSuLa Project: the survey of training needs in the SPSAL(Service for Prevention and Safety in the Work Environment)].

    PubMed

    Martini, Agnese; Iavicoli, Sergio; Bonafede, Michela; Corso, Luca; Iosuel, Michela; Isolani, Lucia; Di Leone, Giorgio; Di Marzio, Davide; Bertazzi, Pier Alberto

    2014-01-01

    According to Italian Legislative Decree 81/2008 and subsequent modifications the Regions and Autonomous Provinces have a innovative and complex role: 1) to regulate and coordinate the total prevention system and 2) to develop interventions/initiatives through regional/local occupational safety and health (OSH) department using not only inspections and controls but education, training and support. Recommendations also include consolidating the role of actors involved in preventing risks to occupational health throughout occupational safety and health education and training, keys for a successful process to improve prevention system. As result of changing world of work and OSH legislation the INSuLa project has creating a national survey involving of all Italian prevention system actors, in order to evaluate implementation and impact of the actual regulations. According to overall objective of the INSuLA project, for the first time in Italy, we studied about operators in regional/local OSH department. The purpose of this paper is to show and recognize the individual learning paths, the perception of adequacy education degree, the exploring criticalities andthe training needs.

  4. Development of a nursing handoff tool: a web-based application to enhance patient safety.

    PubMed

    Goldsmith, Denise; Boomhower, Marc; Lancaster, Diane R; Antonelli, Mary; Kenyon, Mary Anne Murphy; Benoit, Angela; Chang, Frank; Dykes, Patricia C

    2010-11-13

    Dynamic and complex clinical environments present many challenges for effective communication among health care providers. The omission of accurate, timely, easily accessible vital information by health care providers significantly increases risk of patient harm and can have devastating consequences for patient care. An effective nursing handoff supports the standardized transfer of accurate, timely, critical patient information, as well as continuity of care and treatment, resulting in enhanced patient safety. The Brigham and Women's/Faulkner Hospital Healthcare Information Technology Innovation Program (HIP) is supporting the development of a web based nursing handoff tool (NHT). The goal of this project is to develop a "proof of concept" handoff application to be evaluated by nurses on the inpatient intermediate care units. The handoff tool would enable nurses to use existing knowledge of evidence-based handoff methodology in their everyday practice to improve patient care and safety. In this paper, we discuss the results of nursing focus groups designed to identify the current state of handoff practice as well as the functional and data element requirements of a web based Nursing Handoff Tool (NHT).

  5. Numerical Computation of Homogeneous Slope Stability

    PubMed Central

    Xiao, Shuangshuang; Li, Kemin; Ding, Xiaohua; Liu, Tong

    2015-01-01

    To simplify the computational process of homogeneous slope stability, improve computational accuracy, and find multiple potential slip surfaces of a complex geometric slope, this study utilized the limit equilibrium method to derive expression equations of overall and partial factors of safety. This study transformed the solution of the minimum factor of safety (FOS) to solving of a constrained nonlinear programming problem and applied an exhaustive method (EM) and particle swarm optimization algorithm (PSO) to this problem. In simple slope examples, the computational results using an EM and PSO were close to those obtained using other methods. Compared to the EM, the PSO had a small computation error and a significantly shorter computation time. As a result, the PSO could precisely calculate the slope FOS with high efficiency. The example of the multistage slope analysis indicated that this slope had two potential slip surfaces. The factors of safety were 1.1182 and 1.1560, respectively. The differences between these and the minimum FOS (1.0759) were small, but the positions of the slip surfaces were completely different than the critical slip surface (CSS). PMID:25784927

  6. Numerical computation of homogeneous slope stability.

    PubMed

    Xiao, Shuangshuang; Li, Kemin; Ding, Xiaohua; Liu, Tong

    2015-01-01

    To simplify the computational process of homogeneous slope stability, improve computational accuracy, and find multiple potential slip surfaces of a complex geometric slope, this study utilized the limit equilibrium method to derive expression equations of overall and partial factors of safety. This study transformed the solution of the minimum factor of safety (FOS) to solving of a constrained nonlinear programming problem and applied an exhaustive method (EM) and particle swarm optimization algorithm (PSO) to this problem. In simple slope examples, the computational results using an EM and PSO were close to those obtained using other methods. Compared to the EM, the PSO had a small computation error and a significantly shorter computation time. As a result, the PSO could precisely calculate the slope FOS with high efficiency. The example of the multistage slope analysis indicated that this slope had two potential slip surfaces. The factors of safety were 1.1182 and 1.1560, respectively. The differences between these and the minimum FOS (1.0759) were small, but the positions of the slip surfaces were completely different than the critical slip surface (CSS).

  7. Fostering Future Leadership in Quality and Safety in Health Care through Systems Thinking.

    PubMed

    Phillips, Janet M; Stalter, Ann M; Dolansky, Mary A; Lopez, Gloria McKee

    2016-01-01

    There is a critical need for leadership in quality and safety to reform today's disparate spectrum of health services to serve patients in complex health care environments. Nurse graduates of degree completion programs (registered nurse-bachelor of science in nursing [RN-BSN]) are poised for leadership due to their recent education and nursing practice experience. The authors propose that integration of systems thinking into RN-BSN curricula is essential for developing these much needed leadership skills. The purpose of this article is to introduce progressive teaching strategies to help nurse educators achieve the student competencies described in the second essential of the BSN Essentials document (American Association of Colleges of Nursing, 2009), linking them with the competencies in Quality and Safety Education for Nurses (QSEN; L. Cronenwett et al., 2007) using an author-created model for curricular design, the Systems-level Awareness Model. The Systems Thinking Tool (M. A. Dolansky & S. M. Moore, 2013) can be used to evaluate systems thinking in the RN-BSN curriculum. Copyright © 2016 Elsevier Inc. All rights reserved.

  8. Air, rail and road: Medical Guidelines for Employees with a History of Cerebrovascular Disease.

    PubMed

    Klein, Rebecca; Menon, Bijoy K; Rabi, Doreen; Stell, William; Hill, Michael D

    2016-10-01

    Background An acute medical condition following a previous stroke among those who operate trains, airplanes, and commercial vehicles can result in serious accidents. There are guidelines in place to assist physicians and employers in assessing the risks of returning to work after stroke but the extent and comprehensiveness across nations and among safety-critical occupations are not widely known. Methods Medical guidelines currently in place to regulate safety critical occupations including railway engineers, pilots and commercial vehicle drivers were systematically reviewed. Electronic and hand literature searches as well as review of grey literature for Canada, the USA, the UK, and Australia were conducted. Results There is no consistent set of guidelines that address the risk of a second catastrophic event after an initial cerebrovascular event in those employed in safety critical occupations in the four countries assessed. Some broad principles existed between the different countries and occupations but there was major variation in the approach to cerebrovascular disease and its impact on those working in safety-critical occupations. Conclusions A synthesis of current knowledge would assist in establishing risks of a catastrophic event in those who have already suffered from cerebrovascular illness. This will allow the creation of medical guidelines which could be applied to any safety critical occupation in any nation.

  9. CSER 98-003: Criticality safety evaluation report for PFP glovebox HC-21A with button can opening

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    ERICKSON, D.G.

    1999-02-23

    Glovebox HC-21A is an enclosure where cans containing plutonium metal buttons or other plutonium bearing materials are prepared for thermal stabilization in the muffle furnaces. The Inert Atmosphere Confinement (IAC), a new feature added to Glovebox HC-21A, allows the opening of containers suspected of containing hydrided plutonium metal. The argon atmosphere in the IAC prevents an adverse reaction between oxygen and the hydride. The hydride is then stabilized in a controlled manner to prevent glovebox over pressurization. After removal from the containers, the plutonium metal buttons or plutonium bearing materials will be placed into muffle furnace boats and then bemore » sent to one of the muffle furnace gloveboxes for stabilization. The materials allowed to be brought into GloveboxHC-21 A are limited to those with a hydrogen to fissile atom ratio (H/X) {le} 20. Glovebox HC-21A is classified as a DRY glovebox, meaning it has no internal liquid lines, and no free liquids or solutions are allowed to be introduced. The double contingency principle states that designs shall incorporate sufficient factors of safety to require at least two unlikely, independent, and concurrent changes in process conditions before a criticality accident is possible. This criticality safety evaluation report (CSER) shows that the operations to be performed in this glovebox are safe from a criticality standpoint. No single identified event that causes criticality controls to be lost exceeded the criticality safety limit of k{sub eff} = 0.95. Therefore, this CSER meets the requirements for a criticality analysis contained in the Hanford Site Nuclear Criticality Safety Manual, HNF-PRO-334, and meets the double contingency principle.« less

  10. Nuclear criticality safety bounding analysis for the in-tank-precipitation (ITP) process, impacted by fissile isotopic weight fractions

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Bess, C.E.

    The In-Tank Precipitation process (ITP) receives High Level Waste (HLW) supernatant liquid containing radionuclides in waste processing tank 48H. Sodium tetraphenylborate, NaTPB, and monosodium titanate (MST), NaTi{sub 2}O{sub 5}H, are added for removal of radioactive Cs and Sr, respectively. In addition to removal of radio-strontium, MST will also remove plutonium and uranium. The majority of the feed solutions to ITP will come from the dissolution of supernate that had been concentrated by evaporation to a crystallized salt form, commonly referred to as saltcake. The concern for criticality safety arises from the adsorption of U and Pt onto MST. If sufficientmore » mass and optimum conditions are achieved then criticality is credible. The concentration of u and Pt from solution into the smaller volume of precipitate represents a concern for criticality. This report supplements WSRC-TR-93-171, Nuclear Criticality Safety Bounding Analysis For The In-Tank-Precipitation (ITP) Process. Criticality safety in ITP can be analyzed by two bounding conditions: (1) the minimum safe ratio of MST to fissionable material and (2) the maximum fissionable material adsorption capacity of the MST. Calculations have provided the first bounding condition and experimental analysis has established the second. This report combines these conditions with canyon facility data to evaluate the potential for criticality in the ITP process due to the adsorption of the fissionable material from solution. In addition, this report analyzes the potential impact of increased U loading onto MST. Results of this analysis demonstrate a greater safety margin for ITP operations than the previous analysis. This report further demonstrates that the potential for criticality in the ITP process due to adsorption of fissionable material by MST is not credible.« less

  11. Shielding calculation and criticality safety analysis of spent fuel transportation cask in research reactors.

    PubMed

    Mohammadi, A; Hassanzadeh, M; Gharib, M

    2016-02-01

    In this study, shielding calculation and criticality safety analysis were carried out for general material testing reactor (MTR) research reactors interim storage and relevant transportation cask. During these processes, three major terms were considered: source term, shielding, and criticality calculations. The Monte Carlo transport code MCNP5 was used for shielding calculation and criticality safety analysis and ORIGEN2.1 code for source term calculation. According to the results obtained, a cylindrical cask with body, top, and bottom thicknesses of 18, 13, and 13 cm, respectively, was accepted as the dual-purpose cask. Furthermore, it is shown that the total dose rates are below the normal transport criteria that meet the standards specified. Copyright © 2015 Elsevier Ltd. All rights reserved.

  12. 76 FR 71081 - Public Aircraft Oversight Safety Forum

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-16

    ... NATIONAL TRANSPORTATION SAFETY BOARD Public Aircraft Oversight Safety Forum The National Transportation Safety Board (NTSB) will convene a Public Aircraft Oversight Safety Forum which will begin at 9 a... ``Public Aircraft Oversight Forum: Ensuring Safety for Critical Missions'', are to (1) raise awareness of...

  13. 78 FR 45052 - Critical Parts for Airplane Propellers; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-26

    ..., early warning devices, maintenance checks, and other similar equipment or procedures. If items of the..., and maintenance processes for propeller critical parts. An unintentional error was introduced in Sec... transportation, Aircraft, Aviation safety, Safety. The Correcting Amendment In consideration of the foregoing...

  14. 49 CFR 533.6 - Measurement and calculation procedures.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... technology is related to crash-avoidance technologies, safety critical systems or systems affecting safety-critical functions, or technologies designed for the purpose of reducing the frequency of vehicle crashes... improvements related to air conditioning efficiency, off-cycle technologies, and hybridization and other...

  15. Planning the Unplanned Experiment: Towards Assessing the Efficacy of Standards for Safety-Critical Software

    NASA Technical Reports Server (NTRS)

    Graydon, Patrick J.; Holloway, C. M.

    2015-01-01

    Safe use of software in safety-critical applications requires well-founded means of determining whether software is fit for such use. While software in industries such as aviation has a good safety record, little is known about whether standards for software in safety-critical applications 'work' (or even what that means). It is often (implicitly) argued that software is fit for safety-critical use because it conforms to an appropriate standard. Without knowing whether a standard works, such reliance is an experiment; without carefully collecting assessment data, that experiment is unplanned. To help plan the experiment, we organized a workshop to develop practical ideas for assessing software safety standards. In this paper, we relate and elaborate on the workshop discussion, which revealed subtle but important study design considerations and practical barriers to collecting appropriate historical data and recruiting appropriate experimental subjects. We discuss assessing standards as written and as applied, several candidate definitions for what it means for a standard to 'work,' and key assessment strategies and study techniques and the pros and cons of each. Finally, we conclude with thoughts about the kinds of research that will be required and how academia, industry, and regulators might collaborate to overcome the noted barriers.

  16. Work Practice Simulation of Complex Human-Automation Systems in Safety Critical Situations: The Brahms Generalized berlingen Model

    NASA Technical Reports Server (NTRS)

    Clancey, William J.; Linde, Charlotte; Seah, Chin; Shafto, Michael

    2013-01-01

    The transition from the current air traffic system to the next generation air traffic system will require the introduction of new automated systems, including transferring some functions from air traffic controllers to on­-board automation. This report describes a new design verification and validation (V&V) methodology for assessing aviation safety. The approach involves a detailed computer simulation of work practices that includes people interacting with flight-critical systems. The research is part of an effort to develop new modeling and verification methodologies that can assess the safety of flight-critical systems, system configurations, and operational concepts. The 2002 Ueberlingen mid-air collision was chosen for analysis and modeling because one of the main causes of the accident was one crew's response to a conflict between the instructions of the air traffic controller and the instructions of TCAS, an automated Traffic Alert and Collision Avoidance System on-board warning system. It thus furnishes an example of the problem of authority versus autonomy. It provides a starting point for exploring authority/autonomy conflict in the larger system of organization, tools, and practices in which the participants' moment-by-moment actions take place. We have developed a general air traffic system model (not a specific simulation of Überlingen events), called the Brahms Generalized Ueberlingen Model (Brahms-GUeM). Brahms is a multi-agent simulation system that models people, tools, facilities/vehicles, and geography to simulate the current air transportation system as a collection of distributed, interactive subsystems (e.g., airports, air-traffic control towers and personnel, aircraft, automated flight systems and air-traffic tools, instruments, crew). Brahms-GUeM can be configured in different ways, called scenarios, such that anomalous events that contributed to the Überlingen accident can be modeled as functioning according to requirements or in an anomalous condition, as occurred during the accident. Brahms-GUeM thus implicitly defines a class of scenarios, which include as an instance what occurred at Überlingen. Brahms-GUeM is a modeling framework enabling "what if" analysis of alternative work system configurations and thus facilitating design of alternative operations concepts. It enables subsequent adaption (reusing simulation components) for modeling and simulating NextGen scenarios. This project demonstrates that BRAHMS provides the capacity to model the complexity of air transportation systems, going beyond idealized and simple flights to include for example the interaction of pilots and ATCOs. The research shows clearly that verification and validation must include the entire work system, on the one hand to check that mechanisms exist to handle failures of communication and alerting subsystems and/or failures of people to notice, comprehend, or communicate problematic (unsafe) situations; but also to understand how people must use their own judgment in relating fallible systems like TCAS to other sources of information and thus to evaluate how the unreliability of automation affects system safety. The simulation shows in particular that distributed agents (people and automated systems) acting without knowledge of each others' actions can create a complex, dynamic system whose interactive behavior is unexpected and is changing too quickly to comprehend and control.

  17. Crew Launch Vehicle Mobile Launcher Solid Rocket Motor Plume Induced Environment

    NASA Technical Reports Server (NTRS)

    Vu, Bruce T.; Sulyma, Peter

    2008-01-01

    The plume-induced environment created by the Ares 1 first stage, five-segment reusable solid rocket motor (RSRMV) will impose high heating rates and impact pressures on Launch Complex 39. The extremes of these environments pose a potential threat to weaken or even cause structural components to fail if insufficiently designed. Therefore the ability to accurately predict these environments is critical to assist in specifying structural design requirements to insure overall structural integrity and flight safety. This paper presents the predicted thermal and pressure environments induced by the launch of the Crew Launch Vehicle (CLV) from Launch Complex (LC) 39. Once the environments are predicted, a follow-on thermal analysis is required to determine the surface temperature response and the degradation rate of the materials. An example of structures responding to the plume-induced environment will be provided.

  18. An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.

    PubMed

    Tscholl, David W; Weiss, Mona; Kolbe, Michaela; Staender, Sven; Seifert, Burkhardt; Landert, Daniel; Grande, Bastian; Spahn, Donat R; Noethiger, Christoph B

    2015-10-01

    An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked). A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork. One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P < 0.001), knowledge of critical information: 100% vs 90% (P < 0.001), perception of safety: 91% vs 84% (P < 0.001), perception of teamwork: 90% vs 86% (P = 0.028), and clinical performance: 93% vs 93% (P = 0.60). This study provides empirical evidence that the use of a preinduction checklist significantly improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams-all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork.

  19. SU-E-T-201: Safety-Focused Customization of Treatment Plan Documentation.

    PubMed

    Schubert, L; Westerly, D; Stuhr, K; Miften, M

    2012-06-01

    Plan report documentation contains numerous details about the treatment plan, but critical information for patient safety is often presented without special emphasis. This can make it difficult to detect errors from treatment planning and data transfer during the initial chart review. The objective of this work is to improve safety measures in radiation therapy practice by customizing the treatment plan report to emphasize safety-critical information. Commands within the template file from a commercial planning system (Eclipse, Varian Medical Systems) that automatically generates the treatment plan report were reviewed and modified. Safety-critical plan parameters were identified from published risks known to be inherent in the treatment planning process. Risks having medium to high potential impact on patient safety included incorrect patient identifiers, erroneous use of the treatment prescription, and incorrect transfer of beam parameters or consideration of accessories. Specific examples of critical information in the treatment plan report that can be overlooked during a chart review included prescribed dose per fraction and number of fractions, wedge and open field monitor units, presence of beam accessories, and table shifts for patient setup. Critical information was streamlined and concentrated. Patient and plan identification, dose prescription details, and patient positioning couch shift instructions were placed on the first page. Plan information to verify the correct data transfer to the record and verify system was re-organized in an easy to review tabular format and placed in the second page of the customized printout. Placeholders were introduced to indicate both the presence and absence of beam modifiers. Font sizes and spacing were adjusted for clarity, and departmental standards and terminology were introduced to streamline data communication among staff members. Plan reporting documentation has been customized to concentrate and emphasize safety-critical information, which should allow for a more efficient, robust chart review process. © 2012 American Association of Physicists in Medicine.

  20. Approach for validating actinide and fission product compositions for burnup credit criticality safety analyses

    DOE PAGES

    Radulescu, Georgeta; Gauld, Ian C.; Ilas, Germina; ...

    2014-11-01

    This paper describes a depletion code validation approach for criticality safety analysis using burnup credit for actinide and fission product nuclides in spent nuclear fuel (SNF) compositions. The technical basis for determining the uncertainties in the calculated nuclide concentrations is comparison of calculations to available measurements obtained from destructive radiochemical assay of SNF samples. Probability distributions developed for the uncertainties in the calculated nuclide concentrations were applied to the SNF compositions of a criticality safety analysis model by the use of a Monte Carlo uncertainty sampling method to determine bias and bias uncertainty in effective neutron multiplication factor. Application ofmore » the Monte Carlo uncertainty sampling approach is demonstrated for representative criticality safety analysis models of pressurized water reactor spent fuel pool storage racks and transportation packages using burnup-dependent nuclide concentrations calculated with SCALE 6.1 and the ENDF/B-VII nuclear data. Furthermore, the validation approach and results support a recent revision of the U.S. Nuclear Regulatory Commission Interim Staff Guidance 8.« less

  1. Reliability and safety of the electrical power supply complex of the Hanford production reactors

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Robbins, F.D.

    Safety has been and must continue to be the inviolable modulus by which the operation of a nuclear reactor must be judged. A malfunction in any reactor may well result in a release of fission products which may dissipate over a wide geographical area. Such dissipation may place the health, happiness and even the lives of the people in the region in serious jeopardy. As a result, the property damage and liability cost may reach astronomical values in the order of magnitude of billions of dollars. Reliability of the electrical network is an indispensable factor in attaining a high ordermore » of safety assurance. Progress in the peaceful use of atomic energy may take the form of electrical power generation using the nuclear reactor as a source of thermal energy. In view of these factors it seems appropriate and profitable that a critical engineering study be made of the safety and reliability of the Hanford reactors without regard to cost economics. This individual and independent technical engineering analysis was made without regard to Hanford traditional engineering and administration assignments. The main objective has been to focus attention on areas which seem to merit further detailed study on conditions which seem to need adjustment but most of all on those changes which will improve reactor safety. This report is the result of such a study.« less

  2. PFP Public Automatic Exchange (PAX) Commercial Grade Item (CGI) Critical Characteristics

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    WHITE, W.F.

    2000-04-04

    This document specifies the critical characteristics for Commercial Grade Items (CGI) procured for use within the safety envelope of PFP's PAX system as required by HNF-PRO-268 and HNF-PRO-1819. These are the minimum specifications that the equipment must meet in order to properly perform its safety function. There may be several manufacturers or models that meet the critical characteristics for any one item.

  3. The complexity of patient safety reporting systems in UK dentistry.

    PubMed

    Renton, T; Master, S

    2016-10-21

    Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.

  4. An Interactive User Interface for Drug Labeling to Improve Readability and Decision-Making

    PubMed Central

    Abedtash, Hamed; Duke, Jon D.

    2015-01-01

    FDA-approved prescribing information (also known as product labeling or labels) contain critical safety information for health care professionals. Drug labels have often been criticized, however, for being overly complex, difficult to read, and rife with overwarning, leading to high cognitive load. In this project, we aimed to improve the usability of drug labels by increasing the ‘signal-to-noise ratio’ and providing meaningful information to care providers based on patient-specific comorbidities and concomitant medications. In the current paper, we describe the design process and resulting web application, known as myDrugLabel. Using the Structured Product Label documents as a base, we describe the process of label personalization, readability improvements, and integration of diverse evidence sources, including the medical literature from PubMed, pharmacovigilance reports from FDA adverse event reporting system (FAERS), and social media signals directly into the label. PMID:26958158

  5. An Interactive User Interface for Drug Labeling to Improve Readability and Decision-Making.

    PubMed

    Abedtash, Hamed; Duke, Jon D

    FDA-approved prescribing information (also known as product labeling or labels) contain critical safety information for health care professionals. Drug labels have often been criticized, however, for being overly complex, difficult to read, and rife with overwarning, leading to high cognitive load. In this project, we aimed to improve the usability of drug labels by increasing the 'signal-to-noise ratio' and providing meaningful information to care providers based on patient-specific comorbidities and concomitant medications. In the current paper, we describe the design process and resulting web application, known as myDrugLabel. Using the Structured Product Label documents as a base, we describe the process of label personalization, readability improvements, and integration of diverse evidence sources, including the medical literature from PubMed, pharmacovigilance reports from FDA adverse event reporting system (FAERS), and social media signals directly into the label.

  6. LANL: Weapons Infrastructure Briefing to Naval Reactors, July 18, 2017

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Chadwick, Frances

    Presentation slides address: The Laboratory infrastructure supports hundreds of high hazard, complex operations daily; LANL’s unique science and engineering infrastructure is critical to delivering on our mission; LANL FY17 Budget & Workforce; Direct-Funded Infrastructure Accounts; LANL Org Chart; Weapons Infrastructure Program Office; The Laboratory’s infrastructure relies on both Direct and Indirect funding; NA-50’s Operating, Maintenance & Recapitalization funding is critical to the execution of the mission; Los Alamos is currently executing several concurrent Line Item projects; Maintenance @ LANL; NA-50 is helping us to address D&D needs; We are executing a CHAMP Pilot Project at LANL; G2 = Main Toolmore » for Program Management; MDI: Future Investments are centered on facilities with a high Mission Dependency Index; Los Alamos hosted first “Deep Dive” in November 2016; Safety, Infrastructure & Operations is one of the most important programs at LANL, and is foundational for our mission success.« less

  7. Synchrotron x-ray imaging visualization study of capillary-induced flow and critical heat flux on surfaces with engineered micropillars

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Yu, Dong In; Kwak, Ho Jae; Noh, Hyunwoo

    Over the past several decades, phenomena related to critical heat flux (CHF) on structured surfaces have received a large amount of attention from the research community. The purpose of such research has been to enhance the safety and efficiency of a variety of thermal systems. A number of theories have been put forward to explain the key CHF enhancement mechanisms on structured surfaces. However, these theories have not been confirmed experimentally due to limitations in the available visualization techniques and the complexity of the phenomena. To overcome the limitations of the previous visualization techniques and elucidate the CHF enhancement mechanismmore » on the structured surfaces, we introduce synchrotron X-ray imaging with high spatial (~2 μm) and time (~20,000 Hz) resolutions. Lastly, this technique has enabled us to confirm that capillary-induced flow is the key CHF enhancement mechanism on structured surfaces.« less

  8. Synchrotron x-ray imaging visualization study of capillary-induced flow and critical heat flux on surfaces with engineered micropillars

    DOE PAGES

    Yu, Dong In; Kwak, Ho Jae; Noh, Hyunwoo; ...

    2018-02-23

    Over the past several decades, phenomena related to critical heat flux (CHF) on structured surfaces have received a large amount of attention from the research community. The purpose of such research has been to enhance the safety and efficiency of a variety of thermal systems. A number of theories have been put forward to explain the key CHF enhancement mechanisms on structured surfaces. However, these theories have not been confirmed experimentally due to limitations in the available visualization techniques and the complexity of the phenomena. To overcome the limitations of the previous visualization techniques and elucidate the CHF enhancement mechanismmore » on the structured surfaces, we introduce synchrotron X-ray imaging with high spatial (~2 μm) and time (~20,000 Hz) resolutions. Lastly, this technique has enabled us to confirm that capillary-induced flow is the key CHF enhancement mechanism on structured surfaces.« less

  9. Cybersecurity: The Nation’s Greatest Threat to Critical Infrastructure

    DTIC Science & Technology

    2013-03-01

    protection has become a matter of national security, public safety, and economic stability . It is imperative the U.S. Government (USG) examine current...recommendations for federal responsibilities and legislation to direct nation critical infrastructure efforts to ensure national security, public safety and economic stability .

  10. 10 CFR 72.124 - Criteria for nuclear criticality safety.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 10 Energy 2 2013-01-01 2013-01-01 false Criteria for nuclear criticality safety. 72.124 Section 72.124 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) LICENSING REQUIREMENTS FOR THE INDEPENDENT STORAGE OF SPENT NUCLEAR FUEL, HIGH-LEVEL RADIOACTIVE WASTE, AND REACTOR-RELATED GREATER THAN CLASS C...

  11. 10 CFR 72.124 - Criteria for nuclear criticality safety.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 2 2014-01-01 2014-01-01 false Criteria for nuclear criticality safety. 72.124 Section 72.124 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) LICENSING REQUIREMENTS FOR THE INDEPENDENT STORAGE OF SPENT NUCLEAR FUEL, HIGH-LEVEL RADIOACTIVE WASTE, AND REACTOR-RELATED GREATER THAN CLASS C...

  12. 10 CFR 72.124 - Criteria for nuclear criticality safety.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 10 Energy 2 2012-01-01 2012-01-01 false Criteria for nuclear criticality safety. 72.124 Section 72.124 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) LICENSING REQUIREMENTS FOR THE INDEPENDENT STORAGE OF SPENT NUCLEAR FUEL, HIGH-LEVEL RADIOACTIVE WASTE, AND REACTOR-RELATED GREATER THAN CLASS C...

  13. 10 CFR 72.124 - Criteria for nuclear criticality safety.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 10 Energy 2 2011-01-01 2011-01-01 false Criteria for nuclear criticality safety. 72.124 Section 72.124 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) LICENSING REQUIREMENTS FOR THE INDEPENDENT STORAGE OF SPENT NUCLEAR FUEL, HIGH-LEVEL RADIOACTIVE WASTE, AND REACTOR-RELATED GREATER THAN CLASS C...

