Development of STS/Centaur failure probabilities liftoff to Centaur separation

NASA Technical Reports Server (NTRS)

Hudson, J. M.

1982-01-01

The results of an analysis to determine STS/Centaur catastrophic vehicle response probabilities for the phases of vehicle flight from STS liftoff to Centaur separation from the Orbiter are presented. The analysis considers only category one component failure modes as contributors to the vehicle response mode probabilities. The relevant component failure modes are grouped into one of fourteen categories of potential vehicle behavior. By assigning failure rates to each component, for each of its failure modes, the STS/Centaur vehicle response probabilities in each phase of flight can be calculated. The results of this study will be used in a DOE analysis to ascertain the hazard from carrying a nuclear payload on the STS.

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

NASA Technical Reports Server (NTRS)

Robinson, W. W.

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 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. This report documents the independent analysis results corresponding to the Orbiter Pyrotechnics hardware. The IOA analysis process utilized available pyrotechnics 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.

Failure mode and effects analysis and fault tree analysis of surface image guided cranial radiosurgery.

PubMed

Manger, Ryan P; Paxton, Adam B; Pawlicki, Todd; Kim, Gwe-Ya

2015-05-01

Surface image guided, Linac-based radiosurgery (SIG-RS) is a modern approach for delivering radiosurgery that utilizes optical stereoscopic imaging to monitor the surface of the patient during treatment in lieu of using a head frame for patient immobilization. Considering the novelty of the SIG-RS approach and the severity of errors associated with delivery of large doses per fraction, a risk assessment should be conducted to identify potential hazards, determine their causes, and formulate mitigation strategies. The purpose of this work is to investigate SIG-RS using the combined application of failure modes and effects analysis (FMEA) and fault tree analysis (FTA), report on the effort required to complete the analysis, and evaluate the use of FTA in conjunction with FMEA. A multidisciplinary team was assembled to conduct the FMEA on the SIG-RS process. A process map detailing the steps of the SIG-RS was created to guide the FMEA. Failure modes were determined for each step in the SIG-RS process, and risk priority numbers (RPNs) were estimated for each failure mode to facilitate risk stratification. The failure modes were ranked by RPN, and FTA was used to determine the root factors contributing to the riskiest failure modes. Using the FTA, mitigation strategies were formulated to address the root factors and reduce the risk of the process. The RPNs were re-estimated based on the mitigation strategies to determine the margin of risk reduction. The FMEA and FTAs for the top two failure modes required an effort of 36 person-hours (30 person-hours for the FMEA and 6 person-hours for two FTAs). The SIG-RS process consisted of 13 major subprocesses and 91 steps, which amounted to 167 failure modes. Of the 91 steps, 16 were directly related to surface imaging. Twenty-five failure modes resulted in a RPN of 100 or greater. Only one of these top 25 failure modes was specific to surface imaging. The riskiest surface imaging failure mode had an overall RPN-rank of eighth. Mitigation strategies for the top failure mode decreased the RPN from 288 to 72. Based on the FMEA performed in this work, the use of surface imaging for monitoring intrafraction position in Linac-based stereotactic radiosurgery (SRS) did not greatly increase the risk of the Linac-based SRS process. In some cases, SIG helped to reduce the risk of Linac-based RS. The FMEA was augmented by the use of FTA since it divided the failure modes into their fundamental components, which simplified the task of developing mitigation strategies.

Clinical risk analysis with failure mode and effect analysis (FMEA) model in a dialysis unit.

PubMed

Bonfant, Giovanna; Belfanti, Pietro; Paternoster, Giuseppe; Gabrielli, Danila; Gaiter, Alberto M; Manes, Massimo; Molino, Andrea; Pellu, Valentina; Ponzetti, Clemente; Farina, Massimo; Nebiolo, Pier E

2010-01-01

The aim of clinical risk management is to improve the quality of care provided by health care organizations and to assure patients' safety. Failure mode and effect analysis (FMEA) is a tool employed for clinical risk reduction. We applied FMEA to chronic hemodialysis outpatients. FMEA steps: (i) process study: we recorded phases and activities. (ii) Hazard analysis: we listed activity-related failure modes and their effects; described control measures; assigned severity, occurrence and detection scores for each failure mode and calculated the risk priority numbers (RPNs) by multiplying the 3 scores. Total RPN is calculated by adding single failure mode RPN. (iii) Planning: we performed a RPNs prioritization on a priority matrix taking into account the 3 scores, and we analyzed failure modes causes, made recommendations and planned new control measures. (iv) Monitoring: after failure mode elimination or reduction, we compared the resulting RPN with the previous one. Our failure modes with the highest RPN came from communication and organization problems. Two tools have been created to ameliorate information flow: "dialysis agenda" software and nursing datasheets. We scheduled nephrological examinations, and we changed both medical and nursing organization. Total RPN value decreased from 892 to 815 (8.6%) after reorganization. Employing FMEA, we worked on a few critical activities, and we reduced patients' clinical risk. A priority matrix also takes into account the weight of the control measures: we believe this evaluation is quick, because of simple priority selection, and that it decreases action times.

Orbiter subsystem hardware/software interaction analysis. Volume 8: Forward reaction control system

NASA Technical Reports Server (NTRS)

Becker, D. D.

1980-01-01

The results of the orbiter hardware/software interaction analysis for the AFT reaction control system are presented. The interaction between hardware failure modes and software are examined in order to identify associated issues and risks. All orbiter subsystems and interfacing program elements which interact with the orbiter computer flight software are analyzed. The failure modes identified in the subsystem/element failure mode and effects analysis are discussed.

Independent Orbiter Assessment (IOA): Analysis of the communication and tracking subsystem

NASA Technical Reports Server (NTRS)

Gardner, J. R.; Robinson, W. M.; Trahan, W. H.; Daley, E. S.; Long, W. C.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Communication and Tracking hardware. The IOA analysis process utilized available Communication and Tracking 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.

Independent Orbiter Assessment (IOA): Analysis of the purge, vent and drain subsystem

NASA Technical Reports Server (NTRS)

Bynum, M. C., III

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter PV and D (Purge, Vent and Drain) Subsystem hardware. The PV and D Subsystem controls the environment of unpressurized compartments and window cavities, senses hazardous gases, and purges Orbiter/ET Disconnect. The subsystem is divided into six systems: Purge System (controls the environment of unpressurized structural compartments); Vent System (controls the pressure of unpressurized compartments); Drain System (removes water from unpressurized compartments); Hazardous Gas Detection System (HGDS) (monitors hazardous gas concentrations); Window Cavity Conditioning System (WCCS) (maintains clear windows and provides pressure control of the window cavities); and External Tank/Orbiter Disconnect Purge System (prevents cryo-pumping/icing of disconnect hardware). 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. Four of the sixty-two failure modes analyzed were determined as single failures which could result in the loss of crew or vehicle. A possible loss of mission could result if any of twelve single failures occurred. Two of the criticality 1/1 failures are in the Window Cavity Conditioning System (WCCS) outer window cavity, where leakage and/or restricted flow will cause failure to depressurize/repressurize the window cavity. Two criticality 1/1 failures represent leakage and/or restricted flow in the Orbiter/ET disconnect purge network which prevent cryopumping/icing of disconnect hardware. 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.

Application of failure mode and effects analysis to intracranial stereotactic radiation surgery by linear accelerator.

PubMed

Masini, Laura; Donis, Laura; Loi, Gianfranco; Mones, Eleonora; Molina, Elisa; Bolchini, Cesare; Krengli, Marco

2014-01-01

The aim of this study was to analyze the application of the failure modes and effects analysis (FMEA) to intracranial stereotactic radiation surgery (SRS) by linear accelerator in order to identify the potential failure modes in the process tree and adopt appropriate safety measures to prevent adverse events (AEs) and near-misses, thus improving the process quality. A working group was set up to perform FMEA for intracranial SRS in the framework of a quality assurance program. FMEA was performed in 4 consecutive tasks: (1) creation of a visual map of the process; (2) identification of possible failure modes; (3) assignment of a risk probability number (RPN) to each failure mode based on tabulated scores of severity, frequency of occurrence and detectability; and (4) identification of preventive measures to minimize the risk of occurrence. The whole SRS procedure was subdivided into 73 single steps; 116 total possible failure modes were identified and a score of severity, occurrence, and detectability was assigned to each. Based on these scores, RPN was calculated for each failure mode thus obtaining values from 1 to 180. In our analysis, 112/116 (96.6%) RPN values were <60, 2 (1.7%) between 60 and 125 (63, 70), and 2 (1.7%) >125 (135, 180). The 2 highest RPN scores were assigned to the risk of using the wrong collimator's size and incorrect coordinates on the laser target localizer frame. Failure modes and effects analysis is a simple and practical proactive tool for systematic analysis of risks in radiation therapy. In our experience of SRS, FMEA led to the adoption of major changes in various steps of the SRS procedure.

Cycles till failure of silver-zinc cells with completing failures modes: Preliminary data analysis

NASA Technical Reports Server (NTRS)

Sidik, S. M.; Leibecki, H. F.; Bozek, J. M.

1980-01-01

One hundred and twenty nine cells were run through charge-discharge cycles until failure. The experiment design was a variant of a central composite factorial in five factors. Preliminary data analysis consisted of response surface estimation of life. Batteries fail under two basic modes; a low voltage condition and an internal shorting condition. A competing failure modes analysis using maximum likelihood estimation for the extreme value life distribution was performed. Extensive diagnostics such as residual plotting and probability plotting were employed to verify data quality and choice of model.

Failure Modes and Effects Analysis (FMEA): A Bibliography

NASA Technical Reports Server (NTRS)

2000-01-01

Failure modes and effects analysis (FMEA) is a bottom-up analytical process that identifies process hazards, which helps managers understand vulnerabilities of systems, as well as assess and mitigate risk. It is one of several engineering tools and techniques available to program and project managers aimed at increasing the likelihood of safe and successful NASA programs and missions. This bibliography references 465 documents in the NASA STI Database that contain the major concepts, failure modes or failure analysis, in either the basic index of the major subject terms.

The Application of Failure Modes and Effects Analysis Methodology to Intrathecal Drug Delivery for Pain Management

PubMed Central

Patel, Teresa; Fisher, Stanley P.

2016-01-01

Objective This study aimed to utilize failure modes and effects analysis (FMEA) to transform clinical insights into a risk mitigation plan for intrathecal (IT) drug delivery in pain management. Methods The FMEA methodology, which has been used for quality improvement, was adapted to assess risks (i.e., failure modes) associated with IT therapy. Ten experienced pain physicians scored 37 failure modes in the following categories: patient selection for therapy initiation (efficacy and safety concerns), patient safety during IT therapy, and product selection for IT therapy. Participants assigned severity, probability, and detection scores for each failure mode, from which a risk priority number (RPN) was calculated. Failure modes with the highest RPNs (i.e., most problematic) were discussed, and strategies were proposed to mitigate risks. Results Strategic discussions focused on 17 failure modes with the most severe outcomes, the highest probabilities of occurrence, and the most challenging detection. The topic of the highest‐ranked failure mode (RPN = 144) was manufactured monotherapy versus compounded combination products. Addressing failure modes associated with appropriate patient and product selection was predicted to be clinically important for the success of IT therapy. Conclusions The methodology of FMEA offers a systematic approach to prioritizing risks in a complex environment such as IT therapy. Unmet needs and information gaps are highlighted through the process. Risk mitigation and strategic planning to prevent and manage critical failure modes can contribute to therapeutic success. PMID:27477689

Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures.

PubMed

Ashley, Laura; Armitage, Gerry

2010-12-01

To empirically compare 2 different commonly used failure mode and effects analysis (FMEA) scoring procedures with respect to their resultant failure mode scores and prioritization: a mathematical procedure, where scores are assigned independently by FMEA team members and averaged, and a consensus procedure, where scores are agreed on by the FMEA team via discussion. A multidisciplinary team undertook a Healthcare FMEA of chemotherapy administration. This included mapping the chemotherapy process, identifying and scoring failure modes (potential errors) for each process step, and generating remedial strategies to counteract them. Failure modes were scored using both an independent mathematical procedure and a team consensus procedure. Almost three-fifths of the 30 failure modes generated were scored differently by the 2 procedures, and for just more than one-third of cases, the score discrepancy was substantial. Using the Healthcare FMEA prioritization cutoff score, almost twice as many failure modes were prioritized by the consensus procedure than by the mathematical procedure. This is the first study to empirically demonstrate that different FMEA scoring procedures can score and prioritize failure modes differently. It found considerable variability in individual team members' opinions on scores, which highlights the subjective and qualitative nature of failure mode scoring. A consensus scoring procedure may be most appropriate for FMEA as it allows variability in individuals' scores and rationales to become apparent and to be discussed and resolved by the team. It may also yield team learning and communication benefits unlikely to result from a mathematical procedure.

SU-F-T-246: Evaluation of Healthcare Failure Mode And Effect Analysis For Risk Assessment

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

Harry, T; University of California, San Diego, La Jolla, CA; Manger, R

Purpose: To evaluate the differences between the Veteran Affairs Healthcare Failure Modes and Effect Analysis (HFMEA) and the AAPM Task Group 100 Failure and Effect Analysis (FMEA) risk assessment techniques in the setting of a stereotactic radiosurgery (SRS) procedure were compared respectively. Understanding the differences in the techniques methodologies and outcomes will provide further insight into the applicability and utility of risk assessments exercises in radiation therapy. Methods: HFMEA risk assessment analysis was performed on a stereotactic radiosurgery procedure. A previous study from our institution completed a FMEA of our SRS procedure and the process map generated from this workmore » was used for the HFMEA. The process of performing the HFMEA scoring was analyzed, and the results from both analyses were compared. Results: The key differences between the two risk assessments are the scoring criteria for failure modes and identifying critical failure modes for potential hazards. The general consensus among the team performing the analyses was that scoring for the HFMEA was simpler and more intuitive then the FMEA. The FMEA identified 25 critical failure modes while the HFMEA identified 39. Seven of the FMEA critical failure modes were not identified by the HFMEA and 21 of the HFMEA critical failure modes were not identified by the FMEA. HFMEA as described by the Veteran Affairs provides guidelines on which failure modes to address first. Conclusion: HFMEA is a more efficient model for identifying gross risks in a process than FMEA. Clinics with minimal staff, time and resources can benefit from this type of risk assessment to eliminate or mitigate high risk hazards with nominal effort. FMEA can provide more in depth details but at the cost of elevated effort.« less

SU-E-T-421: Failure Mode and Effects Analysis (FMEA) of Xoft Electronic Brachytherapy for the Treatment of Superficial Skin Cancers

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

Hoisak, J; Manger, R; Dragojevic, I

Purpose: To perform a failure mode and effects analysis (FMEA) of the process for treating superficial skin cancers with the Xoft Axxent electronic brachytherapy (eBx) system, given the recent introduction of expanded quality control (QC) initiatives at our institution. Methods: A process map was developed listing all steps in superficial treatments with Xoft eBx, from the initial patient consult to the completion of the treatment course. The process map guided the FMEA to identify the failure modes for each step in the treatment workflow and assign Risk Priority Numbers (RPN), calculated as the product of the failure mode’s probability ofmore » occurrence (O), severity (S) and lack of detectability (D). FMEA was done with and without the inclusion of recent QC initiatives such as increased staffing, physics oversight, standardized source calibration, treatment planning and documentation. The failure modes with the highest RPNs were identified and contrasted before and after introduction of the QC initiatives. Results: Based on the FMEA, the failure modes with the highest RPN were related to source calibration, treatment planning, and patient setup/treatment delivery (Fig. 1). The introduction of additional physics oversight, standardized planning and safety initiatives such as checklists and time-outs reduced the RPNs of these failure modes. High-risk failure modes that could be mitigated with improved hardware and software interlocks were identified. Conclusion: The FMEA analysis identified the steps in the treatment process presenting the highest risk. The introduction of enhanced QC initiatives mitigated the risk of some of these failure modes by decreasing their probability of occurrence and increasing their detectability. This analysis demonstrates the importance of well-designed QC policies, procedures and oversight in a Xoft eBx programme for treatment of superficial skin cancers. Unresolved high risk failure modes highlight the need for non-procedural quality initiatives such as improved planning software and more robust hardware interlock systems.« less

Decomposition-Based Failure Mode Identification Method for Risk-Free Design of Large Systems

NASA Technical Reports Server (NTRS)

Tumer, Irem Y.; Stone, Robert B.; Roberts, Rory A.; Clancy, Daniel (Technical Monitor)

2002-01-01

When designing products, it is crucial to assure failure and risk-free operation in the intended operating environment. Failures are typically studied and eliminated as much as possible during the early stages of design. The few failures that go undetected result in unacceptable damage and losses in high-risk applications where public safety is of concern. Published NASA and NTSB accident reports point to a variety of components identified as sources of failures in the reported cases. In previous work, data from these reports were processed and placed in matrix form for all the system components and failure modes encountered, and then manipulated using matrix methods to determine similarities between the different components and failure modes. In this paper, these matrices are represented in the form of a linear combination of failures modes, mathematically formed using Principal Components Analysis (PCA) decomposition. The PCA decomposition results in a low-dimensionality representation of all failure modes and components of interest, represented in a transformed coordinate system. Such a representation opens the way for efficient pattern analysis and prediction of failure modes with highest potential risks on the final product, rather than making decisions based on the large space of component and failure mode data. The mathematics of the proposed method are explained first using a simple example problem. The method is then applied to component failure data gathered from helicopter, accident reports to demonstrate its potential.

A streamlined failure mode and effects analysis.

PubMed

Ford, Eric C; Smith, Koren; Terezakis, Stephanie; Croog, Victoria; Gollamudi, Smitha; Gage, Irene; Keck, Jordie; DeWeese, Theodore; Sibley, Greg

2014-06-01

Explore the feasibility and impact of a streamlined failure mode and effects analysis (FMEA) using a structured process that is designed to minimize staff effort. FMEA for the external beam process was conducted at an affiliate radiation oncology center that treats approximately 60 patients per day. A structured FMEA process was developed which included clearly defined roles and goals for each phase. A core group of seven people was identified and a facilitator was chosen to lead the effort. Failure modes were identified and scored according to the FMEA formalism. A risk priority number,RPN, was calculated and used to rank failure modes. Failure modes with RPN > 150 received safety improvement interventions. Staff effort was carefully tracked throughout the project. Fifty-two failure modes were identified, 22 collected during meetings, and 30 from take-home worksheets. The four top-ranked failure modes were: delay in film check, missing pacemaker protocol/consent, critical structures not contoured, and pregnant patient simulated without the team's knowledge of the pregnancy. These four failure modes had RPN > 150 and received safety interventions. The FMEA was completed in one month in four 1-h meetings. A total of 55 staff hours were required and, additionally, 20 h by the facilitator. Streamlined FMEA provides a means of accomplishing a relatively large-scale analysis with modest effort. One potential value of FMEA is that it potentially provides a means of measuring the impact of quality improvement efforts through a reduction in risk scores. Future study of this possibility is needed.

Independent Orbiter Assessment (IOA): Analysis of the auxiliary power unit

NASA Technical Reports Server (NTRS)

Barnes, J. E.

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. This report documents the independent analysis results corresponding to the Orbiter Auxiliary Power Unit (APU). The APUs are required to provide power to the Orbiter hydraulics systems during ascent and entry flight phases for aerosurface actuation, main engine gimballing, landing gear extension, and other vital functions. For analysis purposes, the APU system was broken down into ten functional subsystems. 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. A preponderance of 1/1 criticality items were related to failures that allowed the hydrazine fuel to escape into the Orbiter aft compartment, creating a severe fire hazard, and failures that caused loss of the gas generator injector cooling system.

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

Mossahebi, S; Feigenberg, S; Nichols, E

Purpose: GammaPod™, the first stereotactic radiotherapy device for early stage breast cancer treatment, has been recently installed and commissioned at our institution. A multidisciplinary working group applied the failure mode and effects analysis (FMEA) approach to perform a risk analysis. Methods: FMEA was applied to the GammaPod™ treatment process by: 1) generating process maps for each stage of treatment; 2) identifying potential failure modes and outlining their causes and effects; 3) scoring the potential failure modes using the risk priority number (RPN) system based on the product of severity, frequency of occurrence, and detectability (ranging 1–10). An RPN of highermore » than 150 was set as the threshold for minimal concern of risk. For these high-risk failure modes, potential quality assurance procedures and risk control techniques have been proposed. A new set of severity, occurrence, and detectability values were re-assessed in presence of the suggested mitigation strategies. Results: In the single-day image-and-treat workflow, 19, 22, and 27 sub-processes were identified for the stages of simulation, treatment planning, and delivery processes, respectively. During the simulation stage, 38 potential failure modes were found and scored, in terms of RPN, in the range of 9-392. 34 potential failure modes were analyzed in treatment planning with a score range of 16-200. For the treatment delivery stage, 47 potential failure modes were found with an RPN score range of 16-392. The most critical failure modes consisted of breast-cup pressure loss and incorrect target localization due to patient upper-body alignment inaccuracies. The final RPN score of these failure modes based on recommended actions were assessed to be below 150. Conclusion: FMEA risk analysis technique was applied to the treatment process of GammaPod™, a new stereotactic radiotherapy technology. Application of systematic risk analysis methods is projected to lead to improved quality of GammaPod™ treatments. Ying Niu and Cedric Yu are affiliated with Xcision Medical Systems.« less

Operations analysis (study 2.1). Contingency analysis. [of failure modes anticipated during space shuttle upper stage planning

NASA Technical Reports Server (NTRS)

1974-01-01

Future operational concepts for the space transportation system were studied in terms of space shuttle upper stage failure contingencies possible during deployment, retrieval, or space servicing of automated satellite programs. Problems anticipated during mission planning were isolated using a modified 'fault tree' technique, normally used in safety analyses. A comprehensive space servicing hazard analysis is presented which classifies possible failure modes under the catagories of catastrophic collision, failure to rendezvous and dock, servicing failure, and failure to undock. The failure contingencies defined are to be taken into account during design of the upper stage.

Independent Orbiter Assessment (IOA): Analysis of the active thermal control subsystem

NASA Technical Reports Server (NTRS)

Sinclair, S. K.; Parkman, W. E.

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 corresponding to the Orbiter Active Thermal Control Subsystem (ATCS) are documented. The major purpose of the ATCS is to remove the heat, generated during normal Shuttle operations from the Orbiter systems and subsystems. The four major components of the ATCS contributing to the heat removal are: Freon Coolant Loops; Radiator and Flow Control Assembly; Flash Evaporator System; and Ammonia Boiler System. In order to perform the analysis, the IOA process utilized available ATCS 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 310 failure modes analyzed, 101 were determined to be PCIs.

Independent Orbiter Assessment (IOA): Analysis of the hydraulics/water spray boiler subsystem

NASA Technical Reports Server (NTRS)

Duval, J. D.; Davidson, W. R.; Parkman, William E.

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 (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results for the Orbiter Hydraulics/Water Spray Boiler Subsystem. The hydraulic system provides hydraulic power to gimbal the main engines, actuate the main engine propellant control valves, move the aerodynamic flight control surfaces, lower the landing gear, apply wheel brakes, steer the nosewheel, and dampen the external tank (ET) separation. Each hydraulic system has an associated water spray boiler which is used to cool the hydraulic fluid and APU lubricating oil. The IOA analysis process utilized available HYD/WSB hardware drawings, schematics and documents 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 430 failure modes analyzed, 166 were determined to be PCIs.

Independent Orbiter Assessment (IOA): Analysis of the remote manipulator system

NASA Technical Reports Server (NTRS)

Tangorra, F.; Grasmeder, R. F.; Montgomery, A. D.

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 items (PCIs). 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 Orbiter Remote Manipulator System (RMS) are documented. The RMS hardware and software are primarily required for deploying and/or retrieving up to five payloads during a single mission, capture and retrieve free-flying payloads, and for performing Manipulator Foot Restraint operations. Specifically, the RMS hardware consists of the following components: end effector; displays and controls; manipulator controller interface unit; arm based electronics; and the arm. The IOA analysis process utilized available RMS hardware drawings, schematics and documents 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 574 failure modes analyzed, 413 were determined to be PCIs.

Global resilience analysis of water distribution systems.

PubMed

Diao, Kegong; Sweetapple, Chris; Farmani, Raziyeh; Fu, Guangtao; Ward, Sarah; Butler, David

2016-12-01

Evaluating and enhancing resilience in water infrastructure is a crucial step towards more sustainable urban water management. As a prerequisite to enhancing resilience, a detailed understanding is required of the inherent resilience of the underlying system. Differing from traditional risk analysis, here we propose a global resilience analysis (GRA) approach that shifts the objective from analysing multiple and unknown threats to analysing the more identifiable and measurable system responses to extreme conditions, i.e. potential failure modes. GRA aims to evaluate a system's resilience to a possible failure mode regardless of the causal threat(s) (known or unknown, external or internal). The method is applied to test the resilience of four water distribution systems (WDSs) with various features to three typical failure modes (pipe failure, excess demand, and substance intrusion). The study reveals GRA provides an overview of a water system's resilience to various failure modes. For each failure mode, it identifies the range of corresponding failure impacts and reveals extreme scenarios (e.g. the complete loss of water supply with only 5% pipe failure, or still meeting 80% of demand despite over 70% of pipes failing). GRA also reveals that increased resilience to one failure mode may decrease resilience to another and increasing system capacity may delay the system's recovery in some situations. It is also shown that selecting an appropriate level of detail for hydraulic models is of great importance in resilience analysis. The method can be used as a comprehensive diagnostic framework to evaluate a range of interventions for improving system resilience in future studies. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Failure Modes and Effects Analysis (FMEA) Assistant Tool Feasibility Study

NASA Technical Reports Server (NTRS)

Flores, Melissa; Malin, Jane T.

2013-01-01

An effort to determine the feasibility of a software tool to assist in Failure Modes and Effects Analysis (FMEA) has been completed. This new and unique approach to FMEA uses model based systems engineering concepts to recommend failure modes, causes, and effects to the user after they have made several selections from pick lists about a component s functions and inputs/outputs. Recommendations are made based on a library using common failure modes identified over the course of several major human spaceflight programs. However, the tool could be adapted for use in a wide range of applications from NASA to the energy industry.

Failure Modes and Effects Analysis (FMEA) Assistant Tool Feasibility Study

NASA Astrophysics Data System (ADS)

Flores, Melissa D.; Malin, Jane T.; Fleming, Land D.

2013-09-01

An effort to determine the feasibility of a software tool to assist in Failure Modes and Effects Analysis (FMEA) has been completed. This new and unique approach to FMEA uses model based systems engineering concepts to recommend failure modes, causes, and effects to the user after they have made several selections from pick lists about a component's functions and inputs/outputs. Recommendations are made based on a library using common failure modes identified over the course of several major human spaceflight programs. However, the tool could be adapted for use in a wide range of applications from NASA to the energy industry.

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.

Product Support Manager Guidebook

DTIC Science & Technology

2011-04-01

package is being developed using supportability analysis concepts such as Failure Mode, Effects and Criticality Analysis (FMECA), Fault Tree Analysis ( FTA ...Analysis (LORA) Condition Based Maintenance + (CBM+) Fault Tree Analysis ( FTA ) Failure Mode, Effects, and Criticality Analysis (FMECA) Maintenance Task...Reporting and Corrective Action System (FRACAS), Fault Tree Analysis ( FTA ), Level of Repair Analysis (LORA), Maintenance Task Analysis (MTA

A streamlined failure mode and effects analysis

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

Ford, Eric C., E-mail: eford@uw.edu; Smith, Koren; Terezakis, Stephanie

Purpose: Explore the feasibility and impact of a streamlined failure mode and effects analysis (FMEA) using a structured process that is designed to minimize staff effort. Methods: FMEA for the external beam process was conducted at an affiliate radiation oncology center that treats approximately 60 patients per day. A structured FMEA process was developed which included clearly defined roles and goals for each phase. A core group of seven people was identified and a facilitator was chosen to lead the effort. Failure modes were identified and scored according to the FMEA formalism. A risk priority number,RPN, was calculated and usedmore » to rank failure modes. Failure modes with RPN > 150 received safety improvement interventions. Staff effort was carefully tracked throughout the project. Results: Fifty-two failure modes were identified, 22 collected during meetings, and 30 from take-home worksheets. The four top-ranked failure modes were: delay in film check, missing pacemaker protocol/consent, critical structures not contoured, and pregnant patient simulated without the team's knowledge of the pregnancy. These four failure modes hadRPN > 150 and received safety interventions. The FMEA was completed in one month in four 1-h meetings. A total of 55 staff hours were required and, additionally, 20 h by the facilitator. Conclusions: Streamlined FMEA provides a means of accomplishing a relatively large-scale analysis with modest effort. One potential value of FMEA is that it potentially provides a means of measuring the impact of quality improvement efforts through a reduction in risk scores. Future study of this possibility is needed.« less

SU-E-T-627: Failure Modes and Effect Analysis for Monthly Quality Assurance of Linear Accelerator

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

Xie, J; Xiao, Y; Wang, J

2014-06-15

Purpose: To develop and implement a failure mode and effect analysis (FMEA) on routine monthly Quality Assurance (QA) tests (physical tests part) of linear accelerator. Methods: A systematic failure mode and effect analysis method was performed for monthly QA procedures. A detailed process tree of monthly QA was created and potential failure modes were defined. Each failure mode may have many influencing factors. For each factor, a risk probability number (RPN) was calculated from the product of probability of occurrence (O), the severity of effect (S), and detectability of the failure (D). The RPN scores are in a range ofmore » 1 to 1000, with higher scores indicating stronger correlation to a given influencing factor of a failure mode. Five medical physicists in our institution were responsible to discuss and to define the O, S, D values. Results: 15 possible failure modes were identified and all RPN scores of all influencing factors of these 15 failue modes were from 8 to 150, and the checklist of FMEA in monthly QA was drawn. The system showed consistent and accurate response to erroneous conditions. Conclusion: The influencing factors of RPN greater than 50 were considered as highly-correlated factors of a certain out-oftolerance monthly QA test. FMEA is a fast and flexible tool to develop an implement a quality management (QM) frame work of monthly QA, which improved the QA efficiency of our QA team. The FMEA work may incorporate more quantification and monitoring fuctions in future.« less

Comprehensive Deployment Method for Technical Characteristics Base on Multi-failure Modes Correlation Analysis

NASA Astrophysics Data System (ADS)

Zheng, W.; Gao, J. M.; Wang, R. X.; Chen, K.; Jiang, Y.

2017-12-01

This paper put forward a new method of technical characteristics deployment based on Reliability Function Deployment (RFD) by analysing the advantages and shortages of related research works on mechanical reliability design. The matrix decomposition structure of RFD was used to describe the correlative relation between failure mechanisms, soft failures and hard failures. By considering the correlation of multiple failure modes, the reliability loss of one failure mode to the whole part was defined, and a calculation and analysis model for reliability loss was presented. According to the reliability loss, the reliability index value of the whole part was allocated to each failure mode. On the basis of the deployment of reliability index value, the inverse reliability method was employed to acquire the values of technology characteristics. The feasibility and validity of proposed method were illustrated by a development case of machining centre’s transmission system.

Independent Orbiter Assessment (IOA): Analysis of the life support and airlock support subsystems

NASA Technical Reports Server (NTRS)

Arbet, Jim; Duffy, R.; Barickman, K.; Saiidi, Mo J.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Life Support System (LSS) and Airlock Support System (ALSS). 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. The LSS provides for the management of the supply water, collection of metabolic waste, management of waste water, smoke detection, and fire suppression. The ALSS provides water, oxygen, and electricity to support an extravehicular activity in the airlock.

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

Independent Orbiter Assessment (IOA): Analysis of the guidance, navigation, and control subsystem

NASA Technical Reports Server (NTRS)

Trahan, W. H.; Odonnell, R. A.; Pietz, K. C.; Hiott, J. M.

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) is 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 corresponding to the Orbiter Guidance, Navigation, and Control (GNC) Subsystem hardware are documented. The function of the GNC hardware is to respond to guidance, navigation, and control software commands to effect vehicle control and to provide sensor and controller data to GNC software. Some of the GNC hardware for which failure modes analysis was performed includes: hand controllers; Rudder Pedal Transducer Assembly (RPTA); Speed Brake Thrust Controller (SBTC); Inertial Measurement Unit (IMU); Star Tracker (ST); Crew Optical Alignment Site (COAS); Air Data Transducer Assembly (ADTA); Rate Gyro Assemblies; Accelerometer Assembly (AA); Aerosurface Servo Amplifier (ASA); and Ascent Thrust Vector Control (ATVC). The IOA analysis process utilized available GNC hardware drawings, workbooks, specifications, schematics, and systems briefs for defining hardware assemblies, components, and circuits. Each hardware item was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.

Procedure for Failure Mode, Effects, and Criticality Analysis (FMECA)

NASA Technical Reports Server (NTRS)

1966-01-01

This document provides guidelines for the accomplishment of Failure Mode, Effects, and Criticality Analysis (FMECA) on the Apollo program. It is a procedure for analysis of hardware items to determine those items contributing most to system unreliability and crew safety problems.

Independent Orbiter Assessment (IOA): Analysis of the electrical power distribution and control subsystem, volume 1

NASA Technical Reports Server (NTRS)

Schmeckpeper, K. R.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Distribution and Control (EPD and C) hardware. The EPD and C hardware performs the functions of distributing, sensing, and controlling 28 volt DC power and of inverting, distributing, sensing, and controlling 117 volt 400 Hz AC power to all Orbiter subsystems from the three fuel cells in the Electrical Power Generation (EPG) subsystem. 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 1671 failure modes analyzed, 9 single failures were determined to result in loss of crew or vehicle. Three single failures unique to intact abort were determined to result in possible loss of the crew or vehicle. A possible loss of mission could result if any of 136 single failures occurred. Six of the criticality 1/1 failures are in two rotary and two pushbutton switches that control External Tank and Solid Rocket Booster separation. The other 6 criticality 1/1 failures are fuses, one each per Aft Power Control Assembly (APCA) 4, 5, and 6 and one each per Forward Power Control Assembly (FPCA) 1, 2, and 3, that supply power to certain Main Propulsion System (MPS) valves and Forward Reaction Control System (RCS) circuits.

[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.

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.

TU-FG-201-12: Designing a Risk-Based Quality Assurance Program for a Newly Implemented Y-90 Microspheres Procedure

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

Vile, D; Zhang, L; Cuttino, L

2016-06-15

Purpose: To create a quality assurance program based upon a risk-based assessment of a newly implemented SirSpheres Y-90 procedure. Methods: A process map was created for a newly implemented SirSpheres procedure at a community hospital. The process map documented each step of this collaborative procedure, as well as the roles and responsibilities of each member. From the process map, different potential failure modes were determined as well as any current controls in place. From this list, a full failure mode and effects analysis (FMEA) was performed by grading each failure mode’s likelihood of occurrence, likelihood of detection, and potential severity.more » These numbers were then multiplied to compute the risk priority number (RPN) for each potential failure mode. Failure modes were then ranked based on their RPN. Additional controls were then added, with failure modes corresponding to the highest RPNs taking priority. Results: A process map was created that succinctly outlined each step in the SirSpheres procedure in its current implementation. From this, 72 potential failure modes were identified and ranked according to their associated RPN. Quality assurance controls and safety barriers were then added for failure modes associated with the highest risk being addressed first. Conclusion: A quality assurance program was created from a risk-based assessment of the SirSpheres process. Process mapping and FMEA were effective in identifying potential high-risk failure modes for this new procedure, which were prioritized for new quality assurance controls. TG 100 recommends the fault tree analysis methodology to design a comprehensive and effective QC/QM program, yet we found that by simply introducing additional safety barriers to address high RPN failure modes makes the whole process simpler and safer.« less

EVALUATION OF SAFETY IN A RADIATION ONCOLOGY SETTING USING FAILURE MODE AND EFFECTS ANALYSIS

PubMed Central

Ford, Eric C.; Gaudette, Ray; Myers, Lee; Vanderver, Bruce; Engineer, Lilly; Zellars, Richard; Song, Danny Y.; Wong, John; DeWeese, Theodore L.

2013-01-01

Purpose Failure mode and effects analysis (FMEA) is a widely used tool for prospectively evaluating safety and reliability. We report our experiences in applying FMEA in the setting of radiation oncology. Methods and Materials We performed an FMEA analysis for our external beam radiation therapy service, which consisted of the following tasks: (1) create a visual map of the process, (2) identify possible failure modes; assign risk probability numbers (RPN) to each failure mode based on tabulated scores for the severity, frequency of occurrence, and detectability, each on a scale of 1 to 10; and (3) identify improvements that are both feasible and effective. The RPN scores can span a range of 1 to 1000, with higher scores indicating the relative importance of a given failure mode. Results Our process map consisted of 269 different nodes. We identified 127 possible failure modes with RPN scores ranging from 2 to 160. Fifteen of the top-ranked failure modes were considered for process improvements, representing RPN scores of 75 and more. These specific improvement suggestions were incorporated into our practice with a review and implementation by each department team responsible for the process. Conclusions The FMEA technique provides a systematic method for finding vulnerabilities in a process before they result in an error. The FMEA framework can naturally incorporate further quantification and monitoring. A general-use system for incident and near miss reporting would be useful in this regard. PMID:19409731

Failure mode and effects analysis drastically reduced potential risks in clinical trial conduct.

PubMed

Lee, Howard; Lee, Heechan; Baik, Jungmi; Kim, Hyunjung; Kim, Rachel

2017-01-01

Failure mode and effects analysis (FMEA) is a risk management tool to proactively identify and assess the causes and effects of potential failures in a system, thereby preventing them from happening. The objective of this study was to evaluate effectiveness of FMEA applied to an academic clinical trial center in a tertiary care setting. A multidisciplinary FMEA focus group at the Seoul National University Hospital Clinical Trials Center selected 6 core clinical trial processes, for which potential failure modes were identified and their risk priority number (RPN) was assessed. Remedial action plans for high-risk failure modes (RPN >160) were devised and a follow-up RPN scoring was conducted a year later. A total of 114 failure modes were identified with an RPN score ranging 3-378, which was mainly driven by the severity score. Fourteen failure modes were of high risk, 11 of which were addressed by remedial actions. Rescoring showed a dramatic improvement attributed to reduction in the occurrence and detection scores by >3 and >2 points, respectively. FMEA is a powerful tool to improve quality in clinical trials. The Seoul National University Hospital Clinical Trials Center is expanding its FMEA capability to other core clinical trial processes.

Independent Orbiter Assessment (IOA): Analysis of the atmospheric revitalization pressure control subsystem

NASA Technical Reports Server (NTRS)

Saiidi, M. J.; Duffy, R. E.; Mclaughlin, T. D.

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis/Critical Items List (FMEA/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 corresponding to the Orbiter Atmospheric Revitalization and Pressure Control Subsystem (ARPCS) are documented. The ARPCS hardware was categorized into the following subdivisions: (1) Atmospheric Make-up and Control (including the Auxiliary Oxygen Assembly, Oxygen Assembly, and Nitrogen Assembly); and (2) Atmospheric Vent and Control (including the Positive Relief Vent Assembly, Negative Relief Vent Assembly, and Cabin Vent Assembly). The IOA analysis process utilized available ARPCS 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.

Independent Orbiter Assessment (IOA): Analysis of the mechanical actuation subsystem

NASA Technical Reports Server (NTRS)

Bacher, J. L.; Montgomery, A. D.; Bradway, M. W.; Slaughter, W. T.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Mechanical Actuation System (MAS) hardware. Specifically, the MAS hardware consists of the following components: Air Data Probe (ADP); Elevon Seal Panel (ESP); External Tank Umbilical (ETU); Ku-Band Deploy (KBD); Payload Bay Doors (PBD); Payload Bay Radiators (PBR); Personnel Hatches (PH); Vent Door Mechanism (VDM); and Startracker Door Mechanism (SDM). The IOA analysis process utilized available MAS 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.

Independent Orbiter Assessment (IOA): Analysis of the displays and controls subsystem

NASA Technical Reports Server (NTRS)

Trahan, W. H.; Prust, E. E.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Displays and Controls (D and C) subsystem hardware. The function of the D and C hardware is to provide the crew with the monitor, command, and control capabilities required for management of all normal and contingency mission and flight operations. The D and C hardware for which failure modes analysis was performed consists of the following: Acceleration Indicator (G-METER); Head Up Display (HUD); Display Driver Unit (DDU); Alpha/Mach Indicator (AMI); Horizontal Situation Indicator (HSI); Attitude Director Indicator (ADI); Propellant Quantity Indicator (PQI); Surface Position Indicator (SPI); Altitude/Vertical Velocity Indicator (AVVI); Caution and Warning Assembly (CWA); Annunciator Control Assembly (ACA); Event Timer (ET); Mission Timer (MT); Interior Lighting; and Exterior Lighting. Each hardware item was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.

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.

Availability Estimate of a Conceptual ESM System.

DTIC Science & Technology

1979-06-01

affect mission operation.t A functional block level failure modes and effects analysis ( FMEA ) performed on the filter resulted in an assessed failure rate...is based on an FMEA of failures that disable the function (see Appendix A). A further 29 examination of the filter piece-parts reveals that the driver...Digital-to-analog converter DC Direct current DF Direction finding ESM Electronic Support Measures FMEA Failure modes and effects analysis FMPO

Simulation Assisted Risk Assessment: Blast Overpressure Modeling

NASA Technical Reports Server (NTRS)

Lawrence, Scott L.; Gee, Ken; Mathias, Donovan; Olsen, Michael

2006-01-01

A probabilistic risk assessment (PRA) approach has been developed and applied to the risk analysis of capsule abort during ascent. The PRA is used to assist in the identification of modeling and simulation applications that can significantly impact the understanding of crew risk during this potentially dangerous maneuver. The PRA approach is also being used to identify the appropriate level of fidelity for the modeling of those critical failure modes. The Apollo launch escape system (LES) was chosen as a test problem for application of this approach. Failure modes that have been modeled and/or simulated to date include explosive overpressure-based failure, explosive fragment-based failure, land landing failures (range limits exceeded either near launch or Mode III trajectories ending on the African continent), capsule-booster re-contact during separation, and failure due to plume-induced instability. These failure modes have been investigated using analysis tools in a variety of technical disciplines at various levels of fidelity. The current paper focuses on the development and application of a blast overpressure model for the prediction of structural failure due to overpressure, including the application of high-fidelity analysis to predict near-field and headwinds effects.

Practical Implementation of Failure Mode and Effects Analysis for Safety and Efficiency in Stereotactic Radiosurgery

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

Younge, Kelly Cooper, E-mail: kyounge@med.umich.edu; Wang, Yizhen; Thompson, John

2015-04-01

Purpose: To improve the safety and efficiency of a new stereotactic radiosurgery program with the application of failure mode and effects analysis (FMEA) performed by a multidisciplinary team of health care professionals. Methods and Materials: Representatives included physicists, therapists, dosimetrists, oncologists, and administrators. A detailed process tree was created from an initial high-level process tree to facilitate the identification of possible failure modes. Group members were asked to determine failure modes that they considered to be the highest risk before scoring failure modes. Risk priority numbers (RPNs) were determined by each group member individually and then averaged. Results: A totalmore » of 99 failure modes were identified. The 5 failure modes with an RPN above 150 were further analyzed to attempt to reduce these RPNs. Only 1 of the initial items that the group presumed to be high-risk (magnetic resonance imaging laterality reversed) was ranked in these top 5 items. New process controls were put in place to reduce the severity, occurrence, and detectability scores for all of the top 5 failure modes. Conclusions: FMEA is a valuable team activity that can assist in the creation or restructuring of a quality assurance program with the aim of improved safety, quality, and efficiency. Performing the FMEA helped group members to see how they fit into the bigger picture of the program, and it served to reduce biases and preconceived notions about which elements of the program were the riskiest.« less

Failure modes and effects criticality analysis and accelerated life testing of LEDs for medical applications

NASA Astrophysics Data System (ADS)

Sawant, M.; Christou, A.

2012-12-01

While use of LEDs in Fiber Optics and lighting applications is common, their use in medical diagnostic applications is not very extensive. Since the precise value of light intensity will be used to interpret patient results, understanding failure modes [1-4] is very important. We used the Failure Modes and Effects Criticality Analysis (FMECA) tool to identify the critical failure modes of the LEDs. FMECA involves identification of various failure modes, their effects on the system (LED optical output in this context), their frequency of occurrence, severity and the criticality of the failure modes. The competing failure modes/mechanisms were degradation of: active layer (where electron-hole recombination occurs to emit light), electrodes (provides electrical contact to the semiconductor chip), Indium Tin Oxide (ITO) surface layer (used to improve current spreading and light extraction), plastic encapsulation (protective polymer layer) and packaging failures (bond wires, heat sink separation). A FMECA table is constructed and the criticality is calculated by estimating the failure effect probability (β), failure mode ratio (α), failure rate (λ) and the operating time. Once the critical failure modes were identified, the next steps were generation of prior time to failure distribution and comparing with our accelerated life test data. To generate the prior distributions, data and results from previous investigations were utilized [5-33] where reliability test results of similar LEDs were reported. From the graphs or tabular data, we extracted the time required for the optical power output to reach 80% of its initial value. This is our failure criterion for the medical diagnostic application. Analysis of published data for different LED materials (AlGaInP, GaN, AlGaAs), the Semiconductor Structures (DH, MQW) and the mode of testing (DC, Pulsed) was carried out. The data was categorized according to the materials system and LED structure such as AlGaInP-DH-DC, AlGaInP-MQW-DC, GaN-DH-DC, and GaN-DH-DC. Although the reported testing was carried out at different temperature and current, the reported data was converted to the present application conditions of the medical environment. Comparisons between the model data and accelerated test results carried out in the present are reported. The use of accelerating agent modeling and regression analysis was also carried out. We have used the Inverse Power Law model with the current density J as the accelerating agent and the Arrhenius model with temperature as the accelerating agent. Finally, our reported methodology is presented as an approach for analyzing LED suitability for the target medical diagnostic applications.

