The effects of wildfire prevention activities

Treesearch

Douglas Thomas; David Butry; Jeffrey Prestemon

2013-01-01

Eighty percent of wildfires are human caused. Unintentional human-caused fires can be caused by carelessness, failure of equipment, or a number of other factors. A significant proportion of the literature on accidents, in general, focuses on occupational accidents. Approximately 80 % to 90 % of these accidents are thought to be due to human error (Heinrich et al 1980...

Mask induction despite circuit obstruction: an unrecognized hazard of relying on automated machine check technology.

PubMed

Yang, Kamie K; Lewis, Ian H

2014-06-15

Various equipment malfunctions of anesthesia gas delivery systems have been previously reported. Our profession increasingly uses technology as a means to prevent these errors. We report a case of a near-total anesthesia circuit obstruction that went undetected before the induction of anesthesia despite the use of automated machine check technology. This case highlights that automated machine check modules can fail to detect severe equipment failure and demonstrates how, even in this era of expanding technology, manual checks still remain essential components of safe care.

Addressing Medical Errors in Hand Surgery

PubMed Central

Johnson, Shepard P.; Adkinson, Joshua M.; Chung, Kevin C.

2014-01-01

Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is considerable effort to implement system-wide changes, there is little guidance for hand surgeons on how to address medical errors. Admitting an error is difficult, but a transparent environment where patients are notified of errors and offered consolation and compensation is essential to maintain trust. Further, equipping hand surgeons with a guide for addressing medical errors will promote compassionate patient interaction, help identify system failures, provide learning points for safety improvement, and demonstrate a commitment to ethically responsible medical care. PMID:25154576

Vital Signs: Deficiencies in Environmental Control Identified in Outbreaks of Legionnaires' Disease - North America, 2000-2014.

PubMed

Garrison, Laurel E; Kunz, Jasen M; Cooley, Laura A; Moore, Matthew R; Lucas, Claressa; Schrag, Stephanie; Sarisky, John; Whitney, Cynthia G

2016-06-10

The number of reported cases of Legionnaires' disease, a severe pneumonia caused by the bacterium Legionella, is increasing in the United States. During 2000-2014, the rate of reported legionellosis cases increased from 0.42 to 1.62 per 100,000 persons; 4% of reported cases were outbreak-associated. Legionella is transmitted through aerosolization of contaminated water. A new industry standard for prevention of Legionella growth and transmission in water systems in buildings was published in 2015. CDC investigated outbreaks of Legionnaires' disease to identify gaps in building water system maintenance and guide prevention efforts. Information from summaries of CDC Legionnaires' disease outbreak investigations during 2000-2014 was systematically abstracted, and water system maintenance deficiencies from land-based investigations were categorized as process failures, human errors, equipment failures, or unmanaged external changes. During 2000-2014, CDC participated in 38 field investigations of Legionnaires' disease. Among 27 land-based outbreaks, the median number of cases was 10 (range = 3-82) and median outbreak case fatality rate was 7% (range = 0%-80%). Sufficient information to evaluate maintenance deficiencies was available for 23 (85%) investigations. Of these, all had at least one deficiency; 11 (48%) had deficiencies in ≥2 categories. Fifteen cases (65%) were linked to process failures, 12 (52%) to human errors, eight (35%) to equipment failures, and eight (35%) to unmanaged external changes. Multiple common preventable maintenance deficiencies were identified in association with disease outbreaks, highlighting the importance of comprehensive water management programs for water systems in buildings. Properly implemented programs, as described in the new industry standard, could reduce Legionella growth and transmission, preventing Legionnaires' disease outbreaks and reducing disease.

Application of CCG Sensors to a High-Temperature Structure Subjected to Thermo-Mechanical Load.

PubMed

Xie, Weihua; Meng, Songhe; Jin, Hua; Du, Chong; Wang, Libin; Peng, Tao; Scarpa, Fabrizio; Xu, Chenghai

2016-10-13

This paper presents a simple methodology to perform a high temperature coupled thermo-mechanical test using ultra-high temperature ceramic material specimens (UHTCs), which are equipped with chemical composition gratings sensors (CCGs). The methodology also considers the presence of coupled loading within the response provided by the CCG sensors. The theoretical strain of the UHTCs specimens calculated with this technique shows a maximum relative error of 2.15% between the analytical and experimental data. To further verify the validity of the results from the tests, a Finite Element (FE) model has been developed to simulate the temperature, stress and strain fields within the UHTC structure equipped with the CCG. The results show that the compressive stress exceeds the material strength at the bonding area, and this originates a failure by fracture of the supporting structure in the hot environment. The results related to the strain fields show that the relative error with the experimental data decrease with an increase of temperature. The relative error is less than 15% when the temperature is higher than 200 °C, and only 6.71% at 695 °C.

Slips, lapses and mistakes inthe use of equipment by nurses in an intensive care unit.

PubMed

Ribeiro, Gabriella da Silva Rangel; Silva, Rafael Celestino da; Ferreira, Márcia de Assunção; Silva, Grazielle Rezende da

2016-01-01

Toidentify the occurrence of errors in the use of equipment by nurses working in intensive careandanalyzing them in the framework of James Reason's theory of human error. Qualitative field study in the intensive care unit of a federal hospital in the city of Rio de Janeiro. Observation and interviews were conductedwith eight nurses, from March to December 2014. Content analysis was used for the interviews, as well as the description of the scenes observed. Lapses of memory and attention were identified in the handling of infusion pumps, as well as planning failures during the programming of monitors. Errors cause adverse events that compromise patient safety. The authors propose creation of an instrument for daily checking of equipment, with checks throughout the work process in the programming of infusion pumps and monitors, in order to reduce failures and memory lapses. Identificar a ocorrência de erros na utilização de equipamentos por enfermeiros que atuam na terapia intensiva, analisando-os à luz da teoria do erro humano de James Reason. Pesquisa de campo, qualitativa, na Unidade de Terapia Intensiva de um hospital federal do Rio de Janeiro. Realizou-se observação e entrevista com oito enfermeiros, de março a dezembro de 2014. Aplicou-se análise de conteúdo nas entrevistas e descrição densa nas cenas observadas. Identificaram-se falhas de memória e de atenção no manuseio das bombas infusoras e falhas de planejamento durante a programação dos monitores. Os erros causam eventos adversos que comprometem a segurança do paciente. Propõe-se um instrumento de verificação diária dos equipamentos, com checagens ao longo do processo de trabalho da programação das bombas infusoras e monitores, no intuito de reduzir as falhas e esquecimentos.

Normal people working in normal organizations with normal equipment: system safety and cognition in a mid-air collision.

PubMed

de Carvalho, Paulo Victor Rodrigues; Gomes, José Orlando; Huber, Gilbert Jacob; Vidal, Mario Cesar

2009-05-01

A fundamental challenge in improving the safety of complex systems is to understand how accidents emerge in normal working situations, with equipment functioning normally in normally structured organizations. We present a field study of the en route mid-air collision between a commercial carrier and an executive jet, in the clear afternoon Amazon sky in which 154 people lost their lives, that illustrates one response to this challenge. Our focus was on how and why the several safety barriers of a well structured air traffic system melted down enabling the occurrence of this tragedy, without any catastrophic component failure, and in a situation where everything was functioning normally. We identify strong consistencies and feedbacks regarding factors of system day-to-day functioning that made monitoring and awareness difficult, and the cognitive strategies that operators have developed to deal with overall system behavior. These findings emphasize the active problem-solving behavior needed in air traffic control work, and highlight how the day-to-day functioning of the system can jeopardize such behavior. An immediate consequence is that safety managers and engineers should review their traditional safety approach and accident models based on equipment failure probability, linear combinations of failures, rules and procedures, and human errors, to deal with complex patterns of coincidence possibilities, unexpected links, resonance among system functions and activities, and system cognition.

46 CFR 153.1130 - Failure of slops discharge recording equipment; operating with, reporting failures, and replacing...

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 5 2010-10-01 2010-10-01 false Failure of slops discharge recording equipment; operating with, reporting failures, and replacing pollution equipment: Category A, B, C, D. 153.1130 Section... slops discharge recording equipment; operating with, reporting failures, and replacing pollution...

46 CFR 153.1130 - Failure of slops discharge recording equipment; operating with, reporting failures, and replacing...

Code of Federal Regulations, 2011 CFR

2011-10-01

... 46 Shipping 5 2011-10-01 2011-10-01 false Failure of slops discharge recording equipment; operating with, reporting failures, and replacing pollution equipment: Category A, B, C, D. 153.1130 Section... slops discharge recording equipment; operating with, reporting failures, and replacing pollution...

46 CFR 153.1130 - Failure of slops discharge recording equipment; operating with, reporting failures, and replacing...

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 5 2012-10-01 2012-10-01 false Failure of slops discharge recording equipment; operating with, reporting failures, and replacing pollution equipment: Category A, B, C, D. 153.1130 Section... slops discharge recording equipment; operating with, reporting failures, and replacing pollution...

46 CFR 153.1130 - Failure of slops discharge recording equipment; operating with, reporting failures, and replacing...

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 5 2014-10-01 2014-10-01 false Failure of slops discharge recording equipment; operating with, reporting failures, and replacing pollution equipment: Category A, B, C, D. 153.1130 Section... slops discharge recording equipment; operating with, reporting failures, and replacing pollution...

46 CFR 153.1130 - Failure of slops discharge recording equipment; operating with, reporting failures, and replacing...

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 5 2013-10-01 2013-10-01 false Failure of slops discharge recording equipment; operating with, reporting failures, and replacing pollution equipment: Category A, B, C, D. 153.1130 Section... slops discharge recording equipment; operating with, reporting failures, and replacing pollution...

Avoiding common pitfalls in qualitative data collection and transcription.

PubMed

Easton, K L; McComish, J F; Greenberg, R

2000-09-01

The subjective nature of qualitative research necessitates scrupulous scientific methods to ensure valid results. Although qualitative methods such as grounded theory, phenomenology, and ethnography yield rich data, consumers of research need to be able to trust the findings reported in such studies. Researchers are responsible for establishing the trustworthiness of qualitative research through a variety of ways. Specific challenges faced in the field can seriously threaten the dependability of the data. However, by minimizing potential errors that can occur when doing fieldwork, researchers can increase the trustworthiness of the study. The purpose of this article is to present three of the pitfalls that can occur in qualitative research during data collection and transcription: equipment failure, environmental hazards, and transcription errors. Specific strategies to minimize the risk for avoidable errors will be discussed.

Patient injuries from anesthesia gas delivery equipment: a closed claims update.

PubMed

Mehta, Sonya P; Eisenkraft, James B; Posner, Karen L; Domino, Karen B

2013-10-01

Improvements in anesthesia gas delivery equipment and provider training may increase patient safety. The authors analyzed patient injuries related to gas delivery equipment claims from the American Society of Anesthesiologists Closed Claims Project database over the decades from 1970s to the 2000s. After the Institutional Review Board approval, the authors reviewed the Closed Claims Project database of 9,806 total claims. Inclusion criteria were general anesthesia for surgical or obstetric anesthesia care (n = 6,022). Anesthesia gas delivery equipment was defined as any device used to convey gas to or from (but not involving) the airway management device. Claims related to anesthesia gas delivery equipment were compared between time periods by chi-square test, Fisher exact test, and Mann-Whitney U test. Anesthesia gas delivery claims decreased over the decades (P < 0.001) to 1% of claims in the 2000s. Outcomes in claims from 1990 to 2011 (n = 40) were less severe, with a greater proportion of awareness (n = 9, 23%; P = 0.003) and pneumothorax (n = 7, 18%; P = 0.047). Severe injuries (death/permanent brain damage) occurred in supplemental oxygen supply events outside the operating room, breathing circuit events, or ventilator mishaps. The majority (85%) of claims involved provider error with (n = 7) or without (n = 27) equipment failure. Thirty-five percent of claims were judged as preventable by preanesthesia machine check. Gas delivery equipment claims in the Closed Claims Project database decreased in 1990-2011 compared with earlier decades. Provider error contributed to severe injury, especially with inadequate alarms, improvised oxygen delivery systems, and misdiagnosis or treatment of breathing circuit events.

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients.

PubMed

Vélez-Díaz-Pallarés, Manuel; Delgado-Silveira, Eva; Carretero-Accame, María Emilia; Bermejo-Vicedo, Teresa

2013-01-01

To identify actions to reduce medication errors in the process of drug prescription, validation and dispensing, and to evaluate the impact of their implementation. A Health Care Failure Mode and Effect Analysis (HFMEA) was supported by a before-and-after medication error study to measure the actual impact on error rate after the implementation of corrective actions in the process of drug prescription, validation and dispensing in wards equipped with computerised physician order entry (CPOE) and unit-dose distribution system (788 beds out of 1080) in a Spanish university hospital. The error study was carried out by two observers who reviewed medication orders on a daily basis to register prescription errors by physicians and validation errors by pharmacists. Drugs dispensed in the unit-dose trolleys were reviewed for dispensing errors. Error rates were expressed as the number of errors for each process divided by the total opportunities for error in that process times 100. A reduction in prescription errors was achieved by providing training for prescribers on CPOE, updating prescription procedures, improving clinical decision support and automating the software connection to the hospital census (relative risk reduction (RRR), 22.0%; 95% CI 12.1% to 31.8%). Validation errors were reduced after optimising time spent in educating pharmacy residents on patient safety, developing standardised validation procedures and improving aspects of the software's database (RRR, 19.4%; 95% CI 2.3% to 36.5%). Two actions reduced dispensing errors: reorganising the process of filling trolleys and drawing up a protocol for drug pharmacy checking before delivery (RRR, 38.5%; 95% CI 14.1% to 62.9%). HFMEA facilitated the identification of actions aimed at reducing medication errors in a healthcare setting, as the implementation of several of these led to a reduction in errors in the process of drug prescription, validation and dispensing.

Application of CCG Sensors to a High-Temperature Structure Subjected to Thermo-Mechanical Load

PubMed Central

Xie, Weihua; Meng, Songhe; Jin, Hua; Du, Chong; Wang, Libin; Peng, Tao; Scarpa, Fabrizio; Xu, Chenghai

2016-01-01

This paper presents a simple methodology to perform a high temperature coupled thermo-mechanical test using ultra-high temperature ceramic material specimens (UHTCs), which are equipped with chemical composition gratings sensors (CCGs). The methodology also considers the presence of coupled loading within the response provided by the CCG sensors. The theoretical strain of the UHTCs specimens calculated with this technique shows a maximum relative error of 2.15% between the analytical and experimental data. To further verify the validity of the results from the tests, a Finite Element (FE) model has been developed to simulate the temperature, stress and strain fields within the UHTC structure equipped with the CCG. The results show that the compressive stress exceeds the material strength at the bonding area, and this originates a failure by fracture of the supporting structure in the hot environment. The results related to the strain fields show that the relative error with the experimental data decrease with an increase of temperature. The relative error is less than 15% when the temperature is higher than 200 °C, and only 6.71% at 695 °C. PMID:27754356

A systematic review of the extent, nature and likely causes of preventable adverse events arising from hospital care.

PubMed

Sari, A Akbari; Doshmangir, L; Sheldon, T

2010-01-01

Understanding the nature and causes of medical adverse events may help their prevention. This systematic review explores the types, risk factors, and likely causes of preventable adverse events in the hospital sector. MEDLINE (1970-2008), EMBASE, CINAHL (1970-2005) and the reference lists were used to identify the studies and a structured narrative method used to synthesise the data. Operative adverse events were more common but less preventable and diagnostic adverse events less common but more preventable than other adverse events. Preventable adverse events were often associated with more than one contributory factor. The majority of adverse events were linked to individual human error, and a significant proportion of these caused serious patient harm. Equipment failure was involved in a small proportion of adverse events and rarely caused patient harm. The proportion of system failures varied widely ranging from 3% to 85% depending on the data collection and classification methods used. Operative adverse events are more common but less preventable than diagnostic adverse events. Adverse events are usually associated with more than one contributory factor, the majority are linked to individual human error, and a proportion of these with system failure.

Designed for Workarounds: A Qualitative Study of the Causes of Operational Failures in Hospitals

PubMed Central

Tucker, Anita L; Heisler, W Scott; Janisse, Laura D

2014-01-01

Frontline care clinicians and staff in hospitals spend at least 10% of their time working around operational failures: situations in which information, supplies, or equipment needed for patient care are insufficient. However, little is known about underlying causes of operational failures and what hospitals can do to reduce their occurrence. To address this gap, we examined the internal supply chains at 2 hospitals with the aim of discovering organizational factors that contribute to operational failures. We conducted in-depth qualitative research, including observations and interviews of more than 80 individuals from 4 nursing units and the ancillary support departments that provide equipment and supplies needed for patient care. We found that a lack of interconnectedness among interdependent departments’ routines was a major source of operational failures. The low levels of interconnectedness occurred because of how the internal supply chains were designed and managed rather than because of employee error or a shortfall in training. Thus, we propose that the time that hospital staff members spend on workarounds can be reduced through deliberate efforts to increase interconnectedness among hospitals’ internal supply departments. Four dimensions of interconnectedness include: 1) hospital-level—rather than department-level—performance measures; 2) internal supply department routines that respond to specific patients’ needs rather than to predetermined stocking routines; 3) knowledge that is necessary for efficient handoffs of materials that is translated across departmental boundaries; and 4) cross-departmental collaboration mechanisms that enable improvement in the flow of materials across departmental boundaries. PMID:25102517

Designed for workarounds: a qualitative study of the causes of operational failures in hospitals.

PubMed

Tucker, Anita L; Heisler, W Scott; Janisse, Laura D

2014-01-01

Frontline care clinicians and staff in hospitals spend at least 10% of their time working around operational failures: situations in which information, supplies, or equipment needed for patient care are insufficient. However, little is known about underlying causes of operational failures and what hospitals can do to reduce their occurrence. To address this gap, we examined the internal supply chains at 2 hospitals with the aim of discovering organizational factors that contribute to operational failures. We conducted in-depth qualitative research, including observations and interviews of more than 80 individuals from 4 nursing units and the ancillary support departments that provide equipment and supplies needed for patient care. We found that a lack of interconnectedness among interdependent departments' routines was a major source of operational failures. The low levels of interconnectedness occurred because of how the internal supply chains were designed and managed rather than because of employee error or a shortfall in training. Thus, we propose that the time that hospital staff members spend on workarounds can be reduced through deliberate efforts to increase interconnectedness among hospitals' internal supply departments. Four dimensions of interconnectedness include: 1) hospital-level-rather than department-level-performance measures; 2) internal supply department routines that respond to specific patients' needs rather than to predetermined stocking routines; 3) knowledge that is necessary for efficient handoffs of materials that is translated across departmental boundaries; and 4) cross-departmental collaboration mechanisms that enable improvement in the flow of materials across departmental boundaries.

Operational Failures and Interruptions in Hospital Nursing

PubMed Central

Tucker, Anita L; Spear, Steven J

2006-01-01

Objective To describe the work environment of hospital nurses with particular focus on the performance of work systems supplying information, materials, and equipment for patient care. Data Sources Primary observation, semistructured interviews, and surveys of hospital nurses. Study Design We sampled a cross-sectional group of six U.S. hospitals to examine the frequency of work system failures and their impact on nurse productivity. Data Collection We collected minute-by-minute data on the activities of 11 nurses. In addition, we conducted interviews with six of these nurses using questions related to obstacles to care. Finally, we created and administered two surveys in 48 nursing units, one for nurses and one for managers, asking about the frequency of specific work system failures. Principal Findings Nurses we observed experienced an average of 8.4 work system failures per 8-hour shift. The five most frequent types of failures, accounting for 6.4 of these obstacles, involved medications, orders, supplies, staffing, and equipment. Survey questions asking nurses how frequently they experienced these five categories of obstacles yielded similar frequencies. For an average 8-hour shift, the average task time was only 3.1 minutes, and in spite of this, nurses were interrupted mid-task an average of eight times per shift. Conclusions Our findings suggest that nurse effectiveness can be increased by creating improvement processes triggered by the occurrence of work system failures, with the goal of reducing future occurrences. Second, given that nursing work is fragmented and unpredictable, designing processes that are robust to interruption can help prevent errors. PMID:16704505

Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination.

PubMed

Mumma, Joel M; Durso, Francis T; Ferguson, Ashley N; Gipson, Christina L; Casanova, Lisa; Erukunuakpor, Kimberly; Kraft, Colleen S; Walsh, Victoria L; Zimring, Craig; DuBose, Jennifer; Jacob, Jesse T

2018-03-05

Doffing protocols for personal protective equipment (PPE) are critical for keeping healthcare workers (HCWs) safe during care of patients with Ebola virus disease. We assessed the relationship between errors and self-contamination during doffing. Eleven HCWs experienced with doffing Ebola-level PPE participated in simulations in which HCWs donned PPE marked with surrogate viruses (ɸ6 and MS2), completed a clinical task, and were assessed for contamination after doffing. Simulations were video recorded, and a failure modes and effects analysis and fault tree analyses were performed to identify errors during doffing, quantify their risk (risk index), and predict contamination data. Fifty-one types of errors were identified, many having the potential to spread contamination. Hand hygiene and removing the powered air purifying respirator (PAPR) hood had the highest total risk indexes (111 and 70, respectively) and number of types of errors (9 and 13, respectively). ɸ6 was detected on 10% of scrubs and the fault tree predicted a 10.4% contamination rate, likely occurring when the PAPR hood inadvertently contacted scrubs during removal. MS2 was detected on 10% of hands, 20% of scrubs, and 70% of inner gloves and the predicted rates were 7.3%, 19.4%, 73.4%, respectively. Fault trees for MS2 and ɸ6 contamination suggested similar pathways. Ebola-level PPE can both protect and put HCWs at risk for self-contamination throughout the doffing process, even among experienced HCWs doffing with a trained observer. Human factors methodologies can identify error-prone steps, delineate the relationship between errors and self-contamination, and suggest remediation strategies.

SCADA-based Operator Support System for Power Plant Equipment Fault Forecasting

NASA Astrophysics Data System (ADS)

Mayadevi, N.; Ushakumari, S. S.; Vinodchandra, S. S.

2014-12-01

Power plant equipment must be monitored closely to prevent failures from disrupting plant availability. Online monitoring technology integrated with hybrid forecasting techniques can be used to prevent plant equipment faults. A self learning rule-based expert system is proposed in this paper for fault forecasting in power plants controlled by supervisory control and data acquisition (SCADA) system. Self-learning utilizes associative data mining algorithms on the SCADA history database to form new rules that can dynamically update the knowledge base of the rule-based expert system. In this study, a number of popular associative learning algorithms are considered for rule formation. Data mining results show that the Tertius algorithm is best suited for developing a learning engine for power plants. For real-time monitoring of the plant condition, graphical models are constructed by K-means clustering. To build a time-series forecasting model, a multi layer preceptron (MLP) is used. Once created, the models are updated in the model library to provide an adaptive environment for the proposed system. Graphical user interface (GUI) illustrates the variation of all sensor values affecting a particular alarm/fault, as well as the step-by-step procedure for avoiding critical situations and consequent plant shutdown. The forecasting performance is evaluated by computing the mean absolute error and root mean square error of the predictions.

The use of failure mode and effect analysis in a radiation oncology setting: the Cancer Treatment Centers of America experience.

PubMed

Denny, Diane S; Allen, Debra K; Worthington, Nicole; Gupta, Digant

2014-01-01

Delivering radiation therapy in an oncology setting is a high-risk process where system failures are more likely to occur because of increasing utilization, complexity, and sophistication of the equipment and related processes. Healthcare failure mode and effect analysis (FMEA) is a method used to proactively detect risks to the patient in a particular healthcare process and correct potential errors before adverse events occur. FMEA is a systematic, multidisciplinary team-based approach to error prevention and enhancing patient safety. We describe our experience of using FMEA as a prospective risk-management technique in radiation oncology at a national network of oncology hospitals in the United States, capitalizing not only on the use of a team-based tool but also creating momentum across a network of collaborative facilities seeking to learn from and share best practices with each other. The major steps of our analysis across 4 sites and collectively were: choosing the process and subprocesses to be studied, assembling a multidisciplinary team at each site responsible for conducting the hazard analysis, and developing and implementing actions related to our findings. We identified 5 areas of performance improvement for which risk-reducing actions were successfully implemented across our enterprise. © 2012 National Association for Healthcare Quality.

Equipment failures and their contribution to industrial incidents and accidents in the manufacturing industry.

PubMed

Bourassa, Dominic; Gauthier, François; Abdul-Nour, Georges

2016-01-01

Accidental events in manufacturing industries can be caused by many factors, including work methods, lack of training, equipment design, maintenance and reliability. This study is aimed at determining the contribution of failures of commonly used industrial equipment, such as machines, tools and material handling equipment, to the chain of causality of industrial accidents and incidents. Based on a case study which aimed at the analysis of an existing pulp and paper company's accident database, this paper examines the number, type and gravity of the failures involved in these events and their causes. Results from this study show that equipment failures had a major effect on the number and severity of accidents accounted for in the database: 272 out of 773 accidental events were related to equipment failure, where 13 of them had direct human consequences. Failures that contributed directly or indirectly to these events are analyzed.

Nonoperating Failure Rates for Avionics Study.

DTIC Science & Technology

1980-04-01

Missile, 1 August 1973. Temperature Readings at Three Indicated Locations ............................ 3-10 3-7 Operating vs . Nonoperating Failure...Failures vs . Mission Duration for Jet Aircraft Equipment ... ...................... ... 4-39 4-17 Cumulative Total Failures vs . Mission Duration for Jet...AVIONIC EQUIPMENT FIELD CHARACTERISTICS To better understand the type of service exposure avionic equipment must withstand , several aspects of the

Cyber-Informed Engineering: The Need for a New Risk Informed and Design Methodology

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

Price, Joseph Daniel; Anderson, Robert Stephen

Current engineering and risk management methodologies do not contain the foundational assumptions required to address the intelligent adversary’s capabilities in malevolent cyber attacks. Current methodologies focus on equipment failures or human error as initiating events for a hazard, while cyber attacks use the functionality of a trusted system to perform operations outside of the intended design and without the operator’s knowledge. These threats can by-pass or manipulate traditionally engineered safety barriers and present false information, invalidating the fundamental basis of a safety analysis. Cyber threats must be fundamentally analyzed from a completely new perspective where neither equipment nor human operationmore » can be fully trusted. A new risk analysis and design methodology needs to be developed to address this rapidly evolving threatscape.« less

HRA Aerospace Challenges

NASA Technical Reports Server (NTRS)

DeMott, Diana

2013-01-01

Compared to equipment designed to perform the same function over and over, humans are just not as reliable. Computers and machines perform the same action in the same way repeatedly getting the same result, unless equipment fails or a human interferes. Humans who are supposed to perform the same actions repeatedly often perform them incorrectly due to a variety of issues including: stress, fatigue, illness, lack of training, distraction, acting at the wrong time, not acting when they should, not following procedures, misinterpreting information or inattention to detail. Why not use robots and automatic controls exclusively if human error is so common? In an emergency or off normal situation that the computer, robotic element, or automatic control system is not designed to respond to, the result is failure unless a human can intervene. The human in the loop may be more likely to cause an error, but is also more likely to catch the error and correct it. When it comes to unexpected situations, or performing multiple tasks outside the defined mission parameters, humans are the only viable alternative. Human Reliability Assessments (HRA) identifies ways to improve human performance and reliability and can lead to improvements in systems designed to interact with humans. Understanding the context of the situation that can lead to human errors, which include taking the wrong action, no action or making bad decisions provides additional information to mitigate risks. With improved human reliability comes reduced risk for the overall operation or project.

49 CFR 220.38 - Communication equipment failure.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 4 2012-10-01 2012-10-01 false Communication equipment failure. 220.38 Section 220.38 Transportation Other Regulations Relating to Transportation (Continued) FEDERAL RAILROAD... § 220.38 Communication equipment failure. (a) Any radio or wireless communication device found not to be...

49 CFR 220.38 - Communication equipment failure.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 4 2011-10-01 2011-10-01 false Communication equipment failure. 220.38 Section 220.38 Transportation Other Regulations Relating to Transportation (Continued) FEDERAL RAILROAD... § 220.38 Communication equipment failure. (a) Any radio or wireless communication device found not to be...

Application of failure mode and effect analysis in a radiology department.

PubMed

Thornton, Eavan; Brook, Olga R; Mendiratta-Lala, Mishal; Hallett, Donna T; Kruskal, Jonathan B

2011-01-01

With increasing deployment, complexity, and sophistication of equipment and related processes within the clinical imaging environment, system failures are more likely to occur. These failures may have varying effects on the patient, ranging from no harm to devastating harm. Failure mode and effect analysis (FMEA) is a tool that permits the proactive identification of possible failures in complex processes and provides a basis for continuous improvement. This overview of the basic principles and methodology of FMEA provides an explanation of how FMEA can be applied to clinical operations in a radiology department to reduce, predict, or prevent errors. The six sequential steps in the FMEA process are explained, and clinical magnetic resonance imaging services are used as an example for which FMEA is particularly applicable. A modified version of traditional FMEA called Healthcare Failure Mode and Effect Analysis, which was introduced by the U.S. Department of Veterans Affairs National Center for Patient Safety, is briefly reviewed. In conclusion, FMEA is an effective and reliable method to proactively examine complex processes in the radiology department. FMEA can be used to highlight the high-risk subprocesses and allows these to be targeted to minimize the future occurrence of failures, thus improving patient safety and streamlining the efficiency of the radiology department. RSNA, 2010

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

Sarrack, A.G.

The purpose of this report is to document fault tree analyses which have been completed for the Defense Waste Processing Facility (DWPF) safety analysis. Logic models for equipment failures and human error combinations that could lead to flammable gas explosions in various process tanks, or failure of critical support systems were developed for internal initiating events and for earthquakes. These fault trees provide frequency estimates for support systems failures and accidents that could lead to radioactive and hazardous chemical releases both on-site and off-site. Top event frequency results from these fault trees will be used in further APET analyses tomore » calculate accident risk associated with DWPF facility operations. This report lists and explains important underlying assumptions, provides references for failure data sources, and briefly describes the fault tree method used. Specific commitments from DWPF to provide new procedural/administrative controls or system design changes are listed in the ''Facility Commitments'' section. The purpose of the ''Assumptions'' section is to clarify the basis for fault tree modeling, and is not necessarily a list of items required to be protected by Technical Safety Requirements (TSRs).« less

Failure analysis and modeling of a VAXcluster system

NASA Technical Reports Server (NTRS)

Tang, Dong; Iyer, Ravishankar K.; Subramani, Sujatha S.

1990-01-01

This paper discusses the results of a measurement-based analysis of real error data collected from a DEC VAXcluster multicomputer system. In addition to evaluating basic system dependability characteristics such as error and failure distributions and hazard rates for both individual machines and for the VAXcluster, reward models were developed to analyze the impact of failures on the system as a whole. The results show that more than 46 percent of all failures were due to errors in shared resources. This is despite the fact that these errors have a recovery probability greater than 0.99. The hazard rate calculations show that not only errors, but also failures occur in bursts. Approximately 40 percent of all failures occur in bursts and involved multiple machines. This result indicates that correlated failures are significant. Analysis of rewards shows that software errors have the lowest reward (0.05 vs 0.74 for disk errors). The expected reward rate (reliability measure) of the VAXcluster drops to 0.5 in 18 hours for the 7-out-of-7 model and in 80 days for the 3-out-of-7 model.

Implementation of a quality management system according to 9001 standard in a hospital in the home unit: changes and achievements.

PubMed

Rodríguez-Cerrillo, Matilde; Fernández-Diaz, Eddita; Iñurrieta-Romero, Amaia; Poza-Montoro, Ana

2012-01-01

The purpose of this paper is to describe changes and results obtained after implementation of a quality management system (QMS) according to ISO standards in a Hospital in the Home (HIH) Unit. The paper describes changes made and outcomes achieved. This took part in the HiH Unit, Clinico Hospital, Madrid, Spain, and looked at admissions, mean stay, patient satisfaction, adverse events, returns to hospital, no admitted referrals, complaints, compliance to protocols, equipment failures and resolution of urgent consultations. In June 2008, HiH Unit, Clinico Hospital obtained ISO certification. The main results achieved are as follows. There was an increase in patients' satisfaction--in June 2008, assessment of the quality of care provided by staff was scored at 4.7 (on a scale of 1 to 5); in 2010 it has been scored at 4.96. Patient satisfaction rate has increased from 92 percent to 98.8 percent. No complaints from patients were received. Unscheduled returns to hospital have decreased from 7 percent to 3 percent. There were no medical equipment failures. External suppliers' performance has improved. Material and medication needed by staff was available when necessary. The number of admissions has increased. Compliance to protocols has reached 97 percent. Inappropriate referrals have decreased by 8 percent. Six medications-related incidents were detected; in two cases the incident was not due to an error. In the other four cases error could have been detected before reaching the patient. Implementations of an ISO quality management system allow improved quality of care and patient satisfaction in a HIH Unit.

Dialysis Facility Safety: Processes and Opportunities.

PubMed

Garrick, Renee; Morey, Rishikesh

2015-01-01

Unintentional human errors are the source of most safety breaches in complex, high-risk environments. The environment of dialysis care is extremely complex. Dialysis patients have unique and changing physiology, and the processes required for their routine care involve numerous open-ended interfaces between providers and an assortment of technologically advanced equipment. Communication errors, both within the dialysis facility and during care transitions, and lapses in compliance with policies and procedures are frequent areas of safety risk. Some events, such as air emboli and needle dislodgments occur infrequently, but are serious risks. Other adverse events include medication errors, patient falls, catheter and access-related infections, access infiltrations and prolonged bleeding. A robust safety system should evaluate how multiple, sequential errors might align to cause harm. Systems of care can be improved by sharing the results of root cause analyses, and "good catches." Failure mode effects and analyses can be used to proactively identify and mitigate areas of highest risk, and methods drawn from cognitive psychology, simulation training, and human factor engineering can be used to advance facility safety. © 2015 Wiley Periodicals, Inc.

Glovebox and Experiment Safety

NASA Astrophysics Data System (ADS)

Maas, Gerard

2005-12-01

Human spaceflight hardware and operations must comply with NSTS 1700.7. This paper discusses how a glovebox can help.A short layout is given on the process according NSTS/ISS 13830, explaining the responsibility of the payload organization, the approval authority of the PSRP and the defined review phases (0 till III).Amongst others, the following requirement has to be met:"200.1 Design to Tolerate Failures. Failure tolerance is the basic safety requirement that shall be used to control most payload hazards. The payload must tolerate a minimum number of credible failures and/or operator errors determined by the hazard level. This criterion applies when the loss of a function or the inadvertent occurrence of a function results in a hazardous event.200.1a Critical Hazards. Critical hazards shall be controlled such that no single failure or operator error can result in damage to STS/ISS equipment, a nondisabling personnel injury, or the use of unscheduled safing procedures that affect operations of the Orbiter/ISS or another payload.200.1b Catastrophic Hazards. Catastrophic hazards shall be controlled such that no combination of two failures or operator errors can result in the potential for a disabling or fatal personnel injury or loss of the Orbiter/ISS, ground facilities or STS/ISS equipment."For experiments in material science, biological science and life science that require real time operator manipulation, the above requirement may be hard or impossible to meet. Especially if the experiment contains substances that are considered hazardous when released into the habitable environment. In this case operation of the experiment in a glovebox can help to comply.A glovebox provides containment of the experiment and at the same time allows manipulation and visibility to the experiment.The containment inside the glovebox provides failure tolerance because the glovebox uses a negative pressure inside the working volume (WV). The level of failure tolerance is dependent of: the identified failure case and the hazardous substance being released (chemical, biological or different).The principle of the glovebox operation is explained, including: mechanical enclosure, air circulation, air filtration and operational modes.Limitations of the glovebox are presented: inability of an experiment fire to be detected by the ASDA, containment only with respect to specified substances, etc. There are requirements induced by the glovebox that the experiment must comply with: Compatibility with the glovebox filter system, thermal limitations, safe without glovebox services, parameter monitoring when a fire hazard is credible, sufficient containment when entering the glovebox and after the experiment, etc.Experiments that are using a glovebox to be operated in shall assess this integrated set-up and the associated operations for compliance to the safety requirements. During this assessment the PSRP shall determine if the provided failure tolerance is sufficient.The gloveboxes that Bradford Engineering (co-) built for human space flight are: USML-1 and 2, MGBX (STS and MIR), MSG, PGBX, LSG-WVA, BGB and PGB. Some of the evolutions are pointed out (experiment services added without compromising safety levels). The major differences of the gloveboxes are presented. For the gloveboxes that are in operation at this time (MSG) or in the near future (BGB, LSG- WVA and PGB) the specific applications are presented.

Technical Basis for Evaluating Software-Related Common-Cause Failures

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

Muhlheim, Michael David; Wood, Richard

2016-04-01

The instrumentation and control (I&C) system architecture at a nuclear power plant (NPP) incorporates protections against common-cause failures (CCFs) through the use of diversity and defense-in-depth. Even for well-established analog-based I&C system designs, the potential for CCFs of multiple systems (or redundancies within a system) constitutes a credible threat to defeating the defense-in-depth provisions within the I&C system architectures. The integration of digital technologies into the I&C systems provides many advantages compared to the aging analog systems with respect to reliability, maintenance, operability, and cost effectiveness. However, maintaining the diversity and defense-in-depth for both the hardware and software within themore » digital system is challenging. In fact, the introduction of digital technologies may actually increase the potential for CCF vulnerabilities because of the introduction of undetected systematic faults. These systematic faults are defined as a “design fault located in a software component” and at a high level, are predominately the result of (1) errors in the requirement specification, (2) inadequate provisions to account for design limits (e.g., environmental stress), or (3) technical faults incorporated in the internal system (or architectural) design or implementation. Other technology-neutral CCF concerns include hardware design errors, equipment qualification deficiencies, installation or maintenance errors, instrument loop scaling and setpoint mistakes.« less

Cost analysis of equipment failure of a radiology department and possible choices about maintenance.

PubMed

Grisi, Guido; Dalla Palma, Ludovico; Rimondini, Allesandra; Palmolungo, Chiara; Cuttin Zernich, Roberto; Pozzi Mucelli, Roberto

2002-01-01

Our aim was to evaluate the economic impact of equipment failures in a radiology department with a view to guiding maintenance policy decisions. We assessed the negative economic impact caused by the interruption of activity of a radiodiagnostics section due to equipment failure, taking into account: the effects occurring during the first day of equipment down-time (assuming that the equipment failure occurs in the middle of the shift) and the effects during the following days until the repair of the failure; the effects occurring in the short- and long-term. To exemplify the negative impact of inactivity due to equipment failure, we chose three radiology sections with different levels of technological and operational complexity (chest radiology, gastrointestinal radiology and remote-controlled diagnostics). For each, we evaluated the loss of contribution margin and the idle capacity costs (short- and long-term impact). The negative economic effects were: for thoracic radiology, 496,77 Euro in the first day, and 30,99 Euro from the second day onwards; for gastrointestinal radiology, 526,40 Euro for the first day, and 730,39 Euro from the second day onwards; for remote-controlled diagnostics, 786,25 Euro for the first day, and 927,67 Euro from the second days onwards. Our results indicate that the level of idle capacity costs (mainly equipment and staff) increases with the complexity of the equipment, whereas the contribution margin appears to fluctuate, because the charges are state-imposed and do not vary with the complexity of equipment. Moreover, our analysis shows that if the workload of a broken machine can easily be assigned to an additional shift using another machine, losses are considerably reduced from the second day onwards. Once the negative economic impact of equipment failures has been evaluated, the second step is to choose the best kind of maintenance. A sound calculation of the economic impact of equipment failures is very useful for guiding the head of department and the hospital manager in deciding whether to purchase maintenance services (or a long-term guarantee) from the equipment manufacturer, to set up an auxiliary centre for maintenance and repair, or to purchase a third-party maintenance contract.

Evaluation of near-miss and adverse events in radiation oncology using a comprehensive causal factor taxonomy.

PubMed

Spraker, Matthew B; Fain, Robert; Gopan, Olga; Zeng, Jing; Nyflot, Matthew; Jordan, Loucille; Kane, Gabrielle; Ford, Eric

Incident learning systems (ILSs) are a popular strategy for improving safety in radiation oncology (RO) clinics, but few reports focus on the causes of errors in RO. The goal of this study was to test a causal factor taxonomy developed in 2012 by the American Association of Physicists in Medicine and adopted for use in the RO: Incident Learning System (RO-ILS). Three hundred event reports were randomly selected from an institutional ILS database and Safety in Radiation Oncology (SAFRON), an international ILS. The reports were split into 3 groups of 100 events each: low-risk institutional, high-risk institutional, and SAFRON. Three raters retrospectively analyzed each event for contributing factors using the American Association of Physicists in Medicine taxonomy. No events were described by a single causal factor (median, 7). The causal factor taxonomy was found to be applicable for all events, but 4 causal factors were not described in the taxonomy: linear accelerator failure (n = 3), hardware/equipment failure (n = 2), failure to follow through with a quality improvement intervention (n = 1), and workflow documentation was misleading (n = 1). The most common causal factor categories contributing to events were similar in all event types. The most common specific causal factor to contribute to events was a "slip causing physical error." Poor human factors engineering was the only causal factor found to contribute more frequently to high-risk institutional versus low-risk institutional events. The taxonomy in the study was found to be applicable for all events and may be useful in root cause analyses and future studies. Communication and human behaviors were the most common errors affecting all types of events. Poor human factors engineering was found to specifically contribute to high-risk more than low-risk institutional events, and may represent a strategy for reducing errors in all types of events. Copyright © 2017 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Learning from adverse incidents involving medical devices.

PubMed

Amoore, John; Ingram, Paula

While an adverse event involving a medical device is often ascribed to either user error or device failure, the causes are typically multifactorial. A number of incidents involving medical devices are explored using this approach to investigate the various causes of the incident and the protective barriers that minimised or prevented adverse consequences. User factors, including mistakes, omissions and lack of training, conspired with background factors--device controls and device design, storage conditions, hidden device damage and physical layout of equipment when in use--to cause the adverse events. Protective barriers that prevented or minimised the consequences included staff vigilance, operating procedures and alarms.

Safety evaluation of driver cognitive failures and driving errors on right-turn filtering movement at signalized road intersections based on Fuzzy Cellular Automata (FCA) model.

PubMed

Chai, Chen; Wong, Yiik Diew; Wang, Xuesong

2017-07-01

This paper proposes a simulation-based approach to estimate safety impact of driver cognitive failures and driving errors. Fuzzy Logic, which involves linguistic terms and uncertainty, is incorporated with Cellular Automata model to simulate decision-making process of right-turn filtering movement at signalized intersections. Simulation experiments are conducted to estimate the relationships between cognitive failures and driving errors with safety performance. Simulation results show Different types of cognitive failures are found to have varied relationship with driving errors and safety performance. For right-turn filtering movement, cognitive failures are more likely to result in driving errors with denser conflicting traffic stream. Moreover, different driving errors are found to have different safety impacts. The study serves to provide a novel approach to linguistically assess cognitions and replicate decision-making procedures of the individual driver. Compare to crash analysis, the proposed FCA model allows quantitative estimation of particular cognitive failures, and the impact of cognitions on driving errors and safety performance. Copyright © 2017 Elsevier Ltd. All rights reserved.

A cost simulation for mammography examinations taking into account equipment failures and resource utilization characteristics.

PubMed

Coelli, Fernando C; Almeida, Renan M V R; Pereira, Wagner C A

2010-12-01

This work develops a cost analysis estimation for a mammography clinic, taking into account resource utilization and equipment failure rates. Two standard clinic models were simulated, the first with one mammography equipment, two technicians and one doctor, and the second (based on an actually functioning clinic) with two equipments, three technicians and one doctor. Cost data and model parameters were obtained by direct measurements, literature reviews and other hospital data. A discrete-event simulation model was developed, in order to estimate the unit cost (total costs/number of examinations in a defined period) of mammography examinations at those clinics. The cost analysis considered simulated changes in resource utilization rates and in examination failure probabilities (failures on the image acquisition system). In addition, a sensitivity analysis was performed, taking into account changes in the probabilities of equipment failure types. For the two clinic configurations, the estimated mammography unit costs were, respectively, US$ 41.31 and US$ 53.46 in the absence of examination failures. As the examination failures increased up to 10% of total examinations, unit costs approached US$ 54.53 and US$ 53.95, respectively. The sensitivity analysis showed that type 3 (the most serious) failure increases had a very large impact on the patient attendance, up to the point of actually making attendance unfeasible. Discrete-event simulation allowed for the definition of the more efficient clinic, contingent on the expected prevalence of resource utilization and equipment failures. © 2010 Blackwell Publishing Ltd.

Statistical analysis of field data for aircraft warranties

NASA Astrophysics Data System (ADS)

Lakey, Mary J.

Air Force and Navy maintenance data collection systems were researched to determine their scientific applicability to the warranty process. New and unique algorithms were developed to extract failure distributions which were then used to characterize how selected families of equipment typically fails. Families of similar equipment were identified in terms of function, technology and failure patterns. Statistical analyses and applications such as goodness-of-fit test, maximum likelihood estimation and derivation of confidence intervals for the probability density function parameters were applied to characterize the distributions and their failure patterns. Statistical and reliability theory, with relevance to equipment design and operational failures were also determining factors in characterizing the failure patterns of the equipment families. Inferences about the families with relevance to warranty needs were then made.

Research on Application of FMECA in Missile Equipment Maintenance Decision

NASA Astrophysics Data System (ADS)

Kun, Wang

2018-03-01

Fault mode effects and criticality analysis (FMECA) is a method widely used in engineering. Studying the application of FMEA technology in military equipment maintenance decision-making, can help us build a better equipment maintenance support system, and increase the using efficiency of weapons and equipment. Through Failure Modes, Effects and Criticality Analysis (FMECA) of equipment, known and potential failure modes and their causes are found out, and the influence on the equipment performance, operation success, personnel security are determined. Furthermore, according to the synthetical effects of the severity of effects and the failure probability, possible measures for prevention and correction are put forward. Through replacing or adjusting the corresponding parts, corresponding maintenance strategy is decided for preventive maintenance of equipment, which helps improve the equipment reliability.

Experience reveals ways to minimize failures in rod-pumped wells

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

Patterson, J.C.; Bucaram, S.M.; Curfew, J.V.