  14. 10 CFR 72.124 - Criteria for nuclear criticality safety.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 2 2010-01-01 2010-01-01 false Criteria for nuclear criticality safety. 72.124 Section 72.124 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) LICENSING REQUIREMENTS FOR THE INDEPENDENT STORAGE OF SPENT NUCLEAR FUEL, HIGH-LEVEL RADIOACTIVE WASTE, AND REACTOR-RELATED GREATER THAN CLASS C...

  15. Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety.

    PubMed

    Seshia, Shashi S; Bryan Young, G; Makhinson, Michael; Smith, Preston A; Stobart, Kent; Croskerry, Pat

    2018-02-01

    Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement. A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care. Thematic analysis, qualitative information from several sources being used to support argumentation. Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions. The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect. The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally. © 2017 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

  16. Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety

    PubMed Central

    Bryan Young, G.; Makhinson, Michael; Smith, Preston A.; Stobart, Kent; Croskerry, Pat

    2017-01-01

    Abstract Introduction Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care–related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement. Hypothesis A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive‐affective biases plus cascade could advance the understanding of cognitive‐affective processes that underlie decisions and organizational cultures across the continuum of care. Methods Thematic analysis, qualitative information from several sources being used to support argumentation. Discussion Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive‐affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive‐affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive‐affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error‐provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error‐provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive‐affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions. Limitations The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect. Conclusions The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally. PMID:29168290

  17. Concise Review: Mesenchymal Stem (Stromal) Cells: Biology and Preclinical Evidence for Therapeutic Potential for Organ Dysfunction Following Trauma or Sepsis.

    PubMed

    Matthay, Michael A; Pati, Shibani; Lee, Jae-Woo

    2017-02-01

    Several experimental studies have provided evidence that bone-marrow derived mesenchymal stem (stromal) cells (MSC) may be effective in treating critically ill surgical patients who develop traumatic brain injury, acute renal failure, or the acute respiratory distress syndrome. There is also preclinical evidence that MSC may be effective in treating sepsis-induced organ failure, including evidence that MSC have antimicrobial properties. This review considers preclinical studies with direct relevance to organ failure following trauma, sepsis or major infections that apply to critically ill patients. Progress has been made in understanding the mechanisms of benefit, including MSC release of paracrine factors, transfer of mitochondria, and elaboration of exosomes and microvesicles. Regardless of how well they are designed, preclinical studies have limitations in modeling the complexity of clinical syndromes, especially in patients who are critically ill. In order to facilitate translation of the preclinical studies of MSC to critically ill patients, there will need to be more standardization regarding MSC production with a focus on culture methods and cell characterization. Finally, well designed clinical trials will be needed in critically ill patient to assess safety and efficacy. Stem Cells 2017;35:316-324. © 2016 AlphaMed Press.

  18. Capturing Safety Requirements to Enable Effective Task Allocation Between Humans and Automaton in Increasingly Autonomous Systems

    NASA Technical Reports Server (NTRS)

    Neogi, Natasha A.

    2016-01-01

    There is a current drive towards enabling the deployment of increasingly autonomous systems in the National Airspace System (NAS). However, shifting the traditional roles and responsibilities between humans and automation for safety critical tasks must be managed carefully, otherwise the current emergent safety properties of the NAS may be disrupted. In this paper, a verification activity to assess the emergent safety properties of a clearly defined, safety critical, operational scenario that possesses tasks that can be fluidly allocated between human and automated agents is conducted. Task allocation role sets were proposed for a human-automation team performing a contingency maneuver in a reduced crew context. A safety critical contingency procedure (engine out on takeoff) was modeled in the Soar cognitive architecture, then translated into the Hybrid Input Output formalism. Verification activities were then performed to determine whether or not the safety properties held over the increasingly autonomous system. The verification activities lead to the development of several key insights regarding the implicit assumptions on agent capability. It subsequently illustrated the usefulness of task annotations associated with specialized requirements (e.g., communication, timing etc.), and demonstrated the feasibility of this approach.

  19. Definition and means of maintaining the criticality detectors and alarms portion of the PFP safety envelope

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    White, W.F.

    The purpose of this document is to provide the definition and means of maintaining the Safety Envelope (SE) related to the Criticality Alarm System (CAS). This document provides amplification of the Limiting Condition for Operation (LCO) described in the Plutonium Finishing Plant (PFP) Operational Safety Requirements (OSR), WHC-SD-CP-OSR-010, Rev. 0, 1994, Section 3.1.2, Criticality Detectors and Alarms. This document, with its appendices, provides the following: (1) System functional requirements for determining system operability (Section 3); (2) A list of annotated system block diagrams which indicate the safety envelope boundaries (Appendix C); (3) A list of the Safety Class 1 andmore » 2 Safety Envelope (SC-1/2 SE) equipment for input into the Master Component Index (Appendix B); (4) Functional requirements for individual SC-1/2 SE components, including appropriate setpoints and process parameters (Section 6 and Appendix A); (5) A list of the operational, maintenance and surveillance procedures necessary to operate and maintain the SC-1/2 SE components as required by the LCO (Section 6 and Appendix A).« less

  20. An RFID solution for enhancing inpatient medication safety with real-time verifiable grouping-proof.

    PubMed

    Chen, Yu-Yi; Tsai, Meng-Lin

    2014-01-01

    The occurrence of a medication error can threaten patient safety. The medication administration process is complex and cumbersome, and nursing staffs are prone to error when they are tired. Proper Information Technology (IT) can assist the nurse in correct medication administration. We review a recent proposal regarding a leading-edge solution to enhance inpatient medication safety by using RFID technology. The proof mechanism is the kernel concept in their design and worth studying to develop a well-designed grouping-proof scheme. Other RFID grouping-proof protocols could be similarly applied in administering physician orders. We improve on the weaknesses of previous works and develop a reading-order independent RFID grouping-proof scheme in this paper. In our scheme, tags are queried and verified under the direct control of the authorized reader without connecting to the back-end database server. Immediate verification in our design makes this application more portable and efficient and critical security issues have been analyzed by the threat model. Our scheme is suitable for the safe drug administration scenario and the drug package scenario in a hospital environment to enhance inpatient medication safety. It automatically checks for correct drug unit-dose and appropriate inpatient treatments. Copyright © 2013. Published by Elsevier Ireland Ltd.

  1. Safety cases for medical devices and health information technology: involving health-care organisations in the assurance of safety.

    PubMed

    Sujan, Mark A; Koornneef, Floor; Chozos, Nick; Pozzi, Simone; Kelly, Tim

    2013-09-01

    In the United Kingdom, there are more than 9000 reports of adverse events involving medical devices annually. The regulatory processes in Europe and in the United States have been challenged as to their ability to protect patients effectively from unreasonable risk and harm. Two of the major shortcomings of current practice include the lack of transparency in the safety certification process and the lack of involvement of service providers. We reviewed recent international standardisation activities in this area, and we reviewed regulatory practices in other safety-critical industries. The review showed that the use of safety cases is an accepted practice in UK safety-critical industries, but at present, there is little awareness of this concept in health care. Safety cases have the potential to provide greater transparency and confidence in safety certification and to act as a communication tool between manufacturers, service providers, regulators and patients.

  2. 10 CFR 70.62 - Safety program and integrated safety analysis.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ...; (iv) Potential accident sequences caused by process deviations or other events internal to the... of occurrence of each potential accident sequence identified pursuant to paragraph (c)(1)(iv) of this... have experience in nuclear criticality safety, radiation safety, fire safety, and chemical process...

  3. 10 CFR 70.62 - Safety program and integrated safety analysis.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ...; (iv) Potential accident sequences caused by process deviations or other events internal to the... of occurrence of each potential accident sequence identified pursuant to paragraph (c)(1)(iv) of this... have experience in nuclear criticality safety, radiation safety, fire safety, and chemical process...

  4. 10 CFR 70.62 - Safety program and integrated safety analysis.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ...; (iv) Potential accident sequences caused by process deviations or other events internal to the... of occurrence of each potential accident sequence identified pursuant to paragraph (c)(1)(iv) of this... have experience in nuclear criticality safety, radiation safety, fire safety, and chemical process...

  5. Determination of Slope Safety Factor with Analytical Solution and Searching Critical Slip Surface with Genetic-Traversal Random Method

    PubMed Central

    2014-01-01

    In the current practice, to determine the safety factor of a slope with two-dimensional circular potential failure surface, one of the searching methods for the critical slip surface is Genetic Algorithm (GA), while the method to calculate the slope safety factor is Fellenius' slices method. However GA needs to be validated with more numeric tests, while Fellenius' slices method is just an approximate method like finite element method. This paper proposed a new method to determine the minimum slope safety factor which is the determination of slope safety factor with analytical solution and searching critical slip surface with Genetic-Traversal Random Method. The analytical solution is more accurate than Fellenius' slices method. The Genetic-Traversal Random Method uses random pick to utilize mutation. A computer automatic search program is developed for the Genetic-Traversal Random Method. After comparison with other methods like slope/w software, results indicate that the Genetic-Traversal Random Search Method can give very low safety factor which is about half of the other methods. However the obtained minimum safety factor with Genetic-Traversal Random Search Method is very close to the lower bound solutions of slope safety factor given by the Ansys software. PMID:24782679

  6. ZPR-3 Assembly 11 : A cylindrical sssembly of highly enriched uranium and depleted uranium with an average {sup 235}U enrichment of 12 atom % and a depleted uranium reflector.

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Lell, R. M.; McKnight, R. D.; Tsiboulia, A.

    2010-09-30

    Over a period of 30 years, more than a hundred Zero Power Reactor (ZPR) critical assemblies were constructed at Argonne National Laboratory. The ZPR facilities, ZPR-3, ZPR-6, ZPR-9 and ZPPR, were all fast critical assembly facilities. The ZPR critical assemblies were constructed to support fast reactor development, but data from some of these assemblies are also well suited for nuclear data validation and to form the basis for criticality safety benchmarks. A number of the Argonne ZPR/ZPPR critical assemblies have been evaluated as ICSBEP and IRPhEP benchmarks. Of the three classes of ZPR assemblies, engineering mockups, engineering benchmarks and physicsmore » benchmarks, the last group tends to be most useful for criticality safety. Because physics benchmarks were designed to test fast reactor physics data and methods, they were as simple as possible in geometry and composition. The principal fissile species was {sup 235}U or {sup 239}Pu. Fuel enrichments ranged from 9% to 95%. Often there were only one or two main core diluent materials, such as aluminum, graphite, iron, sodium or stainless steel. The cores were reflected (and insulated from room return effects) by one or two layers of materials such as depleted uranium, lead or stainless steel. Despite their more complex nature, a small number of assemblies from the other two classes would make useful criticality safety benchmarks because they have features related to criticality safety issues, such as reflection by soil-like material. ZPR-3 Assembly 11 (ZPR-3/11) was designed as a fast reactor physics benchmark experiment with an average core {sup 235}U enrichment of approximately 12 at.% and a depleted uranium reflector. Approximately 79.7% of the total fissions in this assembly occur above 100 keV, approximately 20.3% occur below 100 keV, and essentially none below 0.625 eV - thus the classification as a 'fast' assembly. This assembly is Fast Reactor Benchmark No. 8 in the Cross Section Evaluation Working Group (CSEWG) Benchmark Specificationsa and has historically been used as a data validation benchmark assembly. Loading of ZPR-3 Assembly 11 began in early January 1958, and the Assembly 11 program ended in late January 1958. The core consisted of highly enriched uranium (HEU) plates and depleted uranium plates loaded into stainless steel drawers, which were inserted into the central square stainless steel tubes of a 31 x 31 matrix on a split table machine. The core unit cell consisted of two columns of 0.125 in.-wide (3.175 mm) HEU plates, six columns of 0.125 in.-wide (3.175 mm) depleted uranium plates and one column of 1.0 in.-wide (25.4 mm) depleted uranium plates. The length of each column was 10 in. (254.0 mm) in each half of the core. The axial blanket consisted of 12 in. (304.8 mm) of depleted uranium behind the core. The thickness of the depleted uranium radial blanket was approximately 14 in. (355.6 mm), and the length of the radial blanket in each half of the matrix was 22 in. (558.8 mm). The assembly geometry approximated a right circular cylinder as closely as the square matrix tubes allowed. According to the logbook and loading records for ZPR-3/11, the reference critical configuration was loading 10 which was critical on January 21, 1958. Subsequent loadings were very similar but less clean for criticality because there were modifications made to accommodate reactor physics measurements other than criticality. Accordingly, ZPR-3/11 loading 10 was selected as the only configuration for this benchmark. As documented below, it was determined to be acceptable as a criticality safety benchmark experiment. A very accurate transformation to a simplified model is needed to make any ZPR assembly a practical criticality-safety benchmark. There is simply too much geometric detail in an exact (as-built) model of a ZPR assembly, even a clean core such as ZPR-3/11 loading 10. The transformation must reduce the detail to a practical level without masking any of the important features of the critical experiment. And it must do this without increasing the total uncertainty far beyond that of the original experiment. Such a transformation is described in Section 3. It was obtained using a pair of continuous-energy Monte Carlo calculations. First, the critical configuration was modeled in full detail - every plate, drawer, matrix tube, and air gap was modeled explicitly. Then the regionwise compositions and volumes from the detailed as-built model were used to construct a homogeneous, two-dimensional (RZ) model of ZPR-3/11 that conserved the mass of each nuclide and volume of each region. The simple cylindrical model is the criticality-safety benchmark model. The difference in the calculated k{sub eff} values between the as-built three-dimensional model and the homogeneous two-dimensional benchmark model was used to adjust the measured excess reactivity of ZPR-3/11 loading 10 to obtain the k{sub eff} for the benchmark model.« less

  7. Evaluation of the concrete shield compositions from the 2010 criticality accident alarm system benchmark experiments at the CEA Valduc SILENE facility

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Miller, Thomas Martin; Celik, Cihangir; Dunn, Michael E

    In October 2010, a series of benchmark experiments were conducted at the French Commissariat a l'Energie Atomique et aux Energies Alternatives (CEA) Valduc SILENE facility. These experiments were a joint effort between the United States Department of Energy Nuclear Criticality Safety Program and the CEA. The purpose of these experiments was to create three benchmarks for the verification and validation of radiation transport codes and evaluated nuclear data used in the analysis of criticality accident alarm systems. This series of experiments consisted of three single-pulsed experiments with the SILENE reactor. For the first experiment, the reactor was bare (unshielded), whereasmore » in the second and third experiments, it was shielded by lead and polyethylene, respectively. The polyethylene shield of the third experiment had a cadmium liner on its internal and external surfaces, which vertically was located near the fuel region of SILENE. During each experiment, several neutron activation foils and thermoluminescent dosimeters (TLDs) were placed around the reactor. Nearly half of the foils and TLDs had additional high-density magnetite concrete, high-density barite concrete, standard concrete, and/or BoroBond shields. CEA Saclay provided all the concrete, and the US Y-12 National Security Complex provided the BoroBond. Measurement data from the experiments were published at the 2011 International Conference on Nuclear Criticality (ICNC 2011) and the 2013 Nuclear Criticality Safety Division (NCSD 2013) topical meeting. Preliminary computational results for the first experiment were presented in the ICNC 2011 paper, which showed poor agreement between the computational results and the measured values of the foils shielded by concrete. Recently the hydrogen content, boron content, and density of these concrete shields were further investigated within the constraints of the previously available data. New computational results for the first experiment are now available that show much better agreement with the measured values.« less

  8. Successful hazard analysis critical control point implementation in the United Kingdom: understanding the barriers through the use of a behavioral adherence model.

    PubMed

    Gilling, S J; Taylor, E A; Kane, K; Taylor, J Z

    2001-05-01

    Hazard analysis critical control point (HACCP), a system of risk management designed to control food safety, has emerged over the last decade as the primary approach to securing the safety of the food supply. It is thus an important tool in combatting the worldwide escalation of foodborne disease. Yet despite wide dissemination and scientific support of its principles, successful HACCP implementation has been limited. This report takes a psychological approach to this problem by examining processes and factors that could impede adherence to the internationally accepted HACCP Guidelines and subsequent successful implementation of HACCP. Utilizing knowledge of medical clinical guideline adherence models and practical experience of HACCP implementation problems, the potential advantages of applying a behavioral model to food safety management are highlighted. The models' applicability was investigated using telephone interviews from over 200 businesses in the United Kingdom. Eleven key barriers to HACCP guideline adherence were identified. In-depth narrative interviews with food business proprietors then confirmed these findings and demonstrated the subsequent negative effect(s) on HACCP implementation. A resultant HACCP awareness to adherence model is proposed that demonstrates the complex range of potential knowledge, attitude, and behavior-related barriers involved in failures of HACCP guideline adherence. The model's specificity and detail provide a tool whereby problems can be identified and located and in this way facilitate tailored and constructive intervention. It is suggested that further investigation into the barriers involved and how to overcome them would be of substantial benefit to successful HACCP implementation and thereby contribute to an overall improvement in public health.

  9. Four Pillars for Improving the Quality of Safety-Critical Software-Reliant Systems

    DTIC Science & Technology

    2013-04-01

    Studies of safety-critical software-reliant systems developed using the current practices of build-then-test show that requirements and architecture ... design defects make up approximately 70% of all defects, many system level related to operational quality attributes, and 80% of these defects are

  10. Extended time-to-collision measures for road traffic safety assessment.

    PubMed

    Minderhoud, M M; Bovy, P H

    2001-01-01

    This article describes two new safety indicators based on the time-to-collision notion suitable for comparative road traffic safety analyses. Such safety indicators can be applied in the comparison of a do-nothing case with an adapted situation, e.g. the introduction of intelligent driver support systems. In contrast to the classical time-to-collision value, measured at a cross section, the improved safety indicators use vehicle trajectories collected over a specific time horizon for a certain roadway segment to calculate the overall safety indicator value. Vehicle-specific indicator values as well as safety-critical probabilities can easily be determined from the developed safety measures. Application of the derived safety indicators is demonstrated for the assessment of the potential safety impacts of driver support systems from which it appears that some Autonomous Intelligent Cruise Control (AICC) designs are more safety-critical than the reference case without these systems. It is suggested that the indicator threshold value to be applied in the safety assessment has to be adapted when advanced AICC-systems with safe characteristics are introduced.

  11. The potential application of behavior-based safety in the trucking industry

    DOT National Transportation Integrated Search

    2000-04-01

    Behavior-based safety (BBS) is a set of methods to improve safety performance in the workplace by engaging workers in the improvement process, identifying critical safety behaviors, performing observations to gather data, providing feedback to encour...

  12. Preparing Florida for deployment of SafetyAnalyst for all roads : [summary].

    DOT National Transportation Integrated Search

    2012-01-01

    Safety on Floridas roads is a top priority for the : Florida Department of Transportation (FDOT). : Identifying and prioritizing locations with high : potential for safety improvement is the critical : step in roadway safety management. New : tech...

  13. 78 FR 20661 - Agency Information Collection Activities; Submission for Office of Management and Budget Review...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-05

    ... Category: For a food additive petition without complex chemistry, manufacturing, efficacy, or safety issues...) Complex Category: For a food additive petition with complex chemistry, manufacturing, efficacy, and/or... additive file without complex chemistry, manufacturing, efficacy, or safety issues, the estimated time...

  14. Testing First-Order Logic Axioms in AutoCert

    NASA Technical Reports Server (NTRS)

    Ahn, Ki Yung; Denney, Ewen

    2009-01-01

    AutoCert [2] is a formal verification tool for machine generated code in safety critical domains, such as aerospace control code generated from MathWorks Real-Time Workshop. AutoCert uses Automated Theorem Provers (ATPs) [5] based on First-Order Logic (FOL) to formally verify safety and functional correctness properties of the code. These ATPs try to build proofs based on user provided domain-specific axioms, which can be arbitrary First-Order Formulas (FOFs). These axioms are the most crucial part of the trusted base, since proofs can be submitted to a proof checker removing the need to trust the prover and AutoCert itself plays the part of checking the code generator. However, formulating axioms correctly (i.e. precisely as the user had really intended) is non-trivial in practice. The challenge of axiomatization arise from several dimensions. First, the domain knowledge has its own complexity. AutoCert has been used to verify mathematical requirements on navigation software that carries out various geometric coordinate transformations involving matrices and quaternions. Axiomatic theories for such constructs are complex enough that mistakes are not uncommon. Second, adjusting axioms for ATPs can add even more complexity. The axioms frequently need to be modified in order to have them in a form suitable for use with ATPs. Such modifications tend to obscure the axioms further. Thirdly, speculating validity of the axioms from the output of existing ATPs is very hard since theorem provers typically do not give any examples or counterexamples.

  15. Multiple Intravenous Infusions Phase 1b

    PubMed Central

    Cassano-Piché, A; Fan, M; Sabovitch, S; Masino, C; Easty, AC

    2012-01-01

    Background Minimal research has been conducted into the potential patient safety issues related to administering multiple intravenous (IV) infusions to a single patient. Previous research has highlighted that there are a number of related safety risks. In Phase 1a of this study, an analysis of 2 national incident-reporting databases (Institute for Safe Medical Practices Canada and United States Food and Drug Administration MAUDE) found that a high percentage of incidents associated with the administration of multiple IV infusions resulted in patient harm. Objectives The primary objectives of Phase 1b of this study were to identify safety issues with the potential to cause patient harm stemming from the administration of multiple IV infusions; and to identify how nurses are being educated on key principles required to safely administer multiple IV infusions. Data Sources and Review Methods A field study was conducted at 12 hospital clinical units (sites) across Ontario, and telephone interviews were conducted with program coordinators or instructors from both the Ontario baccalaureate nursing degree programs and the Ontario postgraduate Critical Care Nursing Certificate programs. Data were analyzed using Rasmussen’s 1997 Risk Management Framework and a Health Care Failure Modes and Effects Analysis. Results Twenty-two primary patient safety issues were identified with the potential to directly cause patient harm. Seventeen of these (critical issues) were categorized into 6 themes. A cause-consequence tree was established to outline all possible contributing factors for each critical issue. Clinical recommendations were identified for immediate distribution to, and implementation by, Ontario hospitals. Future investigation efforts were planned for Phase 2 of the study. Limitations This exploratory field study identifies the potential for errors, but does not describe the direct observation of such errors, except in a few cases where errors were observed. Not all issues are known in advance, and the frequency of errors is too low to be observed in the time allotted and with the limited sample of observations. Conclusions The administration of multiple IV infusions to a single patient is a complex task with many potential associated patient safety risks. Improvements to infusion and infusion-related technology, education standards, clinical best practice guidelines, hospital policies, and unit work practices are required to reduce the risk potential. This report makes several recommendations to Ontario hospitals so that they can develop an awareness of the issues highlighted in this report and minimize some of the risks. Further investigation of mitigating strategies is required and will be undertaken in Phase 2 of this research. Plain Language Summary Patients, particularly in critical care environments, often require multiple intravenous (IV) medications via large volumetric or syringe infusion pumps. The infusion of multiple IV medications is not without risk; unintended errors during these complex procedures have resulted in patient harm. However, the range of associated risks and the factors contributing to these risks are not well understood. Health Quality Ontario’s Ontario Health Technology Advisory Committee commissioned the Health Technology Safety Research Team at the University Health Network to conduct a multi-phase study to identify and mitigate the risks associated with multiple IV infusions. Some of the questions addressed by the team were as follows: What is needed to reduce the risk of errors for individuals who are receiving a lot of medications? What strategies work best? The initial report, Multiple Intravenous Infusions Phase 1a: Situation Scan Summary Report, summarizes the interim findings based on a literature review, an incident database review, and a technology scan. The Health Technology Safety Research Team worked in close collaboration with the Institute for Safe Medication Practices Canada on an exploratory study to understand the risks associated with multiple IV infusions and the degree to which nurses are educated to help mitigate them. The current report, Multiple Intravenous Infusions Phase 1b: Practice and Training Scan, presents the findings of a field study of 12 hospital clinical units across Ontario, as well as 13 interviews with educators from baccalaureate-level nursing degree programs and postgraduate Critical Care Nursing Certificate programs. It makes 9 recommendations that emphasize best practices for the administration of multiple IV infusions and pertain to secondary infusions, line identification, line set-up and removal, and administering IV bolus medications. The Health Technology Safety Research Team has also produced an associated report for hospitals entitled Mitigating the Risks Associated With Multiple IV Infusions: Recommendations Based on a Field Study of Twelve Ontario Hospitals, which highlights the 9 interim recommendations and provides a brief rationale for each one. PMID:23074426

  16. Dependability: a challenge for electrical medical implants.

    PubMed

    Cathébras, Guy; Le Floch, Fanny; Bernard, Serge; Soulier, Fabien

    2010-01-01

    Functional Electrical Stimulation (FES) is an attractive solution to restore some lost or failing physiological functions. Obviously, the FES system may be hazardous for patient and the reliability and dependability of the system must be maximal. Unfortunately, the present context, where the associated systems are more and more complex and their development needs very cross-disciplinary experts, is not favorable to safety. Moreover, the direct adaptation of the existing dependability techniques from domains such as space or automotive is not suitable. Firstly, this paper proposes a strategy for risk management at system level for FES medical implant. The idea is to give a uniform framework where all possible hazards are highlighted and associated consequences are minimized. Then, the paper focuses on critical parts of the FES system: analog micro-circuit which generates the electrical signal to electrode. As this micro-circuit is the closest to the human tissue, any failure might involve very critical consequences for the patient. We propose a concurrent top-down and bottom-up approach where the critical elements are highlighted and an extended risk analysis is performed.

  17. Damage Tolerance Assessment of Friction Pull Plug Welds in an Aluminum Alloy

    NASA Technical Reports Server (NTRS)

    McGill, Preston; Burkholder, Jonathan

    2012-01-01

    Friction stir welding is a solid state welding process used in the fabrication of cryogenic propellant tanks. Self-reacting friction stir welding is one variation of the friction stir weld process being developed for manufacturing tanks. Friction pull plug welding is used to seal the exit hole that remains in a circumferential self-reacting friction stir weld. A friction plug weld placed in a self-reacting friction stir weld results in a non-homogenous weld joint where the initial weld, plug weld, their respective heat affected zones and the base metal all interact. The welded joint is a composite plastically deformed material system with a complex residual stress field. In order to address damage tolerance concerns associated with friction plug welds in safety critical structures, such as propellant tanks, nondestructive inspection and proof testing may be required to screen hardware for mission critical defects. The efficacy of the nondestructive evaluation or the proof test is based on an assessment of the critical flaw size. Test data relating residual strength capability to flaw size in an aluminum alloy friction plug weld will be presented.

  18. Health and the life course: why safety nets matter.

    PubMed Central

    Bartley, M.; Blane, D.; Montgomery, S.

    1997-01-01

    This article argues that a life course approach is necessary to understand social variations in health. This is needed in order to take into account the complex ways in which biological risk interacts with economic, social, and psychological factors in the development of chronic disease. Such an approach reveals biological and social "critical periods" during which social policies that will defend individuals against an accumulation of risk are particularly important. In many ways, the authors of modern welfare states were implicitly addressing these issues, and the contribution of these policies to present day high standards of health in developed countries should not be ignored. PMID:9146402

  19. Modeling and Simulation of Upset-Inducing Disturbances for Digital Systems in an Electromagnetic Reverberation Chamber

    NASA Technical Reports Server (NTRS)

    Torres-Pomales, Wilfredo

    2014-01-01

    This report describes a modeling and simulation approach for disturbance patterns representative of the environment experienced by a digital system in an electromagnetic reverberation chamber. The disturbance is modeled by a multi-variate statistical distribution based on empirical observations. Extended versions of the Rejection Samping and Inverse Transform Sampling techniques are developed to generate multi-variate random samples of the disturbance. The results show that Inverse Transform Sampling returns samples with higher fidelity relative to the empirical distribution. This work is part of an ongoing effort to develop a resilience assessment methodology for complex safety-critical distributed systems.

  20. Orion Returns to KSC after Successful Mission

    NASA Image and Video Library

    2014-12-18

    NASA's Orion crew module, enclosed in its crew module transportation fixture and secured on a flatbed truck passes by the Space Shuttle Atlantis building at the Kennedy Space Center Visitor Complex on its way to the entrance gate to Kennedy Space Center in Florida. Orion made the overland trip from Naval Base San Diego in California. Orion was recovered from the Pacific Ocean after completing a two-orbit, four-and-a-half hour mission Dec. 5 to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. The Ground Systems Development and Operations Program led the recovery, offload and transportation efforts.