Space Shuttle Stiffener Ring Foam Failure Analysis, a Non-Conventional Approach

NASA Technical Reports Server (NTRS)

Howard, Philip M.

2015-01-01

The Space Shuttle Program made use of the excellent properties of rigid polyurethane foam for cryogenic tank insulation and as structural protection on the solid rocket boosters. When foam applications de-bond, classical methods of failure analysis did not provide root cause of the failure of the foam. Realizing that foam is the ideal media to document and preserve its own mode of failure, thin sectioning was seen as a logical approach for foam failure analysis to observe the three dimensional morphology of the foam cells. The cell foam morphology provided a much greater understanding of the failure modes than previously achieved.

Microcircuit failure analysis using the SEM. [Scanning Electron Microscopes

NASA Technical Reports Server (NTRS)

Nicolas, D. P.

1974-01-01

The scanning electron microscope adds a new dimension to the knowledge that can be obtained from a failed microcircuit. When used with conventional techniques, SEM assists and clarifies the analysis, but it does not replace light microscopy. The most advantageous features for microcircuit analysis are long working distances and great depth of field. Manufacturer related failure modes of microcircuits are metallization defects, poor bonding, surface and particle contamination, and design and fabrication faults. User related failure modes are caused by abuse, such as overstress. The Physics of Failure Procedure followed by the Astrionics Laboratory in failure analysis is described, which is designed to obtain maximum information available from each step.

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

NASA Technical Reports Server (NTRS)

Wilson, R. E.; Riccio, J. R.

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. This report documents the independent analysis results for the Orbiter Elevon system hardware. The elevon actuators are located at the trailing edge of the wing surface. The proper function of the elevons is essential during the dynamic flight phases of ascent and entry. In the ascent phase of flight, the elevons are used for relieving high wing loads. For entry, the elevons are used to pitch and roll the vehicle. Specifically, the elevon system hardware comprises the following components: flow cutoff valve; switching valve; electro-hydraulic (EH) servoactuator; secondary delta pressure transducer; bypass valve; power valve; power valve check valve; primary actuator; primary delta pressure transducer; and primary actuator position transducer. 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 25 failure modes analyzed, 18 were determined to be PCIs.

Independent Orbiter Assessment (IOA): Assessment of the life support and airlock support systems, volume 1

NASA Technical Reports Server (NTRS)

Arbet, J. D.; Duffy, R. E.; Barickman, K.; Saiidi, M. J.

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 Life Support and Airlock Support Systems (LSS and ALSS) 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. The discrepancies were flagged for potential future resolution. This report documents the results of that comparison for the Orbiter LSS and ALSS hardware. The IOA product for the LSS and ALSS analysis consisted of 511 failure mode worksheets that resulted in 140 potential critical items. Comparison was made to the NASA baseline which consisted of 456 FMEAs and 101 CIL items. The IOA analysis identified 39 failure modes, 6 of which were classified as CIL items, for components not covered by the NASA FMEAs. It was recommended that these failure modes be added to the NASA FMEA baseline. The overall assessment produced agreement on all but 301 FMEAs which caused differences in 111 CIL items.

Failure mode and effects analysis based risk profile assessment for stereotactic radiosurgery programs at three cancer centers in Brazil.

PubMed

Teixeira, Flavia C; de Almeida, Carlos E; Saiful Huq, M

2016-01-01

The goal of this study was to evaluate the safety and quality management program for stereotactic radiosurgery (SRS) treatment processes at three radiotherapy centers in Brazil by using three industrial engineering tools (1) process mapping, (2) failure modes and effects analysis (FMEA), and (3) fault tree analysis. The recommendations of Task Group 100 of American Association of Physicists in Medicine were followed to apply the three tools described above to create a process tree for SRS procedure for each radiotherapy center and then FMEA was performed. Failure modes were identified for all process steps and values of risk priority number (RPN) were calculated from O, S, and D (RPN = O × S × D) values assigned by a professional team responsible for patient care. The subprocess treatment planning was presented with the highest number of failure modes for all centers. The total number of failure modes were 135, 104, and 131 for centers I, II, and III, respectively. The highest RPN value for each center is as follows: center I (204), center II (372), and center III (370). Failure modes with RPN ≥ 100: center I (22), center II (115), and center III (110). Failure modes characterized by S ≥ 7, represented 68% of the failure modes for center III, 62% for center II, and 45% for center I. Failure modes with RPNs values ≥100 and S ≥ 7, D ≥ 5, and O ≥ 5 were considered as high priority in this study. The results of the present study show that the safety risk profiles for the same stereotactic radiotherapy process are different at three radiotherapy centers in Brazil. Although this is the same treatment process, this present study showed that the risk priority is different and it will lead to implementation of different safety interventions among the centers. Therefore, the current practice of applying universal device-centric QA is not adequate to address all possible failures in clinical processes at different radiotherapy centers. Integrated approaches to device-centric and process specific quality management program specific to each radiotherapy center are the key to a safe quality management program.

Failure mode and effect analysis-based quality assurance for dynamic MLC tracking systems

PubMed Central

Sawant, Amit; Dieterich, Sonja; Svatos, Michelle; Keall, Paul

2010-01-01

Purpose: To develop and implement a failure mode and effect analysis (FMEA)-based commissioning and quality assurance framework for dynamic multileaf collimator (DMLC) tumor tracking systems. Methods: A systematic failure mode and effect analysis was performed for a prototype real-time tumor tracking system that uses implanted electromagnetic transponders for tumor position monitoring and a DMLC for real-time beam adaptation. A detailed process tree of DMLC tracking delivery was created and potential tracking-specific failure modes were identified. For each failure mode, a risk probability number (RPN) was calculated from the product of the probability of occurrence, the severity of effect, and the detectibility of the failure. Based on the insights obtained from the FMEA, commissioning and QA procedures were developed to check (i) the accuracy of coordinate system transformation, (ii) system latency, (iii) spatial and dosimetric delivery accuracy, (iv) delivery efficiency, and (v) accuracy and consistency of system response to error conditions. The frequency of testing for each failure mode was determined from the RPN value. Results: Failures modes with RPN≥125 were recommended to be tested monthly. Failure modes with RPN<125 were assigned to be tested during comprehensive evaluations, e.g., during commissioning, annual quality assurance, and after major software∕hardware upgrades. System latency was determined to be ∼193 ms. The system showed consistent and accurate response to erroneous conditions. Tracking accuracy was within 3%–3 mm gamma (100% pass rate) for sinusoidal as well as a wide variety of patient-derived respiratory motions. The total time taken for monthly QA was ∼35 min, while that taken for comprehensive testing was ∼3.5 h. Conclusions: FMEA proved to be a powerful and flexible tool to develop and implement a quality management (QM) framework for DMLC tracking. The authors conclude that the use of FMEA-based QM ensures efficient allocation of clinical resources because the most critical failure modes receive the most attention. It is expected that the set of guidelines proposed here will serve as a living document that is updated with the accumulation of progressively more intrainstitutional and interinstitutional experience with DMLC tracking. PMID:21302802

WE-G-BRA-08: Failure Modes and Effects Analysis (FMEA) for Gamma Knife Radiosurgery

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

Xu, Y; Bhatnagar, J; Bednarz, G

2015-06-15

Purpose: To perform a failure modes and effects analysis (FMEA) study for Gamma Knife (GK) radiosurgery processes at our institution based on our experience with the treatment of more than 13,000 patients. Methods: A team consisting of medical physicists, nurses, radiation oncologists, neurosurgeons at the University of Pittsburgh Medical Center and an external physicist expert was formed for the FMEA study. A process tree and a failure mode table were created for the GK procedures using the Leksell GK Perfexion and 4C units. Three scores for the probability of occurrence (O), the severity (S), and the probability of no detectionmore » (D) for failure modes were assigned to each failure mode by each professional on a scale from 1 to 10. The risk priority number (RPN) for each failure mode was then calculated (RPN = OxSxD) as the average scores from all data sets collected. Results: The established process tree for GK radiosurgery consists of 10 sub-processes and 53 steps, including a sub-process for frame placement and 11 steps that are directly related to the frame-based nature of the GK radiosurgery. Out of the 86 failure modes identified, 40 failure modes are GK specific, caused by the potential for inappropriate use of the radiosurgery head frame, the imaging fiducial boxes, the GK helmets and plugs, and the GammaPlan treatment planning system. The other 46 failure modes are associated with the registration, imaging, image transfer, contouring processes that are common for all radiation therapy techniques. The failure modes with the highest hazard scores are related to imperfect frame adaptor attachment, bad fiducial box assembly, overlooked target areas, inaccurate previous treatment information and excessive patient movement during MRI scan. Conclusion: The implementation of the FMEA approach for Gamma Knife radiosurgery enabled deeper understanding of the overall process among all professionals involved in the care of the patient and helped identify potential weaknesses in the overall process.« less

Verification and Validation Process for Progressive Damage and Failure Analysis Methods in the NASA Advanced Composites Consortium

NASA Technical Reports Server (NTRS)

Wanthal, Steven; Schaefer, Joseph; Justusson, Brian; Hyder, Imran; Engelstad, Stephen; Rose, Cheryl

2017-01-01

The Advanced Composites Consortium is a US Government/Industry partnership supporting technologies to enable timeline and cost reduction in the development of certified composite aerospace structures. A key component of the consortium's approach is the development and validation of improved progressive damage and failure analysis methods for composite structures. These methods will enable increased use of simulations in design trade studies and detailed design development, and thereby enable more targeted physical test programs to validate designs. To accomplish this goal with confidence, a rigorous verification and validation process was developed. The process was used to evaluate analysis methods and associated implementation requirements to ensure calculation accuracy and to gage predictability for composite failure modes of interest. This paper introduces the verification and validation process developed by the consortium during the Phase I effort of the Advanced Composites Project. Specific structural failure modes of interest are first identified, and a subset of standard composite test articles are proposed to interrogate a progressive damage analysis method's ability to predict each failure mode of interest. Test articles are designed to capture the underlying composite material constitutive response as well as the interaction of failure modes representing typical failure patterns observed in aerospace structures.

Failure mode and effects analysis drastically reduced potential risks in clinical trial conduct

PubMed Central

Baik, Jungmi; Kim, Hyunjung; Kim, Rachel

2017-01-01

Background Failure mode and effects analysis (FMEA) is a risk management tool to proactively identify and assess the causes and effects of potential failures in a system, thereby preventing them from happening. The objective of this study was to evaluate effectiveness of FMEA applied to an academic clinical trial center in a tertiary care setting. Methods A multidisciplinary FMEA focus group at the Seoul National University Hospital Clinical Trials Center selected 6 core clinical trial processes, for which potential failure modes were identified and their risk priority number (RPN) was assessed. Remedial action plans for high-risk failure modes (RPN >160) were devised and a follow-up RPN scoring was conducted a year later. Results A total of 114 failure modes were identified with an RPN score ranging 3–378, which was mainly driven by the severity score. Fourteen failure modes were of high risk, 11 of which were addressed by remedial actions. Rescoring showed a dramatic improvement attributed to reduction in the occurrence and detection scores by >3 and >2 points, respectively. Conclusions FMEA is a powerful tool to improve quality in clinical trials. The Seoul National University Hospital Clinical Trials Center is expanding its FMEA capability to other core clinical trial processes. PMID:29089745

Independent Orbiter Assessment (IOA): Analysis of the ascent thrust vector control actuator subsystem

NASA Technical Reports Server (NTRS)

Wilson, R. E.; Riccio, J. R.

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 Ascent Thrust Vector Control (ATVC) Actuator hardware are documented. The function of the Ascent Thrust Vector Control Actuators (ATVC) is to gimbal the main engines to provide for attitude and flight path control during ascent. During first stage flight, the SRB nozzles provide nearly all the steering. After SRB separation, the Orbiter is steered by gimbaling of its main engines. There are six electrohydraulic servoactuators, one pitch and one yaw for each of the three main engines. Each servoactuator is composed of four electrohydraulic servovalve assemblies, one second stage power spool valve assembly, one primary piston assembly and a switching valve. 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. Critical failures resulting in loss of ATVC were mainly due to loss of hydraulic fluid, fluid contamination and mechanical failures.

Independent Orbiter Assessment (IOA): Analysis of the body flap subsystem

NASA Technical Reports Server (NTRS)

Wilson, R. E.; Riccio, J. R.

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 (PCIs). 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 Orbiter Body Flap (BF) subsystem hardware are documented. The BF is a large aerosurface located at the trailing edge of the lower aft fuselage of the Orbiter. The proper function of the BF is essential during the dynamic flight phases of ascent and entry. During the ascent phase of flight, the BF trails in a fixed position. For entry, the BF provides elevon load relief, trim control, and acts as a heat shield for the main engines. Specifically, the BF hardware comprises the following components: Power Drive Unit (PDU), rotary actuators, and torque tubes. The IOA analysis process utilized available BF 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 35 failure modes analyzed, 19 were determined to be PCIs.

An improved method for risk evaluation in failure modes and effects analysis of CNC lathe

NASA Astrophysics Data System (ADS)

Rachieru, N.; Belu, N.; Anghel, D. C.

2015-11-01

Failure mode and effects analysis (FMEA) is one of the most popular reliability analysis tools for identifying, assessing and eliminating potential failure modes in a wide range of industries. In general, failure modes in FMEA are evaluated and ranked through the risk priority number (RPN), which is obtained by the multiplication of crisp values of the risk factors, such as the occurrence (O), severity (S), and detection (D) of each failure mode. However, the crisp RPN method has been criticized to have several deficiencies. In this paper, linguistic variables, expressed in Gaussian, trapezoidal or triangular fuzzy numbers, are used to assess the ratings and weights for the risk factors S, O and D. A new risk assessment system based on the fuzzy set theory and fuzzy rule base theory is to be applied to assess and rank risks associated to failure modes that could appear in the functioning of Turn 55 Lathe CNC. Two case studies have been shown to demonstrate the methodology thus developed. It is illustrated a parallel between the results obtained by the traditional method and fuzzy logic for determining the RPNs. The results show that the proposed approach can reduce duplicated RPN numbers and get a more accurate, reasonable risk assessment. As a result, the stability of product and process can be assured.

Analysis of the STS-126 Flow Control Valve Structural-Acoustic Coupling Failure

NASA Technical Reports Server (NTRS)

Jones, Trevor M.; Larko, Jeffrey M.; McNelis, Mark E.

2010-01-01

During the Space Transportation System mission STS-126, one of the main engine's flow control valves incurred an unexpected failure. A section of the valve broke off during liftoff. It is theorized that an acoustic mode of the flowing fuel, coupled with a structural mode of the valve, causing a high cycle fatigue failure. This report documents the analysis efforts conducted in an attempt to verify this theory. Hand calculations, computational fluid dynamics, and finite element methods are all implemented and analyses are performed using steady-state methods in addition to transient analysis methods. The conclusion of the analyses is that there is a critical acoustic mode that aligns with a structural mode of the valve

Risk assessment of failure modes of gas diffuser liner of V94.2 siemens gas turbine by FMEA method

NASA Astrophysics Data System (ADS)

Mirzaei Rafsanjani, H.; Rezaei Nasab, A.

2012-05-01

Failure of welding connection of gas diffuser liner and exhaust casing is one of the failure modes of V94.2 gas turbines which are happened in some power plants. This defect is one of the uncertainties of customers when they want to accept the final commissioning of this product. According to this, the risk priority of this failure evaluated by failure modes and effect analysis (FMEA) method to find out whether this failure is catastrophic for turbine performance and is harmful for humans. By using history of 110 gas turbines of this model which are used in some power plants, the severity number, occurrence number and detection number of failure determined and consequently the Risk Priority Number (RPN) of failure determined. Finally, critically matrix of potential failures is created and illustrated that failure modes are located in safe zone.

Meteorological Satellites (METSAT) and Earth Observing System (EOS) Advanced Microwave Sounding Unit-A (AMSU-A) Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL)

NASA Technical Reports Server (NTRS)

1996-01-01

This Failure Modes and Effects Analysis (FMEA) is for the Advanced Microwave Sounding Unit-A (AMSU-A) instruments that are being designed and manufactured for the Meteorological Satellites Project (METSAT) and the Earth Observing System (EOS) integrated programs. The FMEA analyzes the design of the METSAT and EOS instruments as they currently exist. This FMEA is intended to identify METSAT and EOS failure modes and their effect on spacecraft-instrument and instrument-component interfaces. The prime objective of this FMEA is to identify potential catastrophic and critical failures so that susceptibility to the failures and their effects can be eliminated from the METSAT/EOS instruments.

Independent Orbiter Assessment (IOA): Analysis of the electrical power generation/fuel cell powerplant subsystem

NASA Technical Reports Server (NTRS)

Brown, K. L.; Bertsch, P. J.

1986-01-01

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. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Generation (EPG)/Fuel Cell Powerplant (FCP) hardware. The EPG/FCP hardware is required for performing functions of electrical power generation and product water distribution in the Orbiter. Specifically, the EPG/FCP hardware consists of the following divisions: (1) Power Section Assembly (PSA); (2) Reactant Control Subsystem (RCS); (3) Thermal Control Subsystem (TCS); and (4) Water Removal Subsystem (WRS). The IOA analysis process utilized available EPG/FCP 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.

Independent Orbiter Assessment (IOA): Analysis of the orbital maneuvering system

NASA Technical Reports Server (NTRS)

Prust, C. D.; Paul, D. J.; Burkemper, V. J.

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 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 Orbital Maneuvering System (OMS) hardware are documented. The OMS provides the thrust to perform orbit insertion, orbit circularization, orbit transfer, rendezvous, and deorbit. The OMS is housed in two independent pods located one on each side of the tail and consists of the following subsystems: Helium Pressurization; Propellant Storage and Distribution; Orbital Maneuvering Engine; and Electrical Power Distribution and Control. The IOA analysis process utilized available OMS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluted and analyzed for possible failure modes and effects. Criticality was asigned based upon the severity of the effect for each failure mode.

Independent Orbiter Assessment (IOA): Analysis of the manned maneuvering unit

NASA Technical Reports Server (NTRS)

Bailey, P. S.

1986-01-01

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 (PCIs). To preserve indepedence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Manned Maneuvering Unit (MMU) hardware. The MMU is a propulsive backpack, operated through separate hand controllers that input the pilot's translational and rotational maneuvering commands to the control electronics and then to the thrusters. The IOA analysis process utilized available MMU hardware drawings and schematics for defining hardware subsystems, assemblies, components, and hardware items. Final levels of detail were evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the worst case severity of the effect for each identified failure mode. The IOA analysis of the MMU found that the majority of the PCIs identified are resultant from the loss of either the propulsion or control functions, or are resultant from inability to perform an immediate or future mission. The five most severe criticalities identified are all resultant from failures imposed on the MMU hand controllers which have no redundancy within the MMU.

Independent Orbiter Assessment (IOA): Analysis of the nose wheel steering subsystem

NASA Technical Reports Server (NTRS)

Mediavilla, Anthony Scott

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 Orbiter Nose Wheel Steering (NWS) hardware are documented. The NWS hardware provides primary directional control for the Orbiter vehicle during landing rollout. 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. The original NWS design was envisioned as a backup system to differential braking for directional control of the Orbiter during landing rollout. No real effort was made to design the NWS system as fail operational. The brakes have much redundancy built into their design but the poor brake/tire performance has forced the NSTS to upgrade NWS to the primary mode of directional control during rollout. As a result, a large percentage of the NWS system components have become Potential Critical Items (PCI).

Validating FMEA output against incident learning data: A study in stereotactic body radiation therapy.

PubMed

Yang, F; Cao, N; Young, L; Howard, J; Logan, W; Arbuckle, T; Sponseller, P; Korssjoen, T; Meyer, J; Ford, E

2015-06-01

Though failure mode and effects analysis (FMEA) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge, its output has never been validated against data on errors that actually occur. The objective of this study was to perform FMEA of a stereotactic body radiation therapy (SBRT) treatment planning process and validate the results against data recorded within an incident learning system. FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, dosimetrists, and IT technologists. Potential failure modes were identified through a systematic review of the process map. Failure modes were rated for severity, occurrence, and detectability on a scale of one to ten and risk priority number (RPN) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that has been active for two and a half years. Differences between FMEA anticipated failure modes and existing incidents were identified. FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. Combining both methods yielded a total of 76 possible process failures, of which 13 (17%) were missed by FMEA while 43 (57%) identified by FMEA only. When scored for RPN, the 13 events missed by FMEA ranked within the lower half of all failure modes and exhibited significantly lower severity relative to those identified by FMEA (p = 0.02). FMEA, though valuable, is subject to certain limitations. In this study, FMEA failed to identify 17% of actual failure modes, though these were of lower risk. Similarly, an incident learning system alone fails to identify a large number of potentially high-severity process errors. Using FMEA in combination with incident learning may render an improved overview of risks within a process.

Model-OA wind turbine generator - Failure modes and effects analysis

NASA Technical Reports Server (NTRS)

Klein, William E.; Lali, Vincent R.

1990-01-01

The results failure modes and effects analysis (FMEA) conducted for wind-turbine generators are presented. The FMEA was performed for the functional modes of each system, subsystem, or component. The single-point failures were eliminated for most of the systems. The blade system was the only exception. The qualitative probability of a blade separating was estimated at level D-remote. Many changes were made to the hardware as a result of this analysis. The most significant change was the addition of the safety system. Operational experience and need to improve machine availability have resulted in subsequent changes to the various systems, which are also reflected in this FMEA.

Independent Orbiter Assessment (IOA): Assessment of the EPD and C/remote manipulator system FMEA/CIL

NASA Technical Reports Server (NTRS)

Robinson, W. W.

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 Electrical Power Distribution and Control (EPD and C)/Remote Manipulator System (RMS) 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 analysis of the EPD and C/RMS hardware initially generated 345 failure mode worksheets and identified 117 Potential Critical Items (PCIs) before starting the assessment process. These analysis results were compared to the proposed NASA Post 51-L baseline of 132 FMEAs and 66 CIL items.

Preliminary Failure Modes and Effects Analysis of the US DCLL Test Blanket Module

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

Lee C. Cadwallader

2010-06-01

This report presents the results of a preliminary failure modes and effects analysis (FMEA) of a small tritium-breeding test blanket module design for the International Thermonuclear Experimental Reactor. The FMEA was quantified with “generic” component failure rate data, and the failure events are binned into postulated initiating event families and frequency categories for safety assessment. An appendix to this report contains repair time data to support an occupational radiation exposure assessment for test blanket module maintenance.

Preliminary Failure Modes and Effects Analysis of the US DCLL Test Blanket Module

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

Lee C. Cadwallader

2007-08-01

This report presents the results of a preliminary failure modes and effects analysis (FMEA) of a small tritium-breeding test blanket module design for the International Thermonuclear Experimental Reactor. The FMEA was quantified with “generic” component failure rate data, and the failure events are binned into postulated initiating event families and frequency categories for safety assessment. An appendix to this report contains repair time data to support an occupational radiation exposure assessment for test blanket module maintenance.

Independent Orbiter Assessment (IOA): Analysis of the orbiter main propulsion system

NASA Technical Reports Server (NTRS)

Mcnicoll, W. J.; Mcneely, M.; Holden, K. A.; Emmons, T. E.; Lowery, H. J.

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 items (PCIs). 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 Orbiter Main Propulsion System (MPS) hardware are documented. The Orbiter MPS consists of two subsystems: the Propellant Management Subsystem (PMS) and the Helium Subsystem. The PMS is a system of manifolds, distribution lines and valves by which the liquid propellants pass from the External Tank (ET) to the Space Shuttle Main Engines (SSMEs) and gaseous propellants pass from the SSMEs to the ET. The Helium Subsystem consists of a series of helium supply tanks and their associated regulators, check valves, distribution lines, and control valves. The Helium Subsystem supplies helium that is used within the SSMEs for inflight purges and provides pressure for actuation of SSME valves during emergency pneumatic shutdowns. The balance of the helium is used to provide pressure to operate the pneumatically actuated valves within the PMS. Each component was evaluated and analyzed for possible failure modes and effects. Criticalities were assigned based on the worst possible effect of each failure mode. Of the 690 failure modes analyzed, 349 were determined to be PCIs.

Risk assessment of component failure modes and human errors using a new FMECA approach: application in the safety analysis of HDR brachytherapy.

PubMed

Giardina, M; Castiglia, F; Tomarchio, E

2014-12-01

Failure mode, effects and criticality analysis (FMECA) is a safety technique extensively used in many different industrial fields to identify and prevent potential failures. In the application of traditional FMECA, the risk priority number (RPN) is determined to rank the failure modes; however, the method has been criticised for having several weaknesses. Moreover, it is unable to adequately deal with human errors or negligence. In this paper, a new versatile fuzzy rule-based assessment model is proposed to evaluate the RPN index to rank both component failure and human error. The proposed methodology is applied to potential radiological over-exposure of patients during high-dose-rate brachytherapy treatments. The critical analysis of the results can provide recommendations and suggestions regarding safety provisions for the equipment and procedures required to reduce the occurrence of accidental events.

Failure modes and effects analysis automation

NASA Technical Reports Server (NTRS)

Kamhieh, Cynthia H.; Cutts, Dannie E.; Purves, R. Byron

1988-01-01

A failure modes and effects analysis (FMEA) assistant was implemented as a knowledge based system and will be used during design of the Space Station to aid engineers in performing the complex task of tracking failures throughout the entire design effort. The three major directions in which automation was pursued were the clerical components of the FMEA process, the knowledge acquisition aspects of FMEA, and the failure propagation/analysis portions of the FMEA task. The system is accessible to design, safety, and reliability engineers at single user workstations and, although not designed to replace conventional FMEA, it is expected to decrease by many man years the time required to perform the analysis.

Intralaminar and Interlaminar Progressive Failure Analysis of Composite Panels with Circular Cutouts

NASA Technical Reports Server (NTRS)

Goyal, Vinay K.; Jaunky, Navin; Johnson, Eric R.; Ambur, Damodar

2002-01-01

A progressive failure methodology is developed and demonstrated to simulate the initiation and material degradation of a laminated panel due to intralaminar and interlaminar failures. Initiation of intralaminar failure can be by a matrix-cracking mode, a fiber-matrix shear mode, and a fiber failure mode. Subsequent material degradation is modeled using damage parameters for each mode to selectively reduce lamina material properties. The interlaminar failure mechanism such as delamination is simulated by positioning interface elements between adjacent sublaminates. A nonlinear constitutive law is postulated for the interface element that accounts for a multi-axial stress criteria to detect the initiation of delamination, a mixed-mode fracture criteria for delamination progression, and a damage parameter to prevent restoration of a previous cohesive state. The methodology is validated using experimental data available in the literature on the response and failure of quasi-isotropic panels with centrally located circular cutouts loaded into the postbuckling regime. Very good agreement between the progressive failure analyses and the experimental results is achieved if the failure analyses includes the interaction of intralaminar and interlaminar failures.

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

Cheong, S-K; Kim, J

Purpose: The aim of the study is the application of a Failure Modes and Effects Analysis (FMEA) to access the risks for patients undergoing a Low Dose Rate (LDR) Prostate Brachytherapy Treatment. Methods: FMEA was applied to identify all the sub processes involved in the stages of identifying patient, source handling, treatment preparation, treatment delivery, and post treatment. These processes characterize the radiation treatment associated with LDR Prostate Brachytherapy. The potential failure modes together with their causes and effects were identified and ranked in order of their importance. Three indexes were assigned for each failure mode: the occurrence rating (O),more » the severity rating (S), and the detection rating (D). A ten-point scale was used to score each category, ten being the number indicating most severe, most frequent, and least detectable failure mode, respectively. The risk probability number (RPN) was calculated as a product of the three attributes: RPN = O X S x D. The analysis was carried out by a working group (WG) at UPMC. Results: The total of 56 failure modes were identified including 32 modes before the treatment, 13 modes during the treatment, and 11 modes after the treatment. In addition to the protocols already adopted in the clinical practice, the prioritized risk management will be implanted to the high risk procedures on the basis of RPN score. Conclusion: The effectiveness of the FMEA method was established. The FMEA methodology provides a structured and detailed assessment method for the risk analysis of the LDR Prostate Brachytherapy Procedure and can be applied to other radiation treatment modes.« less

Introduction to Concurrent Engineering: Electronic Circuit Design and Production Applications

DTIC Science & Technology

1992-09-01

STD-1629. Failure mode distribution data for many different types of parts may be found in RAC publication FMD -91. FMEA utilizes inductive logic in a...contrasts with a Fault Tree Analysis ( FTA ) which utilizes deductive logic in a "top down" approach. In FTA , a system failure is assumed and traced down...Analysis ( FTA ) is a graphical method of risk analysis used to identify critical failure modes within a system or equipment. Utilizing a pictorial approach

A comparative critical study between FMEA and FTA risk analysis methods

NASA Astrophysics Data System (ADS)

Cristea, G.; Constantinescu, DM

2017-10-01

Today there is used an overwhelming number of different risk analyses techniques with acronyms such as: FMEA (Failure Modes and Effects Analysis) and its extension FMECA (Failure Mode, Effects, and Criticality Analysis), DRBFM (Design Review by Failure Mode), FTA (Fault Tree Analysis) and and its extension ETA (Event Tree Analysis), HAZOP (Hazard & Operability Studies), HACCP (Hazard Analysis and Critical Control Points) and What-if/Checklist. However, the most used analysis techniques in the mechanical and electrical industry are FMEA and FTA. In FMEA, which is an inductive method, information about the consequences and effects of the failures is usually collected through interviews with experienced people, and with different knowledge i.e., cross-functional groups. The FMEA is used to capture potential failures/risks & impacts and prioritize them on a numeric scale called Risk Priority Number (RPN) which ranges from 1 to 1000. FTA is a deductive method i.e., a general system state is decomposed into chains of more basic events of components. The logical interrelationship of how such basic events depend on and affect each other is often described analytically in a reliability structure which can be visualized as a tree. Both methods are very time-consuming to be applied thoroughly, and this is why it is oftenly not done so. As a consequence possible failure modes may not be identified. To address these shortcomings, it is proposed to use a combination of FTA and FMEA.

Failure mode and effects analysis using intuitionistic fuzzy hybrid weighted Euclidean distance operator

NASA Astrophysics Data System (ADS)

Liu, Hu-Chen; Liu, Long; Li, Ping

2014-10-01

Failure mode and effects analysis (FMEA) has shown its effectiveness in examining potential failures in products, process, designs or services and has been extensively used for safety and reliability analysis in a wide range of industries. However, its approach to prioritise failure modes through a crisp risk priority number (RPN) has been criticised as having several shortcomings. The aim of this paper is to develop an efficient and comprehensive risk assessment methodology using intuitionistic fuzzy hybrid weighted Euclidean distance (IFHWED) operator to overcome the limitations and improve the effectiveness of the traditional FMEA. The diversified and uncertain assessments given by FMEA team members are treated as linguistic terms expressed in intuitionistic fuzzy numbers (IFNs). Intuitionistic fuzzy weighted averaging (IFWA) operator is used to aggregate the FMEA team members' individual assessments into a group assessment. IFHWED operator is applied thereafter to the prioritisation and selection of failure modes. Particularly, both subjective and objective weights of risk factors are considered during the risk evaluation process. A numerical example for risk assessment is given to illustrate the proposed method finally.

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.

Evaluating the operational risks of biomedical waste using failure mode and effects analysis.

PubMed

Chen, Ying-Chu; Tsai, Pei-Yi

2017-06-01

The potential problems and risks of biomedical waste generation have become increasingly apparent in recent years. This study applied a failure mode and effects analysis to evaluate the operational problems and risks of biomedical waste. The microbiological contamination of biomedical waste seldom receives the attention of researchers. In this study, the biomedical waste lifecycle was divided into seven processes: Production, classification, packaging, sterilisation, weighing, storage, and transportation. Twenty main failure modes were identified in these phases and risks were assessed based on their risk priority numbers. The failure modes in the production phase accounted for the highest proportion of the risk priority number score (27.7%). In the packaging phase, the failure mode 'sharp articles not placed in solid containers' had the highest risk priority number score, mainly owing to its high severity rating. The sterilisation process is the main difference in the treatment of infectious and non-infectious biomedical waste. The failure modes in the sterilisation phase were mainly owing to human factors (mostly related to operators). This study increases the understanding of the potential problems and risks associated with biomedical waste, thereby increasing awareness of how to improve the management of biomedical waste to better protect workers, the public, and the environment.

Failure mode and effect analysis in blood transfusion: a proactive tool to reduce risks.

PubMed

Lu, Yao; Teng, Fang; Zhou, Jie; Wen, Aiqing; Bi, Yutian

2013-12-01

The aim of blood transfusion risk management is to improve the quality of blood products and to assure patient safety. We utilize failure mode and effect analysis (FMEA), a tool employed for evaluating risks and identifying preventive measures to reduce the risks in blood transfusion. The failure modes and effects occurring throughout the whole process of blood transfusion were studied. Each failure mode was evaluated using three scores: severity of effect (S), likelihood of occurrence (O), and probability of detection (D). Risk priority numbers (RPNs) were calculated by multiplying the S, O, and D scores. The plan-do-check-act cycle was also used for continuous improvement. Analysis has showed that failure modes with the highest RPNs, and therefore the greatest risk, were insufficient preoperative assessment of the blood product requirement (RPN, 245), preparation time before infusion of more than 30 minutes (RPN, 240), blood transfusion reaction occurring during the transfusion process (RPN, 224), blood plasma abuse (RPN, 180), and insufficient and/or incorrect clinical information on request form (RPN, 126). After implementation of preventative measures and reassessment, a reduction in RPN was detected with each risk. The failure mode with the second highest RPN, namely, preparation time before infusion of more than 30 minutes, was shown in detail to prove the efficiency of this tool. FMEA evaluation model is a useful tool in proactively analyzing and reducing the risks associated with the blood transfusion procedure. © 2013 American Association of Blood Banks.

Tensile failure criteria for fiber composite materials

NASA Technical Reports Server (NTRS)

Rosen, B. W.; Zweben, C. H.

1972-01-01

The analysis provides insight into the failure mechanics of these materials and defines criteria which serve as tools for preliminary design material selection and for material reliability assessment. The model incorporates both dispersed and propagation type failures and includes the influence of material heterogeneity. The important effects of localized matrix damage and post-failure matrix shear stress transfer are included in the treatment. The model is used to evaluate the influence of key parameters on the failure of several commonly used fiber-matrix systems. Analyses of three possible failure modes were developed. These modes are the fiber break propagation mode, the cumulative group fracture mode, and the weakest link mode. Application of the new model to composite material systems has indicated several results which require attention in the development of reliable structural composites. Prominent among these are the size effect and the influence of fiber strength variability.

Improving the treatment planning and delivery process of Xoft electronic skin brachytherapy.

PubMed

Manger, Ryan; Rahn, Douglas; Hoisak, Jeremy; Dragojević, Irena

2018-05-14

To develop an improved Xoft electronic skin brachytherapy process and identify areas of further improvement. A multidisciplinary team conducted a failure modes and effects analysis (FMEA) by developing a process map and a corresponding list of failure modes. The failure modes were scored for their occurrence, severity, and detectability, and a risk priority number (RPN) was calculated for each failure mode as the product of occurrence, severity, and detectability. Corrective actions were implemented to address the higher risk failure modes, and a revised process was generated. The RPNs of the failure modes were compared between the initial process and final process to assess the perceived benefits of the corrective actions. The final treatment process consists of 100 steps and 114 failure modes. The FMEA took approximately 20 person-hours (one physician, three physicists, and two therapists) to complete. The 10 most dangerous failure modes had RPNs ranging from 336 to 630. Corrective actions were effective at addressing most failure modes (10 riskiest RPNs ranging from 189 to 310), yet the RPNs were higher than those published for alternative systems. Many of these high-risk failure modes remained due to hardware design limitations. FMEA helps guide process improvement efforts by emphasizing the riskiest steps. Significant risks are apparent when using a Xoft treatment unit for skin brachytherapy due to hardware limitations such as the lack of several interlocks, a short source lifespan, and variability in source output. The process presented in this article is expected to reduce but not eliminate these risks. Copyright © 2018 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Independent Orbiter Assessment (IOA): Assessment of the Orbiter Experiment (OEX) subsystem

NASA Technical Reports Server (NTRS)

Compton, J. M.

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 Orbiter Experiments (OEX) 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. The results of that comparison for the Orbiter OEX hardware are documented. The IOA product for the OEX analysis consisted of 82 failure mode worksheets that resulted in two potential critical items being identified.

Independent Orbiter Assessment (IOA): FMEA/CIL assessment

NASA Technical Reports Server (NTRS)

Saiidi, Mo J.; Swain, L. J.; Compton, J. M.

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. Direction was given by the Orbiter and GFE Projects Office to perform the hardware analysis and assessment using the instructions and ground rules defined in NSTS 22206. The IOA analysis features a top-down approach to determine hardware failure modes, criticality, and potential critical items. To preserve independence, the anlaysis was accomplished without reliance upon the results contained within the NASA and prime contractor FMEA/CIL documentation. The assessment process compares the independently derived failure modes and criticality assignments to the proposed NASA Post 51-L FMEA/CIL documentation. When possible, assessment issues are discussed and resolved with the NASA subsystem managers. The assessment results for each subsystem are summarized. The most important Orbiter assessment finding was the previously unknown stuck autopilot push-button criticality 1/1 failure mode, having a worst case effect of loss of crew/vehicle when a microwave landing system is not active.

Independent Orbiter Assessment (IOA): Analysis of the electrical power distribution and control/electrical power generation subsystem

NASA Technical Reports Server (NTRS)

Patton, Jeff A.

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. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Distribution and Control (EPD and C)/Electrical Power Generation (EPG) hardware. The EPD and C/EPG hardware is required for performing critical functions of cryogenic reactant storage, electrical power generation and product water distribution in the Orbiter. Specifically, the EPD and C/EPG hardware consists of the following components: Power Section Assembly (PSA); Reactant Control Subsystem (RCS); Thermal Control Subsystem (TCS); Water Removal Subsystem (WRS); and Power Reactant Storage and Distribution System (PRSDS). The IOA analysis process utilized available EPD and C/EPG 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.

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2012 CFR

2012-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2010 CFR

2010-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2013 CFR

2013-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2014 CFR

2014-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2011 CFR

2011-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

Determination of Turbine Blade Life from Engine Field Data

NASA Technical Reports Server (NTRS)

Zaretsky, Erwin V.; Litt, Jonathan S.; Hendricks, Robert C.; Soditus, Sherry M.

2013-01-01

It is probable that no two engine companies determine the life of their engines or their components in the same way or apply the same experience and safety factors to their designs. Knowing the failure mode that is most likely to occur minimizes the amount of uncertainty and simplifies failure and life analysis. Available data regarding failure mode for aircraft engine blades, while favoring low-cycle, thermal-mechanical fatigue (TMF) as the controlling mode of failure, are not definitive. Sixteen high-pressure turbine (HPT) T-1 blade sets were removed from commercial aircraft engines that had been commercially flown by a single airline and inspected for damage. Each set contained 82 blades. The damage was cataloged into three categories related to their mode of failure: (1) TMF, (2) Oxidation/erosion (O/E), and (3) Other. From these field data, the turbine blade life was determined as well as the lives related to individual blade failure modes using Johnson-Weibull analysis. A simplified formula for calculating turbine blade life and reliability was formulated. The L10 blade life was calculated to be 2427 cycles (11 077 hr). The resulting blade life attributed to O/E equaled that attributed to TMF. The category that contributed most to blade failure was Other. If there were no blade failures attributed to O/E and TMF, the overall blade L(sub 10) life would increase approximately 11 to 17 percent.

MO-G-BRE-09: Validating FMEA Against Incident Learning Data: A Study in Stereotactic Body Radiation Therapy

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

Yang, F; Cao, N; Young, L

2014-06-15

Purpose: Though FMEA (Failure Mode and Effects Analysis) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge it has never been validated against actual incident learning data. The objective of this study was to perform an FMEA analysis of an SBRT (Stereotactic Body Radiation Therapy) treatment planning process and validate this against data recorded within an incident learning system. Methods: FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, and dosimetrists. Potential failure modes were identified through a systematic review of the workflow process. Failuremore » modes were rated for severity, occurrence, and detectability on a scale of 1 to 10 and RPN (Risk Priority Number) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that had been active for two years. Differences were identified. Results: FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. FMEA failed to anticipate 13 of these events, among which 3 were registered with severity ratings of severe or critical in the incident learning system. Combining both methods yielded a total of 76 failure modes, and when scored for RPN the 13 events missed by FMEA ranked within the middle half of all failure modes. Conclusion: FMEA, though valuable, is subject to certain limitations, among them the limited ability to anticipate all potential errors for a given process. This FMEA exercise failed to identify a significant number of possible errors (17%). Integration of FMEA with retrospective incident data may be able to render an improved overview of risks within a process.« less

Fuzzy-based failure mode and effect analysis (FMEA) of a hybrid molten carbonate fuel cell (MCFC) and gas turbine system for marine propulsion

NASA Astrophysics Data System (ADS)

Ahn, Junkeon; Noh, Yeelyong; Park, Sung Ho; Choi, Byung Il; Chang, Daejun

2017-10-01

This study proposes a fuzzy-based FMEA (failure mode and effect analysis) for a hybrid molten carbonate fuel cell and gas turbine system for liquefied hydrogen tankers. An FMEA-based regulatory framework is adopted to analyze the non-conventional propulsion system and to understand the risk picture of the system. Since the participants of the FMEA rely on their subjective and qualitative experiences, the conventional FMEA used for identifying failures that affect system performance inevitably involves inherent uncertainties. A fuzzy-based FMEA is introduced to express such uncertainties appropriately and to provide flexible access to a risk picture for a new system using fuzzy modeling. The hybrid system has 35 components and has 70 potential failure modes, respectively. Significant failure modes occur in the fuel cell stack and rotary machine. The fuzzy risk priority number is used to validate the crisp risk priority number in the FMEA.

Utility of Failure Mode and Effect Analysis to Improve Safety in Suctioning by Orotracheal Tube.

PubMed

Vázquez-Valencia, Agustín; Santiago-Sáez, Andrés; Perea-Pérez, Bernardo; Labajo-González, Elena; Albarrán-Juan, Maria Elena

2017-02-01

The objective of the study was to use the Failure Mode and Effect Analysis (FMEA) tool to analyze the technique of secretion suctioning on patients with an endotracheal tube who were admitted into an intensive care unit. Brainstorming was carried out within the service to determine the potential errors most frequent in the process. After this, the FMEA was applied, including its stages, prioritizing risk in accordance with the risk prioritization number (RPN), selecting improvement actions in which they have an RPN of more than 300. We obtained 32 failure modes, of which 13 surpassed an RPN of 300. After our result, 21 improvement actions were proposed for those failure modes with RPN scores above 300. FMEA allows us to ascertain possible failures so as to later propose improvement actions for those which have an RPN of more than 300. Copyright © 2016 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

A Case Study on Improving Intensive Care Unit (ICU) Services Reliability: By Using Process Failure Mode and Effects Analysis (PFMEA)

PubMed Central

Yousefinezhadi, Taraneh; Jannesar Nobari, Farnaz Attar; Goodari, Faranak Behzadi; Arab, Mohammad

2016-01-01

Introduction: In any complex human system, human error is inevitable and shows that can’t be eliminated by blaming wrong doers. So with the aim of improving Intensive Care Units (ICU) reliability in hospitals, this research tries to identify and analyze ICU’s process failure modes at the point of systematic approach to errors. Methods: In this descriptive research, data was gathered qualitatively by observations, document reviews, and Focus Group Discussions (FGDs) with the process owners in two selected ICUs in Tehran in 2014. But, data analysis was quantitative, based on failures’ Risk Priority Number (RPN) at the base of Failure Modes and Effects Analysis (FMEA) method used. Besides, some causes of failures were analyzed by qualitative Eindhoven Classification Model (ECM). Results: Through FMEA methodology, 378 potential failure modes from 180 ICU activities in hospital A and 184 potential failures from 99 ICU activities in hospital B were identified and evaluated. Then with 90% reliability (RPN≥100), totally 18 failures in hospital A and 42 ones in hospital B were identified as non-acceptable risks and then their causes were analyzed by ECM. Conclusions: Applying of modified PFMEA for improving two selected ICUs’ processes reliability in two different kinds of hospitals shows that this method empowers staff to identify, evaluate, prioritize and analyze all potential failure modes and also make them eager to identify their causes, recommend corrective actions and even participate in improving process without feeling blamed by top management. Moreover, by combining FMEA and ECM, team members can easily identify failure causes at the point of health care perspectives. PMID:27157162

Ply-level failure analysis of a graphite/epoxy laminate under bearing-bypass loading

NASA Technical Reports Server (NTRS)

Naik, R. A.; Crews, J. H., Jr.

1988-01-01

A combined experimental and analytical study was conducted to investigate and predict the failure modes of a graphite/epoxy laminate subjected to combined bearing and bypass loading. Tests were conducted in a test machine that allowed the bearing-bypass load ratio to be controlled while a single-fastener coupon was loaded to failure in either tension or compression. Onset and ultimate failure modes and strengths were determined for each test case. The damage-onset modes were studied in detail by sectioning and micrographing the damaged specimens. A two-dimensional, finite-element analysis was conducted to determine lamina strains around the bolt hole. Damage onset consisted of matrix cracks, delamination, and fiber failures. Stiffness loss appeared to be caused by fiber failures rather than by matrix cracking and delamination. An unusual offset-compression mode was observed for compressive bearing-bypass laoding in which the specimen failed across its width along a line offset from the hole. The computed lamina strains in the fiber direction were used in a combined analytical and experimental approach to predict bearing-bypass diagrams for damage onset from a few simple tests.

Ply-level failure analysis of a graphite/epoxy laminate under bearing-bypass loading

NASA Technical Reports Server (NTRS)

Naik, R. A.; Crews, J. H., Jr.