From the experience gained over the past 25 years, ARCO Oil and Gas Co. has developed recommendations to reduce equipment failure in sucker-rod pumping installations. These recommendations include equipment selection and design, operating procedures, and chemical treatment. Equipment failure and its attendant costs are extremely important in today's petroleum industry. Because rod pumping is the predominant means of artificial lift, minimizing equipment failure in rod pumped wells can have a significant impact on profitability. This compilation of recommendations comes from field locations throughout the US and other countries. The goal is to address and solve problems on a well-by-well basis.

A Study to Compare the Failure Rates of Current Space Shuttle Ground Support Equipment with the New Pathfinder Equipment and Investigate the Effect that the Proposed GSE Infrastructure Upgrade Might Have to Reduce GSE Infrastructure Failures

NASA Technical Reports Server (NTRS)

Kennedy, Barbara J.

2004-01-01

The purposes of this study are to compare the current Space Shuttle Ground Support Equipment (GSE) infrastructure with the proposed GSE infrastructure upgrade modification. The methodology will include analyzing the first prototype installation equipment at Launch PAD B called the "Pathfinder". This study will begin by comparing the failure rate of the current components associated with the "Hardware interface module (HIM)" at the Kennedy Space Center to the failure rate of the neW Pathfinder components. Quantitative data will be gathered specifically on HIM components and the PAD B Hypergolic Fuel facility and Hypergolic Oxidizer facility areas which has the upgraded pathfinder equipment installed. The proposed upgrades include utilizing industrial controlled modules, software, and a fiber optic network. The results of this study provide evidence that there is a significant difference in the failure rates of the two studied infrastructure equipment components. There is also evidence that the support staff for each infrastructure system is not equal. A recommendation to continue with future upgrades is based on a significant reduction of failures in the new' installed ground system components.

Quantum error-correction failure distributions: Comparison of coherent and stochastic error models

NASA Astrophysics Data System (ADS)

Barnes, Jeff P.; Trout, Colin J.; Lucarelli, Dennis; Clader, B. D.

2017-06-01

We compare failure distributions of quantum error correction circuits for stochastic errors and coherent errors. We utilize a fully coherent simulation of a fault-tolerant quantum error correcting circuit for a d =3 Steane and surface code. We find that the output distributions are markedly different for the two error models, showing that no simple mapping between the two error models exists. Coherent errors create very broad and heavy-tailed failure distributions. This suggests that they are susceptible to outlier events and that mean statistics, such as pseudothreshold estimates, may not provide the key figure of merit. This provides further statistical insight into why coherent errors can be so harmful for quantum error correction. These output probability distributions may also provide a useful metric that can be utilized when optimizing quantum error correcting codes and decoding procedures for purely coherent errors.

Security threats categories in healthcare information systems.

PubMed

Samy, Ganthan Narayana; Ahmad, Rabiah; Ismail, Zuraini

2010-09-01

This article attempts to investigate the various types of threats that exist in healthcare information systems (HIS). A study has been carried out in one of the government-supported hospitals in Malaysia.The hospital has been equipped with a Total Hospital Information System (THIS). The data collected were from three different departments, namely the Information Technology Department (ITD), the Medical Record Department (MRD), and the X-Ray Department, using in-depth structured interviews. The study identified 22 types of threats according to major threat categories based on ISO/IEC 27002 (ISO 27799:2008). The results show that the most critical threat for the THIS is power failure followed by acts of human error or failure and other technological factors. This research holds significant value in terms of providing a complete taxonomy of threat categories in HIS and also an important component in the risk analysis stage.

Pediatric critical incidents reported over 15 years at a tertiary care teaching hospital of a developing country.

PubMed

Abbasi, Shemila; Khan, Fauzia Anis; Khan, Sobia

2018-01-01

The role of critical incident (CI) reporting is well established in improving patient safety but only a limited number of available reports relate to pediatric incidents. Our aim was to analyze the reported CIs specific to pediatric patients in our database and to reevaluate the value of this program in addressing issues in pediatric anesthesia practice. Incidents related to pediatric population from neonatal period till the age of 12 years were selected. A review of all CI records collected between January 1998 and December 2012, in the Department of Anaesthesiology of Aga Khan University hospital was done. This was retrospective form review. The Department has a structured CI form in use since 1998 which is intermittently evaluated and modified if needed. A total of 451 pediatric CIs were included. Thirty-four percent of the incidents were reported in infants. Ninety-six percent of the reported incidents took place during elective surgery and 4% during emergency surgery. Equipment-related events (n = 114), respiratory events (n = 112), and drug events (n = 110) were equally distributed (25.6%, 25.3%, and 24.7%). Human factors accounted for 74% of reports followed by, equipment failure (10%) and patient factors (8%). Only 5% of the incidents were system errors. Failure to check (equipment/drugs/doses) was the most common cause for human factors. Poor outcome was seen in 7% of cases. Medication and equipment are the clinical areas that need to be looked at more closely. We also recommend quality improvement projects in both these areas as well as training of residents and staff in managing airway-related problems in pediatric patients.

Underlying Cause(s) of Letter Perseveration Errors

PubMed Central

Fischer-Baum, Simon; Rapp, Brenda

2011-01-01

Perseverations, the inappropriate intrusion of elements from a previous response into a current response, are commonly observed in individuals with acquired deficits. This study specifically investigates the contribution of failure-to activate and failure-to-inhibit deficit(s) in the generation of letter perseveration errors in acquired dysgraphia. We provide evidence from the performance 12 dysgraphic individuals indicating that a failure to activate graphemes for a target word gives rise to letter perseveration errors. In addition, we also provide evidence that, in some individuals, a failure-to-inhibit deficit may also contribute to the production of perseveration errors. PMID:22178232

40 CFR 63.140 - Process wastewater provisions-delay of repair.

Code of Federal Regulations, 2010 CFR

2010-07-01

... or a gap, crack, tear, or hole has been identified, is allowed if the repair is technically.... (b) Delay of repair of equipment for which a control equipment failure or a gap, crack, tear, or hole... equipment for which a control equipment failure or a gap, crack, tear, or hole has been identified is also...

Blowout Prevention System Events and Equipment Component Failures : 2016 SafeOCS Annual Report

DOT National Transportation Integrated Search

2017-09-22

The SafeOCS 2016 Annual Report, produced by the Bureau of Transportation Statistics (BTS), summarizes blowout prevention (BOP) equipment failures on marine drilling rigs in the Outer Continental Shelf. It includes an analysis of equipment component f...

Exception handling for sensor fusion

NASA Astrophysics Data System (ADS)

Chavez, G. T.; Murphy, Robin R.

1993-08-01

This paper presents a control scheme for handling sensing failures (sensor malfunctions, significant degradations in performance due to changes in the environment, and errant expectations) in sensor fusion for autonomous mobile robots. The advantages of the exception handling mechanism are that it emphasizes a fast response to sensing failures, is able to use only a partial causal model of sensing failure, and leads to a graceful degradation of sensing if the sensing failure cannot be compensated for. The exception handling mechanism consists of two modules: error classification and error recovery. The error classification module in the exception handler attempts to classify the type and source(s) of the error using a modified generate-and-test procedure. If the source of the error is isolated, the error recovery module examines its cache of recovery schemes, which either repair or replace the current sensing configuration. If the failure is due to an error in expectation or cannot be identified, the planner is alerted. Experiments using actual sensor data collected by the CSM Mobile Robotics/Machine Perception Laboratory's Denning mobile robot demonstrate the operation of the exception handling mechanism.

[Multicenter paragliding accident study 1990].

PubMed

Lautenschlager, S; Karli, U; Matter, P

1992-01-01

During the period from 1.1.90 until 31.12.90, 86 injuries associated with paragliding were analyzed in a prospective study in 12 different Swiss hospitals with reference to causes, patterns, and frequencies. The injuries showed a mean score of over 2 and were classified as severe. Most frequent spine injuries (36%) and lesions of the lower extremity (35%) with a high risk of the ankles were diagnosed. One accident was fatal. 60% of the accidents happened during landing, 26% during launching and 14% during flight. Half of the pilots were affected during their primary training course. Most accidents were caused by inflight error of judgement--especially incorrect estimation of wind conditions--and further the choice of unfavourable landing sites. In contrast to previous injury-reports, only one equipment failure could be noted, but often the equipment was not corresponding with the experience and the weight of the pilot. To reduce the frequency of paragliding-injuries an accurate choice of equipment and an increased attention to environmental factors is mandatory. Furthermore an education-program regarding the attitude and intelligence of the pilot should be included in training courses.

29 CFR 1910.1045 - Acrylonitrile.

Code of Federal Regulations, 2010 CFR

2010-07-01

..., equipment failure, rupture of containers, or failure of control equipment, which results in an unexpected... decontamination is completed. (l) Waste disposal. AN waste, scrap, debris, bags, containers, or equipment shall be.... (3) Labels. (i) The employer shall assure that precautionary labels are affixed to all containers of...

Failure analysis and modeling of a multicomputer system. M.S. Thesis

NASA Technical Reports Server (NTRS)

Subramani, Sujatha Srinivasan

1990-01-01

This thesis describes the results of an extensive measurement-based analysis of real error data collected from a 7-machine DEC VaxCluster multicomputer system. In addition to evaluating basic system error and failure characteristics, we develop reward models to analyze the impact of failures and errors on the system. The results show that, although 98 percent of errors in the shared resources recover, they result in 48 percent of all system failures. The analysis of rewards shows that the expected reward rate for the VaxCluster decreases to 0.5 in 100 days for a 3 out of 7 model, which is well over a 100 times that for a 7-out-of-7 model. A comparison of the reward rates for a range of k-out-of-n models indicates that the maximum increase in reward rate (0.25) occurs in going from the 6-out-of-7 model to the 5-out-of-7 model. The analysis also shows that software errors have the lowest reward (0.2 vs. 0.91 for network errors). The large loss in reward rate for software errors is due to the fact that a large proportion (94 percent) of software errors lead to failure. In comparison, the high reward rate for network errors is due to fast recovery from a majority of these errors (median recovery duration is 0 seconds).

Normal accidents: Living with high-risk technologies

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

Perrow, Ch.

1984-01-01

It was a major nuclear accident, the one at Three Mile Island in 1979, that turned Perrow's attention to accidents in general. A specialist in the sociology of organizations, he soon learned that events at TMI were not simply the result of an engineering failure or the result of operator error; rather, they were a consequence of systems failure. What the author learned from his research into the accident at TMI is that there was no coherent theory of accidents in either the engineering or the social science literature, so he set out to create one. This book discusses themore » science of accident research. Since Perrow is an outsider to all of the many technical fields reviewed in the book, ranging from nuclear power to marine transport to DNA research, experts may challenge his sources and point out his errors. Perrow's central thesis is that accidents are inevitable - that is, they are ''normal'' - in technologies that have two system characteristics that he terms ''interactive complexity'' and ''tight coupling''. Using these concepts, Perrow constructs a theory of systems which he believes to be unique in the literature on accidents and the literature on organizations. His theory concentrates upon the properties of systems themselves, rather than on the errors that owners, designers and operators make in running them. He seeks a more basic explanation than operator error; faulty design or equipment; inadequately trained personnel; or the system is too big, under-financed or mismanaged. Nuclear power in the United States may not survive its current economic and regulatory troubles, but discussion continues. Only a small part of the debate concerns plant safety: economic competitiveness, nuclear arms proliferation and nuclear waste disposal are the salient themes.« less

Errors in Bibliographic Citations: A Continuing Problem.

ERIC Educational Resources Information Center

Sweetland, James H.

1989-01-01

Summarizes studies examining citation errors and illustrates errors resulting from a lack of standardization, misunderstanding of foreign languages, failure to examine the document cited, and general lack of training in citation norms. It is argued that the failure to detect and correct citation errors is due to diffusion of responsibility in the…

30 CFR 285.815 - What must I do if I have facility damage or an equipment failure?

Code of Federal Regulations, 2011 CFR

2011-07-01

... Assessments for Activities Conducted Under SAPs, COPs and GAPs Equipment Failure and Adverse Environmental... damage or failure under § 285.831, MMS may require you to revise your SAP, COP, or GAP to describe how you will address the facility damage or failure as required by § 285.634 (COP), § 285.617 (SAP), § 285...

Failure prediction using machine learning and time series in optical network.

PubMed

Wang, Zhilong; Zhang, Min; Wang, Danshi; Song, Chuang; Liu, Min; Li, Jin; Lou, Liqi; Liu, Zhuo

2017-08-07

In this paper, we propose a performance monitoring and failure prediction method in optical networks based on machine learning. The primary algorithms of this method are the support vector machine (SVM) and double exponential smoothing (DES). With a focus on risk-aware models in optical networks, the proposed protection plan primarily investigates how to predict the risk of an equipment failure. To the best of our knowledge, this important problem has not yet been fully considered. Experimental results showed that the average prediction accuracy of our method was 95% when predicting the optical equipment failure state. This finding means that our method can forecast an equipment failure risk with high accuracy. Therefore, our proposed DES-SVM method can effectively improve traditional risk-aware models to protect services from possible failures and enhance the optical network stability.

Visual feedback system to reduce errors while operating roof bolting machines

PubMed Central

Steiner, Lisa J.; Burgess-Limerick, Robin; Eiter, Brianna; Porter, William; Matty, Tim

2015-01-01

Problem Operators of roof bolting machines in underground coal mines do so in confined spaces and in very close proximity to the moving equipment. Errors in the operation of these machines can have serious consequences, and the design of the equipment interface has a critical role in reducing the probability of such errors. Methods An experiment was conducted to explore coding and directional compatibility on actual roof bolting equipment and to determine the feasibility of a visual feedback system to alert operators of critical movements and to also alert other workers in close proximity to the equipment to the pending movement of the machine. The quantitative results of the study confirmed the potential for both selection errors and direction errors to be made, particularly during training. Results Subjective data confirmed a potential benefit of providing visual feedback of the intended operations and movements of the equipment. Impact This research may influence the design of these and other similar control systems to provide evidence for the use of warning systems to improve operator situational awareness. PMID:23398703

Spacecraft and propulsion technician error

NASA Astrophysics Data System (ADS)

Schultz, Daniel Clyde

Commercial aviation and commercial space similarly launch, fly, and land passenger vehicles. Unlike aviation, the U.S. government has not established maintenance policies for commercial space. This study conducted a mixed methods review of 610 U.S. space launches from 1984 through 2011, which included 31 failures. An analysis of the failure causal factors showed that human error accounted for 76% of those failures, which included workmanship error accounting for 29% of the failures. With the imminent future of commercial space travel, the increased potential for the loss of human life demands that changes be made to the standardized procedures, training, and certification to reduce human error and failure rates. Several recommendations were made by this study to the FAA's Office of Commercial Space Transportation, space launch vehicle operators, and maintenance technician schools in an effort to increase the safety of the space transportation passengers.

30 CFR 585.815 - What must I do if I have facility damage or an equipment failure?

Code of Federal Regulations, 2014 CFR

2014-07-01

... Conducted Under SAPs, COPs and GAPs Equipment Failure and Adverse Environmental Effects § 585.815 What must... failure under § 585.831, BOEM may require you to revise your SAP, COP, or GAP to describe how you will address the facility damage or failure as required by § 585.634 (COP), § 585.617 (SAP), § 585.655 (GAP...

30 CFR 585.815 - What must I do if I have facility damage or an equipment failure?

Code of Federal Regulations, 2012 CFR

2012-07-01

... Conducted Under SAPs, COPs and GAPs Equipment Failure and Adverse Environmental Effects § 585.815 What must... failure under § 585.831, BOEM may require you to revise your SAP, COP, or GAP to describe how you will address the facility damage or failure as required by § 585.634 (COP), § 585.617 (SAP), § 585.655 (GAP...

30 CFR 585.815 - What must I do if I have facility damage or an equipment failure?

Code of Federal Regulations, 2013 CFR

2013-07-01

... Conducted Under SAPs, COPs and GAPs Equipment Failure and Adverse Environmental Effects § 585.815 What must... failure under § 585.831, BOEM may require you to revise your SAP, COP, or GAP to describe how you will address the facility damage or failure as required by § 585.634 (COP), § 585.617 (SAP), § 585.655 (GAP...

Modeling the Influences of Electrostatic Discharge in Materials on a Failures of Onboard Electronic Equipment in under Microgcrogravity

NASA Astrophysics Data System (ADS)

Grichshenko, Valentina; Zhantayev, Zhumabek; Mukushev, Acemhan

2016-07-01

It is known, that during SV exploitation failures of automated systems happens as the result of complex influence of Space leading to SV's shorter life span, sometimes to their lose. All of the SV, functioning in the near-Earth Space (NES), subjected to influence of different Space factors. Causes and character of failure onboard equipment are different. Many researchers think that failures of onboard electronics connected to changing solar activity level. However, by the numerous onboard experiments established that even in the absence of solar burst in magnetostatic days there are registered failures of onboard electronics. In this paper discussed the results of modeling the impact of electrostatic discharge (ESD), occurring in the materials, on a failures of electronic onboard equipment in microgravity. The paper discusses the conditions of formation and influence of electrostatic discharge in microgravity on the elements of the onboard electronics in Space. Developed technique using circuit simulation in ISIS Proteus environment is discussed. Developed the recommendations for noise immunity of on-board equipment from ESD in Space. The results are used to predict the failure rate on-board electronics with the long term of space mission. Key words: microgravity, materials, failures, onboard electronics, Space

Tailoring a Human Reliability Analysis to Your Industry Needs

NASA Technical Reports Server (NTRS)

DeMott, D. L.

2016-01-01

Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.

Virtual-Instrument-Based Online Monitoring System for Hands-on Laboratory Experiment of Partial Discharges

ERIC Educational Resources Information Center

Karmakar, Subrata

2017-01-01

Online monitoring of high-voltage (HV) equipment is a vital tool for early detection of insulation failure. Most insulation failures are caused by partial discharges (PDs) inside the HV equipment. Because of the very high cost of establishing HV equipment facility and the limitations of electromagnetic interference-screened laboratories, only a…

Science, practice, and human errors in controlling Clostridium botulinum in heat-preserved food in hermetic containers.

PubMed

Pflug, Irving J

2010-05-01

The incidence of botulism in canned food in the last century is reviewed along with the background science; a few conclusions are reached based on analysis of published data. There are two primary aspects to botulism control: the design of an adequate process and the delivery of the adequate process to containers of food. The probability that the designed process will not be adequate to control Clostridium botulinum is very small, probably less than 1.0 x 10(-6), based on containers of food, whereas the failure of the operator of the processing equipment to deliver the specified process to containers of food may be of the order of 1 in 40, to 1 in 100, based on processing units (retort loads). In the commercial food canning industry, failure to deliver the process will probably be of the order of 1.0 x 10(-4) to 1.0 x 10(-6) when U.S. Food and Drug Administration (FDA) regulations are followed. Botulism incidents have occurred in food canning plants that have not followed the FDA regulations. It is possible but very rare to have botulism result from postprocessing contamination. It may thus be concluded that botulism incidents in canned food are primarily the result of human failure in the delivery of the designed or specified process to containers of food that, in turn, result in the survival, outgrowth, and toxin production of C. botulinum spores. Therefore, efforts in C. botulinum control should be concentrated on reducing human errors in the delivery of the specified process to containers of food.

Quality assurance in mammography: artifact analysis.

PubMed

Hogge, J P; Palmer, C H; Muller, C C; Little, S T; Smith, D C; Fatouros, P P; de Paredes, E S

1999-01-01

Evaluation of mammograms for artifacts is essential for mammographic quality assurance. A variety of mammographic artifacts (i.e., variations in mammographic density not caused by true attenuation differences) can occur and can create pseudolesions or mask true abnormalities. Many artifacts are readily identified, whereas others present a true diagnostic challenge. Factors that create artifacts may be related to the processor (eg, static, dirt or excessive developer buildup on the rollers, excessive roller pressure, damp film, scrapes and scratches, incomplete fixing, power failure, contaminated developer), the technologist (eg, improper film handling and loading, improper use of the mammography unit and related equipment, positioning and darkroom errors), the mammography unit (eg, failure of the collimation mirror to rotate, grid inhomogeneity, failure of the reciprocating grid to move, material in the tube housing, compression failure, improper alignment of the compression paddle with the Bucky tray, defective compression paddle), or the patient (e.g., motion, superimposed objects or substances [jewelry, body parts, clothing, hair, implanted medical devices, foreign bodies, substances on the skin]). Familiarity with the broad range of artifacts and the measures required to eliminate them is vital. Careful attention to darkroom cleanliness, care in film handling, regularly scheduled processor maintenance and chemical replenishment, daily quality assurance activities, and careful attention to detail during patient positioning and mammography can reduce or eliminate most mammographic artifacts.

PACS quality control and automatic problem notifier

NASA Astrophysics Data System (ADS)

Honeyman-Buck, Janice C.; Jones, Douglas; Frost, Meryll M.; Staab, Edward V.

1997-05-01

One side effect of installing a clinical PACS Is that users become dependent upon the technology and in some cases it can be very difficult to revert back to a film based system if components fail. The nature of system failures range from slow deterioration of function as seen in the loss of monitor luminance through sudden catastrophic loss of the entire PACS networks. This paper describes the quality control procedures in place at the University of Florida and the automatic notification system that alerts PACS personnel when a failure has happened or is anticipated. The goal is to recover from a failure with a minimum of downtime and no data loss. Routine quality control is practiced on all aspects of PACS, from acquisition, through network routing, through display, and including archiving. Whenever possible, the system components perform self and between platform checks for active processes, file system status, errors in log files, and system uptime. When an error is detected or a exception occurs, an automatic page is sent to a pager with a diagnostic code. Documentation on each code, trouble shooting procedures, and repairs are kept on an intranet server accessible only to people involved in maintaining the PACS. In addition to the automatic paging system for error conditions, acquisition is assured by an automatic fax report sent on a daily basis to all technologists acquiring PACS images to be used as a cross check that all studies are archived prior to being removed from the acquisition systems. Daily quality control is preformed to assure that studies can be moved from each acquisition and contrast adjustment. The results of selected quality control reports will be presented. The intranet documentation server will be described with the automatic pager system. Monitor quality control reports will be described and the cost of quality control will be quantified. As PACS is accepted as a clinical tool, the same standards of quality control must be established as are expected on other equipment used in the diagnostic process.

New technologies in radiation therapy: ensuring patient safety, radiation safety and regulatory issues in radiation oncology.

PubMed

Amols, Howard I

2008-11-01

New technologies such as intensity modulated and image guided radiation therapy, computer controlled linear accelerators, record and verify systems, electronic charts, and digital imaging have revolutionized radiation therapy over the past 10-15 y. Quality assurance (QA) as historically practiced and as recommended in reports such as American Association of Physicists in Medicine Task Groups 40 and 53 needs to be updated to address the increasing complexity and computerization of radiotherapy equipment, and the increased quantity of data defining a treatment plan and treatment delivery. While new technology has reduced the probability of many types of medical events, seeing new types of errors caused by improper use of new technology, communication failures between computers, corrupted or erroneous computer data files, and "software bugs" are now being seen. The increased use of computed tomography, magnetic resonance, and positron emission tomography imaging has become routine for many types of radiotherapy treatment planning, and QA for imaging modalities is beyond the expertise of most radiotherapy physicists. Errors in radiotherapy rarely result solely from hardware failures. More commonly they are a combination of computer and human errors. The increased use of radiosurgery, hypofractionation, more complex intensity modulated treatment plans, image guided radiation therapy, and increasing financial pressures to treat more patients in less time will continue to fuel this reliance on high technology and complex computer software. Clinical practitioners and regulatory agencies are beginning to realize that QA for new technologies is a major challenge and poses dangers different in nature than what are historically familiar.

Adaptive optimisation-offline cyber attack on remote state estimator

NASA Astrophysics Data System (ADS)

Huang, Xin; Dong, Jiuxiang

2017-10-01

Security issues of cyber-physical systems have received increasing attentions in recent years. In this paper, deception attacks on the remote state estimator equipped with the chi-squared failure detector are considered, and it is assumed that the attacker can monitor and modify all the sensor data. A novel adaptive optimisation-offline cyber attack strategy is proposed, where using the current and previous sensor data, the attack can yield the largest estimation error covariance while ensuring to be undetected by the chi-squared monitor. From the attacker's perspective, the attack is better than the existing linear deception attacks to degrade the system performance. Finally, some numerical examples are provided to demonstrate theoretical results.

Risk of Performance and Behavioral Health Decrements Due to Inadequate Cooperation, Coordination, Communication, and Psychosocial Adaptation within a Team

NASA Technical Reports Server (NTRS)

Landon, Lauren Blackwell; Vessey, William B.; Barrett, Jamie D.

2015-01-01

A team is defined as: "two or more individuals who interact socially and adaptively, have shared or common goals, and hold meaningful task interdependences; it is hierarchically structured and has a limited life span; in it expertise and roles are distributed; and it is embedded within an organization/environmental context that influences and is influenced by ongoing processes and performance outcomes" (Salas, Stagl, Burke, & Goodwin, 2007, p. 189). From the NASA perspective, a team is commonly understood to be a collection of individuals that is assigned to support and achieve a particular mission. Thus, depending on context, this definition can encompass both the spaceflight crew and the individuals and teams in the larger multi-team system who are assigned to support that crew during a mission. The Team Risk outcomes of interest are predominantly performance related, with a secondary emphasis on long-term health; this is somewhat unique in the NASA HRP in that most Risk areas are medically related and primarily focused on long-term health consequences. In many operational environments (e.g., aviation), performance is assessed as the avoidance of errors. However, the research on performance errors is ambiguous. It implies that actions may be dichotomized into "correct" or "incorrect" responses, where incorrect responses or errors are always undesirable. Researchers have argued that this dichotomy is a harmful oversimplification, and it would be more productive to focus on the variability of human performance and how organizations can manage that variability (Hollnagel, Woods, & Leveson, 2006) (Category III1). Two problems occur when focusing on performance errors: 1) the errors are infrequent and, therefore, difficult to observe and record; and 2) the errors do not directly correspond to failure. Research reveals that humans are fairly adept at correcting or compensating for performance errors before such errors result in recognizable or recordable failures. Astronauts are notably adept high performers. Most failures are recorded only when multiple, small errors occur and humans are unable to recognize and correct or compensate for these errors in time to prevent a failure (Dismukes, Berman, Loukopoulos, 2007) (Category III). More commonly, observers record variability in levels of performance. Some teams commit no observable errors but fail to achieve performance objectives or perform only adequately, while other teams commit some errors but perform spectacularly. Successful performance, therefore, cannot be viewed as simply the absence of errors or the avoidance of failure Johnson Space Center (JSC) Joint Leadership Team, 2008). While failure is commonly attributed to making a major error, focusing solely on the elimination of error(s) does not significantly reduce the risk of failure. Failure may also occur when performance is simply insufficient or an effort is incapable of adjusting sufficiently to a contextual change (e.g., changing levels of autonomy).

Reliability Evaluation and Improvement Approach of Chemical Production Man - Machine - Environment System

NASA Astrophysics Data System (ADS)

Miao, Yongchun; Kang, Rongxue; Chen, Xuefeng

2017-12-01

In recent years, with the gradual extension of reliability research, the study of production system reliability has become the hot topic in various industries. Man-machine-environment system is a complex system composed of human factors, machinery equipment and environment. The reliability of individual factor must be analyzed in order to gradually transit to the research of three-factor reliability. Meanwhile, the dynamic relationship among man-machine-environment should be considered to establish an effective blurry evaluation mechanism to truly and effectively analyze the reliability of such systems. In this paper, based on the system engineering, fuzzy theory, reliability theory, human error, environmental impact and machinery equipment failure theory, the reliabilities of human factor, machinery equipment and environment of some chemical production system were studied by the method of fuzzy evaluation. At last, the reliability of man-machine-environment system was calculated to obtain the weighted result, which indicated that the reliability value of this chemical production system was 86.29. Through the given evaluation domain it can be seen that the reliability of man-machine-environment integrated system is in a good status, and the effective measures for further improvement were proposed according to the fuzzy calculation results.

Augmenting Probabilistic Risk Assesment with Malevolent Initiators

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

Curtis Smith; David Schwieder

2011-11-01

As commonly practiced, the use of probabilistic risk assessment (PRA) in nuclear power plants only considers accident initiators such as natural hazards, equipment failures, and human error. Malevolent initiators are ignored in PRA, but are considered the domain of physical security, which uses vulnerability assessment based on an officially specified threat (design basis threat). This paper explores the implications of augmenting and extending existing PRA models by considering new and modified scenarios resulting from malevolent initiators. Teaming the augmented PRA models with conventional vulnerability assessments can cost-effectively enhance security of a nuclear power plant. This methodology is useful for operatingmore » plants, as well as in the design of new plants. For the methodology, we have proposed an approach that builds on and extends the practice of PRA for nuclear power plants for security-related issues. Rather than only considering 'random' failures, we demonstrated a framework that is able to represent and model malevolent initiating events and associated plant impacts.« less

Independent Orbiter Assessment (IOA): Analysis of the crew equipment subsystem

NASA Technical Reports Server (NTRS)

Sinclair, Susan; Graham, L.; Richard, Bill; Saxon, H.

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical (PCIs) items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results coresponding to the Orbiter crew equipment hardware are documented. The IOA analysis process utilized available crew equipment hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 352 failure modes analyzed, 78 were determined to be PCIs.

A Longitudinal Analysis of the Causal Factors in Major Maritime Accidents in the USA and Canada (1996-2006)

NASA Technical Reports Server (NTRS)

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

2007-01-01

Accident reports provide important insights into the causes and contributory factors leading to particular adverse events. In contrast, this paper provides an analysis that extends across the findings presented over ten years investigations into maritime accidents by both the US National Transportation Safety Board (NTSB) and Canadian Transportation Safety Board (TSB). The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of adverse events. In order to communicate our findings, we introduce J-H graphs as a means of representing the proportion of causes and contributory factors associated with human error, equipment failure and other high level classifications in longitudinal studies of accident reports. Our results suggest the proportion of causal and contributory factors attributable to direct human error may be very much smaller than has been suggested elsewhere in the human factors literature. In contrast, more attention should be paid to wider systemic issues, including the managerial and regulatory context of maritime operations.

Analysis of F-16 radar discrepancies

NASA Astrophysics Data System (ADS)

Riche, K. A.

1982-12-01

One hundred and eight aircraft were randomly selected from three USAF F-16 bases and examined. These aircraft included 63 single-seat F-16As and 45 two-seat F-16Bs and encompassed 8,525 sorties and 748 radar system write-ups. Programs supported by the Statistical Package for the Social Sciences (SPSS) were run on the data. Of the 748 discrepancies, over one-third of them occurred within three sorties of each other and half within six sorties. Sixteen percent of all aircraft which had a discrepancy within three sorties had another write-up within the next three sorties. Designated repeat/recurring write-ups represented one-third of all the instances in which the write-up separation interval was three sorties or less. This is an indication that maintenance is unable to correct equipment failures as they occur, most likely because the false alarm rate is too high and maintenance is unable to duplicate the error conditions on the ground for correct error diagnosis.

Simplified Approach Charts Improve Data Retrieval Performance

PubMed Central

Stewart, Michael; Laraway, Sean; Jordan, Kevin; Feary, Michael S.

2016-01-01

The effectiveness of different instrument approach charts to deliver minimum visibility and altitude information during airport equipment outages was investigated. Eighteen pilots flew simulated instrument approaches in three conditions: (a) normal operations using a standard approach chart (standard-normal), (b) equipment outage conditions using a standard approach chart (standard-outage), and (c) equipment outage conditions using a prototype decluttered approach chart (prototype-outage). Errors and retrieval times in identifying minimum altitudes and visibilities were measured. The standard-outage condition produced significantly more errors and longer retrieval times versus the standard-normal condition. The prototype-outage condition had significantly fewer errors and shorter retrieval times than did the standard-outage condition. The prototype-outage condition produced significantly fewer errors but similar retrieval times when compared with the standard-normal condition. Thus, changing the presentation of minima may reduce risk and increase safety in instrument approaches, specifically with airport equipment outages. PMID:28491009

Using failure mode and effects analysis to improve the safety of neonatal parenteral nutrition.

PubMed

Arenas Villafranca, Jose Javier; Gómez Sánchez, Araceli; Nieto Guindo, Miriam; Faus Felipe, Vicente

2014-07-15

Failure mode and effects analysis (FMEA) was used to identify potential errors and to enable the implementation of measures to improve the safety of neonatal parenteral nutrition (PN). FMEA was used to analyze the preparation and dispensing of neonatal PN from the perspective of the pharmacy service in a general hospital. A process diagram was drafted, illustrating the different phases of the neonatal PN process. Next, the failures that could occur in each of these phases were compiled and cataloged, and a questionnaire was developed in which respondents were asked to rate the following aspects of each error: incidence, detectability, and severity. The highest scoring failures were considered high risk and identified as priority areas for improvements to be made. The evaluation process detected a total of 82 possible failures. Among the phases with the highest number of possible errors were transcription of the medical order, formulation of the PN, and preparation of material for the formulation. After the classification of these 82 possible failures and of their relative importance, a checklist was developed to achieve greater control in the error-detection process. FMEA demonstrated that use of the checklist reduced the level of risk and improved the detectability of errors. FMEA was useful for detecting medication errors in the PN preparation process and enabling corrective measures to be taken. A checklist was developed to reduce errors in the most critical aspects of the process. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Fault Injection Techniques and Tools

NASA Technical Reports Server (NTRS)

Hsueh, Mei-Chen; Tsai, Timothy K.; Iyer, Ravishankar K.

1997-01-01

Dependability evaluation involves the study of failures and errors. The destructive nature of a crash and long error latency make it difficult to identify the causes of failures in the operational environment. It is particularly hard to recreate a failure scenario for a large, complex system. To identify and understand potential failures, we use an experiment-based approach for studying the dependability of a system. Such an approach is applied not only during the conception and design phases, but also during the prototype and operational phases. To take an experiment-based approach, we must first understand a system's architecture, structure, and behavior. Specifically, we need to know its tolerance for faults and failures, including its built-in detection and recovery mechanisms, and we need specific instruments and tools to inject faults, create failures or errors, and monitor their effects.

40 CFR 63.301 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-07-01

... by common walls, where coal undergoes destructive distillation under positive pressure to produce..., infrequent, and not reasonably preventable failure of air pollution control equipment, process equipment, or... emission limitations in an applicable standard to be exceeded. Failures caused in part by poor maintenance...

Mars Exploration Rover Potentiometer Problems, Failures and Lessons Learned

NASA Technical Reports Server (NTRS)

Balzer, Mark

2006-01-01

During qualification testing of three types of non-wire-wound precision potentiometers for the Mars Exploration Rover, a variety of problems and failures were encountered. This paper will describe some of the more interesting problems, detail their investigations and present their final solutions. The failures were found to be caused by design errors, manufacturing errors, improper handling, test errors, and carelessness. A trend of decreasing total resistance was noted, and a resistance histogram was used to identify an outlier. A gang fixture is described for simultaneously testing multiple pots, and real time X-ray imaging was used extensively to assist in the failure analyses. Lessons learned are provided.

Mars Exploration Rover potentiometer problems, failures and lessons learned

NASA Technical Reports Server (NTRS)

Balzer, Mark A.

2006-01-01

During qualification testing of three types of nonwire-wound precision potentiometers for the Mars Exploration Rover, a variety of problems and failures were encountered. This paper will describe some of the more interesting problems, detail their investigations and present their final solutions. The failures were found to be caused by design errors, manufacturing errors, improper handling, test errors, and carelessness. A trend of decreasing total resistance was noted, and a resistance histogram was used to identify an outlier. A gang fixture is described for simultaneously testing multiple pots, and real time X-ray imaging was used extensively to assist in the failure analyses. Lessons learned are provided.

A Reliable Wireless Control System for Tomato Hydroponics

PubMed Central

Ibayashi, Hirofumi; Kaneda, Yukimasa; Imahara, Jungo; Oishi, Naoki; Kuroda, Masahiro; Mineno, Hiroshi

2016-01-01

Agricultural systems using advanced information and communication (ICT) technology can produce high-quality crops in a stable environment while decreasing the need for manual labor. The system collects a wide variety of environmental data and provides the precise cultivation control needed to produce high value-added crops; however, there are the problems of packet transmission errors in wireless sensor networks or system failure due to having the equipment in a hot and humid environment. In this paper, we propose a reliable wireless control system for hydroponic tomato cultivation using the 400 MHz wireless band and the IEEE 802.15.6 standard. The 400 MHz band, which is lower than the 2.4 GHz band, has good obstacle diffraction, and zero-data-loss communication is realized using the guaranteed time-slot method supported by the IEEE 802.15.6 standard. In addition, this system has fault tolerance and a self-healing function to recover from faults such as packet transmission failures due to deterioration of the wireless communication quality. In our basic experiments, the 400 MHz band wireless communication was not affected by the plants’ growth, and the packet error rate was less than that of the 2.4 GHz band. In summary, we achieved a real-time hydroponic liquid supply control with no data loss by applying a 400 MHz band WSN to hydroponic tomato cultivation. PMID:27164105

A Reliable Wireless Control System for Tomato Hydroponics.

PubMed

Ibayashi, Hirofumi; Kaneda, Yukimasa; Imahara, Jungo; Oishi, Naoki; Kuroda, Masahiro; Mineno, Hiroshi

2016-05-05

Agricultural systems using advanced information and communication (ICT) technology can produce high-quality crops in a stable environment while decreasing the need for manual labor. The system collects a wide variety of environmental data and provides the precise cultivation control needed to produce high value-added crops; however, there are the problems of packet transmission errors in wireless sensor networks or system failure due to having the equipment in a hot and humid environment. In this paper, we propose a reliable wireless control system for hydroponic tomato cultivation using the 400 MHz wireless band and the IEEE 802.15.6 standard. The 400 MHz band, which is lower than the 2.4 GHz band, has good obstacle diffraction, and zero-data-loss communication is realized using the guaranteed time-slot method supported by the IEEE 802.15.6 standard. In addition, this system has fault tolerance and a self-healing function to recover from faults such as packet transmission failures due to deterioration of the wireless communication quality. In our basic experiments, the 400 MHz band wireless communication was not affected by the plants' growth, and the packet error rate was less than that of the 2.4 GHz band. In summary, we achieved a real-time hydroponic liquid supply control with no data loss by applying a 400 MHz band WSN to hydroponic tomato cultivation.

FMEA of manual and automated methods for commissioning a radiotherapy treatment planning system.

PubMed

Wexler, Amy; Gu, Bruce; Goddu, Sreekrishna; Mutic, Maya; Yaddanapudi, Sridhar; Olsen, Lindsey; Harry, Taylor; Noel, Camille; Pawlicki, Todd; Mutic, Sasa; Cai, Bin

2017-09-01

To evaluate the level of risk involved in treatment planning system (TPS) commissioning using a manual test procedure, and to compare the associated process-based risk to that of an automated commissioning process (ACP) by performing an in-depth failure modes and effects analysis (FMEA). The authors collaborated to determine the potential failure modes of the TPS commissioning process using (a) approaches involving manual data measurement, modeling, and validation tests and (b) an automated process utilizing application programming interface (API) scripting, preloaded, and premodeled standard radiation beam data, digital heterogeneous phantom, and an automated commissioning test suite (ACTS). The severity (S), occurrence (O), and detectability (D) were scored for each failure mode and the risk priority numbers (RPN) were derived based on TG-100 scale. Failure modes were then analyzed and ranked based on RPN. The total number of failure modes, RPN scores and the top 10 failure modes with highest risk were described and cross-compared between the two approaches. RPN reduction analysis is also presented and used as another quantifiable metric to evaluate the proposed approach. The FMEA of a MTP resulted in 47 failure modes with an RPN ave of 161 and S ave of 6.7. The highest risk process of "Measurement Equipment Selection" resulted in an RPN max of 640. The FMEA of an ACP resulted in 36 failure modes with an RPN ave of 73 and S ave of 6.7. The highest risk process of "EPID Calibration" resulted in an RPN max of 576. An FMEA of treatment planning commissioning tests using automation and standardization via API scripting, preloaded, and pre-modeled standard beam data, and digital phantoms suggests that errors and risks may be reduced through the use of an ACP. © 2017 American Association of Physicists in Medicine.

Tin Whiskers: A History of Documented Electrical System Failures

NASA Technical Reports Server (NTRS)

Leidecker, Henning; Brusse, Jay

2006-01-01

This viewgraph presentation reviews the history of tin and other metal whiskers, and the damage they have caused equipment. There are pictures of whiskers on various pieces of electronic equipment, and microscopic views of whiskers. There is also a chart with information on the documented failures associated with metal whiskers. There are also examples of on-orbit failures believed to be caused by whiskers.

Error analysis and experiments of attitude measurement using laser gyroscope

NASA Astrophysics Data System (ADS)

Ren, Xin-ran; Ma, Wen-li; Jiang, Ping; Huang, Jin-long; Pan, Nian; Guo, Shuai; Luo, Jun; Li, Xiao

2018-03-01

The precision of photoelectric tracking and measuring equipment on the vehicle and vessel is deteriorated by the platform's movement. Specifically, the platform's movement leads to the deviation or loss of the target, it also causes the jitter of visual axis and then produces image blur. In order to improve the precision of photoelectric equipment, the attitude of photoelectric equipment fixed with the platform must be measured. Currently, laser gyroscope is widely used to measure the attitude of the platform. However, the measurement accuracy of laser gyro is affected by its zero bias, scale factor, installation error and random error. In this paper, these errors were analyzed and compensated based on the laser gyro's error model. The static and dynamic experiments were carried out on a single axis turntable, and the error model was verified by comparing the gyro's output with an encoder with an accuracy of 0.1 arc sec. The accuracy of the gyroscope has increased from 7000 arc sec to 5 arc sec for an hour after error compensation. The method used in this paper is suitable for decreasing the laser gyro errors in inertial measurement applications.

Syndromic surveillance for health information system failures: a feasibility study.

PubMed

Ong, Mei-Sing; Magrabi, Farah; Coiera, Enrico

2013-05-01

To explore the applicability of a syndromic surveillance method to the early detection of health information technology (HIT) system failures. A syndromic surveillance system was developed to monitor a laboratory information system at a tertiary hospital. Four indices were monitored: (1) total laboratory records being created; (2) total records with missing results; (3) average serum potassium results; and (4) total duplicated tests on a patient. The goal was to detect HIT system failures causing: data loss at the record level; data loss at the field level; erroneous data; and unintended duplication of data. Time-series models of the indices were constructed, and statistical process control charts were used to detect unexpected behaviors. The ability of the models to detect HIT system failures was evaluated using simulated failures, each lasting for 24 h, with error rates ranging from 1% to 35%. In detecting data loss at the record level, the model achieved a sensitivity of 0.26 when the simulated error rate was 1%, while maintaining a specificity of 0.98. Detection performance improved with increasing error rates, achieving a perfect sensitivity when the error rate was 35%. In the detection of missing results, erroneous serum potassium results and unintended repetition of tests, perfect sensitivity was attained when the error rate was as small as 5%. Decreasing the error rate to 1% resulted in a drop in sensitivity to 0.65-0.85. Syndromic surveillance methods can potentially be applied to monitor HIT systems, to facilitate the early detection of failures.

Human factors in airway facilities maintenance : development of a prototype outage assessment inventory.

DOT National Transportation Integrated Search

1994-02-01

The airway facilities (AF) maintenance community is concerned with identifying ways of reducing both the incidence of equipment failure and the amount of time required to restore equipment to operational status following a failure. It is vitally impo...

A 5 year longitudinal study of water quality for final rinsing in the single chamber washer-disinfector with a reverse osmosis plant.

PubMed

Uetera, Yushi; Kishii, Kozue; Yasuhara, Hiroshi; Kumada, Naohito; Moriya, Kyoji; Saito, Ryoichi; Okazaki, Mitsuhiro; Misawa, Yoshiki; Kawamura, Kunio

2013-01-01

This report deals with the construction and management of the reverse osmosis (RO) water system for final rinsing of surgical instruments in the washer-disinfector. Numerous operational challenges were encountered in our RO water system and these were analyzed utilizing the Ishikawa Fishbone diagram. The aim was to find potential problems and promote preventive system management for RO water. It was found that the measures that existed were inappropriate for preventing contamination in the heat-labile RO water system. The storage tank was found to be significantly contaminated and had to be replaced with a new one equipped with a sampling port and water drainage system. Additional filters and an UV treatment lamp were installed. The whole system disinfection started 1.5 years later using a peracetic acid-based compound after confirming the material compatibility. Operator errors were found when a new water engineer took over the duty from his predecessor. It was also found that there were some deficiencies in the standard operating procedures (SOPs), and that on-the-job training was not enough. The water engineer failed to disinfect the sampling port and water drainage system. The RO membrane had been used for 4 years, even though the SOP standard specified changing it as every 3 years. Various bacteria, such as Rothia mucilaginosa, were cultured from the RO water sampled from the equipment. Because Rothia mucilaginosa is a resident in the oral cavity and upper respiratory tract, it is believed that the bacteria were introduced into the system by the maintenance personnel or working environment. Therefore, the presence of R. mucilaginosa implied the failure of sanitary maintenance procedures. This study suggests that water systems should be designed based on the plans for profound system maintenance. It also suggests that SOP and on-the job training are essential to avoid any operator errors. These results must be carefully considered when either constructing new RO systems or performing maintenance and periodical examination of the equipment. Reverse osmosis (RO) water is used for final rinsing in our washer-disinfector. The authors used the Ishikawa Fishbone diagram to clarify the critical points for optimizing RO water quality. There existed no measures to prevent contamination in the heat-labile RO water system. The storage tank was significantly contaminated and had to be replaced with a new one equipped with a sampling port and water drainage system. Additional filters and an UV treatment lamp were installed. The whole system disinfection started 1.5 years later using a peracetic acid-based compound after confirming the material compatibility. Operator errors occurred when a new water engineer took over the duty from his predecessor. There were neither standard operating procedures (SOPs) nor on-the-job training. The new water engineer had failed to disinfect the sampling port and water drainage system. Rothia mucilaginosa was cultured from the RO water. It is a resident in the oral cavity and upper respiratory tract. This implied the possible failure of sanitary procedures in the system maintenance. The Ishikawa Fishbone diagram was useful for this study. It suggests that water systems should be designed with plans for system maintenance taken into account. It also suggests that SOP and on-the job training are essential in order to avoid operator errors.

A Decreasing Failure Rate, Mixed Exponential Model Applied to Reliability.