  1. HSE's safety assessment principles for criticality safety.

    PubMed

    Simister, D N; Finnerty, M D; Warburton, S J; Thomas, E A; Macphail, M R

    2008-06-01

    The Health and Safety Executive (HSE) published its revised Safety Assessment Principles for Nuclear Facilities (SAPs) in December 2006. The SAPs are primarily intended for use by HSE's inspectors when judging the adequacy of safety cases for nuclear facilities. The revised SAPs relate to all aspects of safety in nuclear facilities including the technical discipline of criticality safety. The purpose of this paper is to set out for the benefit of a wider audience some of the thinking behind the final published words and to provide an insight into the development of UK regulatory guidance. The paper notes that it is HSE's intention that the Safety Assessment Principles should be viewed as a reflection of good practice in the context of interpreting primary legislation such as the requirements under site licence conditions for arrangements for producing an adequate safety case and for producing a suitable and sufficient risk assessment under the Ionising Radiations Regulations 1999 (SI1999/3232 www.opsi.gov.uk/si/si1999/uksi_19993232_en.pdf).

  2. 77 FR 19054 - Railroad Safety Advisory Committee; Notice of Meeting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-29

    ... Safety Standards, Critical Incident, Dark Territory, Fatigue Management, Risk Reduction, Electronic... FRA on railroad safety matters. The RSAC is composed of 54 voting representatives from 31 member...

  3. A protocol for the development of a critical thinking assessment tool for nurses using a Delphi technique.

    PubMed

    Jacob, Elisabeth; Duffield, Christine; Jacob, Darren

    2017-08-01

    The aim of this study was to develop an assessment tool to measure the critical thinking ability of nurses. As an increasing number of complex patients are admitted to hospitals, the importance of nurses recognizing changes in health status and picking up on deterioration is more important. To detect early signs of complication requires critical thinking skills. Registered Nurses are expected to commence their clinical careers with the necessary critical thinking skills to ensure safe nursing practice. Currently, there is no published tool to assess critical thinking skills which is context specific to Australian nurses. A modified Delphi study will be used for the project. This study will develop a series of unfolding case scenarios using national health data with multiple-choice questions to assess critical thinking. Face validity of the scenarios will be determined by an expert reference group of clinical and academic nurses. A Delphi study will determine the answers to scenario questions. Panel members will be expert clinicians and educators from two states in Australia. Rasch analysis of the questionnaire will assess validity and reliability of the tool. Funding for the study and Research Ethics Committee approval were obtained in March and November 2016, respectively. Patient outcomes and safety are directly linked to nurses' critical thinking skills. This study will develop an assessment tool to provide a standardized method of measuring nurses' critical thinking skills across Australia. This will provide healthcare providers with greater confidence in the critical thinking level of graduate Registered Nurses. © 2017 John Wiley & Sons Ltd.

  4. Nuclear criticality safety evaluation of SRS 9971 shipping package

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Vescovi, P.J.

    1993-02-01

    This evaluation is requested to revise the criticality evaluation used to generate Chapter 6 (Criticality Evaluation) of the Safety Analysis Report for Packaging (SARP) for shipment Of UO{sub 3} product from the Uranium Solidification Facility (USF) in the SRS 9971 shipping package. The pertinent document requesting this evaluation is included as Attachment I. The results of the evaluation are given in Attachment II which is written as Chapter 6 of a NRC format SARP.

  5. 77 FR 60479 - Burnup Credit in the Criticality Safety Analyses of Pressurized Water Reactor Spent Fuel in...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-03

    ... Pressurized Water Reactor Spent Fuel in Transportation and Storage Casks AGENCY: Nuclear Regulatory Commission... 3, entitled, ``Burnup Credit in the Criticality Safety Analyses of PWR [Pressurized Water Reactor... water reactor spent nuclear fuel (SNF) in transportation packages and storage casks. SFST-ISG-8...

  6. 49 CFR 234.275 - Processor-based systems.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... new or novel technology, or which provide safety-critical data to a railroad signal or train control... requirements. New or novel technology refers to a technology not previously recognized for use as of March 7... but which provides safety-critical data to a signal or train control system shall be included in the...

  7. 49 CFR 234.275 - Processor-based systems.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... new or novel technology, or which provide safety-critical data to a railroad signal or train control... requirements. New or novel technology refers to a technology not previously recognized for use as of March 7... but which provides safety-critical data to a signal or train control system shall be included in the...

  8. 49 CFR 176.704 - Requirements relating to transport indices and criticality safety indices.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 2 2011-10-01 2011-10-01 false Requirements relating to transport indices and... Requirements relating to transport indices and criticality safety indices. (a) The sum of the transport indices..., transport and unloading are to be supervised by persons qualified in the transport of radioactive material...

  9. 49 CFR 176.704 - Requirements relating to transport indices and criticality safety indices.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 2 2010-10-01 2010-10-01 false Requirements relating to transport indices and... Requirements relating to transport indices and criticality safety indices. (a) The sum of the transport indices..., transport and unloading are to be supervised by persons qualified in the transport of radioactive material...

  10. 21 CFR 123.6 - Hazard analysis and Hazard Analysis Critical Control Point (HACCP) plan.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... identified food safety hazards, including as appropriate: (i) Critical control points designed to control... control points designed to control food safety hazards introduced outside the processing plant environment... Control Point (HACCP) plan. 123.6 Section 123.6 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF...

  11. 21 CFR 123.6 - Hazard analysis and Hazard Analysis Critical Control Point (HACCP) plan.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... identified food safety hazards, including as appropriate: (i) Critical control points designed to control... control points designed to control food safety hazards introduced outside the processing plant environment... Control Point (HACCP) plan. 123.6 Section 123.6 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF...

  12. 21 CFR 123.6 - Hazard analysis and Hazard Analysis Critical Control Point (HACCP) plan.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... identified food safety hazards, including as appropriate: (i) Critical control points designed to control... control points designed to control food safety hazards introduced outside the processing plant environment... Control Point (HACCP) plan. 123.6 Section 123.6 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF...

  13. Plutonium Oxide Containment and the Potential for Water-Borne Transport as a Consequence of ARIES Oxide Processing Operations

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Wayne, David Matthew; Rowland, Joel C.

    2015-02-01

    The question of oxide containment during processing and storage has become a primary concern when considering the continued operability of the Plutonium Facility (PF-4) at Los Alamos National Laboratory (LANL). An Evaluation of the Safety of the Situation (ESS), “Potential for Criticality in a Glovebox Due to a Fire” (TA55-ESS-14-002-R2, since revised to R3) first issued in May, 2014 summarizes these concerns: “The safety issue of fire water potentially entering a glovebox is: the potential for the water to accumulate in the bottom of a glovebox and result in an inadvertent criticality due to the presence of fissionable materials inmore » the glovebox locations and the increased reflection and moderation of neutrons from the fire water accumulation.” As a result, the existing documented safety analysis (DSA) was judged inadequate and, while it explicitly considered the potential for criticality resulting from water intrusion into gloveboxes, criticality safety evaluation documents (CSEDs) for the affected locations did not evaluate the potential for fire water intrusion into a glovebox.« less

  14. Modelling emergency decisions: recognition-primed decision making. The literature in relation to an ophthalmic critical incident.

    PubMed

    Bond, Susan; Cooper, Simon

    2006-08-01

    To review and reflect on the literature on recognition-primed decision (RPD) making and influences on emergency decisions with particular reference to an ophthalmic critical incident involving the sub-arachnoid spread of local anaesthesia following the peribulbar injection. This paper critics the literature on recognition-primed decision making, with particular reference to emergency situations. It illustrates the findings by focussing on an ophthalmic critical incident. Systematic literature review with critical incident reflection. Medline, CINAHL and PsychINFO databases were searched for papers on recognition-primed decision making (1996-2004) followed by the 'snowball method'. Studies were selected in accordance with preset criteria. A total of 12 papers were included identifying the recognition-primed decision making as a good theoretical description of acute emergency decisions. In addition, cognitive resources, situational awareness, stress, team support and task complexity were identified as influences on the decision process. Recognition-primed decision-making theory describes the decision processes of experts in time-bound emergency situations and is the foundation for a model of emergency decision making (Fig. 2). Decision theory and models, in this case related to emergency situations, inform practice and enhance clinical effectiveness. The critical incident described highlights the need for nurses to have a comprehensive and in-depth understanding of anaesthetic techniques as well as an ability to manage and resuscitate patients autonomously. In addition, it illustrates how the critical incidents should influence the audit cycle with improvements in patient safety.

  15. Safety impacts of bicycle infrastructure: A critical review.

    PubMed

    DiGioia, Jonathan; Watkins, Kari Edison; Xu, Yanzhi; Rodgers, Michael; Guensler, Randall

    2017-06-01

    This paper takes a critical look at the present state of bicycle infrastructure treatment safety research, highlighting data needs. Safety literature relating to 22 bicycle treatments is examined, including findings, study methodologies, and data sources used in the studies. Some preliminary conclusions related to research efficacy are drawn from the available data and findings in the research. While the current body of bicycle safety literature points toward some defensible conclusions regarding the safety and effectiveness of certain bicycle treatments, such as bike lanes and removal of on-street parking, the vast majority treatments are still in need of rigorous research. Fundamental questions arise regarding appropriate exposure measures, crash measures, and crash data sources. This research will aid transportation departments with regard to decisions about bicycle infrastructure and guide future research efforts toward understanding safety impacts of bicycle infrastructure. Copyright © 2017 Elsevier Ltd and National Safety Council. All rights reserved.

  16. Electron-proton spectrometer: Summary for critical design review

    NASA Technical Reports Server (NTRS)

    1972-01-01

    The electron-proton spectrometer (EPS) is mounted external to the Skylab module complex on the command service module. It is designed to make a 2 pi omni-directional measurement of electrons and protons which result from solar flares or enhancement of the radiation belts. The EPS data will provide accurate radiation dose information so that uncertain Relative biological effectiveness factors are eliminated by measuring the external particle spectra. Astronaut radiation safety, therefore, can be ensured, as the EPS data can be used to correct or qualify radiation dose measurements recorded by other radiation measuring instrumentation within the Skylab module complex. The EPS has the capability of measuring and extremely wide dynamic radiation dose rate range, approaching 10 to the 7th power. Simultaneously the EPS has the capability to process data from extremely high radiation fields such as might be encountered in the wake of an intense solar flare.

  17. Safety management of complex research operators

    NASA Technical Reports Server (NTRS)

    Brown, W. J.

    1981-01-01

    Complex research and technology operations present varied potential hazards which are addressed in a disciplined, independent safety review and approval process. Potential hazards vary from high energy fuels to hydrocarbon fuels, high pressure systems to high voltage systems, toxic chemicals to radioactive materials and high speed rotating machinery to high powered lasers. A Safety Permit System presently covers about 600 potentially hazardous operations. The Safety Management Program described is believed to be a major factor in maintaining an excellent safety record.

  18. Critical inquiry and knowledge translation: exploring compatibilities and tensions

    PubMed Central

    Reimer-Kirkham, Sheryl; Varcoe, Colleen; Browne, Annette J.; Lynam, M. Judith; Khan, Koushambhi Basu; McDonald, Heather

    2016-01-01

    Knowledge translation has been widely taken up as an innovative process to facilitate the uptake of research-derived knowledge into health care services. Drawing on a recent research project, we engage in a philosophic examination of how knowledge translation might serve as vehicle for the transfer of critically oriented knowledge regarding social justice, health inequities, and cultural safety into clinical practice. Through an explication of what might be considered disparate traditions (those of critical inquiry and knowledge translation), we identify compatibilities and discrepancies both within the critical tradition, and between critical inquiry and knowledge translation. The ontological and epistemological origins of the knowledge to be translated carry implications for the synthesis and translation phases of knowledge translation. In our case, the studies we synthesized were informed by various critical perspectives and hence we needed to reconcile differences that exist within the critical tradition. A review of the history of critical inquiry served to articulate the nature of these differences while identifying common purposes around which to strategically coalesce. Other challenges arise when knowledge translation and critical inquiry are brought together. Critique is one of the hallmark methods of critical inquiry and, yet, the engagement required for knowledge translation between researchers and health care administrators, practitioners, and other stakeholders makes an antagonistic stance of critique problematic. While knowledge translation offers expanded views of evidence and the complex processes of knowledge exchange, we have been alerted to the continual pull toward epistemologies and methods reminiscent of the positivist paradigm by their instrumental views of knowledge and assumptions of objectivity and political neutrality. These types of tensions have been productive for us as a research team in prompting a critical reconceptualization of knowledge translation. PMID:19527437

  19. Critical inquiry and knowledge translation: exploring compatibilities and tensions.

    PubMed

    Reimer-Kirkham, Sheryl; Varcoe, Colleen; Browne, Annette J; Lynam, M Judith; Khan, Koushambhi Basu; McDonald, Heather

    2009-07-01

    Knowledge translation has been widely taken up as an innovative process to facilitate the uptake of research-derived knowledge into health care services. Drawing on a recent research project, we engage in a philosophic examination of how knowledge translation might serve as vehicle for the transfer of critically oriented knowledge regarding social justice, health inequities, and cultural safety into clinical practice. Through an explication of what might be considered disparate traditions (those of critical inquiry and knowledge translation), we identify compatibilities and discrepancies both within the critical tradition, and between critical inquiry and knowledge translation. The ontological and epistemological origins of the knowledge to be translated carry implications for the synthesis and translation phases of knowledge translation. In our case, the studies we synthesized were informed by various critical perspectives and hence we needed to reconcile differences that exist within the critical tradition. A review of the history of critical inquiry served to articulate the nature of these differences while identifying common purposes around which to strategically coalesce. Other challenges arise when knowledge translation and critical inquiry are brought together. Critique is one of the hallmark methods of critical inquiry and, yet, the engagement required for knowledge translation between researchers and health care administrators, practitioners, and other stakeholders makes an antagonistic stance of critique problematic. While knowledge translation offers expanded views of evidence and the complex processes of knowledge exchange, we have been alerted to the continual pull toward epistemologies and methods reminiscent of the positivist paradigm by their instrumental views of knowledge and assumptions of objectivity and political neutrality. These types of tensions have been productive for us as a research team in prompting a critical reconceptualization of knowledge translation.

  20. Safety Criticality Standards Using the French CRISTAL Code Package: Application to the AREVA NP UO{sub 2} Fuel Fabrication Plant

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Doucet, M.; Durant Terrasson, L.; Mouton, J.

    2006-07-01

    Criticality safety evaluations implement requirements to proof of sufficient sub critical margins outside of the reactor environment for example in fuel fabrication plants. Basic criticality data (i.e., criticality standards) are used in the determination of sub critical margins for all processes involving plutonium or enriched uranium. There are several criticality international standards, e.g., ARH-600, which is one the US nuclear industry relies on. The French Nuclear Safety Authority (DGSNR and its advising body IRSN) has requested AREVA NP to review the criticality standards used for the evaluation of its Low Enriched Uranium fuel fabrication plants with CRISTAL V0, the recentlymore » updated French criticality evaluation package. Criticality safety is a concern for every phase of the fabrication process including UF{sub 6} cylinder storage, UF{sub 6}-UO{sub 2} conversion, powder storage, pelletizing, rod loading, assembly fabrication, and assembly transportation. Until 2003, the accepted criticality standards were based on the French CEA work performed in the late seventies with the APOLLO1 cell/assembly computer code. APOLLO1 is a spectral code, used for evaluating the basic characteristics of fuel assemblies for reactor physics applications, which has been enhanced to perform criticality safety calculations. Throughout the years, CRISTAL, starting with APOLLO1 and MORET 3 (a 3D Monte Carlo code), has been improved to account for the growth of its qualification database and for increasing user requirements. Today, CRISTAL V0 is an up-to-date computational tool incorporating a modern basic microscopic cross section set based on JEF2.2 and the comprehensive APOLLO2 and MORET 4 codes. APOLLO2 is well suited for criticality standards calculations as it includes a sophisticated self shielding approach, a P{sub ij} flux determination, and a 1D transport (S{sub n}) process. CRISTAL V0 is the result of more than five years of development work focusing on theoretical approaches and the implementation of user-friendly graphical interfaces. Due to its comprehensive physical simulation and thanks to its broad qualification database with more than a thousand benchmark/calculation comparisons, CRISTAL V0 provides outstanding and reliable accuracy for criticality evaluations for configurations covering the entire fuel cycle (i.e. from enrichment, pellet/assembly fabrication, transportation, to fuel reprocessing). After a brief description of the calculation scheme and the physics algorithms used in this code package, results for the various fissile media encountered in a UO{sub 2} fuel fabrication plant will be detailed and discussed. (authors)« less

  1. Nuclear criticality safety assessment of the low level radioactive waste disposal facility trenches

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Kahook, S.D.

    1994-04-01

    Results of the analyses performed to evaluate the possibility of nuclear criticality in the Low Level Radioactive Waste Disposal Facility (LLRWDF) trenches are documented in this report. The studies presented in this document are limited to assessment of the possibility of criticality due to existing conditions in the LLRWDF. This document does not propose nor set limits for enriched uranium (EU) burial in the LLRWDF and is not a nuclear criticality safety evaluation nor analysis. The calculations presented in the report are Level 2 calculations as defined by the E7 Procedure 2.31, Engineering Calculations.

  2. Software Design Improvements. Part 2; Software Quality and the Design and Inspection Process

    NASA Technical Reports Server (NTRS)

    Lalli, Vincent R.; Packard, Michael H.; Ziemianski, Tom

    1997-01-01

    The application of assurance engineering techniques improves the duration of failure-free performance of software. The totality of features and characteristics of a software product are what determine its ability to satisfy customer needs. Software in safety-critical systems is very important to NASA. We follow the System Safety Working Groups definition for system safety software as: 'The optimization of system safety in the design, development, use and maintenance of software and its integration with safety-critical systems in an operational environment. 'If it is not safe, say so' has become our motto. This paper goes over methods that have been used by NASA to make software design improvements by focusing on software quality and the design and inspection process.

  3. GPM Timeline Inhibits For IT Processing

    NASA Technical Reports Server (NTRS)

    Dion, Shirley K.

    2014-01-01

    The Safety Inhibit Timeline Tool was created as one approach to capturing and understanding inhibits and controls from IT through launch. Global Precipitation Measurement (GPM) Mission, which launched from Japan in March 2014, was a joint mission under a partnership between the National Aeronautics and Space Administration (NASA) and the Japan Aerospace Exploration Agency (JAXA). GPM was one of the first NASA Goddard in-house programs that extensively used software controls. Using this tool during the GPM buildup allowed a thorough review of inhibit and safety critical software design for hazardous subsystems such as the high gain antenna boom, solar array, and instrument deployments, transmitter turn-on, propulsion system release, and instrument radar turn-on. The GPM safety team developed a methodology to document software safety as part of the standard hazard report. As a result of this process, a new tool safety inhibit timeline was created for management of inhibits and their controls during spacecraft buildup and testing during IT at GSFC and at the launch range in Japan. The Safety Inhibit Timeline Tool was a pathfinder approach for reviewing software that controls the electrical inhibits. The Safety Inhibit Timeline Tool strengthens the Safety Analysts understanding of the removal of inhibits during the IT process with safety critical software. With this tool, the Safety Analyst can confirm proper safe configuration of a spacecraft during each IT test, track inhibit and software configuration changes, and assess software criticality. In addition to understanding inhibits and controls during IT, the tool allows the Safety Analyst to better communicate to engineers and management the changes in inhibit states with each phase of hardware and software testing and the impact of safety risks. Lessons learned from participating in the GPM campaign at NASA and JAXA will be discussed during this session.

  4. A Silent Safety Program

    NASA Technical Reports Server (NTRS)

    Goodin, James Ronald

    2006-01-01

    NASA's Columbia Accident Investigation Board (CAIB) referred 8 times to the NASA "Silent Safety Program." This term, "Silent Safety Program" was not an original observation but first appeared in the Rogers Commission's Investigation of the Challenger Mishap. The CAIB on page 183 of its report in the paragraph titled 'Encouraging Minority Opinion,' stated "The Naval Reactor Program encourages minority opinions and "bad news." Leaders continually emphasize that when no minority opinions are present, the responsibility for a thorough and critical examination falls to management. . . Board interviews revealed that it is difficult for minority and dissenting opinions to percolate up through the agency's hierarchy. . ." The first question and perhaps the only question is - what is a silent safety program? Well, a silent safety program may be the same as the dog that didn't bark in Sherlock Holmes' "Adventure of the Silver Blaze" because system safety should behave as a devil's advocate for the program barking on every occasion to insure a critical review inclusion. This paper evaluates the NASA safety program and provides suggestions to prevent the recurrence of the silent safety program alluded to in the Challenger Mishap Investigation. Specifically targeted in the CAM report, "The checks and balances the safety system was meant to provide were not working." A silent system safety program is not unique to NASA but could emerge in any and every organization. Principles developed by Irving Janis in his book, Groupthink, listed criteria used to evaluate an organization's cultural attributes that allows a silent safety program to evolve. If evidence validates Jams's criteria, then Jams's recommendations for preventing groupthink can also be used to improve a critical evaluation and thus prevent the development of a silent safety program.

  5. GROWTH OF THE INTERNATIONAL CRITICALITY SAFETY AND REACTOR PHYSICS EXPERIMENT EVALUATION PROJECTS

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    J. Blair Briggs; John D. Bess; Jim Gulliford

    2011-09-01

    Since the International Conference on Nuclear Criticality Safety (ICNC) 2007, the International Criticality Safety Benchmark Evaluation Project (ICSBEP) and the International Reactor Physics Experiment Evaluation Project (IRPhEP) have continued to expand their efforts and broaden their scope. Eighteen countries participated on the ICSBEP in 2007. Now, there are 20, with recent contributions from Sweden and Argentina. The IRPhEP has also expanded from eight contributing countries in 2007 to 16 in 2011. Since ICNC 2007, the contents of the 'International Handbook of Evaluated Criticality Safety Benchmark Experiments1' have increased from 442 evaluations (38000 pages), containing benchmark specifications for 3955 critical ormore » subcritical configurations to 516 evaluations (nearly 55000 pages), containing benchmark specifications for 4405 critical or subcritical configurations in the 2010 Edition of the ICSBEP Handbook. The contents of the Handbook have also increased from 21 to 24 criticality-alarm-placement/shielding configurations with multiple dose points for each, and from 20 to 200 configurations categorized as fundamental physics measurements relevant to criticality safety applications. Approximately 25 new evaluations and 150 additional configurations are expected to be added to the 2011 edition of the Handbook. Since ICNC 2007, the contents of the 'International Handbook of Evaluated Reactor Physics Benchmark Experiments2' have increased from 16 different experimental series that were performed at 12 different reactor facilities to 53 experimental series that were performed at 30 different reactor facilities in the 2011 edition of the Handbook. Considerable effort has also been made to improve the functionality of the searchable database, DICE (Database for the International Criticality Benchmark Evaluation Project) and verify the accuracy of the data contained therein. DICE will be discussed in separate papers at ICNC 2011. The status of the ICSBEP and the IRPhEP will be discussed in the full paper, selected benchmarks that have been added to the ICSBEP Handbook will be highlighted, and a preview of the new benchmarks that will appear in the September 2011 edition of the Handbook will be provided. Accomplishments of the IRPhEP will also be highlighted and the future of both projects will be discussed. REFERENCES (1) International Handbook of Evaluated Criticality Safety Benchmark Experiments, NEA/NSC/DOC(95)03/I-IX, Organisation for Economic Co-operation and Development-Nuclear Energy Agency (OECD-NEA), September 2010 Edition, ISBN 978-92-64-99140-8. (2) International Handbook of Evaluated Reactor Physics Benchmark Experiments, NEA/NSC/DOC(2006)1, Organisation for Economic Co-operation and Development-Nuclear Energy Agency (OECD-NEA), March 2011 Edition, ISBN 978-92-64-99141-5.« less

  6. Motor vehicle occupant safety survey

    DOT National Transportation Integrated Search

    1995-09-01

    This report presents findings from the first Motor Vehicle Occupant Safety Survey. The National Highway Traffic Safety Administration (NHTSA) conducted this survey to collect critical information needed by the agency to develop and implement effectiv...

  7. Automated Pedestrian Detection, Count and Analysis System

    DOT National Transportation Integrated Search

    2015-04-15

    Pedestrian and bicycle count data is necessary for transportation planning, implementing safety countermeasures, and traffic management. This data is critical when evaluating the pedestrian level of service of safety (LOSS) and pedestrian safety perf...

  8. Discrete Abstractions of Hybrid Systems: Verification of Safety and Application to User-Interface Design

    NASA Technical Reports Server (NTRS)

    Oishi, Meeko; Tomlin, Claire; Degani, Asaf

    2003-01-01

    Human interaction with complex hybrid systems involves the user, the automation's discrete mode logic, and the underlying continuous dynamics of the physical system. Often the user-interface of such systems displays a reduced set of information about the entire system. In safety-critical systems, how can we identify user-interface designs which do not have adequate information, or which may confuse the user? Here we describe a methodology, based on hybrid system analysis, to verify that a user-interface contains information necessary to safely complete a desired procedure or task. Verification within a hybrid framework allows us to account for the continuous dynamics underlying the simple, discrete representations displayed to the user. We provide two examples: a car traveling through a yellow light at an intersection and an aircraft autopilot in a landing/go-around maneuver. The examples demonstrate the general nature of this methodology, which is applicable to hybrid systems (not fully automated) which have operational constraints we can pose in terms of safety. This methodology differs from existing work in hybrid system verification in that we directly account for the user's interactions with the system.

  9. Do not blame the driver: a systems analysis of the causes of road freight crashes.

    PubMed

    Newnam, Sharon; Goode, Natassia

    2015-03-01

    Although many have advocated a systems approach in road transportation, this view has not meaningfully penetrated road safety research, practice or policy. In this study, a systems theory-based approach, Rasmussens's (1997) risk management framework and associated Accimap technique, is applied to the analysis of road freight transportation crashes. Twenty-seven highway crash investigation reports were downloaded from the National Transport Safety Bureau website. Thematic analysis was used to identify the complex system of contributory factors, and relationships, identified within the reports. The Accimap technique was then used to represent the linkages and dependencies within and across system levels in the road freight transportation industry and to identify common factors and interactions across multiple crashes. The results demonstrate how a systems approach can increase knowledge in this safety critical domain, while the findings can be used to guide prevention efforts and the development of system-based investigation processes for the heavy vehicle industry. A research agenda for developing an investigation technique to better support the application of the Accimap technique by practitioners in road freight transportation industry is proposed. Copyright © 2015 Elsevier Ltd. All rights reserved.

  10. Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement.

    PubMed

    Lipira, Lauren E; Gallagher, Thomas H

    2014-07-01

    The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians' errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.

  11. Evaluation of Margins of Safety in Brazed Joints

    NASA Technical Reports Server (NTRS)

    Flom, Yury; Wang, Len; Powell, Mollie M.; Soffa, Matthew A.; Rommel, Monica L.

    2009-01-01

    One of the essential steps in assuring reliable performance of high cost critical brazed structures is the assessment of the Margin of Safety (MS) of the brazed joints. In many cases the experimental determination of the failure loads by destructive testing of the brazed assembly is not practical and cost prohibitive. In such cases the evaluation of the MS is performed analytically by comparing the maximum design loads with the allowable ones and incorporating various safety or knock down factors imposed by the customer. Unfortunately, an industry standard methodology for the design and analysis of brazed joints has not been developed. This paper provides an example of an approach that was used to analyze an AlBeMet 162 (38%Be-62%Al) structure brazed with the AWS BAlSi-4 (Al-12%Si) filler metal. A practical and conservative interaction equation combining shear and tensile allowables was developed and validated to evaluate an acceptable (safe) combination of tensile and shear stresses acting in the brazed joint. These allowables are obtained from testing of standard tensile and lap shear brazed specimens. The proposed equation enables the assessment of the load carrying capability of complex brazed joints subjected to multi-axial loading.