1990-01-01

A combined experimental and analytical study was conducted to investigate and predict the failure modes of a graphite/epoxy laminate subjected to combined bearing and bypass loading. Tests were conducted in a test machine that allowed the bearing-bypass load ratio to be controlled while a single-fastener coupon was loaded to failure in either tension or compression. Onset and ultimate failure modes and strengths were determined for each test case. The damage-onset modes were studied in detail by sectioning and micrographing the damaged specimens. A two-dimensional, finite-element analysis was conducted to determine lamina strains around the bolt hole. Damage onset consisted of matrix cracks, delamination, and fiber failures. Stiffness loss appeared to be caused by fiber failures rather than by matrix cracking and delamination. An unusual offset-compression mode was observed for compressive bearing-bypass loading in which the specimen failed across its width along a line offset from the hole. The computed lamina strains in the fiber direction were used in a combined analytical and experimental approach to predict bearing-bypass diagrams for damage onset from a few simple tests.

Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the Middle East.

PubMed

Babiker, Amir; Amer, Yasser S; Osman, Mohamed E; Al-Eyadhy, Ayman; Fatani, Solafa; Mohamed, Sarar; Alnemri, Abdulrahman; Titi, Maher A; Shaikh, Farheen; Alswat, Khalid A; Wahabi, Hayfaa A; Al-Ansary, Lubna A

2018-02-01

Implementation of clinical practice guidelines (CPGs) has been shown to reduce variation in practice and improve health care quality and patients' safety. There is a limited experience of CPG implementation (CPGI) in the Middle East. The CPG program in our institution was launched in 2009. The Quality Management department conducted a Failure Mode and Effect Analysis (FMEA) for further improvement of CPGI. This is a prospective study of a qualitative/quantitative design. Our FMEA included (1) process review and recording of the steps and activities of CPGI; (2) hazard analysis by recording activity-related failure modes and their effects, identification of actions required, assigned severity, occurrence, and detection scores for each failure mode and calculated the risk priority number (RPN) by using an online interactive FMEA tool; (3) planning: RPNs were prioritized, recommendations, and further planning for new interventions were identified; and (4) monitoring: after reduction or elimination of the failure mode. The calculated RPN will be compared with subsequent analysis in post-implementation phase. The data were scrutinized from a feedback of quality team members using a FMEA framework to enhance the implementation of 29 adapted CPGs. The identified potential common failure modes with the highest RPN (≥ 80) included awareness/training activities, accessibility of CPGs, fewer advocates from clinical champions, and CPGs auditing. Actions included (1) organizing regular awareness activities, (2) making CPGs printed and electronic copies accessible, (3) encouraging senior practitioners to get involved in CPGI, and (4) enhancing CPGs auditing as part of the quality sustainability plan. In our experience, FMEA could be a useful tool to enhance CPGI. It helped us to identify potential barriers and prepare relevant solutions. © 2017 John Wiley & Sons, Ltd.

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

Rusu, I; Thomas, T; Roeske, J

Purpose: To identify areas of improvement in our liver stereotactic body radiation therapy (SBRT) program, using failure mode and effect analysis (FMEA). Methods: A multidisciplinary group consisting of one physician, three physicists, one dosimetrist and two therapists was formed. A process map covering 10 major stages of the liver SBRT program from the initial diagnosis to post treatment follow-up was generated. A total of 102 failure modes, together with their causes and effects, were identified. The occurrence (O), severity (S) and lack of detectability (D) were independently scored. The ranking was done using the risk probability number (RPN) defined asmore » the product of average O, S and D numbers for each mode. The scores were normalized to remove inter-observer variability, while preserving individual ranking order. Further, a correlation analysis on the overall agreement on rank order of all failure modes resulted in positive values for successive pairs of evaluators. The failure modes with the highest RPN value were considered for further investigation. Results: The average normalized RPN values for all modes were 39 with a range of 9 to 103. The FMEA analysis resulted in the identification of the top 10 critical failures modes as: Incorrect CT-MR registration, MR scan not performed in treatment position, patient movement between CBCT acquisition and treatment, daily IGRT QA not verified, incorrect or incomplete ITV delineation, OAR contours not verified, inaccurate normal liver effective dose (Veff) calculation, failure of bolus tracking for 4D CT scan, setup instructions not followed for treatment and plan evaluation metrics missed. Conclusion: The application of FMEA to our liver SBRT program led to the identification and possible improvement of areas affecting patient safety.« less

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

NASA Technical Reports Server (NTRS)

Lowery, H. J.; Haufler, W. A.; Pietz, K. C.

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis/Critical Items List (FMEA/CIL) is presented. The IOA approach features a top-down analysis of the hardware to independently determine failure modes, criticality, and potential critical items. The independent analysis results corresponding to the Orbiter Data Processing System (DPS) hardware are documented. The DPS hardware is required for performing critical functions of data acquisition, data manipulation, data display, and data transfer throughout the Orbiter. Specifically, the DPS hardware consists of the following components: Multiplexer/Demultiplexer (MDM); General Purpose Computer (GPC); Multifunction CRT Display System (MCDS); Data Buses and Data Bus Couplers (DBC); Data Bus Isolation Amplifiers (DBIA); Mass Memory Unit (MMU); and Engine Interface Unit (EIU). The IOA analysis process utilized available DPS 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. Due to the extensive redundancy built into the DPS the number of critical items are few. Those identified resulted from premature operation and erroneous output of the GPCs.

Catastrophic optical bulk degradation in high-power single- and multi-mode InGaAs-AlGaAs strained QW lasers: part II

NASA Astrophysics Data System (ADS)

Sin, Yongkun; Ayvazian, Talin; Brodie, Miles; Lingley, Zachary

2018-03-01

High-power single-mode (SM) and multi-mode (MM) InGaAs-AlGaAs strained quantum well (QW) lasers are critical components for both terrestrial and space satellite communications systems. Since these lasers predominantly fail by catastrophic and sudden degradation due to catastrophic optical damage (COD), it is especially crucial for space satellite applications to investigate reliability, failure modes, precursor signatures of failure, and degradation mechanisms of these lasers. Our group reported a new failure mode in MM and SM InGaAs-AlGaAs strained QW lasers in 2009 and 2016, respectively. Our group also reported in 2017 that bulk failure due to catastrophic optical bulk damage (COBD) is the dominant failure mode of both SM and MM lasers that were subject to long-term life-tests. For the present study, we continued our physics of failure investigation by performing long-term life-tests followed by failure mode analysis (FMA) using nondestructive and destructive micro-analytical techniques. We performed long-term accelerated life-tests on state-of-the-art SM and MM InGaAs- AlGaAs strained QW lasers under ACC mode. Our life-tests have accumulated over 25,000 test hours for SM lasers and over 35,000 test hours for MM lasers. We first employed electron beam induced current (EBIC) technique to identify failure modes of degraded SM lasers by observing dark line defects. All the SM failures that we studied showed catastrophic and sudden degradation and all of these failures were bulk failures. Since degradation mechanisms responsible for COBD are still not well understood, we also employed other techniques including focused ion beam (FIB) and high-resolution TEM to further study dark line defects and dislocations in post-aged lasers. Keywor

Failure mode and effects analysis of witnessing protocols for ensuring traceability during IVF.

PubMed

Rienzi, Laura; Bariani, Fiorenza; Dalla Zorza, Michela; Romano, Stefania; Scarica, Catello; Maggiulli, Roberta; Nanni Costa, Alessandro; Ubaldi, Filippo Maria

2015-10-01

Traceability of cells during IVF is a fundamental aspect of treatment, and involves witnessing protocols. Failure mode and effects analysis (FMEA) is a method of identifying real or potential breakdowns in processes, and allows strategies to mitigate risks to be developed. To examine the risks associated with witnessing protocols, an FMEA was carried out in a busy IVF centre, before and after implementation of an electronic witnessing system (EWS). A multidisciplinary team was formed and moderated by human factors specialists. Possible causes of failures, and their potential effects, were identified and risk priority number (RPN) for each failure calculated. A second FMEA analysis was carried out after implementation of an EWS. The IVF team identified seven main process phases, 19 associated process steps and 32 possible failure modes. The highest RPN was 30, confirming the relatively low risk that mismatches may occur in IVF when a manual witnessing system is used. The introduction of the EWS allowed a reduction in the moderate-risk failure mode by two-thirds (highest RPN = 10). In our experience, FMEA is effective in supporting multidisciplinary IVF groups to understand the witnessing process, identifying critical steps and planning changes in practice to enable safety to be enhanced. Copyright © 2015 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Plastic Pipe Failure, Risk, and Threat Analysis

DOT National Transportation Integrated Search

2009-04-29

The three primary failure modes that may be exhibited by polyethylene (PE) gas pipe materials were described in detail. The modes are: ductile rupture, slow crack growth (SCG), and rapid crack propagation (RCP). Short term mechanical tests were evalu...

Risk Assessment Planning for Airborne Systems: An Information Assurance Failure Mode, Effects and Criticality Analysis Methodology

DTIC Science & Technology

2012-06-01

Visa Investigate Data Breach March 30, 2012 Visa and MasterCard are investigating whether a data security breach at one of the main companies that...30). MasterCard and Visa Investigate Data Breach . New York Times . Stamatis, D. (2003). Failure Mode Effect Analysis: FMEA from Theory to Execution

Probabilistic safety analysis of earth retaining structures during earthquakes

NASA Astrophysics Data System (ADS)

Grivas, D. A.; Souflis, C.

1982-07-01

A procedure is presented for determining the probability of failure of Earth retaining structures under static or seismic conditions. Four possible modes of failure (overturning, base sliding, bearing capacity, and overall sliding) are examined and their combined effect is evaluated with the aid of combinatorial analysis. The probability of failure is shown to be a more adequate measure of safety than the customary factor of safety. As Earth retaining structures may fail in four distinct modes, a system analysis can provide a single estimate for the possibility of failure. A Bayesian formulation of the safety retaining walls is found to provide an improved measure for the predicted probability of failure under seismic loading. The presented Bayesian analysis can account for the damage incurred to a retaining wall during an earthquake to provide an improved estimate for its probability of failure during future seismic events.

Fatigue of notched fiber composite laminates. Part 1: Analytical model

NASA Technical Reports Server (NTRS)

Mclaughlin, P. V., Jr.; Kulkarni, S. V.; Huang, S. N.; Rosen, B. W.

1975-01-01

A description is given of a semi-empirical, deterministic analysis for prediction and correlation of fatigue crack growth, residual strength, and fatigue lifetime for fiber composite laminates containing notches (holes). The failure model used for the analysis is based upon composite heterogeneous behavior and experimentally observed failure modes under both static and fatigue loading. The analysis is consistent with the wearout philosophy. Axial cracking and transverse cracking failure modes are treated together in the analysis. Cracking off-axis is handled by making a modification to the axial cracking analysis. The analysis predicts notched laminate failure from unidirectional material fatique properties using constant strain laminate analysis techniques. For multidirectional laminates, it is necessary to know lamina fatique behavior under axial normal stress, transverse normal stress and axial shear stress. Examples of the analysis method are given.

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.

Poster - Thur Eve - 05: Safety systems and failure modes and effects analysis for a magnetic resonance image guided radiation therapy system.

PubMed

Lamey, M; Carlone, M; Alasti, H; Bissonnette, J P; Borg, J; Breen, S; Coolens, C; Heaton, R; Islam, M; van Proojen, M; Sharpe, M; Stanescu, T; Jaffray, D

2012-07-01

An online Magnetic Resonance guided Radiation Therapy (MRgRT) system is under development. The system is comprised of an MRI with the capability of travel between and into HDR brachytherapy and external beam radiation therapy vaults. The system will provide on-line MR images immediately prior to radiation therapy. The MR images will be registered to a planning image and used for image guidance. With the intention of system safety we have performed a failure modes and effects analysis. A process tree of the facility function was developed. Using the process tree as well as an initial design of the facility as guidelines possible failure modes were identified, for each of these failure modes root causes were identified. For each possible failure the assignment of severity, detectability and occurrence scores was performed. Finally suggestions were developed to reduce the possibility of an event. The process tree consists of nine main inputs and each of these main inputs consisted of 5 - 10 sub inputs and tertiary inputs were also defined. The process tree ensures that the overall safety of the system has been considered. Several possible failure modes were identified and were relevant to the design, construction, commissioning and operating phases of the facility. The utility of the analysis can be seen in that it has spawned projects prior to installation and has lead to suggestions in the design of the facility. © 2012 American Association of Physicists in Medicine.

Tensile and compressive failure modes of laminated composites loaded by fatigue with different mean stress

NASA Technical Reports Server (NTRS)

Rotem, Assa

1990-01-01

Laminated composite materials tend to fail differently under tensile or compressive load. Under tension, the material accumulates cracks and fiber fractures, while under compression, the material delaminates and buckles. Tensile-compressive fatigue may cause either of these failure modes depending on the specific damage occurring in the laminate. This damage depends on the stress ratio of the fatigue loading. Analysis of the fatigue behavior of the composite laminate under tension-tension, compression-compression, and tension-compression had led to the development of a fatigue envelope presentation of the failure behavior. This envelope indicates the specific failure mode for any stress ratio and number of loading cycles. The construction of the fatigue envelope is based on the applied stress-cycles to failure (S-N) curves of both tensile-tensile and compressive-compressive fatigue. Test results are presented to verify the theoretical analysis.

Distributed collaborative probabilistic design of multi-failure structure with fluid-structure interaction using fuzzy neural network of regression

NASA Astrophysics Data System (ADS)

Song, Lu-Kai; Wen, Jie; Fei, Cheng-Wei; Bai, Guang-Chen

2018-05-01

To improve the computing efficiency and precision of probabilistic design for multi-failure structure, a distributed collaborative probabilistic design method-based fuzzy neural network of regression (FR) (called as DCFRM) is proposed with the integration of distributed collaborative response surface method and fuzzy neural network regression model. The mathematical model of DCFRM is established and the probabilistic design idea with DCFRM is introduced. The probabilistic analysis of turbine blisk involving multi-failure modes (deformation failure, stress failure and strain failure) was investigated by considering fluid-structure interaction with the proposed method. The distribution characteristics, reliability degree, and sensitivity degree of each failure mode and overall failure mode on turbine blisk are obtained, which provides a useful reference for improving the performance and reliability of aeroengine. Through the comparison of methods shows that the DCFRM reshapes the probability of probabilistic analysis for multi-failure structure and improves the computing efficiency while keeping acceptable computational precision. Moreover, the proposed method offers a useful insight for reliability-based design optimization of multi-failure structure and thereby also enriches the theory and method of mechanical reliability design.

AADL Fault Modeling and Analysis Within an ARP4761 Safety Assessment

DTIC Science & Technology

2014-10-01

Analysis Generator 27 3.2.3 Mapping to OpenFTA Format File 27 3.2.4 Mapping to Generic XML Format 28 3.2.5 AADL and FTA Mapping Rules 28 3.2.6 Issues...PSSA), System Safety Assessment (SSA), Common Cause Analysis (CCA), Fault Tree Analysis ( FTA ), Failure Modes and Effects Analysis (FMEA), Failure...Modes and Effects Summary, Mar - kov Analysis (MA), and Dependence Diagrams (DDs), also referred to as Reliability Block Dia- grams (RBDs). The

Determination of Turbine Blade Life from Engine Field Data

NASA Technical Reports Server (NTRS)

Zaretsky, Erwin V.; Litt, Jonathan S.; Hendricks, Robert C.; Soditus, Sherry M.

2012-01-01

It is probable that no two engine companies determine the life of their engines or their components in the same way or apply the same experience and safety factors to their designs. Knowing the failure mode that is most likely to occur minimizes the amount of uncertainty and simplifies failure and life analysis. Available data regarding failure mode for aircraft engine blades, while favoring low-cycle, thermal mechanical fatigue as the controlling mode of failure, are not definitive. Sixteen high-pressure turbine (HPT) T-1 blade sets were removed from commercial aircraft engines that had been commercially flown by a single airline and inspected for damage. Each set contained 82 blades. The damage was cataloged into three categories related to their mode of failure: (1) Thermal-mechanical fatigue, (2) Oxidation/Erosion, and (3) "Other." From these field data, the turbine blade life was determined as well as the lives related to individual blade failure modes using Johnson-Weibull analysis. A simplified formula for calculating turbine blade life and reliability was formulated. The L(sub 10) blade life was calculated to be 2427 cycles (11 077 hr). The resulting blade life attributed to oxidation/erosion equaled that attributed to thermal-mechanical fatigue. The category that contributed most to blade failure was Other. If there were there no blade failures attributed to oxidation/erosion and thermal-mechanical fatigue, the overall blade L(sub 10) life would increase approximately 11 to 17 percent.

Metallographic and fractographic observations of posttest creep-fatigue specimens of weld-deposited Type 308 CRE stainless steel

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

Williams, M. W.

Type 308 CRE stainless steel weld specimens were subjected to metallographic and fractographic analysis after failure in elevated-temperature (593/sup 0/C) creep-fatigue tests. The failure mode for specimens tested under continuous-cycle fatigue conditions was predominantly transgranular. When the test cycle was modified to include a hold time at the maximum tensile strain, the failure mode became predominantly interphase. Sigma phase was observed within the delta-ferrite regions in the weld. However, the presence of sigma phase did not appear to affect the failure mode.

The Use of Probabilistic Methods to Evaluate the Systems Impact of Component Design Improvements on Large Turbofan Engines

NASA Technical Reports Server (NTRS)

Packard, Michael H.

2002-01-01

Probabilistic Structural Analysis (PSA) is now commonly used for predicting the distribution of time/cycles to failure of turbine blades and other engine components. These distributions are typically based on fatigue/fracture and creep failure modes of these components. Additionally, reliability analysis is used for taking test data related to particular failure modes and calculating failure rate distributions of electronic and electromechanical components. How can these individual failure time distributions of structural, electronic and electromechanical component failure modes be effectively combined into a top level model for overall system evaluation of component upgrades, changes in maintenance intervals, or line replaceable unit (LRU) redesign? This paper shows an example of how various probabilistic failure predictions for turbine engine components can be evaluated and combined to show their effect on overall engine performance. A generic model of a turbofan engine was modeled using various Probabilistic Risk Assessment (PRA) tools (Quantitative Risk Assessment Software (QRAS) etc.). Hypothetical PSA results for a number of structural components along with mitigation factors that would restrict the failure mode from propagating to a Loss of Mission (LOM) failure were used in the models. The output of this program includes an overall failure distribution for LOM of the system. The rank and contribution to the overall Mission Success (MS) is also given for each failure mode and each subsystem. This application methodology demonstrates the effectiveness of PRA for assessing the performance of large turbine engines. Additionally, the effects of system changes and upgrades, the application of different maintenance intervals, inclusion of new sensor detection of faults and other upgrades were evaluated in determining overall turbine engine reliability.

Use of a systematic risk analysis method to improve safety in the production of paediatric parenteral nutrition solutions

PubMed Central

Bonnabry, P; Cingria, L; Sadeghipour, F; Ing, H; Fonzo-Christe, C; Pfister, R

2005-01-01

Background: Until recently, the preparation of paediatric parenteral nutrition formulations in our institution included re-transcription and manual compounding of the mixture. Although no significant clinical problems have occurred, re-engineering of this high risk activity was undertaken to improve its safety. Several changes have been implemented including new prescription software, direct recording on a server, automatic printing of the labels, and creation of a file used to pilot a BAXA MM 12 automatic compounder. The objectives of this study were to compare the risks associated with the old and new processes, to quantify the improved safety with the new process, and to identify the major residual risks. Methods: A failure modes, effects, and criticality analysis (FMECA) was performed by a multidisciplinary team. A cause-effect diagram was built, the failure modes were defined, and the criticality index (CI) was determined for each of them on the basis of the likelihood of occurrence, the severity of the potential effect, and the detection probability. The CIs for each failure mode were compared for the old and new processes and the risk reduction was quantified. Results: The sum of the CIs of all 18 identified failure modes was 3415 for the old process and 1397 for the new (reduction of 59%). The new process reduced the CIs of the different failure modes by a mean factor of 7. The CI was smaller with the new process for 15 failure modes, unchanged for two, and slightly increased for one. The greatest reduction (by a factor of 36) concerned re-transcription errors, followed by readability problems (by a factor of 30) and chemical cross contamination (by a factor of 10). The most critical steps in the new process were labelling mistakes (CI 315, maximum 810), failure to detect a dosage or product mistake (CI 288), failure to detect a typing error during the prescription (CI 175), and microbial contamination (CI 126). Conclusions: Modification of the process resulted in a significant risk reduction as shown by risk analysis. Residual failure opportunities were also quantified, allowing additional actions to be taken to reduce the risk of labelling mistakes. This study illustrates the usefulness of prospective risk analysis methods in healthcare processes. More systematic use of risk analysis is needed to guide continuous safety improvement of high risk activities. PMID:15805453

Use of a systematic risk analysis method to improve safety in the production of paediatric parenteral nutrition solutions.

PubMed

Bonnabry, P; Cingria, L; Sadeghipour, F; Ing, H; Fonzo-Christe, C; Pfister, R E

2005-04-01

Until recently, the preparation of paediatric parenteral nutrition formulations in our institution included re-transcription and manual compounding of the mixture. Although no significant clinical problems have occurred, re-engineering of this high risk activity was undertaken to improve its safety. Several changes have been implemented including new prescription software, direct recording on a server, automatic printing of the labels, and creation of a file used to pilot a BAXA MM 12 automatic compounder. The objectives of this study were to compare the risks associated with the old and new processes, to quantify the improved safety with the new process, and to identify the major residual risks. A failure modes, effects, and criticality analysis (FMECA) was performed by a multidisciplinary team. A cause-effect diagram was built, the failure modes were defined, and the criticality index (CI) was determined for each of them on the basis of the likelihood of occurrence, the severity of the potential effect, and the detection probability. The CIs for each failure mode were compared for the old and new processes and the risk reduction was quantified. The sum of the CIs of all 18 identified failure modes was 3415 for the old process and 1397 for the new (reduction of 59%). The new process reduced the CIs of the different failure modes by a mean factor of 7. The CI was smaller with the new process for 15 failure modes, unchanged for two, and slightly increased for one. The greatest reduction (by a factor of 36) concerned re-transcription errors, followed by readability problems (by a factor of 30) and chemical cross contamination (by a factor of 10). The most critical steps in the new process were labelling mistakes (CI 315, maximum 810), failure to detect a dosage or product mistake (CI 288), failure to detect a typing error during the prescription (CI 175), and microbial contamination (CI 126). Modification of the process resulted in a significant risk reduction as shown by risk analysis. Residual failure opportunities were also quantified, allowing additional actions to be taken to reduce the risk of labelling mistakes. This study illustrates the usefulness of prospective risk analysis methods in healthcare processes. More systematic use of risk analysis is needed to guide continuous safety improvement of high risk activities.

Independent Orbiter Assessment (IOA): Analysis of the electrical power distribution and control/remote manipulator system subsystem

NASA Technical Reports Server (NTRS)

Robinson, W. W.

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 Electrical Power Distribution and Control (EPD and C)/Remote Manipulator System (RMS) hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained in the NASA FMEA/CIL documentation. This report documents the results of the independent analysis of the EPD and C/RMS (both port and starboard) hardware. The EPD and C/RMS subsystem hardware provides the electrical power and power control circuitry required to safely deploy, operate, control, and stow or guillotine and jettison two (one port and one starboard) RMSs. The EPD and C/RMS subsystem is subdivided into the four following functional divisions: Remote Manipulator Arm; Manipulator Deploy Control; Manipulator Latch Control; Manipulator Arm Shoulder Jettison; and Retention Arm Jettison. The IOA analysis process utilized available EPD and C/RMS 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 on the severity of the effect for each failure mode.

Safety and feasibility of STAT RAD: Improvement of a novel rapid tomotherapy-based radiation therapy workflow by failure mode and effects analysis.

PubMed

Jones, Ryan T; Handsfield, Lydia; Read, Paul W; Wilson, David D; Van Ausdal, Ray; Schlesinger, David J; Siebers, Jeffrey V; Chen, Quan

2015-01-01

The clinical challenge of radiation therapy (RT) for painful bone metastases requires clinicians to consider both treatment efficacy and patient prognosis when selecting a radiation therapy regimen. The traditional RT workflow requires several weeks for common palliative RT schedules of 30 Gy in 10 fractions or 20 Gy in 5 fractions. At our institution, we have created a new RT workflow termed "STAT RAD" that allows clinicians to perform computed tomographic (CT) simulation, planning, and highly conformal single fraction treatment delivery within 2 hours. In this study, we evaluate the safety and feasibility of the STAT RAD workflow. A failure mode and effects analysis (FMEA) was performed on the STAT RAD workflow, including development of a process map, identification of potential failure modes, description of the cause and effect, temporal occurrence, and team member involvement in each failure mode, and examination of existing safety controls. A risk probability number (RPN) was calculated for each failure mode. As necessary, workflow adjustments were then made to safeguard failure modes of significant RPN values. After workflow alterations, RPN numbers were again recomputed. A total of 72 potential failure modes were identified in the pre-FMEA STAT RAD workflow, of which 22 met the RPN threshold for clinical significance. Workflow adjustments included the addition of a team member checklist, changing simulation from megavoltage CT to kilovoltage CT, alteration of patient-specific quality assurance testing, and allocating increased time for critical workflow steps. After these modifications, only 1 failure mode maintained RPN significance; patient motion after alignment or during treatment. Performing the FMEA for the STAT RAD workflow before clinical implementation has significantly strengthened the safety and feasibility of STAT RAD. The FMEA proved a valuable evaluation tool, identifying potential problem areas so that we could create a safer workflow. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Independent Orbiter Assessment (IOA): Assessment of the electrical power generation/power reactant storage and distribution subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Ames, B. E.

1988-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) is presented. The IOA effort first completed an analysis of the Electrical Power Generation/Power Reactant Storage and Distribution (EPG/PRSD) subsystem 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 baselines with proposed Post 51-L updates included. A resolution of each discrepancy from the comparison is provided through additional analysis as required. The results of that comparison are documented for the Orbiter EPG/PRSD hardware. The comparison produced agreement on all but 27 FMEAs and 9 CIL items. The discrepancy between the number of IOA findings and NASA FMEAs can be partially explained by the different approaches used by IOA and NASA to group failure modes together to form one FMEA. Also, several IOA items represented inner tank components and ground operations failure modes which were not in the NASA baseline.

Space Shuttle Main Engine Quantitative Risk Assessment: Illustrating Modeling of a Complex System with a New QRA Software Package

NASA Technical Reports Server (NTRS)

Smart, Christian

1998-01-01

During 1997, a team from Hernandez Engineering, MSFC, Rocketdyne, Thiokol, Pratt & Whitney, and USBI completed the first phase of a two year Quantitative Risk Assessment (QRA) of the Space Shuttle. The models for the Shuttle systems were entered and analyzed by a new QRA software package. This system, termed the Quantitative Risk Assessment System(QRAS), was designed by NASA and programmed by the University of Maryland. The software is a groundbreaking PC-based risk assessment package that allows the user to model complex systems in a hierarchical fashion. Features of the software include the ability to easily select quantifications of failure modes, draw Event Sequence Diagrams(ESDs) interactively, perform uncertainty and sensitivity analysis, and document the modeling. This paper illustrates both the approach used in modeling and the particular features of the software package. The software is general and can be used in a QRA of any complex engineered system. The author is the project lead for the modeling of the Space Shuttle Main Engines (SSMEs), and this paper focuses on the modeling completed for the SSMEs during 1997. In particular, the groundrules for the study, the databases used, the way in which ESDs were used to model catastrophic failure of the SSMES, the methods used to quantify the failure rates, and how QRAS was used in the modeling effort are discussed. Groundrules were necessary to limit the scope of such a complex study, especially with regard to a liquid rocket engine such as the SSME, which can be shut down after ignition either on the pad or in flight. The SSME was divided into its constituent components and subsystems. These were ranked on the basis of the possibility of being upgraded and risk of catastrophic failure. Once this was done the Shuttle program Hazard Analysis and Failure Modes and Effects Analysis (FMEA) were used to create a list of potential failure modes to be modeled. The groundrules and other criteria were used to screen out the many failure modes that did not contribute significantly to the catastrophic risk. The Hazard Analysis and FMEA for the SSME were also used to build ESDs that show the chain of events leading from the failure mode occurence to one of the following end states: catastrophic failure, engine shutdown, or siccessful operation( successful with respect to the failure mode under consideration).

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.

Preliminary analysis techniques for ring and stringer stiffened cylindrical shells

NASA Technical Reports Server (NTRS)

Graham, J.

1993-01-01

This report outlines methods of analysis for the buckling of thin-walled circumferentially and longitudinally stiffened cylindrical shells. Methods of analysis for the various failure modes are presented in one cohesive package. Where applicable, more than one method of analysis for a failure mode is presented along with standard practices. The results of this report are primarily intended for use in launch vehicle design in the elastic range. A Microsoft Excel worksheet with accompanying macros has been developed to automate the analysis procedures.

Fuzzy Risk Evaluation in Failure Mode and Effects Analysis Using a D Numbers Based Multi-Sensor Information Fusion Method.

PubMed

Deng, Xinyang; Jiang, Wen

2017-09-12

Failure mode and effect analysis (FMEA) is a useful tool to define, identify, and eliminate potential failures or errors so as to improve the reliability of systems, designs, and products. Risk evaluation is an important issue in FMEA to determine the risk priorities of failure modes. There are some shortcomings in the traditional risk priority number (RPN) approach for risk evaluation in FMEA, and fuzzy risk evaluation has become an important research direction that attracts increasing attention. In this paper, the fuzzy risk evaluation in FMEA is studied from a perspective of multi-sensor information fusion. By considering the non-exclusiveness between the evaluations of fuzzy linguistic variables to failure modes, a novel model called D numbers is used to model the non-exclusive fuzzy evaluations. A D numbers based multi-sensor information fusion method is proposed to establish a new model for fuzzy risk evaluation in FMEA. An illustrative example is provided and examined using the proposed model and other existing method to show the effectiveness of the proposed model.

Fuzzy Risk Evaluation in Failure Mode and Effects Analysis Using a D Numbers Based Multi-Sensor Information Fusion Method

PubMed Central

Deng, Xinyang

2017-01-01

Failure mode and effect analysis (FMEA) is a useful tool to define, identify, and eliminate potential failures or errors so as to improve the reliability of systems, designs, and products. Risk evaluation is an important issue in FMEA to determine the risk priorities of failure modes. There are some shortcomings in the traditional risk priority number (RPN) approach for risk evaluation in FMEA, and fuzzy risk evaluation has become an important research direction that attracts increasing attention. In this paper, the fuzzy risk evaluation in FMEA is studied from a perspective of multi-sensor information fusion. By considering the non-exclusiveness between the evaluations of fuzzy linguistic variables to failure modes, a novel model called D numbers is used to model the non-exclusive fuzzy evaluations. A D numbers based multi-sensor information fusion method is proposed to establish a new model for fuzzy risk evaluation in FMEA. An illustrative example is provided and examined using the proposed model and other existing method to show the effectiveness of the proposed model. PMID:28895905

Independent Orbiter Assessment (IOA): Analysis of the Orbiter Experiment (OEX) subsystem

NASA Technical Reports Server (NTRS)

Compton, J. M.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Experiments hardware. 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. The Orbiter Experiments (OEX) Program consists of a multiple set of experiments for the purpose of gathering environmental and aerodynamic data to develop more accurate ground models for Shuttle performance and to facilitate the design of future spacecraft. This assessment only addresses currently manifested experiments and their support systems. Specifically this list consists of: Shuttle Entry Air Data System (SEADS); Shuttle Upper Atmosphere Mass Spectrometer (SUMS); Forward Fuselage Support System for OEX (FFSSO); Shuttle Infrared Laced Temperature Sensor (SILTS); Aerodynamic Coefficient Identification Package (ACIP); and Support System for OEX (SSO). There are only two potential critical items for the OEX, since the experiments only gather data for analysis post mission and are totally independent systems except for power. Failure of any experiment component usually only causes a loss of experiment data and in no way jeopardizes the crew or mission.

Space Shuttle Stiffener Ring Foam Failure, a Non-Conventional Approach

NASA Technical Reports Server (NTRS)

Howard, Philip M.

2007-01-01

The Space Shuttle makes use of the excellent properties of rigid polyurethane foam for cryogenic tank insulation and as structural protection on the solid rocket boosters. When foam applications debond, classical methods of analysis do not always provide root cause of the failure of the foam. Realizing that foam is the ideal media to document and preserve its own mode of failure, thin sectioning was seen as a logical approach for foam failure analysis. Thin sectioning in two directions, both horizontal and vertical to the application, was chosen to observe the three dimensional morphology of the foam cells. The cell foam morphology provided a much greater understanding of the failure modes than previously achieved.

Proactive risk assessment of blood transfusion process, in pediatric emergency, using the Health Care Failure Mode and Effects Analysis (HFMEA).

PubMed

Dehnavieh, Reza; Ebrahimipour, Hossein; Molavi-Taleghani, Yasamin; Vafaee-Najar, Ali; Noori Hekmat, Somayeh; Esmailzdeh, Hamid

2014-12-25

Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, therefore this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology. This cross-sectional study analyzed the failure mode and effects of blood transfusion process by a mixture of quantitative-qualitative method. The proactive HFMEA was used to identify and analyze the potential failures of the process. The information of the items in HFMEA forms was collected after obtaining a consensus of experts' panel views via the interview and focus group discussion sessions. The Number of 77 failure modes were identified for 24 sub-processes enlisted in 8 processes of blood transfusion. Totally 13 failure modes were identified as non-acceptable risk (a hazard score above 8) in the blood transfusion process and were transferred to the decision tree. Root causes of high risk modes were discussed in cause-effect meetings and were classified based on the UK national health system (NHS) approved classifications model. Action types were classified in the form of acceptance (11.6%), control (74.2%) and elimination (14.2%). Recommendations were placed in 7 categories using TRIZ ("Theory of Inventive Problem Solving.") The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency.

Proactive Risk Assessment of Blood Transfusion Process, in Pediatric Emergency, Using the Health Care Failure Mode and Effects Analysis (HFMEA)

PubMed Central

Dehnavieh, Reza; Ebrahimipour, Hossein; Molavi-Taleghani, Yasamin; Vafaee-Najar, Ali; Hekmat, Somayeh Noori; Esmailzdeh, Hamid

2015-01-01

Introduction: Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, therefore this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology. Methodology: This cross-sectional study analyzed the failure mode and effects of blood transfusion process by a mixture of quantitative-qualitative method. The proactive HFMEA was used to identify and analyze the potential failures of the process. The information of the items in HFMEA forms was collected after obtaining a consensus of experts’ panel views via the interview and focus group discussion sessions. Results: The Number of 77 failure modes were identified for 24 sub-processes enlisted in 8 processes of blood transfusion. Totally 13 failure modes were identified as non-acceptable risk (a hazard score above 8) in the blood transfusion process and were transferred to the decision tree. Root causes of high risk modes were discussed in cause-effect meetings and were classified based on the UK national health system (NHS) approved classifications model. Action types were classified in the form of acceptance (11.6%), control (74.2%) and elimination (14.2%). Recommendations were placed in 7 categories using TRIZ (“Theory of Inventive Problem Solving.”) Conclusion: The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency. PMID:25560332

Multi-institutional application of Failure Mode and Effects Analysis (FMEA) to CyberKnife Stereotactic Body Radiation Therapy (SBRT).

PubMed

Veronese, Ivan; De Martin, Elena; Martinotti, Anna Stefania; Fumagalli, Maria Luisa; Vite, Cristina; Redaelli, Irene; Malatesta, Tiziana; Mancosu, Pietro; Beltramo, Giancarlo; Fariselli, Laura; Cantone, Marie Claire

2015-06-13

A multidisciplinary and multi-institutional working group applied the Failure Mode and Effects Analysis (FMEA) approach to assess the risks for patients undergoing Stereotactic Body Radiation Therapy (SBRT) treatments for lesions located in spine and liver in two CyberKnife® Centres. The various sub-processes characterizing the SBRT treatment were identified to generate the process trees of both the treatment planning and delivery phases. This analysis drove to the identification and subsequent scoring of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system. Novel solutions aimed to increase patient safety were accordingly considered. The process-tree characterising the SBRT treatment planning stage was composed with a total of 48 sub-processes. Similarly, 42 sub-processes were identified in the stage of delivery to liver tumours and 30 in the stage of delivery to spine lesions. All the sub-processes were judged to be potentially prone to one or more failure modes. Nineteen failures (i.e. 5 in treatment planning stage, 5 in the delivery to liver lesions and 9 in the delivery to spine lesions) were considered of high concern in view of the high RPN and/or severity index value. The analysis of the potential failures, their causes and effects allowed to improve the safety strategies already adopted in the clinical practice with additional measures for optimizing quality management workflow and increasing patient safety.

Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes.

PubMed

Sorrentino, Patricia

2016-01-01

The purpose of this article is to describe a quality improvement process using failure mode and effects analysis (FMEA) to evaluate systems handoff communication processes, improve emergency department (ED) throughput and reduce crowding through development of a standardized handoff, and, ultimately, improve patient safety. Risk of patient harm through ineffective communication during handoff transitions is a major reason for breakdown of systems. Complexities of ED processes put patient safety at risk. An increased incidence of submitted patient safety event reports for handoff communication failures between the ED and inpatient units solidified a decision to implement the use of FMEA to identify handoff failures to mitigate patient harm through redesign. The clinical nurse specialist implemented an FMEA. Handoff failure themes were created from deidentified retrospective reviews. Weekly meetings were held over a 3-month period to identify failure modes and determine cause and effect on the process. A functional block diagram process map tool was used to illustrate handoff processes. An FMEA grid was used to list failure modes and assign a risk priority number to quantify results. Multiple areas with actionable failures were identified. A majority of causes for high-priority failure modes were specific to communications. Findings demonstrate the complexity of transition and handoff processes. The FMEA served to identify and evaluate risk of handoff failures and provide a framework for process improvement. A focus on mentoring nurses to quality handoff processes so that it becomes habitual practice is crucial to safe patient transitions. Standardizing content and hardwiring within the system are best practice. The clinical nurse specialist is prepared to provide strong leadership to drive and implement system-wide quality projects.

Application of ISO22000 and Failure Mode and Effect Analysis (fmea) for Industrial Processing of Poultry Products

NASA Astrophysics Data System (ADS)

Varzakas, Theodoros H.; Arvanitoyannis, Ioannis S.

Failure Mode and Effect Analysis (FMEA) model has been applied for the risk assessment of poultry slaughtering and manufacturing. In this work comparison of ISO22000 analysis with HACCP is carried out over poultry slaughtering, processing and packaging. Critical Control points and Prerequisite programs (PrPs) have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram and fishbone diagram).

Independent Orbiter Assessment (IOA): Analysis of the landing/deceleration subsystem

NASA Technical Reports Server (NTRS)

Compton, J. M.; Beaird, H. G.; Weissinger, W. D.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Landing/Deceleration Subsystem hardware. The Landing/Deceleration Subsystem is utilized to allow the Orbiter to perform a safe landing, allowing for landing-gear deploy activities, steering and braking control throughout the landing rollout to wheel-stop, and to allow for ground-handling capability during the ground-processing phase of the flight cycle. Specifically, the Landing/Deceleration hardware consists of the following components: Nose Landing Gear (NLG); Main Landing Gear (MLG); Brake and Antiskid (B and AS) Electrical Power Distribution and Controls (EPD and C); Nose Wheel Steering (NWS); and Hydraulics Actuators. 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. Due to the lack of redundancy in the Landing/Deceleration Subsystems there is a high number of critical items.

Development of pile foundation bias factors using observed behavior of platforms during Hurricane Andrew

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

Aggarwal, R.K.; Litton, R.W.; Cornell, C.A.

1996-12-31

The performance of more than 3,000 offshore platforms in the Gulf of Mexico was observed during the passage of Hurricane Andrew in August 1992. This event provided an opportunity to test the procedures used for platform analysis and design. A global bias was inferred for overall platform capacity and loads in the Andrew Joint Industry Project (JIP) Phase 1. It was predicted that the pile foundations of several platforms should have failed, but did not. These results indicated that the biases specific to foundation failure modes may be higher than those of jacket failure modes. The biases in predictions ofmore » foundation failure modes were therefore investigated further in this study. The work included capacity analysis and calibration of predictions with the observed behavior for 3 jacket platforms and 3 caissons using Bayesian updating. Bias factors for two foundation failure modes, lateral shear and overturning, were determined for each structure. Foundation capacity estimates using conventional methods were found to be conservatively biased overall.« less

Catastrophic optical bulk degradation (COBD) in high-power single- and multi-mode InGaAs-AlGaAs strained quantum well lasers

NASA Astrophysics Data System (ADS)

Sin, Yongkun; Lingley, Zachary; Brodie, Miles; Presser, Nathan; Moss, Steven C.

2017-02-01

High-power single-mode (SM) and multi-mode (MM) InGaAs-AlGaAs strained quantum well (QW) lasers are critical components for both telecommunications and space satellite communications systems. However, little has been reported on failure modes and degradation mechanisms of high-power SM and MM InGaAs-AlGaAs strained QW lasers although it is crucial to understand failure modes and underlying degradation mechanisms in developing these lasers that meet lifetime requirements for space satellite systems, where extremely high reliability of these lasers is required. Our present study addresses the aforementioned issues by performing long-term life-tests followed by failure mode analysis (FMA) and physics of failure investigation. We performed long-term accelerated life-tests on state-of-the-art SM and MM InGaAs-AlGaAs strained QW lasers under ACC (automatic current control) mode. Our life-tests have accumulated over 25,000 test hours for SM lasers and over 35,000 test hours for MM lasers. FMA was performed on failed SM lasers using electron beam induced current (EBIC). This technique allowed us to identify failure types by observing dark line defects. All the SM failures we studied showed catastrophic and sudden degradation and all of these failures were bulk failures. Our group previously reported that bulk failure or COBD (catastrophic optical bulk damage) is the dominant failure mode of MM InGaAs-AlGaAs strained QW lasers. Since degradation mechanisms responsible for COBD are still not well understood, we also employed other techniques including focused ion beam (FIB) processing and high-resolution TEM to further study dark line defects and dislocations in post-aged lasers. Our long-term life-test results and FMA results are reported.

Failure modes and effects analysis (FMEA) for Gamma Knife radiosurgery.

PubMed

Xu, Andy Yuanguang; Bhatnagar, Jagdish; Bednarz, Greg; Flickinger, John; Arai, Yoshio; Vacsulka, Jonet; Feng, Wenzheng; Monaco, Edward; Niranjan, Ajay; Lunsford, L Dade; Huq, M Saiful

2017-11-01

Gamma Knife radiosurgery is a highly precise and accurate treatment technique for treating brain diseases with low risk of serious error that nevertheless could potentially be reduced. We applied the AAPM Task Group 100 recommended failure modes and effects analysis (FMEA) tool to develop a risk-based quality management program for Gamma Knife radiosurgery. A team consisting of medical physicists, radiation oncologists, neurosurgeons, radiation safety officers, nurses, operating room technologists, and schedulers at our institution and an external physicist expert on Gamma Knife was formed for the FMEA study. A process tree and a failure mode table were created for the Gamma Knife radiosurgery procedures using the Leksell Gamma Knife Perfexion and 4C units. Three scores for the probability of occurrence (O), the severity (S), and the probability of no detection for failure mode (D) were assigned to each failure mode by 8 professionals on a scale from 1 to 10. An overall risk priority number (RPN) for each failure mode was then calculated from the averaged O, S, and D scores. The coefficient of variation for each O, S, or D score was also calculated. The failure modes identified were prioritized in terms of both the RPN scores and the severity scores. The established process tree for Gamma Knife radiosurgery consists of 10 subprocesses and 53 steps, including a subprocess for frame placement and 11 steps that are directly related to the frame-based nature of the Gamma Knife radiosurgery. Out of the 86 failure modes identified, 40 Gamma Knife specific failure modes were caused by the potential for inappropriate use of the radiosurgery head frame, the imaging fiducial boxes, the Gamma Knife helmets and plugs, the skull definition tools as well as other features of the GammaPlan treatment planning system. The other 46 failure modes are associated with the registration, imaging, image transfer, contouring processes that are common for all external beam radiation therapy techniques. The failure modes with the highest hazard scores are related to imperfect frame adaptor attachment, bad fiducial box assembly, unsecured plugs/inserts, overlooked target areas, and undetected machine mechanical failure during the morning QA process. The implementation of the FMEA approach for Gamma Knife radiosurgery enabled deeper understanding of the overall process among all professionals involved in the care of the patient and helped identify potential weaknesses in the overall process. The results of the present study give us a basis for the development of a risk based quality management program for Gamma Knife radiosurgery. © 2017 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.

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

Teixeira, Flavia C., E-mail: flavitiz@gmail.com; Almeida, Carlos E. de; Saiful Huq, M.

Purpose: The goal of this study was to evaluate the safety and quality management program for stereotactic radiosurgery (SRS) treatment processes at three radiotherapy centers in Brazil by using three industrial engineering tools (1) process mapping, (2) failure modes and effects analysis (FMEA), and (3) fault tree analysis. Methods: The recommendations of Task Group 100 of American Association of Physicists in Medicine were followed to apply the three tools described above to create a process tree for SRS procedure for each radiotherapy center and then FMEA was performed. Failure modes were identified for all process steps and values of riskmore » priority number (RPN) were calculated from O, S, and D (RPN = O × S × D) values assigned by a professional team responsible for patient care. Results: The subprocess treatment planning was presented with the highest number of failure modes for all centers. The total number of failure modes were 135, 104, and 131 for centers I, II, and III, respectively. The highest RPN value for each center is as follows: center I (204), center II (372), and center III (370). Failure modes with RPN ≥ 100: center I (22), center II (115), and center III (110). Failure modes characterized by S ≥ 7, represented 68% of the failure modes for center III, 62% for center II, and 45% for center I. Failure modes with RPNs values ≥100 and S ≥ 7, D ≥ 5, and O ≥ 5 were considered as high priority in this study. Conclusions: The results of the present study show that the safety risk profiles for the same stereotactic radiotherapy process are different at three radiotherapy centers in Brazil. Although this is the same treatment process, this present study showed that the risk priority is different and it will lead to implementation of different safety interventions among the centers. Therefore, the current practice of applying universal device-centric QA is not adequate to address all possible failures in clinical processes at different radiotherapy centers. Integrated approaches to device-centric and process specific quality management program specific to each radiotherapy center are the key to a safe quality management program.« less

Life Cycle Costing: A Working Level Approach

DTIC Science & Technology

1981-06-01

Effects Analysis ( FMEA ) ...... ................ .. 59 Logistics Performance Factors (LPFs) 60 Planning the Use of Life Cycle Cost in the Demonstration...form. Failure Mode and Effects Analysis ( FMEA ). Description. FMEA is a technique that attempts to improve the design of any particular unit. The FMEA ...failure modes and also eliminate extra parts or ones that are used to achieve more performance than is necessary (16:5-14]. Advantages. FMEA forces

Orbiter subsystem hardware/software interaction analysis. Volume 8: AFT reaction control system, part 2

NASA Technical Reports Server (NTRS)

Becker, D. D.