DTIC Science & Technology

1981-06-01

Trident missile systems have been observed. The mixed exponential distribu- tion has been shown to fit the life data for the electronic equipment on...these systems . This paper discusses some of the estimation problems which occur with the decreasing failure rate mixed exponential distribution when...assumption of constant or increasing failure rate seemed to be incorrect. 2. However, the design of this electronic equipment indicated that

Minimizing treatment planning errors in proton therapy using failure mode and effects analysis

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

Zheng, Yuanshui, E-mail: yuanshui.zheng@okc.procure.com; Johnson, Randall; Larson, Gary

Purpose: Failure mode and effects analysis (FMEA) is a widely used tool to evaluate safety or reliability in conventional photon radiation therapy. However, reports about FMEA application in proton therapy are scarce. The purpose of this study is to apply FMEA in safety improvement of proton treatment planning at their center. Methods: The authors performed an FMEA analysis of their proton therapy treatment planning process using uniform scanning proton beams. The authors identified possible failure modes in various planning processes, including image fusion, contouring, beam arrangement, dose calculation, plan export, documents, billing, and so on. For each error, the authorsmore » estimated the frequency of occurrence, the likelihood of being undetected, and the severity of the error if it went undetected and calculated the risk priority number (RPN). The FMEA results were used to design their quality management program. In addition, the authors created a database to track the identified dosimetric errors. Periodically, the authors reevaluated the risk of errors by reviewing the internal error database and improved their quality assurance program as needed. Results: In total, the authors identified over 36 possible treatment planning related failure modes and estimated the associated occurrence, detectability, and severity to calculate the overall risk priority number. Based on the FMEA, the authors implemented various safety improvement procedures into their practice, such as education, peer review, and automatic check tools. The ongoing error tracking database provided realistic data on the frequency of occurrence with which to reevaluate the RPNs for various failure modes. Conclusions: The FMEA technique provides a systematic method for identifying and evaluating potential errors in proton treatment planning before they result in an error in patient dose delivery. The application of FMEA framework and the implementation of an ongoing error tracking system at their clinic have proven to be useful in error reduction in proton treatment planning, thus improving the effectiveness and safety of proton therapy.« less

Minimizing treatment planning errors in proton therapy using failure mode and effects analysis.

PubMed

Zheng, Yuanshui; Johnson, Randall; Larson, Gary

2016-06-01

Failure mode and effects analysis (FMEA) is a widely used tool to evaluate safety or reliability in conventional photon radiation therapy. However, reports about FMEA application in proton therapy are scarce. The purpose of this study is to apply FMEA in safety improvement of proton treatment planning at their center. The authors performed an FMEA analysis of their proton therapy treatment planning process using uniform scanning proton beams. The authors identified possible failure modes in various planning processes, including image fusion, contouring, beam arrangement, dose calculation, plan export, documents, billing, and so on. For each error, the authors estimated the frequency of occurrence, the likelihood of being undetected, and the severity of the error if it went undetected and calculated the risk priority number (RPN). The FMEA results were used to design their quality management program. In addition, the authors created a database to track the identified dosimetric errors. Periodically, the authors reevaluated the risk of errors by reviewing the internal error database and improved their quality assurance program as needed. In total, the authors identified over 36 possible treatment planning related failure modes and estimated the associated occurrence, detectability, and severity to calculate the overall risk priority number. Based on the FMEA, the authors implemented various safety improvement procedures into their practice, such as education, peer review, and automatic check tools. The ongoing error tracking database provided realistic data on the frequency of occurrence with which to reevaluate the RPNs for various failure modes. The FMEA technique provides a systematic method for identifying and evaluating potential errors in proton treatment planning before they result in an error in patient dose delivery. The application of FMEA framework and the implementation of an ongoing error tracking system at their clinic have proven to be useful in error reduction in proton treatment planning, thus improving the effectiveness and safety of proton therapy.

Stability analysis of chalk sea cliffs using UAV photogrammetry

NASA Astrophysics Data System (ADS)

Barlow, John; Gilham, Jamie

2017-04-01

Cliff erosion and instability poses a significant hazard to communities and infrastructure located is coastal areas. We use point cloud and spectral data derived from close range digital photogrammetry to assess the stability of chalk sea cliffs located at Telscombe, UK. Data captured from an unmanned aerial vehicle (UAV) were used to generate dense point clouds for a 712 m section of cliff face which ranges from 20 to 49 m in height. Generated models fitted our ground control network within a standard error of 0.03 m. Structural features such as joints, bedding planes, and faults were manually mapped and are consistent with results from other studies that have been conducted using direct measurement in the field. Kinematic analysis of these data was used to identify the primary modes of failure at the site. Our results indicate that wedge failure is by far the most likely mode of slope instability. An analysis of sequential surveys taken from the summer of 2016 to the winter of 2017 indicate several large failures have occurred at the site. We establish the volume of failure through change detection between sequential data sets and use back analysis to determine the strength of shear surfaces for each failure. Our results show that data capture through UAV photogrammetry can provide useful information for slope stability analysis over long sections of cliff. The use of this technology offers significant benefits in equipment costs and field time over existing methods.

49 CFR 220.38 - Communication equipment failure.

Code of Federal Regulations, 2013 CFR

2013-10-01

... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD COMMUNICATIONS Radio and Wireless Communication Procedures § 220.38 Communication equipment failure. (a) Any radio or wireless communication device found not to be... other employee designated by the railroad shall be so notified as soon as practicable. (b) If a radio or...

49 CFR 220.38 - Communication equipment failure.

Code of Federal Regulations, 2010 CFR

2010-10-01

... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD COMMUNICATIONS Radio and Wireless Communication Procedures § 220.38 Communication equipment failure. (a) Any radio or wireless communication device found not to be... other employee designated by the railroad shall be so notified as soon as practicable. (b) If a radio or...

49 CFR 220.38 - Communication equipment failure.

Code of Federal Regulations, 2014 CFR

2014-10-01

... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAILROAD COMMUNICATIONS Radio and Wireless Communication Procedures § 220.38 Communication equipment failure. (a) Any radio or wireless communication device found not to be... other employee designated by the railroad shall be so notified as soon as practicable. (b) If a radio or...

Method and apparatus for faulty memory utilization

DOEpatents

Cher, Chen-Yong; Andrade Costa, Carlos H.; Park, Yoonho; Rosenburg, Bryan S.; Ryu, Kyung D.

2016-04-19

A method for faulty memory utilization in a memory system includes: obtaining information regarding memory health status of at least one memory page in the memory system; determining an error tolerance of the memory page when the information regarding memory health status indicates that a failure is predicted to occur in an area of the memory system affecting the memory page; initiating a migration of data stored in the memory page when it is determined that the data stored in the memory page is non-error-tolerant; notifying at least one application regarding a predicted operating system failure and/or a predicted application failure when it is determined that data stored in the memory page is non-error-tolerant and cannot be migrated; and notifying at least one application regarding the memory failure predicted to occur when it is determined that data stored in the memory page is error-tolerant.

32-Bit-Wide Memory Tolerates Failures

NASA Technical Reports Server (NTRS)

Buskirk, Glenn A.

1990-01-01

Electronic memory system of 32-bit words corrects bit errors caused by some common type of failures - even failure of entire 4-bit-wide random-access-memory (RAM) chip. Detects failure of two such chips, so user warned that ouput of memory may contain errors. Includes eight 4-bit-wide DRAM's configured so each bit of each DRAM assigned to different one of four parallel 8-bit words. Each DRAM contributes only 1 bit to each 8-bit word.

A U.S. Partnership with India and Poland to Track Acute Chemical Releases to Serve Public Health

PubMed Central

Ruckart, Perri Zeitz; Orr, Maureen; Pałaszewska-Tkacz, Anna; Dewan, Aruna; Kapil, Vikas

2009-01-01

We describe a collaborative effort between the U.S., India, and Poland to track acute chemical releases during 2005–2007. In all three countries, fixed facility events were more common than transportation-related events; manufacturing and transportation/warehousing were the most frequently involved industries; and equipment failure and human error were the primary contributing factors. The most commonly released nonpetroleum substances were ammonia (India), carbon monoxide (U.S.) and mercury (Poland). More events in India (54%) resulted in victims compared with Poland (15%) and the U.S. (9%). The pilot program showed it is possible to successfully conduct international surveillance of acute hazardous substances releases with careful interpretation of the findings. PMID:19826549

Noise test system of rotating machinery in nuclear power station based on microphone array

NASA Astrophysics Data System (ADS)

Chang, Xincai; Guan, Jishi; Qi, Liangcai

2017-12-01

Rotating machinery plays an important role in all walks of life. Once the equipment fails, equipment maintenance and shutdown will cause great social harm and economic losses. Equipment safety operations at nuclear power stations have always been of top priority. It is prone to noise when the equipment is out of order or aging. Failure to find or develop equipment at the initial stage of equipment failure or ageing will pose a serious threat to the safety of the plant’s equipment. In this paper, sound imaging diagnosis technology is applied as a supplementary method to the condition monitoring and diagnosis system of rotating machinery in nuclear power stations. It provides a powerful guarantee for the condition monitoring and fault diagnosis of rotating machinery in nuclear power stations.

Radiation Tests on 2Gb NAND Flash Memories

NASA Technical Reports Server (NTRS)

Nguyen, Duc N.; Guertin, Steven M.; Patterson, J. D.

2006-01-01

We report on SEE and TID tests of highly scaled Samsung 2Gbits flash memories. Both in-situ and biased interval irradiations were used to characterize the response of the total accumulated dose failures. The radiation-induced failures can be categorized as followings: single event upset (SEU) read errors in biased and unbiased modes, write errors, and single-event-functional-interrupt (SEFI) failures.

Development of KSC program for investigating and generating field failure rates. Reliability handbook for ground support equipment

NASA Technical Reports Server (NTRS)

Bloomquist, C. E.; Kallmeyer, R. H.

1972-01-01

Field failure rates and confidence factors are presented for 88 identifiable components of the ground support equipment at the John F. Kennedy Space Center. For most of these, supplementary information regarding failure mode and cause is tabulated. Complete reliability assessments are included for three systems, eight subsystems, and nine generic piece-part classifications. Procedures for updating or augmenting the reliability results are also included.

Syndromic surveillance for health information system failures: a feasibility study

PubMed Central

Ong, Mei-Sing; Magrabi, Farah; Coiera, Enrico

2013-01-01

Objective To explore the applicability of a syndromic surveillance method to the early detection of health information technology (HIT) system failures. Methods A syndromic surveillance system was developed to monitor a laboratory information system at a tertiary hospital. Four indices were monitored: (1) total laboratory records being created; (2) total records with missing results; (3) average serum potassium results; and (4) total duplicated tests on a patient. The goal was to detect HIT system failures causing: data loss at the record level; data loss at the field level; erroneous data; and unintended duplication of data. Time-series models of the indices were constructed, and statistical process control charts were used to detect unexpected behaviors. The ability of the models to detect HIT system failures was evaluated using simulated failures, each lasting for 24 h, with error rates ranging from 1% to 35%. Results In detecting data loss at the record level, the model achieved a sensitivity of 0.26 when the simulated error rate was 1%, while maintaining a specificity of 0.98. Detection performance improved with increasing error rates, achieving a perfect sensitivity when the error rate was 35%. In the detection of missing results, erroneous serum potassium results and unintended repetition of tests, perfect sensitivity was attained when the error rate was as small as 5%. Decreasing the error rate to 1% resulted in a drop in sensitivity to 0.65–0.85. Conclusions Syndromic surveillance methods can potentially be applied to monitor HIT systems, to facilitate the early detection of failures. PMID:23184193

Effects of simulated altitude on blood glucose meter performance: implications for in-flight blood glucose monitoring.

PubMed

Olateju, Tolu; Begley, Joseph; Flanagan, Daniel; Kerr, David

2012-07-01

Most manufacturers of blood glucose monitoring equipment do not give advice regarding the use of their meters and strips onboard aircraft, and some airlines have blood glucose testing equipment in the aircraft cabin medical bag. Previous studies using older blood glucose meters (BGMs) have shown conflicting results on the performance of both glucose oxidase (GOX)- and glucose dehydrogenase (GDH)-based meters at high altitude. The aim of our study was to evaluate the performance of four new-generation BGMs at sea level and at a simulated altitude equivalent to that used in the cabin of commercial aircrafts. Blood glucose measurements obtained by two GDH and two GOX BGMs at sea level and simulated altitude of 8000 feet in a hypobaric chamber were compared with measurements obtained using a YSI 2300 blood glucose analyzer as a reference method. Spiked venous blood samples of three different glucose levels were used. The accuracy of each meter was determined by calculating percentage error of each meter compared with the YSI reference and was also assessed against standard International Organization for Standardization (ISO) criteria. Clinical accuracy was evaluated using the consensus error grid method. The percentage (standard deviation) error for GDH meters at sea level and altitude was 13.36% (8.83%; for meter 1) and 12.97% (8.03%; for meter 2) with p = .784, and for GOX meters was 5.88% (7.35%; for meter 3) and 7.38% (6.20%; for meter 4) with p = .187. There was variation in the number of time individual meters met the standard ISO criteria ranging from 72-100%. Results from all four meters at both sea level and simulated altitude fell within zones A and B of the consensus error grid, using YSI as the reference. Overall, at simulated altitude, no differences were observed between the performance of GDH and GOX meters. Overestimation of blood glucose concentration was seen among individual meters evaluated, but none of the results obtained would have resulted in dangerous failure to detect and treat blood glucose errors or in giving treatment that was actually contradictory to that required. © 2012 Diabetes Technology Society.

29 CFR 1910.1052 - Methylene Chloride.

Code of Federal Regulations, 2010 CFR

2010-07-01

... limited to, equipment failure, rupture of containers, or failure of control equipment, which results, or... during every work shift, and the employee sampled is expected to have the highest MC exposure. (B) Short... indicate the highest likely 15-minute exposures during such operations for at least one employee in each...

Preventing medical errors by designing benign failures.

PubMed

Grout, John R

2003-07-01

One way to successfully reduce medical errors is to design health care systems that are more resistant to the tendencies of human beings to err. One interdisciplinary approach entails creating design changes, mitigating human errors, and making human error irrelevant to outcomes. This approach is intended to facilitate the creation of benign failures, which have been called mistake-proofing devices and forcing functions elsewhere. USING FAULT TREES TO DESIGN FORCING FUNCTIONS: A fault tree is a graphical tool used to understand the relationships that either directly cause or contribute to the cause of a particular failure. A careful analysis of a fault tree enables the analyst to anticipate how the process will behave after the change. EXAMPLE OF AN APPLICATION: A scenario in which a patient is scalded while bathing can serve as an example of how multiple fault trees can be used to design forcing functions. The first fault tree shows the undesirable event--patient scalded while bathing. The second fault tree has a benign event--no water. Adding a scald valve changes the outcome from the undesirable event ("patient scalded while bathing") to the benign event ("no water") Analysis of fault trees does not ensure or guarantee that changes necessary to eliminate error actually occur. Most mistake-proofing is used to prevent simple errors and to create well-defended processes, but complex errors can also result. The utilization of mistake-proofing or forcing functions can be thought of as changing the logic of a process. Errors that formerly caused undesirable failures can be converted into the causes of benign failures. The use of fault trees can provide a variety of insights into the design of forcing functions that will improve patient safety.

Failure: A Source of Progress in Maintenance and Design

NASA Astrophysics Data System (ADS)

Chaïb, R.; Taleb, M.; Benidir, M.; Verzea, I.; Bellaouar, A.

This approach, allows using the failure as a source of progress in maintenance and design to detect the most critical components in equipment, to determine the priority order maintenance actions to lead and direct the exploitation procedure towards the most penalizing links in this equipment, even define the necessary changes and recommendations for future improvement. Thus, appreciate the pathological behaviour of the material and increase its availability, even increase its lifespan and improve its future design. In this context and in the light of these points, the failures are important in managing the maintenance function. Indeed, it has become important to understand the phenomena of failure and degradation of equipments in order to establish an appropriate maintenance policy for the rational use of mechanical components and move to the practice of proactive maintenance [1], do maintenance at the design [2].

40 CFR 65.112 - Standards: Compressors.

Code of Federal Regulations, 2013 CFR

2013-07-01

... barrier fluid system shall be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. Each sensor shall be observed daily or shall be equipped with an alarm unless the... criterion that indicates failure of the seal system, the barrier fluid system, or both. If the sensor...

40 CFR 63.1031 - Compressors standards.

Code of Federal Regulations, 2013 CFR

2013-07-01

... service. Each barrier fluid system shall be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. Each sensor shall be observed daily or shall be equipped with an... both. If the sensor indicates failure of the seal system, the barrier fluid system, or both based on...

47 CFR 2.946 - Penalty for failure to provide test samples and data.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 47 Telecommunication 1 2012-10-01 2012-10-01 false Penalty for failure to provide test samples and data. 2.946 Section 2.946 Telecommunication FEDERAL COMMUNICATIONS COMMISSION GENERAL FREQUENCY ALLOCATIONS AND RADIO TREATY MATTERS; GENERAL RULES AND REGULATIONS Equipment Authorization Procedures Conditions Attendant to An Equipment Authorizatio...

75 FR 49870 - Effects on Broadband Communications Networks of Damage to or Failure of Network Equipment or...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-16

... FEDERAL COMMUNICATIONS COMMISSION 47 CFR Chapter I [PS Docket No. 10-92; DA 10-1357] Effects on Broadband Communications Networks of Damage to or Failure of Network Equipment or Severe Overload AGENCY: Federal Communications Commission ACTION: Proposed rule; extension of reply comment date. SUMMARY: This...

Human Reliability and the Cost of Doing Business

NASA Technical Reports Server (NTRS)

DeMott, Diana

2014-01-01

Most businesses recognize that people will make mistakes and assume errors are just part of the cost of doing business, but does it need to be? Companies with high risk, or major consequences, should consider the effect of human error. In a variety of industries, Human Errors have caused costly failures and workplace injuries. These have included: airline mishaps, medical malpractice, administration of medication and major oil spills have all been blamed on human error. A technique to mitigate or even eliminate some of these costly human errors is the use of Human Reliability Analysis (HRA). Various methodologies are available to perform Human Reliability Assessments that range from identifying the most likely areas for concern to detailed assessments with human error failure probabilities calculated. Which methodology to use would be based on a variety of factors that would include: 1) how people react and act in different industries, and differing expectations based on industries standards, 2) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 3) type and availability of data and 4) how the industry views risk & reliability influences ( types of emergencies, contingencies and routine tasks versus cost based concerns). The Human Reliability Assessments should be the first step to reduce, mitigate or eliminate the costly mistakes or catastrophic failures. Using Human Reliability techniques to identify and classify human error risks allows a company more opportunities to mitigate or eliminate these risks and prevent costly failures.

Independent Orbiter Assessment (IOA): Assessment of the crew equipment subsystem

NASA Technical Reports Server (NTRS)

Saxon, H.; Richard, Bill; Sinclair, S. K.

1988-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Crew Equipment hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the NASA FMEA/CIL baseline with proposed Post 51-L updates included. A resolution of each discrepancy from the comparison is provided through additional analysis as required. This report documents the results of that comparison for the Orbiter Crew Equipment hardware. The IOA product for the Crew Equipment analysis consisted of 352 failure mode worksheets that resulted in 78 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 351 FMEAs and 82 CIL items.

Development of KSC program for investigating and generating field failure rates. Volume 2: Recommended format for reliability handbook for ground support equipment

NASA Technical Reports Server (NTRS)

Bloomquist, C. E.; Kallmeyer, R. H.

1972-01-01

Field failure rates and confidence factors are presented for 88 identifiable components of the ground support equipment at the John F. Kennedy Space Center. For most of these, supplementary information regarding failure mode and cause is tabulated. Complete reliability assessments are included for three systems, eight subsystems, and nine generic piece-part classifications. Procedures for updating or augmenting the reliability results presented in this handbook are also included.

Designing safety into the minimally invasive surgical revolution: a commentary based on the Jacques Perissat Lecture of the International Congress of the European Association for Endoscopic Surgery.

PubMed

Clarke, John R

2009-01-01

Surgical errors with minimally invasive surgery differ from those in open surgery. Perforations are typically the result of trocar introduction or electrosurgery. Infections include bioburdens, notably enteric viruses, on complex instruments. Retained foreign objects are primarily unretrieved device fragments and lost gallstones or other specimens. Fires and burns come from illuminated ends of fiber-optic cables and from electrosurgery. Pressure ischemia is more likely with longer endoscopic surgical procedures. Gas emboli can occur. Minimally invasive surgery is more dependent on complex equipment, with high likelihood of failures. Standardization, checklists, and problem reporting are solutions for minimizing failures. The necessity of electrosurgery makes education about best electrosurgical practices important. The recording of minimally invasive surgical procedures is an opportunity to debrief in a way that improves the reliability of future procedures. Safety depends on reliability, designing systems to withstand inevitable human errors. Safe systems are characterized by a commitment to safety, formal protocols for communications, teamwork, standardization around best practice, and reporting of problems for improvement of the system. Teamwork requires shared goals, mental models, and situational awareness in order to facilitate mutual monitoring and backup. An effective team has a flat hierarchy; team members are empowered to speak up if they are concerned about problems. Effective teams plan, rehearse, distribute the workload, and debrief. Surgeons doing minimally invasive surgery have a unique opportunity to incorporate the principles of safety into the development of their discipline.

Formal Validation of Aerospace Software

NASA Astrophysics Data System (ADS)

Lesens, David; Moy, Yannick; Kanig, Johannes

2013-08-01

Any single error in critical software can have catastrophic consequences. Even though failures are usually not advertised, some software bugs have become famous, such as the error in the MIM-104 Patriot. For space systems, experience shows that software errors are a serious concern: more than half of all satellite failures from 2000 to 2003 involved software. To address this concern, this paper addresses the use of formal verification of software developed in Ada.

40 CFR 63.342 - Standards.

Code of Federal Regulations, 2013 CFR

2013-07-01

... to the requirements of this subpart, including associated air pollution control equipment and monitoring equipment, in a manner consistent with safety and good air pollution control practices for..., infrequent, and unavoidable failure of air pollution control equipment, process equipment, or a process to...

40 CFR 63.342 - Standards.

Code of Federal Regulations, 2014 CFR

2014-07-01

... to the requirements of this subpart, including associated air pollution control equipment and monitoring equipment, in a manner consistent with safety and good air pollution control practices for..., infrequent, and unavoidable failure of air pollution control equipment, process equipment, or a process to...

Accuracy of acoustic velocity metering systems for measurement of low velocity in open channels

USGS Publications Warehouse

Laenen, Antonius; Curtis, R. E.

1989-01-01

Acoustic velocity meter (AVM) accuracy depends on equipment limitations, the accuracy of acoustic-path length and angle determination, and the stability of the mean velocity to acoustic-path velocity relation. Equipment limitations depend on path length and angle, transducer frequency, timing oscillator frequency, and signal-detection scheme. Typically, the velocity error from this source is about +or-1 to +or-10 mms/sec. Error in acoustic-path angle or length will result in a proportional measurement bias. Typically, an angle error of one degree will result in a velocity error of 2%, and a path-length error of one meter in 100 meter will result in an error of 1%. Ray bending (signal refraction) depends on path length and density gradients present in the stream. Any deviation from a straight acoustic path between transducer will change the unique relation between path velocity and mean velocity. These deviations will then introduce error in the mean velocity computation. Typically, for a 200-meter path length, the resultant error is less than one percent, but for a 1,000 meter path length, the error can be greater than 10%. Recent laboratory and field tests have substantiated assumptions of equipment limitations. Tow-tank tests of an AVM system with a 4.69-meter path length yielded an average standard deviation error of 9.3 mms/sec, and the field tests of an AVM system with a 20.5-meter path length yielded an average standard deviation error of a 4 mms/sec. (USGS)

The problem of automation: Inappropriate feedback and interaction, not overautomation

NASA Technical Reports Server (NTRS)

Norman, Donald A.

1989-01-01

As automation increasingly takes its place in industry, especially high-risk industry, it is often blamed for causing harm and increasing the chance of human error when failures occur. It is proposed that the problem is not the presence of automation, but rather its inappropriate design. The problem is that the operations are performed appropriately under normal conditions, but there is inadequate feedback and interaction with the humans who must control the overall conduct of the task. When the situations exceed the capabilities of the automatic equipment, then the inadequate feedback leads to difficulties for the human controllers. The problem is that the automation is at an intermediate level of intelligence, powerful enough to take over control that which used to be done by people, but not powerful enough to handle all abnormalities. Moreover, its level of intelligence is insufficient to provide the continual, appropriate feedback that occurs naturally among human operators. To solve this problem, the automation should either be made less intelligent or more so, but the current level is quite inappropriate. The overall message is that it is possible to reduce error through appropriate design considerations.

Modeling of a bubble-memory organization with self-checking translators to achieve high reliability.

NASA Technical Reports Server (NTRS)

Bouricius, W. G.; Carter, W. C.; Hsieh, E. P.; Wadia, A. B.; Jessep, D. C., Jr.

1973-01-01

Study of the design and modeling of a highly reliable bubble-memory system that has the capabilities of: (1) correcting a single 16-adjacent bit-group error resulting from failures in a single basic storage module (BSM), and (2) detecting with a probability greater than 0.99 any double errors resulting from failures in BSM's. The results of the study justify the design philosophy adopted of employing memory data encoding and a translator to correct single group errors and detect double group errors to enhance the overall system reliability.

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

DiCostanzo, D; Ayan, A; Woollard, J

Purpose: To predict potential failures of hardware within the Varian TrueBeam linear accelerator in order to proactively replace parts and decrease machine downtime. Methods: Machine downtime is a problem for all radiation oncology departments and vendors. Most often it is the result of unexpected equipment failure, and increased due to lack of in-house clinical engineering support. Preventative maintenance attempts to assuage downtime, but often is ineffective at preemptively preventing many failure modes such as MLC motor failures, the need to tighten a gantry chain, or the replacement of a jaw motor, among other things. To attempt to alleviate downtime, softwaremore » was developed in house that determines the maximum value of each axis enumerated in the Truebeam trajectory log files. After patient treatments, this data is stored in a SQL database. Microsoft Power BI is used to plot the average maximum error of each day of each machine as a function of time. The results are then correlated with actual faults that occurred at the machine with the help of Varian service engineers. Results: Over the course of six months, 76,312 trajectory logs have been written into the database and plotted in Power BI. Throughout the course of analysis MLC motors have been replaced on three machines due to the early warning of the trajectory log analysis. The service engineers have also been alerted to possible gantry issues on one occasion due to the aforementioned analysis. Conclusion: Analyzing the trajectory log data is a viable and effective early warning system for potential failures of the TrueBeam linear accelerator. With further analysis and tightening of the tolerance values used to determine a possible imminent failure, it should be possible to pinpoint future issues more thoroughly and for more axes of motion.« less

40 CFR 60.482-3a - Standards: Compressors.

Code of Federal Regulations, 2012 CFR

2012-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... both. (f) If the sensor indicates failure of the seal system, the barrier system, or both based on the...

Probabilistic evaluation of seismic isolation effect with respect to siting of a fusion reactor facility

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

Takeda, Masatoshi; Komura, Toshiyuki; Hirotani, Tsutomu

1995-12-01

Annual failure probabilities of buildings and equipment were roughly evaluated for two fusion-reactor-like buildings, with and without seismic base isolation, in order to examine the effectiveness of the base isolation system regarding siting issues. The probabilities are calculated considering nonlinearity and rupture of isolators. While the probability of building failure for both buildings on the same site was almost equal, the function failures for equipment showed that the base-isolated building had higher reliability than the non-isolated building. Even if the base-isolated building alone is located on a higher seismic hazard area, it could compete favorably with the ordinary one inmore » reliability of equipment.« less

Underlying Cause(s) of Letter Perseveration Errors

ERIC Educational Resources Information Center

Fischer-Baum, Simon; Rapp, Brenda

2012-01-01

Perseverations, the inappropriate intrusion of elements from a previous response into a current response, are commonly observed in individuals with acquired deficits. This study specifically investigates the contribution of failure-to activate and failure-to-inhibit deficit(s) in the generation of letter perseveration errors in acquired…

Identifying the latent failures underpinning medication administration errors: an exploratory study.

PubMed

Lawton, Rebecca; Carruthers, Sam; Gardner, Peter; Wright, John; McEachan, Rosie R C

2012-08-01

The primary aim of this article was to identify the latent failures that are perceived to underpin medication errors. The study was conducted within three medical wards in a hospital in the United Kingdom. The study employed a cross-sectional qualitative design. Interviews were conducted with 12 nurses and eight managers. Interviews were transcribed and subject to thematic content analysis. A two-step inter-rater comparison tested the reliability of the themes. Ten latent failures were identified based on the analysis of the interviews. These were ward climate, local working environment, workload, human resources, team communication, routine procedures, bed management, written policies and procedures, supervision and leadership, and training. The discussion focuses on ward climate, the most prevalent theme, which is conceptualized here as interacting with failures in the nine other organizational structures and processes. This study is the first of its kind to identify the latent failures perceived to underpin medication errors in a systematic way. The findings can be used as a platform for researchers to test the impact of organization-level patient safety interventions and to design proactive error management tools and incident reporting systems in hospitals. © Health Research and Educational Trust.

Laser Measurements Based for Volumetric Accuracy Improvement of Multi-axis Systems

NASA Astrophysics Data System (ADS)

Vladimir, Sokolov; Konstantin, Basalaev

The paper describes a new developed approach to CNC-controlled multi-axis systems geometric errors compensation based on optimal error correction strategy. Multi-axis CNC-controlled systems - machine-tools and CMM's are the basis of modern engineering industry. Similar design principles of both technological and measurement equipment allow usage of similar approaches to precision management. The approach based on geometric errors compensation are widely used at present time. The paper describes a system for compensation of geometric errors of multi-axis equipment based on the new approach. The hardware basis of the developed system is a multi-function laser interferometer. The principles of system's implementation, results of measurements and system's functioning simulation are described. The effectiveness of application of described principles to multi-axis equipment of different sizes and purposes for different machining directions and zones within workspace is presented. The concepts of optimal correction strategy is introduced and dynamic accuracy control is proposed.

Follow-up on hang gliding injuries in Colorado.

PubMed

Krissoff, W B

1976-01-01

In a period extending from July 1973 to December 1975, seven fatal hang glider accidents were recorded in Colorado, all among experienced pilots. In addition, 11 serious nonfatal injuries were reported, which may represent only a fraction of those occurring. Accidents were noted to be multifactorial, caused by (1) pilot error, (2) equipment failure, (3) terrain hazards, and (4) possible design shortcomings. Accidents can be expected to decline in frequency with improved pilot training programs, grading and regulation of sites, and standardized safety clothing. No doubt over time, the less safe standard Rogallo wing will be replaced by the more stable Superkites and controlled collapsibles, which offer a higher safety margin. In the last analysis, this sport will remain a popular yet high risk endeavor (Figs. 2 through 5).

Non-Traditional Displays for Mission Monitoring

NASA Technical Reports Server (NTRS)

Trujillo, Anna C.; Schutte, Paul C.

1999-01-01

Advances in automation capability and reliability have changed the role of humans from operating and controlling processes to simply monitoring them for anomalies. However, humans are traditionally bad monitors of highly reliable systems over time. Thus, the human is assigned a task for which he is ill equipped. We believe that this has led to the dominance of human error in process control activities such as operating transportation systems (aircraft and trains), monitoring patient health in the medical industry, and controlling plant operations. Research has shown, though, that an automated monitor can assist humans in recognizing and dealing with failures. One possible solution to this predicament is to use a polar-star display that will show deviations from normal states based on parameters that are most indicative of mission health.

Report of the Odyssey FPGA Independent Assessment Team

NASA Technical Reports Server (NTRS)

Mayer, Donald C.; Katz, Richard B.; Osborn, Jon V.; Soden, Jerry M.; Barto, R.; Day, John H. (Technical Monitor)

2001-01-01

An independent assessment team (IAT) was formed and met on April 2, 2001, at Lockheed Martin in Denver, Colorado, to aid in understanding a technical issue for the Mars Odyssey spacecraft scheduled for launch on April 7, 2001. An RP1280A field-programmable gate array (FPGA) from a lot of parts common to the SIRTF, Odyssey, and Genesis missions had failed on a SIRTF printed circuit board. A second FPGA from an earlier Odyssey circuit board was also known to have failed and was also included in the analysis by the IAT. Observations indicated an abnormally high failure rate for flight RP1280A devices (the first flight lot produced using this flow) at Lockheed Martin and the causes of these failures were not determined. Standard failure analysis techniques were applied to these parts, however, additional diagnostic techniques unique for devices of this class were not used, and the parts were prematurely submitted to a destructive physical analysis, making a determination of the root cause of failure difficult. Any of several potential failure scenarios may have caused these failures, including electrostatic discharge, electrical overstress, manufacturing defects, board design errors, board manufacturing errors, FPGA design errors, or programmer errors. Several of these mechanisms would have relatively benign consequences for disposition of the parts currently installed on boards in the Odyssey spacecraft if established as the root cause of failure. However, other potential failure mechanisms could have more dire consequences. As there is no simple way to determine the likely failure mechanisms with reasonable confidence before Odyssey launch, it is not possible for the IAT to recommend a disposition for the other parts on boards in the Odyssey spacecraft based on sound engineering principles.

Management of failure after surgery for gastro-esophageal reflux disease.

PubMed

Gronnier, C; Degrandi, O; Collet, D

2018-04-01

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment. Copyright © 2018. Published by Elsevier Masson SAS.

Risk-based maintenance of ethylene oxide production facilities.

PubMed

Khan, Faisal I; Haddara, Mahmoud R

2004-05-20

This paper discusses a methodology for the design of an optimum inspection and maintenance program. The methodology, called risk-based maintenance (RBM) is based on integrating a reliability approach and a risk assessment strategy to obtain an optimum maintenance schedule. First, the likely equipment failure scenarios are formulated. Out of many likely failure scenarios, the ones, which are most probable, are subjected to a detailed study. Detailed consequence analysis is done for the selected scenarios. Subsequently, these failure scenarios are subjected to a fault tree analysis to determine their probabilities. Finally, risk is computed by combining the results of the consequence and the probability analyses. The calculated risk is compared against known acceptable criteria. The frequencies of the maintenance tasks are obtained by minimizing the estimated risk. A case study involving an ethylene oxide production facility is presented. Out of the five most hazardous units considered, the pipeline used for the transportation of the ethylene is found to have the highest risk. Using available failure data and a lognormal reliability distribution function human health risk factors are calculated. Both societal risk factors and individual risk factors exceeded the acceptable risk criteria. To determine an optimal maintenance interval, a reverse fault tree analysis was used. The maintenance interval was determined such that the original high risk is brought down to an acceptable level. A sensitivity analysis is also undertaken to study the impact of changing the distribution of the reliability model as well as the error in the distribution parameters on the maintenance interval.

Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis.

PubMed

Schulz, Christian M; Burden, Amanda; Posner, Karen L; Mincer, Shawn L; Steadman, Randolph; Wagner, Klaus J; Domino, Karen B

2017-08-01

Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors. Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013. Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common. Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.

Fault Tree Based Diagnosis with Optimal Test Sequencing for Field Service Engineers

NASA Technical Reports Server (NTRS)

Iverson, David L.; George, Laurence L.; Patterson-Hine, F. A.; Lum, Henry, Jr. (Technical Monitor)

1994-01-01

When field service engineers go to customer sites to service equipment, they want to diagnose and repair failures quickly and cost effectively. Symptoms exhibited by failed equipment frequently suggest several possible causes which require different approaches to diagnosis. This can lead the engineer to follow several fruitless paths in the diagnostic process before they find the actual failure. To assist in this situation, we have developed the Fault Tree Diagnosis and Optimal Test Sequence (FTDOTS) software system that performs automated diagnosis and ranks diagnostic hypotheses based on failure probability and the time or cost required to isolate and repair each failure. FTDOTS first finds a set of possible failures that explain exhibited symptoms by using a fault tree reliability model as a diagnostic knowledge to rank the hypothesized failures based on how likely they are and how long it would take or how much it would cost to isolate and repair them. This ordering suggests an optimal sequence for the field service engineer to investigate the hypothesized failures in order to minimize the time or cost required to accomplish the repair task. Previously, field service personnel would arrive at the customer site and choose which components to investigate based on past experience and service manuals. Using FTDOTS running on a portable computer, they can now enter a set of symptoms and get a list of possible failures ordered in an optimal test sequence to help them in their decisions. If facilities are available, the field engineer can connect the portable computer to the malfunctioning device for automated data gathering. FTDOTS is currently being applied to field service of medical test equipment. The techniques are flexible enough to use for many different types of devices. If a fault tree model of the equipment and information about component failure probabilities and isolation times or costs are available, a diagnostic knowledge base for that device can be developed easily.

[Research and implementation of a real-time monitoring system for running status of medical monitors based on the internet of things].

PubMed

Li, Yiming; Qian, Mingli; Li, Long; Li, Bin

2014-07-01

This paper proposed a real-time monitoring system for running status of medical monitors based on the internet of things. In the aspect of hardware, a solution of ZigBee networks plus 470 MHz networks is proposed. In the aspect of software, graphical display of monitoring interface and real-time equipment failure alarm is implemented. The system has the function of remote equipment failure detection and wireless localization, which provides a practical and effective method for medical equipment management.

Media multitasking and failures of attention in everyday life.

PubMed

Ralph, Brandon C W; Thomson, David R; Cheyne, James Allan; Smilek, Daniel

2014-09-01

Using a series of online self-report measures, we examine media multitasking, a particularly pervasive form of multitasking, and its relations to three aspects of everyday attention: (1) failures of attention and cognitive errors (2) mind wandering, and (3) attentional control with an emphasis on attentional switching and distractibility. We observed a positive correlation between levels of media multitasking and self-reports of attentional failures, as well as with reports of both spontaneous and deliberate mind wandering. No correlation was observed between media multitasking and self-reported memory failures, lending credence to the hypothesis that media multitasking may be specifically related to problems of inattention, rather than cognitive errors in general. Furthermore, media multitasking was not related with self-reports of difficulties in attention switching or distractibility. We offer a plausible causal structural model assessing both direct and indirect effects among media multitasking, attentional failures, mind wandering, and cognitive errors, with the heuristic goal of constraining and motivating theories of the effects of media multitasking on inattention.

[Failure modes and effects analysis in the prescription, validation and dispensing process].

PubMed

Delgado Silveira, E; Alvarez Díaz, A; Pérez Menéndez-Conde, C; Serna Pérez, J; Rodríguez Sagrado, M A; Bermejo Vicedo, T

2012-01-01

To apply a failure modes and effects analysis to the prescription, validation and dispensing process for hospitalised patients. A work group analysed all of the stages included in the process from prescription to dispensing, identifying the most critical errors and establishing potential failure modes which could produce a mistake. The possible causes, their potential effects, and the existing control systems were analysed to try and stop them from developing. The Hazard Score was calculated, choosing those that were ≥ 8, and a Severity Index = 4 was selected independently of the hazard Score value. Corrective measures and an implementation plan were proposed. A flow diagram that describes the whole process was obtained. A risk analysis was conducted of the chosen critical points, indicating: failure mode, cause, effect, severity, probability, Hazard Score, suggested preventative measure and strategy to achieve so. Failure modes chosen: Prescription on the nurse's form; progress or treatment order (paper); Prescription to incorrect patient; Transcription error by nursing staff and pharmacist; Error preparing the trolley. By applying a failure modes and effects analysis to the prescription, validation and dispensing process, we have been able to identify critical aspects, the stages in which errors may occur and the causes. It has allowed us to analyse the effects on the safety of the process, and establish measures to prevent or reduce them. Copyright © 2010 SEFH. Published by Elsevier Espana. All rights reserved.

Ground Handling of Batteries at Test and Launch-site Facilities

NASA Technical Reports Server (NTRS)

Jeevarajan, Judith A.; Hohl, Alan R.

2008-01-01

Ground handling of flight as well as engineering batteries at test facilities and launch-site facilities is a safety critical process. Test equipment interfacing with the batteries should have the required controls to prevent a hazardous failure of the batteries. Test equipment failures should not induce catastrophic failures on the batteries. Transportation requirements for batteries should also be taken into consideration for safe transportation. This viewgraph presentation includes information on the safe handling of batteries for ground processing at test facilities as well as launch-site facilities.

Effects of Random Shadings, Phasing Errors, and Element Failures on the Beam Patterns of Linear and Planar Arrays

DTIC Science & Technology

1980-03-14

failure Sigmar (Or) in line 50, the standard deviation of the relative error of the weights Sigmap (o) in line 60, the standard deviation of the phase...200, the weight structures in the x and y coordinates Q in line 210, the probability of element failure Sigmar (Or) in line 220, the standard...NUMBER OF ELEMENTS =u;2*H 120 PRINT "Pr’obability of elemenit failure al;O 130 PRINT "Standard dtvi&t ion’ oe r.1&tive ýrror of wl; Sigmar 14 0 PRINT

Probabilistic failure assessment with application to solid rocket motors

NASA Technical Reports Server (NTRS)

Jan, Darrell L.; Davidson, Barry D.; Moore, Nicholas R.

1990-01-01

A quantitative methodology is being developed for assessment of risk of failure of solid rocket motors. This probabilistic methodology employs best available engineering models and available information in a stochastic framework. The framework accounts for incomplete knowledge of governing parameters, intrinsic variability, and failure model specification error. Earlier case studies have been conducted on several failure modes of the Space Shuttle Main Engine. Work in progress on application of this probabilistic approach to large solid rocket boosters such as the Advanced Solid Rocket Motor for the Space Shuttle is described. Failure due to debonding has been selected as the first case study for large solid rocket motors (SRMs) since it accounts for a significant number of historical SRM failures. Impact of incomplete knowledge of governing parameters and failure model specification errors is expected to be important.

16 CFR 1209.37 - Corrective actions.

Code of Federal Regulations, 2010 CFR

2010-01-01

... Commercial Practices CONSUMER PRODUCT SAFETY COMMISSION CONSUMER PRODUCT SAFETY ACT REGULATIONS INTERIM SAFETY STANDARD FOR CELLULOSE INSULATION Certification § 1209.37 Corrective actions. (a) Test failure... insulation product itself. Corrective action may consist of equipment adjustment, equipment repair, equipment...

Study on the Rationality and Validity of Probit Models of Domino Effect to Chemical Process Equipment caused by Overpressure

NASA Astrophysics Data System (ADS)

Sun, Dongliang; Huang, Guangtuan; Jiang, Juncheng; Zhang, Mingguang; Wang, Zhirong

2013-04-01

Overpressure is one important cause of domino effect in accidents of chemical process equipments. Some models considering propagation probability and threshold values of the domino effect caused by overpressure have been proposed in previous study. In order to prove the rationality and validity of the models reported in the reference, two boundary values of three damage degrees reported were considered as random variables respectively in the interval [0, 100%]. Based on the overpressure data for damage to the equipment and the damage state, and the calculation method reported in the references, the mean square errors of the four categories of damage probability models of overpressure were calculated with random boundary values, and then a relationship of mean square error vs. the two boundary value was obtained, the minimum of mean square error was obtained, compared with the result of the present work, mean square error decreases by about 3%. Therefore, the error was in the acceptable range of engineering applications, the models reported can be considered reasonable and valid.

16 CFR 1207.5 - Design.

Code of Federal Regulations, 2014 CFR

2014-01-01

... pool slide shall be such that no structural failures of any component part shall cause failures of any... such fasteners shall not cause a failure of the tread under the ladder loading conditions specified in... without failure or permanent deformation. (d) Handrails. Swimming pool slide ladders shall be equipped...

16 CFR 1207.5 - Design.

Code of Federal Regulations, 2012 CFR

2012-01-01

... pool slide shall be such that no structural failures of any component part shall cause failures of any... such fasteners shall not cause a failure of the tread under the ladder loading conditions specified in... without failure or permanent deformation. (d) Handrails. Swimming pool slide ladders shall be equipped...

The failures of root canal preparation with hand ProTaper.

PubMed

Bătăiosu, Marilena; Diaconu, Oana; Moraru, Iren; Dăguci, C; Tuculină, Mihaela; Dăguci, Luminiţa; Gheorghiţă, Lelia

2012-07-01

The failures of root canal preparation are due to some anatomical deviation (canal in "C" or "S") and some technique errors. The technique errors are usually present in canal root cleansing and shaping stage and are the result of endodontic treatment objectives deviation. Our study was made on technique errors while preparing the canal roots with hand ProTaper. Our study was made "in vitro" on 84 extracted teeth (molars, premolars, incisors and canines). The canal root of these teeth were cleansed and shaped with hand ProTaper by crown-down technique and canal irrigation with NaOCl(2,5%). The dental preparation control was made by X-ray. During canal root preparation some failures were observed like: canal root overinstrumentation, zipping and stripping phenomenon, discarded and/or fractured instruments. Hand ProTaper represents a revolutionary progress of endodontic treatment, but a deviation from accepted rules of canal root instrumentation can lead to failures of endodontic treatment.

General Monte Carlo reliability simulation code including common mode failures and HARP fault/error-handling

NASA Technical Reports Server (NTRS)

Platt, M. E.; Lewis, E. E.; Boehm, F.

1991-01-01

A Monte Carlo Fortran computer program was developed that uses two variance reduction techniques for computing system reliability applicable to solving very large highly reliable fault-tolerant systems. The program is consistent with the hybrid automated reliability predictor (HARP) code which employs behavioral decomposition and complex fault-error handling models. This new capability is called MC-HARP which efficiently solves reliability models with non-constant failures rates (Weibull). Common mode failure modeling is also a specialty.

A systematic review of cognitive failures in daily life: Healthy populations.

PubMed

Carrigan, Nicole; Barkus, Emma

2016-04-01

Cognitive failures are minor errors in thinking reported by clinical and non-clinical individuals during everyday life. It is not yet clear how subjectively-reported cognitive failures relate to objective neuropsychological ability. We aimed to consolidate the definition of cognitive failures, outline evidence for the relationship with objective cognition, and develop a unified model of factors that increase cognitive failures. We conducted a systematic review of cognitive failures, identifying 45 articles according to the PRISMA statement. Failures were defined as reflecting proneness to errors in 'real world' planned thought and action. Vulnerability to failures was not consistently associated with objective cognitive performance. A range of stable and variable factors were linked to increased risk of cognitive failures. We conclude that cognitive failures measure real world cognitive capacity rather than pure 'unchallenged' ability. Momentary state may interact with predisposing trait factors to increase the likelihood of failures occurring. Inclusion of self-reported cognitive failures in objective cognitive research will increase the translational relevance of ability into more ecologically valid aspects of real world functioning. Copyright © 2016 Elsevier Ltd. All rights reserved.

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report

PubMed Central

Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio

2012-01-01

Objective Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Design and setting Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. Primary outcome To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. Results In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. Conclusions FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children. PMID:23253870

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.

PubMed

Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio

2012-01-01

Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.