  12. LANL Contributions to the B61 LIfe Extension Program

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Corpion, Juan Carlos

    2016-02-10

    The Los Alamos National Laboratory (LANL) has a long, proud heritage in science and innovation that extends 70 years. Although the Laboratory’s primary responsibility is assuring the safety and reliability of the nation’s nuclear deterrent, Laboratory staff work on a broad range of advanced technologies to provide the best, most effective scientific and engineering solutions to the nation’s critical security challenges. The world is rapidly changing, but this essential responsibility remains the LANL’s core mission. LANL is the Design Laboratory for the nuclear explosive package of the B61 Air Force bomb. The B61-12 Life Extension Program (LEP) activities at LANLmore » will increase the lifetime of the bomb and provide safety and security options to meet security environments both today and in the future. The B61’s multiple-platform functionality, unique safety features, and large number of components make the B61-12 LEP one of the most complex LEPs ever attempted. Over 230 LANL scientists, engineers, technicians, and support personnel from across the Laboratory are bringing decades of interdisciplinary knowledge, technical expertise, and leading-edge capabilities to LANL’s work on the LEP.« less

  13. New Challenges for Intervertebral Disc Treatment Using Regenerative Medicine

    PubMed Central

    Masuda, Koichi

    2010-01-01

    The development of tissue engineering therapies for the intervertebral disc is challenging due to ambiguities of disease and pain mechanisms in patients, and lack of consensus on preclinical models for safety and efficacy testing. Although the issues associated with model selection for studying orthopedic diseases or treatments have been discussed often, the multifaceted challenges associated with developing intervertebral disc tissue engineering therapies require special discussion. This review covers topics relevant to the clinical translation of tissue-engineered technologies: (1) the unmet clinical need, (2) appropriate models for safety and efficacy testing, (3) the need for standardized model systems, and (4) the translational pathways leading to a clinical trial. For preclinical evaluation of new therapies, we recommend establishing biologic plausibility of efficacy and safety using models of increasing complexity, starting with cell culture, small animals (rats and rabbits), and then large animals (goat and minipig) that more closely mimic nutritional, biomechanical, and surgical realities of human application. The use of standardized and reproducible experimental procedures and outcome measures is critical for judging relative efficacy. Finally, success will hinge on carefully designed clinical trials with well-defined patient selection criteria, gold-standard controls, and objective outcome metrics to assess performance in the early postoperative period. PMID:19903086

  14. Systems thinking and incivility in nursing practice: An integrative review.

    PubMed

    Phillips, Janet M; Stalter, Ann M; Winegardner, Sherri; Wiggs, Carol; Jauch, Amy

    2018-01-23

    There is a critical need for nurses and interprofessional healthcare providers to implement systems thinking (ST) across international borders, addressing incivility and its perilous effects on patient quality and safety. An estimated one million patients die in hospitals worldwide due to avoidable patient-related errors. Establishing safe and civil workplaces using ST is paramount to promoting clear, level-headed thinking from which patient-centered nursing actions can impact health systems. The purpose of the paper is to answer the research question, What ST evidence fosters the effect of workplace civility in practice settings? Whittemore and Knafl's integrative review method guided this study. The quality of articles was determined using Chu et al.'s Mixed Methods Assessment Tool. Thirty-eight studies were reviewed. Themes emerged describing antecedents and consequences of incivility as embedded within complex systems, suggesting improvements for civility and systems/ST in nursing practice. This integrative review provides information about worldwide incivility in nursing practice from a systems perspective. Several models are offered as a means of promoting civility in nursing practice to improve patient quality and safety. Further study is needed regarding incivility and resultant effects on patient quality and safety. © 2018 Wiley Periodicals, Inc.

  15. Long-term safety and efficacy of a pasteurized nanofiltrated prothrombin complex concentrate (Beriplex P/N): a pharmacovigilance study.

    PubMed

    Hanke, A A; Joch, C; Görlinger, K

    2013-05-01

    The rapid reversal of the effects of vitamin K antagonists is often required in cases of emergency surgery and life-threatening bleeding, or during bleeding associated with high morbidity and mortality such as intracranial haemorrhage. Increasingly, four-factor prothrombin complex concentrates (PCCs) containing high and well-balanced concentrations of vitamin K-dependent coagulation factors are recommended for emergency oral anticoagulation reversal. Both the safety and efficacy of such products are currently in focus, and their administration is now expanding into the critical care setting for the treatment of life-threatening bleeding and coagulopathy resulting either perioperatively or in cases of acute trauma. After 15 yr of clinical use, findings of a pharmacovigilance report (February 1996-March 2012) relating to the four-factor PCC Beriplex P/N (CSL Behring, Marburg, Germany) were analysed and are presented here. Furthermore, a review of the literature with regard to the efficacy and safety of four-factor PCCs was performed. Since receiving marketing authorization (February 21, 1996), ~647 250 standard applications of Beriplex P/N have taken place. During this time, 21 thromboembolic events judged to be possibly related to Beriplex P/N administration have been reported, while no incidences of viral transmission or heparin-induced thrombocytopenia were documented. The low risk of thromboembolic events reported during the observation period (one in ~31 000) is in line with the incidence observed with other four-factor PCCs. In general, four-factor PCCs have proven to be well tolerated and highly effective in the rapid reversal of vitamin K antagonists.

  16. An Approach for Validating Actinide and Fission Product Burnup Credit Criticality Safety Analyses: Criticality (k eff) Predictions

    DOE PAGES

    Scaglione, John M.; Mueller, Don E.; Wagner, John C.

    2014-12-01

    One of the most important remaining challenges associated with expanded implementation of burnup credit in the United States is the validation of depletion and criticality calculations used in the safety evaluation—in particular, the availability and use of applicable measured data to support validation, especially for fission products (FPs). Applicants and regulatory reviewers have been constrained by both a scarcity of data and a lack of clear technical basis or approach for use of the data. In this study, this paper describes a validation approach for commercial spent nuclear fuel (SNF) criticality safety (k eff) evaluations based on best-available data andmore » methods and applies the approach for representative SNF storage and transport configurations/conditions to demonstrate its usage and applicability, as well as to provide reference bias results. The criticality validation approach utilizes not only available laboratory critical experiment (LCE) data from the International Handbook of Evaluated Criticality Safety Benchmark Experiments and the French Haut Taux de Combustion program to support validation of the principal actinides but also calculated sensitivities, nuclear data uncertainties, and limited available FP LCE data to predict and verify individual biases for relevant minor actinides and FPs. The results demonstrate that (a) sufficient critical experiment data exist to adequately validate k eff calculations via conventional validation approaches for the primary actinides, (b) sensitivity-based critical experiment selection is more appropriate for generating accurate application model bias and uncertainty, and (c) calculated sensitivities and nuclear data uncertainties can be used for generating conservative estimates of bias for minor actinides and FPs. Results based on the SCALE 6.1 and the ENDF/B-VII.0 cross-section libraries indicate that a conservative estimate of the bias for the minor actinides and FPs is 1.5% of their worth within the application model. Finally, this paper provides a detailed description of the approach and its technical bases, describes the application of the approach for representative pressurized water reactor and boiling water reactor safety analysis models, and provides reference bias results based on the prerelease SCALE 6.1 code package and ENDF/B-VII nuclear cross-section data.« less

  17. Isolation and quantification of botulinum neurotoxin from complex matrices using the BoTest matrix assays.

    PubMed

    Dunning, F Mark; Piazza, Timothy M; Zeytin, Füsûn N; Tucker, Ward C

    2014-03-03

    Accurate detection and quantification of botulinum neurotoxin (BoNT) in complex matrices is required for pharmaceutical, environmental, and food sample testing. Rapid BoNT testing of foodstuffs is needed during outbreak forensics, patient diagnosis, and food safety testing while accurate potency testing is required for BoNT-based drug product manufacturing and patient safety. The widely used mouse bioassay for BoNT testing is highly sensitive but lacks the precision and throughput needed for rapid and routine BoNT testing. Furthermore, the bioassay's use of animals has resulted in calls by drug product regulatory authorities and animal-rights proponents in the US and abroad to replace the mouse bioassay for BoNT testing. Several in vitro replacement assays have been developed that work well with purified BoNT in simple buffers, but most have not been shown to be applicable to testing in highly complex matrices. Here, a protocol for the detection of BoNT in complex matrices using the BoTest Matrix assays is presented. The assay consists of three parts: The first part involves preparation of the samples for testing, the second part is an immunoprecipitation step using anti-BoNT antibody-coated paramagnetic beads to purify BoNT from the matrix, and the third part quantifies the isolated BoNT's proteolytic activity using a fluorogenic reporter. The protocol is written for high throughput testing in 96-well plates using both liquid and solid matrices and requires about 2 hr of manual preparation with total assay times of 4-26 hr depending on the sample type, toxin load, and desired sensitivity. Data are presented for BoNT/A testing with phosphate-buffered saline, a drug product, culture supernatant, 2% milk, and fresh tomatoes and includes discussion of critical parameters for assay success.

  18. Nuclear criticality safety evaluation of SRS 9971 shipping package. [SRS (Savannah River Site)

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Vescovi, P.J.

    1993-02-01

    This evaluation is requested to revise the criticality evaluation used to generate Chapter 6 (Criticality Evaluation) of the Safety Analysis Report for Packaging (SARP) for shipment Of UO[sub 3] product from the Uranium Solidification Facility (USF) in the SRS 9971 shipping package. The pertinent document requesting this evaluation is included as Attachment I. The results of the evaluation are given in Attachment II which is written as Chapter 6 of a NRC format SARP.

  19. Safety management of a complex R and D ground operating system

    NASA Technical Reports Server (NTRS)

    Connors, J. F.; Maurer, R. A.

    1975-01-01

    A perspective on safety program management was developed for a complex R&D operating system, such as the NASA-Lewis Research Center. Using a systems approach, hazardous operations are subjected to third-party reviews by designated-area safety committees and are maintained under safety permit controls. To insure personnel alertness, emergency containment forces and employees are trained in dry-run emergency simulation exercises. The keys to real safety effectiveness are top management support and visibility of residual risks.

  20. Safety management of a complex R&D ground operating system

    NASA Technical Reports Server (NTRS)

    Connors, J. F.; Maurer, R. A.

    1975-01-01

    A perspective on safety program management has been developed for a complex R&D operating system, such as the NASA-Lewis Research Center. Using a systems approach, hazardous operations are subjected to third-party reviews by designated area safety committees and are maintained under safety permit controls. To insure personnel alertness, emergency containment forces and employees are trained in dry-run emergency simulation exercises. The keys to real safety effectiveness are top management support and visibility of residual risks.

  1. Protection and Safety.

    ERIC Educational Resources Information Center

    American School Board Journal, 1964

    1964-01-01

    Several aspects of school safety and protection are presented for school administrators and architects. Among those topics discussed are--(1) life safety, (2) vandalism controlled through proper design, (3) personal protective devices, and (4) fire alarm systems. Another critical factor in providing a complete school safety program is proper…

  2. Volcanic hazards at distant critical infrastructure: A method for bespoke, multi-disciplinary assessment

    NASA Astrophysics Data System (ADS)

    Odbert, H. M.; Aspinall, W.; Phillips, J.; Jenkins, S.; Wilson, T. M.; Scourse, E.; Sheldrake, T.; Tucker, P.; Nakeshree, K.; Bernardara, P.; Fish, K.

    2015-12-01

    Societies rely on critical services such as power, water, transport networks and manufacturing. Infrastructure may be sited to minimise exposure to natural hazards but not all can be avoided. The probability of long-range transport of a volcanic plume to a site is comparable to other external hazards that must be considered to satisfy safety assessments. Recent advances in numerical models of plume dispersion and stochastic modelling provide a formalized and transparent approach to probabilistic assessment of hazard distribution. To understand the risks to critical infrastructure far from volcanic sources, it is necessary to quantify their vulnerability to different hazard stressors. However, infrastructure assets (e.g. power plantsand operational facilities) are typically complex systems in themselves, with interdependent components that may differ in susceptibility to hazard impact. Usually, such complexity means that risk either cannot be estimated formally or that unsatisfactory simplifying assumptions are prerequisite to building a tractable risk model. We present a new approach to quantifying risk by bridging expertise of physical hazard modellers and infrastructure engineers. We use a joint expert judgment approach to determine hazard model inputs and constrain associated uncertainties. Model outputs are chosen on the basis of engineering or operational concerns. The procedure facilitates an interface between physical scientists, with expertise in volcanic hazards, and infrastructure engineers, with insight into vulnerability to hazards. The result is a joined-up approach to estimating risk from low-probability hazards to critical infrastructure. We describe our methodology and show preliminary results for vulnerability to volcanic hazards at a typical UK industrial facility. We discuss our findings in the context of developing bespoke assessment of hazards from distant sources in collaboration with key infrastructure stakeholders.

  3. Factors predicting change in hospital safety climate and capability in a multi-site patient safety collaborative: a longitudinal survey study.

    PubMed

    Benn, Jonathan; Burnett, Susan; Parand, Anam; Pinto, Anna; Vincent, Charles

    2012-07-01

    The study had two specific objectives: (1) To analyse change in a survey measure of organisational patient safety climate and capability (SCC) resulting from participation in the UK Safer Patients Initiative and (2) To investigate the role of a range of programme and contextual factors in predicting change in SCC scores. Single group longitudinal design with repeated measurement at 12-month follow-up. Multiple service areas within NHS hospital sites across England, Wales, Scotland and Northern Ireland. Stratified sample of 284 respondents representing programme teams at 19 hospital sites. A complex intervention comprising a multi-component quality improvement collaborative focused upon patient safety and designed to impact upon hospital leadership, communication, organisation and safety climate. A survey including a 31-item SCC scale was administered at two time-points. Modest but significant positive movement in SCC score was observed between the study time-points. Individual programme responsibility, availability of early adopters, multi-professional collaboration and extent of process measurement were significant predictors of change in SCC. Hospital type and size, along with a range of programme preconditions, were not found to be significant. A range of social, cultural and organisational factors may be sensitive to this type of intervention but the measurable effect is small. Supporting critical local programme implementation factors may be an effective strategy in achieving development in organisational patient SCC, regardless of contextual factors and organisational preconditions.

  4. Mathematical modelling of active safety system functions as tools for development of driverless vehicles

    NASA Astrophysics Data System (ADS)

    Ryazantsev, V.; Mezentsev, N.; Zakharov, A.

    2018-02-01

    This paper is dedicated to a solution of the issue of synthesis of the vehicle longitudinal dynamics control functions (acceleration and deceleration control) based on the element base of the vehicle active safety system (ESP) - driverless vehicle development tool. This strategy helps to reduce time and complexity of integration of autonomous motion control systems (AMCS) into the vehicle architecture and allows direct control of actuators ensuring the longitudinal dynamics control, as well as reduction of time for calibration works. The “vehicle+wheel+road” longitudinal dynamics control is complicated due to the absence of the required prior information about the control object. Therefore, the control loop becomes an adaptive system, i.e. a self-adjusting monitoring system. Another difficulty is the driver’s perception of the longitudinal dynamics control process in terms of comfort. Traditionally, one doesn’t pay a lot of attention to this issue within active safety systems, and retention of vehicle steerability, controllability and stability in emergency situations are considered to be the quality criteria. This is mainly connected to its operational limits, since it is activated only in critical situations. However, implementation of the longitudinal dynamics control in the AMCS poses another challenge for the developers - providing the driver with comfortable vehicle movement during acceleration and deceleration - while the possible highest safety level in terms of the road grip is provided by the active safety system (ESP). The results of this research are: universal active safety system - AMCS interaction interface; block diagram for the vehicle longitudinal acceleration and deceleration control as one of the active safety system’s integrated functions; ideology of adaptive longitudinal dynamics control, which enables to realize the deceleration and acceleration requested by the AMCS; algorithms synthesised; analytical experiments proving the efficiency and practicability of the chosen concept.

  5. Aviation Safety Concerns for the Future

    NASA Technical Reports Server (NTRS)

    Smith, Brian E.; Roelen, Alfred L. C.; den Hertog, Rudi

    2016-01-01

    The Future Aviation Safety Team (FAST) is a multidisciplinary international group of aviation professionals that was established to identify possible future aviation safety hazards. The principle was adopted that future hazards are undesirable consequences of changes, and a primary activity of FAST became identification and prioritization of possible future changes affecting aviation. Since 2004, FAST has been maintaining a catalogue of "Areas of Change" (AoC) that could potentially influence aviation safety. The horizon for such changes is between 5 to 20 years. In this context, changes must be understood as broadly as possible. An AoC is a description of the change, not an identification of the hazards that result from the change. An ex-post analysis of the AoCs identified in 2004 demonstrates that changes catalogued many years previous were directly implicated in the majority of fatal aviation accidents over the past ten years. This paper presents an overview of the current content of the AoC catalogue and a subsequent discussion of aviation safety concerns related to these possible changes. Interactions among these future changes may weaken critical functions that must be maintained to ensure safe operations. Safety assessments that do not appreciate or reflect the consequences of significant interaction complexity will not be fully informative and can lead to inappropriate trade-offs and increases in other risks. The FAST strongly encourages a system-wide approach to safety risk assessment across the global aviation system, not just within the domain for which future technologies or operational concepts are being considered. The FAST advocates the use of the "Areas of Change" concept, considering that several possible future phenomena may interact with a technology or operational concept under study producing unanticipated hazards.

  6. RICIS Symposium 1992: Mission and Safety Critical Systems Research and Applications

    NASA Technical Reports Server (NTRS)

    1992-01-01

    This conference deals with computer systems which control systems whose failure to operate correctly could produce the loss of life and or property, mission and safety critical systems. Topics covered are: the work of standards groups, computer systems design and architecture, software reliability, process control systems, knowledge based expert systems, and computer and telecommunication protocols.

  7. CSER 99-002: CSER for unrestricted moderation of sludge material with two-boat operations in gloveboxes HC-21A and HC21-C

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    LAN, J.S.

    1999-04-29

    This Criticality Safety Evaluation Report was prepared by Fluor Daniel Northwest under contract to BWHC. This document establishes the criticality safety parameters for unrestricted moderation of Sludge material with two-boat operations in gloveboxes HC-21A and HC-21C.

  8. Jerky driving--An indicator of accident proneness?

    PubMed

    Bagdadi, Omar; Várhelyi, András

    2011-07-01

    This study uses continuously logged driving data from 166 private cars to derive the level of jerks caused by the drivers during everyday driving. The number of critical jerks found in the data is analysed and compared with the self-reported accident involvement of the drivers. The results show that the expected number of accidents for a driver increases with the number of critical jerks caused by the driver. Jerk analyses make it possible to identify safety critical driving behaviour or "accident prone" drivers. They also facilitate the development of safety measures such as active safety systems or advanced driver assistance systems, ADAS, which could be adapted for specific groups of drivers or specific risky driving behaviour. Copyright © 2011 Elsevier Ltd. All rights reserved.

  9. DOE Office of Scientific and Technical Information (OSTI.GOV)

    Van Der Marck, S. C.

    Three nuclear data libraries have been tested extensively using criticality safety benchmark calculations. The three libraries are the new release of the US library ENDF/B-VII.1 (2011), the new release of the Japanese library JENDL-4.0 (2011), and the OECD/NEA library JEFF-3.1 (2006). All calculations were performed with the continuous-energy Monte Carlo code MCNP (version 4C3, as well as version 6-beta1). Around 2000 benchmark cases from the International Handbook of Criticality Safety Benchmark Experiments (ICSBEP) were used. The results were analyzed per ICSBEP category, and per element. Overall, the three libraries show similar performance on most criticality safety benchmarks. The largest differencesmore » are probably caused by elements such as Be, C, Fe, Zr, W. (authors)« less

  10. Critical care medicine in the United States: addressing the intensivist shortage and image of the specialty.

    PubMed

    Halpern, Neil A; Pastores, Stephen M; Oropello, John M; Kvetan, Vladimir

    2013-12-01

    Intensivists are increasingly needed to care for the critically ill and manage ICUs as ICU beds, utilization, acuity of illness, complexity of care and costs continue to rise. However, there is a nationwide shortage of intensivists that has occurred despite years of well publicized warnings of an impending workforce crisis from specialty societies and the federal government. The magnitude of the intensivist shortfall, however, is difficult to determine because there are many perspectives of optimal ICU administration, patient coverage and intensivist availability and a lack of national data on intensivist practices. Nevertheless, the intensivist shortfall is quite real as evidenced by the alternative solutions that hospitals are deploying to provide care for their critically ill patients. In the midst of these manpower struggles, the critical care environment is dynamically changing and becoming more stressful. Severe hospital bed availability and fiscal constraints are forcing ICUs to alter their approaches to triage, throughput and unit staffing. National and local organizations are mandating that hospitals comply with resource intensive and arguably unproven initiatives to monitor and improve patient safety and quality, and informatics systems. Lastly, there is an ongoing sense of professional dissatisfaction among intensivists and a lack of public awareness that critical care medicine is even a distinct specialty. This article offers proposals to increase the adult intensivist workforce through expansion and enhancements of internal medicine based critical care training programs, incentives for recent graduates to enter the critical care medicine field, suggestions for improvements in the critical care profession and workplace to encourage senior intensivists to remain in the field, proactive marketing of critical care, and expanded engagement by the critical care societies in the challenges facing intensivists.

  11. Generalized implementation of software safety policies

    NASA Technical Reports Server (NTRS)

    Knight, John C.; Wika, Kevin G.

    1994-01-01

    As part of a research program in the engineering of software for safety-critical systems, we are performing two case studies. The first case study, which is well underway, is a safety-critical medical application. The second, which is just starting, is a digital control system for a nuclear research reactor. Our goal is to use these case studies to permit us to obtain a better understanding of the issues facing developers of safety-critical systems, and to provide a vehicle for the assessment of research ideas. The case studies are not based on the analysis of existing software development by others. Instead, we are attempting to create software for new and novel systems in a process that ultimately will involve all phases of the software lifecycle. In this abstract, we summarize our results to date in a small part of this project, namely the determination and classification of policies related to software safety that must be enforced to ensure safe operation. We hypothesize that this classification will permit a general approach to the implementation of a policy enforcement mechanism.

  12. Cyber Security Threats to Safety-Critical, Space-Based Infrastructures

    NASA Astrophysics Data System (ADS)

    Johnson, C. W.; Atencia Yepez, A.

    2012-01-01

    Space-based systems play an important role within national critical infrastructures. They are being integrated into advanced air-traffic management applications, rail signalling systems, energy distribution software etc. Unfortunately, the end users of communications, location sensing and timing applications often fail to understand that these infrastructures are vulnerable to a wide range of security threats. The following pages focus on concerns associated with potential cyber-attacks. These are important because future attacks may invalidate many of the safety assumptions that support the provision of critical space-based services. These safety assumptions are based on standard forms of hazard analysis that ignore cyber-security considerations This is a significant limitation when, for instance, security attacks can simultaneously exploit multiple vulnerabilities in a manner that would never occur without a deliberate enemy seeking to damage space based systems and ground infrastructures. We address this concern through the development of a combined safety and security risk assessment methodology. The aim is to identify attack scenarios that justify the allocation of additional design resources so that safety barriers can be strengthened to increase our resilience against security threats.

  13. Napping during night shift: practices, preferences, and perceptions of critical care and emergency department nurses.

    PubMed

    Fallis, Wendy M; McMillan, Diana E; Edwards, Marie P

    2011-04-01

    Nurses working night shifts are at risk for sleep deprivation, which threatens patient and nurse safety. Little nursing research has addressed napping, an effective strategy to improve performance, reduce fatigue, and increase vigilance. To explore nurses' perceptions, experiences, barriers, and safety issues related to napping/not napping during night shift. A convenience sample of critical care nurses working night shift were interviewed to explore demographics, work schedule and environment, and napping/ not napping experiences, perceptions, and barriers. Transcripts were constantly compared, and categories and themes were identified. Participants were 13 critical care nurses with an average of 17 years' experience. Ten nurses napped regularly; 2 avoided napping because of sleep inertia. The need for and benefits of napping or not during night shift break were linked to patient and nurse safety. Ability to nap was affected by the demands of patient care and safety, staffing needs, and organizational and environmental factors. Nurses identified personal health, safety, and patient care issues supporting the need for a restorative nap during night shift. Barriers to napping exist within the organization/work environment.

  14. Quantifying Vermont transportation safety factors.

    DOT National Transportation Integrated Search

    2010-01-01

    VTrans and its partners have selected traffic safety : priority areas in their Strategic Highway Safety Plan. : In this project, researchers focus on three of these : prioritized critical emphasis areas: 1) Keeping vehicles : on the roadway, 2) Young...

  15. Modelling radionuclide transport in fractured media with a dynamic update of K d values

    DOE PAGES

    Trinchero, Paolo; Painter, Scott L.; Ebrahimi, Hedieh; ...

    2015-10-13

    Radionuclide transport in fractured crystalline rocks is a process of interest in evaluating long term safety of potential disposal systems for radioactive wastes. Given their numerical efficiency and the absence of numerical dispersion, Lagrangian methods (e.g. particle tracking algorithms) are appealing approaches that are often used in safety assessment (SA) analyses. In these approaches, many complex geochemical retention processes are typically lumped into a single parameter: the distribution coefficient (Kd). Usually, the distribution coefficient is assumed to be constant over the time frame of interest. However, this assumption could be critical under long-term geochemical changes as it is demonstrated thatmore » the distribution coefficient depends on the background chemical conditions (e.g. pH, Eh, and major chemistry). In this study, we provide a computational framework that combines the efficiency of Lagrangian methods with a sound and explicit description of the geochemical changes of the site and their influence on the radionuclide retention properties.« less

  16. Walking the line: Understanding pedestrian behaviour and risk at rail level crossings with cognitive work analysis.

    PubMed

    Read, Gemma J M; Salmon, Paul M; Lenné, Michael G; Stanton, Neville A

    2016-03-01

    Pedestrian fatalities at rail level crossings (RLXs) are a public safety concern for governments worldwide. There is little literature examining pedestrian behaviour at RLXs and no previous studies have adopted a formative approach to understanding behaviour in this context. In this article, cognitive work analysis is applied to understand the constraints that shape pedestrian behaviour at RLXs in Melbourne, Australia. The five phases of cognitive work analysis were developed using data gathered via document analysis, behavioural observation, walk-throughs and critical decision method interviews. The analysis demonstrates the complex nature of pedestrian decision making at RLXs and the findings are synthesised to provide a model illustrating the influences on pedestrian decision making in this context (i.e. time, effort and social pressures). Further, the CWA outputs are used to inform an analysis of the risks to safety associated with pedestrian behaviour at RLXs and the identification of potential interventions to reduce risk. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

  17. Visual tracking strategies for intelligent vehicle highway systems

    NASA Astrophysics Data System (ADS)

    Smith, Christopher E.; Papanikolopoulos, Nikolaos P.; Brandt, Scott A.; Richards, Charles

    1995-01-01

    The complexity and congestion of current transportation systems often produce traffic situations that jeopardize the safety of the people involved. These situations vary from maintaining a safe distance behind a leading vehicle to safely allowing a pedestrian to cross a busy street. Environmental sensing plays a critical role in virtually all of these situations. Of the sensors available, vision sensors provide information that is richer and more complete than other sensors, making them a logical choice for a multisensor transportation system. In this paper we present robust techniques for intelligent vehicle-highway applications where computer vision plays a crucial role. In particular, we demonstrate that the controlled active vision framework can be utilized to provide a visual sensing modality to a traffic advisory system in order to increase the overall safety margin in a variety of common traffic situations. We have selected two application examples, vehicle tracking and pedestrian tracking, to demonstrate that the framework can provide precisely the type of information required to effectively manage the given situation.

  18. Technological developments and the need for technical competencies in food services.

    PubMed

    Rodgers, Svetlana

    2005-05-01

    The growing scale of institutional and commercial food services poses a technological challenge of producing large quantities of high quality meals in terms of their safety, sensory and nutritional attributes. Developments in food service technology and systems (cook-freeze, cook-chill and others) allow the replacement of fast food with the service of cooked meals, which are often nutritionally superior. Reliance on equipment, packaging and technological 'know-how' makes food service operations more complex. Operators have to minimise the impact of the numerous steps in the production process, the fundamental weaknesses of cook-chill food safety design, coupled with the practical limitations of Hazard Analysis Critical Control Points management, the potential unevenness of temperature distribution and product deterioration during storage. The fundamental knowledge of food science and microbiology, engineering and packaging technologies is needed. At present, the 'high tech' options, which can improve a product's nutritional value, such as natural preservation hurdles or functional meals, are not used in practice.