1980-01-01

The orbiter subsystems and interfacing program elements which interact with the orbiter computer flight software are analyzed. The failure modes identified in the subsystem/element failure mode and effects analysis are examined. Potential interaction with the software is examined through an evaluation of the software requirements. The analysis is restricted to flight software requirements and excludes utility/checkout software. The results of the hardware/software interaction analysis for the forward reaction control system are presented.

Failure Modes and Effects Analysis of bilateral same-day cataract surgery

PubMed Central

Shorstein, Neal H.; Lucido, Carol; Carolan, James; Liu, Liyan; Slean, Geraldine; Herrinton, Lisa J.

2017-01-01

PURPOSE To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN Retrospective cohort study. METHODS Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry. Potential failures in human factors and communication (modes) were identified. Rates of endophthalmitis, toxic anterior segment syndrome (TASS), and unintended intraocular lens (IOL) implantation were assessed in eyes having bilateral same-day surgery from 2010 through 2014. RESULTS The study comprised 4754 eyes. The analysis identified 15 significant potential failure modes. These included lapses in instrument processing and compounding error of intracameral antibiotic that could lead to endophthalmitis or TASS and ambiguous documentation of IOL selection by surgeons, which could lead to unintended IOL implantation. Of the study sample, 1 eye developed endophthalmitis, 1 eye had unintended IOL implantation (rates, 2 per 10 000; 95% confidence intervals [CI] 0.1–12.0 per 10 000), and no eyes developed TASS (upper 95% CI, 8 per 10 000). Recommendations included improving oversight of cleaning and sterilization practices, separating lots of compounded drugs for each eye, and enhancing IOL verification procedures. CONCLUSIONS Potential failure modes and recommended actions in bilateral same-day cataract surgery were determined using a FMEA. These findings might help improve the reliability and safety of bilateral same-day cataract surgery based on current evidence and standards. PMID:28410711

NASA Structural Analysis Report on the American Airlines Flight 587 Accident - Local Analysis of the Right Rear Lug

NASA Technical Reports Server (NTRS)

Raju, Ivatury S; Glaessgen, Edward H.; Mason, Brian H; Krishnamurthy, Thiagarajan; Davila, Carlos G

2005-01-01

A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. From the analyses conducted and presented in this paper, the following conclusions were drawn. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985-certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003- subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs. I.

Quantitative Approach to Failure Mode and Effect Analysis for Linear Accelerator Quality Assurance

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

O'Daniel, Jennifer C., E-mail: jennifer.odaniel@duke.edu; Yin, Fang-Fang

Purpose: To determine clinic-specific linear accelerator quality assurance (QA) TG-142 test frequencies, to maximize physicist time efficiency and patient treatment quality. Methods and Materials: A novel quantitative approach to failure mode and effect analysis is proposed. Nine linear accelerator-years of QA records provided data on failure occurrence rates. The severity of test failure was modeled by introducing corresponding errors into head and neck intensity modulated radiation therapy treatment plans. The relative risk of daily linear accelerator QA was calculated as a function of frequency of test performance. Results: Although the failure severity was greatest for daily imaging QA (imaging vsmore » treatment isocenter and imaging positioning/repositioning), the failure occurrence rate was greatest for output and laser testing. The composite ranking results suggest that performing output and lasers tests daily, imaging versus treatment isocenter and imaging positioning/repositioning tests weekly, and optical distance indicator and jaws versus light field tests biweekly would be acceptable for non-stereotactic radiosurgery/stereotactic body radiation therapy linear accelerators. Conclusions: Failure mode and effect analysis is a useful tool to determine the relative importance of QA tests from TG-142. Because there are practical time limitations on how many QA tests can be performed, this analysis highlights which tests are the most important and suggests the frequency of testing based on each test's risk priority number.« less

Degradation analysis of anode-supported intermediate temperature-solid oxide fuel cells under various failure modes

NASA Astrophysics Data System (ADS)

Lee, Tae-Hee; Park, Ka-Young; Kim, Ji-Tae; Seo, Yongho; Kim, Ki Buem; Song, Sun-Ju; Park, Byoungnam; Park, Jun-Young

2015-02-01

This study focuses on mechanisms and symptoms of several simulated failure modes, which may have significant influences on the long-term durability and operational stability of intermediate temperature-solid oxide fuel cells (IT-SOFCs), including fuel/oxidation starvation by breakdown of fuel/air supply components and wet and dry cycling atmospheres. Anode-supported IT-SOFCs consisting of a Ba0.5Sr0.5Co0.8Fe0.2O3-δ (BSCF)-Nd0.1Ce0.9O2-δ (NDC) composite cathode with an NDC electrolyte on a Ni-NDC anode substrate are fabricated via dry-pressings followed by the co-firing method. Comprehensive and systematic research based on the failure mode and effect analysis (FMEA) of anode-supported IT-SOFCs is conducted using various electrochemical and physiochemical analysis techniques to extend our understanding of the major mechanisms of performance deterioration under SOFC operating conditions. The fuel-starvation condition in the fuel-pump failure mode causes irreversible mechanical degradation of the electrolyte and cathode interface by the dimensional expansion of the anode support due to the oxidation of Ni metal to NiO. In contrast, the BSCF cathode shows poor stability under wet and dry cycling modes of cathode air due to the strong electroactivity of SrO with H2O. On the other hand, the air-depletion phenomena under air-pump failure mode results in the recovery of cell performance during the long-term operation without the visible microstructural transformation through the reduction of anode overvoltage.

Sensitivity analysis by approximation formulas - Illustrative examples. [reliability analysis of six-component architectures

NASA Technical Reports Server (NTRS)

White, A. L.

1983-01-01

This paper examines the reliability of three architectures for six components. For each architecture, the probabilities of the failure states are given by algebraic formulas involving the component fault rate, the system recovery rate, and the operating time. The dominant failure modes are identified, and the change in reliability is considered with respect to changes in fault rate, recovery rate, and operating time. The major conclusions concern the influence of system architecture on failure modes and parameter requirements. Without this knowledge, a system designer may pick an inappropriate structure.

Using the failure mode and effects analysis model to improve parathyroid hormone and adrenocorticotropic hormone testing

PubMed Central

Magnezi, Racheli; Hemi, Asaf; Hemi, Rina

2016-01-01

Background Risk management in health care systems applies to all hospital employees and directors as they deal with human life and emergency routines. There is a constant need to decrease risk and increase patient safety in the hospital environment. The purpose of this article is to review the laboratory testing procedures for parathyroid hormone and adrenocorticotropic hormone (which are characterized by short half-lives) and to track failure modes and risks, and offer solutions to prevent them. During a routine quality improvement review at the Endocrine Laboratory in Tel Hashomer Hospital, we discovered these tests are frequently repeated unnecessarily due to multiple failures. The repetition of the tests inconveniences patients and leads to extra work for the laboratory and logistics personnel as well as the nurses and doctors who have to perform many tasks with limited resources. Methods A team of eight staff members accompanied by the Head of the Endocrine Laboratory formed the team for analysis. The failure mode and effects analysis model (FMEA) was used to analyze the laboratory testing procedure and was designed to simplify the process steps and indicate and rank possible failures. Results A total of 23 failure modes were found within the process, 19 of which were ranked by level of severity. The FMEA model prioritizes failures by their risk priority number (RPN). For example, the most serious failure was the delay after the samples were collected from the department (RPN =226.1). Conclusion This model helped us to visualize the process in a simple way. After analyzing the information, solutions were proposed to prevent failures, and a method to completely avoid the top four problems was also developed. PMID:27980440

Independent Orbiter Assessment (IOA): Assessment of the active thermal control system

NASA Technical Reports Server (NTRS)

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 Active Thermal Control System (ATCS) 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 available NASA FMEA/CIL data. Discrepancies from the comparison were documented, and where enough information was available, recommendations for resolution of the discrepancies were made. This report documents the results of that comparison for the Orbiter ATCS hardware. The IOA product for the ATCS independent analysis consisted of 310 failure mode worksheets that resulted in 101 potential critical items (PCI) being identified. A comparison was made to the available NASA data which consisted of 252 FMEAs and 109 CIL items.

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

[Failure mode and effects analysis to improve quality in clinical trials].

PubMed

Mañes-Sevilla, M; Marzal-Alfaro, M B; Romero Jiménez, R; Herranz-Alonso, A; Sanchez Fresneda, M N; Benedi Gonzalez, J; Sanjurjo-Sáez, M

The failure mode and effects analysis (FMEA) has been used as a tool in risk management and quality improvement. The objective of this study is to identify the weaknesses in processes in the clinical trials area, of a Pharmacy Department (PD) with great research activity, in order to improve the safety of the usual procedures. A multidisciplinary team was created to analyse each of the critical points, identified as possible failure modes, in the development of clinical trial in the PD. For each failure mode, the possible cause and effect were identified, criticality was calculated using the risk priority number and the possible corrective actions were discussed. Six sub-processes were defined in the development of the clinical trials in PD. The FMEA identified 67 failure modes, being the dispensing and prescription/validation sub-processes the most likely to generate errors. All the improvement actions established in the AMFE were implemented in the Clinical Trials area. The FMEA is a useful tool in proactive risk management because it allows us to identify where we are making mistakes and analyze the causes that originate them, to prioritize and to adopt solutions to risk reduction. The FMEA improves process safety and quality in PD. Copyright © 2018 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

An improved approach for flight readiness certification: Methodology for failure risk assessment and application examples. Volume 2: Software documentation

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes, These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.

An improved approach for flight readiness certification: Methodology for failure risk assessment and application examples, volume 1

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.

Consistency of FMEA used in the validation of analytical procedures.

PubMed

Oldenhof, M T; van Leeuwen, J F; Nauta, M J; de Kaste, D; Odekerken-Rombouts, Y M C F; Vredenbregt, M J; Weda, M; Barends, D M

2011-02-20

In order to explore the consistency of the outcome of a Failure Mode and Effects Analysis (FMEA) in the validation of analytical procedures, an FMEA was carried out by two different teams. The two teams applied two separate FMEAs to a High Performance Liquid Chromatography-Diode Array Detection-Mass Spectrometry (HPLC-DAD-MS) analytical procedure used in the quality control of medicines. Each team was free to define their own ranking scales for the probability of severity (S), occurrence (O), and detection (D) of failure modes. We calculated Risk Priority Numbers (RPNs) and we identified the failure modes above the 90th percentile of RPN values as failure modes needing urgent corrective action; failure modes falling between the 75th and 90th percentile of RPN values were identified as failure modes needing necessary corrective action, respectively. Team 1 and Team 2 identified five and six failure modes needing urgent corrective action respectively, with two being commonly identified. Of the failure modes needing necessary corrective actions, about a third were commonly identified by both teams. These results show inconsistency in the outcome of the FMEA. To improve consistency, we recommend that FMEA is always carried out under the supervision of an experienced FMEA-facilitator and that the FMEA team has at least two members with competence in the analytical method to be validated. However, the FMEAs of both teams contained valuable information that was not identified by the other team, indicating that this inconsistency is not always a drawback. Copyright © 2010 Elsevier B.V. All rights reserved.

Some failure modes and analysis techniques for terrestrial solar cell modules

NASA Technical Reports Server (NTRS)

Shumka, A.; Stern, K. H.

1978-01-01

Analysis data are presented on failed/defective silicon solar cell modules of various types and produced by different manufacturers. The failure mode (e.g., internal short and open circuits, output power degradation, isolation resistance degradation, etc.) are discussed in detail and in many cases related to the type of technology used in the manufacture of the modules; wherever applicable, appropriate corrective actions are recommended. Consideration is also given to some failure analysis techniques that are applicable to such modules, including X-ray radiography, capacitance measurement, cell shunt resistance measurement by the shadowing technique, steady-state illumination test station for module performance illumination, laser scanning techniques, and the SEM.

Space tug propulsion system failure mode, effects and criticality analysis

NASA Technical Reports Server (NTRS)

Boyd, J. W.; Hardison, E. P.; Heard, C. B.; Orourke, J. C.; Osborne, F.; Wakefield, L. T.

1972-01-01

For purposes of the study, the propulsion system was considered as consisting of the following: (1) main engine system, (2) auxiliary propulsion system, (3) pneumatic system, (4) hydrogen feed, fill, drain and vent system, (5) oxygen feed, fill, drain and vent system, and (6) helium reentry purge system. Each component was critically examined to identify possible failure modes and the subsequent effect on mission success. Each space tug mission consists of three phases: launch to separation from shuttle, separation to redocking, and redocking to landing. The analysis considered the results of failure of a component during each phase of the mission. After the failure modes of each component were tabulated, those components whose failure would result in possible or certain loss of mission or inability to return the Tug to ground were identified as critical components and a criticality number determined for each. The criticality number of a component denotes the number of mission failures in one million missions due to the loss of that component. A total of 68 components were identified as critical with criticality numbers ranging from 1 to 2990.

A structured analysis of in vitro failure loads and failure modes of fiber, metal, and ceramic post-and-core systems.

PubMed

Fokkinga, Wietske A; Kreulen, Cees M; Vallittu, Pekka K; Creugers, Nico H J

2004-01-01

This study sought to aggregate literature data on in vitro failure loads and failure modes of prefabricated fiber-reinforced composite (FRC) post systems and to compare them to those of prefabricated metal, custom-cast, and ceramic post systems. The literature was searched using MEDLINE from 1984 to 2003 for dental articles in English. Keywords used were (post or core or buildup or dowel) and (teeth or tooth). Additional inclusion/exclusion steps were conducted, each step by two independent readers: (1) Abstracts describing post-and-core techniques to reconstruct endodontically treated teeth and their mechanical and physical characteristics were included (descriptive studies or reviews were excluded); (2) articles that included FRC post systems were selected; (3) in vitro studies, single-rooted human teeth, prefabricated FRC posts, and composite as the core material were the selection criteria; and (4) failure loads and modes were extracted from the selected papers, and failure modes were dichotomized (distinction was made between "favorable failures," defined as reparable failures, and "unfavorable failures,"defined as irreparable [root] fractures). The literature search revealed 1,984 abstracts. Included were 244, 42, and 12 articles in the first, second, and third selection steps, respectively. Custom-cast post systems showed higher failure loads than prefabricated FRC post systems, whereas ceramic showed lower failure loads. Significantly more favorable failures occurred with prefabricated FRC post systems than with prefabricated and custom-cast metal post systems. The variable "post system" had a significant effect on mean failure loads. FRC post systems more frequently showed favorable failure modes than did metal post systems.

Light water reactor lower head failure analysis

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

Rempe, J.L.; Chavez, S.A.; Thinnes, G.L.

1993-10-01

This document presents the results from a US Nuclear Regulatory Commission-sponsored research program to investigate the mode and timing of vessel lower head failure. Major objectives of the analysis were to identify plausible failure mechanisms and to develop a method for determining which failure mode would occur first in different light water reactor designs and accident conditions. Failure mechanisms, such as tube ejection, tube rupture, global vessel failure, and localized vessel creep rupture, were studied. Newly developed models and existing models were applied to predict which failure mechanism would occur first in various severe accident scenarios. So that a broadermore » range of conditions could be considered simultaneously, calculations relied heavily on models with closed-form or simplified numerical solution techniques. Finite element techniques-were employed for analytical model verification and examining more detailed phenomena. High-temperature creep and tensile data were obtained for predicting vessel and penetration structural response.« less

Independent Orbiter Assessment (IOA): Assessment of the remote manipulator system FMEA/CIL

NASA Technical Reports Server (NTRS)

Tangorra, F.; Grasmeder, R. F.; Montgomery, A. D.

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 Remote Manipulator System (RMS) 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 than 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. The results of that comparison for the Orbiter RMS hardware are documented. The IOA product for the RMS analysis consisted of 604 failure mode worksheets that resulted in 458 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 45 FMEAs and 321 CIL items. This comparison produced agreement on all but 154 FMEAs which caused differences in 137 CIL items.

Independent Orbiter Assessment (IOA): Assessment of the hydraulics/water spray boiler subsystem

NASA Technical Reports Server (NTRS)

Bynum, M. C.; Duval, J. D.; Parkman, W. E.; Davidson, W. R.

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 Hydraulics/Water Spray Boiler (HYD/WSB) 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 HYD/WSB hardware. The IOA product for the HYD/WSB analysis consisted of 447 failure mode worksheets that resulted in 183 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 364 FMEAs and 111 CIL items. This comparison produced agreement on all but 68 FMEAs which caused differences in 23 CIL items.

Independent Orbiter Assessment (IOA): Assessment of the Electrical Power Distribution and Control/Electrical Power Generation (EPD and C/EPG) FMEA/CIL

NASA Technical Reports Server (NTRS)

Mccants, C. N.; Bearrow, M.

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 Electrical Power Distribution and Control/Electrical Power Generation (EPD and C/EPG) 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 was provided through additional analysis as required. The results of that comparison is documented for the Orbiter EPD and C/EPG hardware. The IOA product for the EPD and C/EPG analysis consisted of 263 failure mode worksheets that resulted in 42 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 211 FMEA and 47 CIL items.

Independent Orbiter Assessment (IOA): Assessment of the auxiliary power unit

NASA Technical Reports Server (NTRS)

Barnes, J. E.

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 Auxiliary Power Unit (APU) 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 APU hardware. The IOA product for the APU analysis, covering both APU hardware and APU electrical components, consisted of 344 failure mode worksheets that resulted in 178 potential critical items being identified. A comparison was made of the IOA product to the NASA APU hardware FMEA/CIL baseline which consisted of 184 FMEAs and 57 CIL items. The comparison identified 72 discrepancies.

Independent Orbiter Assessment (IOA): Assessment of the guidance, navigation, and control subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Trahan, W. H.; Odonnell, R. A.; Pietz, K. C.; Drapela, L. J.

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 Guidance, Navigation, and Control System (GNC) 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. The results of that comparison for the Orbiter GNC hardware is documented. The IOA product for the GNC analysis consisted of 141 failure mode worksheets that resulted in 24 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 148 FMEAs and 36 CIL items. This comparison produced agreement on all but 56 FMEAs which caused differences in zero CIL items.

Application of Failure Mode and Effect Analysis (FMEA), cause and effect analysis, and Pareto diagram in conjunction with HACCP to a corn curl manufacturing plant.

PubMed

Varzakas, Theodoros H; Arvanitoyannis, Ioannis S

2007-01-01

The Failure Mode and Effect Analysis (FMEA) model has been applied for the risk assessment of corn curl manufacturing. A tentative approach of FMEA application to the snacks industry was attempted in an effort to exclude the presence of GMOs in the final product. This is of crucial importance both from the ethics and the legislation (Regulations EC 1829/2003; EC 1830/2003; Directive EC 18/2001) point of view. The Preliminary Hazard Analysis and the Fault Tree Analysis were used to analyze and predict the occurring failure modes in a food chain system (corn curls processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram, and the fishbone diagram). Finally, Pareto diagrams were employed towards the optimization of GMOs detection potential of FMEA.

Independent Orbiter Assessment (IOA): Assessment of the body flap subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Wilson, R. E.

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 Body Flap (BF) 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 BF hardware. The IOA product for the BF analysis consisted of 43 failure mode worksheets that resulted in 19 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 34 FMEAs and 15 CIL items. This comparison produced agreement on all CIL items. Based on the Pre 51-L baseline, all non-CIL FMEAs were also in agreement.

Independent Orbiter Assessment (IOA): Assessment of the elevon actuator subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Wilson, R. E.

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 Elevon Subsystem 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 Elevon hardware. The IOA product for the Elevon analysis consisted of 25 failure mode worksheets that resulted in 17 potential critical items being identified. Comparison was made to the NASA FMEA/CIL, which consisted of 23 FMEAs and 13 CIL items. This comparison produced agreement on all CIL items. Based on the Pre 51-L baseline, all non-CIL FMEAs were also in agreement.

Independent Orbiter Assessment (IOA): Assessment of instrumental subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Gardner, J. R.; Addis, A. W.

1988-01-01

The McDonnell Douglas Astronautics Company (MDAC) was selected in June 1986 to perform an Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL). The IOA effort first completed an analysis of the Instrumentation 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. A resolution of each discrepancy from the comparison is provided through additional analysis as required. The results of that comparison for the Orbiter Instrumentation hardware are documented. The IOA product for Instrumentation analysis consisted of 107 failure mode worksheets that resulted in 22 critical items being identified. Comparison was made to the Pre 51-L NASA baseline with 14 Post 51-L FMEAs added, which consists of 96 FMEAs and 18 CIL items. This comparison produced agreement on all but 25 FMEAs which caused differences in 5 CIL items.

Advances on the Failure Analysis of the Dam-Foundation Interface of Concrete Dams.

PubMed

Altarejos-García, Luis; Escuder-Bueno, Ignacio; Morales-Torres, Adrián

2015-12-02

Failure analysis of the dam-foundation interface in concrete dams is characterized by complexity, uncertainties on models and parameters, and a strong non-linear softening behavior. In practice, these uncertainties are dealt with a well-structured mixture of experience, best practices and prudent, conservative design approaches based on the safety factor concept. Yet, a sound, deep knowledge of some aspects of this failure mode remain unveiled, as they have been offset in practical applications by the use of this conservative approach. In this paper we show a strategy to analyse this failure mode under a reliability-based approach. The proposed methodology of analysis integrates epistemic uncertainty on spatial variability of strength parameters and data from dam monitoring. The purpose is to produce meaningful and useful information regarding the probability of occurrence of this failure mode that can be incorporated in risk-informed dam safety reviews. In addition, relationships between probability of failure and factors of safety are obtained. This research is supported by a more than a decade of intensive professional practice on real world cases and its final purpose is to bring some clarity, guidance and to contribute to the improvement of current knowledge and best practices on such an important dam safety concern.

Advances on the Failure Analysis of the Dam—Foundation Interface of Concrete Dams

PubMed Central

Altarejos-García, Luis; Escuder-Bueno, Ignacio; Morales-Torres, Adrián

2015-01-01

Failure analysis of the dam-foundation interface in concrete dams is characterized by complexity, uncertainties on models and parameters, and a strong non-linear softening behavior. In practice, these uncertainties are dealt with a well-structured mixture of experience, best practices and prudent, conservative design approaches based on the safety factor concept. Yet, a sound, deep knowledge of some aspects of this failure mode remain unveiled, as they have been offset in practical applications by the use of this conservative approach. In this paper we show a strategy to analyse this failure mode under a reliability-based approach. The proposed methodology of analysis integrates epistemic uncertainty on spatial variability of strength parameters and data from dam monitoring. The purpose is to produce meaningful and useful information regarding the probability of occurrence of this failure mode that can be incorporated in risk-informed dam safety reviews. In addition, relationships between probability of failure and factors of safety are obtained. This research is supported by a more than a decade of intensive professional practice on real world cases and its final purpose is to bring some clarity, guidance and to contribute to the improvement of current knowledge and best practices on such an important dam safety concern. PMID:28793709

Testing of containers made of glass-fiber reinforced plastic with the aid of acoustic emission analysis

NASA Technical Reports Server (NTRS)

Wolitz, K.; Brockmann, W.; Fischer, T.

1979-01-01

Acoustic emission analysis as a quasi-nondestructive test method makes it possible to differentiate clearly, in judging the total behavior of fiber-reinforced plastic composites, between critical failure modes (in the case of unidirectional composites fiber fractures) and non-critical failure modes (delamination processes or matrix fractures). A particular advantage is that, for varying pressure demands on the composites, the emitted acoustic pulses can be analyzed with regard to their amplitude distribution. In addition, definite indications as to how the damages occurred can be obtained from the time curves of the emitted acoustic pulses as well as from the particular frequency spectrum. Distinct analogies can be drawn between the various analytical methods with respect to whether the failure modes can be classified as critical or non-critical.

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.

An improved approach for flight readiness certification: Methodology for failure risk assessment and application examples. Volume 3: Structure and listing of programs

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.

Independent Orbiter Assessment (IOA): Assessment of the electrical power distribution and control subsystem, volume 1

NASA Technical Reports Server (NTRS)

Schmeckpeper, K. R.

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 first completed an analysis of the Electrical Power Distribution and Control (EPD and C) 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 EPD and C hardware. The IOA product for the EPD and C analysis consisted of 1671 failure mode analysis worksheets that resulted in 468 potential critical items being identified. Comparison was made to the proposed NASA Post 51-L baseline which consisted of FMEAs and 158 CIL items. Volume 1 contains the EPD and C subsystem description, analysis results, ground rules and assumptions, and some of the IOA worksheets.

Modes of failure of Osteonics constrained tripolar implants: a retrospective analysis of forty-three failed implants.

PubMed

Guyen, Olivier; Lewallen, David G; Cabanela, Miguel E

2008-07-01

The Osteonics constrained tripolar implant has been one of the most commonly used options to manage recurrent instability after total hip arthroplasty. Mechanical failures were expected and have been reported. The purpose of this retrospective review was to identify the observed modes of failure of this device. Forty-three failed Osteonics constrained tripolar implants were revised at our institution between September 1997 and April 2005. All revisions related to the constrained acetabular component only were considered as failures. All of the devices had been inserted for recurrent or intraoperative instability during revision procedures. Seven different methods of implantation were used. Operative reports and radiographs were reviewed to identify the modes of failure. The average time to failure of the forty-three implants was 28.4 months. A total of five modes of failure were observed: failure at the bone-implant interface (type I), which occurred in eleven hips; failure at the mechanisms holding the constrained liner to the metal shell (type II), in six hips; failure of the retaining mechanism of the bipolar component (type III), in ten hips; dislocation of the prosthetic head at the inner bearing of the bipolar component (type IV), in three hips; and infection (type V), in twelve hips. The mode of failure remained unknown in one hip that had been revised at another institution. The Osteonics constrained tripolar total hip arthroplasty implant is a complex device involving many parts. We showed that failure of this device can occur at most of its interfaces. It would therefore appear logical to limit its application to salvage situations.

Independent Orbiter Assessment (IOA): Assessment of the backup flight system FMEA/CIL

NASA Technical Reports Server (NTRS)

Prust, E. E.; Ewell, J. J., Jr.; Hinsdale, L. W.

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 Backup Flight System (BFS) 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 proposed NASA Post 51-L FMEA/CIL baseline. 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 BFS hardware. The IOA product for the BFS analysis consisted of 29 failure mode worksheets that resulted in 21 Potential Critical Items (PCI) being identified. This product was originally compared with the proposed NASA BFS baseline and subsequently compared with the applicable Data Processing System (DPS), Electrical Power Distribution and Control (EPD and C), and Displays and Controls NASA CIL items. The comparisons determined if there were any results which had been found by the IOA but were not in the NASA baseline. The original assessment determined there were numerous failure modes and potential critical items in the IOA analysis that were not contained in the NASA BFS baseline. Conversely, the NASA baseline contained three FMEAs (IMU, ADTA, and Air Data Probe) for CIL items that were not identified in the IOA product.

Structural Analysis of the Right Rear Lug of American Airlines Flight 587

NASA Technical Reports Server (NTRS)

Raju, Ivatury S.; Glaessgen, Edward H.; Mason, Brian H.; Krishnamurthy, Thiagarajan; Davila, Carlos G.

2006-01-01

A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985- certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003-subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs.

Recognising and referring children exposed to domestic abuse: a multi-professional, proactive systems-based evaluation using a modified Failure Mode and Effects Analysis (FMEA).

PubMed

Ashley, Laura; Armitage, Gerry; Taylor, Julie

2017-03-01

Failure Modes and Effects Analysis (FMEA) is a prospective quality assurance methodology increasingly used in healthcare, which identifies potential vulnerabilities in complex, high-risk processes and generates remedial actions. We aimed, for the first time, to apply FMEA in a social care context to evaluate the process for recognising and referring children exposed to domestic abuse within one Midlands city safeguarding area in England. A multidisciplinary, multi-agency team of 10 front-line professionals undertook the FMEA, using a modified methodology, over seven group meetings. The FMEA included mapping out the process under evaluation to identify its component steps, identifying failure modes (potential errors) and possible causes for each step and generating corrective actions. In this article, we report the output from the FMEA, including illustrative examples of the failure modes and corrective actions generated. We also present an analysis of feedback from the FMEA team and provide future recommendations for the use of FMEA in appraising social care processes and practice. Although challenging, the FMEA was unequivocally valuable for team members and generated a significant number of corrective actions locally for the safeguarding board to consider in its response to children exposed to domestic abuse. © 2016 John Wiley & Sons Ltd.

A novel approach for evaluating the risk of health care failure modes.

PubMed

Chang, Dong Shang; Chung, Jenq Hann; Sun, Kuo Lung; Yang, Fu Chiang

2012-12-01

Failure mode and effects analysis (FMEA) can be employed to reduce medical errors by identifying the risk ranking of the health care failure modes and taking priority action for safety improvement. The purpose of this paper is to propose a novel approach of data analysis. The approach is to integrate FMEA and a mathematical tool-Data envelopment analysis (DEA) with "slack-based measure" (SBM), in the field of data analysis. The risk indexes (severity, occurrence, and detection) of FMEA are viewed as multiple inputs of DEA. The practicality and usefulness of the proposed approach is illustrated by one case of health care. Being a systematic approach for improving the service quality of health care, the approach can offer quantitative corrective information of risk indexes that thereafter reduce failure possibility. For safety improvement, these new targets of the risk indexes could be used for management by objectives. But FMEA cannot provide quantitative corrective information of risk indexes. The novel approach can surely overcome this chief shortcoming of FMEA. After combining DEA SBM model with FMEA, the two goals-increase of patient safety, medical cost reduction-can be together achieved.

A Proposal of Operational Risk Management Method Using FMEA for Drug Manufacturing Computerized System

NASA Astrophysics Data System (ADS)

Takahashi, Masakazu; Nanba, Reiji; Fukue, Yoshinori

This paper proposes operational Risk Management (RM) method using Failure Mode and Effects Analysis (FMEA) for drug manufacturing computerlized system (DMCS). The quality of drug must not be influenced by failures and operational mistakes of DMCS. To avoid such situation, DMCS has to be conducted enough risk assessment and taken precautions. We propose operational RM method using FMEA for DMCS. To propose the method, we gathered and compared the FMEA results of DMCS, and develop a list that contains failure modes, failures and countermeasures. To apply this list, we can conduct RM in design phase, find failures, and conduct countermeasures efficiently. Additionally, we can find some failures that have not been found yet.

Reliability Coupled Sensitivity Based Design Approach for Gravity Retaining Walls

NASA Astrophysics Data System (ADS)

Guha Ray, A.; Baidya, D. K.

2012-09-01

Sensitivity analysis involving different random variables and different potential failure modes of a gravity retaining wall focuses on the fact that high sensitivity of a particular variable on a particular mode of failure does not necessarily imply a remarkable contribution to the overall failure probability. The present paper aims at identifying a probabilistic risk factor ( R f ) for each random variable based on the combined effects of failure probability ( P f ) of each mode of failure of a gravity retaining wall and sensitivity of each of the random variables on these failure modes. P f is calculated by Monte Carlo simulation and sensitivity analysis of each random variable is carried out by F-test analysis. The structure, redesigned by modifying the original random variables with the risk factors, is safe against all the variations of random variables. It is observed that R f for friction angle of backfill soil ( φ 1 ) increases and cohesion of foundation soil ( c 2 ) decreases with an increase of variation of φ 1 , while R f for unit weights ( γ 1 and γ 2 ) for both soil and friction angle of foundation soil ( φ 2 ) remains almost constant for variation of soil properties. The results compared well with some of the existing deterministic and probabilistic methods and found to be cost-effective. It is seen that if variation of φ 1 remains within 5 %, significant reduction in cross-sectional area can be achieved. But if the variation is more than 7-8 %, the structure needs to be modified. Finally design guidelines for different wall dimensions, based on the present approach, are proposed.

Analysis and design of ion-implanted bubble memory devices

NASA Astrophysics Data System (ADS)

Wullert, J. R., II; Kryder, M. H.

1987-04-01

4-μm period ion-implanted contiguous disk bubble memory circuits, designed and fabricated at AT&T Bell Laboratories, Murray Hill, NJ, have been investigated. Quasistatic testing has provided information about both the operational bias field ranges and the exact failure modes. A variety of major loop layouts were investigated and two turns found to severely limit bias field margins are discussed. The generation process, using a hairpin nucleator, was tested and several interesting failure modes were uncovered. Propagation on four different minor loop paths was observed and each was found to have characteristic failure modes. The transfer processes, both into and out of the minor loops, were investigated at higher frequencies to avoid local heating due to long transfer pulses at low frequencies. Again specific failure modes were identified. Overall bias margins for the chip were 9% at 50 Oe drive field and were limited by transfer-in.

a New Method for Fmeca Based on Fuzzy Theory and Expert System

NASA Astrophysics Data System (ADS)

Byeon, Yoong-Tae; Kim, Dong-Jin; Kim, Jin-O.

2008-10-01

Failure Mode Effects and Criticality Analysis (FMECA) is one of most widely used methods in modern engineering system to investigate potential failure modes and its severity upon the system. FMECA evaluates criticality and severity of each failure mode and visualize the risk level matrix putting those indices to column and row variable respectively. Generally, those indices are determined subjectively by experts and operators. However, this process has no choice but to include uncertainty. In this paper, a method for eliciting expert opinions considering its uncertainty is proposed to evaluate the criticality and severity. In addition, a fuzzy expert system is constructed in order to determine the crisp value of risk level for each failure mode. Finally, an illustrative example system is analyzed in the case study. The results are worth considering in deciding the proper policies for each component of the system.

Automated Mixed Traffic Vehicle (AMTV) technology and safety study

NASA Technical Reports Server (NTRS)

Johnston, A. R.; Peng, T. K. C.; Vivian, H. C.; Wang, P. K.

1978-01-01

Technology and safety related to the implementation of an Automated Mixed Traffic Vehicle (AMTV) system are discussed. System concepts and technology status were reviewed and areas where further development is needed are identified. Failure and hazard modes were also analyzed and methods for prevention were suggested. The results presented are intended as a guide for further efforts in AMTV system design and technology development for both near term and long term applications. The AMTV systems discussed include a low speed system, and a hybrid system consisting of low speed sections and high speed sections operating in a semi-guideway. The safety analysis identified hazards that may arise in a properly functioning AMTV system, as well as hardware failure modes. Safety related failure modes were emphasized. A risk assessment was performed in order to create a priority order and significant hazards and failure modes were summarized. Corrective measures were proposed for each hazard.

Safety analysis of occupational exposure of healthcare workers to residual contaminations of cytotoxic drugs using FMECA security approach.

PubMed

Le, Laetitia Minh Mai; Reitter, Delphine; He, Sophie; Bonle, Franck Té; Launois, Amélie; Martinez, Diane; Prognon, Patrice; Caudron, Eric

2017-12-01

Handling cytotoxic drugs is associated with chemical contamination of workplace surfaces. The potential mutagenic, teratogenic and oncogenic properties of those drugs create a risk of occupational exposure for healthcare workers, from reception of starting materials to the preparation and administration of cytotoxic therapies. The Security Failure Mode Effects and Criticality Analysis (FMECA) was used as a proactive method to assess the risks involved in the chemotherapy compounding process. FMECA was carried out by a multidisciplinary team from 2011 to 2016. Potential failure modes of the process were identified based on the Risk Priority Number (RPN) that prioritizes corrective actions. Twenty-five potential failure modes were identified. Based on RPN results, the corrective actions plan was revised annually to reduce the risk of exposure and improve practices. Since 2011, 16 specific measures were implemented successively. In six years, a cumulative RPN reduction of 626 was observed, with a decrease from 912 to 286 (-69%) despite an increase of cytotoxic compounding activity of around 23.2%. In order to anticipate and prevent occupational exposure, FMECA is a valuable tool to identify, prioritize and eliminate potential failure modes for operators involved in the cytotoxic drug preparation process before the failures occur. Copyright © 2017 Elsevier B.V. All rights reserved.

Use of failure mode, effect and criticality analysis to improve safety in the medication administration process.

PubMed

Rodriguez-Gonzalez, Carmen Guadalupe; Martin-Barbero, Maria Luisa; Herranz-Alonso, Ana; Durango-Limarquez, Maria Isabel; Hernandez-Sampelayo, Paloma; Sanjurjo-Saez, Maria

2015-08-01

To critically evaluate the causes of preventable adverse drug events during the nurse medication administration process in inpatient units with computerized prescription order entry and profiled automated dispensing cabinets in order to prioritize interventions that need to be implemented and to evaluate the impact of specific interventions on the criticality index. This is a failure mode, effects and criticality analysis (FMECA) study. A multidisciplinary consensus committee composed of pharmacists, nurses and doctors evaluated the process of administering medications in a hospital setting in Spain. By analysing the process, all failure modes were identified and criticality was determined by rating severity, frequency and likelihood of failure detection on a scale of 1 to 10, using adapted versions of already published scales. Safety strategies were identified and prioritized. Through consensus, the committee identified eight processes and 40 failure modes, of which 20 were classified as high risk. The sum of the criticality indices was 5254. For the potential high-risk failure modes, 21 different potential causes were found resulting in 24 recommendations. Thirteen recommendations were prioritized and developed over a 24-month period, reducing total criticality from 5254 to 3572 (a 32.0% reduction). The recommendations with a greater impact on criticality were the development of an electronic medication administration record (-582) and the standardization of intravenous drug compounding in the unit (-168). Other improvements, such as barcode medication administration technology (-1033), were scheduled for a longer period of time because of lower feasibility. FMECA is a useful approach that can improve the medication administration process. © 2015 John Wiley & Sons, Ltd.

Application of failure mode and effect analysis in managing catheter-related blood stream infection in intensive care unit

PubMed Central

Li, Xixi; He, Mei; Wang, Haiyan

2017-01-01

Abstract In this study, failure mode and effect analysis (FMEA), a proactive tool, was applied to reduce errors associated with the process which begins with assessment of patient and ends with treatment of complications. The aim of this study is to assess whether FMEA implementation will significantly reduce the incidence of catheter-related bloodstream infections (CRBSIs) in intensive care unit. The FMEA team was constructed. A team of 15 medical staff from different departments were recruited and trained. Their main responsibility was to analyze and score all possible processes of central venous catheterization failures. Failure modes with risk priority number (RPN) ≥100 (top 10 RPN scores) were deemed as high-priority-risks, meaning that they needed immediate corrective action. After modifications were put, the resulting RPN was compared with the previous one. A centralized nursing care system was designed. A total of 25 failure modes were identified. High-priority risks were “Unqualified medical device sterilization” (RPN, 337), “leukopenia, very low immunity” (RPN, 222), and “Poor hand hygiene Basic diseases” (RPN, 160). The corrective measures that we took allowed a decrease in the RPNs, especially for the high-priority risks. The maximum reduction was approximately 80%, as observed for the failure mode “Not creating the maximal barrier for patient.” The averaged incidence of CRBSIs was reduced from 5.19% to 1.45%, with 3 months of 0 infection rate. The FMEA can effectively reduce incidence of CRBSIs, improve the security of central venous catheterization technology, decrease overall medical expenses, and improve nursing quality. PMID:29390515

Availability Analysis of Dual Mode Systems

DOT National Transportation Integrated Search

1974-04-01

The analytical procedures presented define a method of evaluating the effects of failures in a complex dual-mode system based on a worst case steady-state analysis. The computed result is an availability figure of merit and not an absolute prediction...

Refurbishment of Railroad Crossties : A Technical and Economic Analysis

DOT National Transportation Integrated Search

1977-12-01

An analysis of the principal modes of failure for wooden railroad crossties was conducted and an evaluation of the technical and economic feasibility of refurbishing these ties was conducted. Among the principal modes of structural deterioration, onl...

Preventing blood transfusion failures: FMEA, an effective assessment method.

PubMed

Najafpour, Zhila; Hasoumi, Mojtaba; Behzadi, Faranak; Mohamadi, Efat; Jafary, Mohamadreza; Saeedi, Morteza

2017-06-30

Failure Mode and Effect Analysis (FMEA) is a method used to assess the risk of failures and harms to patients during the medical process and to identify the associated clinical issues. The aim of this study was to conduct an assessment of blood transfusion process in a teaching general hospital, using FMEA as the method. A structured FMEA was recruited in our study performed in 2014, and corrective actions were implemented and re-evaluated after 6 months. Sixteen 2-h sessions were held to perform FMEA in the blood transfusion process, including five steps: establishing the context, selecting team members, analysis of the processes, hazard analysis, and developing a risk reduction protocol for blood transfusion. Failure modes with the highest risk priority numbers (RPNs) were identified. The overall RPN scores ranged from 5 to 100 among which, four failure modes were associated with RPNs over 75. The data analysis indicated that failures with the highest RPNs were: labelling (RPN: 100), transfusion of blood or the component (RPN: 100), patient identification (RPN: 80) and sampling (RPN: 75). The results demonstrated that mis-transfusion of blood or blood component is the most important error, which can lead to serious morbidity or mortality. Provision of training to the personnel on blood transfusion, knowledge raising on hazards and appropriate preventative measures, as well as developing standard safety guidelines are essential, and must be implemented during all steps of blood and blood component transfusion.

WE-G-BRA-09: Microsphere Brachytherapy Failure Mode and Effects Analysis in a Dual-Vendor Environment

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

Younge, K C; Lee, C I; Feng, M

2015-06-15

Purpose: To improve the safety and quality of a dual-vendor microsphere brachytherapy program with failure mode and effects analysis (FMEA). Methods: A multidisciplinary team including physicists, dosimetrists, a radiation oncologist, an interventional radiologist, and radiation safety personnel performed an FMEA for our dual-vendor microsphere brachytherapy program employing SIR-Spheres (Sirtex Medical Limited, Australia) and Theraspheres (BTG, England). We developed a program process tree and step-by-step instructions which were used to generate a comprehensive list of failure modes. These modes were then ranked according to severity, occurrence rate, and detectability. Risk priority numbers (RPNs) were calculated by multiplying these three scores together.more » Three different severity scales were created: one each for harmful effects to the patient, staff, or the institution. Each failure mode was ranked on one or more of these scales. Results: The group identified 164 failure modes for the microsphere program. 113 of these were ranked using the patient severity scale, 52 using the staff severity scale, and 50 using the institution severity scale. The highest ranked items on the patient severity scale were an error in the automated dosimetry worksheet (RPN = 297.5), and the incorrect target specified on the planning study (RPN = 135). Some failure modes ranked differently between vendors, especially those corresponding to dose vial preparation because of the different methods used. Based on our findings, we made several improvements to our QA program, including documentation to easily identify which product is being used, an additional hand calculation during planning, and reorganization of QA steps before treatment delivery. We will continue to periodically review and revise the FMEA. Conclusion: We have applied FMEA to our dual-vendor microsphere brachytherapy program to identify potential key weaknesses in the treatment chain. Our FMEA results were used to improve the effectiveness of our overall microsphere program.« less

Independent Orbiter Assessment (IOA): Assessment of the rudder/speed brake subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Wilson, R. E.

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 Rudder/Speed Brake (RSB) 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 along with the proposed Post 51-L CIL updates included. A resolution of each discrepancy from the comparison was provided through additional analysis as required. This report documents the results of that comparison for the Orbiter RSB hardware. The IOA product for the RSB analysis consisted of 38 failure mode worksheets that resulted in 27 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 34 FMEAs and 18 CIL items. This comparison produced agreement on all CIL items. Based on the Pre 51-L baseline, all non-CIL FMEAs were also in agreement.

Independent Orbiter Assessment (IOA): Assessment of the manned maneuvering unit

NASA Technical Reports Server (NTRS)

Huynh, M.; Duffy, R. E.; Saiidi, M. J.

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 Manned Maneuvering Unit (MMU) hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contain within the NASA FMEA/CIL documentation. The IOA results were then compared to the proposed Martin Marietta FMEA/CIL Post 51-L updates. A discussion of each discrepancy from the comparison is provided through additional analysis as required. These discrepancies were flagged as issues, and recommendations were made based on the FMEA data available at the time. The results of this comparison for the Orbiter MMU hardware are documented. The IOA product for the MMU analysis consisted of 204 failure mode worksheets that resulted in 95 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 179 FMEAs and 110 CIL items. This comparison produced agreement on all 121 FMEAs which caused differences in 92 CIL items.

Independent Orbiter Assessment (IOA): Analysis of the reaction control system, volume 1

NASA Technical Reports Server (NTRS)

Burkemper, V. J.; Haufler, W. A.; Odonnell, R. A.; Paul, D. J.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results for the Reaction Control System (RCS). The purpose of the RCS is to provide thrust in and about the X, Y, Z axes for External Tank (ET) separation; orbit insertion maneuvers; orbit translation maneuvers; on-orbit attitude control; rendezvous; proximity operations (payload deploy and capture); deorbit maneuvers; and abort attitude control. The RCS is situated in three independent modules, one forward in the orbiter nose and one in each OMS/RCS pod. Each RCS module consists of the following subsystems: Helium Pressurization Subsystem; Propellant Storage and Distribution Subsystem; Thruster Subsystem; and Electrical Power Distribution and Control Subsystem. Of the failure modes analyzed, 307 could potentially result in a loss of life and/or loss of vehicle.

Independent Orbiter Assessment (IOA): Assessment of the landing/deceleration (LDG/DEC) subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Odonnell, R. A.; Weissinger, D.