The Need and Requirements for Validating Damage Detection Capability

DTIC Science & Technology

2011-09-01

Testing of Airborne Equipment [11], 2) Materials / Structure Certification, 3) NDE (POD) Validation Procedures, 4) Failure Mode Effects and Criticality...Analysis (FMECA), and 5) Cost Benefits Analysis [12]. Existing procedures for environmental testing of airborne equipment ensure flight...e.g. ultrasound or eddy current), damage type or failure conditions to detect, criticality of the damage state (e.g. safety of flight), likelihood of

A Survey of Reliability, Maintainability, Supportability, and Testability Software Tools

DTIC Science & Technology

1991-04-01

designs in terms of their contributions toward forced mission termination and vehicle or function loss . Includes the ability to treat failure modes of...ABSTRACT: Inputs: MTBFs, MTTRs, support equipment costs, equipment weights and costs, available targets, military occupational specialty skill level and...US Army CECOM NAME: SPARECOST ABSTRACT: Calculates expected number of failures and performs spares holding optimization based on cost, weight , or

Medical equipment management strategies.

PubMed

Wang, Binseng; Furst, Emanuel; Cohen, Ted; Keil, Ode R; Ridgway, Malcolm; Stiefel, Robert

2006-01-01

Clinical engineering professionals need to continually review and improve their management strategies in order to keep up with improvements in equipment technology, as well as with increasing expectations of health care organizations. In the last 20 years, management strategies have evolved from the initial obsession with electrical safety to flexible criteria that fit the individual institution's needs. Few hospitals, however, are taking full advantage of the paradigm shift offered by the evolution of joint Commission standards. The focus should be on risks caused by equipment failure, rather than on equipment with highest maintenance demands. Furthermore, it is not enough to consider risks posed by individual pieces of equipment to individual patients. It is critical to anticipate the impact of an equipment failure on larger groups of patients, especially when dealing with one of a kind, sophisticated pieces of equipment that are required to provide timely and accurate diagnoses for immediate therapeutic decisions or surgical interventions. A strategy for incorporating multiple criteria to formulate appropriate management strategies is provided in this article.

Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures

PubMed Central

Barger, Laura K; Ayas, Najib T; Cade, Brian E; Cronin, John W; Rosner, Bernard; Speizer, Frank E; Czeisler, Charles A

2006-01-01

Background A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (≥24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States. Methods and Findings We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3–3.7) and 7.5 (95% CI, 7.2–7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4–22) and 7.0 (95% CI, 4.3–11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality. Conclusions In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education. PMID:17194188

40 CFR 49.4166 - Monitoring requirements.

Code of Federal Regulations, 2013 CFR

2013-07-01

... burning pilot flame, electronically controlled automatic igniters, and monitoring system failures, using a... failure, electronically controlled automatic igniter failure, or improper monitoring equipment operation... and natural gas emissions in the event that natural gas recovered for pipeline injection must be...

40 CFR 49.4166 - Monitoring requirements.

Code of Federal Regulations, 2014 CFR

2014-07-01

... burning pilot flame, electronically controlled automatic igniters, and monitoring system failures, using a... failure, electronically controlled automatic igniter failure, or improper monitoring equipment operation... and natural gas emissions in the event that natural gas recovered for pipeline injection must be...

A New Approach to Detection of Systematic Errors in Secondary Substation Monitoring Equipment Based on Short Term Load Forecasting

PubMed Central

Moriano, Javier; Rodríguez, Francisco Javier; Martín, Pedro; Jiménez, Jose Antonio; Vuksanovic, Branislav

2016-01-01

In recent years, Secondary Substations (SSs) are being provided with equipment that allows their full management. This is particularly useful not only for monitoring and planning purposes but also for detecting erroneous measurements, which could negatively affect the performance of the SS. On the other hand, load forecasting is extremely important since they help electricity companies to make crucial decisions regarding purchasing and generating electric power, load switching, and infrastructure development. In this regard, Short Term Load Forecasting (STLF) allows the electric power load to be predicted over an interval ranging from one hour to one week. However, important issues concerning error detection by employing STLF has not been specifically addressed until now. This paper proposes a novel STLF-based approach to the detection of gain and offset errors introduced by the measurement equipment. The implemented system has been tested against real power load data provided by electricity suppliers. Different gain and offset error levels are successfully detected. PMID:26771613

Human error and crew resource management failures in Naval aviation mishaps: a review of U.S. Naval Safety Center data, 1990-96.

PubMed

Wiegmann, D A; Shappell, S A

1999-12-01

The present study examined the role of human error and crew-resource management (CRM) failures in U.S. Naval aviation mishaps. All tactical jet (TACAIR) and rotary wing Class A flight mishaps between fiscal years 1990-1996 were reviewed. Results indicated that over 75% of both TACAIR and rotary wing mishaps were attributable, at least in part, to some form of human error of which 70% were associated with aircrew human factors. Of these aircrew-related mishaps, approximately 56% involved at least one CRM failure. These percentages are very similar to those observed prior to the implementation of aircrew coordination training (ACT) in the fleet, suggesting that the initial benefits of the program have not persisted and that CRM failures continue to plague Naval aviation. Closer examination of these CRM-related mishaps suggest that the type of flight operations (preflight, routine, emergency) do play a role in the etiology of CRM failures. A larger percentage of CRM failures occurred during non-routine or extremis flight situations when TACAIR mishaps were considered. In contrast, a larger percentage of rotary wing CRM mishaps involved failures that occurred during routine flight operations. These findings illustrate the complex etiology of CRM failures within Naval aviation and support the need for ACT programs tailored to the unique problems faced by specific communities in the fleet.

Errors made by animals in memory paradigms are not always due to failure of memory.

PubMed

Wilkie, D M; Willson, R J; Carr, J A

1999-01-01

It is commonly assumed that errors in animal memory paradigms such as delayed matching to sample, radial mazes, and food-cache recovery are due to failures in memory for information necessary to perform the task successfully. A body of research, reviewed here, suggests that this is not always the case: animals sometimes make errors despite apparently being able to remember the appropriate information. In this paper a case study of this phenomenon is described, along with a demonstration of a simple procedural modification that successfully reduced these non-memory errors, thereby producing a better measure of memory.

The Accuracy of Two-Way Satellite Time Transfer Calibrations

DTIC Science & Technology

2005-01-01

20392, USA Abstract Results from successive calibrations of Two-Way Satellite Time and Frequency Transfer ( TWSTFT ) operational equipment at...USNO and five remote stations using portable TWSTFT equipment are analyzed for internal and external errors, finding an average random error of ±0.35...most accurate means of operational long-distance time transfer are Two-Way Satellite Time and Frequency Transfer ( TWSTFT ) and carrier-phase GPS

Advanced risk assessment of the effects of graphite fibers on electronic and electric equipment

NASA Technical Reports Server (NTRS)

Pocinki, L.; Cornell, M.; Kaplan, L.

1980-01-01

An assessment of the risk associated with accidents involving aircraft with carbon fiber composite structural components is examined. The individual fiber segments cause electrical and electronic equipment to fail under certain operating conditions. A Monte Carlo simulation model was used to computer the risk. Aircraft accidents with fire, release of carbon fiber material, entrainment of carbon fibers in a smoke plume transport of fibers downwind, transfer of some fibers/into the the interior of buildings, failures of electrical and electronic equipment, and economic impact of failures are discussed. Risk profiles were prepared for individual airports and the Nation. The vulnerability of electrical transmission equipment to carbon fiber incursion and aircraft accident total costs is investigated.

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia.

PubMed

Martin, Lizabeth D; Grigg, Eliot B; Verma, Shilpa; Latham, Gregory J; Rampersad, Sally E; Martin, Lynn D

2017-06-01

The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety. © 2017 John Wiley & Sons Ltd.

Aircraft Enroute Command and Control Comms Redesign Mechanical Documentation

DTIC Science & Technology

2015-12-01

and power equipment is secured. Custom racks , with 8 server rack bays, are mounted to the pallet, with 2 desk stations for equipment operators...conventional rack equipment. Equipment in the original system was larger and heavier than the new equipment selected for the NG-JC2S. Battery backup was...purposes. The equipment also needed to be easily removable in the event of equipment failure. Surplus rack space available in the NG-JC2S system allowed

40 CFR 61.181 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-07-01

... cooled, condensed, and removed in a solid form. Control device means the air pollution control equipment... failure of air pollution control equipment or process equipment or of a process to operate in a normal or... Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED) NATIONAL...

40 CFR 61.181 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-07-01

... cooled, condensed, and removed in a solid form. Control device means the air pollution control equipment... failure of air pollution control equipment or process equipment or of a process to operate in a normal or... Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED) NATIONAL...

40 CFR 61.181 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-07-01

... cooled, condensed, and removed in a solid form. Control device means the air pollution control equipment... failure of air pollution control equipment or process equipment or of a process to operate in a normal or... Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED) NATIONAL...

40 CFR 61.181 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-07-01

... cooled, condensed, and removed in a solid form. Control device means the air pollution control equipment... failure of air pollution control equipment or process equipment or of a process to operate in a normal or... Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED) NATIONAL...

40 CFR 61.181 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-07-01

... cooled, condensed, and removed in a solid form. Control device means the air pollution control equipment... failure of air pollution control equipment or process equipment or of a process to operate in a normal or... Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED) NATIONAL...

46 CFR 78.47-75 - Ventilation alarm failure.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 3 2013-10-01 2013-10-01 false Ventilation alarm failure. 78.47-75 Section 78.47-75... Fire and Emergency Equipment, Etc. § 78.47-75 Ventilation alarm failure. (a) The alarm required by § 72... FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15284, Dec. 6, 1966] ...

46 CFR 78.47-75 - Ventilation alarm failure.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 3 2014-10-01 2014-10-01 false Ventilation alarm failure. 78.47-75 Section 78.47-75... Fire and Emergency Equipment, Etc. § 78.47-75 Ventilation alarm failure. (a) The alarm required by § 72... FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15284, Dec. 6, 1966] ...

46 CFR 78.47-75 - Ventilation alarm failure.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 3 2010-10-01 2010-10-01 false Ventilation alarm failure. 78.47-75 Section 78.47-75... Fire and Emergency Equipment, Etc. § 78.47-75 Ventilation alarm failure. (a) The alarm required by § 72... FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15284, Dec. 6, 1966] ...

46 CFR 78.47-75 - Ventilation alarm failure.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 3 2012-10-01 2012-10-01 false Ventilation alarm failure. 78.47-75 Section 78.47-75... Fire and Emergency Equipment, Etc. § 78.47-75 Ventilation alarm failure. (a) The alarm required by § 72... FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15284, Dec. 6, 1966] ...

46 CFR 78.47-75 - Ventilation alarm failure.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 46 Shipping 3 2011-10-01 2011-10-01 false Ventilation alarm failure. 78.47-75 Section 78.47-75... Fire and Emergency Equipment, Etc. § 78.47-75 Ventilation alarm failure. (a) The alarm required by § 72... FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15284, Dec. 6, 1966] ...

Commercial diving fatalities.

PubMed

Bradley, M E

1984-08-01

The distributions of fatal diving accidents in commercial diver populations were examined in the Gulf of Mexico from 1968 to 1975 and in the British sector of the North Sea from 1971 to 1978. Influences and causes of death were analyzed by examining the interaction between host, environmental and agent factors. The interaction of host and environmental factors appeared to be the greatest contributing factor to diving fatalities among the estimated 900 commercial divers in the Gulf of Mexico and the 700 in the North Sea. The most significant host factors were level of experience and behavioral dysfunction. They are also the host characteristics most amenable to change through improved and more thorough training. The most significant environmental factors were equipment failure and supervisor/tender errors. These factors would be minimized by improved selection, maintenance and operation of equipment, together with improved operating and emergency diving procedures. In recent years there has been a significant downward trend in mortality rates in the commercial diver populations of this study due to improved diving techniques and operations. Further research is needed, however, on the cause(s) of diver unconsciousness and inexplicable actions that occur at depths below 91.44m (300 ft.).

Normal accidents: human error and medical equipment design.

PubMed

Dain, Steven

2002-01-01

High-risk systems, which are typical of our technologically complex era, include not just nuclear power plants but also hospitals, anesthesia systems, and the practice of medicine and perfusion. In high-risk systems, no matter how effective safety devices are, some types of accidents are inevitable because the system's complexity leads to multiple and unexpected interactions. It is important for healthcare providers to apply a risk assessment and management process to decisions involving new equipment and procedures or staffing matters in order to minimize the residual risks of latent errors, which are amenable to correction because of the large window of opportunity for their detection. This article provides an introduction to basic risk management and error theory principles and examines ways in which they can be applied to reduce and mitigate the inevitable human errors that accompany high-risk systems. The article also discusses "human factor engineering" (HFE), the process which is used to design equipment/ human interfaces in order to mitigate design errors. The HFE process involves interaction between designers and endusers to produce a series of continuous refinements that are incorporated into the final product. The article also examines common design problems encountered in the operating room that may predispose operators to commit errors resulting in harm to the patient. While recognizing that errors and accidents are unavoidable, organizations that function within a high-risk system must adopt a "safety culture" that anticipates problems and acts aggressively through an anonymous, "blameless" reporting mechanism to resolve them. We must continuously examine and improve the design of equipment and procedures, personnel, supplies and materials, and the environment in which we work to reduce error and minimize its effects. Healthcare providers must take a leading role in the day-to-day management of the "Perioperative System" and be a role model in promoting a culture of safety in their organizations.

A study of redundancy management strategy for tetrad strap-down inertial systems. [error detection codes

NASA Technical Reports Server (NTRS)

Hruby, R. J.; Bjorkman, W. S.; Schmidt, S. F.; Carestia, R. A.

1979-01-01

Algorithms were developed that attempt to identify which sensor in a tetrad configuration has experienced a step failure. An algorithm is also described that provides a measure of the confidence with which the correct identification was made. Experimental results are presented from real-time tests conducted on a three-axis motion facility utilizing an ortho-skew tetrad strapdown inertial sensor package. The effects of prediction errors and of quantization on correct failure identification are discussed as well as an algorithm for detecting second failures through prediction.

Diagnosis of the Computer-Controlled Milling Machine, Definition of the Working Errors and Input Corrections on the Basis of Mathematical Model

NASA Astrophysics Data System (ADS)

Starikov, A. I.; Nekrasov, R. Yu; Teploukhov, O. J.; Soloviev, I. V.; Narikov, K. A.

2016-10-01

Manufactures, machinery and equipment improve of constructively as science advances and technology, and requirements are improving of quality and longevity. That is, the requirements for surface quality and precision manufacturing, oil and gas equipment parts are constantly increasing. Production of oil and gas engineering products on modern machine tools with computer numerical control - is a complex synthesis of technical and electrical equipment parts, as well as the processing procedure. Technical machine part wears during operation and in the electrical part are accumulated mathematical errors. Thus, the above-mentioned disadvantages of any of the following parts of metalworking equipment affect the manufacturing process of products in general, and as a result lead to the flaw.

Projected Impact of Compositional Verification on Current and Future Aviation Safety Risk

NASA Technical Reports Server (NTRS)

Reveley, Mary S.; Withrow, Colleen A.; Leone, Karen M.; Jones, Sharon M.

2014-01-01

The projected impact of compositional verification research conducted by the National Aeronautic and Space Administration System-Wide Safety and Assurance Technologies on aviation safety risk was assessed. Software and compositional verification was described. Traditional verification techniques have two major problems: testing at the prototype stage where error discovery can be quite costly and the inability to test for all potential interactions leaving some errors undetected until used by the end user. Increasingly complex and nondeterministic aviation systems are becoming too large for these tools to check and verify. Compositional verification is a "divide and conquer" solution to addressing increasingly larger and more complex systems. A review of compositional verification research being conducted by academia, industry, and Government agencies is provided. Forty-four aviation safety risks in the Biennial NextGen Safety Issues Survey were identified that could be impacted by compositional verification and grouped into five categories: automation design; system complexity; software, flight control, or equipment failure or malfunction; new technology or operations; and verification and validation. One capability, 1 research action, 5 operational improvements, and 13 enablers within the Federal Aviation Administration Joint Planning and Development Office Integrated Work Plan that could be addressed by compositional verification were identified.

Delays in the operating room: signs of an imperfect system.

PubMed

Wong, Janice; Khu, Kathleen Joy; Kaderali, Zul; Bernstein, Mark

2010-06-01

Delays in the operating room have a negative effect on its efficiency and the working environment. In this prospective study, we analyzed data on perioperative system delays. One neurosurgeon prospectively recorded all errors, including perioperative delays, for consecutive patients undergoing elective procedures from May 2000 to February 2009. We analyzed the prevalence, causes and impact of perioperative system delays that occurred in one neurosurgeon's practice. A total of 1531 elective surgical cases were performed during the study period. Delays were the most common type of error (33.6%), and more than half (51.4%) of all cases had at least 1 delay. The most common cause of delay was equipment failure. The first cases of the day and cranial cases had more delays than subsequent cases and spinal cases, respectively. A delay in starting the first case was associated with subsequent delays. Delays frequently occur in the operating room and have a major effect on patient flow and resource utilization. Thorough documentation of perioperative delays provides a basis for the development of solutions for improving operating room efficiency and illustrates the principles underlying the causes of operating room delays across surgical disciplines.

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

Salnykov, A. A., E-mail: admin@rasnpp.org.ru

A method for predicting operating technological failures in nuclear power plants which makes it possible to reduce the unloading of the generator unit during the onset and development of an anomalous engineering state of the equipment by detecting a change in state earlier and taking suitable measures. With the circulating water supply loop of a nuclear power plant as an example, scenarios and algorithms for predicting technological failures in the operation of equipment long before their actual occurrence are discussed.

Proximal antecedents and correlates of adopted error approach: a self-regulatory perspective.

PubMed

Van Dyck, Cathy; Van Hooft, Edwin; De Gilder, Dick; Liesveld, Lillian

2010-01-01

The current study aims to further investigate earlier established advantages of an error mastery approach over an error aversion approach. The two main purposes of the study relate to (1) self-regulatory traits (i.e., goal orientation and action-state orientation) that may predict which error approach (mastery or aversion) is adopted, and (2) proximal, psychological processes (i.e., self-focused attention and failure attribution) that relate to adopted error approach. In the current study participants' goal orientation and action-state orientation were assessed, after which they worked on an error-prone task. Results show that learning goal orientation related to error mastery, while state orientation related to error aversion. Under a mastery approach, error occurrence did not result in cognitive resources "wasted" on self-consciousness. Rather, attention went to internal-unstable, thus controllable, improvement oriented causes of error. Participants that had adopted an aversion approach, in contrast, experienced heightened self-consciousness and attributed failure to internal-stable or external causes. These results imply that when working on an error-prone task, people should be stimulated to take on a mastery rather than an aversion approach towards errors.

Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study.

PubMed

Gilbert, Rachel E; Kozak, Melissa C; Dobish, Roxanne B; Bourrier, Venetia C; Koke, Paul M; Kukreti, Vishal; Logan, Heather A; Easty, Anthony C; Trbovich, Patricia L

2018-05-01

Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards. Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent. Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed. We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.

The failures of root canal preparation with hand ProTaper

PubMed Central

Bătăiosu, Marilena; Diaconu, Oana; Moraru, Iren; Dăguci, C.; Ţuculină, Mihaela; Dăguci, Luminiţa; Gheorghiţă, Lelia

2012-01-01

The failures of root canal preparation are due to some anatomical deviation (canal in “C” or “S”) and some technique errors. The technique errors are usually present in canal root cleansing and shaping stage and are the result of endodontic treatment objectives deviation. Objectives: Our study was made on technique errors while preparing the canal roots with hand ProTaper. Methodology: Our study was made “in vitro” on 84 extracted teeth (molars, premolars, incisors and canines). The canal root of these teeth were cleansed and shaped with hand ProTaper by crown-down technique and canal irrigation with NaOCl(2,5%). The dental preparation control was made by X-ray. Results: During canal root preparation some failures were observed like: canal root overinstrumentation, zipping and stripping phenomenon, discarded and/or fractured instruments. Conclusions: Hand ProTaper represents a revolutionary progress of endodontic treatment, but a deviation from accepted rules of canal root instrumentation can lead to failures of endodontic treatment. PMID:24778848

Risk management of key issues of FPSO

NASA Astrophysics Data System (ADS)

Sun, Liping; Sun, Hai

2012-12-01

Risk analysis of key systems have become a growing topic late of because of the development of offshore structures. Equipment failures of offloading system and fire accidents were analyzed based on the floating production, storage and offloading (FPSO) features. Fault tree analysis (FTA), and failure modes and effects analysis (FMEA) methods were examined based on information already researched on modules of relex reliability studio (RRS). Equipment failures were also analyzed qualitatively by establishing a fault tree and Boolean structure function based on the shortage of failure cases, statistical data, and risk control measures examined. Failure modes of fire accident were classified according to the different areas of fire occurrences during the FMEA process, using risk priority number (RPN) methods to evaluate their severity rank. The qualitative analysis of FTA gave the basic insight of forming the failure modes of FPSO offloading, and the fire FMEA gave the priorities and suggested processes. The research has practical importance for the security analysis problems of FPSO.

46 CFR 97.37-50 - Ventilation alarm failure.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 4 2010-10-01 2010-10-01 false Ventilation alarm failure. 97.37-50 Section 97.37-50... OPERATIONS Markings for Fire and Emergency Equipment, Etc. § 97.37-50 Ventilation alarm failure. (a) The...-inch letters “VENTILATION FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15286, Dec. 6...

46 CFR 97.37-50 - Ventilation alarm failure.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 4 2012-10-01 2012-10-01 false Ventilation alarm failure. 97.37-50 Section 97.37-50... OPERATIONS Markings for Fire and Emergency Equipment, Etc. § 97.37-50 Ventilation alarm failure. (a) The...-inch letters “VENTILATION FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15286, Dec. 6...

46 CFR 97.37-50 - Ventilation alarm failure.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 4 2014-10-01 2014-10-01 false Ventilation alarm failure. 97.37-50 Section 97.37-50... OPERATIONS Markings for Fire and Emergency Equipment, Etc. § 97.37-50 Ventilation alarm failure. (a) The...-inch letters “VENTILATION FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15286, Dec. 6...

46 CFR 97.37-50 - Ventilation alarm failure.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 4 2013-10-01 2013-10-01 false Ventilation alarm failure. 97.37-50 Section 97.37-50... OPERATIONS Markings for Fire and Emergency Equipment, Etc. § 97.37-50 Ventilation alarm failure. (a) The...-inch letters “VENTILATION FAILURE IN VEHICULAR SPACE.” (b) [Reserved] [CGFR 66-33, 31 FR 15286, Dec. 6...

Case Study of the Failure of two 13.8kV Control & Metering Transformers that caused significant Equipment Damage

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

Dreifuerst, G R; Chew, D B; Mangonon, H L

The degradation and failure of cast-coil epoxy windings within 13.8kV control power transformers and metering potential transformers has been shown to be dangerous to both equipment and personnel, even though best industrial design practices were followed. Accident scenes will be examined for two events at a U.S. Department of Energy laboratory. Failure modes will be explained and current design practices discussed with changes suggested to prevent a recurrence and to minimize future risk. New maintenance philosophies utilizing partial discharge testing of the transformers as a prediction of end-of-life will be examined.

Development of an Ontology to Model Medical Errors, Information Needs, and the Clinical Communication Space

PubMed Central

Stetson, Peter D.; McKnight, Lawrence K.; Bakken, Suzanne; Curran, Christine; Kubose, Tate T.; Cimino, James J.

2002-01-01

Medical errors are common, costly and often preventable. Work in understanding the proximal causes of medical errors demonstrates that systems failures predispose to adverse clinical events. Most of these systems failures are due to lack of appropriate information at the appropriate time during the course of clinical care. Problems with clinical communication are common proximal causes of medical errors. We have begun a project designed to measure the impact of wireless computing on medical errors. We report here on our efforts to develop an ontology representing the intersection of medical errors, information needs and the communication space. We will use this ontology to support the collection, storage and interpretation of project data. The ontology’s formal representation of the concepts in this novel domain will help guide the rational deployment of our informatics interventions. A real-life scenario is evaluated using the ontology in order to demonstrate its utility.

SU-F-T-247: Collision Risks in a Modern Radiation Oncology Department: An Efficient Approach to Failure Modes and Effects Analysis

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

Schubert, L; Westerly, D; Vinogradskiy, Y

Purpose: Collisions between treatment equipment and patients are potentially catastrophic. Modern technology now commonly involves automated remote motion during imaging and treatment, yet a systematic assessment to identify and mitigate collision risks has yet to be performed. Failure modes and effects analysis (FMEA) is a method of risk assessment that has been increasingly used in healthcare, yet can be resource intensive. This work presents an efficient approach to FMEA to identify collision risks and implement practical interventions within a modern radiation therapy department. Methods: Potential collisions (e.g. failure modes) were assessed for all treatment and simulation rooms by teams consistingmore » of physicists, therapists, and radiation oncologists. Failure modes were grouped into classes according to similar characteristics. A single group meeting was held to identify implementable interventions for the highest priority classes of failure modes. Results: A total of 60 unique failure modes were identified by 6 different teams of physicists, therapists, and radiation oncologists. Failure modes were grouped into four main classes: specific patient setups, automated equipment motion, manual equipment motion, and actions in QA or service mode. Two of these classes, unusual patient setups and automated machine motion, were identified as being high priority in terms severity of consequence and addressability by interventions. The two highest risk classes consisted of 33 failure modes (55% of the total). In a single one hour group meeting, 6 interventions were identified. Those interventions addressed 100% of the high risk classes of failure modes (55% of all failure modes identified). Conclusion: A class-based approach to FMEA was developed to efficiently identify collision risks and implement interventions in a modern radiation oncology department. Failure modes and interventions will be listed, and a comparison of this approach against traditional FMEA methods will be presented.« less

Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry.

PubMed

Oliven, A; Zalman, D; Shilankov, Y; Yeshurun, D; Odeh, M

2002-01-01

Computerized prescription of drugs is expected to reduce the number of many preventable drug ordering errors. In the present study we evaluated the usefullness of a computerized drug order entry (CDOE) system in reducing prescription errors. A department of internal medicine using a comprehensive CDOE, which included also patient-related drug-laboratory, drug-disease and drug-allergy on-line surveillance was compared to a similar department in which drug orders were handwritten. CDOE reduced prescription errors to 25-35%. The causes of errors remained similar, and most errors, on both departments, were associated with abnormal renal function and electrolyte balance. Residual errors remaining on the CDOE-using department were due to handwriting on the typed order, failure to feed patients' diseases, and system failures. The use of CDOE was associated with a significant reduction in mean hospital stay and in the number of changes performed in the prescription. The findings of this study both quantity the impact of comprehensive CDOE on prescription errors and delineate the causes for remaining errors.

Use of failure mode effect analysis (FMEA) to improve medication management process.

PubMed

Jain, Khushboo

2017-03-13

Purpose Medication management is a complex process, at high risk of error with life threatening consequences. The focus should be on devising strategies to avoid errors and make the process self-reliable by ensuring prevention of errors and/or error detection at subsequent stages. The purpose of this paper is to use failure mode effect analysis (FMEA), a systematic proactive tool, to identify the likelihood and the causes for the process to fail at various steps and prioritise them to devise risk reduction strategies to improve patient safety. Design/methodology/approach The study was designed as an observational analytical study of medication management process in the inpatient area of a multi-speciality hospital in Gurgaon, Haryana, India. A team was made to study the complex process of medication management in the hospital. FMEA tool was used. Corrective actions were developed based on the prioritised failure modes which were implemented and monitored. Findings The percentage distribution of medication errors as per the observation made by the team was found to be maximum of transcription errors (37 per cent) followed by administration errors (29 per cent) indicating the need to identify the causes and effects of their occurrence. In all, 11 failure modes were identified out of which major five were prioritised based on the risk priority number (RPN). The process was repeated after corrective actions were taken which resulted in about 40 per cent (average) and around 60 per cent reduction in the RPN of prioritised failure modes. Research limitations/implications FMEA is a time consuming process and requires a multidisciplinary team which has good understanding of the process being analysed. FMEA only helps in identifying the possibilities of a process to fail, it does not eliminate them, additional efforts are required to develop action plans and implement them. Frank discussion and agreement among the team members is required not only for successfully conducing FMEA but also for implementing the corrective actions. Practical implications FMEA is an effective proactive risk-assessment tool and is a continuous process which can be continued in phases. The corrective actions taken resulted in reduction in RPN, subjected to further evaluation and usage by others depending on the facility type. Originality/value The application of the tool helped the hospital in identifying failures in medication management process, thereby prioritising and correcting them leading to improvement.

Anisotropy measurement of pyrolytic carbon layers of coated particles

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

Vesyolkin, Ju. A., E-mail: Ju.Ves@yandex.ru; Ivanov, A. S., E-mail: asi.kiae@gmail.com; Trushkina, T. V.

2015-12-15

Equipment at the National Research Center Kurchatov Institute intended for the anisotropy determination of pyrolytic carbon layers in coated particles (CPs) of the GT-MGR reactor is tested and calibrated. The dependence of the anisotropy coefficient on the size of the measurement region is investigated. The results of measuring the optical anisotropy factor (OPTAF) for an aluminum mirror, rutile crystal, and available CP samples with the known characteristics measured previously using ORNL equipment (United States) are presented. In addition, measurements of CP samples prepared at VNIINM are performed. A strong dependence of the data on the preparation quality of metallographic sectionsmore » is found. Our investigations allow us to make the conclusion on the working capacity of the existing equipment for measuring the anisotropy of pyrolytic carbon CP coatings using the equipment at the Kurchatov Institute with the relative error of about 1%. It is shown that the elimination of the errors caused by the stochastic fluctuations in a measuring path by mathematical processing of the signal allows us to decrease the relative error of OPTAF measurements to ∼0.3%.« less

Workflow interruptions, cognitive failure and near-accidents in health care.

PubMed

Elfering, Achim; Grebner, Simone; Ebener, Corinne

2015-01-01

Errors are frequent in health care. A specific model was tested that affirms failure in cognitive action regulation to mediate the influence of nurses' workflow interruptions and safety conscientiousness on near-accidents in health care. One hundred and sixty-five nurses from seven Swiss hospitals participated in a questionnaire survey. Structural equation modelling confirmed the hypothesised mediation model. Cognitive failure in action regulation significantly mediated the influence of workflow interruptions on near-accidents (p < .05). An indirect path from conscientiousness to near-accidents via cognitive failure in action regulation was also significant (p < .05). Compliance with safety regulations was significantly related to cognitive failure and near-accidents; moreover, cognitive failure mediated the association between compliance and near-accidents (p < .05). Contrary to expectations, compliance with safety regulations was not related to workflow interruptions. Workflow interruptions caused by colleagues, patients and organisational constraints are likely to trigger errors in nursing. Work redesign is recommended to reduce cognitive failure and improve safety of nurses and patients.

MALPRACTICE AND THE QUALITY OF CARE IN RETINOPATHY OF PREMATURITY (AN AMERICAN OPHTHALMOLOGICAL SOCIETY THESIS)

PubMed Central

Reynolds, James D.

2007-01-01

Purpose A review of retinopathy of prematurity (ROP) malpractice cases will identify specific, repetitive problems in the provision of care and the reasons underlying these problems. Opportunities to improve the quality of care provided to premature infants with ROP will result. Methods A retrospective review of a series of 13 ROP malpractice cases in which the author served as a paid consultant, as well as a review of the literature for additional cases, was conducted. The series of 13 involved a review of the entire medical record as well as testimony and depositions. The characteristics of each case are tabulated, including state, date, allegations, defendants, disposition, award, the medical facts and care issues involved, and the judgment of medical error. In addition, a merit review was performed on the care in each case, and an error assessment was performed. Results The quality of care issues included neonatology failure to refer or follow up in 8 of 13, failure to adequately supervise resident care in 2 of 13, ophthalmologic failure to follow up in 6 of 13, and failure to properly diagnose and manage in 9 of 13. The latter included 4 of 13 that hinged on zone III issues and the presence or absence of full nasal vascularization with or without previous zone II disease. Merit review found negligent error by at least one party in 12 of 13. Ophthalmology error was found in 6 of 13. Malpractice, ie, negligent error causing negligent harm, was judged to be present in 9 of 13. Conclusions Negligent errors are common in malpractice cases that proceed to disposition. There are a limited number of repetitive errors that produce malpractice. An explanation of how these errors occur, coupled with the pertinent pathophysiology, afford an excellent opportunity to improve patient care PMID:18427626

PV System Component Fault and Failure Compilation and Analysis.

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

Klise, Geoffrey Taylor; Lavrova, Olga; Gooding, Renee Lynne

This report describes data collection and analysis of solar photovoltaic (PV) equipment events, which consist of faults and fa ilures that occur during the normal operation of a distributed PV system or PV power plant. We present summary statistics from locations w here maintenance data is being collected at various intervals, as well as reliability statistics gathered from that da ta, consisting of fault/failure distributions and repair distributions for a wide range of PV equipment types.

40 CFR 49.5512 - Federal Implementation Plan Provisions for Four Corners Power Plant, Navajo Nation.

Code of Federal Regulations, 2013 CFR

2013-07-01

... Plant including associated air pollution control equipment in a manner consistent with good air... judicial or administrative proceeding. (2) Air pollution control equipment includes baghouses, particulate... part 75. (7) Malfunction means any sudden and unavoidable failure of air pollution control equipment or...

40 CFR 49.5512 - Federal Implementation Plan Provisions for Four Corners Power Plant, Navajo Nation.

Code of Federal Regulations, 2014 CFR

2014-07-01

... Plant including associated air pollution control equipment in a manner consistent with good air... judicial or administrative proceeding. (2) Air pollution control equipment includes baghouses, particulate... part 75. (7) Malfunction means any sudden and unavoidable failure of air pollution control equipment or...

40 CFR 49.5512 - Federal Implementation Plan Provisions for Four Corners Power Plant, Navajo Nation.

Code of Federal Regulations, 2012 CFR

2012-07-01

... Plant including associated air pollution control equipment in a manner consistent with good air... judicial or administrative proceeding. (2) Air pollution control equipment includes baghouses, particulate... part 75. (7) Malfunction means any sudden and unavoidable failure of air pollution control equipment or...

Trends and problems in development of the power plants electrical part

NASA Astrophysics Data System (ADS)

Gusev, Yu. P.

2015-03-01

The article discusses some problems relating to development of the electrical part of modern nuclear and thermal power plants, which are stemming from the use of new process and electrical equipment, such as gas turbine units, power converters, and intellectual microprocessor devices in relay protection and automated control systems. It is pointed out that the failure rates of electrical equipment at Russian and foreign power plants tend to increase. The ongoing power plant technical refitting and innovative development processes generate the need to significantly widen the scope of research works on the electrical part of power plants and rendering scientific support to works on putting in use innovative equipment. It is indicated that one of main factors causing the growth of electrical equipment failures is that some of components of this equipment have insufficiently compatible dynamic characteristics. This, in turn may be due to lack or obsolescence of regulatory documents specifying the requirements for design solutions and operation of electric power equipment that incorporates electronic and microprocessor control and protection devices. It is proposed to restore the system of developing new and updating existing departmental regulatory technical documents that existed in the 1970s, one of the fundamental principles of which was placing long-term responsibility on higher schools and leading design institutions for rendering scientific-technical support to innovative development of components and systems forming the electrical part of power plants. This will make it possible to achieve lower failure rates of electrical equipment and to steadily improve the competitiveness of the Russian electric power industry and energy efficiency of generating companies.

Flight test results of the strapdown ring laser gyro tetrad inertial navigation system

NASA Technical Reports Server (NTRS)

Carestia, R. A.; Hruby, R. J.; Bjorkman, W. S.

1983-01-01

A helicopter flight test program undertaken to evaluate the performance of Tetrad (a strap down, laser gyro, inertial navigation system) is described. The results of 34 flights show a mean final navigational velocity error of 5.06 knots, with a standard deviation of 3.84 knots; a corresponding mean final position error of 2.66 n. mi., with a standard deviation of 1.48 n. mi.; and a modeled mean position error growth rate for the 34 tests of 1.96 knots, with a standard deviation of 1.09 knots. No laser gyro or accelerometer failures were detected during the flight tests. Off line parity residual studies used simulated failures with the prerecorded flight test and laboratory test data. The airborne Tetrad system's failure--detection logic, exercised during the tests, successfully demonstrated the detection of simulated ""hard'' failures and the system's ability to continue successfully to navigate by removing the simulated faulted sensor from the computations. Tetrad's four ring laser gyros provided reliable and accurate angular rate sensing during the 4 yr of the test program, and no sensor failures were detected during the evaluation of free inertial navigation performance.

40 CFR 240.209-3 - Recommended procedures: Operations.

Code of Federal Regulations, 2010 CFR

2010-07-01

... operation during such emergency situations as power failure, air or water supply failure, equipment... devices such as hard hats, gloves, safety glasses, and footwear should be provided for facility employees...

A Near-Term Concept for Trajectory Based Operations with Air/Ground Data Link Communication

NASA Technical Reports Server (NTRS)

McNally, David; Mueller, Eric; Thipphavong, David; Paielli, Russell; Cheng, Jinn-Hwei; Lee, Chuhan; Sahlman, Scott; Walton, Joe

2010-01-01

An operating concept and required system components for trajectory-based operations with air/ground data link for today's en route and transition airspace is proposed. Controllers are fully responsible for separation as they are today, and no new aircraft equipage is required. Trajectory automation computes integrated solutions to problems like metering, weather avoidance, traffic conflicts and the desire to find and fly more time/fuel efficient flight trajectories. A common ground-based system supports all levels of aircraft equipage and performance including those equipped and not equipped for data link. User interface functions for the radar controller's display make trajectory-based clearance advisories easy to visualize, modify if necessary, and implement. Laboratory simulations (without human operators) were conducted to test integrated operation of selected system components with uncertainty modeling. Results are based on 102 hours of Fort Worth Center traffic recordings involving over 37,000 individual flights. The presence of uncertainty had a marginal effect (5%) on minimum-delay conflict resolution performance, and windfavorable routes had no effect on detection and resolution metrics. Flight plan amendments and clearances were substantially reduced compared to today s operations. Top-of-descent prediction errors are the largest cause of failure indicating that better descent predictions are needed to reliably achieve fuel-efficient descent profiles in medium to heavy traffic. Improved conflict detections for climbing flights could enable substantially more continuous climbs to cruise altitude. Unlike today s Conflict Alert, tactical automation must alert when an altitude amendment is entered, but before the aircraft starts the maneuver. In every other failure case tactical automation prevented losses of separation. A real-time prototype trajectory trajectory-automation system is running now and could be made ready for operational testing at an en route Center in 1-2 years.

49 CFR 234.7 - Accidents involving grade crossing signal failure.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 4 2011-10-01 2011-10-01 false Accidents involving grade crossing signal failure... PLANS Reports and Plans § 234.7 Accidents involving grade crossing signal failure. (a) Each railroad shall report to FRA every impact between on-track railroad equipment and an automobile, bus, truck...

49 CFR 234.7 - Accidents involving grade crossing signal failure.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Accidents involving grade crossing signal failure... PLANS Reports and Plans § 234.7 Accidents involving grade crossing signal failure. (a) Each railroad shall report to FRA every impact between on-track railroad equipment and an automobile, bus, truck...

Reliability issues in active control of large flexible space structures

NASA Technical Reports Server (NTRS)

Vandervelde, W. E.

1986-01-01

Efforts in this reporting period were centered on four research tasks: design of failure detection filters for robust performance in the presence of modeling errors, design of generalized parity relations for robust performance in the presence of modeling errors, design of failure sensitive observers using the geometric system theory of Wonham, and computational techniques for evaluation of the performance of control systems with fault tolerance and redundancy management

Identifying and Synchronizing Health Information Technology (HIT) Events from FDA Medical Device Reports.

PubMed

Kang, Hong; Wang, Frank; Zhou, Sicheng; Miao, Qi; Gong, Yang

2017-01-01

Health information technology (HIT) events, a subtype of patient safety events, pose a major threat and barrier toward a safer healthcare system. It is crucial to gain a better understanding of the nature of the errors and adverse events caused by current HIT systems. The scarcity of HIT event-exclusive databases and event reporting systems indicates the challenge of identifying the HIT events from existing resources. FDA Manufacturer and User Facility Device Experience (MAUDE) database is a potential resource for HIT events. However, the low proportion and the rapid evolvement of HIT-related events present challenges for distinguishing them from other equipment failures and hazards. We proposed a strategy to identify and synchronize HIT events from MAUDE by using a filter based on structured features and classifiers based on unstructured features. The strategy will help us develop and grow an HIT event-exclusive database, keeping pace with updates to MAUDE toward shared learning.

Data Auditor: Analyzing Data Quality Using Pattern Tableaux

NASA Astrophysics Data System (ADS)

Srivastava, Divesh

Monitoring databases maintain configuration and measurement tables about computer systems, such as networks and computing clusters, and serve important business functions, such as troubleshooting customer problems, analyzing equipment failures, planning system upgrades, etc. These databases are prone to many data quality issues: configuration tables may be incorrect due to data entry errors, while measurement tables may be affected by incorrect, missing, duplicate and delayed polls. We describe Data Auditor, a tool for analyzing data quality and exploring data semantics of monitoring databases. Given a user-supplied constraint, such as a boolean predicate expected to be satisfied by every tuple, a functional dependency, or an inclusion dependency, Data Auditor computes "pattern tableaux", which are concise summaries of subsets of the data that satisfy or fail the constraint. We discuss the architecture of Data Auditor, including the supported types of constraints and the tableau generation mechanism. We also show the utility of our approach on an operational network monitoring database.

Hard decoding algorithm for optimizing thresholds under general Markovian noise

NASA Astrophysics Data System (ADS)

Chamberland, Christopher; Wallman, Joel; Beale, Stefanie; Laflamme, Raymond

2017-04-01

Quantum error correction is instrumental in protecting quantum systems from noise in quantum computing and communication settings. Pauli channels can be efficiently simulated and threshold values for Pauli error rates under a variety of error-correcting codes have been obtained. However, realistic quantum systems can undergo noise processes that differ significantly from Pauli noise. In this paper, we present an efficient hard decoding algorithm for optimizing thresholds and lowering failure rates of an error-correcting code under general completely positive and trace-preserving (i.e., Markovian) noise. We use our hard decoding algorithm to study the performance of several error-correcting codes under various non-Pauli noise models by computing threshold values and failure rates for these codes. We compare the performance of our hard decoding algorithm to decoders optimized for depolarizing noise and show improvements in thresholds and reductions in failure rates by several orders of magnitude. Our hard decoding algorithm can also be adapted to take advantage of a code's non-Pauli transversal gates to further suppress noise. For example, we show that using the transversal gates of the 5-qubit code allows arbitrary rotations around certain axes to be perfectly corrected. Furthermore, we show that Pauli twirling can increase or decrease the threshold depending upon the code properties. Lastly, we show that even if the physical noise model differs slightly from the hypothesized noise model used to determine an optimized decoder, failure rates can still be reduced by applying our hard decoding algorithm.

Design of analytical failure detection using secondary observers

NASA Technical Reports Server (NTRS)

Sisar, M.

1982-01-01

The problem of designing analytical failure-detection systems (FDS) for sensors and actuators, using observers, is addressed. The use of observers in FDS is related to the examination of the n-dimensional observer error vector which carries the necessary information on possible failures. The problem is that in practical systems, in which only some of the components of the state vector are measured, one has access only to the m-dimensional observer-output error vector, with m or = to n. In order to cope with these cases, a secondary observer is synthesized to reconstruct the entire observer-error vector from the observer output error vector. This approach leads toward the design of highly sensitive and reliable FDS, with the possibility of obtaining a unique fingerprint for every possible failure. In order to keep the observer's (or Kalman filter) false-alarm rate under a certain specified value, it is necessary to have an acceptable matching between the observer (or Kalman filter) models and the system parameters. A previously developed adaptive observer algorithm is used to maintain the desired system-observer model matching, despite initial mismatching or system parameter variations. Conditions for convergence for the adaptive process are obtained, leading to a simple adaptive law (algorithm) with the possibility of an a priori choice of fixed adaptive gains. Simulation results show good tracking performance with small observer output errors, while accurate and fast parameter identification, in both deterministic and stochastic cases, is obtained.

Independent Orbiter Assessment (IOA): Analysis of the instrumentation subsystem

NASA Technical Reports Server (NTRS)

Howard, B. S.

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Instrumentation Subsystem are documented. The Instrumentation Subsystem (SS) consists of transducers, signal conditioning equipment, pulse code modulation (PCM) encoding equipment, tape recorders, frequency division multiplexers, and timing equipment. For this analysis, the SS is broken into two major groupings: Operational Instrumentation (OI) equipment and Modular Auxiliary Data System (MADS) equipment. The OI equipment is required to acquire, condition, scale, digitize, interleave/multiplex, format, and distribute operational Orbiter and payload data and voice for display, recording, telemetry, and checkout. It also must provide accurate timing for time critical functions for crew and payload specialist use. The MADS provides additional instrumentation to measure and record selected pressure, temperature, strain, vibration, and event data for post-flight playback and analysis. MADS data is used to assess vehicle responses to the flight environment and to permit correlation of such data from flight to flight. The IOA analysis utilized available SS hardware drawings and schematics for identifying hardware assemblies and components and their interfaces. Criticality for each item was assigned on the basis of the worst-case effect of the failure modes identified.

Immersion Cooling of Electronics in DoD Installations

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

Coles, Henry; Herrlin, Magnus

A considerable amount of energy is consumed to cool electronic equipment in data centers. A method for substantially reducing the energy needed for this cooling was demonstrated. The method involves immersing electronic equipment in a non-conductive liquid that changes phase from a liquid to a gas. The liquid used was 3M Novec 649. Two-phase immersion cooling using this liquid is not viable at this time. The primary obstacles are IT equipment failures and costs. However, the demonstrated technology met the performance objectives for energy efficiency and greenhouse gas reduction. Before commercialization of this technology can occur, a root cause analysismore » of the failures should be completed, and the design changes proven.« less

Controlling stress corrosion cracking in mechanism components of ground support equipment

NASA Technical Reports Server (NTRS)

Majid, W. A.

1988-01-01

The selection of materials for mechanism components used in ground support equipment so that failures resulting from stress corrosion cracking will be prevented is described. A general criteria to be used in designing for resistance to stress corrosion cracking is also provided. Stress corrosion can be defined as combined action of sustained tensile stress and corrosion to cause premature failure of materials. Various aluminum, steels, nickel, titanium and copper alloys, and tempers and corrosive environment are evaluated for stress corrosion cracking.