  19. A Review on Internet of Things for Defense and Public Safety

    PubMed Central

    Fraga-Lamas, Paula; Fernández-Caramés, Tiago M.; Suárez-Albela, Manuel; Castedo, Luis; González-López, Miguel

    2016-01-01

    The Internet of Things (IoT) is undeniably transforming the way that organizations communicate and organize everyday businesses and industrial procedures. Its adoption has proven well suited for sectors that manage a large number of assets and coordinate complex and distributed processes. This survey analyzes the great potential for applying IoT technologies (i.e., data-driven applications or embedded automation and intelligent adaptive systems) to revolutionize modern warfare and provide benefits similar to those in industry. It identifies scenarios where Defense and Public Safety (PS) could leverage better commercial IoT capabilities to deliver greater survivability to the warfighter or first responders, while reducing costs and increasing operation efficiency and effectiveness. This article reviews the main tactical requirements and the architecture, examining gaps and shortcomings in existing IoT systems across the military field and mission-critical scenarios. The review characterizes the open challenges for a broad deployment and presents a research roadmap for enabling an affordable IoT for defense and PS. PMID:27782052

  20. A Review on Internet of Things for Defense and Public Safety.

    PubMed

    Fraga-Lamas, Paula; Fernández-Caramés, Tiago M; Suárez-Albela, Manuel; Castedo, Luis; González-López, Miguel

    2016-10-05

    The Internet of Things (IoT) is undeniably transforming the way that organizations communicate and organize everyday businesses and industrial procedures. Its adoption has proven well suited for sectors that manage a large number of assets and coordinate complex and distributed processes. This survey analyzes the great potential for applying IoT technologies (i.e., data-driven applications or embedded automation and intelligent adaptive systems) to revolutionize modern warfare and provide benefits similar to those in industry. It identifies scenarios where Defense and Public Safety (PS) could leverage better commercial IoT capabilities to deliver greater survivability to the warfighter or first responders, while reducing costs and increasing operation efficiency and effectiveness. This article reviews the main tactical requirements and the architecture, examining gaps and shortcomings in existing IoT systems across the military field and mission-critical scenarios. The review characterizes the open challenges for a broad deployment and presents a research roadmap for enabling an affordable IoT for defense and PS.

  1. Management commitment to safety as organizational support: relationships with non-safety outcomes in wood manufacturing employees

    Treesearch

    Judd H. Michael; Demetrice D. Evans; Karen J. Jansen; Joel M. Haight

    2005-01-01

    Employee perceptions of management commitment to safety are known to influence important safety-related outcomes. However, little work has been conducted to explore nonsafety-related outcomes resulting from a commitment to safety. Method: Employee-level outcomes critical to the effective functioning of an organization, including attitudes such as job...

  2. Work-family conflict and safety participation of high-speed railway drivers: Job satisfaction as a mediator.

    PubMed

    Wei, Wei; Guo, Ming; Ye, Long; Liao, Ganli; Yang, Zhehan

    2016-10-01

    Despite the large body of work on the work-family interface, hardly any literature has addressed the work-family interface in safety-critical settings. This study draws from social exchange theory to examine the effect of employees' strain-based work-to-family conflict on their supervisors' rating of their safety participation through job satisfaction. The sample consisted of 494 drivers from a major railway company in China. The results of a structural equation model revealed that drivers' strain-based work-to-family conflict negatively influences safety participation, and the relationship was partially mediated by job satisfaction. These findings highlight the importance of reducing employees' work-to-family conflict in safety-critical organizations. Copyright © 2016 Elsevier Ltd. All rights reserved.

  3. A Software Safety Risk Taxonomy for Use in Retrospective Safety Cases

    NASA Technical Reports Server (NTRS)

    Hill, Janice L.

    2007-01-01

    Safety standards contain technical and process-oriented safely requirements. The best time to include these requirements is early in the development lifecycle of the system. When software safety requirements are levied on a legacy system after the fact, a retrospective safety case will need to be constructed for the software in the system. This can be a difficult task because there may be few to no art facts available to show compliance to the software safely requirements. The risks associated with not meeting safely requirements in a legacy safely-critical computer system must be addressed to give confidence for reuse. This paper introduces a proposal for a software safely risk taxonomy for legacy safely-critical computer systems, by specializing the Software Engineering Institute's 'Software Development Risk Taxonomy' with safely elements and attributes.

  4. Reference Avionics Architecture for Lunar Surface Systems

    NASA Technical Reports Server (NTRS)

    Somervill, Kevin M.; Lapin, Jonathan C.; Schmidt, Oron L.

    2010-01-01

    Developing and delivering infrastructure capable of supporting long-term manned operations to the lunar surface has been a primary objective of the Constellation Program in the Exploration Systems Mission Directorate. Several concepts have been developed related to development and deployment lunar exploration vehicles and assets that provide critical functionality such as transportation, habitation, and communication, to name a few. Together, these systems perform complex safety-critical functions, largely dependent on avionics for control and behavior of system functions. These functions are implemented using interchangeable, modular avionics designed for lunar transit and lunar surface deployment. Systems are optimized towards reuse and commonality of form and interface and can be configured via software or component integration for special purpose applications. There are two core concepts in the reference avionics architecture described in this report. The first concept uses distributed, smart systems to manage complexity, simplify integration, and facilitate commonality. The second core concept is to employ extensive commonality between elements and subsystems. These two concepts are used in the context of developing reference designs for many lunar surface exploration vehicles and elements. These concepts are repeated constantly as architectural patterns in a conceptual architectural framework. This report describes the use of these architectural patterns in a reference avionics architecture for Lunar surface systems elements.

  5. Specialty-care access for community health clinic patients: processes and barriers.

    PubMed

    Ezeonwu, Mabel C

    2018-01-01

    Community health clinics/centers (CHCs) comprise the US's core health-safety net and provide primary care to anyone who walks through their doors. However, access to specialty care for CHC patients is a big challenge. In this descriptive qualitative study, semistructured interviews of 37 referral coordinators of CHCs were used to describe their perspectives on processes and barriers to patients' access to specialty care. Analysis of data was done using content analysis. The process of coordinating care referrals for CHC patients is complex and begins with a provider's order for consultation and ends when the referring provider receives the specialist's note. Poverty, specialist and referral coordinator shortages, lack of insurance, insurance acceptability by providers, transport and clinic-location factors, lack of clinic-hospital affiliations, and poor communication between primary and specialty providers constitute critical barriers to specialty-care access for patients. Understanding the complexities of specialty-care coordination processes and access helps determine the need for comprehensive and uninterrupted access to quality health care for vulnerable populations. Guaranteed access to primary care at CHCs has not translated into improved access to specialty care. It is critical that effective policies be pursued to address the barriers and minimize interruptions in care, and to ensure continuity of care for all patients needing specialty care.

  6. The human factor: the critical importance of effective teamwork and communication in providing safe care.

    PubMed

    Leonard, M; Graham, S; Bonacum, D

    2004-10-01

    Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common "critical language" to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.

  7. A focused approach to safety guidebook.

    DOT National Transportation Integrated Search

    2011-08-23

    "The Federal Highway Administration (FHWA) has developed the Focused Approach to Safety in order to better address the most critical safety challenges by devoting additional attention to high priority States. The purpose of the Focused Approach is to...

  8. A Framework for Reliability and Safety Analysis of Complex Space Missions

    NASA Technical Reports Server (NTRS)

    Evans, John W.; Groen, Frank; Wang, Lui; Austin, Rebekah; Witulski, Art; Mahadevan, Nagabhushan; Cornford, Steven L.; Feather, Martin S.; Lindsey, Nancy

    2017-01-01

    Long duration and complex mission scenarios are characteristics of NASA's human exploration of Mars, and will provide unprecedented challenges. Systems reliability and safety will become increasingly demanding and management of uncertainty will be increasingly important. NASA's current pioneering strategy recognizes and relies upon assurance of crew and asset safety. In this regard, flexibility to develop and innovate in the emergence of new design environments and methodologies, encompassing modeling of complex systems, is essential to meet the challenges.

  9. Organizing safety: conditions for successful information assurance programs.

    PubMed

    Collmann, Jeff; Coleman, Johnathan; Sostrom, Kristen; Wright, Willie

    2004-01-01

    Organizations must continuously seek safety. When considering computerized health information systems, "safety" includes protecting the integrity, confidentiality, and availability of information assets such as patient information, key components of the technical information system, and critical personnel. "High Reliability Theory" (HRT) argues that organizations with strong leadership support, continuous training, redundant safety mechanisms, and "cultures of high reliability" can deploy and safely manage complex, risky technologies such as nuclear weapons systems or computerized health information systems. In preparation for the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Office of the Assistant Secretary of Defense (Health Affairs), the Offices of the Surgeons General of the United States Army, Navy and Air Force, and the Telemedicine and Advanced Technology Research Center (TATRC), US Army Medical Research and Materiel Command sponsored organizational, doctrinal, and technical projects that individually and collectively promote conditions for a "culture of information assurance." These efforts include sponsoring the "P3 Working Group" (P3WG), an interdisciplinary, tri-service taskforce that reviewed all relevant Department of Defense (DoD), Miliary Health System (MHS), Army, Navy and Air Force policies for compliance with the HIPAA medical privacy and data security regulations; supporting development, training, and deployment of OCTAVE(sm), a self-directed information security risk assessment process; and sponsoring development of the Risk Information Management Resource (RIMR), a Web-enabled enterprise portal about health information assurance.

  10. Dismantlement of the TSF-SNAP Reactor Assembly

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Peretz, Fred J

    2009-01-01

    This paper describes the dismantlement of the Tower Shielding Facility (TSF)?Systems for Nuclear Auxiliary Power (SNAP) reactor, a SNAP-10A reactor used to validate radiation source terms and shield performance models at Oak Ridge National Laboratory (ORNL) from 1967 through 1973. After shutdown, it was placed in storage at the Y-12 National Security Complex (Y-12), eventually falling under the auspices of the Highly Enriched Uranium (HEU) Disposition Program. To facilitate downblending of the HEU present in the fuel elements, the TSF-SNAP was moved to ORNL on June 24, 2006. The reactor assembly was removed from its packaging, inspected, and the sodium-potassiummore » (NaK) coolant was drained. A superheated steam process was used to chemically react the residual NaK inside the reactor assembly. The heat exchanger assembly was removed from the top of the reactor vessel, and the criticality safety sleeve was exchanged for a new safety sleeve that allowed for the removal of the vessel lid. A chain-mounted tubing cutter was used to separate the lid from the vessel, and the 36 fuel elements were removed and packaged in four U.S. Department of Transportation 2R/6M containers. The fuel elements were returned to Y-12 on July 13, 2006. The return of the fuel elements and disposal of all other reactor materials accomplished the formal objectives of the dismantlement project. In addition, a project model was established for the handling of a fully fueled liquid-metal?cooled reactor assembly. Current criticality safety codes have been benchmarked against experiments performed by Atomics International in the 1950s and 1960s. Execution of this project provides valuable experience applicable to future projects addressing space and liquid-metal-cooled reactors.« less

  11. Use of SCALE Continuous-Energy Monte Carlo Tools for Eigenvalue Sensitivity Coefficient Calculations

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Perfetti, Christopher M; Rearden, Bradley T

    2013-01-01

    The TSUNAMI code within the SCALE code system makes use of eigenvalue sensitivity coefficients for an extensive number of criticality safety applications, such as quantifying the data-induced uncertainty in the eigenvalue of critical systems, assessing the neutronic similarity between different critical systems, and guiding nuclear data adjustment studies. The need to model geometrically complex systems with improved fidelity and the desire to extend TSUNAMI analysis to advanced applications has motivated the development of a methodology for calculating sensitivity coefficients in continuous-energy (CE) Monte Carlo applications. The CLUTCH and Iterated Fission Probability (IFP) eigenvalue sensitivity methods were recently implemented in themore » CE KENO framework to generate the capability for TSUNAMI-3D to perform eigenvalue sensitivity calculations in continuous-energy applications. This work explores the improvements in accuracy that can be gained in eigenvalue and eigenvalue sensitivity calculations through the use of the SCALE CE KENO and CE TSUNAMI continuous-energy Monte Carlo tools as compared to multigroup tools. The CE KENO and CE TSUNAMI tools were used to analyze two difficult models of critical benchmarks, and produced eigenvalue and eigenvalue sensitivity coefficient results that showed a marked improvement in accuracy. The CLUTCH sensitivity method in particular excelled in terms of efficiency and computational memory requirements.« less

  12. Electron beam processing of fresh produce - A critical review

    NASA Astrophysics Data System (ADS)

    Pillai, Suresh D.; Shayanfar, Shima

    2018-02-01

    To meet the increasing global demand for fresh produce, robust processing methods that ensures both the safety and quality of fresh produce are needed. Since fresh produce cannot withstand thermal processing conditions, most of common safety interventions used in other foods are ineffective. Electron beam (eBeam) is a non-thermal technology that can be used to extend the shelf life and ensure the microbiological safety of fresh produce. There have been studies documenting the application of eBeam to ensure both safety and quality in fresh produce, however, there are still unexplored areas that still need further research. This is a critical review on the current literature on the application of eBeam technology for fresh produce.

  13. Preparation and Quality Control of the [153Sm]-Samarium Maltolate Complex as a Lanthanide Mobilization Product in Rats

    PubMed Central

    Naseri, Zohreh; Hakimi, Amir; Jalilian, Amir R.; Nemati Kharat, Ali; Bahrami-Samani, Ali; Ghannadi-Maragheh, Mohammad

    2011-01-01

    Development of lanthanide detoxification agents and protocols is of great importance in management of overdoses. Due to safety of maltol as a detoxifying agent in metal overloads, it can be used as a lanthanide detoxifying agent. In order to demonstrate the biodistribution of final complex, [153Sm]-samarium maltolate was prepared using Sm-153 chloride (radiochemical purity >99.9%; ITLC and specific activity). The stability of the labeled compound was determined in the final solution up to 24h as well as the partition coefficient. Biodistribution studies of Sm-153 chloride, [153Sm]-samarium maltolate were carried out in wild-type rats comparing the critical organ uptakes. Comparative study for Sm3+ cation and the labeled compound was conducted up to 48 h, demonstrating a more rapid wash out for the labeled compound. The effective and biological half lives of 2.3 h and 2.46h were calculated for the complex. The data suggest the detoxification property of maltol formulation for lanthanide overdoses. PMID:21773065

  14. Complex robotic reconstructive surgical procedures in children with urologic abnormalities.

    PubMed

    Orvieto, Marcelo A; Gundeti, Mohan S

    2011-07-01

    Robot-assisted laparoscopic surgery (RALS) is evolving rapidly in the pediatric surgical field. The unique attributes of the robotic interface makes this technology ideal for children with congenital anomalies who often require reconstructive procedures. Furthermore, the system can generate extremely delicate movements in a confined working space such as the one generally found in the pediatric population. Herein, we critically review the current experience with RALS placing a special emphasis in children undergoing complex reconstructive surgical procedures worldwide. A total of 42 original manuscripts on a variety of robot-assisted urologic surgical procedures in children were identified from a MEDLINE database search. Complex reconstructive procedures that are being currently performed include reoperative pyeloplasty, pyeloplasty in infants, pyelolithotomy, ureteropyelostomy/ureterostomy, bladder augmentation with or without appendico-vesicostomy, bladder neck sling procedure, among others. Initial results with robot assistance are encouraging and have demonstrated safety comparable to open procedures and outcomes at least equivalent to standard laparoscopy. Future development of smaller instruments, incorporating tactile feedback, will likely overcome current limitations and spread out the use of this technique in younger children and more advanced procedures.

  15. Safety Analysis of Soybean Processing for Advanced Life Support

    NASA Technical Reports Server (NTRS)

    Hentges, Dawn L.

    1999-01-01

    Soybeans (cv. Hoyt) is one of the crops planned for food production within the Advanced Life Support System Integration Testbed (ALSSIT), a proposed habitat simulation for long duration lunar/Mars missions. Soybeans may be processed into a variety of food products, including soymilk, tofu, and tempeh. Due to the closed environmental system and importance of crew health maintenance, food safety is a primary concern on long duration space missions. Identification of the food safety hazards and critical control points associated with the closed ALSSIT system is essential for the development of safe food processing techniques and equipment. A Hazard Analysis Critical Control Point (HACCP) model was developed to reflect proposed production and processing protocols for ALSSIT soybeans. Soybean processing was placed in the type III risk category. During the processing of ALSSIT-grown soybeans, critical control points were identified to control microbiological hazards, particularly mycotoxins, and chemical hazards from antinutrients. Critical limits were suggested at each CCP. Food safety recommendations regarding the hazards and risks associated with growing, harvesting, and processing soybeans; biomass management; and use of multifunctional equipment were made in consideration of the limitations and restraints of the closed ALSSIT.

  16. Nurse manager cognitive decision-making amidst stress and work complexity.

    PubMed

    Shirey, Maria R; Ebright, Patricia R; McDaniel, Anna M

    2013-01-01

      The present study provides insight into nurse manager cognitive decision-making amidst stress and work complexity.   Little is known about nurse manager decision-making amidst stress and work complexity. Because nurse manager decisions have the potential to impact patient care quality and safety, understanding their decision-making processes is useful for designing supportive interventions.   This qualitative descriptive study interviewed 21 nurse managers from three hospitals to answer the research question: What decision-making processes do nurse managers utilize to address stressful situations in their nurse manager role? Face-to-face interviews incorporating components of the Critical Decision Method illuminated expert-novice practice differences. Content analysis identified one major theme and three sub-themes.   The present study produced a cognitive model that guides nurse manager decision-making related to stressful situations. Experience in the role, organizational context and situation factors influenced nurse manager cognitive decision-making processes.   Study findings suggest that chronic exposure to stress and work complexity negatively affects nurse manager health and their decision-making processes potentially threatening individual, patient and organizational outcomes.   Cognitive decision-making varies based on nurse manager experience and these differences have coaching and mentoring implications. This present study contributes a current understanding of nurse manager decision-making amidst stress and work complexity. © 2012 Blackwell Publishing Ltd.

  17. Visual warning system for worker safety on roadside work-zones.

    DOT National Transportation Integrated Search

    2016-08-01

    Growing traffic on US roadways and heavy construction machinery on road construction sites pose a critical safety : threat to construction workers. This report summarizes the design and development of a worker safety system using : Dedicated Short Ra...

  18. Criticality Safety Evaluation of Standard Criticality Safety Requirements #1-520 g Operations in PF-4

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Yamanaka, Alan Joseph Jr.

    Guidance has been requested from the Nuclear Criticality Safety Division (NCSD) regarding processes that involve 520 grams of fissionable material or less. This Level-3 evaluation was conducted and documented in accordance with NCS-AP-004 (Ref. 1), formerly NCS-GUIDE-01. This evaluation is being written as a generic evaluation for all operations that will be able to operate using a 520-gram mass limit. Implementation for specific operations will be performed using a Level 1 CSED, which will confirm and document that this CSED can be used for the specific operation as discussed in NCS-MEMO-17-007 (Ref. 2). This Level 3 CSED updates and supersedesmore » the analysis performed in NCS-TECH-14-014 (Ref. 3).« less

  19. Sustainable development and next generation's health: a long-term perspective about the consequences of today's activities for food safety.

    PubMed

    Frazzoli, Chiara; Petrini, Carlo; Mantovani, Alberto

    2009-01-01

    Development is defined sustainable when it meets the needs of the present without compromising the ability of future generations to meet their own needs. Pivoting on social, environmental and economic aspects of food chain sustainability, this paper presents the concept of sustainable food safety based on the prevention of risks and burden of poor health for generations to come. Under this respect, the assessment of long-term, transgenerational risks is still hampered by serious scientific uncertainties. Critical issues to the development of a sustainable food safety framework may include: endocrine disrupters as emerging contaminants that specifically target developing organisms; toxicological risks assessment in Countries at the turning point of development; translating knowledge into toxicity indexes to support risk management approaches, such as hazard analysis and critical control points (HACCP); the interplay between chemical hazards and social determinants. Efforts towards the comprehensive knowledge and management of key factors of sustainable food safety appear critical to the effectiveness of the overall sustainability policies.

  20. KSC-2014-4766

    NASA Image and Video Library

    2014-12-05

    SAN DIEGO, Calif. -- NASA's Orion spacecraft splashed down in the Pacific Ocean after its first flight test atop a Delta IV Heavy rocket from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida. U.S. Navy divers in Zodiac boats prepare to recover Orion and tow her in to the well deck of the USS Anchorage. NASA's Orion spacecraft completed a two-orbit, four-and-a-half hour mission to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. The Ground Systems Development and Operations Program is leading the recovery efforts. For more information, visit www.nasa.gov/orion Photo credit: Courtesy of U.S. Navy

  1. Orion Splashdown Recovery

    NASA Image and Video Library

    2014-12-06

    The Orion crew module is recovered after splashdown in the Pacific Ocean about 600 miles off the coast of San Diego, California. NASA, the U.S. Navy and Lockheed Martin coordinated efforts to recover Orion and secure the spacecraft inside the well deck of the USS Anchorage. After lifting off at 7:05 a.m. EST atop a Delta IV Heavy rocket from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida, NASA's Orion spacecraft completed a two-orbit, four-and-a-half hour mission to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. The Ground Systems Development and Operations Program is leading the recovery efforts.

  2. Orion in the Well Deck After Splashdown and Recovery

    NASA Image and Video Library

    2014-12-05

    NASA's Orion spacecraft is secured with tether lines inside the flooded well deck of the USS Anchorage in the Pacific Ocean about 600 miles off the coast of San Diego, California. After lifting off at 7:05 a.m. EST atop a Delta IV Heavy rocket from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida, Orion completed a two-orbit, four-and-a-half hour mission to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. NASA, the U.S. Navy and Lockheed Martin coordinated efforts to recover Orion after splashdown. The Ground Systems Development and Operations Program is leading the recovery efforts.

  3. Orion in the Well Deck After Splashdown and Recovery

    NASA Image and Video Library

    2014-12-05

    NASA's Orion spacecraft has been recovered inside the flooded well deck of the USS Anchorage in the Pacific Ocean about 600 miles off the coast of San Diego, California. After lifting off at 7:05 a.m. EST atop a Delta IV Heavy rocket from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida, Orion completed a two-orbit, four-and-a-half hour mission to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. NASA, the U.S. Navy and Lockheed Martin coordinated efforts to recover Orion after splashdown. The Ground Systems Development and Operations Program is leading the recovery efforts.

  4. Aerial of the Orion EFT-1 Arrival at KSC

    NASA Image and Video Library

    2014-12-18

    An aerial view near NASA's Kennedy Space Center Visitor Complex reveals the Orion crew module, enclosed in its crew module transportation fixture and secured on a flatbed truck on the NASA Causeway that leads to the entrance gate to Kennedy Space Center in Florida. Orion made the 2,700 mile overland trip from Naval Base San Diego in California. The spacecraft was recovered from the Pacific Ocean after completing a two-orbit, four-and-a-half hour mission Dec. 5 to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. The Ground Systems Development and Operations Program led the recovery, offload and transportation efforts.

  5. Aerial of the Orion EFT-1 Arrival at KSC

    NASA Image and Video Library

    2014-12-18

    An aerial view near NASA's Kennedy Space Center Visitor Complex reveals the Orion crew module, enclosed in its crew module transportation fixture and secured on a flatbed truck that is proceeding along the NASA Causeway to the entrance gate to Kennedy Space Center in Florida. Orion made the 2,700 mile overland trip from Naval Base San Diego in California. The spacecraft was recovered from the Pacific Ocean after completing a two-orbit, four-and-a-half hour mission Dec. 5 to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. The Ground Systems Development and Operations Program led the recovery, offload and transportation efforts.

  6. Aerial of the Orion EFT-1 Arrival at KSC

    NASA Image and Video Library

    2014-12-18

    An aerial view near NASA's Kennedy Space Center Visitor Complex reveals the Orion crew module, enclosed in its crew module transportation fixture and secured on a flatbed truck that is proceeding onto the NASA Causeway that leads to the entrance gate to Kennedy Space Center in Florida. Orion made the 2,700 mile overland trip from Naval Base San Diego in California. The spacecraft was recovered from the Pacific Ocean after completing a two-orbit, four-and-a-half hour mission Dec. 5 to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. The Ground Systems Development and Operations Program led the recovery, offload and transportation efforts.

  7. Feasibility and safety of virtual-reality-based early neurocognitive stimulation in critically ill patients.

    PubMed

    Turon, Marc; Fernandez-Gonzalo, Sol; Jodar, Mercè; Gomà, Gemma; Montanya, Jaume; Hernando, David; Bailón, Raquel; de Haro, Candelaria; Gomez-Simon, Victor; Lopez-Aguilar, Josefina; Magrans, Rudys; Martinez-Perez, Melcior; Oliva, Joan Carles; Blanch, Lluís

    2017-12-01

    Growing evidence suggests that critical illness often results in significant long-term neurocognitive impairments in one-third of survivors. Although these neurocognitive impairments are long-lasting and devastating for survivors, rehabilitation rarely occurs during or after critical illness. Our aim is to describe an early neurocognitive stimulation intervention based on virtual reality for patients who are critically ill and to present the results of a proof-of-concept study testing the feasibility, safety, and suitability of this intervention. Twenty critically ill adult patients undergoing or having undergone mechanical ventilation for ≥24 h received daily 20-min neurocognitive stimulation sessions when awake and alert during their ICU stay. The difficulty of the exercises included in the sessions progressively increased over successive sessions. Physiological data were recorded before, during, and after each session. Safety was assessed through heart rate, peripheral oxygen saturation, and respiratory rate. Heart rate variability analysis, an indirect measure of autonomic activity sensitive to cognitive demands, was used to assess the efficacy of the exercises in stimulating attention and working memory. Patients successfully completed the sessions on most days. No sessions were stopped early for safety concerns, and no adverse events occurred. Heart rate variability analysis showed that the exercises stimulated attention and working memory. Critically ill patients considered the sessions enjoyable and relaxing without being overly fatiguing. The results in this proof-of-concept study suggest that a virtual-reality-based neurocognitive intervention is feasible, safe, and tolerable, stimulating cognitive functions and satisfying critically ill patients. Future studies will evaluate the impact of interventions on neurocognitive outcomes. Trial registration Clinical trials.gov identifier: NCT02078206.

  8. Analytical methodology for safety validation of computer controlled subsystems. Volume 1 : state-of-the-art and assessment of safety verification/validation methodologies

    DOT National Transportation Integrated Search

    1995-09-01

    This report describes the development of a methodology designed to assure that a sufficiently high level of safety is achieved and maintained in computer-based systems which perform safety critical functions in high-speed rail or magnetic levitation ...

  9. 77 FR 38127 - Agency Information Collection Activities: Request for Comments for a New Information Collection

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ... on all public roads through the implementation of infrastructure-related highway safety improvements. Using federal and state funds to assist local agencies in improving safety on local roads is critical... apply safety funding resources to local agencies for road safety improvement projects. The survey will...

  10. The Inside Information about Safety Surfacing.

    ERIC Educational Resources Information Center

    Thompson, Donna; Hudson, Susan

    2003-01-01

    Tested the impact attenuation characteristics of safety surfaces used in indoor child care play settings. Found that the most common surfaces used were indoor/outdoor carpet, various types of mats, and safety floor tiles. Nearly 60 percent of tested materials had a critical fall height of 1 foot or less. Concluded that carpet, safety tile, and…

  11. Validation of Safety-Critical Systems for Aircraft Loss-of-Control Prevention and Recovery

    NASA Technical Reports Server (NTRS)

    Belcastro, Christine M.

    2012-01-01

    Validation of technologies developed for loss of control (LOC) prevention and recovery poses significant challenges. Aircraft LOC can result from a wide spectrum of hazards, often occurring in combination, which cannot be fully replicated during evaluation. Technologies developed for LOC prevention and recovery must therefore be effective under a wide variety of hazardous and uncertain conditions, and the validation framework must provide some measure of assurance that the new vehicle safety technologies do no harm (i.e., that they themselves do not introduce new safety risks). This paper summarizes a proposed validation framework for safety-critical systems, provides an overview of validation methods and tools developed by NASA to date within the Vehicle Systems Safety Project, and develops a preliminary set of test scenarios for the validation of technologies for LOC prevention and recovery

  12. Culture theorizing past and present: trends and challenges.

    PubMed

    Vandenberg, Helen E R

    2010-10-01

    Over the past several decades, nurses have been increasingly theorizing about the relationships between culture, health, and nursing practice. This culture theorizing has changed over time and has recently been subject to much critical examination. The purpose of this paper is to identify the challenges impeding nurses' ability to build theory about the relationships between culture and health. Through a historical overview, I argue that continued support for the essentialist view of culture can maintain a limited view of complex race relations. I also argue that attempts to apply culture theory, without knowledge of important historical, political, and economic factors, has often resulted in oversimplified versions of what was originally intended. Furthermore, I argue that individual-level interventions alone will be insufficient to address health inequities related to culture. Despite new critical conceptualizations of culture and the uptake of cultural safety, nursing scholars must better address the broader organizational, population, and political interventions needed to address inequities in health. I conclude with suggestions for how nurses might proceed with culture theorizing given these challenges.