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 Landing/Deceleration (LDG/DEC) 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 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 LDG/DEC hardware. The IOA product for the LDG/DEC analysis consisted of 259 failure mode worksheets that resulted in 124 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 267 FMEA's and 120 CIL items. This comparison produced agreement on all but 75 FMEA's which caused differences in 51 CIL items.

Independent Orbiter Assessment (IOA): Assessment of the ascent thrust vector control actuator subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Wilson, R. E.

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 Ascent Thrust Vector Control Actuator (ATVD) 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 ATVC hardware. The IOA product for the ATVC actuator analysis consisted of 25 failure mode worksheets that resulted in 16 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 21 FMEAs and 13 CIL items. This comparison produced agreement on all CIL items. Based on the Pre 51-L baseline, all non-CIL FMEAs were also in agreement.

Independent Orbiter Assessment (IOA): Analysis of the extravehicular mobility unit

NASA Technical Reports Server (NTRS)

Raffaelli, Gary G.

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 (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Extravehicular Mobility Unit (EMU) hardware. The EMU is an independent anthropomorphic system that provides environmental protection, mobility, life support, and communications for the Shuttle crewmember to perform Extravehicular Activity (EVA) in Earth orbit. Two EMUs are included on each baseline Orbiter mission, and consumables are provided for three two-man EVAs. The EMU consists of the Life Support System (LSS), Caution and Warning System (CWS), and the Space Suit Assembly (SSA). Each level of hardware was evaluated and analyzed for possible failure modes and effects. The majority of these PCIs are resultant from failures which cause loss of one or more primary functions: pressurization, oxygen delivery, environmental maintenance, and thermal maintenance. It should also be noted that the quantity of PCIs would significantly increase if the SOP were to be treated as an emergency system rather than as an unlike redundant element.

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

Independent Orbiter Assessment (IOA): Analysis of the rudder/speed brake subsystem

NASA Technical Reports Server (NTRS)

Wilson, R. E.; Riccio, J. R.

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 Orbiter Rudder/Speedbrake Actuation Mechanism is documented. The function of the Rudder/Speedbrake (RSB) is to provide directional control and to provide a means of energy control during entry. The system consists of two panels on a vertical hinge mounted on the aft part of the vertical stabilizer. These two panels move together to form a rudder but split apart to make a speedbrake. The Rudder/Speedbrake Actuation Mechanism consists of the following elements: (1) Power Drive Unit (PDU) which is composed of hydraulic valve module and a hydraulic motor-powered gearbox which contains differentials and mixer gears to provide PDU torque output; (2) four geared rotary actuators which apply the PDU generated torque to the rudder/speedbrake panels; and (3) ten torque shafts which join the PDU to the rotary actuators and interconnect the four rotary actuators. Each level of hardware was evaluated and analyzed for possible failures and causes. Criticality was assigned based upon the severity of the effect for each failure mode. Critical RSB failures which result in potential loss of vehicle control were mainly due to loss of hydraulic fluid, fluid contaminators, and mechanical failures in gears and shafts.

Delamination modeling of laminate plate made of sublaminates

NASA Astrophysics Data System (ADS)

Kormaníková, Eva; Kotrasová, Kamila

2017-07-01

The paper presents the mixed-mode delamination of plates made of sublaminates. To this purpose an opening load mode of delamination is proposed as failure model. The failure model is implemented in ANSYS code to calculate the mixed-mode delamination response as energy release rate. The analysis is based on interface techniques. Within the interface finite element modeling there are calculated the individual components of damage parameters as spring reaction forces, relative displacements and energy release rates along the lamination front.

Accelerated fatigue durability of a high performance composite

NASA Technical Reports Server (NTRS)

Rotem, A.

1982-01-01

The fatigue behavior of multidirectional graphite-epoxy laminates was analyzed theoretically and experimentally in an effort to establish an accelerated testing methodology. Analysis of the failure mechanism in fatigue of the laminates led to the determination of the failure mode governing fracture. The nonlinear, cyclic-dependent shear modulus was used to calculate the changing stress field in the laminate during the fatigue loading. Fatigue tests were performed at three different temperatures: 25 C, 74 C, and 114 C. The prediction of the S-N curves was made based on the artificial static strength artificial static strength at a reference temperature and the fatigue functions associated with them. The prediction of an S-N curve at other temperatures was performed using shifting factors determined for the specific failure mode. For multidirectional laminates, different S-N curves at different temperatures could be predicted using these shifting factors. Different S-N curves at different temperatures occur only when the fatigue failure mode is matrix dominated. It was found that whenever the fatigue failure mode is fiber dominated, temperature, over the range investigated, had no influence on the fatigue life. These results permit the prediction of long-time, low temperature fatigue behavior from data obtained in short time, high temperature testing, for laminates governed by a matrix failure mode.

Fatigue damage accumulation in various metal matrix composites

NASA Technical Reports Server (NTRS)

Johnson, W. S.

1987-01-01

The purpose of this paper is to review some of the latest understanding of the fatigue behavior of continuous fiber reinforced metal matrix composites. The emphasis is on the development of an understanding of different fatigue damage mechanisms and why and how they occur. The fatigue failure modes in continuous fiber reinforced metal matrix composites are controlled by the three constituents of the system: fiber, matrix, and fiber/matrix interface. The relative strains to fatigue failure of the fiber and matrix will determine the failure mode. Several examples of matrix, fiber, and self-similar damage growth dominated fatigue damage are given for several metal matrix composite systems. Composite analysis, failure modes, and damage modeling are discussed. Boron/aluminum, silicon-carbide/aluminum, FP/aluminum, and borsic/titanium metal matrix composites are discussed.

A Selection of Composites Simulation Practices at NASA Langley Research Center

NASA Technical Reports Server (NTRS)

Ratcliffe, James G.

2007-01-01

One of the major areas of study at NASA Langley Research Center is the development of technologies that support the use of advanced composite materials in aerospace applications. Amongst the supporting technologies are analysis tools used to simulate the behavior of these materials. This presentation will discuss a number of examples of analysis tools and simulation practices conducted at NASA Langley. The presentation will include examples of damage tolerance analyses for both interlaminar and intralaminar failure modes. Tools for modeling interlaminar failure modes include fracture mechanics and cohesive methods, whilst tools for modeling intralaminar failure involve the development of various progressive failure analyses. Other examples of analyses developed at NASA Langley include a thermo-mechanical model of an orthotropic material and the simulation of delamination growth in z-pin reinforced laminates.

Numerical simulation of failure behavior of granular debris flows based on flume model tests.

PubMed

Zhou, Jian; Li, Ye-xun; Jia, Min-cai; Li, Cui-na

2013-01-01

In this study, the failure behaviors of debris flows were studied by flume model tests with artificial rainfall and numerical simulations (PFC(3D)). Model tests revealed that grain sizes distribution had profound effects on failure mode, and the failure in slope of medium sand started with cracks at crest and took the form of retrogressive toe sliding failure. With the increase of fine particles in soil, the failure mode of the slopes changed to fluidized flow. The discrete element method PFC(3D) can overcome the hypothesis of the traditional continuous medium mechanic and consider the simple characteristics of particle. Thus, a numerical simulations model considering liquid-solid coupled method has been developed to simulate the debris flow. Comparing the experimental results, the numerical simulation result indicated that the failure mode of the failure of medium sand slope was retrogressive toe sliding, and the failure of fine sand slope was fluidized sliding. The simulation result is consistent with the model test and theoretical analysis, and grain sizes distribution caused different failure behavior of granular debris flows. This research should be a guide to explore the theory of debris flow and to improve the prevention and reduction of debris flow.

Composite Structural Analysis of Flat-Back Shaped Blade for Multi-MW Class Wind Turbine

NASA Astrophysics Data System (ADS)

Kim, Soo-Hyun; Bang, Hyung-Joon; Shin, Hyung-Ki; Jang, Moon-Seok

2014-06-01

This paper provides an overview of failure mode estimation based on 3D structural finite element (FE) analysis of the flat-back shaped wind turbine blade. Buckling stability, fiber failure (FF), and inter-fiber failure (IFF) analyses were performed to account for delamination or matrix failure of composite materials and to predict the realistic behavior of the entire blade region. Puck's fracture criteria were used for IFF evaluation. Blade design loads applicable to multi-megawatt (MW) wind turbine systems were calculated according to the Germanischer Lloyd (GL) guideline and the International Electrotechnical Commission (IEC) 61400-1 standard, under Class IIA wind conditions. After the post-processing of final load results, a number of principal load cases were selected and converted into applied forces at the each section along the blade's radius of the FE model. Nonlinear static analyses were performed for laminate failure, FF, and IFF check. For buckling stability, linear eigenvalue analysis was performed. As a result, we were able to estimate the failure mode and locate the major weak point.

Matrix Failure Modes and Effects Analysis as a Knowledge Base for a Real Time Automated Diagnosis Expert System

NASA Technical Reports Server (NTRS)

Herrin, Stephanie; Iverson, David; Spukovska, Lilly; Souza, Kenneth A. (Technical Monitor)

1994-01-01

Failure Modes and Effects Analysis contain a wealth of information that can be used to create the knowledge base required for building automated diagnostic Expert systems. A real time monitoring and diagnosis expert system based on an actual NASA project's matrix failure modes and effects analysis was developed. This Expert system Was developed at NASA Ames Research Center. This system was first used as a case study to monitor the Research Animal Holding Facility (RAHF), a Space Shuttle payload that is used to house and monitor animals in orbit so the effects of space flight and microgravity can be studied. The techniques developed for the RAHF monitoring and diagnosis Expert system are general enough to be used for monitoring and diagnosis of a variety of other systems that undergo a Matrix FMEA. This automated diagnosis system was successfully used on-line and validated on the Space Shuttle flight STS-58, mission SLS-2 in October 1993.

Application of Failure Mode and Effects Analysis to Intraoperative Radiation Therapy Using Mobile Electron Linear Accelerators

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

Ciocca, Mario, E-mail: mario.ciocca@cnao.it; Cantone, Marie-Claire; Veronese, Ivan

2012-02-01

Purpose: Failure mode and effects analysis (FMEA) represents a prospective approach for risk assessment. A multidisciplinary working group of the Italian Association for Medical Physics applied FMEA to electron beam intraoperative radiation therapy (IORT) delivered using mobile linear accelerators, aiming at preventing accidental exposures to the patient. Methods and Materials: FMEA was applied to the IORT process, for the stages of the treatment delivery and verification, and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system,more » based on the product of three parameters (severity, frequency of occurrence and detectability, each ranging from 1 to 10); 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. Results: Twenty-four subprocesses were identified. Ten potential failure modes were found and scored, in terms of RPN, in the range of 42-216. The most critical failure modes consisted of internal shield misalignment, wrong Monitor Unit calculation and incorrect data entry at treatment console. Potential causes of failure included shield displacement, human errors, such as underestimation of CTV extension, mainly because of lack of adequate training and time pressures, failure in the communication between operators, and machine malfunctioning. The main effects of failure were represented by CTV underdose, wrong dose distribution and/or delivery, unintended normal tissue irradiation. As additional safety measures, the utilization of a dedicated staff for IORT, double-checking of MU calculation and data entry and finally implementation of in vivo dosimetry were suggested. Conclusions: FMEA appeared as a useful tool for prospective evaluation of patient safety in radiotherapy. The application of this method to IORT lead to identify three safety measures for risk mitigation.« less

Independent Orbiter Assessment (IOA): FMEA/CIL assessment

NASA Technical Reports Server (NTRS)

Hinsdale, L. W.; Swain, L. J.; Barnes, J. E.

1988-01-01

The McDonnell Douglas Astronautics Company (MDAC) was selected to perform an Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL). Direction was given by the Orbiter and GFE Projects Office to perform the hardware analysis and assessment using the instructions and ground rules defined in NSTS 22206. The IOA analysis featured a top-down approach to determine hardware failure modes, criticality, and potential critical items. To preserve independence, the analysis was accomplished without reliance upon the results contained within the NASA and Prime Contractor FMEA/CIL documentation. The assessment process compared the independently derived failure modes and criticality assignments to the proposed NASA post 51-L FMEA/CIL documentation. When possible, assessment issues were discussed and resolved with the NASA subsystem managers. Unresolved issues were elevated to the Orbiter and GFE Projects Office manager, Configuration Control Board (CCB), or Program Requirements Control Board (PRCB) for further resolution. The most important Orbiter assessment finding was the previously unknown stuck autopilot push-button criticality 1/1 failure mode. The worst case effect could cause loss of crew/vehicle when the microwave landing system is not active. It is concluded that NASA and Prime Contractor Post 51-L FMEA/CIL documentation assessed by IOA is believed to be technically accurate and complete. All CIL issues were resolved. No FMEA issues remain that have safety implications. Consideration should be given, however, to upgrading NSTS 22206 with definitive ground rules which more clearly spell out the limits of redundancy.

Independent Orbiter Assessment (IOA): Assessment of the main propulsion subsystem FMEA/CIL, volume 3

NASA Technical Reports Server (NTRS)

Holden, K. A.

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 Main Propulsion System (MPS) 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 available data from the Rockwell Downey/NASA JSC FMEA/CIL review. Volume 3 continues the presentation of IOA worksheets and includes the potential critical items list.

Independent Orbiter Assessment (IOA): Assessment of the main propulsion subsystem FMEA/CIL, volume 2

NASA Technical Reports Server (NTRS)

Holden, K. A.

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 Main Propulsion System (MPS) 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 than compared to available data from the Rockwell Downey/NASA JSC FMEA/CIL review. Volume 2 continues the presentation of IOA worksheets for MPS hardware items.

Independent Orbiter Assessment (IOA): Assessment of the communication and tracking subsystem, volume 2

NASA Technical Reports Server (NTRS)

Long, W. C.

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 and analysis of the Communication and Tracking hardware, generating draft failure modes and potential critical items. The IOA results were then compared to the NASA FMEA/CIL baseline. 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 Communication and Tracking hardware. Volume 2 continues the presentation of IOA worksheets.

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

Application of failure mode and effect analysis in managing catheter-related blood stream infection in intensive care unit.

PubMed

Li, Xixi; He, Mei; Wang, Haiyan

2017-12-01

In this study, failure mode and effect analysis (FMEA), a proactive tool, was applied to reduce errors associated with the process which begins with assessment of patient and ends with treatment of complications. The aim of this study is to assess whether FMEA implementation will significantly reduce the incidence of catheter-related bloodstream infections (CRBSIs) in intensive care unit.The FMEA team was constructed. A team of 15 medical staff from different departments were recruited and trained. Their main responsibility was to analyze and score all possible processes of central venous catheterization failures. Failure modes with risk priority number (RPN) ≥100 (top 10 RPN scores) were deemed as high-priority-risks, meaning that they needed immediate corrective action. After modifications were put, the resulting RPN was compared with the previous one. A centralized nursing care system was designed.A total of 25 failure modes were identified. High-priority risks were "Unqualified medical device sterilization" (RPN, 337), "leukopenia, very low immunity" (RPN, 222), and "Poor hand hygiene Basic diseases" (RPN, 160). The corrective measures that we took allowed a decrease in the RPNs, especially for the high-priority risks. The maximum reduction was approximately 80%, as observed for the failure mode "Not creating the maximal barrier for patient." The averaged incidence of CRBSIs was reduced from 5.19% to 1.45%, with 3 months of 0 infection rate.The FMEA can effectively reduce incidence of CRBSIs, improve the security of central venous catheterization technology, decrease overall medical expenses, and improve nursing quality. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

SU-E-T-420: Failure Effects Mode Analysis for Trigeminal Neuralgia Frameless Radiosurgery

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

Howe, J

2015-06-15

Purpose: Functional radiosurgery has been used successfully in the treatment of trigeminal neuralgia but presents significant challenges to ensuring the high prescription dose is delivered accurately. A review of existing practice should help direct the focus of quality improvement for this treatment regime. Method: Failure modes and effects analysis was used to identify the processes in preparing radiosurgery treatment for TN. The map was developed by a multidisciplinary team including: neurosurgeon, radiation oncology, physicist and therapist. Potential failure modes were identified for each step in the process map as well as potential causes and end effect. A risk priority numbermore » was assigned to each cause. Results: The process map identified 66 individual steps (see attached supporting document). Corrective actions were developed for areas of high risk priority number. Wrong site treatment is at higher risk for trigeminal neuralgia treatment due to the lack of site specific pathologic imaging on MR and CT – additional site specific checks were implemented to minimize the risk of wrong site treatment. Failed collision checks resulted from an insufficient collision model in the treatment planning system and a plan template was developed to address this problem. Conclusion: Failure modes and effects analysis is an effective tool for developing quality improvement in high risk radiotherapy procedures such as functional radiosurgery.« less

A comparison of two prospective risk analysis methods: Traditional FMEA and a modified healthcare FMEA.

PubMed

Rah, Jeong-Eun; Manger, Ryan P; Yock, Adam D; Kim, Gwe-Ya

2016-12-01

To examine the abilities of a traditional failure mode and effects analysis (FMEA) and modified healthcare FMEA (m-HFMEA) scoring methods by comparing the degree of congruence in identifying high risk failures. The authors applied two prospective methods of the quality management to surface image guided, linac-based radiosurgery (SIG-RS). For the traditional FMEA, decisions on how to improve an operation were based on the risk priority number (RPN). The RPN is a product of three indices: occurrence, severity, and detectability. The m-HFMEA approach utilized two indices, severity and frequency. A risk inventory matrix was divided into four categories: very low, low, high, and very high. For high risk events, an additional evaluation was performed. Based upon the criticality of the process, it was decided if additional safety measures were needed and what they comprise. The two methods were independently compared to determine if the results and rated risks matched. The authors' results showed an agreement of 85% between FMEA and m-HFMEA approaches for top 20 risks of SIG-RS-specific failure modes. The main differences between the two approaches were the distribution of the values and the observation that failure modes (52, 54, 154) with high m-HFMEA scores do not necessarily have high FMEA-RPN scores. In the m-HFMEA analysis, when the risk score is determined, the basis of the established HFMEA Decision Tree™ or the failure mode should be more thoroughly investigated. m-HFMEA is inductive because it requires the identification of the consequences from causes, and semi-quantitative since it allows the prioritization of high risks and mitigation measures. It is therefore a useful tool for the prospective risk analysis method to radiotherapy.

Independent Orbiter Assessment (IOA): Assessment of the main propulsion subsystem FMEA/CIL, volume 4

NASA Technical Reports Server (NTRS)

Slaughter, B. C.

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 Main Propulsion System (MPS) 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 than compared to available data from the Rockwell Downey/NASA JSC FMEA/CIL review. Volume 4 contains the IOA analysis worksheets and the NASA FMEA to IOA worksheet cross reference and recommendations.

Independent Orbiter Assessment (IOA): Assessment of the nose wheel steering subsystem

NASA Technical Reports Server (NTRS)

Mediavilla, Anthony Scott

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 Nose Wheel Steering (NWS) 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 proposed NASA post 51-L FMEA/CIL baseline. 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 NWS hardware.

The Utility of Failure Modes and Effects Analysis of Consultations in a Tertiary, Academic, Medical Center.

PubMed

Niv, Yaron; Itskoviz, David; Cohen, Michal; Hendel, Hagit; Bar-Giora, Yonit; Berkov, Evgeny; Weisbord, Irit; Leviron, Yifat; Isasschar, Assaf; Ganor, Arian

Failure modes and effects analysis (FMEA) is a tool used to identify potential risks in health care processes. We used the FMEA tool for improving the process of consultation in an academic medical center. A team of 10 staff members-5 physicians, 2 quality experts, 2 organizational consultants, and 1 nurse-was established. The consultation process steps, from ordering to delivering, were computed. Failure modes were assessed for likelihood of occurrence, detection, and severity. A risk priority number (RPN) was calculated. An interventional plan was designed according to the highest RPNs. Thereafter, we compared the percentage of completed computer-based documented consultations before and after the intervention. The team identified 3 main categories of failure modes that reached the highest RPNs: initiation of consultation by a junior staff physician without senior approval, failure to document the consultation in the computerized patient registry, and asking for consultation on the telephone. An interventional plan was designed, including meetings to update knowledge of the consultation request process, stressing the importance of approval by a senior physician, training sessions for closing requests in the patient file, and reporting of telephone requests. The number of electronically documented consultation results and recommendations significantly increased (75%) after intervention. FMEA is an important and efficient tool for improving the consultation process in an academic medical center.

Single- versus double-row repair for full-thickness rotator cuff tears using suture anchors. A systematic review and meta-analysis of basic biomechanical studies.

PubMed

Hohmann, Erik; König, Anya; Kat, Cor-Jacques; Glatt, Vaida; Tetsworth, Kevin; Keough, Natalie

2018-07-01

The purpose of this study was to perform a systematic review and meta-analysis comparing single- and double-row biomechanical studies to evaluate load to failure, mode of failure and gap formation. A systematic review of MEDLINE, Embase, Scopus and Google Scholar was performed from 1990 through 2016. The inclusion criteria were: documentation of ultimate load to failure, failure modes and documentation of elongation or gap formation. Studies were excluded if the study protocol did not use human specimens. Publication bias was assessed by funnel plot and Egger's test. The risk of bias was established using the Cochrane Collaboration's risk of bias tool. Heterogeneity was assessed using χ 2 and I 2 statistic. Eight studies were included. The funnel plot was asymmetric suggesting publication bias, which was confirmed by Egger's test (p = 0.04). The pooled estimate for load to failure demonstrated significant differences (SMD 1.228, 95% CI: 0.55-5.226, p = 0.006, I 2  = 60.47%), favouring double-row repair. There were no differences for failure modes. The pooled estimate for elongation/gap formation demonstrated significant differences (SMD 0.783, 95% CI: 0.169-1.398, p = 0.012, I 2  = 58.8%), favouring double-row repair. The results of this systematic review and meta-analysis suggest that double-row repair is able to tolerate a significantly greater load to failure. Gap formation was also significantly lower in the double-row repair group, but both of these findings should be interpreted with caution because of the inherent interstudy heterogeneity. Systematic review and meta-analysis.

Reliability analysis of airship remote sensing system

NASA Astrophysics Data System (ADS)

Qin, Jun

1998-08-01

Airship Remote Sensing System (ARSS) for obtain the dynamic or real time images in the remote sensing of the catastrophe and the environment, is a mixed complex system. Its sensor platform is a remote control airship. The achievement of a remote sensing mission depends on a series of factors. For this reason, it is very important for us to analyze reliability of ARSS. In first place, the system model was simplified form multi-stage system to two-state system on the basis of the result of the failure mode and effect analysis and the failure tree failure mode effect and criticality analysis. The failure tree was created after analyzing all factors and their interrelations. This failure tree includes four branches, e.g. engine subsystem, remote control subsystem, airship construction subsystem, flying metrology and climate subsystem. By way of failure tree analysis and basic-events classing, the weak links were discovered. The result of test running shown no difference in comparison with theory analysis. In accordance with the above conclusions, a plan of the reliability growth and reliability maintenance were posed. System's reliability are raised from 89 percent to 92 percent with the reformation of the man-machine interactive interface, the augmentation of the secondary better-groupie and the secondary remote control equipment.

Fractography can be used to analyze failure modes in polytetrafluoroethylene

NASA Technical Reports Server (NTRS)

Nerren, B. H.

1969-01-01

Fractographic principles used for analyzing failure in metals are applied to the analysis of the microstructure and fracture of polytetrafluoroethylene. This material is used as seals in cryogenic systems.

Evaluation of the split cantilever beam for Mode 3 delamination testing

NASA Technical Reports Server (NTRS)

Martin, Roderick H.

1989-01-01

A test rig for testing a thick split cantilever beam for scissoring delamination (mode 3) fracture toughness was developed. A 3-D finite element analysis was conducted on the test specimen to determine the strain energy release rate, G, distribution along the delamination front. The virtual crack closure technique was used to calculate the G components resulting from interlaminar tension, GI, interlaminar sliding shear, GII, and interlaminar tearing shear, GIII. The finite element analysis showed that at the delamination front no GI component existed, but a GII component was present in addition to a GIII component. Furthermore, near the free edges, the GII component was significantly higher than the GIII component. The GII/GIII ratio was found to increase with delamination length but was insensitive to the beam depth. The presence of GII at the delamination front was verified experimentally by examination of the failure surfaces. At the center of the beam, where the failure was in mode 3, there was significant fiber bridging. However, at the edges of the beam where the failure was in mode 3, there was no fiber bridging and mode 2 shear hackles were observed. Therefore, it was concluded that the split cantilever beam configuration does not represent a pure mode 3 test. The experimental work showed that the mode 2 fracture toughness, GIIc, must be less than the mode 3 fracture toughness, GIIIc. Therefore, a conservative approach to characterizing mode 3 delamination is to equate GIIIc to GIIc.

Failure Atlas for Rolling Bearings in Wind Turbines

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

Tallian, T. E.

2006-01-01

This Atlas is structured as a supplement to the book: T.E. Tallian: Failure Atlas for Hertz Contact Machine Elements, 2nd edition, ASME Press New York, (1999). The content of the atlas comprises plate pages from the book that contain bearing failure images, application data, and descriptions of failure mode, image, and suspected failure causes. Rolling bearings are a critical component of the mainshaft system, gearbox and generator in the rapidly developing technology of power generating wind turbines. The demands for long service life are stringent; the design load, speed and temperature regimes are demanding and the environmental conditions including weather,more » contamination, impediments to monitoring and maintenance are often unfavorable. As a result, experience has shown that the rolling bearings are prone to a variety of failure modes that may prevent achievement of design lives. Morphological failure diagnosis is extensively used in the failure analysis and improvement of bearing operation. Accumulated experience shows that the failure appearance and mode of failure causation in wind turbine bearings has many distinguishing features. The present Atlas is a first effort to collect an interpreted database of specifically wind turbine related rolling bearing failures and make it widely available. This Atlas is structured as a supplement to the book: T. E. Tallian: Failure Atlas for Hertz Contact Machine Elements, 2d edition, ASME Press New York, (1999). The main body of that book is a comprehensive collection of self-contained pages called Plates, containing failure images, bearing and application data, and three descriptions: failure mode, image and suspected failure causes. The Plates are sorted by main failure mode into chapters. Each chapter is preceded by a general technical discussion of the failure mode, its appearance and causes. The Plates part is supplemented by an introductory part, describing the appearance classification and failure classification systems used, and by several indexes. The present Atlas is intended as a supplement to the book. It has the same structure but contains only Plate pages, arranged in chapters, each with a chapter heading page giving a short definition of the failure mode illustrated. Each Plate page is self contained, with images, bearing and application data, and descriptions of the failure mode, the images and the suspected causes. Images are provided in two resolutions: The text page includes 6 by 9 cm images. In addition, high resolution image files are attached, to be retrieved by clicking on their 'push pin' icon. While the material in the present Atlas is self-contained, it is nonetheless a supplement to the book and the complete interpretation of the terse image descriptions and of the system underlying the failure code presupposes familiarity with the book. Since this Atlas is a supplement to the book, its chapter numbering follows that of the book. Not all failure modes covered in the book have been found among the observed wind turbines. For that reason, and because of the omission of introductory matter, the chapter numbers in this Atlas are not a continuous sequence.« less

SU-E-T-87: A TG-100 Approach for Quality Improvement of Associated Dosimetry Equipment

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

Manger, R; Pawlicki, T; Kim, G

2015-06-15

Purpose: Dosimetry protocols devote so much time to the discussion of ionization chamber choice, use and performance that is easy to forget about the importance of the associated dosimetry equipment (ADE) in radiation dosimetry - barometer, thermometer, electrometer, phantoms, triaxial cables, etc. Improper use and inaccuracy of these devices may significantly affect the accuracy of radiation dosimetry. The purpose of this study is to evaluate the risk factors in the monthly output dosimetry procedure and recommend corrective actions using a TG-100 approach. Methods: A failure mode and effects analysis (FMEA) of the monthly linac output check procedure was performed tomore » determine which steps and failure modes carried the greatest risk. In addition, a fault tree analysis (FTA) was performed to expand the initial list of failure modes making sure that none were overlooked. After determining the failure modes with the highest risk priority numbers (RPNs), 11 physicists were asked to score corrective actions based on their ease of implementation and potential impact. The results were aggregated into an impact map to determine the implementable corrective actions. Results: Three of the top five failure modes were related to the thermometer and barometer. The two highest RPN-ranked failure modes were related to barometric pressure inaccuracy due to their high lack-of-detectability scores. Six corrective actions were proposed to address barometric pressure inaccuracy, and the survey results found the following two corrective actions to be implementable: 1) send the barometer for recalibration at a calibration laboratory and 2) check the barometer accuracy against the local airport and correct for elevation. Conclusion: An FMEA on monthly output measurements displayed the importance of ADE for accurate radiation dosimetry. When brainstorming for corrective actions, an impact map is helpful for visualizing the overall impact versus the ease of implementation.« less

A Diagnostic Approach for Electro-Mechanical Actuators in Aerospace Systems

NASA Technical Reports Server (NTRS)

Balaban, Edward; Saxena, Abhinav; Bansal, Prasun; Goebel, Kai Frank; Stoelting, Paul; Curran, Simon

2009-01-01

Electro-mechanical actuators (EMA) are finding increasing use in aerospace applications, especially with the trend towards all all-electric aircraft and spacecraft designs. However, electro-mechanical actuators still lack the knowledge base accumulated for other fielded actuator types, particularly with regard to fault detection and characterization. This paper presents a thorough analysis of some of the critical failure modes documented for EMAs and describes experiments conducted on detecting and isolating a subset of them. The list of failures has been prepared through an extensive Failure Modes and Criticality Analysis (FMECA) reference, literature review, and accessible industry experience. Methods for data acquisition and validation of algorithms on EMA test stands are described. A variety of condition indicators were developed that enabled detection, identification, and isolation among the various fault modes. A diagnostic algorithm based on an artificial neural network is shown to operate successfully using these condition indicators and furthermore, robustness of these diagnostic routines to sensor faults is demonstrated by showing their ability to distinguish between them and component failures. The paper concludes with a roadmap leading from this effort towards developing successful prognostic algorithms for electromechanical actuators.

Bending strength of delaminated aerospace composites.

PubMed

Kinawy, Moustafa; Butler, Richard; Hunt, Giles W

2012-04-28

Buckling-driven delamination is considered among the most critical failure modes in composite laminates. This paper examines the propagation of delaminations in a beam under pure bending. A pre-developed analytical model to predict the critical buckling moment of a thin sub-laminate is extended to account for propagation prediction, using mixed-mode fracture analysis. Fractography analysis is performed to distinguish between mode I and mode II contributions to the final failure of specimens. Comparison between experimental results and analysis shows agreement to within 5 per cent in static propagation moment for two different materials. It is concluded that static fracture is almost entirely driven by mode II effects. This result was unexpected because it arises from a buckling mode that opens the delamination. For this reason, and because of the excellent repeatability of the experiments, the method of testing may be a promising means of establishing the critical value of mode II fracture toughness, G(IIC), of the material. Fatigue testing on similar samples showed that buckled delamination resulted in a fatigue threshold that was over 80 per cent lower than the static propagation moment. Such an outcome highlights the significance of predicting snap-buckling moment and subsequent propagation for design purposes.

Independent Orbiter Assessment (IOA): Assessment of the orbital maneuvering system FMEA/CIL, volume 1

NASA Technical Reports Server (NTRS)

Prust, Chet D.; Haufler, W. A.; Marino, A. J.

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 Orbital Maneuvering System (OMS) hardware and Electrical Power Distribution and Control (EPD and C), 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 proposed Post 51-L NASA FMEA/CIL baseline. This report documents the results of that comparison for the Orbiter OMS hardware. The IOA analysis defined the OMS as being comprised of the following subsystems: helium pressurization, propellant storage and distribution, Orbital Maneuvering Engine, and EPD and C. The IOA product for the OMS analysis consisted of 284 hardware and 667 EPD and C failure mode worksheets that resulted in 160 hardware and 216 EPD and C potential critical items (PCIs) being identified. A comparison was made of the IOA product to the NASA FMEA/CIL baseline which consisted of 101 hardware and 142 EPD and C CIL items.

Failure mechanics in low-velocity impacts on thin composite plates

NASA Technical Reports Server (NTRS)

Elber, W.

1983-01-01

Eight-ply quasi-isotropic composite plates of Thornel 300 graphite in Narmco 5208 epoxy resin (T300/5208) were tested to establish the degree of equivalence between low-velocity impact and static testing. Both the deformation and failure mechanics under impact were representable by static indentation tests. Under low-velocity impacts such as tool drops, the dominant deformation mode of the plates was the first, or static, mode. Higher modes are excited on contact, but they decay significantly by the time the first-mode load reaches a maximum. The delamination patterns were observed by X-ray analysis. The areas of maximum delamination patterns were observed by X-ray analysis. The areas of maximum delamination coincided with the areas of highest peel stresses. The extent of delamination was similar for static and impact tests. Fiber failure damage was established by tensile tests on small fiber bundles obtained by deplying test specimens. The onset of fiber damage was in internal plies near the lower surface of the plates. The distribution and amount of fiber damage was similar fo impact and static tests.

An improved approach for flight readiness certification: Probabilistic models for flaw propagation and turbine blade failure. Volume 1: Methodology and applications

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with analytical modeling of failure phenomena to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in analytical modeling, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which analytical models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. State-of-the-art analytical models currently employed for designs failure prediction, or performance analysis are used in this methodology. The rationale for the statistical approach taken in the PFA methodology is discussed, the PFA methodology is described, and examples of its application to structural failure modes are presented. The engineering models and computer software used in fatigue crack growth and fatigue crack initiation applications are thoroughly documented.

An improved approach for flight readiness certification: Probabilistic models for flaw propagation and turbine blade failure. Volume 2: Software documentation

NASA Technical Reports Server (NTRS)

Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.

1992-01-01

An improved methodology for quantitatively evaluating failure risk of spaceflights systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with analytical modeling of failure phenomena to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in analytical modeling, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which analytical models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. State-of-the-art analytical models currently employed for design, failure prediction, or performance analysis are used in this methodology. The rationale for the statistical approach taken in the PFA methodology is discussed, the PFA methodology is described, and examples of its application to structural failure modes are presented. The engineering models and computer software used in fatigue crack growth and fatigue crack initiation applications are thoroughly documented.

Failure mode and effect analysis: improving intensive care unit risk management processes.

PubMed

Askari, Roohollah; Shafii, Milad; Rafiei, Sima; Abolhassani, Mohammad Sadegh; Salarikhah, Elaheh

2017-04-18

Purpose Failure modes and effects analysis (FMEA) is a practical tool to evaluate risks, discover failures in a proactive manner and propose corrective actions to reduce or eliminate potential risks. The purpose of this paper is to apply FMEA technique to examine the hazards associated with the process of service delivery in intensive care unit (ICU) of a tertiary hospital in Yazd, Iran. Design/methodology/approach This was a before-after study conducted between March 2013 and December 2014. By forming a FMEA team, all potential hazards associated with ICU services - their frequency and severity - were identified. Then risk priority number was calculated for each activity as an indicator representing high priority areas that need special attention and resource allocation. Findings Eight failure modes with highest priority scores including endotracheal tube defect, wrong placement of endotracheal tube, EVD interface, aspiration failure during suctioning, chest tube failure, tissue injury and deep vein thrombosis were selected for improvement. Findings affirmed that improvement strategies were generally satisfying and significantly decreased total failures. Practical implications Application of FMEA in ICUs proved to be effective in proactively decreasing the risk of failures and corrected the control measures up to acceptable levels in all eight areas of function. Originality/value Using a prospective risk assessment approach, such as FMEA, could be beneficial in dealing with potential failures through proposing preventive actions in a proactive manner. The method could be used as a tool for healthcare continuous quality improvement so that the method identifies both systemic and human errors, and offers practical advice to deal effectively with them.

Application of failure mode and effects analysis (FMEA) to pretreatment phases in tomotherapy.

PubMed

Broggi, Sara; Cantone, Marie Claire; Chiara, Anna; Di Muzio, Nadia; Longobardi, Barbara; Mangili, Paola; Veronese, Ivan

2013-09-06

The aim of this paper was the application of the failure mode and effects analysis (FMEA) approach to assess the risks for patients undergoing radiotherapy treatments performed by means of a helical tomotherapy unit. FMEA was applied to the preplanning imaging, volume determination, and treatment planning stages of the tomotherapy process and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system; and 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. A total of 74 failure modes were identified: 38 in the stage of preplanning imaging and volume determination, and 36 in the stage of planning. The threshold of 125 for RPN was exceeded in four cases: one case only in the phase of preplanning imaging and volume determination, and three cases in the stage of planning. The most critical failures appeared related to (i) the wrong or missing definition and contouring of the overlapping regions, (ii) the wrong assignment of the overlap priority to each anatomical structure, (iii) the wrong choice of the computed tomography calibration curve for dose calculation, and (iv) the wrong (or not performed) choice of the number of fractions in the planning station. On the basis of these findings, in addition to the safety strategies already adopted in the clinical practice, novel solutions have been proposed for mitigating the risk of these failures and to increase patient safety.

Hazards/Failure Modes and Effects Analysis MK 1 MOD 0 LSO-HUD Console System.

DTIC Science & Technology

1980-03-24

AsI~f~ ! 127 = 3gc Z Isre -0 -q ~sI I I 𔃻~~~ ~ _ _ 3_______ II! -0udC Z Z’ P4 12 d-U * ~s ’:i~i42 S- 60 -, Uh ~ U3l I OM -C ~ . - U 4~ dcd 8U-q Ali...8 VI SCOPE AND METHODOLOGY OF ANALYSIS ........ 1O FIGURE 1: H/ FMEA /(SSA) WORK SHEET FORMAT ........... 14 APPENDIX A: HAZARD/FAILURE MODES AND...EFFECTS ANALYSIS (H/ FMEA ) -- WORK SHEETS ......... 15(A-O) TABLE: SUBSYSTEM: UNIT I Heads-Up Display Console .............. 17(A-1) UNIT 2 Auxiliary

3D visualization of membrane failures in fuel cells

NASA Astrophysics Data System (ADS)

Singh, Yadvinder; Orfino, Francesco P.; Dutta, Monica; Kjeang, Erik

2017-03-01

Durability issues in fuel cells, due to chemical and mechanical degradation, are potential impediments in their commercialization. Hydrogen leak development across degraded fuel cell membranes is deemed a lifetime-limiting failure mode and potential safety issue that requires thorough characterization for devising effective mitigation strategies. The scope and depth of failure analysis has, however, been limited by the 2D nature of conventional imaging. In the present work, X-ray computed tomography is introduced as a novel, non-destructive technique for 3D failure analysis. Its capability to acquire true 3D images of membrane damage is demonstrated for the very first time. This approach has enabled unique and in-depth analysis resulting in novel findings regarding the membrane degradation mechanism; these are: significant, exclusive membrane fracture development independent of catalyst layers, localized thinning at crack sites, and demonstration of the critical impact of cracks on fuel cell durability. Evidence of crack initiation within the membrane is demonstrated, and a possible new failure mode different from typical mechanical crack development is identified. X-ray computed tomography is hereby established as a breakthrough approach for comprehensive 3D characterization and reliable failure analysis of fuel cell membranes, and could readily be extended to electrolyzers and flow batteries having similar structure.

Independent Orbiter Assessment (IOA): Assessment of the reaction control system, volume 5

NASA Technical Reports Server (NTRS)

Prust, Chet D.; Hartman, Dan W.

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 aft and forward Reaction Control System (RCS) hardware and Electrical Power Distribution and Control (EPD and C), generating draft failure modes and potential critical items. The IOA results were then compared to the proposed Post 51-L NASA FMEA/CIL baseline. This report documents the results of that comparison for the Orbiter RCS hardware and EPD and C systems. Volume 5 contains detailed analysis and superseded analysis worksheets and the NASA FMEA to IOA worksheet cross reference and recommendations.

Independent Orbiter Assessment (IOA): Assessment of the communication and tracking subsystem, volume 3

NASA Technical Reports Server (NTRS)

Long, W. C.

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 and analysis of the Communication and Tracking hardware, generating draft failure modes and potential critical items. The IOA results were then compared to the NASA FMEA/CIL baseline. 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 Communication and Tracking hardware. Volume 3 continues the presentation of IOA worksheets and contains the potential critical items list, detailed analysis, and the NASA FMEA to IOA worksheet cross reference and recommendations.

Independent Orbiter Assessment (IOA): Assessment of the extravehicular mobility unit, volume 1

NASA Technical Reports Server (NTRS)

Raffaelli, Gary G.

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 performed an independent analysis of the Extravehicular Mobility Unit (EMU) hardware and system, generating draft failure modes criticalities 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 than compared to the most recent proposed Post 51-L NASA FMEA/CIL baseline. A resolution of each discrepancy from the comparison was provided through additional analysis as required. This report documents the results of that comparison for the Orbiter EMU hardware.

Independent Orbiter Assessment (IOA): Assessment of the data processing system FMEA/CIL

NASA Technical Reports Server (NTRS)

Lowery, H. J.; Haufler, W. A.

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 effort first completed an analysis of the Data Processing System (DPS) 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. The results of that comparison is documented for the Orbiter DPS hardware.

Failure mode analysis of silicon-based intracortical microelectrode arrays in non-human primates

PubMed Central

Barrese, James C; Rao, Naveen; Paroo, Kaivon; Triebwasser, Corey; Vargas-Irwin, Carlos; Franquemont, Lachlan; Donoghue, John P

2016-01-01

Objective Brain–computer interfaces (BCIs) using chronically implanted intracortical microelectrode arrays (MEAs) have the potential to restore lost function to people with disabilities if they work reliably for years. Current sensors fail to provide reliably useful signals over extended periods of time for reasons that are not clear. This study reports a comprehensive retrospective analysis from a large set of implants of a single type of intracortical MEA in a single species, with a common set of measures in order to evaluate failure modes. Approach Since 1996, 78 silicon MEAs were implanted in 27 monkeys (Macaca mulatta). We used two approaches to find reasons for sensor failure. First, we classified the time course leading up to complete recording failure as acute (abrupt) or chronic (progressive). Second, we evaluated the quality of electrode recordings over time based on signal features and electrode impedance. Failure modes were divided into four categories: biological, material, mechanical, and unknown. Main results Recording duration ranged from 0 to 2104 days (5.75 years), with a mean of 387 days and a median of 182 days (n = 78). Sixty-two arrays failed completely with a mean time to failure of 332 days (median = 133 days) while nine array experiments were electively terminated for experimental reasons (mean = 486 days). Seven remained active at the close of this study (mean = 753 days). Most failures (56%) occurred within a year of implantation, with acute mechanical failures the most common class (48%), largely because of connector issues (83%). Among grossly observable biological failures (24%), a progressive meningeal reaction that separated the array from the parenchyma was most prevalent (14.5%). In the absence of acute interruptions, electrode recordings showed a slow progressive decline in spike amplitude, noise amplitude, and number of viable channels that predicts complete signal loss by about eight years. Impedance measurements showed systematic early increases, which did not appear to affect recording quality, followed by a slow decline over years. The combination of slowly falling impedance and signal quality in these arrays indicate that insulating material failure is the most significant factor. Significance This is the first long-term failure mode analysis of an emerging BCI technology in a large series of non-human primates. The classification system introduced here may be used to standardize how neuroprosthetic failure modes are evaluated. The results demonstrate the potential for these arrays to record for many years, but achieving reliable sensors will require replacing connectors with implantable wireless systems, controlling the meningeal reaction, and improving insulation materials. These results will focus future research in order to create clinical neuroprosthetic sensors, as well as valuable research tools, that are able to safely provide reliable neural signals for over a decade. PMID:24216311

Failure mode analysis of silicon-based intracortical microelectrode arrays in non-human primates

NASA Astrophysics Data System (ADS)

Barrese, James C.; Rao, Naveen; Paroo, Kaivon; Triebwasser, Corey; Vargas-Irwin, Carlos; Franquemont, Lachlan; Donoghue, John P.

2013-12-01

Objective. Brain-computer interfaces (BCIs) using chronically implanted intracortical microelectrode arrays (MEAs) have the potential to restore lost function to people with disabilities if they work reliably for years. Current sensors fail to provide reliably useful signals over extended periods of time for reasons that are not clear. This study reports a comprehensive retrospective analysis from a large set of implants of a single type of intracortical MEA in a single species, with a common set of measures in order to evaluate failure modes. Approach. Since 1996, 78 silicon MEAs were implanted in 27 monkeys (Macaca mulatta). We used two approaches to find reasons for sensor failure. First, we classified the time course leading up to complete recording failure as acute (abrupt) or chronic (progressive). Second, we evaluated the quality of electrode recordings over time based on signal features and electrode impedance. Failure modes were divided into four categories: biological, material, mechanical, and unknown. Main results. Recording duration ranged from 0 to 2104 days (5.75 years), with a mean of 387 days and a median of 182 days (n = 78). Sixty-two arrays failed completely with a mean time to failure of 332 days (median = 133 days) while nine array experiments were electively terminated for experimental reasons (mean = 486 days). Seven remained active at the close of this study (mean = 753 days). Most failures (56%) occurred within a year of implantation, with acute mechanical failures the most common class (48%), largely because of connector issues (83%). Among grossly observable biological failures (24%), a progressive meningeal reaction that separated the array from the parenchyma was most prevalent (14.5%). In the absence of acute interruptions, electrode recordings showed a slow progressive decline in spike amplitude, noise amplitude, and number of viable channels that predicts complete signal loss by about eight years. Impedance measurements showed systematic early increases, which did not appear to affect recording quality, followed by a slow decline over years. The combination of slowly falling impedance and signal quality in these arrays indicates that insulating material failure is the most significant factor. Significance. This is the first long-term failure mode analysis of an emerging BCI technology in a large series of non-human primates. The classification system introduced here may be used to standardize how neuroprosthetic failure modes are evaluated. The results demonstrate the potential for these arrays to record for many years, but achieving reliable sensors will require replacing connectors with implantable wireless systems, controlling the meningeal reaction, and improving insulation materials. These results will focus future research in order to create clinical neuroprosthetic sensors, as well as valuable research tools, that are able to safely provide reliable neural signals for over a decade.