Surveys for sensitivity to fibers and potential impacts from fiber induced failures

NASA Technical Reports Server (NTRS)

Butterfield, A. J.

1979-01-01

The surveys for sensitivities to fibers and potential impacts from fiber induced failures begins with a review of the survey work completed to date and then describes an impact study involving four industrial installations located in Virginia. The observations and results from both the surveys and the study provide guidelines for future efforts. The survey work was done with three broad objectives: (1) identify the pieces of potentially vulnerable equipment as candidates for test; (2) support the transfer function work by gaining an understanding of how fibers could get into a building; and (3) support the economic analysis by understanding what would happen if fibers precipitated a failure in an item of equipment.

A Gait Generation for an Unlocked Joint Failure of the Quadruped Robot with Balance Weight

NASA Astrophysics Data System (ADS)

Cho, C. H.; Min, B. C.; Kim, D. H.

Assurance of a stability margin for a stabilized gait is the most important issue for the quadruped robot. Although various studies for dynamic stability of the quadruped robot have been studied, problems in which one of the legs has an unlocked joint failure haven’t been relatively studied so far. In this paper, assurance of stability margin for the unlocked joint failure of the quadruped robot is suggested by using gait stabilization and a control method of the moment of inertia. Then, efficiency of BW (balance weight) will be experimentally verified by comparing the two types of robot; one is equipped with the BW, the other is not equipped with BW.

A fuzzy set approach for reliability calculation of valve controlling electric actuators

NASA Astrophysics Data System (ADS)

Karmachev, D. P.; Yefremov, A. A.; Luneva, E. E.

2017-02-01

The oil and gas equipment and electric actuators in particular frequently perform in various operational modes and under dynamic environmental conditions. These factors affect equipment reliability measures in a vague, uncertain way. To eliminate the ambiguity, reliability model parameters could be defined as fuzzy numbers. We suggest a technique that allows constructing fundamental fuzzy-valued performance reliability measures based on an analysis of electric actuators failure data in accordance with the amount of work, completed before the failure, instead of failure time. Also, this paper provides a computation example of fuzzy-valued reliability and hazard rate functions, assuming Kumaraswamy complementary Weibull geometric distribution as a lifetime (reliability) model for electric actuators.

Credit Assignment in a Motor Decision Making Task Is Influenced by Agency and Not Sensory Prediction Errors.

PubMed

Parvin, Darius E; McDougle, Samuel D; Taylor, Jordan A; Ivry, Richard B

2018-05-09

Failures to obtain reward can occur from errors in action selection or action execution. Recently, we observed marked differences in choice behavior when the failure to obtain a reward was attributed to errors in action execution compared with errors in action selection (McDougle et al., 2016). Specifically, participants appeared to solve this credit assignment problem by discounting outcomes in which the absence of reward was attributed to errors in action execution. Building on recent evidence indicating relatively direct communication between the cerebellum and basal ganglia, we hypothesized that cerebellar-dependent sensory prediction errors (SPEs), a signal indicating execution failure, could attenuate value updating within a basal ganglia-dependent reinforcement learning system. Here we compared the SPE hypothesis to an alternative, "top-down" hypothesis in which changes in choice behavior reflect participants' sense of agency. In two experiments with male and female human participants, we manipulated the strength of SPEs, along with the participants' sense of agency in the second experiment. The results showed that, whereas the strength of SPE had no effect on choice behavior, participants were much more likely to discount the absence of rewards under conditions in which they believed the reward outcome depended on their ability to produce accurate movements. These results provide strong evidence that SPEs do not directly influence reinforcement learning. Instead, a participant's sense of agency appears to play a significant role in modulating choice behavior when unexpected outcomes can arise from errors in action execution. SIGNIFICANCE STATEMENT When learning from the outcome of actions, the brain faces a credit assignment problem: Failures of reward can be attributed to poor choice selection or poor action execution. Here, we test a specific hypothesis that execution errors are implicitly signaled by cerebellar-based sensory prediction errors. We evaluate this hypothesis and compare it with a more "top-down" hypothesis in which the modulation of choice behavior from execution errors reflects participants' sense of agency. We find that sensory prediction errors have no significant effect on reinforcement learning. Instead, instructions influencing participants' belief of causal outcomes appear to be the main factor influencing their choice behavior. Copyright © 2018 the authors 0270-6474/18/384521-10$15.00/0.

The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure

PubMed Central

Lenderink, Albert W.; Widdershoven, Jos W. M. G.; van den Bemt, Patricia M. L. A.

2010-01-01

Objective Heart failure patients are regularly admitted to hospital and frequently use multiple medication. Besides intentional changes in pharmacotherapy, unintentional changes may occur during hospitalisation. The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure. Setting A general teaching hospital in Tilburg, the Netherlands. Method An open randomized intervention study was performed comparing an intervention group, with a control group receiving regular care by doctors and nurses. The clinical pharmacist discharge service consisted of review of discharge medication, communicating prescribing errors with the cardiologist, giving patients information, preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication. Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured. Main outcome measure The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined. Results Forty-four patients were included in the control group and 41 in the intervention group. Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39% in the intervention group (RR 0.57 (95% CI 0.37–0.88)). The percentage of medications with a discrepancy or prescription error in the control group was 14.6% and in the intervention group it was 6.1% (RR 0.42 (95% CI 0.27–0.66)). Conclusion This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge. PMID:20809276

WE-H-BRC-08: Examining Credentialing Criteria and Poor Performance Indicators for IROC Houston’s Anthropomorphic Head and Neck Phantom

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

Carson, M; Molineu, A; Taylor, P

Purpose: To analyze the most recent results of IROC Houston’s anthropomorphic H&N phantom to determine the nature of failing irradiations and the feasibility of altering pass/fail credentialing criteria. Methods: IROC Houston’s H&N phantom, used for IMRT credentialing for NCI-sponsored clinical trials, requires that an institution’s treatment plan must agree with measurement within 7% (TLD doses) and ≥85% pixels must pass 7%/4 mm gamma analysis. 156 phantom irradiations (November 2014 – October 2015) were re-evaluated using tighter criteria: 1) 5% TLD and 5%/4 mm, 2) 5% TLD and 5%/3 mm, 3) 4% TLD and 4%/4 mm, and 4) 3% TLD andmore » 3%/3 mm. Failure/poor performance rates were evaluated with respect to individual film and TLD performance by location in the phantom. Overall poor phantom results were characterized qualitatively as systematic (dosimetric) errors, setup errors/positional shifts, global but non-systematic errors, and errors affecting only a local region. Results: The pass rate for these phantoms using current criteria is 90%. Substituting criteria 1-4 reduces the overall pass rate to 77%, 70%, 63%, and 37%, respectively. Statistical analyses indicated the probability of noise-induced TLD failure at the 5% criterion was <0.5%. Using criteria 1, TLD results were most often the cause of failure (86% failed TLD while 61% failed film), with most failures identified in the primary PTV (77% cases). Other criteria posed similar results. Irradiations that failed from film only were overwhelmingly associated with phantom shifts/setup errors (≥80% cases). Results failing criteria 1 were primarily diagnosed as systematic: 58% of cases. 11% were setup/positioning errors, 8% were global non-systematic errors, and 22% were local errors. Conclusion: This study demonstrates that 5% TLD and 5%/4 mm gamma criteria may be both practically and theoretically achievable. Further work is necessary to diagnose and resolve dosimetric inaccuracy in these trials, particularly for systematic dose errors. This work is funded by NCI Grant CA180803.« less

40 CFR 141.561 - What happens if my system's turbidity monitoring equipment fails?

Code of Federal Regulations, 2013 CFR

2013-07-01

... 40 Protection of Environment 24 2013-07-01 2013-07-01 false What happens if my system's turbidity monitoring equipment fails? 141.561 Section 141.561 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY... happens if my system's turbidity monitoring equipment fails? If there is a failure in the continuous...

40 CFR 141.561 - What happens if my system's turbidity monitoring equipment fails?

Code of Federal Regulations, 2011 CFR

2011-07-01

... 40 Protection of Environment 23 2011-07-01 2011-07-01 false What happens if my system's turbidity monitoring equipment fails? 141.561 Section 141.561 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY... happens if my system's turbidity monitoring equipment fails? If there is a failure in the continuous...

40 CFR 141.561 - What happens if my system's turbidity monitoring equipment fails?

Code of Federal Regulations, 2012 CFR

2012-07-01

... 40 Protection of Environment 24 2012-07-01 2012-07-01 false What happens if my system's turbidity monitoring equipment fails? 141.561 Section 141.561 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY... happens if my system's turbidity monitoring equipment fails? If there is a failure in the continuous...

40 CFR 141.561 - What happens if my system's turbidity monitoring equipment fails?

Code of Federal Regulations, 2014 CFR

2014-07-01

... 40 Protection of Environment 23 2014-07-01 2014-07-01 false What happens if my system's turbidity monitoring equipment fails? 141.561 Section 141.561 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY... happens if my system's turbidity monitoring equipment fails? If there is a failure in the continuous...

40 CFR 60.482-3a - Standards: Compressors.

Code of Federal Regulations, 2010 CFR

2010-07-01

... (2) Equipped with a barrier fluid system degassing reservoir that is routed to a process or fuel gas... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped...

40 CFR 60.482-3a - Standards: Compressors.

Code of Federal Regulations, 2011 CFR

2011-07-01

... (2) Equipped with a barrier fluid system degassing reservoir that is routed to a process or fuel gas... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped...

MS-BWME: A Wireless Real-Time Monitoring System for Brine Well Mining Equipment

PubMed Central

Xiao, Xinqing; Zhu, Tianyu; Qi, Lin; Moga, Liliana Mihaela; Zhang, Xiaoshuan

2014-01-01

This paper describes a wireless real-time monitoring system (MS-BWME) to monitor the running state of pumps equipment in brine well mining and prevent potential failures that may produce unexpected interruptions with severe consequences. MS-BWME consists of two units: the ZigBee Wireless Sensors Network (WSN) unit and the real-time remote monitoring unit. MS-BWME was implemented and tested in sampled brine wells mining in Qinghai Province and four kinds of indicators were selected to evaluate the performance of the MS-BWME, i.e., sensor calibration, the system's real-time data reception, Received Signal Strength Indicator (RSSI) and sensor node lifetime. The results show that MS-BWME can accurately judge the running state of the pump equipment by acquiring and transmitting the real-time voltage and electric current data of the equipment from the spot and provide real-time decision support aid to help workers overhaul the equipment in a timely manner and resolve failures that might produce unexpected production down-time. The MS-BWME can also be extended to a wide range of equipment monitoring applications. PMID:25340455

Medication errors: definitions and classification

PubMed Central

Aronson, Jeffrey K

2009-01-01

To understand medication errors and to identify preventive strategies, we need to classify them and define the terms that describe them. The four main approaches to defining technical terms consider etymology, usage, previous definitions, and the Ramsey–Lewis method (based on an understanding of theory and practice). A medication error is ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’. Prescribing faults, a subset of medication errors, should be distinguished from prescription errors. A prescribing fault is ‘a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient’. The converse of this, ‘balanced prescribing’ is ‘the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm’. This excludes all forms of prescribing faults, such as irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing. A prescription error is ‘a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription’. The ‘normal features’ include the identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency, and duration of administration. Medication errors can be classified, invoking psychological theory, as knowledge-based mistakes, rule-based mistakes, action-based slips, and memory-based lapses. This classification informs preventive strategies. PMID:19594526

Directional control-response relationships for mining equipment.

PubMed

Burgess-Limerick, R; Krupenia, V; Wallis, G; Pratim-Bannerjee, A; Steiner, L

2010-06-01

A variety of directional control-response relationships are currently found in mining equipment. Two experiments were conducted in a virtual environment to determine optimal direction control-response relationships in a wide variety of circumstances. Direction errors were measured as a function of control orientation (horizontal or vertical), location (left, front, right) and directional control-response relationships. The results confirm that the principles of consistent direction and visual field compatibility are applicable to the majority of situations. An exception is that fewer direction errors were observed when an upward movement of a horizontal lever or movement of a vertical lever away from the participants caused extension (lengthening) of the controlled device, regardless of whether the direction of movement of the control is consistent with the direction in which the extension occurs. Further, both the control of slew by horizontally oriented controls and the control of device movements in a frontal plane by the perpendicular movements of vertical levers were associated with relatively high rates of directional errors, regardless of the directional control-response relationship, and these situations should be avoided. STATEMENT OF RELEVANCE: The results are particularly applicable to the design of mining equipment such as drilling and bolting machines, and have been incorporated into MDG35.1 Guideline for bolting & drilling plant in mines (Industry & Investment NSW, 2010). The results are also relevant to the design of any equipment where vertical or horizontal levers are used to control the movement of equipment appendages, e.g. cranes mounted to mobile equipment and the like.

Probabilistic confidence for decisions based on uncertain reliability estimates

NASA Astrophysics Data System (ADS)

Reid, Stuart G.

2013-05-01

Reliability assessments are commonly carried out to provide a rational basis for risk-informed decisions concerning the design or maintenance of engineering systems and structures. However, calculated reliabilities and associated probabilities of failure often have significant uncertainties associated with the possible estimation errors relative to the 'true' failure probabilities. For uncertain probabilities of failure, a measure of 'probabilistic confidence' has been proposed to reflect the concern that uncertainty about the true probability of failure could result in a system or structure that is unsafe and could subsequently fail. The paper describes how the concept of probabilistic confidence can be applied to evaluate and appropriately limit the probabilities of failure attributable to particular uncertainties such as design errors that may critically affect the dependability of risk-acceptance decisions. This approach is illustrated with regard to the dependability of structural design processes based on prototype testing with uncertainties attributable to sampling variability.

Teacher Perceptions of High School Student Failure in the Classroom: Identifying Preventive Practices of Failure Using Critical Incident Technique

ERIC Educational Resources Information Center

Kalahar, Kory G.

2011-01-01

Student failure is a prominent issue in many comprehensive secondary schools nationwide. Researchers studying error, reliability, and performance in organizations have developed and employed a method known as critical incident technique (CIT) for investigating failure. Adopting an action research model, this study involved gathering and analyzing…

[The error, source of learning].

PubMed

Joyeux, Stéphanie; Bohic, Valérie

2016-05-01

The error itself is not recognised as a fault. It is the intentionality which differentiates between an error and a fault. An error is unintentional while a fault is a failure to respect known rules. The risk of error is omnipresent in health institutions. Public authorities have therefore set out a series of measures to reduce this risk. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

The errors of metacognitive evaluation on metacognitive failure of students in mathematical problem solving

NASA Astrophysics Data System (ADS)

Huda, Nizlel; Sutawidjaja, Akbar; Subanji; Rahardjo, Swasono

2018-04-01

Metacognitive activity is very important in mathematical problems solving. Metacognitive activity consists of metacognitive awareness, metacognitive evaluation and metacognitive regulation. This study aimed to reveal the errors of metacognitive evaluation in students’ metacognitive failure in solving mathematical problems. 20 students taken as research subjects were grouped into three groups: the first group was students who experienced one metacognitive failure, the second group was students who experienced two metacognitive failures and the third group was students who experienced three metacognitive failures. One person was taken from each group as the reasearch subject. The research data was collected from worksheets done using think aload then followed by interviewing the research subjects based on the results’ of subject work. The findings in this study were students who experienced metacognitive failure in solving mathematical problems tends to miscalculate metacognitive evaluation in considering the effectiveness and limitations of their thinking and the effectiveness of their chosen strategy of completion.

Forecasting volcanic eruptions and other material failure phenomena: An evaluation of the failure forecast method

NASA Astrophysics Data System (ADS)

Bell, Andrew F.; Naylor, Mark; Heap, Michael J.; Main, Ian G.

2011-08-01

Power-law accelerations in the mean rate of strain, earthquakes and other precursors have been widely reported prior to material failure phenomena, including volcanic eruptions, landslides and laboratory deformation experiments, as predicted by several theoretical models. The Failure Forecast Method (FFM), which linearizes the power-law trend, has been routinely used to forecast the failure time in retrospective analyses; however, its performance has never been formally evaluated. Here we use synthetic and real data, recorded in laboratory brittle creep experiments and at volcanoes, to show that the assumptions of the FFM are inconsistent with the error structure of the data, leading to biased and imprecise forecasts. We show that a Generalized Linear Model method provides higher-quality forecasts that converge more accurately to the eventual failure time, accounting for the appropriate error distributions. This approach should be employed in place of the FFM to provide reliable quantitative forecasts and estimate their associated uncertainties.

Identification of the actual state and entity availability forecasting in power engineering using neural-network technologies

NASA Astrophysics Data System (ADS)

Protalinsky, O. M.; Shcherbatov, I. A.; Stepanov, P. V.

2017-11-01

A growing number of severe accidents in RF call for the need to develop a system that could prevent emergency situations. In a number of cases accident rate is stipulated by careless inspections and neglects in developing repair programs. Across the country rates of accidents are growing because of a so-called “human factor”. In this regard, there has become urgent the problem of identification of the actual state of technological facilities in power engineering using data on engineering processes running and applying artificial intelligence methods. The present work comprises four model states of manufacturing equipment of engineering companies: defect, failure, preliminary situation, accident. Defect evaluation is carried out using both data from SCADA and ASEPCR and qualitative information (verbal assessments of experts in subject matter, photo- and video materials of surveys processed using pattern recognition methods in order to satisfy the requirements). Early identification of defects makes possible to predict the failure of manufacturing equipment using mathematical techniques of artificial neural network. In its turn, this helps to calculate predicted characteristics of reliability of engineering facilities using methods of reliability theory. Calculation of the given parameters provides the real-time estimation of remaining service life of manufacturing equipment for the whole operation period. The neural networks model allows evaluating possibility of failure of a piece of equipment consistent with types of actual defects and their previous reasons. The article presents the grounds for a choice of training and testing samples for the developed neural network, evaluates the adequacy of the neural networks model, and shows how the model can be used to forecast equipment failure. There have been carried out simulating experiments using a computer and retrospective samples of actual values for power engineering companies. The efficiency of the developed model for different types of manufacturing equipment has been proved. There have been offered other research areas in terms of the presented subject matter.

Using PHM to measure equipment usable life on the Air Force's next generation reusable space booster

NASA Astrophysics Data System (ADS)

Blasdel, A.

The U.S. Air Force procures many launch vehicles and launch vehicle services to place their satellites at their desired location in space. The equipment on-board these satellite and launch vehicle often suffer from premature failures that result in the total loss of the satellite or a shortened mission life sometimes requiring the purchase of a replacement satellite and launch vehicle. The Air Force uses its EELV to launch its high priority satellites. Due to a rise in the cost of purchasing a launch using the Air Force's EELV from 72M in 1997 to as high as 475M per launch today, the Air Force is working to replace the EELV with a reusable space booster (RSB). The RSB will be similar in design and operations to the recently cancelled NASA reusable space booster known as the Space Shuttle. If the Air Force uses the same process that procures the EELV and other launch vehicles and satellites, the RSB will also suffer from premature equipment failures thus putting the payloads at a similar high risk of mission failure. The RSB is expected to lower each launch cost by 50% compared to the EELV. The development of the RSB offers the Air Force an opportunity to use a new reliability paradigm that includes a prognostic and health management program and a condition-based maintenance program. These both require using intelligent, decision making self-prognostic equipment The prognostic and health management program and its condition-based maintenance program allows increases in RSB equipment usable life, lower logistics and maintenance costs, while increasing safety and mission assurance. The PHM removes many decisions from personnel that, in the past resulted in catastrophic failures and loss of life. Adding intelligent, decision-making self-prognostic equipment to the RSB will further decrease launch costs while decreasing risk and increasing safety and mission assurance.

40 CFR 63.164 - Standards: Compressors.

Code of Federal Regulations, 2013 CFR

2013-07-01

... with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be observed daily or shall be equipped with an... indicates failure of the seal system, the barrier fluid system, or both. (f) If the sensor indicates failure...

40 CFR 63.164 - Standards: Compressors.

Code of Federal Regulations, 2012 CFR

2012-07-01

... with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be observed daily or shall be equipped with an... indicates failure of the seal system, the barrier fluid system, or both. (f) If the sensor indicates failure...

Maximizing Peak Running on Race Day

ERIC Educational Resources Information Center

Consolo, Kitty

2008-01-01

Distance runners spend many hours training assiduously for competition, yet on race day they can often make mistakes that sabotage their performance. This article addresses five common race-day mistakes: (1) failure to bring proper equipment to the race; (2) failure to eat an appropriate race-day meal; (3) failure to hydrate properly; (4) failure…

Addressee Errors in ATC Communications: The Call Sign Problem

NASA Technical Reports Server (NTRS)

Monan, W. P.

1983-01-01

Communication errors involving aircraft call signs were portrayed in reports of 462 hazardous incidents voluntarily submitted to the ASRS during an approximate four-year period. These errors resulted in confusion, disorder, and uncoordinated traffic conditions and produced the following types of operational anomalies: altitude deviations, wrong-way headings, aborted takeoffs, go arounds, runway incursions, missed crossing altitude restrictions, descents toward high terrain, and traffic conflicts in flight and on the ground. Analysis of the report set resulted in identification of five categories of errors involving call signs: (1) faulty radio usage techniques, (2) call sign loss or smearing due to frequency congestion, (3) confusion resulting from similar sounding call signs, (4) airmen misses of call signs leading to failures to acknowledge or readback, and (5) controller failures regarding confirmation of acknowledgements or readbacks. These error categories are described in detail and several associated hazard mitigating measures that might be aken are considered.

The NASA F-15 Intelligent Flight Control Systems: Generation II

NASA Technical Reports Server (NTRS)

Buschbacher, Mark; Bosworth, John

2006-01-01

The Second Generation (Gen II) control system for the F-15 Intelligent Flight Control System (IFCS) program implements direct adaptive neural networks to demonstrate robust tolerance to faults and failures. The direct adaptive tracking controller integrates learning neural networks (NNs) with a dynamic inversion control law. The term direct adaptive is used because the error between the reference model and the aircraft response is being compensated or directly adapted to minimize error without regard to knowing the cause of the error. No parameter estimation is needed for this direct adaptive control system. In the Gen II design, the feedback errors are regulated with a proportional-plus-integral (PI) compensator. This basic compensator is augmented with an online NN that changes the system gains via an error-based adaptation law to improve aircraft performance at all times, including normal flight, system failures, mispredicted behavior, or changes in behavior resulting from damage.

Quality of care and investment in property, plant, and equipment in hospitals.

PubMed

Levitt, S W

1994-02-01

This study explores the relationship between quality of care and investment in property, plant, and equipment (PPE) in hospitals. Hospitals' investment in PPE was derived from audited financial statements for the fiscal years 1984-1989. Peer Review Organization (PRO) Generic Quality Screen (GQS) reviews and confirmed failures between April 1989 and September 1990 were obtained from the Massachusetts PRO. Weighted least squares regression models used PRO GQS confirmed failure rates as the dependent variable, and investment in PPE as the key explanatory variable. Investment in PPE was standardized, summed by the hospital over the six years, and divided by the hospital's average number of beds in that period. The number of PRO reviewed cases with one or more GQS confirmed failures was divided by the total number of cases reviewed to create confirmed failure rates. Investment in PPE in Massachusetts hospitals is correlated with GQS confirmed failure rates. A financial variable, investment in PPE, predicts certain dimensions of quality of care in hospitals.

Memory and the Moses illusion: failures to detect contradictions with stored knowledge yield negative memorial consequences.

PubMed

Bottoms, Hayden C; Eslick, Andrea N; Marsh, Elizabeth J

2010-08-01

Although contradictions with stored knowledge are common in daily life, people often fail to notice them. For example, in the Moses illusion, participants fail to notice errors in questions such as "How many animals of each kind did Moses take on the Ark?" despite later showing knowledge that the Biblical reference is to Noah, not Moses. We examined whether error prevalence affected participants' ability to detect distortions in questions, and whether this in turn had memorial consequences. Many of the errors were overlooked, but participants were better able to catch them when they were more common. More generally, the failure to detect errors had negative memorial consequences, increasing the likelihood that the errors were used to answer later general knowledge questions. Methodological implications of this finding are discussed, as it suggests that typical analyses likely underestimate the size of the Moses illusion. Overall, answering distorted questions can yield errors in the knowledge base; most importantly, prior knowledge does not protect against these negative memorial consequences.

Soft error evaluation and vulnerability analysis in Xilinx Zynq-7010 system-on chip

NASA Astrophysics Data System (ADS)

Du, Xuecheng; He, Chaohui; Liu, Shuhuan; Zhang, Yao; Li, Yonghong; Xiong, Ceng; Tan, Pengkang

2016-09-01

Radiation-induced soft errors are an increasingly important threat to the reliability of modern electronic systems. In order to evaluate system-on chip's reliability and soft error, the fault tree analysis method was used in this work. The system fault tree was constructed based on Xilinx Zynq-7010 All Programmable SoC. Moreover, the soft error rates of different components in Zynq-7010 SoC were tested by americium-241 alpha radiation source. Furthermore, some parameters that used to evaluate the system's reliability and safety were calculated using Isograph Reliability Workbench 11.0, such as failure rate, unavailability and mean time to failure (MTTF). According to fault tree analysis for system-on chip, the critical blocks and system reliability were evaluated through the qualitative and quantitative analysis.

Dynamic modelling and estimation of the error due to asynchronism in a redundant asynchronous multiprocessor system

NASA Technical Reports Server (NTRS)

Huynh, Loc C.; Duval, R. W.

1986-01-01

The use of Redundant Asynchronous Multiprocessor System to achieve ultrareliable Fault Tolerant Control Systems shows great promise. The development has been hampered by the inability to determine whether differences in the outputs of redundant CPU's are due to failures or to accrued error built up by slight differences in CPU clock intervals. This study derives an analytical dynamic model of the difference between redundant CPU's due to differences in their clock intervals and uses this model with on-line parameter identification to idenitify the differences in the clock intervals. The ability of this methodology to accurately track errors due to asynchronisity generate an error signal with the effect of asynchronisity removed and this signal may be used to detect and isolate actual system failures.

Ironic Effects of Drawing Attention to Story Errors

PubMed Central

Eslick, Andrea N.; Fazio, Lisa K.; Marsh, Elizabeth J.

2014-01-01

Readers learn errors embedded in fictional stories and use them to answer later general knowledge questions (Marsh, Meade, & Roediger, 2003). Suggestibility is robust and occurs even when story errors contradict well-known facts. The current study evaluated whether suggestibility is linked to participants’ inability to judge story content as correct versus incorrect. Specifically, participants read stories containing correct and misleading information about the world; some information was familiar (making error discovery possible), while some was more obscure. To improve participants’ monitoring ability, we highlighted (in red font) a subset of story phrases requiring evaluation; readers no longer needed to find factual information. Rather, they simply needed to evaluate its correctness. Readers were more likely to answer questions with story errors if they were highlighted in red font, even if they contradicted well-known facts. Though highlighting to-be-evaluated information freed cognitive resources for monitoring, an ironic effect occurred: Drawing attention to specific errors increased rather than decreased later suggestibility. Failure to monitor for errors, not failure to identify the information requiring evaluation, leads to suggestibility. PMID:21294039

Relating design and environmental variables to reliability

NASA Astrophysics Data System (ADS)

Kolarik, William J.; Landers, Thomas L.

The combination of space application and nuclear power source demands high reliability hardware. The possibilities of failure, either an inability to provide power or a catastrophic accident, must be minimized. Nuclear power experiences on the ground have led to highly sophisticated probabilistic risk assessment procedures, most of which require quantitative information to adequately assess such risks. In the area of hardware risk analysis, reliability information plays a key role. One of the lessons learned from the Three Mile Island experience is that thorough analyses of critical components are essential. Nuclear grade equipment shows some reliability advantages over commercial. However, no statistically significant difference has been found. A recent study pertaining to spacecraft electronics reliability, examined some 2500 malfunctions on more than 300 aircraft. The study classified the equipment failures into seven general categories. Design deficiencies and lack of environmental protection accounted for about half of all failures. Within each class, limited reliability modeling was performed using a Weibull failure model.

Reliability Programs for Nonelectronic Designs. Volume 2

DTIC Science & Technology

1983-04-01

afforded. Differ- ences between critical and minor failures must be defined in the RFP so that the test need not be stopped for minor failures. However...not be afforded. Specialized test plans must be developed for nonelectronic equipment. First, differences between critical and minor failures must be...determined prior to initiating the test program so that the test need not be stopped for minor failures. Second, although the test must be interrupted

Multisite Parent-Centered Risk Assessment to Reduce Pediatric Oral Chemotherapy Errors

PubMed Central

Walsh, Kathleen E.; Mazor, Kathleen M.; Roblin, Douglas; Biggins, Colleen; Wagner, Joann L.; Houlahan, Kathleen; Li, Justin W.; Keuker, Christopher; Wasilewski-Masker, Karen; Donovan, Jennifer; Kanaan, Abir; Weingart, Saul N.

2013-01-01

Purpose: Observational studies describe high rates of errors in home oral chemotherapy use in children. In hospitals, proactive risk assessment methods help front-line health care workers develop error prevention strategies. Our objective was to engage parents of children with cancer in a multisite study using proactive risk assessment methods to identify how errors occur at home and propose risk reduction strategies. Methods: We recruited parents from three outpatient pediatric oncology clinics in the northeast and southeast United States to participate in failure mode and effects analyses (FMEA). An FMEA is a systematic team-based proactive risk assessment approach in understanding ways a process can fail and develop prevention strategies. Steps included diagram the process, brainstorm and prioritize failure modes (places where things go wrong), and propose risk reduction strategies. We focused on home oral chemotherapy administration after a change in dose because prior studies identified this area as high risk. Results: Parent teams consisted of four parents at two of the sites and 10 at the third. Parents developed a 13-step process map, with two to 19 failure modes per step. The highest priority failure modes included miscommunication when receiving instructions from the clinician (caused by conflicting instructions or parent lapses) and unsafe chemotherapy handling at home. Recommended risk assessment strategies included novel uses of technology to improve parent access to information, clinicians, and other parents while at home. Conclusion: Parents of pediatric oncology patients readily participated in a proactive risk assessment method, identifying processes that pose a risk for medication errors involving home oral chemotherapy. PMID:23633976

Radiomic machine-learning classifiers for prognostic biomarkers of advanced nasopharyngeal carcinoma.

PubMed

Zhang, Bin; He, Xin; Ouyang, Fusheng; Gu, Dongsheng; Dong, Yuhao; Zhang, Lu; Mo, Xiaokai; Huang, Wenhui; Tian, Jie; Zhang, Shuixing

2017-09-10

We aimed to identify optimal machine-learning methods for radiomics-based prediction of local failure and distant failure in advanced nasopharyngeal carcinoma (NPC). We enrolled 110 patients with advanced NPC. A total of 970 radiomic features were extracted from MRI images for each patient. Six feature selection methods and nine classification methods were evaluated in terms of their performance. We applied the 10-fold cross-validation as the criterion for feature selection and classification. We repeated each combination for 50 times to obtain the mean area under the curve (AUC) and test error. We observed that the combination methods Random Forest (RF) + RF (AUC, 0.8464 ± 0.0069; test error, 0.3135 ± 0.0088) had the highest prognostic performance, followed by RF + Adaptive Boosting (AdaBoost) (AUC, 0.8204 ± 0.0095; test error, 0.3384 ± 0.0097), and Sure Independence Screening (SIS) + Linear Support Vector Machines (LSVM) (AUC, 0.7883 ± 0.0096; test error, 0.3985 ± 0.0100). Our radiomics study identified optimal machine-learning methods for the radiomics-based prediction of local failure and distant failure in advanced NPC, which could enhance the applications of radiomics in precision oncology and clinical practice. Copyright © 2017 Elsevier B.V. All rights reserved.

The precision of a special purpose analog computer in clinical cardiac output determination.

PubMed Central

Sullivan, F J; Mroz, E A; Miller, R E

1975-01-01

Three hundred dye-dilution curves taken during our first year of clinical experience with the Waters CO-4 cardiac output computer were analyzed to estimate the errors involved in its use. Provided that calibration is accurate and 5.0 mg of dye are injected for each curve, then the percentage standard deviation of measurement using this computer is about 8.7%. Included in this are the errors inherent in the computer, errors due to baseline drift, errors in the injection of dye and acutal variation of cardiac output over a series of successive determinations. The size of this error is comparable to that involved in manual calculation. The mean value of five successive curves will be within 10% of the real value in 99 cases out of 100. Advances in methodology and equipment are discussed which make calibration simpler and more accurate, and which should also improve the quality of computer determination. A list of suggestions is given to minimize the errors involved in the clinical use of this equipment. Images Fig. 4. PMID:1089394

A critical incident reporting system in anaesthesia.

PubMed

Madzimbamuto, F D; Chiware, R

2001-01-01

To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department. Cross sectional study. A critical incident was defined as 'any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient'. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. Between May and October 2000, 62 completed critical incident forms were collected. The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. A total of 14,165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14,165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57%, oxymetry 90% and ECG 100%. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15% died, 23% were unplanned admissions to HDU while 62% were discharged to the ward with little or no adverse outcome. Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The stress under which everyone has to work includes poor morale, drug shortages, poor equipment and power cuts with no backup generator. Despite this, the challenge for senior personnel is to improve quality of care. In other countries similar audits have led to change of practice and improvement in the safety features of the service provided by the hospital and staff.

2006 Combat Vehicles Conference

DTIC Science & Technology

2006-10-25

stressed or worn out beyond economic repair due to combat operations by repairing, rebuilding, or procuring replacement equipment. These...lives Vehicle Hardening Logistics Solutions for the Warfighter • Unique and economical surge capability • Support in coordination with op tempo...Speed, • Diagnostics Indicators – DECU Health Check Indicator, Utility Bus Comm Failure, 1553 Bus Comm Failure; MPU Critical Failure, Cautions and

Annual Report Nucelar Energy Research and Development Program Nuclear Energy Research Initiative

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

Hively, LM

2003-02-13

NERI Project No.2000-0109 began in August 2000 and has three tasks. The first project year addressed Task 1, namely development of nonlinear prognostication for critical equipment in nuclear power facilities. That work is described in the first year's annual report (ORNLTM-2001/195). The current (second) project year (FY02) addresses Task 2, while the third project year will address Tasks 2-3. This report describes the work for the second project year, spanning August 2001 through August 2002, including status of the tasks, issues and concerns, cost performance, and status summary of tasks. The objective of the second project year's work is amore » compelling demonstration of the nonlinear prognostication algorithm using much more data. The guidance from Dr. Madeline Feltus (DOE/NE-20) is that it would be preferable to show forewarning of failure for different kinds of nuclear-grade equipment, as opposed to many different failure modes from one piece of equipment. Long-term monitoring of operational utility equipment is possible in principle, but is not practically feasible for the following reason. Time and funding constraints for this project do not allow us to monitor the many machines (thousands) that will be necessary to obtain even a few failure sequences, due to low failure rates (<10{sup -3}/year) in the operational environment. Moreover, the ONLY way to guarantee a controlled failure sequence is to seed progressively larger faults in the equipment or to overload the equipment for accelerated tests. Both of these approaches are infeasible for operational utility machinery, but are straight-forward in a test environment. Our subcontractor has provided such test sequences. Thus, we have revised Tasks 2.1-2.4 to analyze archival test data from such tests. The second phase of our work involves validation of the nonlinear prognostication over the second and third years of the proposed work. Recognizing the inherent limitations outlined in the previous paragraph, Dr. Feltus urged Oak Ridge National Laboratory (ORNL) to contact other researchers for additional data from other test equipment. Consequently, we have revised the work plan for Tasks 2.1-2.2, with corresponding changes to the work plan as shown in the Status Summary of NERI Tasks. The revised tasks are as follows: Task 2.1--ORNL will obtain test data from a subcontractor and other researchers for various test equipment. This task includes development of a test plan or a description of the historical testing, as appropriate: test facility, equipment to be tested, choice of failure mode(s), testing protocol, data acquisition equipment, and resulting data from the test sequence. ORNL will analyze this data for quality, and subsequently via the nonlinear paradigm for prognostication. Task 2.2--ORNL will evaluate the prognostication capability of the nonlinear paradigm. The comparison metrics for reliability of the predictions will include the true positives, true negatives, and the forewarning times. Task 2.3--ORNL will improve the nonlinear paradigm as appropriate, in accord with the results of Tasks 2.1-2.2, to maximize the rate of true positive and true negative indications of failure. Maximal forewarning time is also highly desirable. Task 2.4--ORNL will develop advanced algorithms for the phase-space distribution function (PS-DF) pattern change recognition, based on the results of Task 2.3. This implementation will provide a capability for automated prognostication, as part of the maintenance decision-making. Appendix A provides a detailed description of the analysis methods, which include conventional statistics, traditional nonlinear measures, and ORNL's patented nonlinear PSDM. The body of this report focuses on results of this analysis.« less

Guidelines for Design and Test of a Built-In Self Test (BIST) Circuit For Space Radiation Studies of High-Speed IC Technologies

NASA Technical Reports Server (NTRS)

Carts, M. A.; Marshall, P. W.; Reed, R.; Curie, S.; Randall, B.; LaBel, K.; Gilbert, B.; Daniel, E.

2006-01-01

Serial Bit Error Rate Testing under radiation to characterize single particle induced errors in high-speed IC technologies generally involves specialized test equipment common to the telecommunications industry. As bit rates increase, testing is complicated by the rapidly increasing cost of equipment able to test at-speed. Furthermore as rates extend into the tens of billions of bits per second test equipment ceases to be broadband, a distinct disadvantage for exploring SEE mechanisms in the target technologies. In this presentation the authors detail the testing accomplished in the CREST project and apply the knowledge gained to establish a set of guidelines suitable for designing arbitrarily high speed radiation effects tests.

On-Board Failure-Protection Requirements for Railroad-Vehicle Equipment

DOT National Transportation Integrated Search

1979-03-01

An analysis of the 1975 railroad-equipment-caused accidents was made. Data reported to the FRA were the primary source of derailment information; however, data from other sources were also used. Individual cause codes were consolidated into groups wh...

40 CFR 63.1250 - Applicability.

Code of Federal Regulations, 2014 CFR

2014-07-01

..., including associated air pollution control equipment and monitoring equipment, in a manner consistent with safety and good air pollution control practices for minimizing emissions. The general duty to minimize... were caused by a sudden, infrequent, and unavoidable failure of air pollution control and monitoring...

40 CFR 63.1250 - Applicability.

Code of Federal Regulations, 2011 CFR

2011-07-01

..., including associated air pollution control equipment and monitoring equipment, in a manner consistent with safety and good air pollution control practices for minimizing emissions. The general duty to minimize... were caused by a sudden, infrequent, and unavoidable failure of air pollution control and monitoring...

40 CFR 63.1250 - Applicability.

Code of Federal Regulations, 2012 CFR

2012-07-01

..., including associated air pollution control equipment and monitoring equipment, in a manner consistent with safety and good air pollution control practices for minimizing emissions. The general duty to minimize... were caused by a sudden, infrequent, and unavoidable failure of air pollution control and monitoring...

40 CFR 63.1250 - Applicability.

Code of Federal Regulations, 2013 CFR

2013-07-01

..., including associated air pollution control equipment and monitoring equipment, in a manner consistent with safety and good air pollution control practices for minimizing emissions. The general duty to minimize... were caused by a sudden, infrequent, and unavoidable failure of air pollution control and monitoring...

30 CFR 77.701 - Grounding metallic frames, casings, and other enclosures of electric equipment.

Code of Federal Regulations, 2010 CFR

2010-07-01

... AND SURFACE WORK AREAS OF UNDERGROUND COAL MINES Grounding § 77.701 Grounding metallic frames, casings... equipment that can become “alive” through failure of insulation or by contact with energized parts shall be...

Small Portable Analyzer Diagnostic Equipment (SPADE) Program -- Diagnostic Software Validation

DTIC Science & Technology

1984-07-01

Electronic Equipment Electromagnetic Emission and Susceptibility Requirements for the Control of Electromagnetic Interference Electromagnetic...ONLY. ORIENTATION OF DEFECT LOOKING HHO QIlILL: t -ed’-o· Significant efforts were expended to simulate spalling failures associated with naturally

Apollo 15 30-day failure and anomaly listing report

NASA Technical Reports Server (NTRS)

1971-01-01

The significant anomalies that occurred during the Apollo 15 mission are discussed. The five major areas are command and service modules, lunar module, scientific instrument module experiments, Apollo lunar surface experiment package and associated equipment, and government furnished equipment.

A measurement-based performability model for a multiprocessor system

NASA Technical Reports Server (NTRS)

Ilsueh, M. C.; Iyer, Ravi K.; Trivedi, K. S.

1987-01-01

A measurement-based performability model based on real error-data collected on a multiprocessor system is described. Model development from the raw errror-data to the estimation of cumulative reward is described. Both normal and failure behavior of the system are characterized. The measured data show that the holding times in key operational and failure states are not simple exponential and that semi-Markov process is necessary to model the system behavior. A reward function, based on the service rate and the error rate in each state, is then defined in order to estimate the performability of the system and to depict the cost of different failure types and recovery procedures.

Human factors process failure modes and effects analysis (HF PFMEA) software tool

NASA Technical Reports Server (NTRS)

Chandler, Faith T. (Inventor); Relvini, Kristine M. (Inventor); Shedd, Nathaneal P. (Inventor); Valentino, William D. (Inventor); Philippart, Monica F. (Inventor); Bessette, Colette I. (Inventor)

2011-01-01

Methods, computer-readable media, and systems for automatically performing Human Factors Process Failure Modes and Effects Analysis for a process are provided. At least one task involved in a process is identified, where the task includes at least one human activity. The human activity is described using at least one verb. A human error potentially resulting from the human activity is automatically identified, the human error is related to the verb used in describing the task. A likelihood of occurrence, detection, and correction of the human error is identified. The severity of the effect of the human error is identified. The likelihood of occurrence, and the severity of the risk of potential harm is identified. The risk of potential harm is compared with a risk threshold to identify the appropriateness of corrective measures.

Learning to Fail in Aphasia: An Investigation of Error Learning in Naming

PubMed Central

Middleton, Erica L.; Schwartz, Myrna F.

2013-01-01

Purpose To determine if the naming impairment in aphasia is influenced by error learning and if error learning is related to type of retrieval strategy. Method Nine participants with aphasia and ten neurologically-intact controls named familiar proper noun concepts. When experiencing tip-of-the-tongue naming failure (TOT) in an initial TOT-elicitation phase, participants were instructed to adopt phonological or semantic self-cued retrieval strategies. In the error learning manipulation, items evoking TOT states during TOT-elicitation were randomly assigned to a short or long time condition where participants were encouraged to continue to try to retrieve the name for either 20 seconds (short interval) or 60 seconds (long). The incidence of TOT on the same items was measured on a post test after 48-hours. Error learning was defined as a higher rate of recurrent TOTs (TOT at both TOT-elicitation and post test) for items assigned to the long (versus short) time condition. Results In the phonological condition, participants with aphasia showed error learning whereas controls showed a pattern opposite to error learning. There was no evidence for error learning in the semantic condition for either group. Conclusion Error learning is operative in aphasia, but dependent on the type of strategy employed during naming failure. PMID:23816662

Evaluating the prevalence and impact of examiner errors on the Wechsler scales of intelligence: A meta-analysis.

PubMed

Styck, Kara M; Walsh, Shana M

2016-01-01

The purpose of the present investigation was to conduct a meta-analysis of the literature on examiner errors for the Wechsler scales of intelligence. Results indicate that a mean of 99.7% of protocols contained at least 1 examiner error when studies that included a failure to record examinee responses as an error were combined and a mean of 41.2% of protocols contained at least 1 examiner error when studies that ignored errors of omission were combined. Furthermore, graduate student examiners were significantly more likely to make at least 1 error on Wechsler intelligence test protocols than psychologists. However, psychologists made significantly more errors per protocol than graduate student examiners regardless of the inclusion or exclusion of failure to record examinee responses as errors. On average, 73.1% of Full-Scale IQ (FSIQ) scores changed as a result of examiner errors, whereas 15.8%-77.3% of scores on the Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index changed as a result of examiner errors. In addition, results suggest that examiners tend to overestimate FSIQ scores and underestimate VCI scores. However, no strong pattern emerged for the PRI and WMI. It can be concluded that examiner errors occur frequently and impact index and FSIQ scores. Consequently, current estimates for the standard error of measurement of popular IQ tests may not adequately capture the variance due to the examiner. (c) 2016 APA, all rights reserved).

Beyond the Mechanics of Spreadsheets: Using Design Instruction to Address Spreadsheet Errors

ERIC Educational Resources Information Center

Schneider, Kent N.; Becker, Lana L.; Berg, Gary G.

2017-01-01

Given that the usage and complexity of spreadsheets in the accounting profession are expected to increase, it is more important than ever to ensure that accounting graduates are aware of the dangers of spreadsheet errors and are equipped with design skills to minimize those errors. Although spreadsheet mechanics are prevalent in accounting…

An Autonomous Self-Aware and Adaptive Fault Tolerant Routing Technique for Wireless Sensor Networks

PubMed Central

Abba, Sani; Lee, Jeong-A

2015-01-01

We propose an autonomous self-aware and adaptive fault-tolerant routing technique (ASAART) for wireless sensor networks. We address the limitations of self-healing routing (SHR) and self-selective routing (SSR) techniques for routing sensor data. We also examine the integration of autonomic self-aware and adaptive fault detection and resiliency techniques for route formation and route repair to provide resilience to errors and failures. We achieved this by using a combined continuous and slotted prioritized transmission back-off delay to obtain local and global network state information, as well as multiple random functions for attaining faster routing convergence and reliable route repair despite transient and permanent node failure rates and efficient adaptation to instantaneous network topology changes. The results of simulations based on a comparison of the ASAART with the SHR and SSR protocols for five different simulated scenarios in the presence of transient and permanent node failure rates exhibit a greater resiliency to errors and failure and better routing performance in terms of the number of successfully delivered network packets, end-to-end delay, delivered MAC layer packets, packet error rate, as well as efficient energy conservation in a highly congested, faulty, and scalable sensor network. PMID:26295236

An Autonomous Self-Aware and Adaptive Fault Tolerant Routing Technique for Wireless Sensor Networks.