  13. Additive-manufactured sandwich lattice structures: A numerical and experimental investigation

    NASA Astrophysics Data System (ADS)

    Fergani, Omar; Tronvoll, Sigmund; Brøtan, Vegard; Welo, Torgeir; Sørby, Knut

    2017-10-01

    The utilization of additive-manufactured lattice structures in engineered products is becoming more and more common as the competitiveness of AM as a production technology has increased during the past several years. Lattice structures may enable important weight reductions as well as open opportunities to build products with customized functional properties, thanks to the flexibility of AM for producing complex geometrical configurations. One of the most critical aspects related to taking AM into new application areas—such as safety critical products—is currently the limited understanding of the mechanical behavior of sandwich-based lattice structure mechanical under static and dynamic loading. In this study, we evaluate manufacturability of lattice structures and the impact of AM processing parameters on the structural behavior of this type of sandwich structures. For this purpose, we conducted static compression testing for a variety of geometry and manufacturing parameters. Further, the study discusses a numerical model capable of predicting the behavior of different lattice structure. A reasonably good correlation between the experimental and numerical results was observed.

  14. Enhancing the Safety of Children in Foster Care and Family Support Programs: Automated Critical Incident Reporting

    ERIC Educational Resources Information Center

    Brenner, Eliot; Freundlich, Madelyn

    2006-01-01

    The Adoption and Safe Families Act of 1997 has made child safety an explicit focus in child welfare. The authors describe an automated critical incident reporting program designed for use in foster care and family-support programs. The program, which is based in Lotus Notes and uses e-mail to route incident reports from direct service staff to…

  15. An Approach for Validating Actinide and Fission Product Burnup Credit Criticality Safety Analyses--Criticality (keff) Predictions

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Scaglione, John M; Mueller, Don; Wagner, John C

    2011-01-01

    One of the most significant remaining challenges associated with expanded implementation of burnup credit in the United States is the validation of depletion and criticality calculations used in the safety evaluation - in particular, the availability and use of applicable measured data to support validation, especially for fission products. Applicants and regulatory reviewers have been constrained by both a scarcity of data and a lack of clear technical basis or approach for use of the data. U.S. Nuclear Regulatory Commission (NRC) staff have noted that the rationale for restricting their Interim Staff Guidance on burnup credit (ISG-8) to actinide-only ismore » based largely on the lack of clear, definitive experiments that can be used to estimate the bias and uncertainty for computational analyses associated with using burnup credit. To address the issue of validation, the NRC initiated a project with the Oak Ridge National Laboratory to (1) develop and establish a technically sound validation approach (both depletion and criticality) for commercial spent nuclear fuel (SNF) criticality safety evaluations based on best-available data and methods and (2) apply the approach for representative SNF storage and transport configurations/conditions to demonstrate its usage and applicability, as well as to provide reference bias results. The purpose of this paper is to describe the criticality (k{sub eff}) validation approach, and resulting observations and recommendations. Validation of the isotopic composition (depletion) calculations is addressed in a companion paper at this conference. For criticality validation, the approach is to utilize (1) available laboratory critical experiment (LCE) data from the International Handbook of Evaluated Criticality Safety Benchmark Experiments and the French Haut Taux de Combustion (HTC) program to support validation of the principal actinides and (2) calculated sensitivities, nuclear data uncertainties, and the limited available fission product LCE data to predict and verify individual biases for relevant minor actinides and fission products. This paper (1) provides a detailed description of the approach and its technical bases, (2) describes the application of the approach for representative pressurized water reactor and boiling water reactor safety analysis models to demonstrate its usage and applicability, (3) provides reference bias results based on the prerelease SCALE 6.1 code package and ENDF/B-VII nuclear cross-section data, and (4) provides recommendations for application of the results and methods to other code and data packages.« less

  16. 10 CFR 76.89 - Criticality accident requirements.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 10 Energy 2 2011-01-01 2011-01-01 false Criticality accident requirements. 76.89 Section 76.89 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) CERTIFICATION OF GASEOUS DIFFUSION PLANTS Safety § 76.89 Criticality accident requirements. (a) The Corporation must maintain and operate a criticality monitoring and...

  17. 10 CFR 76.89 - Criticality accident requirements.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 2 2014-01-01 2014-01-01 false Criticality accident requirements. 76.89 Section 76.89 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) CERTIFICATION OF GASEOUS DIFFUSION PLANTS Safety § 76.89 Criticality accident requirements. (a) The Corporation must maintain and operate a criticality monitoring and...

  18. 10 CFR 76.89 - Criticality accident requirements.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 10 Energy 2 2013-01-01 2013-01-01 false Criticality accident requirements. 76.89 Section 76.89 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) CERTIFICATION OF GASEOUS DIFFUSION PLANTS Safety § 76.89 Criticality accident requirements. (a) The Corporation must maintain and operate a criticality monitoring and...

  19. 10 CFR 76.89 - Criticality accident requirements.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 10 Energy 2 2012-01-01 2012-01-01 false Criticality accident requirements. 76.89 Section 76.89 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) CERTIFICATION OF GASEOUS DIFFUSION PLANTS Safety § 76.89 Criticality accident requirements. (a) The Corporation must maintain and operate a criticality monitoring and...

  20. 10 CFR 76.89 - Criticality accident requirements.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 2 2010-01-01 2010-01-01 false Criticality accident requirements. 76.89 Section 76.89 Energy NUCLEAR REGULATORY COMMISSION (CONTINUED) CERTIFICATION OF GASEOUS DIFFUSION PLANTS Safety § 76.89 Criticality accident requirements. (a) The Corporation must maintain and operate a criticality monitoring and...

  1. Tiger Team Assessment of the Los Alamos National Laboratory

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Not Available

    1991-11-01

    The purpose of the safety and health assessment was to determine the effectiveness of representative safety and health programs at the Los Alamos National Laboratory (LANL). Within the safety and health programs at LANL, performance was assessed in the following technical areas: Organization and Administration, Quality Verification, Operations, Maintenance, Training and Certification, Auxiliary Systems, Emergency Preparedness, Technical Support, Packaging and Transportation, Nuclear Criticality Safety, Security/Safety Interface, Experimental Activities, Site/Facility Safety Review, Radiological Protection, Personnel Protection, Worker Safety and Health (OSHA) Compliance, Fire Protection, Aviation Safety, Explosives Safety, Natural Phenomena, and Medical Services.

  2. Criticality safety strategy and analysis summary for the fuel cycle facility electrorefiner at Argonne National Laboratory West

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Mariani, R.D.; Benedict, R.W.; Lell, R.M.

    1996-05-01

    As part of the termination activities of Experimental Breeder Reactor II (EBR-II) at Argonne National Laboratory (ANL) West, the spent metallic fuel from EBR-II will be treated in the fuel cycle facility (FCF). A key component of the spent-fuel treatment process in the FCF is the electrorefiner (ER) in which the actinide metals are separated from the active metal fission products and the reactive bond sodium. In the electrorefining process, the metal fuel is anodically dissolved into a high-temperature molten salt, and refined uranium or uranium/plutonium products are deposited at cathodes. The criticality safety strategy and analysis for the ANLmore » West FCF ER is summarized. The FCF ER operations and processes formed the basis for evaluating criticality safety and control during actinide metal fuel refining. To show criticality safety for the FCF ER, the reference operating conditions for the ER had to be defined. Normal operating envelopes (NOEs) were then defined to bracket the important operating conditions. To keep the operating conditions within their NOEs, process controls were identified that can be used to regulate the actinide forms and content within the ER. A series of operational checks were developed for each operation that will verify the extent or success of an operation. The criticality analysis considered the ER operating conditions at their NOE values as the point of departure for credible and incredible failure modes. As a result of the analysis, FCF ER operations were found to be safe with respect to criticality.« less

  3. Constraints to microbial food safety policy: opinions from stakeholder groups along the farm to fork continuum.

    PubMed

    Sargeant, J M; Ramsingh, B; Wilkins, A; Travis, R G; Gavrus, D; Snelgrove, J W

    2007-01-01

    This exploratory qualitative study was conducted to identify constraints to microbial food safety policy in Canada and the USA from the perspective of stakeholder groups along the farm to fork continuum. Thirty-seven stakeholders participated in interviews or a focus group where semi-structured questions were used to facilitate discussion about constraints to policy development and implementation. An emergent grounded theory approach was used to determine themes and concepts that arose from the data (versus fitting the data to a hypothesis or a priori classification). Despite the plurality of stakeholders and the range of content expertise, participant perceptions emerged into five common themes, although, there were often disagreements as to the positive or negative attributes of specific concepts. The five themes included challenges related to measurement and objectives of microbial food safety policy goals, challenges arising from lack of knowledge, or problems with communication of knowledge coupled with current practices, beliefs and traditions; the complexity of the food system and the plurality of stakeholders; the economics of producing safe food and the limited resources to address the problem; and, issues related to decision-making and policy, including ownership of the problem and inappropriate inputs to the decision-making process. Responsibilities for food safety and for food policy failure were attributed to all stakeholders along the farm to fork continuum. While challenges regarding the biology of food safety were identified as constraints, a broader range of policy inputs encompassing social, economic and political considerations were also highlighted as critical to the development and implementation of effective food safety policy. Strategies to address these other inputs may require new, transdisciplinary approaches as an adjunct to the traditional science-based risk assessment model.

  4. Assuring safety without animal testing: Unilever's ongoing research programme to deliver novel ways to assure consumer safety.

    PubMed

    Westmoreland, Carl; Carmichael, Paul; Dent, Matt; Fentem, Julia; MacKay, Cameron; Maxwell, Gavin; Pease, Camilla; Reynolds, Fiona

    2010-01-01

    Assuring consumer safety without the generation of new animal data is currently a considerable challenge. However, through the application of new technologies and the further development of risk-based approaches for safety assessment, we remain confident it is ultimately achievable. For many complex, multi-organ consumer safety endpoints, the development, evaluation and application of new, non-animal approaches is hampered by a lack of biological understanding of the underlying mechanistic processes involved. The enormity of this scientific challenge should not be underestimated. To tackle this challenge a substantial research programme was initiated by Unilever in 2004 to critically evaluate the feasibility of a new conceptual approach based upon the following key components: 1.Developing new, exposure-driven risk assessment approaches. 2.Developing new biological (in vitro) and computer-based (in silico) predictive models. 3.Evaluating the applicability of new technologies for generating data (e.g. "omics", informatics) and for integrating new types of data (e.g. systems approaches) for risk-based safety assessment. Our research efforts are focussed in the priority areas of skin allergy, cancer and general toxicity (including inhaled toxicity). In all of these areas, a long-term investment is essential to increase the scientific understanding of the underlying biology and molecular mechanisms that we believe will ultimately form a sound basis for novel risk assessment approaches. Our research programme in these priority areas consists of in-house research as well as Unilever-sponsored academic research, involvement in EU-funded projects (e.g. Sens-it-iv, Carcinogenomics), participation in cross-industry collaborative research (e.g. Colipa, EPAA) and ongoing involvement with other scientific initiatives on non-animal approaches to risk assessment (e.g. UK NC3Rs, US "Human Toxicology Project" consortium).

  5. Planning the Safety of Atrial Fibrillation Ablation Registry Initiative (SAFARI) as a Collaborative Pan-Stakeholder Critical Path Registry Model: a Cardiac Safety Research Consortium "Incubator" Think Tank.

    PubMed

    Al-Khatib, Sana M; Calkins, Hugh; Eloff, Benjamin C; Packer, Douglas L; Ellenbogen, Kenneth A; Hammill, Stephen C; Natale, Andrea; Page, Richard L; Prystowsky, Eric; Jackman, Warren M; Stevenson, William G; Waldo, Albert L; Wilber, David; Kowey, Peter; Yaross, Marcia S; Mark, Daniel B; Reiffel, James; Finkle, John K; Marinac-Dabic, Danica; Pinnow, Ellen; Sager, Phillip; Sedrakyan, Art; Canos, Daniel; Gross, Thomas; Berliner, Elise; Krucoff, Mitchell W

    2010-01-01

    Atrial fibrillation (AF) is a major public health problem in the United States that is associated with increased mortality and morbidity. Of the therapeutic modalities available to treat AF, the use of percutaneous catheter ablation of AF is expanding rapidly. Randomized clinical trials examining the efficacy and safety of AF ablation are currently underway; however, such trials can only partially determine the safety and durability of the effect of the procedure in routine clinical practice, in more complex patients, and over a broader range of techniques and operator experience. These limitations of randomized trials of AF ablation, particularly with regard to safety issues, could be addressed using a synergistically structured national registry, which is the intention of the SAFARI. To facilitate discussions about objectives, challenges, and steps for such a registry, the Cardiac Safety Research Consortium and the Duke Clinical Research Institute, Durham, NC, in collaboration with the US Food and Drug Administration, the American College of Cardiology, and the Heart Rhythm Society, organized a Think Tank meeting of experts in the field. Other participants included the National Heart, Lung and Blood Institute, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Society of Thoracic Surgeons, the AdvaMed AF working group, and additional industry representatives. The meeting took place on April 27 to 28, 2009, at the US Food and Drug Administration headquarters in Silver Spring, MD. This article summarizes the issues and directions presented and discussed at the meeting. Copyright 2010 Mosby, Inc. All rights reserved.

  6. Natural Language Interface for Safety Certification of Safety-Critical Software

    NASA Technical Reports Server (NTRS)

    Denney, Ewen; Fischer, Bernd

    2011-01-01

    Model-based design and automated code generation are being used increasingly at NASA. The trend is to move beyond simulation and prototyping to actual flight code, particularly in the guidance, navigation, and control domain. However, there are substantial obstacles to more widespread adoption of code generators in such safety-critical domains. Since code generators are typically not qualified, there is no guarantee that their output is correct, and consequently the generated code still needs to be fully tested and certified. The AutoCert generator plug-in supports the certification of automatically generated code by formally verifying that the generated code is free of different safety violations, by constructing an independently verifiable certificate, and by explaining its analysis in a textual form suitable for code reviews.

  7. Association rule mining in the US Vaccine Adverse Event Reporting System (VAERS).

    PubMed

    Wei, Lai; Scott, John

    2015-09-01

    Spontaneous adverse event reporting systems are critical tools for monitoring the safety of licensed medical products. Commonly used signal detection algorithms identify disproportionate product-adverse event pairs and may not be sensitive to more complex potential signals. We sought to develop a computationally tractable multivariate data-mining approach to identify product-multiple adverse event associations. We describe an application of stepwise association rule mining (Step-ARM) to detect potential vaccine-symptom group associations in the US Vaccine Adverse Event Reporting System. Step-ARM identifies strong associations between one vaccine and one or more adverse events. To reduce the number of redundant association rules found by Step-ARM, we also propose a clustering method for the post-processing of association rules. In sample applications to a trivalent intradermal inactivated influenza virus vaccine and to measles, mumps, rubella, and varicella (MMRV) vaccine and in simulation studies, we find that Step-ARM can detect a variety of medically coherent potential vaccine-symptom group signals efficiently. In the MMRV example, Step-ARM appears to outperform univariate methods in detecting a known safety signal. Our approach is sensitive to potentially complex signals, which may be particularly important when monitoring novel medical countermeasure products such as pandemic influenza vaccines. The post-processing clustering algorithm improves the applicability of the approach as a screening method to identify patterns that may merit further investigation. Copyright © 2015 John Wiley & Sons, Ltd.

  8. Manufacturing of biodrugs: need for harmonization in regulatory standards.

    PubMed

    Sahoo, Niharika; Choudhury, Koel; Manchikanti, Padmavati

    2009-01-01

    Biodrugs (biologics) are much more complex than chemically synthesized drugs because of their structural heterogeneity and interactions within a given biologic system. The manufacturing process in the biodrug industry varies with each type of molecule and is far more elaborate and stringent due to the use of living organisms and complex substrates. Product purity and altered structural characteristics leading to potential immunogenicity have often been of concern when establishing quality and safety in the use of biodrugs. Regulatory compliance in manufacturing and commercialization of biodrugs involves quality control, quality assurance, and batch documentation. Many factors such as host cell development, cell bank establishment, cell culture, protein production, purification, analysis, formulation, storage, and handling are critical for ensuring the purity, activity, and safety of the finished product. Good Manufacturing Practice (GMP) for biodrugs has been developed in certain regions such as the EU, US, and Japan. Due to differences in manufacturing methods and systems, product-specific GMP guidelines are evolving. In general, there are variations in GMP guidelines between countries, which lead to difficulty for the manufacturers in conforming to different standards, thus entailing delays in the commercialization of biodrugs. There is a need to develop a unified regulatory guideline for biodrug manufacturing across various countries, which would be helpful in the marketing of products and trade. This review deals with the comparative framework and analysis of GMP regulation of biodrugs.

  9. Cynthia Szydlek | NREL

    Science.gov Websites

    Cynthia Szydlek Photo of Cynthia Szydlek Cynthia Szydlek NWTC Training Coordinator/Project Support increased safety expectations and comply with comprehensive training requirements. She maintains the NWTC's Environmental, Health, and Safety (EHS) training and safety management systems and ensures all critical on-site

  10. Demonstration of a Safety Analysis on a Complex System

    NASA Technical Reports Server (NTRS)

    Leveson, Nancy; Alfaro, Liliana; Alvarado, Christine; Brown, Molly; Hunt, Earl B.; Jaffe, Matt; Joslyn, Susan; Pinnell, Denise; Reese, Jon; Samarziya, Jeffrey; hide

    1997-01-01

    For the past 17 years, Professor Leveson and her graduate students have been developing a theoretical foundation for safety in complex systems and building a methodology upon that foundation. The methodology includes special management structures and procedures, system hazard analyses, software hazard analysis, requirements modeling and analysis for completeness and safety, special software design techniques including the design of human-machine interaction, verification, operational feedback, and change analysis. The Safeware methodology is based on system safety techniques that are extended to deal with software and human error. Automation is used to enhance our ability to cope with complex systems. Identification, classification, and evaluation of hazards is done using modeling and analysis. To be effective, the models and analysis tools must consider the hardware, software, and human components in these systems. They also need to include a variety of analysis techniques and orthogonal approaches: There exists no single safety analysis or evaluation technique that can handle all aspects of complex systems. Applying only one or two may make us feel satisfied, but will produce limited results. We report here on a demonstration, performed as part of a contract with NASA Langley Research Center, of the Safeware methodology on the Center-TRACON Automation System (CTAS) portion of the air traffic control (ATC) system and procedures currently employed at the Dallas/Fort Worth (DFW) TRACON (Terminal Radar Approach CONtrol). CTAS is an automated system to assist controllers in handling arrival traffic in the DFW area. Safety is a system property, not a component property, so our safety analysis considers the entire system and not simply the automated components. Because safety analysis of a complex system is an interdisciplinary effort, our team included system engineers, software engineers, human factors experts, and cognitive psychologists.

  11. Medication safety infrastructure in critical-access hospitals in Florida.

    PubMed

    Winterstein, Almut G; Hartzema, Abraham G; Johns, Thomas E; De Leon, Jessica M; McDonald, Kathie; Henshaw, Zak; Pannell, Robert

    2006-03-01

    The medication safety infrastructure of critical-access hospitals (CAHs) in Florida was evaluated. Qualitative assessments, including a self-administered survey and site visits, were conducted in seven of nine CAHs between January and June 2003. The survey consisted of the Institute for Safe Medication Practices Medication Safety Self-assessment, the 2003 Joint Commission on Accreditation of Healthcare Organizations patient safety goals, health information technology (HIT) questions, and medication-use-process flow charts. On-site visits included interviews of CAH personnel who had safety responsibility and inspections of pharmacy facilities. The findings were compiled into a matrix reflecting structural and procedural components of the CAH medication safety infrastructure. The nine characteristics that emerged as targets for quality improvement (QI) were medication accessibility and storage, sterile product compounding, access to drug information, access to and utilization of patient information in medication order review, advanced safety technology, drug formularies and standardized medication protocols, safety culture, and medication reconciliation. Based on weighted importance and feasibility, QI efforts in CAHs should focus on enhancing medication order review systems, standardizing procedures for handling high-risk medications, promoting an appropriate safety culture, involvement in seamless care, and investment in HIT.

  12. Stem cell-derived models to improve mechanistic understanding and prediction of human drug-induced liver injury.

    PubMed

    Goldring, Christopher; Antoine, Daniel J; Bonner, Frank; Crozier, Jonathan; Denning, Chris; Fontana, Robert J; Hanley, Neil A; Hay, David C; Ingelman-Sundberg, Magnus; Juhila, Satu; Kitteringham, Neil; Silva-Lima, Beatriz; Norris, Alan; Pridgeon, Chris; Ross, James A; Young, Rowena Sison; Tagle, Danilo; Tornesi, Belen; van de Water, Bob; Weaver, Richard J; Zhang, Fang; Park, B Kevin

    2017-02-01

    Current preclinical drug testing does not predict some forms of adverse drug reactions in humans. Efforts at improving predictability of drug-induced tissue injury in humans include using stem cell technology to generate human cells for screening for adverse effects of drugs in humans. The advent of induced pluripotent stem cells means that it may ultimately be possible to develop personalized toxicology to determine interindividual susceptibility to adverse drug reactions. However, the complexity of idiosyncratic drug-induced liver injury means that no current single-cell model, whether of primary liver tissue origin, from liver cell lines, or derived from stem cells, adequately emulates what is believed to occur during human drug-induced liver injury. Nevertheless, a single-cell model of a human hepatocyte which emulates key features of a hepatocyte is likely to be valuable in assessing potential chemical risk; furthermore, understanding how to generate a relevant hepatocyte will also be critical to efforts to build complex multicellular models of the liver. Currently, hepatocyte-like cells differentiated from stem cells still fall short of recapitulating the full mature hepatocellular phenotype. Therefore, we convened a number of experts from the areas of preclinical and clinical hepatotoxicity and safety assessment, from industry, academia, and regulatory bodies, to specifically explore the application of stem cells in hepatotoxicity safety assessment and to make recommendations for the way forward. In this short review, we particularly discuss the importance of benchmarking stem cell-derived hepatocyte-like cells to their terminally differentiated human counterparts using defined phenotyping, to make sure the cells are relevant and comparable between labs, and outline why this process is essential before the cells are introduced into chemical safety assessment. (Hepatology 2017;65:710-721). © 2016 by the American Association for the Study of Liver Diseases.

  13. On the monitoring and implications of growing damages caused by manufacturing defects in composite structures

    NASA Astrophysics Data System (ADS)

    Schagerl, M.; Viechtbauer, C.; Hörrmann, S.

    2015-07-01

    Damage tolerance is a classical safety concept for the design of aircraft structures. Basically, this approach considers possible damages in the structure, predicts the damage growth under applied loading conditions and predicts the following decrease of the structural strength. As a fundamental result the damage tolerance approach yields the maximum inspection interval, which is the time a damage grows from a detectable to a critical level. The above formulation of the damage tolerance safety concept targets on metallic structures where the damage is typically a simple fatigue crack. Fiber-reinforced polymers show a much more complex damage behavior, such as delaminationsin laminated composites. Moreover, progressive damage in composites is often initiated by manufacturing defects. The complex manufacturing processes for composite structures almost certainly yield parts with defects, e.g. pores in the matrix or undulations of fibers. From such defects growing damages may start after a certain time of operation. The demand to simplify or even avoid the inspection of composite structures has therefore led to a comeback of the traditional safe-life safety concept. The aim of the so-called safe-life flaw tolerance concept is a structure that is capable of carrying the static loads during operation, despite significant damages and after a representative fatigue load spectrum. A structure with this property does not need to be inspected, respectively monitored at all during its service life. However, its load carrying capability is thereby not fully utilized. This article presents the possible refinement of the state-of-the-art safe-life flaw tolerance concept for composite structures towards a damage tolerance approach considering also the influence of manufacturing defects on damage initiation and growth. Based on fundamental physical relations and experimental observations the challenges when developing damage growth and residual strength curves are discussed.

  14. A critical care network pressure ulcer prevention quality improvement project.

    PubMed

    McBride, Joanna; Richardson, Annette

    2015-03-30

    Pressure ulcer prevention is an important safety issue, often underrated and an extremely painful event harming patients. Critically ill patients are one of the highest risk groups in hospital. The impact of pressure ulcers are wide ranging, and they can result in increased critical care and the hospital length of stay, significant interference with functional recovery and rehabilitation and increase cost. This quality improvement project had four aims: (1) to establish a critical care network pressure ulcer prevention group; (2) to establish baseline pressure ulcer prevention practices; (3) to measure, compare and monitor pressure ulcers prevalence; (4) to develop network pressure ulcer prevention standards. The approach used to improve quality included strong critical care nursing leadership to develop a cross-organisational pressure ulcer prevention group and a benchmarking exercise of current practices across a well-established critical care Network in the North of England. The National Safety Thermometer tool was used to measure pressure ulcer prevalence in 23 critical care units, and best available evidence, local consensus and another Critical Care Networks' bundle of interventions were used to develop a local pressure ulcer prevention standards document. The aims of the quality improvement project were achieved. This project was driven by successful leadership and had an agreed common goal. The National Safety Thermometer tool was an innovative approach to measure and compare pressure ulcer prevalence rates at a regional level. A limitation was the exclusion of moisture lesions. The project showed excellent engagement and collaborate working in the quest to prevent pressure ulcers from many critical care nurses with the North of England Critical Care Network. A concise set of Network standards was developed for use in conjunction with local guidelines to enhance pressure ulcer prevention. © 2015 British Association of Critical Care Nurses.

  15. Confirming criticality safety of TRU waste with neutron measurements and risk analyses

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Winn, W.G.; Hochel, R.D.

    1992-04-01

    The criticality safety of {sup 239}Pu in 55-gallon drums stored in TRU waste containers (culverts) is confirmed using NDA neutron measurements and risk analyses. The neutron measurements yield a {sup 239}Pu mass and k{sub eff} for a culvert, which contains up to 14 drums. Conservative probabilistic risk analyses were developed for both drums and culverts. Overall {sup 239}Pu mass estimates are less than a calculated safety limit of 2800 g per culvert. The largest measured k{sub eff} is 0.904. The largest probability for a critical drum is 6.9 {times} 10{sup {minus}8} and that for a culvert is 1.72 {times} 10{supmore » {minus}7}. All examined suspect culverts, totaling 118 in number, are appraised as safe based on these observations.« less

  16. ESAS Deliverable PS 1.1.2.3: Customer Survey on Code Generations in Safety-Critical Applications

    NASA Technical Reports Server (NTRS)

    Schumann, Johann; Denney, Ewen

    2006-01-01

    Automated code generators (ACG) are tools that convert a (higher-level) model of a software (sub-)system into executable code without the necessity for a developer to actually implement the code. Although both commercially supported and in-house tools have been used in many industrial applications, little data exists on how these tools are used in safety-critical domains (e.g., spacecraft, aircraft, automotive, nuclear). The aims of the survey, therefore, were threefold: 1) to determine if code generation is primarily used as a tool for prototyping, including design exploration and simulation, or for fiight/production code; 2) to determine the verification issues with code generators relating, in particular, to qualification and certification in safety-critical domains; and 3) to determine perceived gaps in functionality of existing tools.

  17. Apollo Spacecraft and Saturn V Launch Vehicle Pyrotechnics/Explosive Devices

    NASA Technical Reports Server (NTRS)

    Interbartolo, Michael

    2009-01-01

    The Apollo Mission employs more than 210 pyrotechnic devices per mission.These devices are either automatic of commanded from the Apollo spacecraft systems. All devices require high reliability and safety and most are classified as either crew safety critical or mission critical. Pyrotechnic devices have a wide variety of applications including: launch escape tower separation, separation rocket ignition, parachute deployment and release and electrical circuit opening and closing. This viewgraph presentation identifies critical performance, design requirements and safety measures used to ensure quality, reliability and performance of Apollo pyrotechnic/explosive devices. The major components and functions of a typical Apollo pyrotechnic/explosive device are listed and described (initiators, cartridge assemblies, detonators, core charges). The presentation also identifies the major locations and uses for the devices on: the Command and Service Module, Lunar Module and all stages of the launch vehicle.