Failure modes of single and multi-bolted joint in the pultruded fiber reinforced polymer composite members

NASA Astrophysics Data System (ADS)

Kim, S. Y.; Yoo, J. H.; Kim, H. K.; Shin, K. Y.; Yoon, S. J.

2018-06-01

In this paper, we discussed the structural behavior of bolted lap-joint connections in pultruded FRP structural members. Especially, bolted connections in pultruded FRP members are investigated for their failure modes and strength. Specimens with single and multiple bolt-holes are tested in tension under bolt-loading conditions. All of the specimens are instrumented with strain gages and the load-strain responses are monitored. The failed specimens are examined for the cracks and failure patterns. The purpose of this paper is to predict the failure strength by using the ratio of the results obtained by the experiment and the finite element analysis. In the study, several tests are conducted to determine the mechanical properties of pultruded FRP materials before the main experiment. The results are used in the finite element analysis for single and multiple bolted lap-joint specimens. The results obtained by the experiment are compared with the results obtained by the finite element analysis.

Characterization of the Edge Crack Torsion (ECT) Test for Mode III Fracture Toughness Measurement of Laminated Composites

NASA Technical Reports Server (NTRS)

Ratcliffe, James G.

2004-01-01

The edge crack torsion (ECT) test is designed to initiate mode III delamination growth in composite laminates. The test has undergone several design changes during its development. The objective of this paper was to determine the suitability of the current ECT test design a mode III fracture test. To this end, ECT tests were conducted on specimens manufactured from IM7/8552 and S2/8552 tape laminates. Three-dimensional finite element analyses were performed. The analysis results were used to calculate the distribution of mode I, mode II, and mode III strain energy release rate along the delamination front. The results indicated that mode IIIdominated delamination growth would be initiated from the specimen center. However, in specimens of both material types, the measured values of GIIIc exhibited significant dependence on delamination length. Load-displacement response of the specimens exhibited significant deviation from linearity before specimen failure. X-radiographs of a sample of specimens revealed that damage was initiated in the specimens prior to failure. Further inspection of the failure surfaces is required to identify the damage and determine that mode III delamination is initiated in the specimens.

Automatic Monitoring System Design and Failure Probability Analysis for River Dikes on Steep Channel

NASA Astrophysics Data System (ADS)

Chang, Yin-Lung; Lin, Yi-Jun; Tung, Yeou-Koung

2017-04-01

The purposes of this study includes: (1) design an automatic monitoring system for river dike; and (2) develop a framework which enables the determination of dike failure probabilities for various failure modes during a rainstorm. The historical dike failure data collected in this study indicate that most dikes in Taiwan collapsed under the 20-years return period discharge, which means the probability of dike failure is much higher than that of overtopping. We installed the dike monitoring system on the Chiu-She Dike which located on the middle stream of Dajia River, Taiwan. The system includes: (1) vertical distributed pore water pressure sensors in front of and behind the dike; (2) Time Domain Reflectometry (TDR) to measure the displacement of dike; (3) wireless floating device to measure the scouring depth at the toe of dike; and (4) water level gauge. The monitoring system recorded the variation of pore pressure inside the Chiu-She Dike and the scouring depth during Typhoon Megi. The recorded data showed that the highest groundwater level insides the dike occurred 15 hours after the peak discharge. We developed a framework which accounts for the uncertainties from return period discharge, Manning's n, scouring depth, soil cohesion, and friction angle and enables the determination of dike failure probabilities for various failure modes such as overtopping, surface erosion, mass failure, toe sliding and overturning. The framework was applied to Chiu-She, Feng-Chou, and Ke-Chuang Dikes on Dajia River. The results indicate that the toe sliding or overturning has the highest probability than other failure modes. Furthermore, the overall failure probability (integrate different failure modes) reaches 50% under 10-years return period flood which agrees with the historical failure data for the study reaches.

Recent advances in computational structural reliability analysis methods

NASA Astrophysics Data System (ADS)

Thacker, Ben H.; Wu, Y.-T.; Millwater, Harry R.; Torng, Tony Y.; Riha, David S.

1993-10-01

The goal of structural reliability analysis is to determine the probability that the structure will adequately perform its intended function when operating under the given environmental conditions. Thus, the notion of reliability admits the possibility of failure. Given the fact that many different modes of failure are usually possible, achievement of this goal is a formidable task, especially for large, complex structural systems. The traditional (deterministic) design methodology attempts to assure reliability by the application of safety factors and conservative assumptions. However, the safety factor approach lacks a quantitative basis in that the level of reliability is never known and usually results in overly conservative designs because of compounding conservatisms. Furthermore, problem parameters that control the reliability are not identified, nor their importance evaluated. A summary of recent advances in computational structural reliability assessment is presented. A significant level of activity in the research and development community was seen recently, much of which was directed towards the prediction of failure probabilities for single mode failures. The focus is to present some early results and demonstrations of advanced reliability methods applied to structural system problems. This includes structures that can fail as a result of multiple component failures (e.g., a redundant truss), or structural components that may fail due to multiple interacting failure modes (e.g., excessive deflection, resonate vibration, or creep rupture). From these results, some observations and recommendations are made with regard to future research needs.

Recent advances in computational structural reliability analysis methods

NASA Technical Reports Server (NTRS)

Thacker, Ben H.; Wu, Y.-T.; Millwater, Harry R.; Torng, Tony Y.; Riha, David S.

1993-01-01

The goal of structural reliability analysis is to determine the probability that the structure will adequately perform its intended function when operating under the given environmental conditions. Thus, the notion of reliability admits the possibility of failure. Given the fact that many different modes of failure are usually possible, achievement of this goal is a formidable task, especially for large, complex structural systems. The traditional (deterministic) design methodology attempts to assure reliability by the application of safety factors and conservative assumptions. However, the safety factor approach lacks a quantitative basis in that the level of reliability is never known and usually results in overly conservative designs because of compounding conservatisms. Furthermore, problem parameters that control the reliability are not identified, nor their importance evaluated. A summary of recent advances in computational structural reliability assessment is presented. A significant level of activity in the research and development community was seen recently, much of which was directed towards the prediction of failure probabilities for single mode failures. The focus is to present some early results and demonstrations of advanced reliability methods applied to structural system problems. This includes structures that can fail as a result of multiple component failures (e.g., a redundant truss), or structural components that may fail due to multiple interacting failure modes (e.g., excessive deflection, resonate vibration, or creep rupture). From these results, some observations and recommendations are made with regard to future research needs.

The practical impact of elastohydrodynamic lubrication

NASA Technical Reports Server (NTRS)

Anderson, W. J.

1978-01-01

The use of elastohydrodynamics in the analysis of rolling element bearings is discussed. Relationships for minimum film thickness and tractive force were incorporated into computer codes and used for bearing performance prediction. The lambda parameter (ratio of film thickness to composite surface roughness) was shown to be important in predicting bearing life and failure mode. Results indicate that at values of lambda below 3 failure modes other than the classic subsurface initiated fatigue can occur.

Failure analysis in the identification of synergies between cleaning monitoring methods.

PubMed

Whiteley, Greg S; Derry, Chris; Glasbey, Trevor

2015-02-01

The 4 monitoring methods used to manage the quality assurance of cleaning outcomes within health care settings are visual inspection, microbial recovery, fluorescent marker assessment, and rapid ATP bioluminometry. These methods each generate different types of information, presenting a challenge to the successful integration of monitoring results. A systematic approach to safety and quality control can be used to interrogate the known qualities of cleaning monitoring methods and provide a prospective management tool for infection control professionals. We investigated the use of failure mode and effects analysis (FMEA) for measuring failure risk arising through each cleaning monitoring method. FMEA uses existing data in a structured risk assessment tool that identifies weaknesses in products or processes. Our FMEA approach used the literature and a small experienced team to construct a series of analyses to investigate the cleaning monitoring methods in a way that minimized identified failure risks. FMEA applied to each of the cleaning monitoring methods revealed failure modes for each. The combined use of cleaning monitoring methods in sequence is preferable to their use in isolation. When these 4 cleaning monitoring methods are used in combination in a logical sequence, the failure modes noted for any 1 can be complemented by the strengths of the alternatives, thereby circumventing the risk of failure of any individual cleaning monitoring method. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

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.

Independent Orbiter Assessment (IOA): Assessment of the communication and tracking subsystem, volume 1

NASA Technical Reports Server (NTRS)

Long, W. C.

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 and analysis of the Communication and Tracking 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. 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 Communication and Tracking hardware. The IOA product for the Communication and Tracking consisted of 1,108 failure mode worksheets that resulted in 298 critical items being identified. Comparison was made to the NASA baseline which consists of 697 FMEAs and 239 CIL items. The comparison determined if there were any results which had been found by IOA but were not in the NASA baseline. This comparison produced agreement on all but 407 FMEAs which caused differences in 294 CIL items. Volume 1 contains the subsystem description, assessment results, ground rules and assumptions, and some of the IOA worksheets.

How to make the most of failure mode and effect analysis.

PubMed

Stalhandske, Erik; DeRosier, Joseph; Patail, Bryanne; Gosbee, John

2003-01-01

Current accreditation standards issued by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) require hospitals to carry out a proactive risk assessment on at least 1 high-risk activity each year for each accredited program. Because hospital risk managers and patient safety managers generally do not have the knowledge or level of comfort for conducting a proactive risk assessment, they will appreciate the expertise offered by biomedical equipment technicians (BMETs), occupational safety and health professionals, and others. The skills that have been developed by BMETs and others while conducting job safety analyses or failure mode effect analysis can now be applied to a health care proactive analysis. This article touches on the Health Care Failure Mode and Effect Analysis (HFMEA) model that the Department of Veterans Affairs (VA) National Center for Patient Safety developed for proactive risk assessment within the health care community. The goal of this article is to enlighten BMETs and others on the growth of proactive risk assessment within health care and also on the support documents and materials produced by the VA. For additional information on HFMEA, visit the VA website at www.patientsafety.gov/HFMEA.html.

Independent Orbiter Assessment (IOA): Assessment of the mechanical actuation subsystem, volume 1

NASA Technical Reports Server (NTRS)

Bradway, M. W.; Slaughter, W. T.

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 approach features a top-down analysis of the hardware to determine draft 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 IOA results were then compared to the proposed Post 51-L NASA FMEA/CIL baseline that was available. A resolution of each discrepancy from the comparison was provided through additional analysis as required. These discrepancies were flagged as issues, and recommendations were made based on the FMEA data available at the time. This report documents the results of that comparison for the Orbiter Mechanical Actuation System (MAS) hardware. Specifically, the MAS hardware consists of the following components: Air Data Probe (ADP); Elevon Seal Panel (ESP); External Tank Umbilical (ETU); Ku-Band Deploy (KBD); Payload Bay Doors (PBD); Payload Bay Radiators (PBR); Personnel Hatches (PH); Vent Door Mechanism (VDM); and Startracker Door Mechanism (SDM). Criticality was assigned based upon the severity of the effect for each failure mode.

Application of failure mode and effects analysis to treatment planning in scanned proton beam radiotherapy

PubMed Central

2013-01-01

Background A multidisciplinary and multi-institutional working group applied the Failure Mode and Effects Analysis (FMEA) approach to the actively scanned proton beam radiotherapy process implemented at CNAO (Centro Nazionale di Adroterapia Oncologica), aiming at preventing accidental exposures to the patient. Methods FMEA was applied to the treatment planning stage and consisted of three steps: i) identification of the involved sub-processes; ii) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system, iii) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. Results Thirty-four sub-processes were identified, twenty-two of them were judged to be potentially prone to one or more failure modes. A total of forty-four failure modes were recognized, 52% of them characterized by an RPN score equal to 80 or higher. The threshold of 125 for RPN was exceeded in five cases only. The most critical sub-process appeared related to the delineation and correction of artefacts in planning CT data. Failures associated to that sub-process were inaccurate delineation of the artefacts and incorrect proton stopping power assignment to body regions. Other significant failure modes consisted of an outdated representation of the patient anatomy, an improper selection of beam direction and of the physical beam model or dose calculation grid. The main effects of these failures were represented by wrong dose distribution (i.e. deviating from the planned one) delivered to the patient. Additional strategies for risk mitigation, easily and immediately applicable, consisted of a systematic information collection about any known implanted prosthesis directly from each patient and enforcing a short interval time between CT scan and treatment start. Moreover, (i) the investigation of dedicated CT image reconstruction algorithms, (ii) further evaluation of treatment plan robustness and (iii) implementation of independent methods for dose calculation (such as Monte Carlo simulations) may represent novel solutions to increase patient safety. Conclusions FMEA is a useful tool for prospective evaluation of patient safety in proton beam radiotherapy. The application of this method to the treatment planning stage lead to identify strategies for risk mitigation in addition to the safety measures already adopted in clinical practice. PMID:23705626

Using Failure Mode and Effects Analysis to design a comfortable automotive driver seat.

PubMed

Kolich, Mike

2014-07-01

Given enough time and use, all designs will fail. There are no fail-free designs. This is especially true when it comes to automotive seating comfort where the characteristics and preferences of individual customers are many and varied. To address this problem, individuals charged with automotive seating comfort development have, traditionally, relied on iterative and, as a result, expensive build-test cycles. Cost pressures being placed on today's vehicle manufacturers have necessitated the search for more efficient alternatives. This contribution aims to fill this need by proposing the application of an analytical technique common to engineering circles (but new to seating comfort development), namely Design Failure Mode and Effects Analysis (DFMEA). An example is offered to describe how development teams can use this systematic and disciplined approach to highlight potential seating comfort failure modes, reduce their risk, and bring capable designs to life. Copyright © 2014 Elsevier Ltd and The Ergonomics Society. All rights reserved.

A case study in nonconformance and performance trend analysis

NASA Technical Reports Server (NTRS)

Maloy, Joseph E.; Newton, Coy P.

1990-01-01

As part of NASA's effort to develop an agency-wide approach to trend analysis, a pilot nonconformance and performance trending analysis study was conducted on the Space Shuttle auxiliary power unit (APU). The purpose of the study was to (1) demonstrate that nonconformance analysis can be used to identify repeating failures of a specific item (and the associated failure modes and causes) and (2) determine whether performance parameters could be analyzed and monitored to provide an indication of component or system degradation prior to failure. The nonconformance analysis of the APU did identify repeating component failures, which possibly could be reduced if key performance parameters were monitored and analyzed. The performance-trending analysis verified that the characteristics of hardware parameters can be effective in detecting degradation of hardware performance prior to failure.

Independent Orbiter Assessment (IOA): Assessment of the reaction control system, volume 3

NASA Technical Reports Server (NTRS)

Prust, Chet D.; Hartman, Dan W.

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 aft and forward Reaction Control System (RCS) hardware and Electrical Power Distribution and Control (EPD and C), generating draft failure modes and potential critical items. The IOA results were then compared to the proposed Post 51-L NASA FMEA/CIL baseline. This report documents the results of that comparison for the Orbiter RCS hardware and EPD and C systems. Volume 3 continues the presentation of IOA worksheets.

Independent Orbiter Assessment (IOA): Assessment of the reaction control system, volume 2

NASA Technical Reports Server (NTRS)

Prust, Chet D.; Hartman, Dan W.

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 aft and forward Reaction Control System (RCS) hardware and Electrical Power Distribution and Control (EPD and C), generating draft failure modes and potential critical items. The IOA results were then compared to the proposed Post 51-L NASA FMEA/CIL baseline. This report documents the results of that comparison for the Orbiter RCS hardware and EPD and C systems. Volume 2 continues the presentation of IOA worksheets.

The Effect of Delamination on Damage Path and Failure Load Prediction for Notched Composite Laminates

NASA Technical Reports Server (NTRS)

Satyanarayana, Arunkumar; Bogert, Philip B.; Chunchu, Prasad B.

2007-01-01

The influence of delamination on the progressing damage path and initial failure load in composite laminates is investigated. Results are presented from a numerical and an experimental study of center-notched tensile-loaded coupons. The numerical study includes two approaches. The first approach considers only intralaminar (fiber breakage and matrix cracking) damage modes in calculating the progression of the damage path. In the second approach, the model is extended to consider the effect of interlaminar (delamination) damage modes in addition to the intralaminar damage modes. The intralaminar damage is modeled using progressive damage analysis (PDA) methodology implemented with the VUMAT subroutine in the ABAQUS finite element code. The interlaminar damage mode has been simulated using cohesive elements in ABAQUS. In the experimental study, 2-3 specimens each of two different stacking sequences of center-notched laminates are tensile loaded. The numerical results from the two different modeling approaches are compared with each other and the experimentally observed results for both laminate types. The comparisons reveal that the second modeling approach, where the delamination damage mode is included together with the intralaminar damage modes, better simulates the experimentally observed damage modes and damage paths, which were characterized by splitting failures perpendicular to the notch tips in one or more layers. Additionally, the inclusion of the delamination mode resulted in a better prediction of the loads at which the failure took place, which were higher than those predicted by the first modeling approach which did not include delaminations.

Structural analysis considerations for wind turbine blades

NASA Technical Reports Server (NTRS)

Spera, D. A.

1979-01-01

Approaches to the structural analysis of wind turbine blade designs are reviewed. Specifications and materials data are discussed along with the analysis of vibrations, loads, stresses, and failure modes.

Integrating FMEA in a Model-Driven Methodology

NASA Astrophysics Data System (ADS)

Scippacercola, Fabio; Pietrantuono, Roberto; Russo, Stefano; Esper, Alexandre; Silva, Nuno

2016-08-01

Failure Mode and Effects Analysis (FMEA) is a well known technique for evaluating the effects of potential failures of components of a system. FMEA demands for engineering methods and tools able to support the time- consuming tasks of the analyst. We propose to make FMEA part of the design of a critical system, by integration into a model-driven methodology. We show how to conduct the analysis of failure modes, propagation and effects from SysML design models, by means of custom diagrams, which we name FMEA Diagrams. They offer an additional view of the system, tailored to FMEA goals. The enriched model can then be exploited to automatically generate FMEA worksheet and to conduct qualitative and quantitative analyses. We present a case study from a real-world project.

Morphological features (defects) in fuel cell membrane electrode assemblies

NASA Astrophysics Data System (ADS)

Kundu, S.; Fowler, M. W.; Simon, L. C.; Grot, S.

Reliability and durability issues in fuel cells are becoming more important as the technology and the industry matures. Although research in this area has increased, systematic failure analysis, such as a failure modes and effects analysis (FMEA), are very limited in the literature. This paper presents a categorization scheme of causes, modes, and effects related to fuel cell degradation and failure, with particular focus on the role of component quality, that can be used in FMEAs for polymer electrolyte membrane (PEM) fuel cells. The work also identifies component defects imparted on catalyst-coated membranes (CCM) by manufacturing and proposes mechanisms by which they can influence overall degradation and reliability. Six major defects have been identified on fresh CCM materials, i.e., cracks, orientation, delamination, electrolyte clusters, platinum clusters, and thickness variations.

Application of failure mode and effects analysis (FMEA) to pretreatment phases in tomotherapy

PubMed Central

Broggi, Sara; Cantone, Marie Claire; Chiara, Anna; Muzio, Nadia Di; Longobardi, Barbara; Mangili, Paola

2013-01-01

The aim of this paper was the application of the failure mode and effects analysis (FMEA) approach to assess the risks for patients undergoing radiotherapy treatments performed by means of a helical tomotherapy unit. FMEA was applied to the preplanning imaging, volume determination, and treatment planning stages of the tomotherapy process and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system; and 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. A total of 74 failure modes were identified: 38 in the stage of preplanning imaging and volume determination, and 36 in the stage of planning. The threshold of 125 for RPN was exceeded in four cases: one case only in the phase of preplanning imaging and volume determination, and three cases in the stage of planning. The most critical failures appeared related to (i) the wrong or missing definition and contouring of the overlapping regions, (ii) the wrong assignment of the overlap priority to each anatomical structure, (iii) the wrong choice of the computed tomography calibration curve for dose calculation, and (iv) the wrong (or not performed) choice of the number of fractions in the planning station. On the basis of these findings, in addition to the safety strategies already adopted in the clinical practice, novel solutions have been proposed for mitigating the risk of these failures and to increase patient safety. PACS number: 87.55.Qr PMID:24036868

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.

PubMed

Wetterneck, Tosha B; Skibinski, Kathleen A; Roberts, Tanita L; Kleppin, Susan M; Schroeder, Mark E; Enloe, Myra; Rough, Steven S; Hundt, Ann Schoofs; Carayon, Pascale

2006-08-15

Failure mode and effects analysis (FMEA) was used to evaluate a smart i.v. pump as it was implemented into a redesigned medication-use process. A multidisciplinary team conducted a FMEA to guide the implementation of a smart i.v. pump that was designed to prevent pump programming errors. The smart i.v. pump was equipped with a dose-error reduction system that included a pre-defined drug library in which dosage limits were set for each medication. Monitoring for potential failures and errors occurred for three months postimplementation of FMEA. Specific measures were used to determine the success of the actions that were implemented as a result of the FMEA. The FMEA process at the hospital identified key failure modes in the medication process with the use of the old and new pumps, and actions were taken to avoid errors and adverse events. I.V. pump software and hardware design changes were also recommended. Thirteen of the 18 failure modes reported in practice after pump implementation had been identified by the team. A beneficial outcome of FMEA was the development of a multidisciplinary team that provided the infrastructure for safe technology implementation and effective event investigation after implementation. With the continual updating of i.v. pump software and hardware after implementation, FMEA can be an important starting place for safe technology choice and implementation and can produce site experts to follow technology and process changes over time. FMEA was useful in identifying potential problems in the medication-use process with the implementation of new smart i.v. pumps. Monitoring for system failures and errors after implementation remains necessary.

Compression After Impact on Honeycomb Core Sandwich Panels with Thin Facesheets, Part 2: Analysis

NASA Technical Reports Server (NTRS)

Mcquigg, Thomas D.; Kapania, Rakesh K.; Scotti, Stephen J.; Walker, Sandra P.

2012-01-01

A two part research study has been completed on the topic of compression after impact (CAI) of thin facesheet honeycomb core sandwich panels. The research has focused on both experiments and analysis in an effort to establish and validate a new understanding of the damage tolerance of these materials. Part 2, the subject of the current paper, is focused on the analysis, which corresponds to the CAI testings described in Part 1. Of interest, are sandwich panels, with aerospace applications, which consist of very thin, woven S2-fiberglass (with MTM45-1 epoxy) facesheets adhered to a Nomex honeycomb core. Two sets of materials, which were identical with the exception of the density of the honeycomb core, were tested in Part 1. The results highlighted the need for analysis methods which taken into account multiple failure modes. A finite element model (FEM) is developed here, in Part 2. A commercial implementation of the Multicontinuum Failure Theory (MCT) for progressive failure analysis (PFA) in composite laminates, Helius:MCT, is included in this model. The inclusion of PFA in the present model provided a new, unique ability to account for multiple failure modes. In addition, significant impact damage detail is included in the model. A sensitivity study, used to assess the effect of each damage parameter on overall analysis results, is included in an appendix. Analysis results are compared to the experimental results for each of the 32 CAI sandwich panel specimens tested to failure. The failure of each specimen is predicted using the high-fidelity, physicsbased analysis model developed here, and the results highlight key improvements in the understanding of honeycomb core sandwich panel CAI failure. Finally, a parametric study highlights the strength benefits compared to mass penalty for various core densities.

Independent Orbiter Assessment (IOA): Assessment of the electrical power generation/fuel cell powerplant subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Brown, K. L.; Bertsch, P. J.

1987-01-01

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 Electrical Power Generation/Fuel Cell Powerplant (EPG/FCP) 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 proposed Post 51-L NASA FMEA/CIL baseline. A resolution of each discrepancy from the comparison was provided through additional analysis as required. This report documents the results of that comparison for the Orbiter EPG/FCP hardware.

Model authoring system for fail safe analysis

NASA Technical Reports Server (NTRS)

Sikora, Scott E.

1990-01-01

The Model Authoring System is a prototype software application for generating fault tree analyses and failure mode and effects analyses for circuit designs. Utilizing established artificial intelligence and expert system techniques, the circuits are modeled as a frame-based knowledge base in an expert system shell, which allows the use of object oriented programming and an inference engine. The behavior of the circuit is then captured through IF-THEN rules, which then are searched to generate either a graphical fault tree analysis or failure modes and effects analysis. Sophisticated authoring techniques allow the circuit to be easily modeled, permit its behavior to be quickly defined, and provide abstraction features to deal with complexity.

Direct modeling parameter signature analysis and failure mode prediction of physical systems using hybrid computer optimization

NASA Technical Reports Server (NTRS)

Drake, R. L.; Duvoisin, P. F.; Asthana, A.; Mather, T. W.

1971-01-01

High speed automated identification and design of dynamic systems, both linear and nonlinear, are discussed. Special emphasis is placed on developing hardware and techniques which are applicable to practical problems. The basic modeling experiment and new results are described. Using the improvements developed successful identification of several systems, including a physical example as well as simulated systems, was obtained. The advantages of parameter signature analysis over signal signature analysis in go-no go testing of operational systems were demonstrated. The feasibility of using these ideas in failure mode prediction in operating systems was also investigated. An improved digital controlled nonlinear function generator was developed, de-bugged, and completely documented.

Application of Function-Failure Similarity Method to Rotorcraft Component Design

NASA Technical Reports Server (NTRS)

Roberts, Rory A.; Stone, Robert E.; Tumer, Irem Y.; Clancy, Daniel (Technical Monitor)

2002-01-01

Performance and safety are the top concerns of high-risk aerospace applications at NASA. Eliminating or reducing performance and safety problems can be achieved with a thorough understanding of potential failure modes in the designs that lead to these problems. The majority of techniques use prior knowledge and experience as well as Failure Modes and Effects as methods to determine potential failure modes of aircraft. During the design of aircraft, a general technique is needed to ensure that every potential failure mode is considered, while avoiding spending time on improbable failure modes. In this work, this is accomplished by mapping failure modes to specific components, which are described by their functionality. The failure modes are then linked to the basic functions that are carried within the components of the aircraft. Using this technique, designers can examine the basic functions, and select appropriate analyses to eliminate or design out the potential failure modes. The fundamentals of this method were previously introduced for a simple rotating machine test rig with basic functions that are common to a rotorcraft. In this paper, this technique is applied to the engine and power train of a rotorcraft, using failures and functions obtained from accident reports and engineering drawings.

Failure Analysis of Network Based Accessible Pedestrian Signals in Closed-Loop Operation

DOT National Transportation Integrated Search

2011-03-01

The potential failure modes of a network based accessible pedestrian system were analyzed to determine the limitations and benefits of closed-loop operation. The vulnerabilities of the system are accessed using the industry standard process known as ...

The use of failure mode and effects analysis to construct an effective disposal and prevention mechanism for infectious hospital waste

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

Ho, Chao Chung, E-mail: ho919@pchome.com.tw; Liao, Ching-Jong

Highlights: > This study is based on a real case in a regional teaching hospital in Taiwan. > We use Failure mode and effects analysis (FMEA) as the evaluation method. > We successfully identify the risk factors of infectious waste disposal. > We propose plans for the detection of exceptional cases of infectious waste. - Abstract: In recent times, the quality of medical care has been continuously improving in medical institutions wherein patient-centred care has been emphasized. Failure mode and effects analysis (FMEA) has also been promoted as a method of basic risk management and as part of total qualitymore » management (TQM) for improving the quality of medical care and preventing mistakes. Therefore, a study was conducted using FMEA to evaluate the potential risk causes in the process of infectious medical waste disposal, devise standard procedures concerning the waste, and propose feasible plans for facilitating the detection of exceptional cases of infectious waste. The analysis revealed the following results regarding medical institutions: (a) FMEA can be used to identify the risk factors of infectious waste disposal. (b) During the infectious waste disposal process, six items were scored over 100 in the assessment of uncontrolled risks: erroneous discarding of infectious waste by patients and their families, erroneous discarding by nursing staff, erroneous discarding by medical staff, cleaning drivers pierced by sharp articles, cleaning staff pierced by sharp articles, and unmarked output units. Therefore, the study concluded that it was necessary to (1) provide education and training about waste classification to the medical staff, patients and their families, nursing staff, and cleaning staff; (2) clarify the signs of caution; and (3) evaluate the failure mode and strengthen the effects.« less

Is it possible to identify a trend in problem/failure data

NASA Technical Reports Server (NTRS)

Church, Curtis K.

1990-01-01

One of the major obstacles in identifying and interpreting a trend is the small number of data points. Future trending reports will begin with 1983 data. As the problem/failure data are aggregated by year, there are just seven observations (1983 to 1989) for the 1990 reports. Any statistical inferences with a small amount of data will have a large degree of uncertainty. Consequently, a regression technique approach to identify a trend is limited. Though trend determination by failure mode may be unrealistic, the data may be explored for consistency or stability and the failure rate investigated. Various alternative data analysis procedures are briefly discussed. Techniques that could be used to explore problem/failure data by failure mode are addressed. The data used are taken from Section One, Space Shuttle Main Engine, of the Calspan Quarterly Report dated April 2, 1990.

A Fault Tree Approach to Analysis of Behavioral Systems: An Overview.

ERIC Educational Resources Information Center

Stephens, Kent G.

Developed at Brigham Young University, Fault Tree Analysis (FTA) is a technique for enhancing the probability of success in any system by analyzing the most likely modes of failure that could occur. It provides a logical, step-by-step description of possible failure events within a system and their interaction--the combinations of potential…

ALS rocket engine combustion devices design and demonstration

NASA Technical Reports Server (NTRS)

Arreguin, Steve

1989-01-01

Work performed during Phase one is summarized and the significant technical and programmatic accomplishments occurring during this period are documented. Besides a summary of the results, methodologies, trade studies, design, fabrication, and hardware conditions; the following are included: the evolving Maintainability Plan, Reliability Program Plan, Failure Summary and Analysis Report, and the Failure Mode and Effect Analysis.

Failure detection system risk reduction assessment

NASA Technical Reports Server (NTRS)

Aguilar, Robert B. (Inventor); Huang, Zhaofeng (Inventor)

2012-01-01

A process includes determining a probability of a failure mode of a system being analyzed reaching a failure limit as a function of time to failure limit, determining a probability of a mitigation of the failure mode as a function of a time to failure limit, and quantifying a risk reduction based on the probability of the failure mode reaching the failure limit and the probability of the mitigation.

Deriving Function-failure Similarity Information for Failure-free Rotorcraft Component Design

NASA Technical Reports Server (NTRS)

Roberts, Rory A.; Stone, Robert B.; Tumer, Irem Y.; Clancy, Daniel (Technical Monitor)

2002-01-01

Performance and safety are the top concerns of high-risk aerospace applications at NASA. Eliminating or reducing performance and safety problems can be achieved with a thorough understanding of potential failure modes in the design that lead to these problems. The majority of techniques use prior knowledge and experience as well as Failure Modes and Effects as methods to determine potential failure modes of aircraft. The aircraft design needs to be passed through a general technique to ensure that every potential failure mode is considered, while avoiding spending time on improbable failure modes. In this work, this is accomplished by mapping failure modes to certain components, which are described by their functionality. In turn, the failure modes are then linked to the basic functions that are carried within the components of the aircraft. Using the technique proposed in this paper, designers can examine the basic functions, and select appropriate analyses to eliminate or design out the potential failure modes. This method was previously applied to a simple rotating machine test rig with basic functions that are common to a rotorcraft. In this paper, this technique is applied to the engine and power train of a rotorcraft, using failures and functions obtained from accident reports and engineering drawings.

Study Of The Risks Arising From Natural Disasters And Hazards On Urban And Intercity Motorways By Using Failure Mode Effect Analysis (FMEA) Methods

NASA Astrophysics Data System (ADS)

DELİCE, Yavuz

2015-04-01

Highways, Located in the city and intercity locations are generally prone to many kind of natural disaster risks. Natural hazards and disasters that may occur firstly from highway project making to construction and operation stages and later during the implementation of highway maintenance and repair stages have to be taken into consideration. And assessment of risks that may occur against adverse situations is very important in terms of project design, construction, operation maintenance and repair costs. Making hazard and natural disaster risk analysis is largely depending on the definition of the likelihood of the probable hazards on the highways. However, assets at risk , and the impacts of the events must be examined and to be rated in their own. With the realization of these activities, intended improvements against natural hazards and disasters will be made with the utilization of Failure Mode Effects Analysis (FMEA) method and their effects will be analyzed with further works. FMEA, is a useful method to identify the failure mode and effects depending on the type of failure rate effects priorities and finding the most optimum economic and effective solution. Although relevant measures being taken for the identified risks by this analysis method , it may also provide some information for some public institutions about the nature of these risks when required. Thus, the necessary measures will have been taken in advance in the city and intercity highways. Many hazards and natural disasters are taken into account in risk assessments. The most important of these dangers can be listed as follows; • Natural disasters 1. Meteorological based natural disasters (floods, severe storms, tropical storms, winter storms, avalanches, etc.). 2. Geological based natural disasters (earthquakes, tsunamis, landslides, subsidence, sinkholes, etc) • Human originated disasters 1. Transport accidents (traffic accidents), originating from the road surface defects (icing, signaling caused malfunctions and risks), fire or explosion etc.- In this study, with FMEA method, risk analysis of the urban and intercity motorways against natural disasters and hazards have been performed and found solutions were brought against these risks. Keywords: Failure Modes Effects Analysis (FMEA), Pareto Analyses (PA), Highways, Risk Management.

Random safety auditing, root cause analysis, failure mode and effects analysis.

PubMed

Ursprung, Robert; Gray, James

2010-03-01

Improving quality and safety in health care is a major concern for health care providers, the general public, and policy makers. Errors and quality issues are leading causes of morbidity and mortality across the health care industry. There is evidence that patients in the neonatal intensive care unit (NICU) are at high risk for serious medical errors. To facilitate compliance with safe practices, many institutions have established quality-assurance monitoring procedures. Three techniques that have been found useful in the health care setting are failure mode and effects analysis, root cause analysis, and random safety auditing. When used together, these techniques are effective tools for system analysis and redesign focused on providing safe delivery of care in the complex NICU system. Copyright 2010 Elsevier Inc. All rights reserved.

Effects of Modes, Obesity, and Body Position on Non-invasive Positive Pressure Ventilation Success in the Intensive Care Unit: A Randomized Controlled Study.

PubMed

Türk, Murat; Aydoğdu, Müge; Gürsel, Gül

2018-01-01

Different outcomes and success rates of non-invasive positive pressure ventilation (NPPV) in patients with acute hypercapnic respiratory failure (AHRF) still pose a significant problem in intensive care units. Previous studies investigating different modes, body positioning, and obesity-associated hypoventilation in patients with chronic respiratory failure showed that these factors may affect ventilator mechanics to achieve a better minute ventilation. This study tried to compare pressure support (BiPAP-S) and average volume targeted pressure support (AVAPS-S) modes in patients with acute or acute-on-chronic hypercapnic respiratory failure. In addition, short-term effects of body position and obesity within both modes were analyzed. We conducted a randomized controlled study in a 7-bed intensive care unit. The course of blood gas analysis and differences in ventilation variables were compared between BiPAP-S (n=33) and AVAPS-S (n=29), and between semi-recumbent and lateral positions in both modes. No difference was found in the length of hospital stay and the course of PaCO2, pH, and HCO3 levels between the modes. There was a mean reduction of 5.7±4.1 mmHg in the PaCO2 levels in the AVAPS-S mode, and 2.7±2.3 mmHg in the BiPAP-S mode per session (p<0.05). Obesity didn't have any effect on the course of PaCO2 in both the modes. Body positioning had no notable effect in both modes. Although the decrease in the PaCO2 levels in the AVAPS-S mode per session was remarkably high, the course was similar in both modes. Furthermore, obesity and body positioning had no prominent effect on the PaCO2 response and ventilator mechanics. Post hoc power analysis showed that the sample size was not adequate to detect a significant difference between the modes.

Material wear and failure mode analysis of breakfast cereal extruder barrels and screw elements

NASA Astrophysics Data System (ADS)

Mastio, Michael Joseph, Jr.

2005-11-01

Nearly seventy-five years ago, the single screw extruder was introduced as a means to produce metal products. Shortly after that, the extruder found its way into the plastics industry. Today much of the world's polymer industry utilizes extruders to produce items such as soda bottles, PVC piping, and toy figurines. Given the significant economical advantages of extruders over conventional batch flow systems, extruders have also migrated into the food industry. Food applications include the meat, pet food, and cereal industries to name just a few. Cereal manufacturers utilize extruders to produce various forms of Ready-to-Eat (RTE) cereals. These cereals are made from grains such as rice, oats, wheat, and corn. The food industry has been incorrectly viewed as an extruder application requiring only minimal energy control and performance capability. This misconception has resulted in very little research in the area of material wear and failure mode analysis of breakfast cereal extruders. Breakfast cereal extruder barrels and individual screw elements are subjected to the extreme pressures and temperatures required to shear and cook the cereal ingredients, resulting in excessive material wear and catastrophic failure of these components. Therefore, this project focuses on the material wear and failure mode analysis of breakfast cereal extruder barrels and screw elements, modeled as a Discrete Time Markov Chain (DTMC) process in which historical data is used to predict future failures. Such predictive analysis will yield cost savings opportunities by providing insight into extruder maintenance scheduling and interchangeability of screw elements. In this DTMC wear analysis, four states of wear are defined and a probability transition matrix is determined based upon 24,041 hours of operational data. This probability transition matrix is used to predict when an extruder component will move to the next state of wear and/or failure. This information can be used to determine maintenance schedules and screw element interchangeability.

Demonstration Advanced Avionics System (DAAS), Phase 1

NASA Technical Reports Server (NTRS)

Bailey, A. J.; Bailey, D. G.; Gaabo, R. J.; Lahn, T. G.; Larson, J. C.; Peterson, E. M.; Schuck, J. W.; Rodgers, D. L.; Wroblewski, K. A.

1981-01-01

Demonstration advanced anionics system (DAAS) function description, hardware description, operational evaluation, and failure mode and effects analysis (FMEA) are provided. Projected advanced avionics system (PAAS) description, reliability analysis, cost analysis, maintainability analysis, and modularity analysis are discussed.

SU-F-T-245: The Investigation of Failure Mode and Effects Analysis and PDCA for the Radiotherapy Risk Reduction

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

Xie, J; Wang, J; P, J

2016-06-15

Purpose: To optimize the clinical processes of radiotherapy and to reduce the radiotherapy risks by implementing the powerful risk management tools of failure mode and effects analysis(FMEA) and PDCA(plan-do-check-act). Methods: A multidiciplinary QA(Quality Assurance) team from our department consisting of oncologists, physicists, dosimetrists, therapists and administrator was established and an entire workflow QA process management using FMEA and PDCA tools was implemented for the whole treatment process. After the primary process tree was created, the failure modes and Risk priority numbers(RPNs) were determined by each member, and then the RPNs were averaged after team discussion. Results: 3 of 9 failuremore » modes with RPN above 100 in the practice were identified in the first PDCA cycle, which were further analyzed to investigate the RPNs: including of patient registration error, prescription error and treating wrong patient. New process controls reduced the occurrence, or detectability scores from the top 3 failure modes. Two important corrective actions reduced the highest RPNs from 300 to 50, and the error rate of radiotherapy decreased remarkably. Conclusion: FMEA and PDCA are helpful in identifying potential problems in the radiotherapy process, which was proven to improve the safety, quality and efficiency of radiation therapy in our department. The implementation of the FMEA approach may improve the understanding of the overall process of radiotherapy while may identify potential flaws in the whole process. Further more, repeating the PDCA cycle can bring us closer to the goal: higher safety and accuracy radiotherapy.« less

Development of GENOA Progressive Failure Parallel Processing Software Systems

NASA Technical Reports Server (NTRS)

Abdi, Frank; Minnetyan, Levon

1999-01-01

A capability consisting of software development and experimental techniques has been developed and is described. The capability is integrated into GENOA-PFA to model polymer matrix composite (PMC) structures. The capability considers the physics and mechanics of composite materials and structure by integration of a hierarchical multilevel macro-scale (lamina, laminate, and structure) and micro scale (fiber, matrix, and interface) simulation analyses. The modeling involves (1) ply layering methodology utilizing FEM elements with through-the-thickness representation, (2) simulation of effects of material defects and conditions (e.g., voids, fiber waviness, and residual stress) on global static and cyclic fatigue strengths, (3) including material nonlinearities (by updating properties periodically) and geometrical nonlinearities (by Lagrangian updating), (4) simulating crack initiation. and growth to failure under static, cyclic, creep, and impact loads. (5) progressive fracture analysis to determine durability and damage tolerance. (6) identifying the percent contribution of various possible composite failure modes involved in critical damage events. and (7) determining sensitivities of failure modes to design parameters (e.g., fiber volume fraction, ply thickness, fiber orientation. and adhesive-bond thickness). GENOA-PFA progressive failure analysis is now ready for use to investigate the effects on structural responses to PMC material degradation from damage induced by static, cyclic (fatigue). creep, and impact loading in 2D/3D PMC structures subjected to hygrothermal environments. Its use will significantly facilitate targeting design parameter changes that will be most effective in reducing the probability of a given failure mode occurring.

An Abrupt Transition to an Intergranular Failure Mode in the Near-Threshold Fatigue Crack Growth Regime in Ni-Based Superalloys

NASA Astrophysics Data System (ADS)

Telesman, J.; Smith, T. M.; Gabb, T. P.; Ring, A. J.

2018-06-01

Cyclic near-threshold fatigue crack growth (FCG) behavior of two disk superalloys was evaluated and was shown to exhibit an unexpected sudden failure mode transition from a mostly transgranular failure mode at higher stress intensity factor ranges to an almost completely intergranular failure mode in the threshold regime. The change in failure modes was associated with a crossover of FCG resistance curves in which the conditions that produced higher FCG rates in the Paris regime resulted in lower FCG rates and increased ΔK th values in the threshold region. High-resolution scanning and transmission electron microscopy were used to carefully characterize the crack tips at these near-threshold conditions. Formation of stable Al-oxide followed by Cr-oxide and Ti-oxides was found to occur at the crack tip prior to formation of unstable oxides. To contrast with the threshold failure mode regime, a quantitative assessment of the role that the intergranular failure mode has on cyclic FCG behavior in the Paris regime was also performed. It was demonstrated that even a very limited intergranular failure content dominates the FCG response under mixed mode failure conditions.

Signal analysis techniques for incipient failure detection in turbomachinery

NASA Technical Reports Server (NTRS)

Coffin, T.

1985-01-01

Signal analysis techniques for the detection and classification of incipient mechanical failures in turbomachinery were developed, implemented and evaluated. Signal analysis techniques available to describe dynamic measurement characteristics are reviewed. Time domain and spectral methods are described, and statistical classification in terms of moments is discussed. Several of these waveform analysis techniques were implemented on a computer and applied to dynamic signals. A laboratory evaluation of the methods with respect to signal detection capability is described. Plans for further technique evaluation and data base development to characterize turbopump incipient failure modes from Space Shuttle main engine (SSME) hot firing measurements are outlined.

Memory Circuit Fault Simulator

NASA Technical Reports Server (NTRS)

Sheldon, Douglas J.; McClure, Tucker

2013-01-01

Spacecraft are known to experience significant memory part-related failures and problems, both pre- and postlaunch. These memory parts include both static and dynamic memories (SRAM and DRAM). These failures manifest themselves in a variety of ways, such as pattern-sensitive failures, timingsensitive failures, etc. Because of the mission critical nature memory devices play in spacecraft architecture and operation, understanding their failure modes is vital to successful mission operation. To support this need, a generic simulation tool that can model different data patterns in conjunction with variable write and read conditions was developed. This tool is a mathematical and graphical way to embed pattern, electrical, and physical information to perform what-if analysis as part of a root cause failure analysis effort.

Model 0A wind turbine generator FMEA

NASA Technical Reports Server (NTRS)

Klein, William E.; Lalli, Vincent R.

1989-01-01

The results of Failure Modes and Effects Analysis (FMEA) conducted for the Wind Turbine Generators are presented. The FMEA was performed for the functional modes of each system, subsystem, or component. The single-point failures were eliminated for most of the systems. The blade system was the only exception. The qualitative probability of a blade separating was estimated at level D-remote. Many changes were made to the hardware as a result of this analysis. The most significant change was the addition of the safety system. Operational experience and need to improve machine availability have resulted in subsequent changes to the various systems which are also reflected in this FMEA.

Independent Orbiter Assessment (IOA): Assessment of the reaction control system, volume 4

NASA Technical Reports Server (NTRS)

Prust, Chet D.; Hartman, Dan W.

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 aft and forward Reaction Control System (RCS) hardware and Electrical Power Distribution and Control (EPD and C), generating draft failure modes and potential critical items. The IOA results were then compared to the proposed Post 51-L NASA FMEA/CIL baseline. This report documents the results of that comparison for the Orbiter RCS hardware and EPD and C systems. Volume 4 continues the presentation of IOA worksheets and contains the potential critical items list.

Root causes investigation of catastrophic optical bulk damage in high-power InGaAs-AlGaAs strained QW lasers

NASA Astrophysics Data System (ADS)

Sin, Yongkun; Lingley, Zachary; Ayvazian, Talin; Brodie, Miles; Ives, Neil

2018-02-01

High-power single-mode (SM) and multi-mode (MM) InGaAs-AlGaAs strained quantum well (QW) lasers are critical components for both terrestrial and space satellite communications systems. Since these lasers predominantly fail by catastrophic and sudden degradation due to COD, it is especially crucial for space satellite applications to investigate reliability, failure modes, and degradation mechanisms of these lasers. Our group reported a new failure mode in MM and SM InGaAs-AlGaAs strained QW lasers in 2009 and 2016, respectively. Our group also reported in 2017 that bulk failure due to catastrophic optical bulk damage (COBD) is the dominant failure mode of both SM and MM lasers that were subject to long-term life-tests. For the present study, we report root causes investigation of COBD by performing long-term lifetests followed by failure mode analysis (FMA) using various micro-analytical techniques including electron beam induced current (EBIC), time-resolved electroluminescence (EL), focused ion beam (FIB), high-resolution transmission electron microscopy (TEM), and deep level transient spectroscopy (DLTS). Our life-tests with accumulated test hours of over 25,000 hours for SM lasers and over 35,000 hours for MM lasers generated a number of COBD failures with various failure times. EBIC techniques were employed to study dark line defects (DLDs) generated in SM COBD failures stressed under different test conditions. FIB and high-resolution TEM were employed to prepare cross sectional and plan view TEM specimens to study DLD areas (dislocations) in post-aged SM lasers. Time-resolved EL techniques were employed to study initiation and progressions of dark spots and dark lines in real time as MM lasers were aged. Lastly, to investigate precursor signatures of failure and degradation mechanisms responsible for COBD in both SM and MM lasers, we employed DLTS techniques to study a role that electron traps (non-radiative recombination centers) play in degradation of these lasers. Our in-depth root causes investigation results are reported.