PubMed

Abba, Sani; Lee, Jeong-A

2015-08-18

We propose an autonomous self-aware and adaptive fault-tolerant routing technique (ASAART) for wireless sensor networks. We address the limitations of self-healing routing (SHR) and self-selective routing (SSR) techniques for routing sensor data. We also examine the integration of autonomic self-aware and adaptive fault detection and resiliency techniques for route formation and route repair to provide resilience to errors and failures. We achieved this by using a combined continuous and slotted prioritized transmission back-off delay to obtain local and global network state information, as well as multiple random functions for attaining faster routing convergence and reliable route repair despite transient and permanent node failure rates and efficient adaptation to instantaneous network topology changes. The results of simulations based on a comparison of the ASAART with the SHR and SSR protocols for five different simulated scenarios in the presence of transient and permanent node failure rates exhibit a greater resiliency to errors and failure and better routing performance in terms of the number of successfully delivered network packets, end-to-end delay, delivered MAC layer packets, packet error rate, as well as efficient energy conservation in a highly congested, faulty, and scalable sensor network.

A Formal Approach to the Selection by Minimum Error and Pattern Method for Sensor Data Loss Reduction in Unstable Wireless Sensor Network Communications

PubMed Central

Kim, Changhwa; Shin, DongHyun

2017-01-01

There are wireless networks in which typically communications are unsafe. Most terrestrial wireless sensor networks belong to this category of networks. Another example of an unsafe communication network is an underwater acoustic sensor network (UWASN). In UWASNs in particular, communication failures occur frequently and the failure durations can range from seconds up to a few hours, days, or even weeks. These communication failures can cause data losses significant enough to seriously damage human life or property, depending on their application areas. In this paper, we propose a framework to reduce sensor data loss during communication failures and we present a formal approach to the Selection by Minimum Error and Pattern (SMEP) method that plays the most important role for the reduction in sensor data loss under the proposed framework. The SMEP method is compared with other methods to validate its effectiveness through experiments using real-field sensor data sets. Moreover, based on our experimental results and performance comparisons, the SMEP method has been validated to be better than others in terms of the average sensor data value error rate caused by sensor data loss. PMID:28498312

A Formal Approach to the Selection by Minimum Error and Pattern Method for Sensor Data Loss Reduction in Unstable Wireless Sensor Network Communications.

PubMed

Kim, Changhwa; Shin, DongHyun

2017-05-12

There are wireless networks in which typically communications are unsafe. Most terrestrial wireless sensor networks belong to this category of networks. Another example of an unsafe communication network is an underwater acoustic sensor network (UWASN). In UWASNs in particular, communication failures occur frequently and the failure durations can range from seconds up to a few hours, days, or even weeks. These communication failures can cause data losses significant enough to seriously damage human life or property, depending on their application areas. In this paper, we propose a framework to reduce sensor data loss during communication failures and we present a formal approach to the Selection by Minimum Error and Pattern (SMEP) method that plays the most important role for the reduction in sensor data loss under the proposed framework. The SMEP method is compared with other methods to validate its effectiveness through experiments using real-field sensor data sets. Moreover, based on our experimental results and performance comparisons, the SMEP method has been validated to be better than others in terms of the average sensor data value error rate caused by sensor data loss.

LDRD report: Smoke effects on electrical equipment

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

TANAKA,TINA J.; BAYNES JR.,EDWARD E.; NOWLEN,STEVEN P.

2000-03-01

Smoke is known to cause electrical equipment failure, but the likelihood of immediate failure during a fire is unknown. Traditional failure assessment techniques measure the density of ionic contaminants deposited on surfaces to determine the need for cleaning or replacement of electronic equipment exposed to smoke. Such techniques focus on long-term effects, such as corrosion, but do not address the immediate effects of the fire. This document reports the results of tests on the immediate effects of smoke on electronic equipment. Various circuits and components were exposed to smoke from different fields in a static smoke exposure chamber and weremore » monitored throughout the exposure. Electrically, the loss of insulation resistance was the most important change caused by smoke. For direct current circuits, soot collected on high-voltage surfaces sometimes formed semi-conductive soot bridges that shorted the circuit. For high voltage alternating current circuits, the smoke also tended to increase the likelihood of arcing, but did not accumulate on the surfaces. Static random access memory chips failed for high levels of smoke, but hard disk drives did not. High humidity increased the conductive properties of the smoke. The conductivity does not increase linearly with smoke density as first proposed; however, it does increase with quantity. The data can be used to give a rough estimate of the amount of smoke that will cause failures in CMOS memory chips, dc and ac circuits. Comparisons of this data to other fire tests can be made through the optical and mass density measurements of the smoke.« less

Understanding and managing the effects of battery charger and inverter aging

NASA Astrophysics Data System (ADS)

Gunther, W.; Aggarwal, S.

An aging assessment of battery chargers and inverters was conducted under the auspices of the NRC's Nuclear Plant Aging Research (NPAR) Program. The intentions of this program are to resolve issues related to the aging and service wear of equipment and systems at operating reactor facilities and to assess their impact on safety. Inverters and battery chargers are used in nuclear power plants to perform significant functions related to plant safety and availability. The specific impact of a battery charger or inverter failure varies with plant configuration. Operating experience data have demonstrated that reactor trips, safety injection system actuations, and inoperable emergency core cooling systems have resulted from inverter failures; and dc bus degradation leading to diesel generator inoperability or loss of control room annunication and indication have resulted from battery and battery charger failures. For the battery charger and inverter, the aging and service wear of subcomponents have contributed significantly to equipment failures. This paper summarizes the data and then describes methods that can be used to detect battery charger and inverter degradation prior to failure, as well as methods to minimize the failure effects. In both cases, the managing of battery charger and inverter aging is emphasized.

Frequency Analysis of Failure Scenarios from Shale Gas Development.

PubMed

Abualfaraj, Noura; Gurian, Patrick L; Olson, Mira S

2018-04-29

This study identified and prioritized potential failure scenarios for natural gas drilling operations through an elicitation of people who work in the industry. A list of twelve failure scenarios of concern was developed focusing on specific events that may occur during the shale gas extraction process involving an operational failure or a violation of regulations. Participants prioritized the twelve scenarios based on their potential impact on the health and welfare of the general public, potential impact on worker safety, how well safety guidelines protect against their occurrence, and how frequently they occur. Illegal dumping of flowback water, while rated as the least frequently occurring scenario, was considered the scenario least protected by safety controls and the one of most concern to the general public. In terms of worker safety, the highest concern came from improper or inadequate use of personal protective equipment (PPE). While safety guidelines appear to be highly protective regarding PPE usage, inadequate PPE is the most directly witnessed failure scenario. Spills of flowback water due to equipment failure are of concern both with regards to the welfare of the general public and worker safety as they occur more frequently than any other scenario examined in this study.

Frequency Analysis of Failure Scenarios from Shale Gas Development

PubMed Central

Abualfaraj, Noura; Olson, Mira S.

2018-01-01

This study identified and prioritized potential failure scenarios for natural gas drilling operations through an elicitation of people who work in the industry. A list of twelve failure scenarios of concern was developed focusing on specific events that may occur during the shale gas extraction process involving an operational failure or a violation of regulations. Participants prioritized the twelve scenarios based on their potential impact on the health and welfare of the general public, potential impact on worker safety, how well safety guidelines protect against their occurrence, and how frequently they occur. Illegal dumping of flowback water, while rated as the least frequently occurring scenario, was considered the scenario least protected by safety controls and the one of most concern to the general public. In terms of worker safety, the highest concern came from improper or inadequate use of personal protective equipment (PPE). While safety guidelines appear to be highly protective regarding PPE usage, inadequate PPE is the most directly witnessed failure scenario. Spills of flowback water due to equipment failure are of concern both with regards to the welfare of the general public and worker safety as they occur more frequently than any other scenario examined in this study. PMID:29710821

Fail Better: Toward a Taxonomy of E-Learning Error

ERIC Educational Resources Information Center

Priem, Jason

2010-01-01

The study of student error, important across many fields of educational research, has begun to attract interest in the field of e-learning, particularly in relation to usability. However, it remains unclear when errors should be avoided (as usability failures) or embraced (as learning opportunities). Many domains have benefited from taxonomies of…

Quality of care and investment in property, plant, and equipment in hospitals.

PubMed Central

Levitt, S W

1994-01-01

OBJECTIVE. This study explores the relationship between quality of care and investment in property, plant, and equipment (PPE) in hospitals. DATA SOURCES. Hospitals' investment in PPE was derived from audited financial statements for the fiscal years 1984-1989. Peer Review Organization (PRO) Generic Quality Screen (GQS) reviews and confirmed failures between April 1989 and September 1990 were obtained from the Massachusetts PRO. STUDY DESIGN. Weighted least squares regression models used PRO GQS confirmed failure rates as the dependent variable, and investment in PPE as the key explanatory variable. DATA EXTRACTION. Investment in PPE was standardized, summed by the hospital over the six years, and divided by the hospital's average number of beds in that period. The number of PRO reviewed cases with one or more GQS confirmed failures was divided by the total number of cases reviewed to create confirmed failure rates. PRINCIPAL FINDINGS. Investment in PPE in Massachusetts hospitals is correlated with GQS confirmed failure rates. CONCLUSIONS. A financial variable, investment in PPE, predicts certain dimensions of quality of care in hospitals. PMID:8113054

Improving online risk assessment with equipment prognostics and health monitoring

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

Coble, Jamie B.; Liu, Xiaotong; Briere, Chris

The current approach to evaluating the risk of nuclear power plant (NPP) operation relies on static probabilities of component failure, which are based on industry experience with the existing fleet of nominally similar light water reactors (LWRs). As the nuclear industry looks to advanced reactor designs that feature non-light water coolants (e.g., liquid metal, high temperature gas, molten salt), this operating history is not available. Many advanced reactor designs use advanced components, such as electromagnetic pumps, that have not been used in the US commercial nuclear fleet. Given the lack of rich operating experience, we cannot accurately estimate the evolvingmore » probability of failure for basic components to populate the fault trees and event trees that typically comprise probabilistic risk assessment (PRA) models. Online equipment prognostics and health management (PHM) technologies can bridge this gap to estimate the failure probabilities for components under operation. The enhanced risk monitor (ERM) incorporates equipment condition assessment into the existing PRA and risk monitor framework to provide accurate and timely estimates of operational risk.« less

Electricity Breakdown Management for Sarawak Energy: Use of Condition-Based Equipment for Detection of Defective Insulator

NASA Astrophysics Data System (ADS)

Tan, J. K.; Abas, N.

2017-07-01

Managing electricity breakdown is vital since an outage causes economic losses for customers and the utility companies. However, electricity breakdown is unavoidable due to some internal or external factors beyond our control. Electricity breakdown on overhead lines tend occur more frequently because it is prone to external disturbances such as animal, overgrown vegetation and defective pole top accessories. In Sarawak Energy Berhad (SEB), majority of the network are composed of overhead lines and hence, is more prone to failure. Conventional method of equipment inspection and fault finding are not effective to quickly identify the root cause of failure. SEB has engaged the use of corona discharge camera as condition-based monitoring equipment to carry out condition based inspection on the line in order to diagnose the condition of the lines prior to failure. Experimental testing has been carried out to determine the correlation between the corona discharge count and the level of defect on line insulator. The result shall be tabulated and will be used as reference for future scanning and diagnostic on any defect on the lines.

Compensating for the effects of site and equipment variation on delphinid species identification from their echolocation clicks.

PubMed

Roch, Marie A; Stinner-Sloan, Johanna; Baumann-Pickering, Simone; Wiggins, Sean M

2015-01-01

A concern for applications of machine learning techniques to bioacoustics is whether or not classifiers learn the categories for which they were trained. Unfortunately, information such as characteristics of specific recording equipment or noise environments can also be learned. This question is examined in the context of identifying delphinid species by their echolocation clicks. To reduce the ambiguity between species classification performance and other confounding factors, species whose clicks can be readily distinguished were used in this study: Pacific white-sided and Risso's dolphins. A subset of data from autonomous acoustic recorders located at seven sites in the Southern California Bight collected between 2006 and 2012 was selected. Cepstral-based features were extracted for each echolocation click and Gaussian mixture models were used to classify groups of 100 clicks. One hundred Monte-Carlo three-fold experiments were conducted to examine classification performance where fold composition was determined by acoustic encounter, recorder characteristics, or recording site. The error rate increased from 6.1% when grouped by acoustic encounter to 18.1%, 46.2%, and 33.2% for grouping by equipment, equipment category, and site, respectively. A noise compensation technique reduced error for these grouping schemes to 2.7%, 4.4%, 6.7%, and 11.4%, respectively, a reduction in error rate of 56%-86%.

Managing Errors to Reduce Accidents in High Consequence Networked Information Systems

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

Ganter, J.H.

1999-02-01

Computers have always helped to amplify and propagate errors made by people. The emergence of Networked Information Systems (NISs), which allow people and systems to quickly interact worldwide, has made understanding and minimizing human error more critical. This paper applies concepts from system safety to analyze how hazards (from hackers to power disruptions) penetrate NIS defenses (e.g., firewalls and operating systems) to cause accidents. Such events usually result from both active, easily identified failures and more subtle latent conditions that have resided in the system for long periods. Both active failures and latent conditions result from human errors. We classifymore » these into several types (slips, lapses, mistakes, etc.) and provide NIS examples of how they occur. Next we examine error minimization throughout the NIS lifecycle, from design through operation to reengineering. At each stage, steps can be taken to minimize the occurrence and effects of human errors. These include defensive design philosophies, architectural patterns to guide developers, and collaborative design that incorporates operational experiences and surprises into design efforts. We conclude by looking at three aspects of NISs that will cause continuing challenges in error and accident management: immaturity of the industry, limited risk perception, and resource tradeoffs.« less

Mobile Uninterruptible Power Supply

NASA Technical Reports Server (NTRS)

Mears, Robert L.

1990-01-01

Proposed mobile unit provides 20 kVA of uninterruptible power. Used with mobile secondary power-distribution centers to provide power to test equipment with minimal cabling, hazards, and obstacles. Wheeled close to test equipment and system being tested so only short cable connections needed. Quickly moved and set up in new location. Uninterruptible power supply intended for tests which data lost or equipment damaged during even transient power failure.

Skylab communications carrier 16536G and filter bypass adapter assembly 12535G. [development of communications equipment for use with Skylab spacecraft

NASA Technical Reports Server (NTRS)

1974-01-01

Communications equipment for use with the Skylab project is examined to show compliance with contract requirements. The items of equipment considered are: (1) communications carrier assemblies, (2) filter bypass adapter assemblies, and (3) sub-assemblies, parts, and repairs. Additional information is provided concerning contract requirements, test requirements, and failure investigation actions.

A preliminary taxonomy of medical errors in family practice

PubMed Central

Dovey, S; Meyers, D; Phillips, R; Green, L; Fryer, G; Galliher, J; Kappus, J; Grob, P

2002-01-01

Objective: To develop a preliminary taxonomy of primary care medical errors. Design: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. Setting: The National Network for Family Practice and Primary Care Research. Participants: Family physicians. Main outcome measures: Medical error category, context, and consequence. Results: Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failures (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. Conclusions: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors. PMID:12486987

A preliminary taxonomy of medical errors in family practice.

PubMed

Dovey, S M; Meyers, D S; Phillips, R L; Green, L A; Fryer, G E; Galliher, J M; Kappus, J; Grob, P

2002-09-01

To develop a preliminary taxonomy of primary care medical errors. Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. The National Network for Family Practice and Primary Care Research. Family physicians. Medical error category, context, and consequence. Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Determining Component Probability using Problem Report Data for Ground Systems used in Manned Space Flight

NASA Technical Reports Server (NTRS)

Monaghan, Mark W.; Gillespie, Amanda M.

2013-01-01

During the shuttle era NASA utilized a failure reporting system called the Problem Reporting and Corrective Action (PRACA) it purpose was to identify and track system non-conformance. The PRACA system over the years evolved from a relatively nominal way to identify system problems to a very complex tracking and report generating data base. The PRACA system became the primary method to categorize any and all anomalies from corrosion to catastrophic failure. The systems documented in the PRACA system range from flight hardware to ground or facility support equipment. While the PRACA system is complex, it does possess all the failure modes, times of occurrence, length of system delay, parts repaired or replaced, and corrective action performed. The difficulty is mining the data then to utilize that data in order to estimate component, Line Replaceable Unit (LRU), and system reliability analysis metrics. In this paper, we identify a methodology to categorize qualitative data from the ground system PRACA data base for common ground or facility support equipment. Then utilizing a heuristic developed for review of the PRACA data determine what reports identify a credible failure. These data are the used to determine inter-arrival times to perform an estimation of a metric for repairable component-or LRU reliability. This analysis is used to determine failure modes of the equipment, determine the probability of the component failure mode, and support various quantitative differing techniques for performing repairable system analysis. The result is that an effective and concise estimate of components used in manned space flight operations. The advantage is the components or LRU's are evaluated in the same environment and condition that occurs during the launch process.

Personal protective equipment for the Ebola virus disease: A comparison of 2 training programs.

PubMed

Casalino, Enrique; Astocondor, Eugenio; Sanchez, Juan Carlos; Díaz-Santana, David Enrique; Del Aguila, Carlos; Carrillo, Juan Pablo

2015-12-01

Personal protective equipment (PPE) for preventing Ebola virus disease (EVD) includes basic PPE (B-PPE) and enhanced PPE (E-PPE). Our aim was to compare conventional training programs (CTPs) and reinforced training programs (RTPs) on the use of B-PPE and E-PPE. Four groups were created, designated CTP-B, CTP-E, RTP-B, and RTP-E. All groups received the same theoretical training, followed by 3 practical training sessions. A total of 120 students were included (30 per group). In all 4 groups, the frequency and number of total errors and critical errors decreased significantly over the course of the training sessions (P < .01). The RTP was associated with a greater reduction in the number of total errors and critical errors (P < .0001). During the third training session, we noted an error frequency of 7%-43%, a critical error frequency of 3%-40%, 0.3-1.5 total errors, and 0.1-0.8 critical errors per student. The B-PPE groups had the fewest errors and critical errors (P < .0001). Our results indicate that both training methods improved the student's proficiency, that B-PPE appears to be easier to use than E-PPE, that the RTP achieved better proficiency for both PPE types, and that a number of students are still potentially at risk for EVD contamination despite the improvements observed during the training. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

40 CFR 61.161 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-07-01

... conditioned to produce molten glass. The unit includes foundations, superstructure and retaining walls, raw... aerosols. Malfunction means any sudden failure of air pollution control equipment or process equipment or... melted by indirect heating. The openings of the vessels are in the outside wall of the furnace and are...

Systematic analysis of video data from different human-robot interaction studies: a categorization of social signals during error situations.

PubMed

Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred

2015-01-01

Human-robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human-robot interaction experiments. For that, we analyzed 201 videos of five human-robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human-robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies.

Systematic analysis of video data from different human–robot interaction studies: a categorization of social signals during error situations

PubMed Central

Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred

2015-01-01

Human–robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human–robot interaction experiments. For that, we analyzed 201 videos of five human–robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human–robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies. PMID:26217266

International Space Station (ISS) Environmental Control and Life Support (ECLS) System Overview of Events: February 2002 - 2004

NASA Technical Reports Server (NTRS)

Gentry, Gregory J.; Reysa, Richard P.; Williams, Dave E.

2004-01-01

The International Space Station continues to build up its life support equipment capability. Several ECLS equipment failures have occurred since Lab activation in February 2001. Major problems occurring between February 2001 and February 2002 were discussed in other works. Major problems occurring between February 2002 and February 2003 are discussed in this paper, as are updates from previously ongoing unresolved problems. This paper addresses failures, and root cause, with particular emphasis on likely micro-gravity causes. Impact to overall station operations and proposed and accomplished fixes will also be discussed.

Development of a computer program to generate typical measurement values for various systems on a space station

NASA Technical Reports Server (NTRS)

Deacetis, Louis A.

1987-01-01

The elements of a simulation program written in Ada were developed. The program will eventually serve as a data generator of typical readings from various space station equipment involved with Communications and Tracking, and will simulate various scenarios that may arise due to equipment malfunction or failure, power failure, etc. In addition, an evaluation of the Ada language was made from the viewpoint of a FORTRAN programmer learning Ada for the first time. Various strengths and difficulties associated with the learning and use of Ada are considered.

Deterioration of ZnO/SiO2 diode packages in high humidity

NASA Technical Reports Server (NTRS)

Evans, John; Wagner, Scott

1987-01-01

A case study is reported in which the ZnO/SiO2 glass used to package a power rectifier combined with the design to produce a catastropic corrosion failure of the system. Metallic Zn inclusions, present in the glass, played a critical role in creating a conductive path for corrosion currents. Actual equipment failure was the result of an open circuit trace created by corrosion. It is concluded that the presence of Zn inclusions in the glass of this type of package may result in long-term reliability problems for equipment used in high humidity environments.

Damping treatment for an aircraft hard-mounted antenna system in a vibroacoustic environment

NASA Astrophysics Data System (ADS)

Tate, Ralph E.; Rupert, Carl L.

1990-10-01

This paper discusses the design, analysis, and testing of 'add-on' damping treatments for the Band 6, 7, 8 radar antenna packages that are hard-mounted on the B-1B Aft Equipment Bay (AEB) where equipment failures are routinely occurring during take-off maneuvers at maximum throttle settings. This damage results from the intense vibroacoustical environment generated by the three-stage afterburning engines. Failure rates have been sufficiently high to warrant a 'quick fix' involving damping treatments that can be installed in a short time with minimal modification to the existing structure.

Fatigue failure of pb-free electronic packages under random vibration loads

NASA Astrophysics Data System (ADS)

Saravanan, S.; Prabhu, S.; Muthukumar, R.; Gowtham Raj, S.; Arun Veerabagu, S.

2018-03-01

The electronic equipment are used in several fields like, automotive, aerospace, consumer goods where they are subjected to vibration loads leading to failure of solder joints used in these equipment. This paper presents a methodology to predict the fatigue life of Pb-free surface mounted BGA packages subjected to random vibrations. The dynamic characteristics of the PCB, such as the natural frequencies, mode shapes and damping ratios were determined. Spectrum analysis was used to determine the stress response of the critical solder joint and the cumulative fatigue damage accumulated by the solder joint for a specific duration was determined.

Comparison of Models of Stress Relaxation in Failure Analysis for Connectors under Long-term Storage

NASA Astrophysics Data System (ADS)

Zhou, Yilin; Wan, Mengru

2018-03-01

Reliability requirements of the system equipment under long-term storage are put forward especially for the military products, so that the connectors in the equipment also need long-term storage life correspondingly. In this paper, the effects of stress relaxation of the elastic components on electrical contact of the connectors in long-term storage process were studied from the failure mechanism and degradation models. A wire spring connector was taken as an example to discuss the life prediction method for electrical contacts of the connectors based on stress relaxation degradation under long -term storage.

TU-AB-BRD-02: Failure Modes and Effects Analysis

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

Huq, M.

2015-06-15

Current quality assurance and quality management guidelines provided by various professional organizations are prescriptive in nature, focusing principally on performance characteristics of planning and delivery devices. However, published analyses of events in radiation therapy show that most events are often caused by flaws in clinical processes rather than by device failures. This suggests the need for the development of a quality management program that is based on integrated approaches to process and equipment quality assurance. Industrial engineers have developed various risk assessment tools that are used to identify and eliminate potential failures from a system or a process before amore » failure impacts a customer. These tools include, but are not limited to, process mapping, failure modes and effects analysis, fault tree analysis. Task Group 100 of the American Association of Physicists in Medicine has developed these tools and used them to formulate an example risk-based quality management program for intensity-modulated radiotherapy. This is a prospective risk assessment approach that analyzes potential error pathways inherent in a clinical process and then ranks them according to relative risk, typically before implementation, followed by the design of a new process or modification of the existing process. Appropriate controls are then put in place to ensure that failures are less likely to occur and, if they do, they will more likely be detected before they propagate through the process, compromising treatment outcome and causing harm to the patient. Such a prospective approach forms the basis of the work of Task Group 100 that has recently been approved by the AAPM. This session will be devoted to a discussion of these tools and practical examples of how these tools can be used in a given radiotherapy clinic to develop a risk based quality management program. Learning Objectives: Learn how to design a process map for a radiotherapy process Learn how to perform failure modes and effects analysis analysis for a given process Learn what fault trees are all about Learn how to design a quality management program based upon the information obtained from process mapping, failure modes and effects analysis and fault tree analysis. Dunscombe: Director, TreatSafely, LLC and Center for the Assessment of Radiological Sciences; Consultant to IAEA and Varian Thomadsen: President, Center for the Assessment of Radiological Sciences Palta: Vice President of the Center for the Assessment of Radiological Sciences.« less

Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.

PubMed

Regenbogen, Scott E; Greenberg, Caprice C; Studdert, David M; Lipsitz, Stuart R; Zinner, Michael J; Gawande, Atul A

2007-11-01

To identify the most prevalent patterns of technical errors in surgery, and evaluate commonly recommended interventions in light of these patterns. The majority of surgical adverse events involve technical errors, but little is known about the nature and causes of these events. We examined characteristics of technical errors and common contributing factors among closed surgical malpractice claims. Surgeon reviewers analyzed 444 randomly sampled surgical malpractice claims from four liability insurers. Among 258 claims in which injuries due to error were detected, 52% (n = 133) involved technical errors. These technical errors were further analyzed with a structured review instrument designed by qualitative content analysis. Forty-nine percent of the technical errors caused permanent disability; an additional 16% resulted in death. Two-thirds (65%) of the technical errors were linked to manual error, 9% to errors in judgment, and 26% to both manual and judgment error. A minority of technical errors involved advanced procedures requiring special training ("index operations"; 16%), surgeons inexperienced with the task (14%), or poorly supervised residents (9%). The majority involved experienced surgeons (73%), and occurred in routine, rather than index, operations (84%). Patient-related complexities-including emergencies, difficult or unexpected anatomy, and previous surgery-contributed to 61% of technical errors, and technology or systems failures contributed to 21%. Most technical errors occur in routine operations with experienced surgeons, under conditions of increased patient complexity or systems failure. Commonly recommended interventions, including restricting high-complexity operations to experienced surgeons, additional training for inexperienced surgeons, and stricter supervision of trainees, are likely to address only a minority of technical errors. Surgical safety research should instead focus on improving decision-making and performance in routine operations for complex patients and circumstances.

49 CFR Appendix A to Part 238 - Schedule of Civil Penalties 1

Code of Federal Regulations, 2014 CFR

2014-10-01

....15Movement of power brake defects: (b) Improper movement from Class I or IA brake test 5,000 7,500 (c... required design features 5,000 7,500 (e) Failure to comply with hardware and software safety program 5,000... test previously used equipment 7,500 11,000 (b)(1) Failure to develop plan 7,500 11,000 (b)(2) Failure...

49 CFR Appendix A to Part 238 - Schedule of Civil Penalties 1

Code of Federal Regulations, 2010 CFR

2010-10-01

....15Movement of power brake defects: (b) Improper movement from Class I or IA brake test 5,000 7,500 (c... required design features 5,000 7,500 (e) Failure to comply with hardware and software safety program 5,000... test previously used equipment 7,500 11,000 (b)(1) Failure to develop plan 7,500 11,000 (b)(2) Failure...

49 CFR Appendix A to Part 238 - Schedule of Civil Penalties 1

Code of Federal Regulations, 2013 CFR

2013-10-01

... movement from Class I or IA brake test 5,000 7,500 (c) Improper movement of en route defect 2,500 5,000 (2...) Failure to include required design features 5,000 7,500 (e) Failure to comply with hardware and software... properly test previously used equipment 7,500 11,000 (b)(1) Failure to develop plan 7,500 11,000 (b)(2...

Malpractice claims related to musculoskeletal imaging. Incidence and anatomical location of lesions.

PubMed

Fileni, Adriano; Fileni, Gaia; Mirk, Paoletta; Magnavita, Giulia; Nicoli, Marzia; Magnavita, Nicola

2013-12-01

Failure to detect lesions of the musculoskeletal system is a frequent cause of malpractice claims against radiologists. We examined all the malpractice claims related to alleged errors in musculoskeletal imaging filed against Italian radiologists over a period of 14 years (1993-2006). During the period considered, a total of 416 claims for alleged diagnostic errors relating to the musculoskeletal system were filed against radiologists; of these, 389 (93.5%) concerned failure to report fractures, and 15 (3.6%) failure to diagnose a tumour. Incorrect interpretation of bone pathology is among the most common causes of litigation against radiologists; alone, it accounts for 36.4% of all malpractice claims filed during the observation period. Awareness of this risk should encourage extreme caution and diligence.

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

Kang, D. I.; Han, S. H.

A PSA analyst has been manually determining fire-induced component failure modes and modeling them into the PSA logics. These can be difficult and time-consuming tasks as they need much information and many events are to be modeled. KAERI has been developing the IPRO-ZONE (interface program for constructing zone effect table) to facilitate fire PSA works for identifying and modeling fire-induced component failure modes, and to construct a one top fire event PSA model. With the output of the IPRO-ZONE, the AIMS-PSA, and internal event one top PSA model, one top fire events PSA model is automatically constructed. The outputs ofmore » the IPRO-ZONE include information on fire zones/fire scenarios, fire propagation areas, equipment failure modes affected by a fire, internal PSA basic events corresponding to fire-induced equipment failure modes, and fire events to be modeled. This paper introduces the IPRO-ZONE, and its application results to fire PSA of Ulchin Unit 3 and SMART(System-integrated Modular Advanced Reactor). (authors)« less

Performance analysis of the word synchronization properties of the outer code in a TDRSS decoder

NASA Technical Reports Server (NTRS)

Costello, D. J., Jr.; Lin, S.

1984-01-01

A self-synchronizing coding scheme for NASA's TDRSS satellite system is a concatenation of a (2,1,7) inner convolutional code with a (255,223) Reed-Solomon outer code. Both symbol and word synchronization are achieved without requiring that any additional symbols be transmitted. An important parameter which determines the performance of the word sync procedure is the ratio of the decoding failure probability to the undetected error probability. Ideally, the former should be as small as possible compared to the latter when the error correcting capability of the code is exceeded. A computer simulation of a (255,223) Reed-Solomon code as carried out. Results for decoding failure probability and for undetected error probability are tabulated and compared.

Human Factors Process Task Analysis: Liquid Oxygen Pump Acceptance Test Procedure at the Advanced Technology Development Center

NASA Technical Reports Server (NTRS)

Diorio, Kimberly A.; Voska, Ned (Technical Monitor)

2002-01-01

This viewgraph presentation provides information on Human Factors Process Failure Modes and Effects Analysis (HF PFMEA). HF PFMEA includes the following 10 steps: Describe mission; Define System; Identify human-machine; List human actions; Identify potential errors; Identify factors that effect error; Determine likelihood of error; Determine potential effects of errors; Evaluate risk; Generate solutions (manage error). The presentation also describes how this analysis was applied to a liquid oxygen pump acceptance test.

Renewal of radiological equipment.

PubMed

2014-10-01

In this century, medical imaging is at the heart of medical practice. Besides providing fast and accurate diagnosis, advances in radiology equipment offer new and previously non-existing options for treatment guidance with quite low morbidity, resulting in the improvement of health outcomes and quality of life for the patients. Although rapid technological development created new medical imaging modalities and methods, the same progress speed resulted in accelerated technical and functional obsolescence of the same medical imaging equipment, consequently creating a need for renewal. Older equipment has a high risk of failures and breakdowns, which might cause delays in diagnosis and treatment of the patient, and safety problems both for the patient and the medical staff. The European Society of Radiology is promoting the use of up-to-date equipment, especially in the context of the EuroSafe Imaging Campaign, as the use of up-to-date equipment will improve quality and safety in medical imaging. Every healthcare institution or authority should have a plan for medical imaging equipment upgrade or renewal. This plan should look forward a minimum of 5 years, with annual updates. Teaching points • Radiological equipment has a definite life cycle span, resulting in unavoidable breakdown and decrease or loss of image quality which renders equipment useless after a certain time period.• Equipment older than 10 years is no longer state-of-the art equipment and replacement is essential. Operating costs of older equipment will be high when compared with new equipment, and sometimes maintenance will be impossible if no spare parts are available.• Older equipment has a high risk of failure and breakdown, causing delays in diagnosis and treatment of the patient and safety problems both for the patient and the medical staff.• Every healthcare institution or authority should have a plan for medical imaging equipment upgrade or replacement. This plan should look forward a minimum of 5 years, with annual updating.

Syntactical and Punctuation Errors: An Analysis of Technical Writing of University Students Science College, Taif University, KSA

ERIC Educational Resources Information Center

Alamin, Abdulamir; Ahmed, Sawsan

2012-01-01

Analyzing errors committed by second language learners during their first year of study at the University of Taif, can offer insights and knowledge of the learners' difficulties in acquiring technical English communication. With reference to the errors analyzed, the researcher found that the learners' failure to understand basic English grammar…

46 CFR 34.15-50 - Lockout valves-T/ALL.

Code of Federal Regulations, 2012 CFR

2012-10-01

... COAST GUARD, DEPARTMENT OF HOMELAND SECURITY TANK VESSELS FIREFIGHTING EQUIPMENT Carbon Dioxide... carbon dioxide extinguishing system protecting a space over 6,000 cubic feet in volume and installed or... or spaces, making it impossible for carbon dioxide to discharge in the event of equipment failure...

46 CFR 34.15-50 - Lockout valves-T/ALL.

Code of Federal Regulations, 2014 CFR

2014-10-01

... COAST GUARD, DEPARTMENT OF HOMELAND SECURITY TANK VESSELS FIREFIGHTING EQUIPMENT Carbon Dioxide... carbon dioxide extinguishing system protecting a space over 6,000 cubic feet in volume and installed or... or spaces, making it impossible for carbon dioxide to discharge in the event of equipment failure...

46 CFR 34.15-50 - Lockout valves-T/ALL.

Code of Federal Regulations, 2013 CFR

2013-10-01

... COAST GUARD, DEPARTMENT OF HOMELAND SECURITY TANK VESSELS FIREFIGHTING EQUIPMENT Carbon Dioxide... carbon dioxide extinguishing system protecting a space over 6,000 cubic feet in volume and installed or... or spaces, making it impossible for carbon dioxide to discharge in the event of equipment failure...

29 CFR 1910.1047 - Ethylene oxide.

Code of Federal Regulations, 2011 CFR

2011-07-01

..., rupture of containers, or failure of control equipment that is likely to or does result in an unexpected... there has been a change in the production, process, control equipment, personnel or work practices that... controls and work practices. (i) The employer shall institute engineering controls and work practices to...

40 CFR 63.6175 - What definitions apply to this subpart?

Code of Federal Regulations, 2011 CFR

2011-07-01

.... Malfunction means any sudden, infrequent, and not reasonably preventable failure of air pollution control... appurtenances, and equipment used transporting gas from a production plant, delivery point of purchased gas... source to emit a pollutant, including air pollution control equipment and restrictions on hours of...

40 CFR 63.6175 - What definitions apply to this subpart?

Code of Federal Regulations, 2013 CFR

2013-07-01

.... Malfunction means any sudden, infrequent, and not reasonably preventable failure of air pollution control... appurtenances, and equipment used transporting gas from a production plant, delivery point of purchased gas... source to emit a pollutant, including air pollution control equipment and restrictions on hours of...

40 CFR 63.6175 - What definitions apply to this subpart?

Code of Federal Regulations, 2010 CFR

2010-07-01

.... Malfunction means any sudden, infrequent, and not reasonably preventable failure of air pollution control... appurtenances, and equipment used transporting gas from a production plant, delivery point of purchased gas... source to emit a pollutant, including air pollution control equipment and restrictions on hours of...

40 CFR 63.6175 - What definitions apply to this subpart?

Code of Federal Regulations, 2012 CFR

2012-07-01

.... Malfunction means any sudden, infrequent, and not reasonably preventable failure of air pollution control... appurtenances, and equipment used transporting gas from a production plant, delivery point of purchased gas... source to emit a pollutant, including air pollution control equipment and restrictions on hours of...

40 CFR 63.6175 - What definitions apply to this subpart?

Code of Federal Regulations, 2014 CFR

2014-07-01

.... Malfunction means any sudden, infrequent, and not reasonably preventable failure of air pollution control... appurtenances, and equipment used transporting gas from a production plant, delivery point of purchased gas... source to emit a pollutant, including air pollution control equipment and restrictions on hours of...

Common-Cause Failure Treatment in Event Assessment: Basis for a Proposed New Model

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

Dana Kelly; Song-Hua Shen; Gary DeMoss

2010-06-01

Event assessment is an application of probabilistic risk assessment in which observed equipment failures and outages are mapped into the risk model to obtain a numerical estimate of the event’s risk significance. In this paper, we focus on retrospective assessments to estimate the risk significance of degraded conditions such as equipment failure accompanied by a deficiency in a process such as maintenance practices. In modeling such events, the basic events in the risk model that are associated with observed failures and other off-normal situations are typically configured to be failed, while those associated with observed successes and unchallenged components aremore » assumed capable of failing, typically with their baseline probabilities. This is referred to as the failure memory approach to event assessment. The conditioning of common-cause failure probabilities for the common cause component group associated with the observed component failure is particularly important, as it is insufficient to simply leave these probabilities at their baseline values, and doing so may result in a significant underestimate of risk significance for the event. Past work in this area has focused on the mathematics of the adjustment. In this paper, we review the Basic Parameter Model for common-cause failure, which underlies most current risk modelling, discuss the limitations of this model with respect to event assessment, and introduce a proposed new framework for common-cause failure, which uses a Bayesian network to model underlying causes of failure, and which has the potential to overcome the limitations of the Basic Parameter Model with respect to event assessment.« less

The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review.

PubMed

Tully, Mary P; Ashcroft, Darren M; Dornan, Tim; Lewis, Penny J; Taylor, David; Wass, Val

2009-01-01

Prescribing errors are common, they result in adverse events and harm to patients and it is unclear how best to prevent them because recommendations are more often based on surmized rather than empirically collected data. The aim of this systematic review was to identify all informative published evidence concerning the causes of and factors associated with prescribing errors in specialist and non-specialist hospitals, collate it, analyse it qualitatively and synthesize conclusions from it. Seven electronic databases were searched for articles published between 1985-July 2008. The reference lists of all informative studies were searched for additional citations. To be included, a study had to be of handwritten prescriptions for adult or child inpatients that reported empirically collected data on the causes of or factors associated with errors. Publications in languages other than English and studies that evaluated errors for only one disease, one route of administration or one type of prescribing error were excluded. Seventeen papers reporting 16 studies, selected from 1268 papers identified by the search, were included in the review. Studies from the US and the UK in university-affiliated hospitals predominated (10/16 [62%]). The definition of a prescribing error varied widely and the included studies were highly heterogeneous. Causes were grouped according to Reason's model of accident causation into active failures, error-provoking conditions and latent conditions. The active failure most frequently cited was a mistake due to inadequate knowledge of the drug or the patient. Skills-based slips and memory lapses were also common. Where error-provoking conditions were reported, there was at least one per error. These included lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals. Latent conditions included reluctance to question senior colleagues and inadequate provision of training. Prescribing errors are often multifactorial, with several active failures and error-provoking conditions often acting together to cause them. In the face of such complexity, solutions addressing a single cause, such as lack of knowledge, are likely to have only limited benefit. Further rigorous study, seeking potential ways of reducing error, needs to be conducted. Multifactorial interventions across many parts of the system are likely to be required.

Application of a truncated normal failure distribution in reliability testing

NASA Technical Reports Server (NTRS)

Groves, C., Jr.

1968-01-01

Statistical truncated normal distribution function is applied as a time-to-failure distribution function in equipment reliability estimations. Age-dependent characteristics of the truncated function provide a basis for formulating a system of high-reliability testing that effectively merges statistical, engineering, and cost considerations.

76 FR 26320 - Draft Regulatory Guide: Reissuance and Availability

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-06

... Guide, DG-1217 ``Protection Against Turbine Missiles.'' SUMMARY: On November 2, 2009 (74 FR 56672), the... availability of Draft Regulatory Guide (DG)--1217, ``Protection Against Turbine Missiles.'' The guide is being... appropriately protected against the effects of missiles that might result from equipment failures. Failures that...

Apollo 16 Mission: Oxidizer Deservicing Tank Failure. No. 1; Anomaly Report

NASA Technical Reports Server (NTRS)

1972-01-01

An explosive failure of a ground support equipment decontamination unit tank occurred during the postflight deactivation of the oxidizer (nitrogen tetroxide) portion of the Apollo 16 command module reaction control system. A discussion of the significant aspects of the incident and conclusions are included.

Design of forging process variables under uncertainties

NASA Astrophysics Data System (ADS)

Repalle, Jalaja; Grandhi, Ramana V.

2005-02-01

Forging is a complex nonlinear process that is vulnerable to various manufacturing anomalies, such as variations in billet geometry, billet/die temperatures, material properties, and workpiece and forging equipment positional errors. A combination of these uncertainties could induce heavy manufacturing losses through premature die failure, final part geometric distortion, and reduced productivity. Identifying, quantifying, and controlling the uncertainties will reduce variability risk in a manufacturing environment, which will minimize the overall production cost. In this article, various uncertainties that affect the forging process are identified, and their cumulative effect on the forging tool life is evaluated. Because the forging process simulation is time-consuming, a response surface model is used to reduce computation time by establishing a relationship between the process performance and the critical process variables. A robust design methodology is developed by incorporating reliability-based optimization techniques to obtain sound forging components. A case study of an automotive-component forging-process design is presented to demonstrate the applicability of the method.

Public health consequences on vulnerable populations from acute chemical releases.

PubMed

Ruckart, Perri Zeitz; Orr, Maureen F

2008-07-09

Data from a large, multi-state surveillance system on acute chemical releases were analyzed to describe the type of events that are potentially affecting vulnerable populations (children, elderly and hospitalized patients) in order to better prevent and plan for these types of incidents in the future. During 2003-2005, there were 231 events where vulnerable populations were within ¼ mile of the event and the area of impact was greater than 200 feet from the facility/point of release. Most events occurred on a weekday during times when day care centers or schools were likely to be in session. Equipment failure and human error caused a majority of the releases. Agencies involved in preparing for and responding to chemical emergencies should work with hospitals, nursing homes, day care centers, and schools to develop policies and procedures for initiating appropriate protective measures and managing the medical needs of patients. Chemical emergency response drills should involve the entire community to protect those that may be more susceptible to harm.

Public Health Consequences on Vulnerable Populations from Acute Chemical Releases

PubMed Central

Ruckart, Perri Zeitz; Orr, Maureen F.

2008-01-01

Data from a large, multi-state surveillance system on acute chemical releases were analyzed to describe the type of events that are potentially affecting vulnerable populations (children, elderly and hospitalized patients) in order to better prevent and plan for these types of incidents in the future. During 2003–2005, there were 231 events where vulnerable populations were within ¼ mile of the event and the area of impact was greater than 200 feet from the facility/point of release. Most events occurred on a weekday during times when day care centers or schools were likely to be in session. Equipment failure and human error caused a majority of the releases. Agencies involved in preparing for and responding to chemical emergencies should work with hospitals, nursing homes, day care centers, and schools to develop policies and procedures for initiating appropriate protective measures and managing the medical needs of patients. Chemical emergency response drills should involve the entire community to protect those that may be more susceptible to harm. PMID:21572842

The distribution and public health consequences of releases of chemicals intended for pool use in 17 states, 2001-2009.

PubMed

Anderson, Ayana R; Welles, Wanda Lizak; Drew, James; Orr, Maureen F

2014-05-01

To keep swimming pool water clean and clear, consumers purchase, transport, store, use, and dispose of large amounts of potentially hazardous chemicals. Data about incidents due to the use of these chemicals and the resultant public health impacts are limited. The authors analyzed pool chemical release data from 17 states that participated in the Agency for Toxic Substances and Disease Registry's chemical event surveillance system during 2001-2009. In 400 pool chemical incidents, 60% resulted in injuries. Of the 732 injured persons, 67% were members of the public and 50% were under 18 years old. Incidents occurred most frequently in private residences (39%), but incidents with the most injured persons (34%) occurred at recreational facilities. Human error (71.9%) was the most frequent primary contributing factor, followed by equipment failure (22.8%). Interventions designed to mitigate the public health impact associated with pool chemical releases should target both private pool owners and public pool operators.

Safe use of chemicals for sterilization in healthcare.

PubMed

Warburton, P Richard

2012-01-01

Chemical sterilization is necessary for temperature sensitive items that cannot be sterilized with steam. These chemical sterilants are by their nature hazardous; otherwise, they would not function well. Modern sterilizers and associated equipment are designed so that these chemicals can be used safely. Whether through mechanical failure, wear and tear, or user error, leaks do sometimes occur. The maximum chemical exposure is determined by OSHA permissible exposure limits, if available, and if not available, employers should use recognized standards. Employers have a duty to ensure safe work environment and take appropriate action to mitigate potential risks. Employers should therefore assess the hazards of the chemicals used, the potential modes for leakage, means for identifying leaks and the risk of exposure of employees. Ideally, work practices should be developed by healthcare facilities so that sterile processing employees know what to do in case of a chemical leak or spill, and how to safely use these chemicals to ensure their own, and patient safety.

Degradations to microprocessor-based systems due to environmental stressors

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

Messman, P. A.; Peilai, Z.; Goodenow, D. A.

Recent studies indicate that EMI/RFI is the most significant environmental Stressor with potential for leading to digital systems degradation and failure. With digital I and C and wireless technology becoming standard in many industrial environments, nuclear power plant operators of current and future plants will or already have implemented these technologies seeking to leverage the economic benefits of such technology. With digital I and C systems' higher susceptibility to EMI/RFI and the increased environmental noise introduced by wireless-based systems, this produces a dangerous combination that could lead to logic errors, equipment damage, and faults in digital I and C. Failuresmore » to these systems, especially to safety-critical systems, could lead to loss of system, which would pose a safety risk and decrease in operational efficiency. In order to better understand system degradations by these means and aid in regulation and guidance, we propose to experimentally study the susceptibility of digital I and C to wireless technology. (authors)« less

14 CFR 125.205 - Equipment requirements: Airplanes under IFR.

Code of Federal Regulations, 2014 CFR

2014-01-01

... airplane under IFR unless it has— (a) A vertical speed indicator; (b) A free-air temperature indicator; (c) A heated pitot tube for each airspeed indicator; (d) A power failure warning device or vacuum... equipment necessary for safe emergency operation of the airplane; and (g) Two independent sources of energy...

14 CFR 125.205 - Equipment requirements: Airplanes under IFR.

Code of Federal Regulations, 2012 CFR

2012-01-01

... airplane under IFR unless it has— (a) A vertical speed indicator; (b) A free-air temperature indicator; (c) A heated pitot tube for each airspeed indicator; (d) A power failure warning device or vacuum... equipment necessary for safe emergency operation of the airplane; and (g) Two independent sources of energy...