  18. Does the concept of safety culture help or hinder systems thinking in safety?

    PubMed

    Reiman, Teemu; Rollenhagen, Carl

    2014-07-01

    The concept of safety culture has become established in safety management applications in all major safety-critical domains. The idea that safety culture somehow represents a "systemic view" on safety is seldom explicitly spoken out, but nevertheless seem to linger behind many safety culture discourses. However, in this paper we argue that the "new" contribution to safety management from safety culture never really became integrated with classical engineering principles and concepts. This integration would have been necessary for the development of a more genuine systems-oriented view on safety; e.g. a conception of safety in which human, technological, organisational and cultural factors are understood as mutually interacting elements. Without of this integration, researchers and the users of the various tools and methods associated with safety culture have sometimes fostered a belief that "safety culture" in fact represents such a systemic view about safety. This belief is, however, not backed up by theoretical or empirical evidence. It is true that safety culture, at least in some sense, represents a holistic term-a totality of factors that include human, organisational and technological aspects. However, the departure for such safety culture models is still human and organisational factors rather than technology (or safety) itself. The aim of this paper is to critically review the various uses of the concept of safety culture as representing a systemic view on safety. The article will take a look at the concepts of culture and safety culture based on previous studies, and outlines in more detail the theoretical challenges in safety culture as a systems concept. The paper also presents recommendations on how to make safety culture more systemic. Copyright © 2013 Elsevier Ltd. All rights reserved.

  19. The Critical Mass Laboratory at Rocky Flats

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Rothe, Robert E

    2003-10-15

    The Critical Mass Laboratory (CML) at Rocky Flats northwest of Denver, Colorado, was built in 1964 and commissioned to conduct nuclear experiments on January 28, 1965. It was built to attain more accurate and precise experimental data to ensure nuclear criticality safety at the plant than were previously possible. Prior to its construction, safety data were obtained from long extrapolations of subcritical data (called in situ experiments), calculated parameters from reactor engineering 'models', and a few other imprecise methods. About 1700 critical and critical-approach experiments involving several chemical forms of enriched uranium and plutonium were performed between then and 1988.more » These experiments included single units and arrays of fissile materials, reflected and 'bare' systems, and configurations with various degrees of moderation, as well as some containing strong neutron absorbers. In 1989, a raid by the Federal Bureau of Investigation (FBI) caused the plant as a whole to focus on 'resumption' instead of further criticality safety experiments. Though either not recognized or not admitted for a few years, that FBI raid did sound the death knell for the CML. The plant's optimistic goal of resumption evolved to one of deactivation, decommissioning, and plantwide demolition during the 1990s. The once-proud CML facility was finally demolished in April of 2002.« less

  20. Safety Sufficiency for NextGen: Assessment of Selected Existing Safety Methods, Tools, Processes, and Regulations

    NASA Technical Reports Server (NTRS)

    Xu, Xidong; Ulrey, Mike L.; Brown, John A.; Mast, James; Lapis, Mary B.

    2013-01-01

    NextGen is a complex socio-technical system and, in many ways, it is expected to be more complex than the current system. It is vital to assess the safety impact of the NextGen elements (technologies, systems, and procedures) in a rigorous and systematic way and to ensure that they do not compromise safety. In this study, the NextGen elements in the form of Operational Improvements (OIs), Enablers, Research Activities, Development Activities, and Policy Issues were identified. The overall hazard situation in NextGen was outlined; a high-level hazard analysis was conducted with respect to multiple elements in a representative NextGen OI known as OI-0349 (Automation Support for Separation Management); and the hazards resulting from the highly dynamic complexity involved in an OI-0349 scenario were illustrated. A selected but representative set of the existing safety methods, tools, processes, and regulations was then reviewed and analyzed regarding whether they are sufficient to assess safety in the elements of that OI and ensure that safety will not be compromised and whether they might incur intolerably high costs.

  1. Identification of Core Competencies for an Undergraduate Food Safety Curriculum Using a Modified Delphi Approach

    ERIC Educational Resources Information Center

    Johnston, Lynette M.; Wiedmann, Martin; Orta-Ramirez, Alicia; Oliver, Haley F.; Nightingale, Kendra K.; Moore, Christina M.; Stevenson, Clinton D.; Jaykus, Lee-Ann

    2014-01-01

    Identification of core competencies for undergraduates in food safety is critical to assure courses and curricula are appropriate in maintaining a well-qualified food safety workforce. The purpose of this study was to identify and refine core competencies relevant to postsecondary food safety education using a modified Delphi method. Twenty-nine…

  2. Development of a generalized perturbation theory method for sensitivity analysis using continuous-energy Monte Carlo methods

    DOE PAGES

    Perfetti, Christopher M.; Rearden, Bradley T.

    2016-03-01

    The sensitivity and uncertainty analysis tools of the ORNL SCALE nuclear modeling and simulation code system that have been developed over the last decade have proven indispensable for numerous application and design studies for nuclear criticality safety and reactor physics. SCALE contains tools for analyzing the uncertainty in the eigenvalue of critical systems, but cannot quantify uncertainty in important neutronic parameters such as multigroup cross sections, fuel fission rates, activation rates, and neutron fluence rates with realistic three-dimensional Monte Carlo simulations. A more complete understanding of the sources of uncertainty in these design-limiting parameters could lead to improvements in processmore » optimization, reactor safety, and help inform regulators when setting operational safety margins. A novel approach for calculating eigenvalue sensitivity coefficients, known as the CLUTCH method, was recently explored as academic research and has been found to accurately and rapidly calculate sensitivity coefficients in criticality safety applications. The work presented here describes a new method, known as the GEAR-MC method, which extends the CLUTCH theory for calculating eigenvalue sensitivity coefficients to enable sensitivity coefficient calculations and uncertainty analysis for a generalized set of neutronic responses using high-fidelity continuous-energy Monte Carlo calculations. Here, several criticality safety systems were examined to demonstrate proof of principle for the GEAR-MC method, and GEAR-MC was seen to produce response sensitivity coefficients that agreed well with reference direct perturbation sensitivity coefficients.« less

  3. Systematic review of safety and tolerability of a complex micronutrient formula used in mental health.

    PubMed

    Simpson, J Steven A; Crawford, Susan G; Goldstein, Estelle T; Field, Catherine; Burgess, Ellen; Kaplan, Bonnie J

    2011-04-18

    Theoretically, consumption of complex, multinutrient formulations of vitamins and minerals should be safe, as most preparations contain primarily the nutrients that have been in the human diet for millennia, and at safe levels as defined by the Dietary Reference Intakes. However, the safety profile of commercial formulae may differ from foods because of the amounts and combinations of nutrients they contain. As these complex formulae are being studied and used clinically with increasing frequency, there is a need for direct evaluation of safety and tolerability. All known safety and tolerability data collected on one complex nutrient formula was compiled and evaluated. Data were assembled from all the known published and unpublished studies for the complex formula with the largest amount of published research in mental health. Biological safety data from 144 children and adults were available from six sources: there were no occurrences of clinically meaningful negative outcomes/effects or abnormal blood tests that could be attributed to toxicity. Adverse event (AE) information from 157 children and adults was available from six studies employing the current version of this formula, and only minor, transitory reports of headache and nausea emerged. Only one of the studies permitted a direct comparison between micronutrient treatment and medication: none of the 88 pediatric and adult participants had any clinically meaningful abnormal laboratory values, but tolerability data in the group treated with micronutrients revealed significantly fewer AEs and less weight gain. This compilation of safety and tolerability data is reassuring with respect to the broad spectrum approach that employs complex nutrient formulae as a primary treatment.

  4. Defense Contract Management Agency Santa Ana Quality Assurance Oversight Needs lmprovement

    DTIC Science & Technology

    2013-04-19

    Management Agency Santa Ana Quality Assurance Oversight Needs Improvement What We Did We determined whether the Defense Contract Management Agency (DCMA...for critical safety items (CSIs). For this audit, we reviewed QA oversight of four contracts valued at about $278 million. What We Found The DCMA...limited assurance that 18,507 critical safety items, consisting of T-11 parachutes, oxygen masks, drone parachutes, and breathing apparatuses met

  5. Security for safety critical space borne systems

    NASA Technical Reports Server (NTRS)

    Legrand, Sue

    1987-01-01

    The Space Station contains safety critical computer software components in systems that can affect life and vital property. These components require a multilevel secure system that provides dynamic access control of the data and processes involved. A study is under way to define requirements for a security model providing access control through level B3 of the Orange Book. The model will be prototyped at NASA-Johnson Space Center.

  6. Nuclear and chemical safety analysis: Purex Plant 1970 thorium campaign

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Boldt, A.L.; Oberg, G.C.

    The purpose of this document is to discuss the flowsheet and the related processing equipment with respect to nuclear and chemical safety. The analyses presented are based on equipment utilization and revised piping as outlined in the design criteria. Processing of thorium and uranium-233 in the Purex Plant can be accomplished within currently accepted levels of risk with respect to chemical and nuclear safety if minor instrumentation changes are made. Uranium-233 processing is limited to a rate of about 670 grams per hour by equipment capacities and criticality safety considerations. The major criticality prevention problems result from the potential accumulationmore » of uranium-233 in a solvent phase in E-H4 (ICU concentrator), TK-J1 (IUC receiver), and TK-J21 (2AF pump tank). The same potential problems exist in TK-J5 (3AF pump tank) and TK-N1 (3BU receiver), but the probabilities of reaching a critical condition are not as great. In order to prevent the excessive accumulation of uranium-233 in any of these vessels by an extraction mechanism, it is necessary to maintain the uranium-233 and salting agent concentrations below the point at which a critical concentration of uranium-233 could be reached in a solvent phase.« less

  7. Water Ingress Testing of the Turbula Jar and U-233 Lead Pig Containers

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Reeves, Kirk Patrick; Karns, Tristan; Smith, Paul Herrick

    Understanding the water ingress behavior of containers used at the TA-55 Plutonium Facility has significant implications for criticality safety. The purpose of this report is to document the water ingress behavior of the Turbula Jar with Bakelite lid and Viton gaskets (Turbula Jar) used in oxide blending operations and the U-233 lead pig container used to store and transport U-233 material. The technical basis for water resistant containers at TA-55 is described in LA-UR-15-22781, “Water Resistant Container Technical Basis Document for the TA-55 Criticality Safety Program.” Testing of the water ingress behavior of various containers is described in LA-CP-13-00695, “Watermore » Penetration Tests on the Filters of Hagan and SAVY Containers,” LA-UR-15-23121, “Water Ingress into Crimped Convenience Containers under Flooding Conditions,” and in LA-UR- 16-2411, “Water Ingress Testing for TA-55 Containers.” Water ingress criteria are defined in TA55-AP-522 “TA-55 Criticality Safety Program”, and in PA-RD-01009 “TA55 Criticality Safety Requirements.” The water ingress criteria for submersion is no more than 50 ml of water ingress at a 6” water column height for a period of 2 hours.« less

  8. An assessment of commercial motor vehicle driver distraction using naturalistic driving data.

    PubMed

    Hickman, Jeffrey S; Hanowski, Richard J

    2012-01-01

    This study analyzed naturalistic driving data from commercial trucks (3-axle and tractor-trailer/tanker) and buses (transit and motorcoach) during a 3-month period. The data set contained 183 commercial truck and bus fleets comprising 13,306 vehicles and included 1085 crashes, 8375 near crashes, 30,661 crash-relevant conflicts, and 211,171 baseline events. Study results documented the prevalence of tertiary tasks and the risks associated with performing these tasks while driving. Results indicated the odds of involvement in a safety-critical event differed as a function of performing different cell phone-related subtasks while driving. Although the odds ratio for talking/listening on a cell phone while driving was found to not significantly increase the likelihood of involvement in a safety-critical event, other cell phone subtasks (e.g., texting, dialing, reaching) were found to significantly increase the odds of involvement in a safety-critical event. The results suggest that cell phone use while driving should not be considered a simple dichotomous task (yes/no). Consideration should instead be made for a set of discrete cell phone subtasks that are each associated with varying levels of risk. Several hypotheses are presented to explain why cell phone use while driving was found to not increase the likelihood of involvement in a safety-critical event.

  9. Formal Verification of Complex Systems based on SysML Functional Requirements

    DTIC Science & Technology

    2014-12-23

    Formal Verification of Complex Systems based on SysML Functional Requirements Hoda Mehrpouyan1, Irem Y. Tumer2, Chris Hoyle2, Dimitra Giannakopoulou3...requirements for design of complex engineered systems. The proposed ap- proach combines a SysML modeling approach to document and structure safety requirements...methods and tools to support the integration of safety into the design solution. 2.1. SysML for Complex Engineered Systems Traditional methods and tools

  10. Development of a highway safety fundamental course.

    DOT National Transportation Integrated Search

    2015-05-01

    Although the need for road safety education was first recognized in the 1960s, it has become an increasingly urgent issue : in recent years. To fulfill the hefty goal set up by the AASHTO Highway Safety Strategy and by state DOTS, it is critical : to...

  11. 29 CFR 1910.67 - Vehicle-mounted elevating and rotating work platforms.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ....67 Section 1910.67 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR OCCUPATIONAL SAFETY AND HEALTH STANDARDS Powered Platforms, Manlifts, and...) Bursting safety factor. All critical hydraulic and pneumatic components shall comply with the provisions of...

  12. Introduction to HACCP.

    USDA-ARS?s Scientific Manuscript database

    The Hazard Analysis and Critical Control Point (HACCP) food safety inspection program is utilized by both USDA Food Safety Inspection Service (FSIS) and FDA for many of the products they regulate. This science-based program was implemented by the USDA FSIS to enhance the food safety of meat and pou...

  13. Application of the SCALE TSUNAMI Tools for the Validation of Criticality Safety Calculations Involving 233U

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Mueller, Don; Rearden, Bradley T; Hollenbach, Daniel F

    2009-02-01

    The Radiochemical Development Facility at Oak Ridge National Laboratory has been storing solid materials containing 233U for decades. Preparations are under way to process these materials into a form that is inherently safe from a nuclear criticality safety perspective. This will be accomplished by down-blending the {sup 233}U materials with depleted or natural uranium. At the request of the U.S. Department of Energy, a study has been performed using the SCALE sensitivity and uncertainty analysis tools to demonstrate how these tools could be used to validate nuclear criticality safety calculations of selected process and storage configurations. ISOTEK nuclear criticality safetymore » staff provided four models that are representative of the criticality safety calculations for which validation will be needed. The SCALE TSUNAMI-1D and TSUNAMI-3D sequences were used to generate energy-dependent k{sub eff} sensitivity profiles for each nuclide and reaction present in the four safety analysis models, also referred to as the applications, and in a large set of critical experiments. The SCALE TSUNAMI-IP module was used together with the sensitivity profiles and the cross-section uncertainty data contained in the SCALE covariance data files to propagate the cross-section uncertainties ({Delta}{sigma}/{sigma}) to k{sub eff} uncertainties ({Delta}k/k) for each application model. The SCALE TSUNAMI-IP module was also used to evaluate the similarity of each of the 672 critical experiments with each application. Results of the uncertainty analysis and similarity assessment are presented in this report. A total of 142 experiments were judged to be similar to application 1, and 68 experiments were judged to be similar to application 2. None of the 672 experiments were judged to be adequately similar to applications 3 and 4. Discussion of the uncertainty analysis and similarity assessment is provided for each of the four applications. Example upper subcritical limits (USLs) were generated for application 1 based on trending of the energy of average lethargy of neutrons causing fission, trending of the TSUNAMI similarity parameters, and use of data adjustment techniques.« less

  14. 14 CFR 35.16 - Propeller critical parts.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 14 Aeronautics and Space 1 2014-01-01 2014-01-01 false Propeller critical parts. 35.16 Section 35... AIRWORTHINESS STANDARDS: PROPELLERS Design and Construction § 35.16 Propeller critical parts. The integrity of each propeller critical part identified by the safety analysis required by § 35.15 must be established...

  15. A Process-Centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement

    DTIC Science & Technology

    2005-01-01

    next patient safety steps in individual health care organizations. The low priority given to Category 3 (Focus on patients , other customers , and...presents a patient safety applicator tool for implementing and assessing patient safety systems in health care institutions. The applicator tool consists...the survey rounds. The study addressed three research questions: 1. What critical processes should be included in health care patient safety systems

  16. Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons from other parts of the public sector?

    PubMed

    Ocloo, Josephine E; Fulop, Naomi J

    2012-12-01

    There has been considerable momentum within the NHS over the last 10 years to develop greater patient and public involvement (PPI). This commitment has been reflected in numerous policy initiatives. In patient safety, the drive to increase involvement has increasingly been seen as an important way of building a safety culture. Evidence suggests, however, that progress has been slow and even more variable than in health care generally. Given this context, the paper analyses some of the key underlying drivers for involvement in the wider context of health and social care and makes some suggestions on what lessons can be learned for developing the PPI agenda in patient safety. To develop PPI further, it is argued that a greater understanding is needed of the contested nature of involvement in patient safety and how this has similarities to the emergence of user involvement in other parts of the public services. This understanding has led to the development of a range of critical theories to guide involvement that also make more explicit the underlying factors that support and hinder involvement processes, often related to power inequities and control. Achieving greater PPI in patient safety is therefore seen to require a more critical framework for understanding processes of involvement that can also help guide and evaluate involvement practices. © 2011 Blackwell Publishing Ltd.

  17. Biosimilars--global issues, national solutions.

    PubMed

    Knezevic, Ivana; Griffiths, Elwyn

    2011-09-01

    Biotechnology derived medicinal products are presently the best characterized biologicals with considerable production and clinical experience, and have revolutionized the treatment of some of the most difficult-to-treat diseases, prolonging and improving the quality of life and patient care. They are also currently one of the fastest growing segments of the pharmaceutical industry market. The critical challenge that the biopharmaceutical industry is facing is the expiry of patents for the first generation of biopharmaceuticals, mainly recombinant DNA derived products, such as interferons, growth hormone and erythropoetin. The question that immediately arose was how should such copies of the originator products be licensed, bearing in mind that they are highly complex biological molecules produced by equally complex biological production processes with their inherent problem of biological variability. Copying biologicals is much more complex than copying small molecules and the critical issue was how to handle the licensing of products if relying in part on data from an innovator product. Since 2004 there has been considerable international consultation on how to deal with biosimilars and biological copy products. This has led to a better understanding of the challenges in the regulatory evaluation of the quality, safety and efficacy of "biosimilars", to the exchange of information between regulators, as well as to the identification of key issues. The aim of this article is to provide a brief overview of the scientific and regulatory challenges faced in developing and evaluating similar biotherapeutic products for global use. It is intended as an introduction to the series of articles in this special issue of Biologicals devoted to similar biotherapeutic products. Copyright © 2011. Published by Elsevier Ltd.

  18. 78 FR 11737 - Improving Critical Infrastructure Cybersecurity

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-19

    ... of America, it is hereby ordered as follows: Section 1. Policy. Repeated cyber intrusions into critical infrastructure demonstrate the need for improved cybersecurity. The cyber threat to critical... cyber environment that encourages efficiency, innovation, and economic prosperity while promoting safety...

  19. A tailored online safety and health intervention for women experiencing intimate partner violence: the iCAN Plan 4 Safety randomized controlled trial protocol.

    PubMed

    Ford-Gilboe, Marilyn; Varcoe, Colleen; Scott-Storey, Kelly; Wuest, Judith; Case, James; Currie, Leanne M; Glass, Nancy; Hodgins, Marilyn; MacMillan, Harriet; Perrin, Nancy; Wathen, C Nadine

    2017-03-21

    Intimate partner violence (IPV) threatens the safety and health of women worldwide. Safety planning is a widely recommended, evidence-based intervention for women experiencing IPV, yet fewer than 1 in 5 Canadian women access safety planning through domestic violence services. Rural, Indigenous, racialized, and immigrant women, those who prioritize their privacy, and/or women who have partners other than men, face unique safety risks and access barriers. Online IPV interventions tailored to the unique features of women's lives, and to maximize choice and control, have potential to reduce access barriers, and improve fit and inclusiveness, maximizing effectiveness of these interventions for diverse groups. In this double blind randomized controlled trial, 450 Canadian women who have experienced IPV in the previous 6 months will be randomized to either a tailored, interactive online safety and health intervention (iCAN Plan 4 Safety) or general online safety information (usual care). iCAN engages women in activities designed to increase their awareness of safety risks, reflect on their plans for their relationships and priorities, and create a personalize action plan of strategies and resources for addressing their safety and health concerns. Self-reported outcome measures will be collected at baseline and 3, 6, and 12 months post-baseline. Primary outcomes are depressive symptoms (Center for Epidemiological Studies Depression Scale, Revised) and PTSD Symptoms (PTSD Checklist, Civilian Version). Secondary outcomes include helpful safety actions, safety planning self-efficacy, mastery, and decisional conflict. In-depth qualitative interviews with approximately 60 women who have completed the trial and website utilization data will be used to explore women's engagement with the intervention and processes of change. This trial will contribute timely evidence about the effectiveness of online safety and health interventions appropriate for diverse life contexts. If effective, iCAN could be readily adopted by health and social services and/or accessed by women to work through options independently. This study will produce contextualized knowledge about how women engage with the intervention; its strengths and weaknesses; whether specific groups benefit more than others; and the processes explaining any positive outcomes. Such information is critical for effective scale up of any complex intervention. Clinicaltrials.gov ID NCT02258841 (Registered on Oct 2, 2014).

  20. A Virtual Laboratory for Aviation and Airspace Prognostics Research

    NASA Technical Reports Server (NTRS)

    Kulkarni, Chetan; Gorospe, George; Teubert, Christ; Quach, Cuong C.; Hogge, Edward; Darafsheh, Kaveh

    2017-01-01

    Integration of Unmanned Aerial Vehicles (UAVs), autonomy, spacecraft, and other aviation technologies, in the airspace is becoming more and more complicated, and will continue to do so in the future. Inclusion of new technology and complexity into the airspace increases the importance and difficulty of safety assurance. Additionally, testing new technologies on complex aviation systems and systems of systems can be challenging, expensive, and at times unsafe when implementing real life scenarios. The application of prognostics to aviation and airspace management may produce new tools and insight into these problems. Prognostic methodology provides an estimate of the health and risks of a component, vehicle, or airspace and knowledge of how that will change over time. That measure is especially useful in safety determination, mission planning, and maintenance scheduling. In our research, we develop a live, distributed, hardware- in-the-loop Prognostics Virtual Laboratory testbed for aviation and airspace prognostics. The developed testbed will be used to validate prediction algorithms for the real-time safety monitoring of the National Airspace System (NAS) and the prediction of unsafe events. In our earlier work1 we discussed the initial Prognostics Virtual Laboratory testbed development work and related results for milestones 1 & 2. This paper describes the design, development, and testing of the integrated tested which are part of milestone 3, along with our next steps for validation of this work. Through a framework consisting of software/hardware modules and associated interface clients, the distributed testbed enables safe, accurate, and inexpensive experimentation and research into airspace and vehicle prognosis that would not have been possible otherwise. The testbed modules can be used cohesively to construct complex and relevant airspace scenarios for research. Four modules are key to this research: the virtual aircraft module which uses the X-Plane simulator and X-PlaneConnect toolbox, the live aircraft module which connects fielded aircraft using onboard cellular communications devices, the hardware in the loop (HITL) module which connects laboratory based bench-top hardware testbeds and the research module which contains diagnostics and prognostics tools for analysis of live air traffic situations and vehicle health conditions. The testbed also features other modules for data recording and playback, information visualization, and air traffic generation. Software reliability, safety, and latency are some of the critical design considerations in development of the testbed.

  1. The potential risk of communication media in conveying critical information in the aircraft maintenance organisation: a case study

    NASA Astrophysics Data System (ADS)

    Shukri, S. Ahmad; Millar, R. M.; Gratton, G.; Garner, M.

    2016-10-01

    In the world of aircraft maintenance organisation, verbal and written communication plays a pivotal role in transferring critical information in relation to aircraft safety and efficiency. The communication media used to convey the critical information between departments at an aircraft maintenance organisation have potential risk in misunderstanding of the information. In this study, technical and non-technical personnel from five different departments at an aircraft maintenance organisation were interviewed on the communication media they normally utilised to communicate six different work procedures that are closely related to aircraft safety and efficiency. This is to discover which communication media pose higher risk in misunderstanding critical information. The findings reveal that written communication pose higher risk of misinterpretation compared with verbal communication when conveying critical information between departments.

  2. Structural Element Testing in Support of the Design of the NASA Composite Crew Module

    NASA Technical Reports Server (NTRS)

    Kellas, Sotiris; Jackson, Wade C.; Thesken, John C.; Schleicher, Eric; Wagner, Perry; Kirsch, Michael T.

    2012-01-01

    In January 2007, the NASA Administrator and Associate Administrator for the Exploration Systems Mission Directorate chartered the NASA Engineering and Safety Center (NESC) to design, build, and test a full-scale Composite Crew Module (CCM). For the design and manufacturing of the CCM, the team adopted the building block approach where design and manufacturing risks were mitigated through manufacturing trials and structural testing at various levels of complexity. Following NASA's Structural Design Verification Requirements, a further objective was the verification of design analysis methods and the provision of design data for critical structural features. Test articles increasing in complexity from basic material characterization coupons through structural feature elements and large structural components, to full-scale structures were evaluated. This paper discusses only four elements tests three of which include joints and one that includes a tapering honeycomb core detail. For each test series included are specimen details, instrumentation, test results, a brief analysis description, test analysis correlation and conclusions.

  3. Applying Formal Methods to NASA Projects: Transition from Research to Practice

    NASA Technical Reports Server (NTRS)

    Othon, Bill

    2009-01-01

    NASA project managers attempt to manage risk by relying on mature, well-understood process and technology when designing spacecraft. In the case of crewed systems, the margin for error is even tighter and leads to risk aversion. But as we look to future missions to the Moon and Mars, the complexity of the systems will increase as the spacecraft and crew work together with less reliance on Earth-based support. NASA will be forced to look for new ways to do business. Formal methods technologies can help NASA develop complex but cost effective spacecraft in many domains, including requirements and design, software development and inspection, and verification and validation of vehicle subsystems. To realize these gains, the technologies must be matured and field-tested so that they are proven when needed. During this discussion, current activities used to evaluate FM technologies for Orion spacecraft design will be reviewed. Also, suggestions will be made to demonstrate value to current designers, and mature the technology for eventual use in safety-critical NASA missions.

  4. Neutralization and clearance of GM-CSF by autoantibodies in pulmonary alveolar proteinosis

    PubMed Central

    Piccoli, Luca; Campo, Ilaria; Fregni, Chiara Silacci; Rodriguez, Blanca Maria Fernandez; Minola, Andrea; Sallusto, Federica; Luisetti, Maurizio; Corti, Davide; Lanzavecchia, Antonio

    2015-01-01

    Pulmonary alveolar proteinosis (PAP) is a severe autoimmune disease caused by autoantibodies that neutralize GM-CSF resulting in impaired function of alveolar macrophages. In this study, we characterize 21 GM-CSF autoantibodies from PAP patients and find that somatic mutations critically determine their specificity for the self-antigen. Individual antibodies only partially neutralize GM-CSF activity using an in vitro bioassay, depending on the experimental conditions, while, when injected in mice together with human GM-CSF, they lead to the accumulation of a large pool of circulating GM-CSF that remains partially bioavailable. In contrast, a combination of three non-cross-competing antibodies completely neutralizes GM-CSF activity in vitro by sequestering the cytokine in high-molecular-weight complexes, and in vivo promotes the rapid degradation of GM-CSF-containing immune complexes in an Fc-dependent manner. Taken together, these findings provide a plausible explanation for the severe phenotype of PAP patients and for the safety of treatments based on single anti-GM-CSF monoclonal antibodies. PMID:26077231

  5. A Novel Interdisciplinary Approach to Socio-Technical Complexity

    NASA Astrophysics Data System (ADS)

    Bassetti, Chiara

    The chapter presents a novel interdisciplinary approach that integrates micro-sociological analysis into computer-vision and pattern-recognition modeling and algorithms, the purpose being to tackle socio-technical complexity at a systemic yet micro-grounded level. The approach is empirically-grounded and both theoretically- and analytically-driven, yet systemic and multidimensional, semi-supervised and computable, and oriented towards large scale applications. The chapter describes the proposed approach especially as for its sociological foundations, and as applied to the analysis of a particular setting --i.e. sport-spectator crowds. Crowds, better defined as large gatherings, are almost ever-present in our societies, and capturing their dynamics is crucial. From social sciences to public safety management and emergency response, modeling and predicting large gatherings' presence and dynamics, thus possibly preventing critical situations and being able to properly react to them, is fundamental. This is where semi/automated technologies can make the difference. The work presented in this chapter is intended as a scientific step towards such an objective.