A quality risk management model approach for cell therapy manufacturing.

PubMed

Lopez, Fabio; Di Bartolo, Chiara; Piazza, Tommaso; Passannanti, Antonino; Gerlach, Jörg C; Gridelli, Bruno; Triolo, Fabio

2010-12-01

International regulatory authorities view risk management as an essential production need for the development of innovative, somatic cell-based therapies in regenerative medicine. The available risk management guidelines, however, provide little guidance on specific risk analysis approaches and procedures applicable in clinical cell therapy manufacturing. This raises a number of problems. Cell manufacturing is a poorly automated process, prone to operator-introduced variations, and affected by heterogeneity of the processed organs/tissues and lot-dependent variability of reagent (e.g., collagenase) efficiency. In this study, the principal challenges faced in a cell-based product manufacturing context (i.e., high dependence on human intervention and absence of reference standards for acceptable risk levels) are identified and addressed, and a risk management model approach applicable to manufacturing of cells for clinical use is described for the first time. The use of the heuristic and pseudo-quantitative failure mode and effect analysis/failure mode and critical effect analysis risk analysis technique associated with direct estimation of severity, occurrence, and detection is, in this specific context, as effective as, but more efficient than, the analytic hierarchy process. Moreover, a severity/occurrence matrix and Pareto analysis can be successfully adopted to identify priority failure modes on which to act to mitigate risks. The application of this approach to clinical cell therapy manufacturing in regenerative medicine is also discussed. © 2010 Society for Risk Analysis.

Independent Orbiter Assessment (IOA): Assessment of the mechanical actuation subsystem, volume 2

NASA Technical Reports Server (NTRS)

Bradway, M. W.; Slaughter, W. T.

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 approach features a top-down analysis of the hardware to determine draft 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 IOA results were then compared to the proposed Post 51-L NASA FMEA/CIL baseline that was available. A resolution of each discrepancy from the comparison was provided through additional analysis as required. These discrepancies were flagged as issues, and recommendations were made based on the FMEA data available at the time. This report documents the results of that comparison for the Orbiter Mechanical Actuation System (MAS) hardware. Specifically, the MAS hardware consists of the following components: Air Data Probe (ADP); Elevon Seal Panel (ESP); External Tank Umbilical (ETU); Ku-Band Deploy (KBD); Payload Bay Doors (PBD); Payload Bay Radiators (PBR); Personnel Hatches (PH); Vent Door Mechanism (VDM); and Startracker Door Mechanism (SDM). Criticality was assigned based upon the severity of the effect for each failure mode. Volume 2 continues the presentation of IOA analysis worksheets and contains the potential critical items list, detailed analysis, and NASA FMEA/CIL to IOA worksheet cross reference and recommendations.

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.

Independent Orbiter Assessment (IOA): Analysis of the reaction control system, volume 3

NASA Technical Reports Server (NTRS)

Burkemper, V. J.; Haufler, W. A.; Odonnell, R. A.; Paul, D. J.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results for the Reaction Control System (RCS). The RCS is situated in three independent modules, one forward in the orbiter nose and one in each OMS/RCS pod. Each RCS module consists of the following subsystems: Helium Pressurization Subsystem; Propellant Storage and Distribution Subsystem; Thruster Subsystem; and Electrical Power Distribution and Control Subsystem. Volume 3 continues the presentation of IOA analysis worksheets and the potential critical items list.

Failure Mode and Effect Analysis for Delivery of Lung Stereotactic Body Radiation Therapy

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

Perks, Julian R., E-mail: julian.perks@ucdmc.ucdavis.edu; Stanic, Sinisa; Stern, Robin L.

2012-07-15

Purpose: To improve the quality and safety of our practice of stereotactic body radiation therapy (SBRT), we analyzed the process following the failure mode and effects analysis (FMEA) method. Methods: The FMEA was performed by a multidisciplinary team. For each step in the SBRT delivery process, a potential failure occurrence was derived and three factors were assessed: the probability of each occurrence, the severity if the event occurs, and the probability of detection by the treatment team. A rank of 1 to 10 was assigned to each factor, and then the multiplied ranks yielded the relative risks (risk priority numbers).more » The failure modes with the highest risk priority numbers were then considered to implement process improvement measures. Results: A total of 28 occurrences were derived, of which nine events scored with significantly high risk priority numbers. The risk priority numbers of the highest ranked events ranged from 20 to 80. These included transcription errors of the stereotactic coordinates and machine failures. Conclusion: Several areas of our SBRT delivery were reconsidered in terms of process improvement, and safety measures, including treatment checklists and a surgical time-out, were added for our practice of gantry-based image-guided SBRT. This study serves as a guide for other users of SBRT to perform FMEA of their own practice.« less

Failure Engineering Study and Accelerated Stress Test Results for the Mars Global Surveyor Spacecraft's Power Shunt Assemblies

NASA Technical Reports Server (NTRS)

Gibbel, Mark; Larson, Timothy

2000-01-01

An Engineering-of-Failure approach to designing and executing an accelerated product qualification test was performed to support a risk assessment of a "work-around" necessitated by an on-orbit failure of another piece of hardware on the Mars Global Surveyor spacecraft. The proposed work-around involved exceeding the previous qualification experience both in terms of extreme cold exposure level and in terms of demonstrated low cycle fatigue life for the power shunt assemblies. An analysis was performed to identify potential failure sites, modes and associated failure mechanisms consistent with the new use conditions. A test was then designed and executed which accelerated the failure mechanisms identified by analysis. Verification of the resulting failure mechanism concluded the effort.

Fuzzy Failure Analysis: A New Approach to Service Quality Analysis in Higher Education Institutions (Case Study: Vali-e-asr University of Rafsanjan-Iran)

ERIC Educational Resources Information Center

Takalo, Salim Karimi; Abadi, Ali Reza Naser Sadr; Vesal, Seyed Mahdi; Mirzaei, Amir; Nawaser, Khaled

2013-01-01

In recent years, concurrent with steep increase in the growth of higher education institutions, improving of educational service quality with an emphasis on students' satisfaction has become an important issue. The present study is going to use the Failure Mode and Effect Analysis (FMEA) in order to evaluate the quality of educational services in…

Analytical Method to Evaluate Failure Potential During High-Risk Component Development

NASA Technical Reports Server (NTRS)

Tumer, Irem Y.; Stone, Robert B.; Clancy, Daniel (Technical Monitor)

2001-01-01

Communicating failure mode information during design and manufacturing is a crucial task for failure prevention. Most processes use Failure Modes and Effects types of analyses, as well as prior knowledge and experience, to determine the potential modes of failures a product might encounter during its lifetime. When new products are being considered and designed, this knowledge and information is expanded upon to help designers extrapolate based on their similarity with existing products and the potential design tradeoffs. This paper makes use of similarities and tradeoffs that exist between different failure modes based on the functionality of each component/product. In this light, a function-failure method is developed to help the design of new products with solutions for functions that eliminate or reduce the potential of a failure mode. The method is applied to a simplified rotating machinery example in this paper, and is proposed as a means to account for helicopter failure modes during design and production, addressing stringent safety and performance requirements for NASA applications.

Investigation of Spiral Bevel Gear Condition Indicator Validation Via AC-29-2C Using Damage Progression Tests

NASA Technical Reports Server (NTRS)

Dempsey, Paula J.

2014-01-01

This report documents the results of spiral bevel gear rig tests performed under a NASA Space Act Agreement with the Federal Aviation Administration (FAA) to support validation and demonstration of rotorcraft Health and Usage Monitoring Systems (HUMS) for maintenance credits via FAA Advisory Circular (AC) 29-2C, Section MG-15, Airworthiness Approval of Rotorcraft (HUMS) (Ref. 1). The overarching goal of this work was to determine a method to validate condition indicators in the lab that better represent their response to faults in the field. Using existing in-service helicopter HUMS flight data from faulted spiral bevel gears as a "Case Study," to better understand the differences between both systems, and the availability of the NASA Glenn Spiral Bevel Gear Fatigue Rig, a plan was put in place to design, fabricate and test comparable gear sets with comparable failure modes within the constraints of the test rig. The research objectives of the rig tests were to evaluate the capability of detecting gear surface pitting fatigue and other generated failure modes on spiral bevel gear teeth using gear condition indicators currently used in fielded HUMS. Nineteen final design gear sets were tested. Tables were generated for each test, summarizing the failure modes observed on the gear teeth for each test during each inspection interval and color coded based on damage mode per inspection photos. Gear condition indicators (CI) Figure of Merit 4 (FM4), Root Mean Square (RMS), +/- 1 Sideband Index (SI1) and +/- 3 Sideband Index (SI3) were plotted along with rig operational parameters. Statistical tables of the means and standard deviations were calculated within inspection intervals for each CI. As testing progressed, it became clear that certain condition indicators were more sensitive to a specific component and failure mode. These tests were clustered together for further analysis. Maintenance actions during testing were also documented. Correlation coefficients were calculated between each CI, component, damage state and torque. Results found test rig and gear design, type of fault and data acquisition can affect CI performance. Results found FM4, SI1 and SI3 can be used to detect macro pitting on two more gear or pinion teeth as long as it is detected prior to progressing to other components or transitioning to another failure mode. The sensitivity of RMS to system and operational conditions limit its reliability for systems that are not maintained at steady state. Failure modes that occurred due to scuffing or fretting were challenging to detect with current gear diagnostic tools, since the damage is distributed across all the gear and pinion teeth, smearing the impacting signatures typically used to differentiate between a healthy and damaged tooth contact. This is one of three final reports published on the results of this project. In the second report, damage modes experienced in the field will be mapped to the failure modes created in the test rig. The helicopter CI data will then be re-processed with the same analysis techniques applied to spiral bevel rig test data. In the third report, results from the rig and helicopter data analysis will be correlated. Observations, findings and lessons learned using sub-scale rig failure progression tests to validate helicopter gear condition indicators will be presented.

A Summary of Taxonomies of Digital System Failure Modes Provided by the DigRel Task Group

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

Chu T. L.; Yue M.; Postma, W.

2012-06-25

Recently, the CSNI directed WGRisk to set up a task group called DIGREL to initiate a new task on developing a taxonomy of failure modes of digital components for the purposes of PSA. It is an important step towards standardized digital I&C reliability assessment techniques for PSA. The objective of this paper is to provide a comparison of the failure mode taxonomies provided by the participants. The failure modes are classified in terms of their levels of detail. Software and hardware failure modes are discussed separately.

Mixed-mode cyclic debonding of adhesively bonded composite joints. M.S. Thesis

NASA Technical Reports Server (NTRS)

Rezaizadeh, M. A.; Mall, S.

1985-01-01

A combined experimental-analytical investigation to characterize the cyclic failure mechanism of a simple composite-to-composite bonded joint is conducted. The cracked lap shear (CLS) specimens of graphite/epoxy adherend bonded with EC-3445 adhesive are tested under combined mode 1 and 2 loading. In all specimens tested, fatigue failure occurs in the form of cyclic debonding. The cyclic debond growth rates are measured. The finite element analysis is employed to compute the mode 1, mode 2, and total strain energy release rates (i.e., GI, GII, and GT). A wide range of mixed-mode loading, i.e., GI/GII ranging from 0.03 to 0.38, is obtained. The total strain energy release rate, G sub T, appeared to be the driving parameter for cyclic debonding in the tested composite bonded system.

Fault Tree Analysis: An Operations Research Tool for Identifying and Reducing Undesired Events in Training.

ERIC Educational Resources Information Center

Barker, Bruce O.; Petersen, Paul D.

This paper explores the fault-tree analysis approach to isolating failure modes within a system. Fault tree investigates potentially undesirable events and then looks for failures in sequence that would lead to their occurring. Relationships among these events are symbolized by AND or OR logic gates, AND used when single events must coexist to…

Application of multi attribute failure mode analysis of milk production using analytical hierarchy process method

NASA Astrophysics Data System (ADS)

Rucitra, A. L.

2018-03-01

Pusat Koperasi Induk Susu (PKIS) Sekar Tanjung, East Java is one of the modern dairy industries producing Ultra High Temperature (UHT) milk. A problem that often occurs in the production process in PKIS Sekar Tanjung is a mismatch between the production process and the predetermined standard. The purpose of applying Analytical Hierarchy Process (AHP) was to identify the most potential cause of failure in the milk production process. Multi Attribute Failure Mode Analysis (MAFMA) method was used to eliminate or reduce the possibility of failure when viewed from the failure causes. This method integrates the severity, occurrence, detection, and expected cost criteria obtained from depth interview with the head of the production department as an expert. The AHP approach was used to formulate the priority ranking of the cause of failure in the milk production process. At level 1, the severity has the highest weight of 0.41 or 41% compared to other criteria. While at level 2, identifying failure in the UHT milk production process, the most potential cause was the average mixing temperature of more than 70 °C which was higher than the standard temperature (≤70 ° C). This failure cause has a contributes weight of 0.47 or 47% of all criteria Therefore, this study suggested the company to control the mixing temperature to minimise or eliminate the failure in this process.

On a common critical state in localized and diffuse failure modes

NASA Astrophysics Data System (ADS)

Zhu, Huaxiang; Nguyen, Hien N. G.; Nicot, François; Darve, Félix

2016-10-01

Accurately modeling the critical state mechanical behavior of granular material largely relies on a better understanding and characterizing the critical state fabric in different failure modes, i.e. localized and diffuse failure modes. In this paper, a mesoscopic scale is introduced, in which the organization of force-transmission paths (force-chains) and cells encompassed by contacts (meso-loops) can be taken into account. Numerical drained biaxial tests using a discrete element method are performed with different initial void ratios, in order to investigate the critical state fabric on the meso-scale in both localized and diffuse failure modes. According to the displacement and strain fields extracted from tests, the failure mode and failure area of each specimen are determined. Then convergent critical state void ratios are observed in failure area of specimens. Different mechanical features of two kinds of meso-structures (force-chains and meso-loops) are investigated, to clarify whether there exists a convergent meso-structure inside the failure area of granular material, as the signature of critical state. Numerical results support a positive answer. Failure area of both localized and diffuse failure modes therefore exhibits the same fabric in critical state. Hence, these two failure modes prove to be homological with respect to the concept of the critical state.

Failure mode effect analysis and fault tree analysis as a combined methodology in risk management

NASA Astrophysics Data System (ADS)

Wessiani, N. A.; Yoshio, F.

2018-04-01

There have been many studies reported the implementation of Failure Mode Effect Analysis (FMEA) and Fault Tree Analysis (FTA) as a method in risk management. However, most of the studies usually only choose one of these two methods in their risk management methodology. On the other side, combining these two methods will reduce the drawbacks of each methods when implemented separately. This paper aims to combine the methodology of FMEA and FTA in assessing risk. A case study in the metal company will illustrate how this methodology can be implemented. In the case study, this combined methodology will assess the internal risks that occur in the production process. Further, those internal risks should be mitigated based on their level of risks.

Independent Orbiter Assessment (IOA): Assessment of the Electrical Power Distribution and Control Subsystem, Volume 2

NASA Technical Reports Server (NTRS)

Schmeckpeper, K. R.

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 first completed an analysis of the Electrical Power Distribution and Control (EPD and C) 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 EPD and C hardware. Volume 2 continues the presentation of IOA worksheets.

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.

A failure modes and effects analysis study for gynecologic high-dose-rate brachytherapy.

PubMed

Mayadev, Jyoti; Dieterich, Sonja; Harse, Rick; Lentz, Susan; Mathai, Mathew; Boddu, Sunita; Kern, Marianne; Courquin, Jean; Stern, Robin L

2015-01-01

To improve the quality of our gynecologic brachytherapy practice and reduce reportable events, we performed a process analysis after the failure modes and effects analysis (FMEA). The FMEA included a multidisciplinary team specifically targeting the tandem and ring brachytherapy procedure. The treatment process was divided into six subprocesses and failure modes (FMs). A scoring guideline was developed based on published FMEA studies and assigned through team consensus. FMs were ranked according to overall and severity scores. FM ranking >5% of the highest risk priority number (RPN) score was selected for in-depth analysis. The efficiency of each existing quality assurance to detect each FM was analyzed. We identified 170 FMs, and 99 were scored. RPN scores ranged from 1 to 192. Of the 13 highest-ranking FMs with RPN scores >80, half had severity scores of 8 or 9, with no mode having severity of 10. Of these FM, the originating process steps were simulation (5), treatment planning (5), treatment delivery (2), and insertion (1). Our high-ranking FM focused on communication and the potential for applicator movement. Evaluation of the efficiency and the comprehensiveness of our quality assurance program showed coverage of all but three of the top 49 FMs ranked by RPN. This is the first reported FMEA process for a comprehensive gynecologic brachytherapy procedure overview. We were able to identify FMs that could potentially and severely impact the patient's treatment. We continue to adjust our quality assurance program based on the results of our FMEA analysis. Published by Elsevier Inc.

Qualification of computerized monitoring systems in a cell therapy facility compliant with the good manufacturing practices.

PubMed

Del Mazo-Barbara, Anna; Mirabel, Clémentine; Nieto, Valentín; Reyes, Blanca; García-López, Joan; Oliver-Vila, Irene; Vives, Joaquim

2016-09-01

Computerized systems (CS) are essential in the development and manufacture of cell-based medicines and must comply with good manufacturing practice, thus pushing academic developers to implement methods that are typically found within pharmaceutical industry environments. Qualitative and quantitative risk analyses were performed by Ishikawa and Failure Mode and Effects Analysis, respectively. A process for qualification of a CS that keeps track of environmental conditions was designed and executed. The simplicity of the Ishikawa analysis permitted to identify critical parameters that were subsequently quantified by Failure Mode Effects Analysis, resulting in a list of test included in the qualification protocols. The approach presented here contributes to simplify and streamline the qualification of CS in compliance with pharmaceutical quality standards.

Geometrically nonlinear analysis of adhesively bonded joints

NASA Technical Reports Server (NTRS)

Dattaguru, B.; Everett, R. A., Jr.; Whitcomb, J. D.; Johnson, W. S.

1982-01-01

A geometrically nonlinear finite element analysis of cohesive failure in typical joints is presented. Cracked-lap-shear joints were chosen for analysis. Results obtained from linear and nonlinear analysis show that nonlinear effects, due to large rotations, significantly affect the calculated mode 1, crack opening, and mode 2, inplane shear, strain-energy-release rates. The ratio of the mode 1 to mode 2 strain-energy-relase rates (G1/G2) was found to be strongly affected by he adhesive modulus and the adherend thickness. The ratios between 0.2 and 0.8 can be obtained by varying adherend thickness and using either a single or double cracked-lap-shear specimen configuration. Debond growth rate data, together with the analysis, indicate that mode 1 strain-energy-release rate governs debond growth. Results from the present analysis agree well with experimentally measured joint opening displacements.

Independent Orbiter Assessment (IOA): Assessment of the extravehicular mobility unit, volume 2

NASA Technical Reports Server (NTRS)

Raffaelli, Gary G.

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 performed an independent analysis of the Extravehicular Mobility Unit (EMU) hardware and system, generating draft failure modes criticalities 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 most recent proposed Post 51-L NASA FMEA/CIL baseline. A resolution of each discrepancy from the comparison was provided through additional analysis as required. This report documents the results of that comparison for the Orbiter EMU hardware. Volume 2 continues the presentation of IOA analysis worksheets and contains the potential critical items list and NASA FMEA to IOA worksheet cross references and recommendations.

Aging assessment of large electric motors in nuclear power plants

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

Villaran, M.; Subudhi, M.

1996-03-01

Large electric motors serve as the prime movers to drive high capacity pumps, fans, compressors, and generators in a variety of nuclear plant systems. This study examined the stressors that cause degradation and aging in large electric motors operating in various plant locations and environments. The operating history of these machines in nuclear plant service was studied by review and analysis of failure reports in the NPRDS and LER databases. This was supplemented by a review of motor designs, and their nuclear and balance of plant applications, in order to characterize the failure mechanisms that cause degradation, aging, and failuremore » in large electric motors. A generic failure modes and effects analysis for large squirrel cage induction motors was performed to identify the degradation and aging mechanisms affecting various components of these large motors, the failure modes that result, and their effects upon the function of the motor. The effects of large motor failures upon the systems in which they are operating, and on the plant as a whole, were analyzed from failure reports in the databases. The effectiveness of the industry`s large motor maintenance programs was assessed based upon the failure reports in the databases and reviews of plant maintenance procedures and programs.« less

Analysis of failure and maintenance experiences of motor operated valves in a Finnish nuclear power plant

NASA Astrophysics Data System (ADS)

Simola, Kaisa; Laakso, Kari

1992-01-01

Eight years of operating experiences of 104 motor operated closing valves in different safety systems in nuclear power units were analyzed in a systematic way. The qualitative methods used were Failure Mode and Effect Analysis (FMEA) and Maintenance Effects and Criticality Analysis (MECA). These reliability engineering methods are commonly used in the design stage of equipment. The successful application of these methods for analysis and utilization of operating experiences was demonstrated.

SU-E-T-635: Process Mapping of Eye Plaque Brachytherapy

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

Huynh, J; Kim, Y

Purpose: To apply a risk-based assessment and analysis technique (AAPM TG 100) to eye plaque brachytherapy treatment of ocular melanoma. Methods: The role and responsibility of personnel involved in the eye plaque brachytherapy is defined for retinal specialist, radiation oncologist, nurse and medical physicist. The entire procedure was examined carefully. First, major processes were identified and then details for each major process were followed. Results: Seventy-one total potential modes were identified. Eight major processes (corresponding detailed number of modes) are patient consultation (2 modes), pretreatment tumor localization (11), treatment planning (13), seed ordering and calibration (10), eye plaque assembly (10),more » implantation (11), removal (11), and deconstruction (3), respectively. Half of the total modes (36 modes) are related to physicist while physicist is not involved in processes such as during the actual procedure of suturing and removing the plaque. Conclusion: Not only can failure modes arise from physicist-related procedures such as treatment planning and source activity calibration, but it can also exist in more clinical procedures by other medical staff. The improvement of the accurate communication for non-physicist-related clinical procedures could potentially be an approach to prevent human errors. More rigorous physics double check would reduce the error for physicist-related procedures. Eventually, based on this detailed process map, failure mode and effect analysis (FMEA) will identify top tiers of modes by ranking all possible modes with risk priority number (RPN). For those high risk modes, fault tree analysis (FTA) will provide possible preventive action plans.« less

Failure Analysis of Alumina Reinforced Aluminum Microtruss and Tube Composites

NASA Astrophysics Data System (ADS)

Chien, Hsueh Fen (Karen)

The energy absorption capacity of cellular materials can be dramatically increased by applying a structural coating. This thesis examined the failure mechanisms of alumina reinforced 3003 aluminum alloy microtrusses and tubes. Alumina coatings were produced by hard anodizing and by plasma electrolytic oxidation (PEO). The relatively thin and discontinuous oxide coating at the hinge acted as a localized weak spot which triggered a chain reaction of failure, including oxide fracture, oxide spallation, oxide penetration to the aluminum core and severe local plastic deformation of the core. For the PEO microtrusses, delamination occurred within the oxide coating resulting in a global strut buckling failure mode. A new failure mode for the anodized tubes was observed: (i) axisymmetric folding of the aluminum core, (ii) longitudinal fracture, and (iii) alumina pulverization. Overall, the alumina coating enhanced the buckling resistance of the composites, while the aluminum core supported the oxide during the damage propagation.

Mechanical Failure Mode of Metal Nanowires: Global Deformation versus Local Deformation

PubMed Central

Ho, Duc Tam; Im, Youngtae; Kwon, Soon-Yong; Earmme, Youn Young; Kim, Sung Youb

2015-01-01

It is believed that the failure mode of metal nanowires under tensile loading is the result of the nucleation and propagation of dislocations. Such failure modes can be slip, partial slip or twinning and therefore they are regarded as local deformation. Here we provide numerical and theoretical evidences to show that global deformation is another predominant failure mode of nanowires under tensile loading. At the global deformation mode, nanowires fail with a large contraction along a lateral direction and a large expansion along the other lateral direction. In addition, there is a competition between global and local deformations. Nanowires loaded at low temperature exhibit global failure mode first and then local deformation follows later. We show that the global deformation originates from the intrinsic instability of the nanowires and that temperature is a main parameter that decides the global or local deformation as the failure mode of nanowires. PMID:26087445

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

Probabilistic Risk Assessment: A Bibliography

NASA Technical Reports Server (NTRS)

2000-01-01

Probabilistic risk analysis is an integration of failure modes and effects analysis (FMEA), fault tree analysis and other techniques to assess the potential for failure and to find ways to reduce risk. This bibliography references 160 documents in the NASA STI Database that contain the major concepts, probabilistic risk assessment, risk and probability theory, in the basic index or major subject terms, An abstract is included with most citations, followed by the applicable subject terms.

The Local Wind Pump for Marginal Societies in Indonesia: A Perspective of Fault Tree Analysis

NASA Astrophysics Data System (ADS)

Gunawan, Insan; Taufik, Ahmad

2007-10-01

There are many efforts to reduce a cost of investment of well established hybrid wind pump applied to rural areas. A recent study on a local wind pump (LWP) for marginal societies in Indonesia (traditional farmers, peasant and tribes) was one of the efforts reporting a new application area. The objectives of the study were defined to measure reliability value of the LWP due to fluctuated wind intensity, low wind speed, economic point of view regarding a prolong economic crisis occurring and an available local component of the LWP and to sustain economics productivity (agriculture product) of the society. In the study, a fault tree analysis (FTA) was deployed as one of three methods used for assessing the LWP. In this article, the FTA has been thoroughly discussed in order to improve a better performance of the LWP applied in dry land watering system of Mesuji district of Lampung province-Indonesia. In the early stage, all of local component of the LWP was classified in term of its function. There were four groups of the components. Moreover, all of the sub components of each group were subjected to failure modes of the FTA, namely (1) primary failure modes; (2) secondary failure modes and (3) common failure modes. In the data processing stage, an available software package, ITEM was deployed. It was observed that the component indicated obtaining relative a long life duration of operational life cycle in 1,666 hours. Moreover, to enhance high performance the LWP, maintenance schedule, critical sub component suffering from failure and an overhaul priority have been identified in term of quantity values. Throughout a year pilot project, it can be concluded that the LWP is a reliable product to the societies enhancing their economics productivities.

Comprehensive analysis of cochlear implant failure: usefulness of clinical symptom-based algorithm combined with in situ integrity testing.

PubMed

Yamazaki, Hiroshi; O'Leary, Stephen; Moran, Michelle; Briggs, Robert

2014-04-01

Accurate diagnosis of cochlear implant failures is important for management; however, appropriate strategies to assess possible device failures are not always clear. The purpose of this study is to understand correlation between causes of device failure and the presenting clinical symptoms as well as results of in situ integrity testing and to propose effective strategies for diagnosis of device failure. Retrospective case review. Cochlear implant center at a tertiary referral hospital. Twenty-seven cases with suspected device failure of Cochlear Nucleus systems (excluding CI512 failures) on the basis of deterioration in auditory perception from January 2000 to September 2012 in the Melbourne cochlear implant clinic. Clinical presentations and types of abnormalities on in situ integrity testing were compared with modes of device failure detected by returned device analysis. Sudden deterioration in auditory perception was always observed in cases with "critical damage": either fracture of the integrated circuit or most or all of the electrode wires. Subacute or gradually progressive deterioration in auditory perception was significantly associated with a more limited number of broken electrode wires. Cochlear implant mediated auditory and nonauditory symptoms were significantly associated with an insulation problem. An algorithm based on the time course of deterioration in auditory perception and cochlear implant-mediated auditory and nonauditory symptoms was developed on the basis of these retrospective analyses, to help predict the mode of device failure. In situ integrity testing, which included close monitoring of device function in routine programming sessions as well as repeating the manufacturer's integrity test battery, was sensitive enough to detect malfunction in all suspected device failures, and each mode of device failure showed a characteristic abnormality on in situ integrity testing. Our clinical manifestation-based algorithm combined with in situ integrity testing may be useful for accurate diagnosis and appropriate management of device failure. Close monitoring of device function in routine programming sessions as well as repeating the manufacturer's integrity test battery is important if the initial in situ integrity testing is inconclusive because objective evidence of failure in the implanted device is essential to recommend explantation/reimplantation.

Failure mode analysis in adrenal vein sampling: a single-center experience.

PubMed

Trerotola, Scott O; Asmar, Melissa; Yan, Yan; Fraker, Douglas L; Cohen, Debbie L

2014-10-01

To analyze failure modes in a high-volume adrenal vein sampling (AVS) practice in an effort to identify preventable causes of nondiagnostic sampling. A retrospective database was constructed containing 343 AVS procedures performed over a 10-year period. Each nondiagnostic AVS procedure was reviewed for failure mode and correlated with results of any repeat AVS. Data collected included selectivity index, lateralization index, adrenalectomy outcomes if performed, and details of AVS procedure. All AVS procedures were performed after cosyntropin stimulation, using sequential technique. AVS was nondiagnostic in 12 of 343 (3.5%) primary procedures and 2 secondary procedures. Failure was right-sided in 8 (57%) procedures, left-sided in 4 (29%) procedures, bilateral in 1 procedure, and neither in 1 procedure (laboratory error). Failure modes included diluted sample from correctly identified vein (n = 7 [50%]; 3 right and 4 left), vessel misidentified as adrenal vein (n = 3 [21%]; all right), failure to locate an adrenal vein (n = 2 [14%]; both right), cosyntropin stimulation failure (n = 1 [7%]; diagnostic by nonstimulated criteria), and laboratory error (n = 1 [7%]; specimen loss). A second AVS procedure was diagnostic in three of five cases (60%), and a third AVS procedure was diagnostic in one of one case (100%). Among the eight patients in whom AVS ultimately was not diagnostic, four underwent adrenalectomy based on diluted AVS samples, and one underwent adrenalectomy based on imaging; all five experienced improvement in aldosteronism. A substantial percentage of AVS failures occur on the left, all related to dilution. Even when technically nondiagnostic per strict criteria, some "failed" AVS procedures may be sufficient to guide therapy. Repeat AVS has a good yield. Copyright © 2014 SIR. Published by Elsevier Inc. All rights reserved.

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

Storage reliability analysis summary report. Volume 2: Electro mechanical devices

NASA Astrophysics Data System (ADS)

Smith, H. B., Jr.; Krulac, I. L.

1982-09-01

This document summarizes storage reliability data collected by the US Army Missile Command on electro-mechanical devices over a period of several years. Sources of data are detailed, major failure modes and mechanisms are listed and discussed. Non-operational failure rate prediction methodology is given, and conclusions and recommendations for enhancing the storage reliability of devices are drawn from the analysis of collected data.

Analysis of Gas Turbine Engine Failure Modes.

DTIC Science & Technology

1974-01-01

failure due to factors ex- ternal (foreign to the power plant. Because in practice it is virtually impossible to distinguish accurately between the two, all...45 55 APPEN’DIX E WHEN DISCO ’=RED z z J-79 ENGINE AND HIGH FAILURE COMPONENTS H z Compressor R or242 Copeo R F4 -C H C s SeH UPi 0. 0- H U 4 C, Engine

Independent Orbiter Assessment (IOA): Analysis of the Electrical Power Distribution and Control Subsystem, Volume 2

NASA Technical Reports Server (NTRS)

Schmeckpeper, K. R.

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 items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Distribution and Control (EPD and C) hardware. The EPD and C hardware performs the functions of distributing, sensing, and controlling 28 volt DC power and of inverting, distributing, sensing, and controlling 117 volt 400 Hz AC power to all Orbiter subsystems from the three fuel cells in the Electrical Power Generation (EPG) subsystem. Volume 2 continues the presentation of IOA analysis worksheets and contains the potential critical items list.

FEMA and RAM Analysis for the Multi Canister Overpack (MCO) Handling Machine

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

SWENSON, C.E.

2000-06-01

The Failure Modes and Effects Analysis and the Reliability, Availability, and Maintainability Analysis performed for the Multi-Canister Overpack Handling Machine (MHM) has shown that the current design provides for a safe system, but the reliability of the system (primarily due to the complexity of the interlocks and permissive controls) is relatively low. No specific failure modes were identified where significant consequences to the public occurred, or where significant impact to nearby workers should be expected. The overall reliability calculation for the MHM shows a 98.1 percent probability of operating for eight hours without failure, and an availability of the MHMmore » of 90 percent. The majority of the reliability issues are found in the interlocks and controls. The availability of appropriate spare parts and maintenance personnel, coupled with well written operating procedures, will play a more important role in successful mission completion for the MHM than other less complicated systems.« less

Materials testing of the IUS techroll seal material

NASA Technical Reports Server (NTRS)

Nichols, R. L.; Hall, W. B.

1984-01-01

As a part of the investigation of the control system failure Inertial Upper Stage on IUS-1 flight to position a Tracking and Data Relay Satellite (TDRS) in geosynchronous orbit, the materials utilized in the techroll seal are evaluated for possible failure models. Studies undertaken included effect of temperature on the strength of the system, effect of fatigue on the strength of the system, thermogravimetric analysis, thermomechanical analysis, differential scanning calorimeter analysis, dynamic mechanical analysis, and peel test. The most likely failure mode is excessive temperature in the seal. In addition, the seal material is susceptible to fatigue damage which could be a contributing factor.

[Fractographic analysis of clinically failed anterior all ceramic crowns].

PubMed

DU, Qian; Zhou, Min-bo; Zhang, Xin-ping; Zhao, Ke

2012-04-01

To identify the site of crack initiation and propagation path of clinically failed all ceramic crowns by fractographic analysis. Three clinically failed anterior IPS Empress II crowns and two anterior In-Ceram alumina crowns were retrieved. Fracture surfaces were examined using both optical stereo and scanning electron microscopy. Fractographic theory and fracture mechanics principles were applied to disclose the damage characteristics and fracture mode. All the crowns failed by cohesive failure within the veneer on the labial surface. Critical crack originated at the incisal contact area and propagated gingivally. Porosity was found within the veneer because of slurry preparation and the sintering of veneer powder. Cohesive failure within the veneer is the main failure mode of all ceramic crown. Veneer becomes vulnerable when flaws are present. To reduce the chances of chipping, multi-point occlusal contacts are recommended, and layering and sintering technique of veneering layer should also be improved.

Risk Analysis Methods for Deepwater Port Oil Transfer Systems

DOT National Transportation Integrated Search

1976-06-01

This report deals with the risk analysis methodology for oil spills from the oil transfer systems in deepwater ports. Failure mode and effect analysis in combination with fault tree analysis are identified as the methods best suited for the assessmen...

Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.

PubMed

Fassett, William E

2011-10-10

As colleges and schools of pharmacy develop core courses related to patient safety, course-level outcomes will need to include both knowledge and performance measures. Three key performance outcomes for patient safety coursework, measured at the course level, are the ability to perform root cause analyses and healthcare failure mode effects analyses, and the ability to generate effective safety communications using structured formats such as the Situation-Background-Assessment-Recommendation (SBAR) situational briefing model. Each of these skills is widely used in patient safety work and competence in their use is essential for a pharmacist's ability to contribute as a member of a patient safety team.

IDA/OSD(Institute for Defense Analyses/Office of the Secretary of Defense) Reliability and Maintainability Study. Volume 3. Case Study Analysis.

DTIC Science & Technology

1983-11-01

Isolation FIT Fault Isolation Test FMC Fully Mission Capable FMEA Failure Modes and Effects Analysis FMECA Failure Modes, Effects and Criticality...8217 ..* ,/- " , " A ’’"""¢ 9 % ’ k " . " ~ .[:, .- v," . , , .’ % , o4,o 100 92 88 0 80 76 PERCENT -- __ OF F-16 60 FLIGHTS WITHOUT NATO NATO RADAR HILL BASE BASE...to manage a growth program adequately. 822/1-13 IV-13 %. - 70 60 F-ill 50 F-1 5 40- CL. C.c 30 - IF-1 S20 ICIC p 10 I~* -. -. - - -____ F-5E -4 -3 -2

A systematic risk management approach employed on the CloudSat project

NASA Technical Reports Server (NTRS)

Basilio, R. R.; Plourde, K. S.; Lam, T.

2000-01-01

The CloudSat Project has developed a simplified approach for fault tree analysis and probabilistic risk assessment. A system-level fault tree has been constructed to identify credible fault scenarios and failure modes leading up to a potential failure to meet the nominal mission success criteria.

Comprehension and retrieval of failure cases in airborne observatories

NASA Technical Reports Server (NTRS)

Alvarado, Sergio J.; Mock, Kenrick J.

1995-01-01

This paper describes research dealing with the computational problem of analyzing and repairing failures of electronic and mechanical systems of telescopes in NASA's airborne observatories, such as KAO (Kuiper Airborne Observatory) and SOFIA (Stratospheric Observatory for Infrared Astronomy). The research has resulted in the development of an experimental system that acquires knowledge of failure analysis from input text, and answers questions regarding failure detection and correction. The system's design builds upon previous work on text comprehension and question answering, including: knowledge representation for conceptual analysis of failure descriptions, strategies for mapping natural language into conceptual representations, case-based reasoning strategies for memory organization and indexing, and strategies for memory search and retrieval. These techniques have been combined into a model that accounts for: (a) how to build a knowledge base of system failures and repair procedures from descriptions that appear in telescope-operators' logbooks and FMEA (failure modes and effects analysis) manuals; and (b) how to use that knowledge base to search and retrieve answers to questions about causes and effects of failures, as well as diagnosis and repair procedures. This model has been implemented in FANSYS (Failure ANalysis SYStem), a prototype text comprehension and question answering program for failure analysis.

Comprehension and retrieval of failure cases in airborne observatories

NASA Astrophysics Data System (ADS)

Alvarado, Sergio J.; Mock, Kenrick J.

1995-05-01

This paper describes research dealing with the computational problem of analyzing and repairing failures of electronic and mechanical systems of telescopes in NASA's airborne observatories, such as KAO (Kuiper Airborne Observatory) and SOFIA (Stratospheric Observatory for Infrared Astronomy). The research has resulted in the development of an experimental system that acquires knowledge of failure analysis from input text, and answers questions regarding failure detection and correction. The system's design builds upon previous work on text comprehension and question answering, including: knowledge representation for conceptual analysis of failure descriptions, strategies for mapping natural language into conceptual representations, case-based reasoning strategies for memory organization and indexing, and strategies for memory search and retrieval. These techniques have been combined into a model that accounts for: (a) how to build a knowledge base of system failures and repair procedures from descriptions that appear in telescope-operators' logbooks and FMEA (failure modes and effects analysis) manuals; and (b) how to use that knowledge base to search and retrieve answers to questions about causes and effects of failures, as well as diagnosis and repair procedures. This model has been implemented in FANSYS (Failure ANalysis SYStem), a prototype text comprehension and question answering program for failure analysis.

Ageing and degradation determines failure mode on sea urchin spines.

PubMed

Merino, Monica; Vicente, Erika; Gonzales, Karen N; Torres, Fernando G

2017-09-01

Sea urchin spines are an example of a hard natural composite with mineral and organic phases. The role of the organic phase in the response to mechanical stress was assessed by promoting the degradation of such spines by exposing them to ageing and ultraviolet (UV) irradiation. Thermal and structural characterization of the irradiated samples show that this UV irradiation treatment promotes degradation of the organic and inorganic phase of spines. Uniaxial compression tests carried out on aged and UV irradiated samples showed that both treatments affected the mechanical properties of the spines. Scanning electron microscopy (SEM) images of failed specimens were used to analyze the failure mechanisms of the compressed spines. The analysis of the fracture surfaces showed that the failure mechanisms of spines were modified as a consequence of UV irradiation, leading in the last case to mostly brittle fracture surfaces. We suggest that the proteins responsible for the formation of calcite also determine the mechanical properties and the failure mode of spines. This system can be used as a model for the study of the failure modes of other natural and synthetic hard composites. Copyright © 2017 Elsevier B.V. All rights reserved.

Analysis of Factors Affecting the Performance of RLV Thrust Cell Liners

NASA Technical Reports Server (NTRS)

Arnold, Steven M. (Technical Monitor); Butler, Daniel T., Jr.; Pinders, Marek-Jerzy

2004-01-01

The reusable launch vehicle (RLV) thrust cell liner, or thrust chamber, is a critical component of the Space Shuttle Main Engine (SSME). It is designed to operate in some of the most severe conditions seen in engineering practice. This requirement, in conjunction with experimentally observed 'dog-house' failure modes characterized by bulging and thinning of the cooling channel wall, provides the motivation to study the factors that influence RLV thrust cell liner performance. Factors or parameters believed to be directly related to the observed characteristic deformation modes leading to failure under in-service loading conditions are identified, and subsequently investigated using the cylindrical version of the higher-order theory for functionally graded materials in conjunction with the Robinson's unified viscoplasticity theory and the power-law creep model for modeling the response of the liner s constituents. Configurations are analyzed in which specific modifications in cooling channel wall thickness or constituent materials are made to determine the influence of these parameters on the deformations resulting in the observed failure modes in the outer walls of the cooling channel. The application of thermal barrier coatings and functional grading are also investigated within this context. Comparison of the higher-order theory results based on the Robinson and power-law creep model predictions has demonstrated that, using the available material parameters, the power-law creep model predicts more precisely the experimentally observed deformation leading to the 'dog-house' failure mode for multiple short cycles, while also providing much improved computational efficiency. However, for a single long cycle, both models predict virtually identical deformations. Increasing the power-law creep model coefficients produces appreciable deformations after just one long cycle that would normally be obtained after multiple cycles, thereby enhancing the efficiency of the analysis. This provides a basis for the development of an accelerated modeling procedure to further characterize dog-house deformation modes in RLV thrust cell liners. Additionally, the results presented herein have demonstrated that the mechanism responsible for deformation leading to 'dog-house' failure modes is driven by pressure, creep/relaxation and geometric effects.

Independent Orbiter Assessment (IOA): Assessment of the purge, vent and drain subsystem

NASA Technical Reports Server (NTRS)

Bynum, M. C., III

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 Purge, Vent and Drain (PV and D) 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 PV and D hardware. The PV and D Subsystem controls the environment of unpressurized compartments and window cavities, senses hazardous gases, and purges Orbiter/ET disconnect.

Why Do Medial Unicompartmental Knee Arthroplasties Fail Today?

PubMed

van der List, Jelle P; Zuiderbaan, Hendrik A; Pearle, Andrew D

2016-05-01

Failure rates are higher in medial unicompartmental knee arthroplasty (UKA) than total knee arthroplasty. To improve these failure rates, it is important to understand why medial UKA fail. Because individual studies lack power to show failure modes, a systematic review was performed to assess medial UKA failure modes. Furthermore, we compared cohort studies with registry-based studies, early with midterm and late failures and fixed-bearing with mobile-bearing implants. Databases of PubMed, EMBASE, and Cochrane and annual registries were searched for medial UKA failures. Studies were included when they reported >25 failures or when they reported early (<5 years), midterm (5-10 years), or late failures (>10 years). Thirty-seven cohort studies (4 level II studies and 33 level III studies) and 2 registry-based studies were included. A total of 3967 overall failures, 388 time-dependent failures, and 1305 implant design failures were identified. Aseptic loosening (36%) and osteoarthritis (OA) progression (20%) were the most common failure modes. Aseptic loosening (26%) was most common early failure mode, whereas OA progression was more commonly seen in midterm and late failures (38% and 40%, respectively). Polyethylene wear (12%) and instability (12%) were more common in fixed-bearing implants, whereas pain (14%) and bearing dislocation (11%) were more common in mobile-bearing implants. This level III systematic review identified aseptic loosening and OA progression as the major failure modes. Aseptic loosening was the main failure mode in early years and mobile-bearing implants, whereas OA progression caused most failures in late years and fixed-bearing implants. Copyright © 2016 Elsevier Inc. All rights reserved.

Failure detection and recovery in the assembly/contingency subsystem

NASA Technical Reports Server (NTRS)

Gantenbein, Rex E.

1993-01-01

The Assembly/Contingency Subsystem (ACS) is the primary communications link on board the Space Station. Any failure in a component of this system or in the external devices through which it communicates with ground-based systems will isolate the Station. The ACS software design includes a failure management capability (ACFM) that provides protocols for failure detection, isolation, and recovery (FDIR). The the ACFM design requirements as outlined in the current ACS software requirements specification document are reviewed. The activities carried out in this review include: (1) an informal, but thorough, end-to-end failure mode and effects analysis of the proposed software architecture for the ACFM; and (2) a prototype of the ACFM software, implemented as a C program under the UNIX operating system. The purpose of this review is to evaluate the FDIR protocols specified in the ACS design and the specifications themselves in light of their use in implementing the ACFM. The basis of failure detection in the ACFM is the loss of signal between the ground and the Station, which (under the appropriate circumstances) will initiate recovery to restore communications. This recovery involves the reconfiguration of the ACS to either a backup set of components or to a degraded communications mode. The initiation of recovery depends largely on the criticality of the failure mode, which is defined by tables in the ACFM and can be modified to provide a measure of flexibility in recovery procedures.