14 CFR 125.205 - Equipment requirements: Airplanes under IFR.

Code of Federal Regulations, 2013 CFR

2013-01-01

... airplane under IFR unless it has— (a) A vertical speed indicator; (b) A free-air temperature indicator; (c) A heated pitot tube for each airspeed indicator; (d) A power failure warning device or vacuum... equipment necessary for safe emergency operation of the airplane; and (g) Two independent sources of energy...

14 CFR 125.205 - Equipment requirements: Airplanes under IFR.

Code of Federal Regulations, 2010 CFR

2010-01-01

... airplane under IFR unless it has— (a) A vertical speed indicator; (b) A free-air temperature indicator; (c) A heated pitot tube for each airspeed indicator; (d) A power failure warning device or vacuum... equipment necessary for safe emergency operation of the airplane; and (g) Two independent sources of energy...

14 CFR 125.205 - Equipment requirements: Airplanes under IFR.

Code of Federal Regulations, 2011 CFR

2011-01-01

... airplane under IFR unless it has— (a) A vertical speed indicator; (b) A free-air temperature indicator; (c) A heated pitot tube for each airspeed indicator; (d) A power failure warning device or vacuum... equipment necessary for safe emergency operation of the airplane; and (g) Two independent sources of energy...

31 CFR 356.11 - How are bids submitted in an auction?

Code of Federal Regulations, 2012 CFR

2012-07-01

..., our computer time stamp will establish the receipt time. You are bound by your bids after the closing... failures or disruptions of equipment or communications facilities used for participating in Treasury auctions. (4) Submitters are responsible for bids submitted using computer equipment on their premises...

31 CFR 356.11 - How are bids submitted in an auction?

Code of Federal Regulations, 2011 CFR

2011-07-01

..., our computer time stamp will establish the receipt time. You are bound by your bids after the closing... failures or disruptions of equipment or communications facilities used for participating in Treasury auctions. (4) Submitters are responsible for bids submitted using computer equipment on their premises...

40 CFR 60.482-3a - Standards: Compressors.

Code of Federal Regulations, 2013 CFR

2013-07-01

... of VOC in the Synthetic Organic Chemicals Manufacturing Industry for Which Construction... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped...

40 CFR 60.482-3 - Standards: Compressors.

Code of Federal Regulations, 2012 CFR

2012-07-01

... of VOC in the Synthetic Organic Chemicals Manufacturing Industry for which Construction... be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) shall be checked daily or shall be equipped with an...

40 CFR 60.482-3 - Standards: Compressors.

Code of Federal Regulations, 2013 CFR

2013-07-01

... of VOC in the Synthetic Organic Chemicals Manufacturing Industry for which Construction... be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) shall be checked daily or shall be equipped with an...

40 CFR 60.482-3a - Standards: Compressors.

Code of Federal Regulations, 2014 CFR

2014-07-01

... of VOC in the Synthetic Organic Chemicals Manufacturing Industry for Which Construction... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped...

40 CFR 60.482-3 - Standards: Compressors.

Code of Federal Regulations, 2014 CFR

2014-07-01

... of VOC in the Synthetic Organic Chemicals Manufacturing Industry for which Construction... be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) shall be checked daily or shall be equipped with an...

40 CFR 57.103 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-07-01

... specifically indicated, means the State or local air pollution control agency to which a smelter's owner has... unavoidable failure of air pollution control equipment or process equipment or of a process to operate in a... pursuant to that section, may not be used to reduce the degree of emission limitation otherwise required in...

40 CFR 57.103 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-07-01

... specifically indicated, means the State or local air pollution control agency to which a smelter's owner has... unavoidable failure of air pollution control equipment or process equipment or of a process to operate in a... pursuant to that section, may not be used to reduce the degree of emission limitation otherwise required in...

40 CFR 57.103 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-07-01

... specifically indicated, means the State or local air pollution control agency to which a smelter's owner has... unavoidable failure of air pollution control equipment or process equipment or of a process to operate in a... pursuant to that section, may not be used to reduce the degree of emission limitation otherwise required in...

40 CFR 57.103 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-07-01

... specifically indicated, means the State or local air pollution control agency to which a smelter's owner has... unavoidable failure of air pollution control equipment or process equipment or of a process to operate in a... pursuant to that section, may not be used to reduce the degree of emission limitation otherwise required in...

40 CFR 57.103 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-07-01

... specifically indicated, means the State or local air pollution control agency to which a smelter's owner has... unavoidable failure of air pollution control equipment or process equipment or of a process to operate in a... pursuant to that section, may not be used to reduce the degree of emission limitation otherwise required in...

40 CFR 63.140 - Process wastewater provisions-delay of repair.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 40 Protection of Environment 10 2014-07-01 2014-07-01 false Process wastewater provisions-delay of... Manufacturing Industry for Process Vents, Storage Vessels, Transfer Operations, and Wastewater § 63.140 Process wastewater provisions—delay of repair. (a) Delay of repair of equipment for which a control equipment failure...

40 CFR 63.140 - Process wastewater provisions-delay of repair.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 40 Protection of Environment 10 2012-07-01 2012-07-01 false Process wastewater provisions-delay of... Manufacturing Industry for Process Vents, Storage Vessels, Transfer Operations, and Wastewater § 63.140 Process wastewater provisions—delay of repair. (a) Delay of repair of equipment for which a control equipment failure...

40 CFR 63.140 - Process wastewater provisions-delay of repair.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 40 Protection of Environment 9 2011-07-01 2011-07-01 false Process wastewater provisions-delay of... Manufacturing Industry for Process Vents, Storage Vessels, Transfer Operations, and Wastewater § 63.140 Process wastewater provisions—delay of repair. (a) Delay of repair of equipment for which a control equipment failure...

40 CFR 63.140 - Process wastewater provisions-delay of repair.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 40 Protection of Environment 10 2013-07-01 2013-07-01 false Process wastewater provisions-delay of... Manufacturing Industry for Process Vents, Storage Vessels, Transfer Operations, and Wastewater § 63.140 Process wastewater provisions—delay of repair. (a) Delay of repair of equipment for which a control equipment failure...

Error, blame, and the law in health care--an antipodean perspective.

PubMed

Runciman, William B; Merry, Alan F; Tito, Fiona

2003-06-17

Patients are frequently harmed by problems arising from the health care process itself. Addressing these problems requires understanding the role of errors, violations, and system failures in their genesis. Problem-solving is inhibited by a tendency to blame those involved, often inappropriately. This has been aggravated by the need to attribute blame before compensation can be obtained through tort and the human failing of attributing blame simply because there has been a serious outcome. Blaming and punishing for errors that are made by well-intentioned people working in the health care system drives the problem of iatrogenic harm underground and alienates people who are best placed to prevent such problems from recurring. On the other hand, failure to assign blame when it is due is also undesirable and erodes trust in the medical profession. Understanding the distinction between blameworthy behavior and inevitable human errors and appreciating the systemic factors that underlie most failures in complex systems are essential for the response to a harmed patient to be informed, fair, and effective in improving safety. It is important to meet society's needs to blame and exact retribution when appropriate. However, this should not be a prerequisite for compensation, which should be appropriately structured, fair, timely, and, ideally, properly funded as an intrinsic part of health care and social security systems.

Reconfigurable Control with Neural Network Augmentation for a Modified F-15 Aircraft

NASA Technical Reports Server (NTRS)

Burken, John J.; Williams-Hayes, Peggy; Kaneshige, John T.; Stachowiak, Susan J.

2006-01-01

Description of the performance of a simplified dynamic inversion controller with neural network augmentation follows. Simulation studies focus on the results with and without neural network adaptation through the use of an F-15 aircraft simulator that has been modified to include canards. Simulated control law performance with a surface failure, in addition to an aerodynamic failure, is presented. The aircraft, with adaptation, attempts to minimize the inertial cross-coupling effect of the failure (a control derivative anomaly associated with a jammed control surface). The dynamic inversion controller calculates necessary surface commands to achieve desired rates. The dynamic inversion controller uses approximate short period and roll axis dynamics. The yaw axis controller is a sideslip rate command system. Methods are described to reduce the cross-coupling effect and maintain adequate tracking errors for control surface failures. The aerodynamic failure destabilizes the pitching moment due to angle of attack. The results show that control of the aircraft with the neural networks is easier (more damped) than without the neural networks. Simulation results show neural network augmentation of the controller improves performance with aerodynamic and control surface failures in terms of tracking error and cross-coupling reduction.

Adaptive Control Using Neural Network Augmentation for a Modified F-15 Aircraft

NASA Technical Reports Server (NTRS)

Burken, John J.; Williams-Hayes, Peggy; Karneshige, J. T.; Stachowiak, Susan J.

2006-01-01

Description of the performance of a simplified dynamic inversion controller with neural network augmentation follows. Simulation studies focus on the results with and without neural network adaptation through the use of an F-15 aircraft simulator that has been modified to include canards. Simulated control law performance with a surface failure, in addition to an aerodynamic failure, is presented. The aircraft, with adaptation, attempts to minimize the inertial cross-coupling effect of the failure (a control derivative anomaly associated with a jammed control surface). The dynamic inversion controller calculates necessary surface commands to achieve desired rates. The dynamic inversion controller uses approximate short period and roll axis dynamics. The yaw axis controller is a sideslip rate command system. Methods are described to reduce the cross-coupling effect and maintain adequate tracking errors for control surface failures. The aerodynamic failure destabilizes the pitching moment due to angle of attack. The results show that control of the aircraft with the neural networks is easier (more damped) than without the neural networks. Simulation results show neural network augmentation of the controller improves performance with aerodynamic and control surface failures in terms of tracking error and cross-coupling reduction.

A vector-based failure detection and isolation algorithm for a dual fail-operational redundant strapdown inertial measurement unit

NASA Technical Reports Server (NTRS)

Morrell, Frederick R.; Bailey, Melvin L.

1987-01-01

A vector-based failure detection and isolation technique for a skewed array of two degree-of-freedom inertial sensors is developed. Failure detection is based on comparison of parity equations with a threshold, and isolation is based on comparison of logic variables which are keyed to pass/fail results of the parity test. A multi-level approach to failure detection is used to ensure adequate coverage for the flight control, display, and navigation avionics functions. Sensor error models are introduced to expose the susceptibility of the parity equations to sensor errors and physical separation effects. The algorithm is evaluated in a simulation of a commercial transport operating in a range of light to severe turbulence environments. A bias-jump failure level of 0.2 deg/hr was detected and isolated properly in the light and moderate turbulence environments, but not detected in the extreme turbulence environment. An accelerometer bias-jump failure level of 1.5 milli-g was detected over all turbulence environments. For both types of inertial sensor, hard-over, and null type failures were detected in all environments without incident. The algorithm functioned without false alarm or isolation over all turbulence environments for the runs tested.

Application of failure mode and effect analysis in an assisted reproduction technology laboratory.

PubMed

Intra, Giulia; Alteri, Alessandra; Corti, Laura; Rabellotti, Elisa; Papaleo, Enrico; Restelli, Liliana; Biondo, Stefania; Garancini, Maria Paola; Candiani, Massimo; Viganò, Paola

2016-08-01

Assisted reproduction technology laboratories have a very high degree of complexity. Mismatches of gametes or embryos can occur, with catastrophic consequences for patients. To minimize the risk of error, a multi-institutional working group applied failure mode and effects analysis (FMEA) to each critical activity/step as a method of risk assessment. This analysis led to the identification of the potential failure modes, together with their causes and effects, using the risk priority number (RPN) scoring system. In total, 11 individual steps and 68 different potential failure modes were identified. The highest ranked failure modes, with an RPN score of 25, encompassed 17 failures and pertained to "patient mismatch" and "biological sample mismatch". The maximum reduction in risk, with RPN reduced from 25 to 5, was mostly related to the introduction of witnessing. The critical failure modes in sample processing were improved by 50% in the RPN by focusing on staff training. Three indicators of FMEA success, based on technical skill, competence and traceability, have been evaluated after FMEA implementation. Witnessing by a second human operator should be introduced in the laboratory to avoid sample mix-ups. These findings confirm that FMEA can effectively reduce errors in assisted reproduction technology laboratories. Copyright © 2016 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Improving FMEA risk assessment through reprioritization of failures

NASA Astrophysics Data System (ADS)

Ungureanu, A. L.; Stan, G.

2016-08-01

Most of the current methods used to assess the failure and to identify the industrial equipment defects are based on the determination of Risk Priority Number (RPN). Although conventional RPN calculation is easy to understand and use, the methodology presents some limitations, such as the large number of duplicates and the difficulty of assessing the RPN indices. In order to eliminate the afore-mentioned shortcomings, this paper puts forward an easy and efficient computing method, called Failure Developing Mode and Criticality Analysis (FDMCA), which takes into account the failures and the defect evolution in time, from failure appearance to a breakdown.

Acute Chemical Incidents With Injured First Responders, 2002-2012.

PubMed

Melnikova, Natalia; Wu, Jennifer; Yang, Alice; Orr, Maureen

2018-04-01

IntroductionFirst responders, including firefighters, police officers, emergency medical services, and company emergency response team members, have dangerous jobs that can bring them in contact with hazardous chemicals among other dangers. Limited information is available on responder injuries that occur during hazardous chemical incidents. We analyzed 2002-2012 data on acute chemical incidents with injured responders from 2 Agency for Toxic Substances and Disease Registry chemical incident surveillance programs. To learn more about such injuries, we performed descriptive analysis and looked for trends. The percentage of responders among all injured people in chemical incidents has not changed over the years. Firefighters were the most frequently injured group of responders, followed by police officers. Respiratory system problems were the most often reported injury, and the respiratory irritants, ammonia, methamphetamine-related chemicals, and carbon monoxide were the chemicals more often associated with injuries. Most of the incidents with responder injuries were caused by human error or equipment failure. Firefighters wore personal protective equipment (PPE) most frequently and police officers did so rarely. Police officers' injuries were mostly associated with exposure to ammonia and methamphetamine-related chemicals. Most responders did not receive basic awareness-level hazardous material training. All responders should have at least basic awareness-level hazardous material training to recognize and avoid exposure. Research on improving firefighter PPE should continue. (Disaster Med Public Health Preparedness. 2018;12:211-221).

Design of the Detector II: A CMOS Gate Array for the Study of Concurrent Error Detection Techniques.

DTIC Science & Technology

1987-07-01

detection schemes and temporary failures. The circuit consists- or of six different adders with concurrent error detection schemes . The error detection... schemes are - simple duplication, duplication with functional dual implementation, duplication with different &I [] .6implementations, two-rail encoding...THE SYSTEM. .. .... ...... ...... ...... 5 7. DESIGN OF CED SCHEMES .. ... ...... ...... ........ 7 7.1 Simple Duplication

Error and attack tolerance of complex networks

NASA Astrophysics Data System (ADS)

Albert, Réka; Jeong, Hawoong; Barabási, Albert-László

2000-07-01

Many complex systems display a surprising degree of tolerance against errors. For example, relatively simple organisms grow, persist and reproduce despite drastic pharmaceutical or environmental interventions, an error tolerance attributed to the robustness of the underlying metabolic network. Complex communication networks display a surprising degree of robustness: although key components regularly malfunction, local failures rarely lead to the loss of the global information-carrying ability of the network. The stability of these and other complex systems is often attributed to the redundant wiring of the functional web defined by the systems' components. Here we demonstrate that error tolerance is not shared by all redundant systems: it is displayed only by a class of inhomogeneously wired networks, called scale-free networks, which include the World-Wide Web, the Internet, social networks and cells. We find that such networks display an unexpected degree of robustness, the ability of their nodes to communicate being unaffected even by unrealistically high failure rates. However, error tolerance comes at a high price in that these networks are extremely vulnerable to attacks (that is, to the selection and removal of a few nodes that play a vital role in maintaining the network's connectivity). Such error tolerance and attack vulnerability are generic properties of communication networks.

Covariate Measurement Error Correction Methods in Mediation Analysis with Failure Time Data

PubMed Central

Zhao, Shanshan

2014-01-01

Summary Mediation analysis is important for understanding the mechanisms whereby one variable causes changes in another. Measurement error could obscure the ability of the potential mediator to explain such changes. This paper focuses on developing correction methods for measurement error in the mediator with failure time outcomes. We consider a broad definition of measurement error, including technical error and error associated with temporal variation. The underlying model with the ‘true’ mediator is assumed to be of the Cox proportional hazards model form. The induced hazard ratio for the observed mediator no longer has a simple form independent of the baseline hazard function, due to the conditioning event. We propose a mean-variance regression calibration approach and a follow-up time regression calibration approach, to approximate the partial likelihood for the induced hazard function. Both methods demonstrate value in assessing mediation effects in simulation studies. These methods are generalized to multiple biomarkers and to both case-cohort and nested case-control sampling design. We apply these correction methods to the Women's Health Initiative hormone therapy trials to understand the mediation effect of several serum sex hormone measures on the relationship between postmenopausal hormone therapy and breast cancer risk. PMID:25139469

Covariate measurement error correction methods in mediation analysis with failure time data.

PubMed

Zhao, Shanshan; Prentice, Ross L

2014-12-01

Mediation analysis is important for understanding the mechanisms whereby one variable causes changes in another. Measurement error could obscure the ability of the potential mediator to explain such changes. This article focuses on developing correction methods for measurement error in the mediator with failure time outcomes. We consider a broad definition of measurement error, including technical error, and error associated with temporal variation. The underlying model with the "true" mediator is assumed to be of the Cox proportional hazards model form. The induced hazard ratio for the observed mediator no longer has a simple form independent of the baseline hazard function, due to the conditioning event. We propose a mean-variance regression calibration approach and a follow-up time regression calibration approach, to approximate the partial likelihood for the induced hazard function. Both methods demonstrate value in assessing mediation effects in simulation studies. These methods are generalized to multiple biomarkers and to both case-cohort and nested case-control sampling designs. We apply these correction methods to the Women's Health Initiative hormone therapy trials to understand the mediation effect of several serum sex hormone measures on the relationship between postmenopausal hormone therapy and breast cancer risk. © 2014, The International Biometric Society.

49 CFR 234.7 - Accidents involving grade crossing signal failure.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 4 2014-10-01 2014-10-01 false Accidents involving grade crossing signal failure..., STATE ACTION PLANS, AND EMERGENCY NOTIFICATION SYSTEMS Reports and Plans § 234.7 Accidents involving... railroad equipment and an automobile, bus, truck, motorcycle, bicycle, farm vehicle, or pedestrian at a...

49 CFR 234.7 - Accidents involving grade crossing signal failure.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 4 2012-10-01 2012-10-01 false Accidents involving grade crossing signal failure..., STATE ACTION PLANS, AND EMERGENCY NOTIFICATION SYSTEMS Reports and Plans § 234.7 Accidents involving... railroad equipment and an automobile, bus, truck, motorcycle, bicycle, farm vehicle, or pedestrian at a...

49 CFR 234.7 - Accidents involving grade crossing signal failure.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 4 2013-10-01 2013-10-01 false Accidents involving grade crossing signal failure..., STATE ACTION PLANS, AND EMERGENCY NOTIFICATION SYSTEMS Reports and Plans § 234.7 Accidents involving... railroad equipment and an automobile, bus, truck, motorcycle, bicycle, farm vehicle, or pedestrian at a...

46 CFR 113.43-5 - Power supply.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 4 2013-10-01 2013-10-01 false Power supply. 113.43-5 Section 113.43-5 Shipping COAST GUARD, DEPARTMENT OF HOMELAND SECURITY (CONTINUED) ELECTRICAL ENGINEERING COMMUNICATION AND ALARM SYSTEMS AND EQUIPMENT Steering Failure Alarm Systems § 113.43-5 Power supply. Each steering failure alarm...

46 CFR 113.43-5 - Power supply.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 4 2014-10-01 2014-10-01 false Power supply. 113.43-5 Section 113.43-5 Shipping COAST GUARD, DEPARTMENT OF HOMELAND SECURITY (CONTINUED) ELECTRICAL ENGINEERING COMMUNICATION AND ALARM SYSTEMS AND EQUIPMENT Steering Failure Alarm Systems § 113.43-5 Power supply. Each steering failure alarm...

46 CFR 113.43-5 - Power supply.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 4 2012-10-01 2012-10-01 false Power supply. 113.43-5 Section 113.43-5 Shipping COAST GUARD, DEPARTMENT OF HOMELAND SECURITY (CONTINUED) ELECTRICAL ENGINEERING COMMUNICATION AND ALARM SYSTEMS AND EQUIPMENT Steering Failure Alarm Systems § 113.43-5 Power supply. Each steering failure alarm...

29 CFR 1910.1051 - 1,3-Butadiene.

Code of Federal Regulations, 2010 CFR

2010-07-01

... mixtures in intact containers or in transportation pipelines sealed in such a manner as to fully contain BD... means any occurrence such as, but not limited to, equipment failure, rupture of containers, or failure... representative employee exposure for that operation from the shift during which the highest exposure is expected...

33 CFR 164.82 - Maintenance, failure, and reporting.

Code of Federal Regulations, 2011 CFR

2011-07-01

... safety, such as propulsion machinery, steering gear, radar, gyrocompass, echo depth-sounding or other... repair within 96 hours an inoperative marine radar required by § 164.72(a) shall so notify the Captain of... navigational-safety equipment, including but not limited to failure of one of two installed radars, where each...

33 CFR 164.82 - Maintenance, failure, and reporting.

Code of Federal Regulations, 2013 CFR

2013-07-01

... safety, such as propulsion machinery, steering gear, radar, gyrocompass, echo depth-sounding or other... repair within 96 hours an inoperative marine radar required by § 164.72(a) shall so notify the Captain of... navigational-safety equipment, including but not limited to failure of one of two installed radars, where each...

33 CFR 164.82 - Maintenance, failure, and reporting.

Code of Federal Regulations, 2014 CFR

2014-07-01

... safety, such as propulsion machinery, steering gear, radar, gyrocompass, echo depth-sounding or other... repair within 96 hours an inoperative marine radar required by § 164.72(a) shall so notify the Captain of... navigational-safety equipment, including but not limited to failure of one of two installed radars, where each...

33 CFR 164.82 - Maintenance, failure, and reporting.

Code of Federal Regulations, 2012 CFR

2012-07-01

... safety, such as propulsion machinery, steering gear, radar, gyrocompass, echo depth-sounding or other... repair within 96 hours an inoperative marine radar required by § 164.72(a) shall so notify the Captain of... navigational-safety equipment, including but not limited to failure of one of two installed radars, where each...

Identification of Parts Failures. FOS: Fundamentals of Service.

ERIC Educational Resources Information Center

John Deere Co., Moline, IL.

This parts failures identification manual is one of a series of power mechanics texts and visual aids covering theory of operation, diagnosis of trouble problems, and repair of automotive and off-the-road construction and agricultural equipment. Materials provide basic information with many illustrations for use by vocational students and teachers…

Reduction in pediatric identification band errors: a quality collaborative.

PubMed

Phillips, Shannon Connor; Saysana, Michele; Worley, Sarah; Hain, Paul D

2012-06-01

Accurate and consistent placement of a patient identification (ID) band is used in health care to reduce errors associated with patient misidentification. Multiple safety organizations have devoted time and energy to improving patient ID, but no multicenter improvement collaboratives have shown scalability of previously successful interventions. We hoped to reduce by half the pediatric patient ID band error rate, defined as absent, illegible, or inaccurate ID band, across a quality improvement learning collaborative of hospitals in 1 year. On the basis of a previously successful single-site intervention, we conducted a self-selected 6-site collaborative to reduce ID band errors in heterogeneous pediatric hospital settings. The collaborative had 3 phases: preparatory work and employee survey of current practice and barriers, data collection (ID band failure rate), and intervention driven by data and collaborative learning to accelerate change. The collaborative audited 11377 patients for ID band errors between September 2009 and September 2010. The ID band failure rate decreased from 17% to 4.1% (77% relative reduction). Interventions including education of frontline staff regarding correct ID bands as a safety strategy; a change to softer ID bands, including "luggage tag" type ID bands for some patients; and partnering with families and patients through education were applied at all institutions. Over 13 months, a collaborative of pediatric institutions significantly reduced the ID band failure rate. This quality improvement learning collaborative demonstrates that safety improvements tested in a single institution can be disseminated to improve quality of care across large populations of children.

NASA ground terminal communication equipment automated fault isolation expert systems

NASA Technical Reports Server (NTRS)

Tang, Y. K.; Wetzel, C. R.

1990-01-01

The prototype expert systems are described that diagnose the Distribution and Switching System I and II (DSS1 and DSS2), Statistical Multiplexers (SM), and Multiplexer and Demultiplexer systems (MDM) at the NASA Ground Terminal (NGT). A system level fault isolation expert system monitors the activities of a selected data stream, verifies that the fault exists in the NGT and identifies the faulty equipment. Equipment level fault isolation expert systems are invoked to isolate the fault to a Line Replaceable Unit (LRU) level. Input and sometimes output data stream activities for the equipment are available. The system level fault isolation expert system compares the equipment input and output status for a data stream and performs loopback tests (if necessary) to isolate the faulty equipment. The equipment level fault isolation system utilizes the process of elimination and/or the maintenance personnel's fault isolation experience stored in its knowledge base. The DSS1, DSS2 and SM fault isolation systems, using the knowledge of the current equipment configuration and the equipment circuitry issues a set of test connections according to the predefined rules. The faulty component or board can be identified by the expert system by analyzing the test results. The MDM fault isolation system correlates the failure symptoms with the faulty component based on maintenance personnel experience. The faulty component can be determined by knowing the failure symptoms. The DSS1, DSS2, SM, and MDM equipment simulators are implemented in PASCAL. The DSS1 fault isolation expert system was converted to C language from VP-Expert and integrated into the NGT automation software for offline switch diagnoses. Potentially, the NGT fault isolation algorithms can be used for the DSS1, SM, amd MDM located at Goddard Space Flight Center (GSFC).

The proposed coding standard at GSFC

NASA Technical Reports Server (NTRS)

Morakis, J. C.; Helgert, H. J.

1977-01-01

As part of the continuing effort to introduce standardization of spacecraft and ground equipment in satellite systems, NASA's Goddard Space Flight Center and other NASA facilities have supported the development of a set of standards for the use of error control coding in telemetry subsystems. These standards are intended to ensure compatibility between spacecraft and ground encoding equipment, while allowing sufficient flexibility to meet all anticipated mission requirements. The standards which have been developed to date cover the application of block codes in error detection and error correction modes, as well as short and long constraint length convolutional codes decoded via the Viterbi and sequential decoding algorithms, respectively. Included are detailed specifications of the codes, and their implementation. Current effort is directed toward the development of standards covering channels with burst noise characteristics, channels with feedback, and code concatenation.

Electronic equipment vulnerability to fire released carbon fibers

NASA Technical Reports Server (NTRS)

Pride, R. A.; Mchatton, A. D.; Musselman, K. A.

1980-01-01

The vulnerability of electronic equipment to damage by carbon fibers released from burning aircraft type structural composite materials was investigated. Tests were conducted on commercially available stereo power amplifiers which showed that the equipment was damaged by fire released carbon fibers but not by the composite resin residue, soot and products of combustion of the fuel associated with burning the carbon fiber composites. Results indicate that the failure rates of the equipment exposed to the fire released fiber were consistent with predictions based on tests using virgin fibers.

[Development of Hospital Equipment Maintenance Information System].

PubMed

Zhou, Zhixin

2015-11-01

Hospital equipment maintenance information system plays an important role in improving medical treatment quality and efficiency. By requirement analysis of hospital equipment maintenance, the system function diagram is drawed. According to analysis of input and output data, tables and reports in connection with equipment maintenance process, relationships between entity and attribute is found out, and E-R diagram is drawed and relational database table is established. Software development should meet actual process requirement of maintenance and have a friendly user interface and flexible operation. The software can analyze failure cause by statistical analysis.

Learning time-dependent noise to reduce logical errors: real time error rate estimation in quantum error correction

NASA Astrophysics Data System (ADS)

Huo, Ming-Xia; Li, Ying

2017-12-01

Quantum error correction is important to quantum information processing, which allows us to reliably process information encoded in quantum error correction codes. Efficient quantum error correction benefits from the knowledge of error rates. We propose a protocol for monitoring error rates in real time without interrupting the quantum error correction. Any adaptation of the quantum error correction code or its implementation circuit is not required. The protocol can be directly applied to the most advanced quantum error correction techniques, e.g. surface code. A Gaussian processes algorithm is used to estimate and predict error rates based on error correction data in the past. We find that using these estimated error rates, the probability of error correction failures can be significantly reduced by a factor increasing with the code distance.

High Reliability Organizations--Medication Safety.

PubMed

Yip, Luke; Farmer, Brenna

2015-06-01

High reliability organizations (HROs), such as the aviation industry, successfully engage in high-risk endeavors and have low incidence of adverse events. HROs have a preoccupation with failure and errors. They analyze each event to effect system wide change in an attempt to mitigate the occurrence of similar errors. The healthcare industry can adapt HRO practices, specifically with regard to teamwork and communication. Crew resource management concepts can be adapted to healthcare with the use of certain tools such as checklists and the sterile cockpit to reduce medication errors. HROs also use The Swiss Cheese Model to evaluate risk and look for vulnerabilities in multiple protective barriers, instead of focusing on one failure. This model can be used in medication safety to evaluate medication management in addition to using the teamwork and communication tools of HROs.

Calculating and Mitigating the Risk of a Cut Glove to a Space Walking Astronaut

NASA Technical Reports Server (NTRS)

Castillo, Theresa; Haught, Megan

2013-01-01

One of the high risk operations on the International Space Station (ISS) is conducting a space walk, or an Extra Vehicular Activity (EVA). Threats to the space walking crew include airlock failures, space suit failures, and strikes from micro ]meteoroids and orbital debris (MM/OD). There are risks of becoming untethered from the space station, being pinched between the robotic arm and a piece of equipment, tearing your suit on a sharp edge, and other human errors that can be catastrophic. For decades NASA identified and tried to control sharp edges on external structure and equipment by design; however a new and unexpected source of sharp edges has since become apparent. Until recently, one of the underappreciated environmental risks was damage to EVA gloves during a spacewalk. The ISS has some elements which have been flying in the environment of space for over 14 years. It has and continues to be bombarded with MM/OD strikes that have created small, sharp craters all over the structure, including the dedicated EVA handrails and surrounding structure. These craters are capable of cutting through several layers of the EVA gloves. Starting in 2006, five EVA crewmembers reported cuts in their gloves so large they rendered the gloves unusable and in some cases cut the spacewalk short for the safety of the crew. This new hazard took engineers and managers by surprise. NASA has set out to mitigate this risk to safety and operations by redesigning the spacesuit gloves to be more resilient and designing a clamp to isolate MM/OD strikes on handrails, and is considering the necessity of an additional tool to repair strikes on non ]handrail surfaces (such as a file). This paper will address how the ISS Risk Team quantified an estimate of the MM/OD damage to the ISS, and the resulting likelihood of sustaining a cut glove in order to measure the effectiveness of the solutions being investigated to mitigate this risk to the mission and crew.

Using Utility Functions to Control a Distributed Storage System

DTIC Science & Technology

2008-05-01

Pinheiro et al. [2007] suggest this is not an accurate assumption. Nicola and Goyal [1990] examined correlated failures across multiversion software...F. and Goyal, A. (1990). Modeling of correlated failures and community error recovery in multiversion software. IEEE Transactions on Software

Performance of concatenated Reed-Solomon/Viterbi channel coding

NASA Technical Reports Server (NTRS)

Divsalar, D.; Yuen, J. H.

1982-01-01

The concatenated Reed-Solomon (RS)/Viterbi coding system is reviewed. The performance of the system is analyzed and results are derived with a new simple approach. A functional model for the input RS symbol error probability is presented. Based on this new functional model, we compute the performance of a concatenated system in terms of RS word error probability, output RS symbol error probability, bit error probability due to decoding failure, and bit error probability due to decoding error. Finally we analyze the effects of the noisy carrier reference and the slow fading on the system performance.

Applications of Augmented Reality-Based Natural Interactive Learning in Magnetic Field Instruction

ERIC Educational Resources Information Center

Cai, Su; Chiang, Feng-Kuang; Sun, Yuchen; Lin, Chenglong; Lee, Joey J.

2017-01-01

Educators must address several challenges inherent to the instruction of scientific disciplines such as physics -- expensive or insufficient laboratory equipment, equipment error, difficulty in simulating certain experimental conditions. Augmented reality (AR) can be a promising approach to address these challenges. In this paper, we discuss the…

Commercial application of rainfall simulation

NASA Astrophysics Data System (ADS)

Loch, Rob J.

2010-05-01

Landloch Pty Ltd is a commercial consulting firm, providing advice on a range of land management issues to the mining and construction industries in Australia. As part of the company's day-to-day operations, rainfall simulation is used to assess material erodibility and to investigate a range of site attributes. (Landloch does carry out research projects, though such are not its core business.) When treated as an everyday working tool, several aspects of rainfall simulation practice are distinctively modified. Firstly, the equipment used is regularly maintained, and regularly upgraded with a primary focus on ease, safety, and efficiency of use and on reliability of function. As well, trained and experienced technical support is considered essential. Landloch's chief technician has over 10 years experience in running rainfall simulators at locations across Australia and in Africa and the Pacific. Secondly, the specific experimental conditions established for each set of rainfall simulator runs are carefully considered to ensure that they accurately represent the field conditions to which the data will be subsequently applied. Considerations here include: • wetting and drying cycles to ensure material consolidation and/or cementation if appropriate; • careful attention to water quality if dealing with clay soils or with amendments such as gypsum; • strong focus on ensuring that the erosion processes considered are those of greatest importance to the field situation of concern; and • detailed description of both material and plot properties, to increase the potential for data to be applicable to a wider range of projects and investigations. Other important company procedures include: • For each project, the scientist or engineer responsible for analysing and reporting rainfall simulator data is present during the running of all field plots, as it is essential that they be aware of any specific conditions that may have developed when the plots were subjected to rain; and • Regular calibration of all equipment. In general, typical errors when rainfall simulation is carried out by inexperienced researchers include: • Failure to accurately measure rainfall rates (the most common error); • Inappropriate initial conditions, including wetting treatments; • Use of inappropriately small plots - relating to our concern at the erosion processes considered be those of genuine field relevance; • Inappropriate rainfall kinetic energies; and • Failure to observe critical processes operating on the study plots, such as saturation excess or the presence of impeding layers at shallow depths. Landloch regularly uses erodibility data to design stable batter profiles for minesite waste dumps. Subsequent monitoring of designed dumps has confirmed that modelled erosion rates are consistent with those subsequently measured under field conditions.

A randomised controlled trial of cognitive aids for emergency airway equipment preparation in a Paediatric Emergency Department.

PubMed

Long, Elliot; Fitzpatrick, Patrick; Cincotta, Domenic R; Grindlay, Joanne; Barrett, Michael Joseph

2016-01-27

Safety of emergency intubation may be improved by standardising equipment preparation; the efficacy of cognitive aids is unknown. This randomised controlled trial compared no cognitive aid (control) with the use of a checklist or picture template for emergency airway equipment preparation in the Emergency Department of The Royal Children's Hospital, Melbourne. Sixty-three participants were recruited, 21 randomised to each group. Equal numbers of nursing, junior medical, and senior medical staff were included in each group. Compared to controls, the checklist or template group had significantly lower equipment omission rates (median 30% IQR 20-40% control, median 10% IQR 5-10 % checklist, median 10% IQR 5-20% template; p < 0.05). The combined omission rate and sizing error rate was lower using a checklist or template (median 35 % IQR 30-45 % control, median 15% IQR 10-20% checklist, median 15% IQR 10-30% template; p < 0.05). The template group had less variation in equipment location compared to checklist or controls. There was no significant difference in preparation time in controls (mean 3 min 14 s sd 56 s) compared to checklist (mean 3 min 46 s sd 1 min 15 s) or template (mean 3 min 6 s sd 49 s; p = 0.06). Template use reduces variation in airway equipment location during preparation foremergency intubation, with an equivalent reduction in equipment omission rate to the use of a checklist. The use of a template for equipment preparation and a checklist for team, patient, and monitoring preparation may provide the best combination of both cognitive aids. The use of a cognitive aid for emergency airway equipment preparation reduces errors of omission. Template utilisation reduces variation in equipment location. Australian and New Zealand Trials Registry (ACTRN12615000541505).

TU-AB-BRD-00: Task Group 100

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

NONE

2015-06-15

Current quality assurance and quality management guidelines provided by various professional organizations are prescriptive in nature, focusing principally on performance characteristics of planning and delivery devices. However, published analyses of events in radiation therapy show that most events are often caused by flaws in clinical processes rather than by device failures. This suggests the need for the development of a quality management program that is based on integrated approaches to process and equipment quality assurance. Industrial engineers have developed various risk assessment tools that are used to identify and eliminate potential failures from a system or a process before amore » failure impacts a customer. These tools include, but are not limited to, process mapping, failure modes and effects analysis, fault tree analysis. Task Group 100 of the American Association of Physicists in Medicine has developed these tools and used them to formulate an example risk-based quality management program for intensity-modulated radiotherapy. This is a prospective risk assessment approach that analyzes potential error pathways inherent in a clinical process and then ranks them according to relative risk, typically before implementation, followed by the design of a new process or modification of the existing process. Appropriate controls are then put in place to ensure that failures are less likely to occur and, if they do, they will more likely be detected before they propagate through the process, compromising treatment outcome and causing harm to the patient. Such a prospective approach forms the basis of the work of Task Group 100 that has recently been approved by the AAPM. This session will be devoted to a discussion of these tools and practical examples of how these tools can be used in a given radiotherapy clinic to develop a risk based quality management program. Learning Objectives: Learn how to design a process map for a radiotherapy process Learn how to perform failure modes and effects analysis analysis for a given process Learn what fault trees are all about Learn how to design a quality management program based upon the information obtained from process mapping, failure modes and effects analysis and fault tree analysis. Dunscombe: Director, TreatSafely, LLC and Center for the Assessment of Radiological Sciences; Consultant to IAEA and Varian Thomadsen: President, Center for the Assessment of Radiological Sciences Palta: Vice President of the Center for the Assessment of Radiological Sciences.« less

TU-AB-BRD-03: Fault Tree Analysis

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

Dunscombe, P.

2015-06-15

Current quality assurance and quality management guidelines provided by various professional organizations are prescriptive in nature, focusing principally on performance characteristics of planning and delivery devices. However, published analyses of events in radiation therapy show that most events are often caused by flaws in clinical processes rather than by device failures. This suggests the need for the development of a quality management program that is based on integrated approaches to process and equipment quality assurance. Industrial engineers have developed various risk assessment tools that are used to identify and eliminate potential failures from a system or a process before amore » failure impacts a customer. These tools include, but are not limited to, process mapping, failure modes and effects analysis, fault tree analysis. Task Group 100 of the American Association of Physicists in Medicine has developed these tools and used them to formulate an example risk-based quality management program for intensity-modulated radiotherapy. This is a prospective risk assessment approach that analyzes potential error pathways inherent in a clinical process and then ranks them according to relative risk, typically before implementation, followed by the design of a new process or modification of the existing process. Appropriate controls are then put in place to ensure that failures are less likely to occur and, if they do, they will more likely be detected before they propagate through the process, compromising treatment outcome and causing harm to the patient. Such a prospective approach forms the basis of the work of Task Group 100 that has recently been approved by the AAPM. This session will be devoted to a discussion of these tools and practical examples of how these tools can be used in a given radiotherapy clinic to develop a risk based quality management program. Learning Objectives: Learn how to design a process map for a radiotherapy process Learn how to perform failure modes and effects analysis analysis for a given process Learn what fault trees are all about Learn how to design a quality management program based upon the information obtained from process mapping, failure modes and effects analysis and fault tree analysis. Dunscombe: Director, TreatSafely, LLC and Center for the Assessment of Radiological Sciences; Consultant to IAEA and Varian Thomadsen: President, Center for the Assessment of Radiological Sciences Palta: Vice President of the Center for the Assessment of Radiological Sciences.« less

TU-AB-BRD-01: Process Mapping

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

Palta, J.

2015-06-15

Current quality assurance and quality management guidelines provided by various professional organizations are prescriptive in nature, focusing principally on performance characteristics of planning and delivery devices. However, published analyses of events in radiation therapy show that most events are often caused by flaws in clinical processes rather than by device failures. This suggests the need for the development of a quality management program that is based on integrated approaches to process and equipment quality assurance. Industrial engineers have developed various risk assessment tools that are used to identify and eliminate potential failures from a system or a process before amore » failure impacts a customer. These tools include, but are not limited to, process mapping, failure modes and effects analysis, fault tree analysis. Task Group 100 of the American Association of Physicists in Medicine has developed these tools and used them to formulate an example risk-based quality management program for intensity-modulated radiotherapy. This is a prospective risk assessment approach that analyzes potential error pathways inherent in a clinical process and then ranks them according to relative risk, typically before implementation, followed by the design of a new process or modification of the existing process. Appropriate controls are then put in place to ensure that failures are less likely to occur and, if they do, they will more likely be detected before they propagate through the process, compromising treatment outcome and causing harm to the patient. Such a prospective approach forms the basis of the work of Task Group 100 that has recently been approved by the AAPM. This session will be devoted to a discussion of these tools and practical examples of how these tools can be used in a given radiotherapy clinic to develop a risk based quality management program. Learning Objectives: Learn how to design a process map for a radiotherapy process Learn how to perform failure modes and effects analysis analysis for a given process Learn what fault trees are all about Learn how to design a quality management program based upon the information obtained from process mapping, failure modes and effects analysis and fault tree analysis. Dunscombe: Director, TreatSafely, LLC and Center for the Assessment of Radiological Sciences; Consultant to IAEA and Varian Thomadsen: President, Center for the Assessment of Radiological Sciences Palta: Vice President of the Center for the Assessment of Radiological Sciences.« less

TU-AB-BRD-04: Development of Quality Management Program

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

Thomadsen, B.

2015-06-15

Current quality assurance and quality management guidelines provided by various professional organizations are prescriptive in nature, focusing principally on performance characteristics of planning and delivery devices. However, published analyses of events in radiation therapy show that most events are often caused by flaws in clinical processes rather than by device failures. This suggests the need for the development of a quality management program that is based on integrated approaches to process and equipment quality assurance. Industrial engineers have developed various risk assessment tools that are used to identify and eliminate potential failures from a system or a process before amore » failure impacts a customer. These tools include, but are not limited to, process mapping, failure modes and effects analysis, fault tree analysis. Task Group 100 of the American Association of Physicists in Medicine has developed these tools and used them to formulate an example risk-based quality management program for intensity-modulated radiotherapy. This is a prospective risk assessment approach that analyzes potential error pathways inherent in a clinical process and then ranks them according to relative risk, typically before implementation, followed by the design of a new process or modification of the existing process. Appropriate controls are then put in place to ensure that failures are less likely to occur and, if they do, they will more likely be detected before they propagate through the process, compromising treatment outcome and causing harm to the patient. Such a prospective approach forms the basis of the work of Task Group 100 that has recently been approved by the AAPM. This session will be devoted to a discussion of these tools and practical examples of how these tools can be used in a given radiotherapy clinic to develop a risk based quality management program. Learning Objectives: Learn how to design a process map for a radiotherapy process Learn how to perform failure modes and effects analysis analysis for a given process Learn what fault trees are all about Learn how to design a quality management program based upon the information obtained from process mapping, failure modes and effects analysis and fault tree analysis. Dunscombe: Director, TreatSafely, LLC and Center for the Assessment of Radiological Sciences; Consultant to IAEA and Varian Thomadsen: President, Center for the Assessment of Radiological Sciences Palta: Vice President of the Center for the Assessment of Radiological Sciences.« less

Data compression/error correction digital test system. Appendix 3: Maintenance. Book 2: Receiver assembly drawings

NASA Technical Reports Server (NTRS)

1972-01-01

The assembly drawings of the receiver unit are presented for the data compression/error correction digital test system. Equipment specifications are given for the various receiver parts, including the TV input buffer register, delta demodulator, TV sync generator, memory devices, and data storage devices.

Multichannel error correction code decoder

NASA Technical Reports Server (NTRS)

Wagner, Paul K.; Ivancic, William D.

1993-01-01

A brief overview of a processing satellite for a mesh very-small-aperture (VSAT) communications network is provided. The multichannel error correction code (ECC) decoder system, the uplink signal generation and link simulation equipment, and the time-shared decoder are described. The testing is discussed. Applications of the time-shared decoder are recommended.

Use of a Modern Polymerization Pilot-Plant for Undergraduate Control Projects.

ERIC Educational Resources Information Center

Mendoza-Bustos, S. A.; And Others

1991-01-01

Described is a project where students gain experience in handling large volumes of hazardous materials, process start up and shut down, equipment failures, operational variations, scaling up, equipment cleaning, and run-time scheduling while working in a modern pilot plant. Included are the system design, experimental procedures, and results. (KR)

40 CFR 265.1053 - Standards: Compressors.

Code of Federal Regulations, 2010 CFR

2010-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 264.1053 - Standards: Compressors.

Code of Federal Regulations, 2010 CFR

2010-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 264.1053 - Standards: Compressors.

Code of Federal Regulations, 2011 CFR

2011-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 265.1053 - Standards: Compressors.

Code of Federal Regulations, 2011 CFR

2011-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

49 CFR 238.219 - Truck-to-car-body attachment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 4 2011-10-01 2011-10-01 false Truck-to-car-body attachment. 238.219 Section 238... I Passenger Equipment § 238.219 Truck-to-car-body attachment. Passenger equipment shall have a truck-to-car-body attachment with an ultimate strength sufficient to resist without failure the following...

49 CFR 238.219 - Truck-to-car-body attachment.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 4 2012-10-01 2012-10-01 false Truck-to-car-body attachment. 238.219 Section 238... I Passenger Equipment § 238.219 Truck-to-car-body attachment. Passenger equipment shall have a truck-to-car-body attachment with an ultimate strength sufficient to resist without failure the following...

49 CFR 238.219 - Truck-to-car-body attachment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Truck-to-car-body attachment. 238.219 Section 238... I Passenger Equipment § 238.219 Truck-to-car-body attachment. Passenger equipment shall have a truck-to-car-body attachment with an ultimate strength sufficient to resist without failure the following...

49 CFR 238.219 - Truck-to-car-body attachment.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 4 2013-10-01 2013-10-01 false Truck-to-car-body attachment. 238.219 Section 238... I Passenger Equipment § 238.219 Truck-to-car-body attachment. Passenger equipment shall have a truck-to-car-body attachment with an ultimate strength sufficient to resist without failure the following...