  6. Space and Time Partitioning with Hardware Support for Space Applications

    NASA Astrophysics Data System (ADS)

    Pinto, S.; Tavares, A.; Montenegro, S.

    2016-08-01

    Complex and critical systems like airplanes and spacecraft implement a very fast growing amount of functions. Typically, those systems were implemented with fully federated architectures, but the number and complexity of desired functions of todays systems led aerospace industry to follow another strategy. Integrated Modular Avionics (IMA) arose as an attractive approach for consolidation, by combining several applications into one single generic computing resource. Current approach goes towards higher integration provided by space and time partitioning (STP) of system virtualization. The problem is existent virtualization solutions are not ready to fully provide what the future of aerospace are demanding: performance, flexibility, safety, security while simultaneously containing Size, Weight, Power and Cost (SWaP-C).This work describes a real time hypervisor for space applications assisted by commercial off-the-shell (COTS) hardware. ARM TrustZone technology is exploited to implement a secure virtualization solution with low overhead and low memory footprint. This is demonstrated by running multiple guest partitions of RODOS operating system on a Xilinx Zynq platform.

  7. 76 FR 72997 - Railroad Safety Advisory Committee (RSAC); Working Group Activity Update

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-28

    ... equivalent in safety to equipment meeting the design standards in the Passenger Equipment Safety Standards..., locomotive alerters, and remote control locomotives. The group reached consensus regarding critical... employee and their railroad contractor and subcontractor equivalents, as required by RSIA. The group has...

  8. The principles of HACCP.

    USDA-ARS?s Scientific Manuscript database

    The Hazard Analysis and Critical Control Point (HACCP) food safety inspection program is utilized by both USDA Food Safety Inspection Service (FSIS) and FDA for many of the products they regulate. This science-based program was implemented by the USDA FSIS to enhance the food safety of meat and pou...

  9. Safety assessment for the postictal confusional phase following complex partial seizure.

    PubMed

    Tucker, C

    1985-06-01

    Misunderstanding of the postictal confusional state that follows the complex partial seizure has caused emotional and physical harm to patients. Concern about this phenomenon and its effects upon the patient prompted this study to explore, describe, and document one method of intervention to lessen these harmful effects. An evaluative descriptive research design was employed to assess patient safety during and after the postictal confusional phase following a complex partial seizure. A closed-structured questionnaire and participant observation were the methods used to collect data for this study. A Level of Safety Tool was specifically designed for this study.

  10. Packaging Strategies for Criticality Safety for "Other" DOE Fuels in a Repository

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Larry L Taylor

    2004-06-01

    Since 1998, there has been an ongoing effort to gain acceptance of U.S. Department of Energy (DOE)-owned spent nuclear fuel (SNF) in the national repository. To accomplish this goal, the fuel matrix was used as a discriminating feature to segregate fuels into nine distinct groups. From each of those groups, a characteristic fuel was selected and analyzed for criticality safety based on a proposed packaging strategy. This report identifies and quantifies the important criticality parameters for the canisterized fuels within each criticality group to: (1) demonstrate how the “other” fuels in the group are bounded by the baseline calculations ormore » (2) allow identification of individual type fuels that might require special analysis and packaging.« less

  11. Safety management of complex research operations

    NASA Technical Reports Server (NTRS)

    Brown, W. J.

    1981-01-01

    Complex research and technology operations present many varied potential hazards which must be addressed in a disciplined independent safety review and approval process. The research and technology effort at the Lewis Research Center is divided into programmatic areas of aeronautics, space and energy. Potential hazards vary from high energy fuels to hydrocarbon fuels, high pressure systems to high voltage systems, toxic chemicals to radioactive materials and high speed rotating machinery to high powered lasers. A Safety Permit System presently covers about 600 potentially hazardous operations. The Safety Management Program described in this paper is believed to be a major factor in maintaining an excellent safety record at the Lewis Research Center.

  12. Patterns of patient safety culture: a complexity and arts-informed project of knowledge translation.

    PubMed

    Mitchell, Gail J; Tregunno, Deborah; Gray, Julia; Ginsberg, Liane

    2011-01-01

    The purpose of this paper is to describe patterns of patient safety culture that emerged from an innovative collaboration among health services researchers and fine arts colleagues. The group engaged in an arts-informed knowledge translation project to produce a dramatic expression of patient safety culture research for inclusion in a symposium. Scholars have called for a deeper understanding of the complex interrelationships among structure, process and outcomes relating to patient safety. Four patterns of patient safety culture--blinding familiarity, unyielding determination, illusion of control and dismissive urgency--are described with respect to how they informed creation of an arts-informed project for knowledge translation.

  13. A simulation-optimization model for Stone column-supported embankment stability considering rainfall effect

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Deb, Kousik, E-mail: kousik@civil.iitkgp.ernet.in; Dhar, Anirban, E-mail: anirban@civil.iitkgp.ernet.in; Purohit, Sandip, E-mail: sandip.purohit91@gmail.com

    Landslide due to rainfall has been and continues to be one of the most important concerns of geotechnical engineering. The paper presents the variation of factor of safety of stone column-supported embankment constructed over soft soil due to change in water level for an incessant period of rainfall. A combined simulation-optimization based methodology has been proposed to predict the critical surface of failure of the embankment and to optimize the corresponding factor of safety under rainfall conditions using an evolutionary genetic algorithm NSGA-II (Non-Dominated Sorted Genetic Algorithm-II). It has been observed that the position of water table can be reliablymore » estimated with varying periods of infiltration using developed numerical method. The parametric study is presented to study the optimum factor of safety of the embankment and its corresponding critical failure surface under the steady-state infiltration condition. Results show that in case of floating stone columns, period of infiltration has no effect on factor of safety. Even critical failure surfaces for a particular floating column length remain same irrespective of rainfall duration.« less

  14. Safe separation distance score: A new metric for evaluating wildland firefighter safety zones using lidar

    Treesearch

    Michael J. Campbell; Philip E. Dennison; Bret W. Butler

    2016-01-01

    Safety zones are areas where firefighters can retreat to in order to avoid bodily harm when threatened by burnover or entrapment from wildland fire. At present, safety zones are primarily designated by firefighting personnel as part of daily fire management activities. Though critical to safety zone assessment, the effectiveness of this approach is inherently limited...

  15. Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

    PubMed

    McNab, Duncan; Bowie, Paul; Morrison, Jill; Ross, Alastair

    2016-11-01

    Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners' curriculum. Current methods that are taught and employed to improve safety often use a 'find-and-fix' approach to identify components of a system (including humans) where performance could be improved. However, the complex interactions and inter-dependence between components in healthcare systems mean that cause and effect are not always linked in a predictable manner. The Safety-II approach has been proposed as a new way to understand how safety is achieved in complex systems that may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and various ways to achieve success, dependent on work conditions, may be possible. Traditional approaches to improve the quality and safety of care often aim to constrain variability but understanding and managing variability may be a more beneficial approach. The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with 'traditional' methods to enhance patient safety training, outcomes and curriculum coverage.

  16. Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis

    PubMed Central

    2013-01-01

    Background This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety. Methods We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes. Results Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks. Conclusions Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile. PMID:24286376

  17. Criticality safety strategy for the Fuel Cycle Facility electrorefiner at Argonne National Laboratory, West

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Mariani, R.D.; Benedict, R.W.; Lell, R.M.

    1993-09-01

    The Integral Fast Reactor being developed by Argonne National Laboratory (ANL) combines the advantages of metal-fueled, liquid-metal-cooled reactors and a closed fuel cycle. Presently, the Fuel Cycle Facility (FCF) at ANL-West in Idaho Falls, Idaho is being modified to recycle spent metallic fuel from Experimental Breeder Reactor II as part of a demonstration project sponsored by the Department of Energy. A key component of the FCF is the electrorefiner (ER) in which the actinides are separated from the fission products. In the electrorefining process, the metal fuel is anodically dissolved into a high-temperature molten salt and refined uranium or uranium/plutoniummore » products are deposited at cathodes. In this report, the criticality safety strategy for the FCF ER is summarized. FCF ER operations and processes formed the basis for evaluating criticality safety and control during actinide metal fuel refining. In order to show criticality safety for the FCF ER, the reference operating conditions for the ER had to be defined. Normal operating envelopes (NOES) were then defined to bracket the important operating conditions. To keep the operating conditions within their NOES, process controls were identified that can be used to regulate the actinide forms and content within the ER. A series of operational checks were developed for each operation that wig verify the extent or success of an operation. The criticality analysis considered the ER operating conditions at their NOE values as the point of departure for credible and incredible failure modes. As a result of the analysis, FCF ER operations were found to be safe with respect to criticality.« less

  18. Implementation of a critical incident reporting system in a neurosurgical department.

    PubMed

    Kantelhardt, P; Müller, M; Giese, A; Rohde, V; Kantelhardt, S R

    2011-02-01

    Critical incident monitoring is an important tool for quality improvement and the maintenance of high safety standards. It was developed for aviation safety and is now widely accepted as a useful tool to reduce medical care-related morbidity and mortality. Despite this widespread acceptance, the literature has no reports on any neurosurgical applications of critical incident monitoring. We describe the introduction of a mono-institutional critical incident reporting system in a neurosurgical department. Furthermore, we have developed a formula to assess possible counterstrategies. All staff members of a neurosurgical department were advised to report critical incidents. The anonymous reporting form contained a box for the description of the incident, several multiple-choice questions on specific risk factors, place and reason for occurrence of the incident, severity of the consequences and suggested counterstrategies. The incident data was entered into an online documentation system (ADKA DokuPik) and evaluated by an external specialist. For data analysis we applied a modified assessment scheme initially designed for flight safety. Data collection was started in September 2008. The average number of reported incidents was 18 per month (currently 216 in total). Most incidents occurred on the neurosurgical ward (64%). Human error was involved in 86% of the reported incidents. The largest group of incidents consisted of medication-related problems. Accordingly, counterstrategies were developed, resulting in a decrease in the relative number of reported medication-related incidents from 42% (March 09) to 30% (September 09). Implementation of the critical incident reporting system presented no technical problems. The reporting rate was high compared to that reported in the current literature. The formulation, evaluation and introduction of specific counterstrategies to guard against selected groups of incidents may improve patient safety in neurosurgical departments. © Georg Thieme Verlag KG Stuttgart · New York.

  19. Critical review of controlled release packaging to improve food safety and quality.

    PubMed

    Chen, Xi; Chen, Mo; Xu, Chenyi; Yam, Kit L

    2018-03-19

    Controlled release packaging (CRP) is an innovative technology that uses the package to release active compounds in a controlled manner to improve safety and quality for a wide range of food products during storage. This paper provides a critical review of the uniqueness, design considerations, and research gaps of CRP, with a focus on the kinetics and mechanism of active compounds releasing from the package. Literature data and practical examples are presented to illustrate how CRP controls what active compounds to release, when and how to release, how much and how fast to release, in order to improve food safety and quality.

  20. Issues in Software System Safety: Polly Ann Smith Co. versus Ned I. Ludd

    NASA Technical Reports Server (NTRS)

    Holloway, C. Michael

    2002-01-01

    This paper is a work of fiction, but it is fiction with a very real purpose: to stimulate careful thought and friendly discussion about some questions for which thought is often careless and discussion is often unfriendly. To accomplish this purpose, the paper creates a fictional legal case. The most important issue in this fictional case is whether certain proffered expert testimony about software engineering for safety critical systems should be admitted. Resolving this issue requires deciding the extent to which current practices and research in software engineering, especially for safety-critical systems, can rightly be considered based on knowledge, rather than opinion.

  1. A review on on-board challenges of magnesium-based hydrogen storage materials for automobile applications

    NASA Astrophysics Data System (ADS)

    Rahman, Md. Wasikur

    2017-06-01

    The attempt of the review is to realize on-board hydrogen storage technologies concerning magnesium based solid-state matrix to allow fuel cell devices to facilitate sufficient storage capacity, cost, safety and performance requirements to be competitive with current vehicles. Hydrogen, a potential and clean fuel, can be applied in the state-of-the-art technology of `zero emission' vehicles. Hydrogen economy infrastructure both for stationary and mobile purposes is complicated due to its critical physico-chemical properties and materials play crucial roles in every stage of hydrogen production to utilization in fuel cells in achieving high conversion efficiency, safety and robustness of the technologies involved. Moreover, traditional hydrogen storage facilities are rather complicated due to its anomalous properties such as highly porous solids and polymers have intrinsic microporosity, which is the foremost favorable characteristics of fast kinetics and reversibility, but the major drawback is the low storage capacity. In contrast, metal hydrides and complex hydrides have high hydrogen storage capacity but thermodynamically unfavorable. Therefore, hydrogen storage is a real challenge to realize `hydrogen economy' that will solve the critical issues of humanity such as energy depletion, greenhouse emission, air pollution and ultimately climate change. Magnesium based materials, particularly magnesium hydride (MgH2) has been proposed as a potential hydrogen storage material due to its high gravimetric and volumetric capacity as well as environmentally benign properties to work the grand challenge out.

  2. 75 FR 81710 - Proposed Agency Information Collection Activities; Comment Request

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-28

    ... clearance by OMB as required by the PRA. Title: Safety Integration Plans. OMB Control Number: 2130-0557... for the development and implementation of safety integration plans (``SIPs'' or ``plans'') by a Class... affected railroads (Class Is and some Class IIs) address critical safety issues unique to the amalgamation...

  3. 3 CFR 8672 - Proclamation 8672 of May 9, 2011. National Building Safety Month, 2011

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... public and private sectors—to implement effective standards and codes that sustain safe and resilient structures. We need innovation and partnerships at all levels of society to develop transformative... Proclamation Building safety is a critical component of our homeland security, our personal and public safety...

  4. School Safety under NCLB's Unsafe School Choice Option

    ERIC Educational Resources Information Center

    Gastic, Billie; Gasiewski, Josephine Ann

    2008-01-01

    Despite its flaws, the USCO created the conditions for an unprecedented national statement on school safety. This study asks: How do states conceptualize school safety? While critics have denounced the dizzying assortment of states' persistently dangerous criteria, we argue that these differences have been grossly exaggerated. We contend that…

  5. 77 FR 18879 - Agency Information Collection Activities: Notice of Request for Approval of a New Information...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-28

    ... local agencies in improving safety on local roads is critical for reducing fatalities and serious..., prioritizing, developing, and implementing safety projects on local roads. The requested information collection... agencies for road safety improvement projects. The survey will also help identify challenges and barriers...

  6. A Critical Examination of Safety Texts: Implications for Trade and Industrial Education.

    ERIC Educational Resources Information Center

    Gregson, James A.

    1996-01-01

    Qualitative content analysis of three texts used to prepare trade and industrial teachers in occupational safety and health examined definitions of health/safety problems, allocation of responsibility, social context, and collective responsibility. Implementing practices from these texts could free teachers from responsibility for negligence and…

  7. 77 FR 26647 - National Building Safety Month, 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-04

    ... Building Safety Month, 2012 By the President of the United States of America A Proclamation In... to an America built to last, and during National Building Safety Month, we recommit to strengthening... critical role in making America safe, strong, and sustainable. This month, we celebrate their work, and we...

  8. PNNL Results from 2010 CALIBAN Criticality Accident Dosimeter Intercomparison Exercise

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Hill, Robin L.; Conrady, Matthew M.

    2011-10-28

    This document reports the results of the Hanford personnel nuclear accident dosimeter (PNAD) and fixed nuclear accident dosimeter (FNAD) during a criticality accident dosimeter intercomparison exercise at the CEA Valduc Center on September 20-23, 2010. Pacific Northwest National Laboratory (PNNL) participated in a criticality accident dosimeter intercomparison exercise at the Commissariat a Energie Atomique (CEA) Valduc Center near Dijon, France on September 20-23, 2010. The intercomparison exercise was funded by the U.S. Department of Energy, Nuclear Criticality Safety Program, with Lawrence Livermore National Laboratory as the lead Laboratory. PNNL was one of six invited DOE Laboratory participants. The other participatingmore » Laboratories were: Lawrence Livermore National Laboratory (LLNL), Los Alamos National Laboratory (LANL), Savannah River Site (SRS), the Y-12 National Security Complex at Oak Ridge, and Sandia National Laboratory (SNL). The goals of PNNL's participation in the intercomparison exercise were to test and validate the procedures and algorithm currently used for the Hanford personnel nuclear accident dosimeters (PNADs) on the metallic reactor, CALIBAN, to test exposures to PNADs from the side and from behind a phantom, and to test PNADs that were taken from a historical batch of Hanford PNADs that had varying degrees of degradation of the bare indium foil. Similar testing of the PNADs was done on the Valduc SILENE test reactor in 2009 (Hill and Conrady, 2010). The CALIBAN results are reported here.« less

  9. Impact of modeling Choices on Inventory and In-Cask Criticality Calculations for Forsmark 3 BWR Spent Fuel

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Martinez-Gonzalez, Jesus S.; Ade, Brian J.; Bowman, Stephen M.

    2015-01-01

    Simulation of boiling water reactor (BWR) fuel depletion poses a challenge for nuclide inventory validation and nuclear criticality safety analyses. This challenge is due to the complex operating conditions and assembly design heterogeneities that characterize these nuclear systems. Fuel depletion simulations and in-cask criticality calculations are affected by (1) completeness of design information, (2) variability of operating conditions needed for modeling purposes, and (3) possible modeling choices. These effects must be identified, quantified, and ranked according to their significance. This paper presents an investigation of BWR fuel depletion using a complete set of actual design specifications and detailed operational datamore » available for five operating cycles of the Swedish BWR Forsmark 3 reactor. The data includes detailed axial profiles of power, burnup, and void fraction in a very fine temporal mesh for a GE14 (10×10) fuel assembly. The specifications of this case can be used to assess the impacts of different modeling choices on inventory prediction and in-cask criticality, specifically regarding the key parameters that drive inventory and reactivity throughout fuel burnup. This study focused on the effects of the fidelity with which power history and void fraction distributions are modeled. The corresponding sensitivity of the reactivity in storage configurations is assessed, and the impacts of modeling choices on decay heat and inventory are addressed.« less

  10. Specialty-care access for community health clinic patients: processes and barriers

    PubMed Central

    Ezeonwu, Mabel C

    2018-01-01

    Introduction Community health clinics/centers (CHCs) comprise the US’s core health-safety net and provide primary care to anyone who walks through their doors. However, access to specialty care for CHC patients is a big challenge. Materials and methods In this descriptive qualitative study, semistructured interviews of 37 referral coordinators of CHCs were used to describe their perspectives on processes and barriers to patients’ access to specialty care. Analysis of data was done using content analysis. Results The process of coordinating care referrals for CHC patients is complex and begins with a provider’s order for consultation and ends when the referring provider receives the specialist’s note. Poverty, specialist and referral coordinator shortages, lack of insurance, insurance acceptability by providers, transport and clinic-location factors, lack of clinic–hospital affiliations, and poor communication between primary and specialty providers constitute critical barriers to specialty-care access for patients. Conclusion Understanding the complexities of specialty-care coordination processes and access helps determine the need for comprehensive and uninterrupted access to quality health care for vulnerable populations. Guaranteed access to primary care at CHCs has not translated into improved access to specialty care. It is critical that effective policies be pursued to address the barriers and minimize interruptions in care, and to ensure continuity of care for all patients needing specialty care. PMID:29503559

  11. Using Smart Pumps to Understand and Evaluate Clinician Practice Patterns to Ensure Patient Safety

    PubMed Central

    Mansfield, Jennifer; Jarrett, Steven

    2013-01-01

    Background: Safety software installed on intravenous (IV) infusion pumps has been shown to positively impact the quality of patient care through avoidance of medication errors. The data derived from the use of smart pumps are often overlooked, although these data provide helpful insight into the delivery of quality patient care. Objective: The objectives of this report are to describe the value of implementing IV infusion safety software and analyzing the data and reports generated by this system. Case study: Based on experience at the Carolinas HealthCare System (CHS), executive score cards provide an aggregate view of compliance rate, number of alerts, overrides, and edits. The report of serious errors averted (ie, critical catches) supplies the location, date, and time of the critical catch, thereby enabling management to pinpoint the end-user for educational purposes. By examining the number of critical catches, a return on investment may be calculated. Assuming 3,328 of these events each year, an estimated cost avoidance would be $29,120,000 per year for CHS. Other reports allow benchmarking between institutions. Conclusion: A review of the data about medication safety across CHS has helped garner support for a medication safety officer position with the goal of ultimately creating a safer environment for the patient. PMID:24474836

  12. Advancing a sociotechnical systems approach to workplace safety – developing the conceptual framework

    PubMed Central

    Carayon, Pascale; Hancock, Peter; Leveson, Nancy; Noy, Ian; Sznelwar, Laerte; van Hootegem, Geert

    2015-01-01

    Traditional efforts to deal with the enormous problem of workplace safety have proved insufficient, as they have tended to neglect the broader sociotechnical environment that surrounds workers. Here, we advocate a sociotechnical systems approach that describes the complex multi-level system factors that contribute to workplace safety. From the literature on sociotechnical systems, complex systems and safety, we develop a sociotechnical model of workplace safety with concentric layers of the work system, socio-organisational context and the external environment. The future challenges that are identified through the model are highlighted. Practitioner Summary: Understanding the environmental, organisational and work system factors that contribute to workplace safety will help to develop more effective and integrated solutions to deal with persistent workplace safety problems. Solutions to improve workplace safety need to recognise the broad sociotechnical system and the respective interactions between the system elements and levels. PMID:25831959

  13. Advancing a sociotechnical systems approach to workplace safety--developing the conceptual framework.

    PubMed

    Carayon, Pascale; Hancock, Peter; Leveson, Nancy; Noy, Ian; Sznelwar, Laerte; van Hootegem, Geert

    2015-01-01

    Traditional efforts to deal with the enormous problem of workplace safety have proved insufficient, as they have tended to neglect the broader sociotechnical environment that surrounds workers. Here, we advocate a sociotechnical systems approach that describes the complex multi-level system factors that contribute to workplace safety. From the literature on sociotechnical systems, complex systems and safety, we develop a sociotechnical model of workplace safety with concentric layers of the work system, socio-organisational context and the external environment. The future challenges that are identified through the model are highlighted. Understanding the environmental, organisational and work system factors that contribute to workplace safety will help to develop more effective and integrated solutions to deal with persistent workplace safety problems. Solutions to improve workplace safety need to recognise the broad sociotechnical system and the respective interactions between the system elements and levels.

  14. Orion in the Well Deck After Splashdown and Recovery

    NASA Image and Video Library

    2014-12-05

    After splashdown, NASA's Orion spacecraft has been recovered and is positioned on rubber "speed bumps" inside the flooded well deck of the USS Anchorage in the Pacific Ocean about 600 miles off the coast of San Diego, California. After lifting off at 7:05 a.m. EST atop a Delta IV Heavy rocket from Space Launch Complex 37 at Cape Canaveral Air Force Station in Florida, Orion completed a two-orbit, four-and-a-half hour mission to test systems critical to crew safety, including the launch abort system, the heat shield and the parachute system. NASA, the U.S. Navy and Lockheed Martin coordinated efforts to recover Orion after splashdown. The Ground Systems Development and Operations Program is leading the recovery efforts.

  15. KSC00spn002

    NASA Image and Video Library

    2001-07-26

    KENNEDY SPACE CENTER, FLA. -- Day in the Life page 2. Preparing the pad. Workers maintain Pad A at Kennedy Space Center’s Launch Complex 39. Robert Lust of IVEY Construction pauses on his way to install a safety handrail. This photograph was taken for a special color edition of Spaceport News designed to portray in photographs a single day at KSC, July 26, 2000. The special edition, published Aug. 25, 2000, was created to give readers a look at KSC’s diverse workforce and the critical roles workers play in the nation’s space program. Spaceport News is an official publication of the Kennedy Space Center and is published on alternate Fridays by the Public Affairs Office in the interest of KSC civil service and contractor employees

  16. Selected computations of transonic cavity flows

    NASA Technical Reports Server (NTRS)

    Atwood, Christopher A.

    1993-01-01

    An efficient diagonal scheme implemented in an overset mesh framework has permitted the analysis of geometrically complex cavity flows via the Reynolds averaged Navier-Stokes equations. Use of rapid hyperbolic and algebraic grid methods has allowed simple specification of critical turbulent regions with an algebraic turbulence model. Comparisons between numerical and experimental results are made in two dimensions for the following problems: a backward-facing step; a resonating cavity; and two quieted cavity configurations. In three-dimensions the flow about three early concepts of the stratospheric Observatory For Infrared Astronomy (SOFIA) are compared to wind-tunnel data. Shedding frequencies of resolved shear layer structures are compared against experiment for the quieted cavities. The results demonstrate the progress of computational assessment of configuration safety and performance.

  17. Healthcare software assurance.

    PubMed

    Cooper, Jason G; Pauley, Keith A

    2006-01-01

    Software assurance is a rigorous, lifecycle phase-independent set of activities which ensure completeness, safety, and reliability of software processes and products. This is accomplished by guaranteeing conformance to all requirements, standards, procedures, and regulations. These assurance processes are even more important when coupled with healthcare software systems, embedded software in medical instrumentation, and other healthcare-oriented life-critical systems. The current Food and Drug Administration (FDA) regulatory requirements and guidance documentation do not address certain aspects of complete software assurance activities. In addition, the FDA's software oversight processes require enhancement to include increasingly complex healthcare systems such as Hospital Information Systems (HIS). The importance of complete software assurance is introduced, current regulatory requirements and guidance discussed, and the necessity for enhancements to the current processes shall be highlighted.

  18. Healthcare Software Assurance

    PubMed Central

    Cooper, Jason G.; Pauley, Keith A.

    2006-01-01

    Software assurance is a rigorous, lifecycle phase-independent set of activities which ensure completeness, safety, and reliability of software processes and products. This is accomplished by guaranteeing conformance to all requirements, standards, procedures, and regulations. These assurance processes are even more important when coupled with healthcare software systems, embedded software in medical instrumentation, and other healthcare-oriented life-critical systems. The current Food and Drug Administration (FDA) regulatory requirements and guidance documentation do not address certain aspects of complete software assurance activities. In addition, the FDA’s software oversight processes require enhancement to include increasingly complex healthcare systems such as Hospital Information Systems (HIS). The importance of complete software assurance is introduced, current regulatory requirements and guidance discussed, and the necessity for enhancements to the current processes shall be highlighted. PMID:17238324

  19. How are drugs approved? Part 1: the evolution of the Food and Drug Administration.

    PubMed

    Howland, Robert H

    2008-01-01

    The discovery, development, and marketing of drugs for clinical use is a process that is complex, arduous, expensive, highly regulated, often criticized, and sometimes controversial. In the United States, the Food and Drug Administration (FDA) is the governmental agency responsible for regulating the development and marketing of drugs, medical devices, biologics, foods, cosmetics, radiation-emitting electronic devices, and veterinary products, with the objective of ensuring their safety and efficacy. As part of a broad overview of the drug development process, this article will describe the historical evolution of the FDA. This will provide background for two subsequent articles in this series, which will describe the ethical foundations of clinical research and hethe stages of drug development.

  20. Adaptive and Adaptable Automation Design: A Critical Review of the Literature and Recommendations for Future Research

    NASA Technical Reports Server (NTRS)

    Prinzel, Lawrence J., III; Kaber, David B.

    2006-01-01

    This report presents a review of literature on approaches to adaptive and adaptable task/function allocation and adaptive interface technologies for effective human management of complex systems that are likely to be issues for the Next Generation Air Transportation System, and a focus of research under the Aviation Safety Program, Integrated Intelligent Flight Deck Project. Contemporary literature retrieved from an online database search is summarized and integrated. The major topics include the effects of delegation-type, adaptable automation on human performance, workload and situation awareness, the effectiveness of various automation invocation philosophies and strategies to function allocation in adaptive systems, and the role of user modeling in adaptive interface design and the performance implications of adaptive interface technology.

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