49 CFR 238.219 - Truck-to-car-body attachment.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 4 2014-10-01 2014-10-01 false Truck-to-car-body attachment. 238.219 Section 238... I Passenger Equipment § 238.219 Truck-to-car-body attachment. Passenger equipment shall have a truck-to-car-body attachment with an ultimate strength sufficient to resist without failure the following...

40 CFR 264.1053 - Standards: Compressors.

Code of Federal Regulations, 2014 CFR

2014-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 264.1053 - Standards: Compressors.

Code of Federal Regulations, 2013 CFR

2013-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 265.1053 - Standards: Compressors.

Code of Federal Regulations, 2013 CFR

2013-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 265.1053 - Standards: Compressors.

Code of Federal Regulations, 2012 CFR

2012-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 264.1053 - Standards: Compressors.

Code of Federal Regulations, 2012 CFR

2012-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 265.1053 - Standards: Compressors.

Code of Federal Regulations, 2014 CFR

2014-07-01

... equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section shall be checked daily or shall be equipped... compressor is located within the boundary of an unmanned plant site, in which case the sensor must be checked...

40 CFR 63.10001 - Affirmative defense for exceedence of emission limit during malfunction.

Code of Federal Regulations, 2013 CFR

2013-07-01

... unavoidable failure of air pollution control and monitoring equipment, process equipment, or a process to..., proper design or better operation and maintenance practices; and (iii) Did not stem from any activity or... ambient air quality, the environment and human health; and (6) All emissions monitoring and control...

40 CFR 63.11226 - Affirmative defense for violation of emission standards during malfunction.

Code of Federal Regulations, 2013 CFR

2013-07-01

..., infrequent, and unavoidable failure of air pollution control equipment, process equipment, or a process to..., proper design or better operation and maintenance practices; and (iii) Did not stem from any activity or... minimize the impact of the violation on ambient air quality, the environment, and human health; and (6) All...

40 CFR 65.112 - Standards: Compressors.

Code of Federal Regulations, 2010 CFR

2010-07-01

... fuel gas system, or connected by a closed vent system to a control device that meets the requirements... barrier fluid system shall be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. Each sensor shall be observed daily or shall be equipped with an alarm unless the...

40 CFR 63.1031 - Compressors standards.

Code of Federal Regulations, 2011 CFR

2011-07-01

... gas system or connected by a closed-vent system to a control device that meets the requirements of... service. Each barrier fluid system shall be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. Each sensor shall be observed daily or shall be equipped with an...

40 CFR 65.112 - Standards: Compressors.

Code of Federal Regulations, 2011 CFR

2011-07-01

... fuel gas system, or connected by a closed vent system to a control device that meets the requirements... barrier fluid system shall be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. Each sensor shall be observed daily or shall be equipped with an alarm unless the...

40 CFR 63.1031 - Compressors standards.

Code of Federal Regulations, 2010 CFR

2010-07-01

... gas system or connected by a closed-vent system to a control device that meets the requirements of... service. Each barrier fluid system shall be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. Each sensor shall be observed daily or shall be equipped with an...

78 FR 31851 - Harmonization of Airworthiness Standards-Gust and Maneuver Load Requirements

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-28

... airplanes equipped with wing-mounted engines; revise the engine torque loads criteria; add an engine failure... equipped with wing-mounted engines. Following an accident in which an airplane shed a large wing- mounted...-93-137, November 15, 1993). This recommendation was specifically aimed at gust loads on wing-mounted...

40 CFR 60.5415 - How do I demonstrate continuous compliance with the standards for my gas well affected facility...

Code of Federal Regulations, 2014 CFR

2014-07-01

... plants? 60.5415 Section 60.5415 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR... used to reduce emissions, you must demonstrate continuous compliance with the performance requirements... sudden, infrequent, and unavoidable failure of air pollution control equipment, process equipment, or a...

76 FR 40219 - Airworthiness Directives; Various Aircraft Equipped With Rotax Aircraft Engines 912 A Series Engine

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-08

... Airworthiness Directives; Various Aircraft Equipped With Rotax Aircraft Engines 912 A Series Engine AGENCY... installed on a limited number of engines. No defective washers have been shipped as spare parts. This... consequent ignition failure, possibly resulting in damage to the engine, in- flight engine shutdown and...

Typical uses of NASTRAN in a petrochemical industry

NASA Technical Reports Server (NTRS)

Winter, J. R.

1978-01-01

NASTRAN was principally used to perform failure analysis and redesign process equipment. It was also employed in the evaluation of vendor designs and proposed design modifications to existing process equipment. Stress analysis of forced draft fans, distillation trays, metal stacks, jacketed pipes, heat exchangers, large centrifugal fans, and agitator support structures are described.

33 CFR 154.1035 - Specific requirements for facilities that could reasonably be expected to cause significant and...

Code of Federal Regulations, 2010 CFR

2010-07-01

... spill management team member within the organizational structure described in paragraph (b)(3)(iii) of... discharge, potential discharge, or emergency involving the following equipment and scenarios: (A) Failure of manifold, mechanical loading arm, other transfer equipment, or hoses, as appropriate; (B) Tank overfill; (C...

Modeling Security Aspects of Network

NASA Astrophysics Data System (ADS)

Schoch, Elmar

With more and more widespread usage of computer systems and networks, dependability becomes a paramount requirement. Dependability typically denotes tolerance or protection against all kinds of failures, errors and faults. Sources of failures can basically be accidental, e.g., in case of hardware errors or software bugs, or intentional due to some kind of malicious behavior. These intentional, malicious actions are subject of security. A more complete overview on the relations between dependability and security can be found in [31]. In parallel to the increased use of technology, misuse also has grown significantly, requiring measures to deal with it.

Failure Analysis of a Complex Learning Framework Incorporating Multi-Modal and Semi-Supervised Learning

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

Pullum, Laura L; Symons, Christopher T

2011-01-01

Machine learning is used in many applications, from machine vision to speech recognition to decision support systems, and is used to test applications. However, though much has been done to evaluate the performance of machine learning algorithms, little has been done to verify the algorithms or examine their failure modes. Moreover, complex learning frameworks often require stepping beyond black box evaluation to distinguish between errors based on natural limits on learning and errors that arise from mistakes in implementation. We present a conceptual architecture, failure model and taxonomy, and failure modes and effects analysis (FMEA) of a semi-supervised, multi-modal learningmore » system, and provide specific examples from its use in a radiological analysis assistant system. The goal of the research described in this paper is to provide a foundation from which dependability analysis of systems using semi-supervised, multi-modal learning can be conducted. The methods presented provide a first step towards that overall goal.« less

Common data buffer system. [communication with computational equipment utilized in spacecraft operations

NASA Technical Reports Server (NTRS)

Byrne, F. (Inventor)

1981-01-01

A high speed common data buffer system is described for providing an interface and communications medium between a plurality of computers utilized in a distributed computer complex forming part of a checkout, command and control system for space vehicles and associated ground support equipment. The system includes the capability for temporarily storing data to be transferred between computers, for transferring a plurality of interrupts between computers, for monitoring and recording these transfers, and for correcting errors incurred in these transfers. Validity checks are made on each transfer and appropriate error notification is given to the computer associated with that transfer.

Error begat error: design error analysis and prevention in social infrastructure projects.

PubMed

Love, Peter E D; Lopez, Robert; Edwards, David J; Goh, Yang M

2012-09-01

Design errors contribute significantly to cost and schedule growth in social infrastructure projects and to engineering failures, which can result in accidents and loss of life. Despite considerable research that has addressed their error causation in construction projects they still remain prevalent. This paper identifies the underlying conditions that contribute to design errors in social infrastructure projects (e.g. hospitals, education, law and order type buildings). A systemic model of error causation is propagated and subsequently used to develop a learning framework for design error prevention. The research suggests that a multitude of strategies should be adopted in congruence to prevent design errors from occurring and so ensure that safety and project performance are ameliorated. Copyright © 2011. Published by Elsevier Ltd.

Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system.

PubMed

Yang, Shu-Hui; Jerng, Jih-Shuin; Chen, Li-Chin; Li, Yu-Tsu; Huang, Hsiao-Fang; Wu, Chao-Ling; Chan, Jing-Yuan; Huang, Szu-Fen; Liang, Huey-Wen; Sun, Jui-Sheng

2017-11-03

Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm. This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Repair & Reinforcing Pallet Stringers With Metal Plates

Treesearch

John W. Clarke; Thomas E. McLain; Marshall S. White; Philip A. Araman

1993-01-01

Notches significantly reduce the bending strength and life expectancy of stringer-class pallets with partial 4-way entry. Common failures include cracking between the notches (BN), bending failures in the region above the notch (AN) and splitting of end feet. In recent years, several suppliers and manufacturers of metal connector plates (MCPs) have developed equipment...

40 CFR 61.242-3 - Standards: Compressors.

Code of Federal Regulations, 2012 CFR

2012-07-01

... paragraphs (a)-(c) of this section shall be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) of this section... system, or both. (f) If the sensor indicates failure of the seal system, the barrier fluid system, or...

40 CFR 1065.410 - Maintenance limits for stabilized test engines.

Code of Federal Regulations, 2013 CFR

2013-07-01

... engineering grade tools to identify bad engine components. Any equipment, instruments, or tools used for... no longer use it as an emission-data engine. Also, if your test engine has a major mechanical failure... your test engine has a major mechanical failure that requires you to take it apart, you may no longer...

40 CFR 1065.410 - Maintenance limits for stabilized test engines.

Code of Federal Regulations, 2012 CFR

2012-07-01

... engineering grade tools to identify bad engine components. Any equipment, instruments, or tools used for... no longer use it as an emission-data engine. Also, if your test engine has a major mechanical failure... your test engine has a major mechanical failure that requires you to take it apart, you may no longer...

Selection and Application of Liquid and Semi-Solid Lubricants in Aerospace Vehicles and Supporting Equipment

DTIC Science & Technology

1965-10-01

lubrication method even though the Correct lubricant and method of xubrioation were readily available with a long history of successful operation under...grease has failed. During the discussion of the lubricant failure it is disclosed that the failure is due to corrosion of titani ™ *etal located

46 CFR 113.43-5 - Power supply.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 46 Shipping 4 2011-10-01 2011-10-01 false Power supply. 113.43-5 Section 113.43-5 Shipping COAST... SYSTEMS AND EQUIPMENT Steering Failure Alarm Systems § 113.43-5 Power supply. Each steering failure alarm system must be supplied by a circuit that: (a) Is independent of other steering gear system and steering...

46 CFR 113.43-5 - Power supply.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 4 2010-10-01 2010-10-01 false Power supply. 113.43-5 Section 113.43-5 Shipping COAST... SYSTEMS AND EQUIPMENT Steering Failure Alarm Systems § 113.43-5 Power supply. Each steering failure alarm system must be supplied by a circuit that: (a) Is independent of other steering gear system and steering...

40 CFR 63.655 - Reporting and recordkeeping requirements.

Code of Federal Regulations, 2010 CFR

2010-07-01

... a process shutdown shall be recorded and retained for 2 years. (ii) [Reserved] (2) The Notification... failure is detected in the control equipment. (i) For vessels for which annual inspections are required... listed in paragraphs (g)(2)(i)(A) through (g)(2)(i)(C) of this section apply. (A) A failure is defined as...

49 CFR 179.102-3 - Materials poisonous by inhalation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... equipped with a top fitting protection system and nozzle capable of sustaining, without failure, a rollover... the geometric center of the loaded tank car as a transverse vector. Failure is deemed to occur when... off. The tank nozzle must meet the performance standard in paragraph (a)(1) of this section and only...

Lessons from aviation - the role of checklists in minimally invasive cardiac surgery.

PubMed

Hussain, S; Adams, C; Cleland, A; Jones, P M; Walsh, G; Kiaii, B

2016-01-01

We describe an adverse event during minimally invasive cardiac surgery that resulted in a multi-disciplinary review of intra-operative errors and the creation of a procedural checklist. This checklist aims to prevent errors of omission and communication failures that result in increased morbidity and mortality. We discuss the application of the aviation - led "threats and errors model" to medical practice and the role of checklists and other strategies aimed at reducing medical errors. © The Author(s) 2015.

Stochastic Models of Human Errors

NASA Technical Reports Server (NTRS)

Elshamy, Maged; Elliott, Dawn M. (Technical Monitor)

2002-01-01

Humans play an important role in the overall reliability of engineering systems. More often accidents and systems failure are traced to human errors. Therefore, in order to have meaningful system risk analysis, the reliability of the human element must be taken into consideration. Describing the human error process by mathematical models is a key to analyzing contributing factors. Therefore, the objective of this research effort is to establish stochastic models substantiated by sound theoretic foundation to address the occurrence of human errors in the processing of the space shuttle.

The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management

PubMed Central

Huq, M. Saiful; Fraass, Benedick A.; Dunscombe, Peter B.; Gibbons, John P.; Mundt, Arno J.; Mutic, Sasa; Palta, Jatinder R.; Rath, Frank; Thomadsen, Bruce R.; Williamson, Jeffrey F.; Yorke, Ellen D.

2016-01-01

The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for “intensity modulated radiation therapy (IMRT)” as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient. PMID:27370140

The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management

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

Huq, M. Saiful, E-mail: HUQS@UPMC.EDU

The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact ofmore » possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for “intensity modulated radiation therapy (IMRT)” as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient.« less

The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management.

PubMed

Huq, M Saiful; Fraass, Benedick A; Dunscombe, Peter B; Gibbons, John P; Ibbott, Geoffrey S; Mundt, Arno J; Mutic, Sasa; Palta, Jatinder R; Rath, Frank; Thomadsen, Bruce R; Williamson, Jeffrey F; Yorke, Ellen D

2016-07-01

The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for "intensity modulated radiation therapy (IMRT)" as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient.

Considerations for analysis of time-to-event outcomes measured with error: Bias and correction with SIMEX.

PubMed

Oh, Eric J; Shepherd, Bryan E; Lumley, Thomas; Shaw, Pamela A

2018-04-15

For time-to-event outcomes, a rich literature exists on the bias introduced by covariate measurement error in regression models, such as the Cox model, and methods of analysis to address this bias. By comparison, less attention has been given to understanding the impact or addressing errors in the failure time outcome. For many diseases, the timing of an event of interest (such as progression-free survival or time to AIDS progression) can be difficult to assess or reliant on self-report and therefore prone to measurement error. For linear models, it is well known that random errors in the outcome variable do not bias regression estimates. With nonlinear models, however, even random error or misclassification can introduce bias into estimated parameters. We compare the performance of 2 common regression models, the Cox and Weibull models, in the setting of measurement error in the failure time outcome. We introduce an extension of the SIMEX method to correct for bias in hazard ratio estimates from the Cox model and discuss other analysis options to address measurement error in the response. A formula to estimate the bias induced into the hazard ratio by classical measurement error in the event time for a log-linear survival model is presented. Detailed numerical studies are presented to examine the performance of the proposed SIMEX method under varying levels and parametric forms of the error in the outcome. We further illustrate the method with observational data on HIV outcomes from the Vanderbilt Comprehensive Care Clinic. Copyright © 2017 John Wiley & Sons, Ltd.

Identification and assessment of common errors in the admission process of patients in Isfahan Fertility and Infertility Center based on "failure modes and effects analysis".

PubMed

Dehghan, Ashraf; Abumasoudi, Rouhollah Sheikh; Ehsanpour, Soheila

2016-01-01

Infertility and errors in the process of its treatment have a negative impact on infertile couples. The present study was aimed to identify and assess the common errors in the reception process by applying the approach of "failure modes and effects analysis" (FMEA). In this descriptive cross-sectional study, the admission process of fertility and infertility center of Isfahan was selected for evaluation of its errors based on the team members' decision. At first, the admission process was charted through observations and interviewing employees, holding multiple panels, and using FMEA worksheet, which has been used in many researches all over the world and also in Iran. Its validity was evaluated through content and face validity, and its reliability was evaluated through reviewing and confirmation of the obtained information by the FMEA team, and eventually possible errors, causes, and three indicators of severity of effect, probability of occurrence, and probability of detection were determined and corrective actions were proposed. Data analysis was determined by the number of risk priority (RPN) which is calculated by multiplying the severity of effect, probability of occurrence, and probability of detection. Twenty-five errors with RPN ≥ 125 was detected through the admission process, in which six cases of error had high priority in terms of severity and occurrence probability and were identified as high-risk errors. The team-oriented method of FMEA could be useful for assessment of errors and also to reduce the occurrence probability of errors.

Identification and assessment of common errors in the admission process of patients in Isfahan Fertility and Infertility Center based on “failure modes and effects analysis”

PubMed Central

Dehghan, Ashraf; Abumasoudi, Rouhollah Sheikh; Ehsanpour, Soheila

2016-01-01

Background: Infertility and errors in the process of its treatment have a negative impact on infertile couples. The present study was aimed to identify and assess the common errors in the reception process by applying the approach of “failure modes and effects analysis” (FMEA). Materials and Methods: In this descriptive cross-sectional study, the admission process of fertility and infertility center of Isfahan was selected for evaluation of its errors based on the team members’ decision. At first, the admission process was charted through observations and interviewing employees, holding multiple panels, and using FMEA worksheet, which has been used in many researches all over the world and also in Iran. Its validity was evaluated through content and face validity, and its reliability was evaluated through reviewing and confirmation of the obtained information by the FMEA team, and eventually possible errors, causes, and three indicators of severity of effect, probability of occurrence, and probability of detection were determined and corrective actions were proposed. Data analysis was determined by the number of risk priority (RPN) which is calculated by multiplying the severity of effect, probability of occurrence, and probability of detection. Results: Twenty-five errors with RPN ≥ 125 was detected through the admission process, in which six cases of error had high priority in terms of severity and occurrence probability and were identified as high-risk errors. Conclusions: The team-oriented method of FMEA could be useful for assessment of errors and also to reduce the occurrence probability of errors. PMID:28194208

WE-H-BRC-09: Simulated Errors in Mock Radiotherapy Plans to Quantify the Effectiveness of the Physics Plan Review

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

Gopan, O; Kalet, A; Smith, W

2016-06-15

Purpose: A standard tool for ensuring the quality of radiation therapy treatments is the initial physics plan review. However, little is known about its performance in practice. The goal of this study is to measure the effectiveness of physics plan review by introducing simulated errors into “mock” treatment plans and measuring the performance of plan review by physicists. Methods: We generated six mock treatment plans containing multiple errors. These errors were based on incident learning system data both within the department and internationally (SAFRON). These errors were scored for severity and frequency. Those with the highest scores were included inmore » the simulations (13 errors total). Observer bias was minimized using a multiple co-correlated distractor approach. Eight physicists reviewed these plans for errors, with each physicist reviewing, on average, 3/6 plans. The confidence interval for the proportion of errors detected was computed using the Wilson score interval. Results: Simulated errors were detected in 65% of reviews [51–75%] (95% confidence interval [CI] in brackets). The following error scenarios had the highest detection rates: incorrect isocenter in DRRs/CBCT (91% [73–98%]) and a planned dose different from the prescribed dose (100% [61–100%]). Errors with low detection rates involved incorrect field parameters in record and verify system (38%, [18–61%]) and incorrect isocenter localization in planning system (29% [8–64%]). Though pre-treatment QA failure was reliably identified (100%), less than 20% of participants reported the error that caused the failure. Conclusion: This is one of the first quantitative studies of error detection. Although physics plan review is a key safety measure and can identify some errors with high fidelity, others errors are more challenging to detect. This data will guide future work on standardization and automation. Creating new checks or improving existing ones (i.e., via automation) will help in detecting those errors with low detection rates.« less

Forecasting the brittle failure of heterogeneous, porous geomaterials

NASA Astrophysics Data System (ADS)

Vasseur, Jérémie; Wadsworth, Fabian; Heap, Michael; Main, Ian; Lavallée, Yan; Dingwell, Donald

2017-04-01

Heterogeneity develops in magmas during ascent and is dominated by the development of crystal and importantly, bubble populations or pore-network clusters which grow, interact, localize, coalesce, outgas and resorb. Pore-scale heterogeneity is also ubiquitous in sedimentary basin fill during diagenesis. As a first step, we construct numerical simulations in 3D in which randomly generated heterogeneous and polydisperse spheres are placed in volumes and which are permitted to overlap with one another, designed to represent the random growth and interaction of bubbles in a liquid volume. We use these simulated geometries to show that statistical predictions of the inter-bubble lengthscales and evolving bubble surface area or cluster densities can be made based on fundamental percolation theory. As a second step, we take a range of well constrained random heterogeneous rock samples including sandstones, andesites, synthetic partially sintered glass bead samples, and intact glass samples and subject them to a variety of stress loading conditions at a range of temperatures until failure. We record in real time the evolution of the number of acoustic events that precede failure and show that in all scenarios, the acoustic event rate accelerates toward failure, consistent with previous findings. Applying tools designed to forecast the failure time based on these precursory signals, we constrain the absolute error on the forecast time. We find that for all sample types, the error associated with an accurate forecast of failure scales non-linearly with the lengthscale between the pore clusters in the material. Moreover, using a simple micromechanical model for the deformation of porous elastic bodies, we show that the ratio between the equilibrium sub-critical crack length emanating from the pore clusters relative to the inter-pore lengthscale, provides a scaling for the error on forecast accuracy. Thus for the first time we provide a potential quantitative correction for forecasting the failure of porous brittle solids that build the Earth's crust.

Identification of priorities for medication safety in neonatal intensive care.

PubMed

Kunac, Desireé L; Reith, David M

2005-01-01

Although neonates are reported to be at greater risk of medication error than infants and older children, little is known about the causes and characteristics of error in this patient group. Failure mode and effects analysis (FMEA) is a technique used in industry to evaluate system safety and identify potential hazards in advance. The aim of this study was to identify and prioritize potential failures in the neonatal intensive care unit (NICU) medication use process through application of FMEA. Using the FMEA framework and a systems-based approach, an eight-member multidisciplinary panel worked as a team to create a flow diagram of the neonatal unit medication use process. Then by brainstorming, the panel identified all potential failures, their causes and their effects at each step in the process. Each panel member independently rated failures based on occurrence, severity and likelihood of detection to allow calculation of a risk priority score (RPS). The panel identified 72 failures, with 193 associated causes and effects. Vulnerabilities were found to be distributed across the entire process, but multiple failures and associated causes were possible when prescribing the medication and when preparing the drug for administration. The top ranking issue was a perceived lack of awareness of medication safety issues (RPS score 273), due to a lack of medication safety training. The next highest ranking issues were found to occur at the administration stage. Common potential failures related to errors in the dose, timing of administration, infusion pump settings and route of administration. Perceived causes were multiple, but were largely associated with unsafe systems for medication preparation and storage in the unit, variable staff skill level and lack of computerised technology. Interventions to decrease medication-related adverse events in the NICU should aim to increase staff awareness of medication safety issues and focus on medication administration processes.

Level 1 Tornado PRA for the High Flux Beam Reactor

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

Bozoki, G.E.; Conrad, C.S.

This report describes a risk analysis primarily directed at providing an estimate for the frequency of tornado induced damage to the core of the High Flux Beam Reactor (HFBR), and thus it constitutes a Level 1 Probabilistic Risk Assessment (PRA) covering tornado induced accident sequences. The basic methodology of the risk analysis was to develop a ``tornado specific`` plant logic model that integrates the internal random hardware failures with failures caused externally by the tornado strike and includes operator errors worsened by the tornado modified environment. The tornado hazard frequency, as well as earlier prepared structural and equipment fragility data,more » were used as input data to the model. To keep modeling/calculational complexity as simple as reasonable a ``bounding`` type, slightly conservative, approach was applied. By a thorough screening process a single dominant initiating event was selected as a representative initiator, defined as: ``Tornado Induced Loss of Offsite Power.`` The frequency of this initiator was determined to be 6.37E-5/year. The safety response of the HFBR facility resulted in a total Conditional Core Damage Probability of .621. Thus, the point estimate of the HFBR`s Tornado Induced Core Damage Frequency (CDF) was found to be: (CDF){sub Tornado} = 3.96E-5/year. This value represents only 7.8% of the internal CDF and thus is considered to be a small contribution to the overall facility risk expressed in terms of total Core Damage Frequency. In addition to providing the estimate of (CDF){sub Tornado}, the report documents, the relative importance of various tornado induced system, component, and operator failures that contribute most to (CDF){sub Tornado}.« less

Reliability analysis of a wastewater treatment plant using fault tree analysis and Monte Carlo simulation.

PubMed

Taheriyoun, Masoud; Moradinejad, Saber

2015-01-01

The reliability of a wastewater treatment plant is a critical issue when the effluent is reused or discharged to water resources. Main factors affecting the performance of the wastewater treatment plant are the variation of the influent, inherent variability in the treatment processes, deficiencies in design, mechanical equipment, and operational failures. Thus, meeting the established reuse/discharge criteria requires assessment of plant reliability. Among many techniques developed in system reliability analysis, fault tree analysis (FTA) is one of the popular and efficient methods. FTA is a top down, deductive failure analysis in which an undesired state of a system is analyzed. In this study, the problem of reliability was studied on Tehran West Town wastewater treatment plant. This plant is a conventional activated sludge process, and the effluent is reused in landscape irrigation. The fault tree diagram was established with the violation of allowable effluent BOD as the top event in the diagram, and the deficiencies of the system were identified based on the developed model. Some basic events are operator's mistake, physical damage, and design problems. The analytical method is minimal cut sets (based on numerical probability) and Monte Carlo simulation. Basic event probabilities were calculated according to available data and experts' opinions. The results showed that human factors, especially human error had a great effect on top event occurrence. The mechanical, climate, and sewer system factors were in subsequent tier. Literature shows applying FTA has been seldom used in the past wastewater treatment plant (WWTP) risk analysis studies. Thus, the developed FTA model in this study considerably improves the insight into causal failure analysis of a WWTP. It provides an efficient tool for WWTP operators and decision makers to achieve the standard limits in wastewater reuse and discharge to the environment.

Causes and consequences of timing errors associated with global positioning system collar accelerometer activity monitors

Treesearch

Adam J. Gaylord; Dana M. Sanchez

2014-01-01

Direct behavioral observations of multiple free-ranging animals over long periods of time and large geographic areas is prohibitively difficult. However, recent improvements in technology, such as Global Positioning System (GPS) collars equipped with motion-sensitive activity monitors, create the potential to remotely monitor animal behavior. Accelerometer-equipped...

A study of the viability of exploiting memory content similarity to improve resilience to memory errors

DOE PAGES

Levy, Scott; Ferreira, Kurt B.; Bridges, Patrick G.; ...

2014-12-09

Building the next-generation of extreme-scale distributed systems will require overcoming several challenges related to system resilience. As the number of processors in these systems grow, the failure rate increases proportionally. One of the most common sources of failure in large-scale systems is memory. In this paper, we propose a novel runtime for transparently exploiting memory content similarity to improve system resilience by reducing the rate at which memory errors lead to node failure. We evaluate the viability of this approach by examining memory snapshots collected from eight high-performance computing (HPC) applications and two important HPC operating systems. Based on themore » characteristics of the similarity uncovered, we conclude that our proposed approach shows promise for addressing system resilience in large-scale systems.« less

Software reliability experiments data analysis and investigation

NASA Technical Reports Server (NTRS)

Walker, J. Leslie; Caglayan, Alper K.

1991-01-01

The objectives are to investigate the fundamental reasons which cause independently developed software programs to fail dependently, and to examine fault tolerant software structures which maximize reliability gain in the presence of such dependent failure behavior. The authors used 20 redundant programs from a software reliability experiment to analyze the software errors causing coincident failures, to compare the reliability of N-version and recovery block structures composed of these programs, and to examine the impact of diversity on software reliability using subpopulations of these programs. The results indicate that both conceptually related and unrelated errors can cause coincident failures and that recovery block structures offer more reliability gain than N-version structures if acceptance checks that fail independently from the software components are available. The authors present a theory of general program checkers that have potential application for acceptance tests.

Robust THP Transceiver Designs for Multiuser MIMO Downlink with Imperfect CSIT

NASA Astrophysics Data System (ADS)

Ubaidulla, P.; Chockalingam, A.

2009-12-01

We present robust joint nonlinear transceiver designs for multiuser multiple-input multiple-output (MIMO) downlink in the presence of imperfections in the channel state information at the transmitter (CSIT). The base station (BS) is equipped with multiple transmit antennas, and each user terminal is equipped with one or more receive antennas. The BS employs Tomlinson-Harashima precoding (THP) for interuser interference precancellation at the transmitter. We consider robust transceiver designs that jointly optimize the transmit THP filters and receive filter for two models of CSIT errors. The first model is a stochastic error (SE) model, where the CSIT error is Gaussian-distributed. This model is applicable when the CSIT error is dominated by channel estimation error. In this case, the proposed robust transceiver design seeks to minimize a stochastic function of the sum mean square error (SMSE) under a constraint on the total BS transmit power. We propose an iterative algorithm to solve this problem. The other model we consider is a norm-bounded error (NBE) model, where the CSIT error can be specified by an uncertainty set. This model is applicable when the CSIT error is dominated by quantization errors. In this case, we consider a worst-case design. For this model, we consider robust (i) minimum SMSE, (ii) MSE-constrained, and (iii) MSE-balancing transceiver designs. We propose iterative algorithms to solve these problems, wherein each iteration involves a pair of semidefinite programs (SDPs). Further, we consider an extension of the proposed algorithm to the case with per-antenna power constraints. We evaluate the robustness of the proposed algorithms to imperfections in CSIT through simulation, and show that the proposed robust designs outperform nonrobust designs as well as robust linear transceiver designs reported in the recent literature.

Erratum to Dynamic stresses, Coulomb failure, and remote triggering and to Surface wave potential for triggering tectonic (nonvolcanic) tremor

USGS Publications Warehouse

Hill, David P.

2012-01-01

Hill (2008) and Hill (2010) contain two technical errors: (1) a missing factor of 2 for computed Love‐wave amplitudes, and (2) a sign error in the off‐diagonal elements in the Euler rotation matrix.

High-throughput sequencing: a failure mode analysis.

PubMed

Yang, George S; Stott, Jeffery M; Smailus, Duane; Barber, Sarah A; Balasundaram, Miruna; Marra, Marco A; Holt, Robert A

2005-01-04

Basic manufacturing principles are becoming increasingly important in high-throughput sequencing facilities where there is a constant drive to increase quality, increase efficiency, and decrease operating costs. While high-throughput centres report failure rates typically on the order of 10%, the causes of sporadic sequencing failures are seldom analyzed in detail and have not, in the past, been formally reported. Here we report the results of a failure mode analysis of our production sequencing facility based on detailed evaluation of 9,216 ESTs generated from two cDNA libraries. Two categories of failures are described; process-related failures (failures due to equipment or sample handling) and template-related failures (failures that are revealed by close inspection of electropherograms and are likely due to properties of the template DNA sequence itself). Preventative action based on a detailed understanding of failure modes is likely to improve the performance of other production sequencing pipelines.

Generalized Phenomenological Cyclic Stress-Strain-Strength Characterization of Granular Media.

DTIC Science & Technology

1984-09-02

could be fitted to a comprehensive data set. i ’../., Unfortunately, such equipment is not available at present, and most researchers still rely on the...notably, Lade and Duncan (1975), using a comprehensive series of test data obtained from a true triaxial device (Lade, 1973), have suggested that failure...0 VV 2. Shear Strain, low indeterminate (prior to failure) (at failure) 3. Deformation small large 4. Void Ratio (e) any e ecritical 5. Grain

Pre-cue Fronto-Occipital Alpha Phase and Distributed Cortical Oscillations Predict Failures of Cognitive Control

PubMed Central

Hamm, Jordan P.; Dyckman, Kara A.; McDowell, Jennifer E.; Clementz, Brett A.

2012-01-01

Cognitive control is required for correct performance on antisaccade tasks, including the ability to inhibit an externally driven ocular motor repsonse (a saccade to a peripheral stimulus) in favor of an internally driven ocular motor goal (a saccade directed away from a peripheral stimulus). Healthy humans occasionally produce errors during antisaccade tasks, but the mechanisms associated with such failures of cognitive control are uncertain. Most research on cognitive control failures focuses on post-stimulus processing, although a growing body of literature highlights a role of intrinsic brain activity in perceptual and cognitive performance. The current investigation used dense array electroencephalography and distributed source analyses to examine brain oscillations across a wide frequency bandwidth in the period prior to antisaccade cue onset. Results highlight four important aspects of ongoing and preparatory brain activations that differentiate error from correct antisaccade trials: (i) ongoing oscillatory beta (20–30Hz) power in anterior cingulate prior to trial initiation (lower for error trials), (ii) instantaneous phase of ongoing alpha-theta (7Hz) in frontal and occipital cortices immediately before trial initiation (opposite between trial types), (iii) gamma power (35–60Hz) in posterior parietal cortex 100 ms prior to cue onset (greater for error trials), and (iv) phase locking of alpha (5–12Hz) in parietal and occipital cortices immediately prior to cue onset (lower for error trials). These findings extend recently reported effects of pre-trial alpha phase on perception to cognitive control processes, and help identify the cortical generators of such phase effects. PMID:22593071

Means to improve light source productivity: from proof of concept to field implementation

NASA Astrophysics Data System (ADS)

Rausa, E.; Cacouris, T.; Conley, W.; Jackson, M.; Luo, S.; Murthy, S.; Rechtsteiner, G.; Steiner, K.

2016-03-01

Light source technological performance is key to enabling chipmaker yield and production success. Just as important is ensuring that performance is consistent over time to help maintain as high an uptime as possible on litho-cells (scanner and track combination). While it is common to see average tool uptime of over 99% based on service intervention time, we will show that there are opportunities to improve equipment availability through a multifaceted approach that can deliver favorable results and significantly improve on the actual production efficiency of equipment. The majority of chipmakers are putting light source data generated by tools such as Cymer OnLine (COL), OnPulse Plus, and SmartPulse to good use. These data sets, combined with in-depth knowledge of the equipment, makes it possible to draw powerful conclusions that help increase both chip manufacturing consistency as well as equipment productivity. This discussion will focus on the latter, equipment availability, and how data analysis can help increase equipment availability for Cymer customers. There are several types of opportunities for increasing equipment availability, but in general we can focus on two primary categories: 1) scheduled downtime and 2) unscheduled downtime. For equipment that is under control of a larger entity, as the laser is to the scanner, there are additional categories related to either communication errors or better synchronization of events that can maximize overall litho-cell efficiency. In this article we will focus on general availability without highlighting the specific cause of litho-cell (laser, scanner and track). The goal is to increase equipment available time with a primary focus is on opportunities to minimize errors and variabilities.

Machine Protection with a 700 MJ Beam

NASA Astrophysics Data System (ADS)

Baer, T.; Schmidt, R.; Wenninger, J.; Wollmann, D.; Zerlauth, M.

After the high luminosity upgrade of the LHC, the stored energy per proton beam will increase by a factor of two as compared to the nominal LHC. Therefore, many damage studies need to be revisited to ensure a safe machine operation with the new beam parameters. Furthermore, new accelerator equipment like crab cavities might cause new failure modes, which are not sufficiently covered by the current machine protection system of the LHC. These failure modes have to be carefully studied and mitigated by new protection systems. Finally the ambitious goals for integrated luminosity delivered to the experiments during the era of HL-LHC require an increase of the machine availability without jeopardizing equipment protection.

Navigation errors encountered using weather-mapping radar for helicopter IFR guidance to oil rigs

NASA Technical Reports Server (NTRS)

Phillips, J. D.; Bull, J. S.; Hegarty, D. M.; Dugan, D. C.

1980-01-01

In 1978 a joint NASA-FAA helicopter flight test was conducted to examine the use of weather-mapping radar for IFR guidance during landing approaches to oil rig helipads. The following navigation errors were measured: total system error, radar-range error, radar-bearing error, and flight technical error. Three problem areas were identified: (1) operational problems leading to pilot blunders, (2) poor navigation to the downwind final approach point, and (3) pure homing on final approach. Analysis of these problem areas suggests improvement in the radar equipment, approach procedure, and pilot training, and gives valuable insight into the development of future navigation aids to serve the off-shore oil industry.

Grammar Errors Made by ESL Tertiary Students in Writing

ERIC Educational Resources Information Center

Singh, Charanjit Kaur Swaran; Singh, Amreet Kaur Jageer; Razak, Nur Qistina Abd; Ravinthar, Thilaga

2017-01-01

The educational context in Malaysia demands students to be equipped with sound grammar so that they can produce good essays in the examination. However, despite having learnt English in primary and secondary schools, students in the higher learning institutions tend to make some grammatical errors in their writing. This study presents the…

Link Performance Analysis and monitoring - A unified approach to divergent requirements

NASA Astrophysics Data System (ADS)

Thom, G. A.

Link Performance Analysis and real-time monitoring are generally covered by a wide range of equipment. Bit Error Rate testers provide digital link performance measurements but are not useful during real-time data flows. Real-time performance monitors utilize the fixed overhead content but vary widely from format to format. Link quality information is also present from signal reconstruction equipment in the form of receiver AGC, bit synchronizer AGC, and bit synchronizer soft decision level outputs, but no general approach to utilizing this information exists. This paper presents an approach to link tests, real-time data quality monitoring, and results presentation that utilizes a set of general purpose modules in a flexible architectural environment. The system operates over a wide range of bit rates (up to 150 Mbs) and employs several measurement techniques, including P/N code errors or fixed PCM format errors, derived real-time BER from frame sync errors, and Data Quality Analysis derived by counting significant sync status changes. The architecture performs with a minimum of elements in place to permit a phased update of the user's unit in accordance with his needs.

40 CFR 60.482-2 - Standards: Pumps in light liquid service.

Code of Federal Regulations, 2011 CFR

2011-07-01

...; or (ii) Equipped with a barrier fluid degassing reservoir that is routed to a process or fuel gas... in VOC service. (3) Each barrier fluid system is equipped with a sensor that will detect failure of...) Designate the visual indications of liquids dripping as a leak. (5)(i) Each sensor as described in paragraph...

40 CFR 60.482-3 - Standards: Compressors.

Code of Federal Regulations, 2010 CFR

2010-07-01

... process or fuel gas system or connected by a closed vent system to a control device that complies with the... be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) shall be checked daily or shall be equipped with an...

40 CFR 60.482-3 - Standards: Compressors.

Code of Federal Regulations, 2011 CFR

2011-07-01

... process or fuel gas system or connected by a closed vent system to a control device that complies with the... be equipped with a sensor that will detect failure of the seal system, barrier fluid system, or both. (e)(1) Each sensor as required in paragraph (d) shall be checked daily or shall be equipped with an...

40 CFR 60.482-2 - Standards: Pumps in light liquid service.

Code of Federal Regulations, 2010 CFR

2010-07-01

...; or (ii) Equipped with a barrier fluid degassing reservoir that is routed to a process or fuel gas... in VOC service. (3) Each barrier fluid system is equipped with a sensor that will detect failure of...) Designate the visual indications of liquids dripping as a leak. (5)(i) Each sensor as described in paragraph...

40 CFR 60.5415 - How do I demonstrate continuous compliance with the standards for my gas well affected facility...

Code of Federal Regulations, 2013 CFR

2013-07-01

... plants? 60.5415 Section 60.5415 Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR..., and unavoidable failure of air pollution control equipment, process equipment, or a process to operate... control systems were kept in operation if at all possible, consistent with safety and good air pollution...

40 CFR 112.7 - General requirements for Spill Prevention, Control, and Countermeasure Plans.

Code of Federal Regulations, 2014 CFR

2014-07-01

... discharged from the facility as a result of each type of major equipment failure. (c) Provide appropriate... written commitment of manpower, equipment, and materials required to expeditiously control and remove any... described in § 112.1(b) that are the result of natural disasters, acts of war or terrorism); and (2...

40 CFR 112.7 - General requirements for Spill Prevention, Control, and Countermeasure Plans.

Code of Federal Regulations, 2010 CFR

2010-07-01

... discharged from the facility as a result of each type of major equipment failure. (c) Provide appropriate... written commitment of manpower, equipment, and materials required to expeditiously control and remove any... described in § 112.1(b) that are the result of natural disasters, acts of war or terrorism); and (2...

40 CFR 112.7 - General requirements for Spill Prevention, Control, and Countermeasure Plans.

Code of Federal Regulations, 2012 CFR

2012-07-01

... discharged from the facility as a result of each type of major equipment failure. (c) Provide appropriate... written commitment of manpower, equipment, and materials required to expeditiously control and remove any... described in § 112.1(b) that are the result of natural disasters, acts of war or terrorism); and (2...

40 CFR 112.7 - General requirements for Spill Prevention, Control, and Countermeasure Plans.

Code of Federal Regulations, 2013 CFR

2013-07-01

... discharged from the facility as a result of each type of major equipment failure. (c) Provide appropriate... written commitment of manpower, equipment, and materials required to expeditiously control and remove any... described in § 112.1(b) that are the result of natural disasters, acts of war or terrorism); and (2...

40 CFR 112.7 - General requirements for Spill Prevention, Control, and Countermeasure Plans.

Code of Federal Regulations, 2011 CFR

2011-07-01

... discharged from the facility as a result of each type of major equipment failure. (c) Provide appropriate... written commitment of manpower, equipment, and materials required to expeditiously control and remove any... described in § 112.1(b) that are the result of natural disasters, acts of war or terrorism); and (2...

Pressure Safety: Advanced Live 11459

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

Glass, George

Many Los Alamos National Laboratory (LANL) operations use pressure equipment and systems. Failure to follow proper procedures when designing or operating pressure systems can result in injuries to personnel and damage to equipment and/or the environment. This manual presents an overview of the requirements and recommendations that address the safe design and operation of pressure systems at LANL.

75 FR 81433 - Airworthiness Directives; Airbus Model A321-211, -212, -231, and -232 Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-28

... join individual electrical wires in the Wing Tank harness installations to in-tank equipment on QT... are used to join individual electrical wires in the Wing Tank harness installations to in-tank... electrical wires in the Wing Tank harness installations to in-tank equipment on QT circuit. The failure of a...

Error floor behavior study of LDPC codes for concatenated codes design

NASA Astrophysics Data System (ADS)

Chen, Weigang; Yin, Liuguo; Lu, Jianhua

2007-11-01

Error floor behavior of low-density parity-check (LDPC) codes using quantized decoding algorithms is statistically studied with experimental results on a hardware evaluation platform. The results present the distribution of the residual errors after decoding failure and reveal that the number of residual error bits in a codeword is usually very small using quantized sum-product (SP) algorithm. Therefore, LDPC code may serve as the inner code in a concatenated coding system with a high code rate outer code and thus an ultra low error floor can be achieved. This conclusion is also verified by the experimental results.

47 CFR 1.1112 - Form of payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Commission. Failure to comply with the Commission's procedures will result in the return of the application... not receive final payment and such failure is not excused by bank error. (2) The Commission will... attached to the receipt copy a stamped self-addressed envelope of sufficient size to contain the date...

Experience of automation failures in training: effects on trust, automation bias, complacency and performance.

PubMed

Sauer, Juergen; Chavaillaz, Alain; Wastell, David

2016-06-01

This work examined the effects of operators' exposure to various types of automation failures in training. Forty-five participants were trained for 3.5 h on a simulated process control environment. During training, participants either experienced a fully reliable, automatic fault repair facility (i.e. faults detected and correctly diagnosed), a misdiagnosis-prone one (i.e. faults detected but not correctly diagnosed) or a miss-prone one (i.e. faults not detected). One week after training, participants were tested for 3 h, experiencing two types of automation failures (misdiagnosis, miss). The results showed that automation bias was very high when operators trained on miss-prone automation encountered a failure of the diagnostic system. Operator errors resulting from automation bias were much higher when automation misdiagnosed a fault than when it missed one. Differences in trust levels that were instilled by the different training experiences disappeared during the testing session. Practitioner Summary: The experience of automation failures during training has some consequences. A greater potential for operator errors may be expected when an automatic system failed to diagnose a fault than when it failed to detect one.

Remote maintenance monitoring system

NASA Technical Reports Server (NTRS)

Simpkins, Lorenz G. (Inventor); Owens, Richard C. (Inventor); Rochette, Donn A. (Inventor)

1992-01-01

A remote maintenance monitoring system retrofits to a given hardware device with a sensor implant which gathers and captures failure data from the hardware device, without interfering with its operation. Failure data is continuously obtained from predetermined critical points within the hardware device, and is analyzed with a diagnostic expert system, which isolates failure origin to a particular component within the hardware device. For example, monitoring of a computer-based device may include monitoring of parity error data therefrom, as well as monitoring power supply fluctuations therein, so that parity error and power supply anomaly data may be used to trace the failure origin to a particular plane or power supply within the computer-based device. A plurality of sensor implants may be rerofit to corresponding plural devices comprising a distributed large-scale system. Transparent interface of the sensors to the devices precludes operative interference with the distributed network. Retrofit capability of the sensors permits monitoring of even older devices having no built-in testing technology. Continuous real time monitoring of a distributed network of such devices, coupled with diagnostic expert system analysis thereof, permits capture and analysis of even intermittent failures, thereby facilitating maintenance of the monitored large-scale system.

Natural Selection as an Emergent Process: Instructional Implications

ERIC Educational Resources Information Center

Cooper, Robert A.

2017-01-01

Student reasoning about cases of natural selection is often plagued by errors that stem from miscategorising selection as a direct, causal process, misunderstanding the role of randomness, and from the intuitive ideas of intentionality, teleology and essentialism. The common thread throughout many of these reasoning errors is a failure to apply…

Evaluating wood failure in plywood shear by optical image analysis

Treesearch

Charles W. McMillin

1984-01-01

This exploratory study evaulates the potential of using an automatic image analysis method to measure percent wood failure in plywood shear specimens. The results suggest that this method my be as accurate as the visual method in tracking long-term gluebond quality. With further refinement, the method could lead to automated equipment replacing the subjective visual...

46 CFR 113.43-3 - Alarm system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 46 Shipping 4 2011-10-01 2011-10-01 false Alarm system. 113.43-3 Section 113.43-3 Shipping COAST... SYSTEMS AND EQUIPMENT Steering Failure Alarm Systems § 113.43-3 Alarm system. (a) Each vessel must have a steering failure alarm system that actuates an audible and visible alarm in the pilothouse when the actual...

46 CFR 113.43-3 - Alarm system.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 4 2013-10-01 2013-10-01 false Alarm system. 113.43-3 Section 113.43-3 Shipping COAST... SYSTEMS AND EQUIPMENT Steering Failure Alarm Systems § 113.43-3 Alarm system. (a) Each vessel must have a steering failure alarm system that actuates an audible and visible alarm in the pilothouse when the actual...