Mechanics of dual-mode dilative failure in subaqueous sediment deposits

NASA Astrophysics Data System (ADS)

You, Yao; Flemings, Peter; Mohrig, David

2014-07-01

We introduce dual-mode dilative failure with flume experiments. Dual-mode dilative failure combines slow and steady release of sediments by breaching with periodic sliding, which rapidly releases an internally coherent wedge of sediments. It occurs in dilative sandy deposits. This periodic slope failure results from cyclic evolution of the excess pore pressure in the deposit. Sliding generates large, transient, negative excess pore pressure that strengthens the deposit and allows breaching to occur. During breaching, negative excess pore pressure dissipates, the deposit weakens, and ultimately sliding occurs once again. We show that the sliding frequency is proportional to the coefficient of consolidation. We find that thicker deposits are more susceptible to dual-mode dilative failure. Discovery of dual-mode dilative failure provides a new mechanism to consider when interpreting the sedimentary deposits linked to submarine slope failures.

Common Cause Failures and Ultra Reliability

NASA Technical Reports Server (NTRS)

Jones, Harry W.

2012-01-01

A common cause failure occurs when several failures have the same origin. Common cause failures are either common event failures, where the cause is a single external event, or common mode failures, where two systems fail in the same way for the same reason. Common mode failures can occur at different times because of a design defect or a repeated external event. Common event failures reduce the reliability of on-line redundant systems but not of systems using off-line spare parts. Common mode failures reduce the dependability of systems using off-line spare parts and on-line redundancy.

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.

System safety in Stirling engine development

NASA Technical Reports Server (NTRS)

Bankaitis, H.

1981-01-01

The DOE/NASA Stirling Engine Project Office has required that contractors make safety considerations an integral part of all phases of the Stirling engine development program. As an integral part of each engine design subtask, analyses are evolved to determine possible modes of failure. The accepted system safety analysis techniques (Fault Tree, FMEA, Hazards Analysis, etc.) are applied in various degrees of extent at the system, subsystem and component levels. The primary objectives are to identify critical failure areas, to enable removal of susceptibility to such failures or their effects from the system and to minimize risk.

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-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

Analysis of rockbolt performance at the Waste Isolation Pilot Plant

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

Terrill, L.J.; Francke, C.T.; Saeb, S.

Rockbolt failures at the Waste Isolation Pilot Plant have been recorded since 1990 and are categorized in terms of mode of failure. The failures are evaluated in terms of physical location of installation within the mine, local excavation geometry and stratigraphy, proximity to other excavations or shafts, and excavation age. The database of failures has revealed discrete ares of the mine containing relatively large numbers of failures. The results of metallurgical analyses and standard rockbolt load testing have generally been in agreement with the in situ evaluations.

Creating and evaluating a data-driven curriculum for central venous catheter placement.

PubMed

Duncan, James R; Henderson, Katherine; Street, Mandie; Richmond, Amy; Klingensmith, Mary; Beta, Elio; Vannucci, Andrea; Murray, David

2010-09-01

Central venous catheter placement is a common procedure with a high incidence of error. Other fields requiring high reliability have used Failure Mode and Effects Analysis (FMEA) to prioritize quality and safety improvement efforts. To use FMEA in the development of a formal, standardized curriculum for central venous catheter training. We surveyed interns regarding their prior experience with central venous catheter placement. A multidisciplinary team used FMEA to identify high-priority failure modes and to develop online and hands-on training modules to decrease the frequency, diminish the severity, and improve the early detection of these failure modes. We required new interns to complete the modules and tracked their progress using multiple assessments. Survey results showed new interns had little prior experience with central venous catheter placement. Using FMEA, we created a curriculum that focused on planning and execution skills and identified 3 priority topics: (1) retained guidewires, which led to training on handling catheters and guidewires; (2) improved needle access, which prompted the development of an ultrasound training module; and (3) catheter-associated bloodstream infections, which were addressed through training on maximum sterile barriers. Each module included assessments that measured progress toward recognition and avoidance of common failure modes. Since introducing this curriculum, the number of retained guidewires has fallen more than 4-fold. Rates of catheter-associated infections have not yet declined, and it will take time before ultrasound training will have a measurable effect. The FMEA provided a process for curriculum development. Precise definitions of failure modes for retained guidewires facilitated development of a curriculum that contributed to a dramatic decrease in the frequency of this complication. Although infections and access complications have not yet declined, failure mode identification, curriculum development, and monitored implementation show substantial promise for improving patient safety during placement of central venous catheters.

Failure of Non-Circular Composite Cylinders

NASA Technical Reports Server (NTRS)

Hyer, M. W.

2004-01-01

In this study, a progressive failure analysis is used to investigate leakage in internally pressurized non-circular composite cylinders. This type of approach accounts for the localized loss of stiffness when material failure occurs at some location in a structure by degrading the local material elastic properties by a certain factor. The manner in which this degradation of material properties takes place depends on the failure modes, which are determined by the application of a failure criterion. The finite-element code STAGS, which has the capability to perform progressive failure analysis using different degradation schemes and failure criteria, is utilized to analyze laboratory scale, graphite-epoxy, elliptical cylinders with quasi-isotropic, circumferentially-stiff, and axially-stiff material orthotropies. The results are divided into two parts. The first part shows that leakage, which is assumed to develop if there is material failure in every layer at some axial and circumferential location within the cylinder, does not occur without failure of fibers. Moreover before fibers begin to fail, only matrix tensile failures, or matrix cracking, takes place, and at least one layer in all three cylinders studied remain uncracked, preventing the formation of a leakage path. That determination is corroborated by the use of different degradation schemes and various failure criteria. Among the degradation schemes investigated are the degradation of different engineering properties, the use of various degradation factors, the recursive or non-recursive degradation of the engineering properties, and the degradation of material properties using different computational approaches. The failure criteria used in the analysis include the noninteractive maximum stress criterion and the interactive Hashin and Tsai-Wu criteria. The second part of the results shows that leakage occurs due to a combination of matrix tensile and compressive, fiber tensile and compressive, and inplane shear failure modes in all three cylinders. Leakage develops after a relatively low amount of fiber damage, at about the same pressure for three material orthotropies, and at approximately the same location.

Failure mode and effects analysis (FMEA) for the Space Shuttle solid rocket motor

NASA Technical Reports Server (NTRS)

Russell, D. L.; Blacklock, K.; Langhenry, M. T.

1988-01-01

The recertification of the Space Shuttle Solid Rocket Booster (SRB) and Solid Rocket Motor (SRM) has included an extensive rewriting of the Failure Mode and Effects Analysis (FMEA) and Critical Items List (CIL). The evolution of the groundrules and methodology used in the analysis is discussed and compared to standard FMEA techniques. Especially highlighted are aspects of the FMEA/CIL which are unique to the analysis of an SRM. The criticality category definitions are presented and the rationale for assigning criticality is presented. The various data required by the CIL and contribution of this data to the retention rationale is also presented. As an example, the FMEA and CIL for the SRM nozzle assembly is discussed in detail. This highlights some of the difficulties associated with the analysis of a system with the unique mission requirements of the Space Shuttle.

Interoperability-oriented Integration of Failure Knowledge into Functional Knowledge and Knowledge Transformation based on Concepts Mapping

NASA Astrophysics Data System (ADS)

Koji, Yusuke; Kitamura, Yoshinobu; Kato, Yoshikiyo; Tsutsui, Yoshio; Mizoguchi, Riichiro

In conceptual design, it is important to develop functional structures which reflect the rich experience in the knowledge from previous design failures. Especially, if a designer learns possible abnormal behaviors from a previous design failure, he or she can add an additional function which prevents such abnormal behaviors and faults. To do this, it is a crucial issue to share such knowledge about possible faulty phenomena and how to cope with them. In fact, a part of such knowledge is described in FMEA (Failure Mode and Effect Analysis) sheets, function structure models for systematic design and fault trees for FTA (Fault Tree Analysis).

Systems Theoretic Process Analysis Applied to an Offshore Supply Vessel Dynamic Positioning System

DTIC Science & Technology

2016-06-01

additional safety issues that were either not identified or inadequately mitigated through the use of Fault Tree Analysis and Failure Modes and...Techniques ...................................................................................................... 15 1.3.1. Fault Tree Analysis...49 3.2. Fault Tree Analysis Comparison

Independent Orbiter Assessment (IOA): Assessment of the reaction control system, volume 1

NASA Technical Reports Server (NTRS)

Prust, Chet D.; Hartman, Dan W.

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 aft and forward Reaction Control System (RCS) hardware, and Electrical Power Distribution and Control (EPD and C), 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 proposed Post 51-L NASA FMEA/CIL baseline. This report documents the results of that comparison for the Orbiter RCS hardware and EPD and C systems. The IOA product for the RCS analysis consisted of 208 hardware and 2064 EPD and C failure mode worksheets that resulted in 141 hardware and 449 EPD and C potential critical items (PCIs) being identified. A comparison was made of the IOA product to the NASA FMEA/CIL baseline. After comparison and discussions with the NASA subsystem manager, 96 hardware issues, 83 of which concern CIL items or PCIs, and 280 EPD and C issues, 158 of which concern CIL items or PCIs, and 280 EPD and C issues, 158 of which concern CIL items or PCIs, remain unresolved. Volume 1 contains the subsystem description, assessment results, and some of the IOA worksheets.

Debonding Stress Concentrations in a Pressurized Lobed Sandwich-Walled Generic Cryogenic Tank

NASA Technical Reports Server (NTRS)

Ko, William L.

2004-01-01

A finite-element stress analysis has been conducted on a lobed composite sandwich tank subjected to internal pressure and cryogenic cooling. The lobed geometry consists of two obtuse circular walls joined together with a common flat wall. Under internal pressure and cryogenic cooling, this type of lobed tank wall will experience open-mode (a process in which the honeycomb is stretched in the depth direction) and shear stress concentrations at the junctures where curved wall changes into flat wall (known as a curve-flat juncture). Open-mode and shear stress concentrations occur in the honeycomb core at the curve-flat junctures and could cause debonding failure. The levels of contributions from internal pressure and temperature loading to the open-mode and shear debonding failure are compared. The lobed fuel tank with honeycomb sandwich walls has been found to be a structurally unsound geometry because of very low debonding failure strengths. The debonding failure problem could be eliminated if the honeycomb core at the curve-flat juncture is replaced with a solid core.

Failure modes and effects analysis for ocular brachytherapy.

PubMed

Lee, Yongsook C; Kim, Yongbok; Huynh, Jason Wei-Yeong; Hamilton, Russell J

The aim of the study was to identify potential failure modes (FMs) having a high risk and to improve our current quality management (QM) program in Collaborative Ocular Melanoma Study (COMS) ocular brachytherapy by undertaking a failure modes and effects analysis (FMEA) and a fault tree analysis (FTA). Process mapping and FMEA were performed for COMS ocular brachytherapy. For all FMs identified in FMEA, risk priority numbers (RPNs) were determined by assigning and multiplying occurrence, severity, and lack of detectability values, each ranging from 1 to 10. FTA was performed for the major process that had the highest ranked FM. Twelve major processes, 121 sub-process steps, 188 potential FMs, and 209 possible causes were identified. For 188 FMs, RPN scores ranged from 1.0 to 236.1. The plaque assembly process had the highest ranked FM. The majority of FMs were attributable to human failure (85.6%), and medical physicist-related failures were the most numerous (58.9% of all causes). After FMEA, additional QM methods were included for the top 10 FMs and 6 FMs with severity values > 9.0. As a result, for these 16 FMs and the 5 major processes involved, quality control steps were increased from 8 (50%) to 15 (93.8%), and major processes having quality assurance steps were increased from 2 to 4. To reduce high risk in current clinical practice, we proposed QM methods. They mainly include a check or verification of procedures/steps and the use of checklists for both ophthalmology and radiation oncology staff, and intraoperative ultrasound-guided plaque positioning for ophthalmology staff. Copyright © 2017 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Stress redistribution and damage in interconnects caused by electromigration

NASA Astrophysics Data System (ADS)

Chiras, Stefanie Ruth

Electromigration has long been recognized as a phenomenon that induces mass redistribution in metals which, when constrained, can lead to the creation of stress. Since the development of the integrated circuit, electromigration. in interconnects, (the metal lines which carry current between devices in integrated circuits), has become a reliability concern. The primary failure mechanism in the interconnects is usually voiding, which causes electrical resistance increases in the circuit. In some cases, however, another failure mode occurs, fracture of the surrounding dielectric driven by electromigration induced compressive stresses within the interconnect. It is this failure mechanism that is the focus of this thesis. To study dielectric fracture, both residual processing stresses and the development of electromigration induced stress in isolated, constrained interconnects was measured. The high-resolution measurements were made using two types of piezospectroscopy, complemented by finite element analysis (FEA). Both procedures directly measured stress in the underlying or neighboring substrate and used FEA to determine interconnect stresses. These interconnect stresses were related to the effected circuit failure mode through post-test scanning electron microscopy and resistance measurements taken during electromigration testing. The results provide qualitative evidence of electromigration driven passivation fracture, and quantitative analysis of the theoretical model of the failure, the "immortal" interconnect concept.

Comprehensive reliability allocation method for CNC lathes based on cubic transformed functions of failure mode and effects analysis

NASA Astrophysics Data System (ADS)

Yang, Zhou; Zhu, Yunpeng; Ren, Hongrui; Zhang, Yimin

2015-03-01

Reliability allocation of computerized numerical controlled(CNC) lathes is very important in industry. Traditional allocation methods only focus on high-failure rate components rather than moderate failure rate components, which is not applicable in some conditions. Aiming at solving the problem of CNC lathes reliability allocating, a comprehensive reliability allocation method based on cubic transformed functions of failure modes and effects analysis(FMEA) is presented. Firstly, conventional reliability allocation methods are introduced. Then the limitations of direct combination of comprehensive allocation method with the exponential transformed FMEA method are investigated. Subsequently, a cubic transformed function is established in order to overcome these limitations. Properties of the new transformed functions are discussed by considering the failure severity and the failure occurrence. Designers can choose appropriate transform amplitudes according to their requirements. Finally, a CNC lathe and a spindle system are used as an example to verify the new allocation method. Seven criteria are considered to compare the results of the new method with traditional methods. The allocation results indicate that the new method is more flexible than traditional methods. By employing the new cubic transformed function, the method covers a wider range of problems in CNC reliability allocation without losing the advantages of traditional methods.

Failure analysis of aluminum alloy components

NASA Technical Reports Server (NTRS)

Johari, O.; Corvin, I.; Staschke, J.

1973-01-01

Analysis of six service failures in aluminum alloy components which failed in aerospace applications is reported. Identification of fracture surface features from fatigue and overload modes was straightforward, though the specimens were not always in a clean, smear-free condition most suitable for failure analysis. The presence of corrosion products and of chemically attacked or mechanically rubbed areas here hindered precise determination of the cause of crack initiation, which was then indirectly inferred from the scanning electron fractography results. In five failures the crack propagation was by fatigue, though in each case the fatigue crack initiated from a different cause. Some of these causes could be eliminated in future components by better process control. In one failure, the cause was determined to be impact during a crash; the features of impact fracture were distinguished from overload fractures by direct comparisons of the received specimens with laboratory-generated failures.

Reliability and failure modes of implant-supported zirconium-oxide fixed dental prostheses related to veneering techniques

PubMed Central

Baldassarri, Marta; Zhang, Yu; Thompson, Van P.; Rekow, Elizabeth D.; Stappert, Christian F. J.

2011-01-01

Summary Objectives To compare fatigue failure modes and reliability of hand-veneered and over-pressed implant-supported three-unit zirconium-oxide fixed-dental-prostheses(FDPs). Methods Sixty-four custom-made zirconium-oxide abutments (n=32/group) and thirty-two zirconium-oxide FDP-frameworks were CAD/CAM manufactured. Frameworks were veneered with hand-built up or over-pressed porcelain (n=16/group). Step-stress-accelerated-life-testing (SSALT) was performed in water applying a distributed contact load at the buccal cusp-pontic-area. Post failure examinations were carried out using optical (polarized-reflected-light) and scanning electron microscopy (SEM) to visualize crack propagation and failure modes. Reliability was compared using cumulative-damage step-stress analysis (Alta-7-Pro, Reliasoft). Results Crack propagation was observed in the veneering porcelain during fatigue. The majority of zirconium-oxide FDPs demonstrated porcelain chipping as the dominant failure mode. Nevertheless, fracture of the zirconium-oxide frameworks was also observed. Over-pressed FDPs failed earlier at a mean failure load of 696 ± 149 N relative to hand-veneered at 882 ± 61 N (profile I). Weibull-stress-number of cycles-unreliability-curves were generated. The reliability (2-sided at 90% confidence bounds) for a 400N load at 100K cycles indicated values of 0.84 (0.98-0.24) for the hand-veneered FDPs and 0.50 (0.82-0.09) for their over-pressed counterparts. Conclusions Both zirconium-oxide FDP systems were resistant under accelerated-life-time-testing. Over-pressed specimens were more susceptible to fatigue loading with earlier veneer chipping. PMID:21557985

The challenge of measuring emergency preparedness: integrating component metrics to build system-level measures for strategic national stockpile operations.

PubMed

Jackson, Brian A; Faith, Kay Sullivan

2013-02-01

Although significant progress has been made in measuring public health emergency preparedness, system-level performance measures are lacking. This report examines a potential approach to such measures for Strategic National Stockpile (SNS) operations. We adapted an engineering analytic technique used to assess the reliability of technological systems-failure mode and effects analysis-to assess preparedness. That technique, which includes systematic mapping of the response system and identification of possible breakdowns that affect performance, provides a path to use data from existing SNS assessment tools to estimate likely future performance of the system overall. Systems models of SNS operations were constructed and failure mode analyses were performed for each component. Linking data from existing assessments, including the technical assistance review and functional drills, to reliability assessment was demonstrated using publicly available information. The use of failure mode and effects estimates to assess overall response system reliability was demonstrated with a simple simulation example. Reliability analysis appears an attractive way to integrate information from the substantial investment in detailed assessments for stockpile delivery and dispensing to provide a view of likely future response performance.

Performance and sensitivity analysis of the generalized likelihood ratio method for failure detection. M.S. Thesis

NASA Technical Reports Server (NTRS)

Bueno, R. A.

1977-01-01

Results of the generalized likelihood ratio (GLR) technique for the detection of failures in aircraft application are presented, and its relationship to the properties of the Kalman-Bucy filter is examined. Under the assumption that the system is perfectly modeled, the detectability and distinguishability of four failure types are investigated by means of analysis and simulations. Detection of failures is found satisfactory, but problems in identifying correctly the mode of a failure may arise. These issues are closely examined as well as the sensitivity of GLR to modeling errors. The advantages and disadvantages of this technique are discussed, and various modifications are suggested to reduce its limitations in performance and computational complexity.

A Framework for Final Drive Simultaneous Failure Diagnosis Based on Fuzzy Entropy and Sparse Bayesian Extreme Learning Machine

PubMed Central

Ye, Qing; Pan, Hao; Liu, Changhua

2015-01-01

This research proposes a novel framework of final drive simultaneous failure diagnosis containing feature extraction, training paired diagnostic models, generating decision threshold, and recognizing simultaneous failure modes. In feature extraction module, adopt wavelet package transform and fuzzy entropy to reduce noise interference and extract representative features of failure mode. Use single failure sample to construct probability classifiers based on paired sparse Bayesian extreme learning machine which is trained only by single failure modes and have high generalization and sparsity of sparse Bayesian learning approach. To generate optimal decision threshold which can convert probability output obtained from classifiers into final simultaneous failure modes, this research proposes using samples containing both single and simultaneous failure modes and Grid search method which is superior to traditional techniques in global optimization. Compared with other frequently used diagnostic approaches based on support vector machine and probability neural networks, experiment results based on F 1-measure value verify that the diagnostic accuracy and efficiency of the proposed framework which are crucial for simultaneous failure diagnosis are superior to the existing approach. PMID:25722717

Comparison of mode of failure between primary and revision total knee arthroplasties.

PubMed

Liang, H; Bae, J K; Park, C H; Kim, K I; Bae, D K; Song, S J

2018-04-01

Cognizance of common reasons for failure in primary and revision TKA, together with their time course, facilitates prevention. However, there have been few reports specifically comparing modes of failure for primary vs. revision TKA using a single prosthesis. The goal of the study was to compare the survival rates, modes of failure, and time periods associated with each mode of failure, of primary vs. revision TKA. The survival rates, modes of failure, time period for each mode of failure, and risk factors would differ between primary and revision TKA. Data from a consecutive cohort comprising 1606 knees (1174 patients) of primary TKA patients, and 258 knees (224 patients) of revision TKA patients, in all of whom surgery involved a P.F.C ® prosthesis (Depuy, Johnson & Johnson, Warsaw, IN), was retrospectively reviewed. The mean follow-up periods of primary and revision TKAs were 9.2 and 9.8 years, respectively. The average 10- and 15-year survival rates for primary TKA were 96.7% (CI 95%,±0.7%) and 85.4% (CI 95%,±2.0%), and for revision TKA 91.4% (CI 95%,±2.5%) and 80.5% (CI 95%,±4.5%). Common modes of failure included polyethylene wear, loosening, and infection. The most common mode of failure was polyethylene wear in primary TKA, and infection in revision TKA. The mean periods (i.e., latencies) of polyethylene wear and loosening did not differ between primary and revision TKAs, but the mean period of infection was significantly longer for revision TKA (1.2 vs. 4.8 years, P=0.003). Survival rates decreased with time, particularly more than 10 years post-surgery, for both primary and revision TKAs. Continuous efforts are required to prevent and detect the various modes of failure during long-term follow-up. Greater attention is necessary to detect late infection-induced failure following revision TKA. Case-control study, Level III. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Revised Risk Priority Number in Failure Mode and Effects Analysis Model from the Perspective of Healthcare System

PubMed Central

Rezaei, Fatemeh; Yarmohammadian, Mohmmad H.; Haghshenas, Abbas; Fallah, Ali; Ferdosi, Masoud

2018-01-01

Background: Methodology of Failure Mode and Effects Analysis (FMEA) is known as an important risk assessment tool and accreditation requirement by many organizations. For prioritizing failures, the index of “risk priority number (RPN)” is used, especially for its ease and subjective evaluations of occurrence, the severity and the detectability of each failure. In this study, we have tried to apply FMEA model more compatible with health-care systems by redefining RPN index to be closer to reality. Methods: We used a quantitative and qualitative approach in this research. In the qualitative domain, focused groups discussion was used to collect data. A quantitative approach was used to calculate RPN score. Results: We have studied patient's journey in surgery ward from holding area to the operating room. The highest priority failures determined based on (1) defining inclusion criteria as severity of incident (clinical effect, claim consequence, waste of time and financial loss), occurrence of incident (time - unit occurrence and degree of exposure to risk) and preventability (degree of preventability and defensive barriers) then, (2) risks priority criteria quantified by using RPN index (361 for the highest rate failure). The ability of improved RPN scores reassessed by root cause analysis showed some variations. Conclusions: We concluded that standard criteria should be developed inconsistent with clinical linguistic and special scientific fields. Therefore, cooperation and partnership of technical and clinical groups are necessary to modify these models. PMID:29441184

Enhancing Induction Coil Reliability

NASA Astrophysics Data System (ADS)

Kreter, K.; Goldstein, R.; Yakey, C.; Nemkov, V.

2014-12-01

In induction hardening, thermal fatigue is one of the main copper failure modes of induction heat treating coils. There have been papers published that describe this failure mode and others that describe some good design practices. The variables previously identified as the sources of thermal fatigue include radiation from the part surface, frequency, current, concentrator losses, water pressure and coil wall thickness. However, there is very little quantitative data on the factors that influence thermal fatigue in induction coils is available in the public domain. By using finite element analysis software this study analyzes the effect of common design variables of inductor cooling, and quantifies the relative importance of these variables. A comprehensive case study for a single shot induction coil with Fluxtrol A concentrator applied is used for the analysis.

Reliability Assessment for Low-cost Unmanned Aerial Vehicles

NASA Astrophysics Data System (ADS)

Freeman, Paul Michael

Existing low-cost unmanned aerospace systems are unreliable, and engineers must blend reliability analysis with fault-tolerant control in novel ways. This dissertation introduces the University of Minnesota unmanned aerial vehicle flight research platform, a comprehensive simulation and flight test facility for reliability and fault-tolerance research. An industry-standard reliability assessment technique, the failure modes and effects analysis, is performed for an unmanned aircraft. Particular attention is afforded to the control surface and servo-actuation subsystem. Maintaining effector health is essential for safe flight; failures may lead to loss of control incidents. Failure likelihood, severity, and risk are qualitatively assessed for several effector failure modes. Design changes are recommended to improve aircraft reliability based on this analysis. Most notably, the control surfaces are split, providing independent actuation and dual-redundancy. The simulation models for control surface aerodynamic effects are updated to reflect the split surfaces using a first-principles geometric analysis. The failure modes and effects analysis is extended by using a high-fidelity nonlinear aircraft simulation. A trim state discovery is performed to identify the achievable steady, wings-level flight envelope of the healthy and damaged vehicle. Tolerance of elevator actuator failures is studied using familiar tools from linear systems analysis. This analysis reveals significant inherent performance limitations for candidate adaptive/reconfigurable control algorithms used for the vehicle. Moreover, it demonstrates how these tools can be applied in a design feedback loop to make safety-critical unmanned systems more reliable. Control surface impairments that do occur must be quickly and accurately detected. This dissertation also considers fault detection and identification for an unmanned aerial vehicle using model-based and model-free approaches and applies those algorithms to experimental faulted and unfaulted flight test data. Flight tests are conducted with actuator faults that affect the plant input and sensor faults that affect the vehicle state measurements. A model-based detection strategy is designed and uses robust linear filtering methods to reject exogenous disturbances, e.g. wind, while providing robustness to model variation. A data-driven algorithm is developed to operate exclusively on raw flight test data without physical model knowledge. The fault detection and identification performance of these complementary but different methods is compared. Together, enhanced reliability assessment and multi-pronged fault detection and identification techniques can help to bring about the next generation of reliable low-cost unmanned aircraft.

Open-Mode Debonding Analysis of Curved Sandwich Panels Subjected to Heating and Cryogenic Cooling on Opposite Faces

NASA Technical Reports Server (NTRS)

Ko, William L.

1999-01-01

Increasing use of curved sandwich panels as aerospace structure components makes it vital to fully understand their thermostructural behavior and identify key factors affecting the open-mode debonding failure. Open-mode debonding analysis is performed on a family of curved honeycomb-core sandwich panels with different radii of curvature. The curved sandwich panels are either simply supported or clamped, and are subjected to uniform heating on the convex side and uniform cryogenic cooling on the concave side. The finite-element method was used to study the effects of panel curvature and boundary condition on the open-mode stress (radial tensile stress) and displacement fields in the curved sandwich panels. The critical stress point, where potential debonding failure could initiate, was found to be at the midspan (or outer span) of the inner bonding interface between the sandwich core and face sheet on the concave side, depending on the boundary condition and panel curvature. Open-mode stress increases with increasing panel curvature, reaching a maximum value at certain high curvature, and then decreases slightly as the panel curvature continues to increase and approach that of quarter circle. Changing the boundary condition from simply supported to clamped reduces the magnitudes of open-mode stresses and the associated sandwich core depth stretching.

Independent Orbiter Assessment (IOA): Assessment of the electrical power distribution and control subsystem, volume 3

NASA Technical Reports Server (NTRS)

Schmeckpeper, K. R.

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 first completed an analysis of the Electrical Power Distribution and Control (EPD and C) 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 EPD and C hardware. Volume 3 continues the presentation of IOA worksheets and contains the potential critical items list and the NASA FMEA to IOA worksheet cross reference and recommendations.

Independent Orbiter Assessment (IOA): Assessment of the atmospheric revitalization pressure control subsystem FMEA/CIL

NASA Technical Reports Server (NTRS)

Saiidi, M. J.

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 atmospheric Revitalization Pressure Control Subsystem (ARPCS) 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 proposed Post 51-L updates based upon the CCB/PRCB presentations and an informal criticality summary listing. A discussion of each discrepancy from the comparison is provided through additional analysis as required. These discrepancies were flagged as issues, and recommendations were made based on the FMEA data available at the time. This report documents the results of that comparison for the Orbiter ARPCS hardware.

Analysis of progressive damage in thin circular laminates due to static-equivalent impact loads

NASA Technical Reports Server (NTRS)

Shivakumar, K. N.; Elber, W.; Illg, W.

1983-01-01

Clamped circular graphite/epoxy plates (25.4, 38.1, and 50.8 mm radii) with an 8-ply quasi-isotropic layup were analyzed for static-equivalent impact loads using the minimum-total-potential-energy method and the von Karman strain-displacement equations. A step-by-step incremental transverse displacement procedure was used to calculate plate load and ply stresses. The ply failure region was calculated using the Tsai-Wu criterion. The corresponding failure modes (splitting and fiber failure) were determined using the maximum stress criteria. The first-failure mode was splitting and initiated first in the bottom ply. The splitting-failure thresholds were relatively low and tended to be lower for larger plates than for small plates. The splitting-damage region in each ply was elongated in its fiber direction; the bottom ply had the largest damage region. The calculated damage region for the 25.4-mm-radius plate agreed with limited static test results from the literature.

Statistical analysis of lithium iron sulfide status cell cycle life and failure mode

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

Gay, E.C.; Battles, J.E.; Miller, W.E.

1983-08-01

A statistical model was developed for life cycle testing of electrochemical cell life cycle trials and verified experimentally. The Weibull distribution was selected to predict the end of life for a cell, based on a 20 percent loss of initial stabilized capacity or a decrease to less than 95 percent coulombic efficiency. Groups of 12 or more Li-alloy/FeS cells were cycled to determine the mean time to failure (MTTF) and also to identify the failure modes. The cells were all full size electric vehicle batteries with 150-350 A-hr capacity. The Weibull shape factors were determined and verified in prediction ofmore » the number of cell failures in two 10 cell modules. The short circuit failure in the cells with BN-felt and MgO powder separators were found to be caused by the formation of Li-Al protrusions that penetrated the BN-felt separators, and the extrusion of active material at the edge of the electrodes.« less

Mechanical Behavior of Brittle Rock-Like Specimens with Pre-existing Fissures Under Uniaxial Loading: Experimental Studies and Particle Mechanics Approach

NASA Astrophysics Data System (ADS)

Cao, Ri-hong; Cao, Ping; Lin, Hang; Pu, Cheng-zhi; Ou, Ke

2016-03-01

Joints and fissures with similar orientation or characteristics are common in natural rocks; the inclination and density of the fissures affect the mechanical properties and failure mechanism of the rock mass. However, the strength, crack coalescence pattern, and failure mode of rock specimens containing multi-fissures have not been studied comprehensively. In this paper, combining similar material testing and discrete element numerical method (PFC2D), the peak strength and failure characteristics of rock-like materials with multi-fissures are explored. Rock-like specimens were made of cement and sand and pre-existing fissures created by inserting steel shims into cement mortar paste and removing them during curing. The peak strength of multi-fissure specimens depends on the fissure angle α (which is measured counterclockwise from horizontal) and fissure number ( N f). Under uniaxial compressional loading, the peak strength increased with increasing α. The material strength was lowest for α = 25°, and highest for α = 90°. The influence of N f on the peak strength depended on α. For α = 25° and 45°, N f had a strong effect on the peak strength, while for higher α values, especially for the 90° sample, there were no obvious changes in peak strength with different N f. Under uniaxial compression, the coalescence modes between the fissures can be classified into three categories: S-mode, T-mode, and M-mode. Moreover, the failure mode can be classified into four categories: mixed failure, shear failure, stepped path failure, and intact failure. The failure mode of the specimen depends on α and N f. The peak strength and failure modes in the numerically simulated and experimental results are in good agreement.

Response of Honeycomb Core Sandwich Panel with Minimum Gage GFRP Face-Sheets to Compression Loading After Impact

NASA Technical Reports Server (NTRS)

McQuigg, Thomas D.; Kapania, Rakesh K.; Scotti, Stephen J.; Walker, Sandra P.

2011-01-01

A compression after impact study has been conducted to determine the residual strength of three sandwich panel constructions with two types of thin glass fiber reinforced polymer face-sheets and two hexagonal honeycomb Nomex core densities. Impact testing is conducted to first determine the characteristics of damage resulting from various impact energy levels. Two modes of failure are found during compression after impact tests with the density of the core precipitating the failure mode present for a given specimen. A finite element analysis is presented for prediction of the residual compressive strength of the impacted specimens. The analysis includes progressive damage modeling in the face-sheets. Preliminary analysis results were similar to the experimental results; however, a higher fidelity core material model is expected to improve the correlation.

Independent Orbiter Assessment (IOA): Assessment of the orbital maneuvering subsystem, volume 2

NASA Technical Reports Server (NTRS)

Haufler, W. A.

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 Orbital Maneuvering System (OMS) hardware and electrical power distribution and control (EPD and C), 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 proposed Post 51-L NASA FMEA/CIL baseline. This report documents the results of that comparison for the Orbiter OMS hardware and EPD and C systems. Volume 2 continues the presentation of IOA worksheets and contains the critical items list and the NASA FMEA to IOA worksheet cross reference and recommendations.

A Comparison of Functional Models for Use in the Function-Failure Design Method

NASA Technical Reports Server (NTRS)

Stock, Michael E.; Stone, Robert B.; Tumer, Irem Y.

2006-01-01

When failure analysis and prevention, guided by historical design knowledge, are coupled with product design at its conception, shorter design cycles are possible. By decreasing the design time of a product in this manner, design costs are reduced and the product will better suit the customer s needs. Prior work indicates that similar failure modes occur with products (or components) with similar functionality. To capitalize on this finding, a knowledge base of historical failure information linked to functionality is assembled for use by designers. One possible use for this knowledge base is within the Elemental Function-Failure Design Method (EFDM). This design methodology and failure analysis tool begins at conceptual design and keeps the designer cognizant of failures that are likely to occur based on the product s functionality. The EFDM offers potential improvement over current failure analysis methods, such as FMEA, FMECA, and Fault Tree Analysis, because it can be implemented hand in hand with other conceptual design steps and carried throughout a product s design cycle. These other failure analysis methods can only truly be effective after a physical design has been completed. The EFDM however is only as good as the knowledge base that it draws from, and therefore it is of utmost importance to develop a knowledge base that will be suitable for use across a wide spectrum of products. One fundamental question that arises in using the EFDM is: At what level of detail should functional descriptions of components be encoded? This paper explores two approaches to populating a knowledge base with actual failure occurrence information from Bell 206 helicopters. Functional models expressed at various levels of detail are investigated to determine the necessary detail for an applicable knowledge base that can be used by designers in both new designs as well as redesigns. High level and more detailed functional descriptions are derived for each failed component based on NTSB accident reports. To best record this data, standardized functional and failure mode vocabularies are used. Two separate function-failure knowledge bases are then created aid compared. Results indicate that encoding failure data using more detailed functional models allows for a more robust knowledge base. Interestingly however, when applying the EFDM, high level descriptions continue to produce useful results when using the knowledge base generated from the detailed functional models.

Failure behavior of glass ionomer cement under Hertzian indentation.

PubMed

Wang, Yan; Darvell, B W

2008-09-01

To investigate the load-bearing capacity and failure mode of various types of glass ionomer cement (GIC) under Hertzian indentation, exploring the relationship between the failure behavior and formulation, and examining claims of filler-reinforcement of GIC. Discs 2mm thick, 10mm diameter, 8-18 replicates, were fabricated for two filler-reinforced GICs, four unmodified and unreinforced GICs, and four resin-modified GICs, with a dental silver amalgam and a filled-resin restorative material for comparison. Testing was at 23 degrees C, wet, after 7d storage at 37 degrees C in artificial saliva at pH 6, using a 20mm diameter hard steel ball and filled-nylon substrate (E: 10GPa). First failure was detected acoustically; mode was determined visually. At least 1/3 of specimens in each case were examined under scanning electronic microscope for corroboration. Reinforced and unmodified-unreinforced GICs were indistinguishable by failure load (one-way analysis of variance, P=0.425, overall 260+/-70N) and mode. Failure loads for resin-modified GICs were 360-1150N, amalgam approximately 680N, and filled resin approximately 1200N. Resin-modified GICs tended to be tougher (incomplete fracture), all others gave complete fracture (radial cracking). The stronger materials (two resin-modified GICs and filled resin) showed some cone cracking. While resin-modified GICs showed various extents of increase of failure load over that of the plain GICs, consistent with the hybrid chemistry, filler-reinforcement was not evident for the two claimed products, consistent with structural and theoretical expectations.

Preliminary design of a solar central receiver for a site-specific repowering application (Saguaro Power Plant). Volume IV. Appendixes. Final report, October 1982-September 1983

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

Weber, E.R.

1983-09-01

The appendixes for the Saguaro Power Plant includes the following: receiver configuration selection report; cooperating modes and transitions; failure modes analysis; control system analysis; computer codes and simulation models; procurement package scope descriptions; responsibility matrix; solar system flow diagram component purpose list; thermal storage component and system test plans; solar steam generator tube-to-tubesheet weld analysis; pipeline listing; management control schedule; and system list and definitions.

Application of Failure Mode and Effect Analysis (FMEA) and cause and effect analysis in conjunction with ISO 22000 to a snails (Helix aspersa) processing plant; A case study.

PubMed

Arvanitoyannis, Ioannis S; Varzakas, Theodoros H

2009-08-01

Failure Mode and Effect Analysis (FMEA) has been applied for the risk assessment of snails manufacturing. A tentative approach of FMEA application to the snails industry was attempted in conjunction with ISO 22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (snails processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram, and fishbone diagram). In this work a comparison of ISO22000 analysis with HACCP is carried out over snails processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the RPN per identified processing hazard. Sterilization of tins, bioaccumulation of heavy metals, packaging of shells and poisonous mushrooms, were the processes identified as the ones with the highest RPN (280, 240, 147, 144, respectively) and corrective actions were undertaken. Following the application of corrective actions, a second calculation of RPN values was carried out leading to considerably lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO22000 system of a snails processing industry is considered imperative.

Field failure mechanisms for photovoltaic modules

NASA Technical Reports Server (NTRS)

Dumas, L. N.; Shumka, A.

1981-01-01

Beginning in 1976, Department of Energy field centers have installed and monitored a number of field tests and application experiments using current state-of-the-art photovoltaic modules. On-site observations of module physical and electrical degradation, together with in-depth laboratory analysis of failed modules, permits an overall assessment of the nature and causes of early field failures. Data on failure rates are presented, and key failure mechanisms are analyzed with respect to origin, effect, and prospects for correction. It is concluded that all failure modes identified to date are avoidable or controllable through sound design and production practices.

Detailed investigation of causes of avionics field failures

NASA Astrophysics Data System (ADS)

Kallis, J. M.; Buechler, D. W.; Richardson, Z. C.; Backes, P. G.; Lopez, S. B.; Erickson, J. J.; van Westerhuyzen, D. H.

A detailed analysis of digital and analog modules from the F-15 AN/APG-63 Radar was performed to identify the kinds, types, and number of life models based on observed failure modes, mechanisms, locations, and characteristics needed to perform a Failure Free Operating Period prediction for these items. It is found that a significant fraction of the failures of the analog module and a small fraction of those of the digital module resulted from the exacerbation of latent defects by environmental stresses. It is also found that the fraction of failures resulting from thermal cycling and vibration is small.

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.

Panel Stiffener Debonding Analysis using a Shell/3D Modeling Technique

NASA Technical Reports Server (NTRS)

Krueger, Ronald; Ratcliffe, James G.; Minguet, Pierre J.

2008-01-01

A shear loaded, stringer reinforced composite panel is analyzed to evaluate the fidelity of computational fracture mechanics analyses of complex structures. Shear loading causes the panel to buckle. The resulting out -of-plane deformations initiate skin/stringer separation at the location of an embedded defect. The panel and surrounding load fixture were modeled with shell elements. A small section of the stringer foot, web and noodle as well as the panel skin near the delamination front were modeled with a local 3D solid model. Across the width of the stringer fo to, the mixed-mode strain energy release rates were calculated using the virtual crack closure technique. A failure index was calculated by correlating the results with a mixed-mode failure criterion of the graphite/epoxy material. The objective was to study the effect of the fidelity of the local 3D finite element model on the computed mixed-mode strain energy release rates and the failure index.

Panel-Stiffener Debonding and Analysis Using a Shell/3D Modeling Technique

NASA Technical Reports Server (NTRS)

Krueger, Ronald; Ratcliffe, James G.; Minguet, Pierre J.

2007-01-01

A shear loaded, stringer reinforced composite panel is analyzed to evaluate the fidelity of computational fracture mechanics analyses of complex structures. Shear loading causes the panel to buckle. The resulting out-of-plane deformations initiate skin/stringer separation at the location of an embedded defect. The panel and surrounding load fixture were modeled with shell elements. A small section of the stringer foot, web and noodle as well as the panel skin near the delamination front were modeled with a local 3D solid model. Across the width of the stringer foot, the mixed-mode strain energy release rates were calculated using the virtual crack closure technique. A failure index was calculated by correlating the results with a mixed-mode failure criterion of the graphite/epoxy material. The objective was to study the effect of the fidelity of the local 3D finite element model on the computed mixed-mode strain energy release rates and the failure index.

Indoor Soiling Method and Outdoor Statistical Risk Analysis of Photovoltaic Power Plants

NASA Astrophysics Data System (ADS)

Rajasekar, Vidyashree

This is a two-part thesis. Part 1 presents an approach for working towards the development of a standardized artificial soiling method for laminated photovoltaic (PV) cells or mini-modules. Construction of an artificial chamber to maintain controlled environmental conditions and components/chemicals used in artificial soil formulation is briefly explained. Both poly-Si mini-modules and a single cell mono-Si coupons were soiled and characterization tests such as I-V, reflectance and quantum efficiency (QE) were carried out on both soiled, and cleaned coupons. From the results obtained, poly-Si mini-modules proved to be a good measure of soil uniformity, as any non-uniformity present would not result in a smooth curve during I-V measurements. The challenges faced while executing reflectance and QE characterization tests on poly-Si due to smaller size cells was eliminated on the mono-Si coupons with large cells to obtain highly repeatable measurements. This study indicates that the reflectance measurements between 600-700 nm wavelengths can be used as a direct measure of soil density on the modules. Part 2 determines the most dominant failure modes of field aged PV modules using experimental data obtained in the field and statistical analysis, FMECA (Failure Mode, Effect, and Criticality Analysis). The failure and degradation modes of about 744 poly-Si glass/polymer frameless modules fielded for 18 years under the cold-dry climate of New York was evaluated. Defect chart, degradation rates (both string and module levels) and safety map were generated using the field measured data. A statistical reliability tool, FMECA that uses Risk Priority Number (RPN) is used to determine the dominant failure or degradation modes in the strings and modules by means of ranking and prioritizing the modes. This study on PV power plants considers all the failure and degradation modes from both safety and performance perspectives. The indoor and outdoor soiling studies were jointly performed by two Masters Students, Sravanthi Boppana and Vidyashree Rajasekar. This thesis presents the indoor soiling study, whereas the other thesis presents the outdoor soiling study. Similarly, the statistical risk analyses of two power plants (model J and model JVA) were jointly performed by these two Masters students. Both power plants are located at the same cold-dry climate, but one power plant carries framed modules and the other carries frameless modules. This thesis presents the results obtained on the frameless modules.

The assessment of low probability containment failure modes using dynamic PRA

NASA Astrophysics Data System (ADS)

Brunett, Acacia Joann

Although low probability containment failure modes in nuclear power plants may lead to large releases of radioactive material, these modes are typically crudely modeled in system level codes and have large associated uncertainties. Conventional risk assessment techniques (i.e. the fault-tree/event-tree methodology) are capable of accounting for these failure modes to some degree, however, they require the analyst to pre-specify the ordering of events, which can vary within the range of uncertainty of the phenomena. More recently, dynamic probabilistic risk assessment (DPRA) techniques have been developed which remove the dependency on the analyst. Through DPRA, it is now possible to perform a mechanistic and consistent analysis of low probability phenomena, with the timing of the possible events determined by the computational model simulating the reactor behavior. The purpose of this work is to utilize DPRA tools to assess low probability containment failure modes and the driving mechanisms. Particular focus is given to the risk-dominant containment failure modes considered in NUREG-1150, which has long been the standard for PRA techniques. More specifically, this work focuses on the low probability phenomena occurring during a station blackout (SBO) with late power recovery in the Zion Nuclear Power Plant, a Westinghouse pressurized water reactor (PWR). Subsequent to the major risk study performed in NUREG-1150, significant experimentation and modeling regarding the mechanisms driving containment failure modes have been performed. In light of this improved understanding, NUREG-1150 containment failure modes are reviewed in this work using the current state of knowledge. For some unresolved mechanisms, such as containment loading from high pressure melt ejection and combustion events, additional analyses are performed using the accident simulation tool MELCOR to explore the bounding containment loads for realistic scenarios. A dynamic treatment in the characterization of combustible gas ignition is also presented in this work. In most risk studies, combustion is treated simplistically in that it is assumed an ignition occurs if the gas mixture achieves a concentration favorable for ignition under the premise that an adequate ignition source is available. However, the criteria affecting ignition (such as the magnitude, location and frequency of the ignition sources) are complicated. This work demonstrates a technique for characterizing the properties of an ignition source to determine a probability of ignition. The ignition model developed in this work and implemented within a dynamic framework is utilized to analyze the implications and risk significance of late combustion events. This work also explores the feasibility of using dynamic event trees (DETs) with a deterministic sampling approach to analyze low probability phenomena. The flexibility of this approach is demonstrated through the rediscretization of containment fragility curves used in construction of the DET to show convergence to a true solution. Such a rediscretization also reduces the computational burden introduced through extremely fine fragility curve discretization by subsequent refinement of fragility curve regions of interest. Another advantage of the approach is the ability to perform sensitivity studies on the cumulative distribution functions (CDFs) used to determine branching probabilities without the need for rerunning the simulation code. Through review of the NUREG-1150 containment failure modes using the current state of knowledge, it is found that some failure modes, such as Alpha and rocket, can be excluded from further studies; other failure modes, such as failure to isolate, bypass, high pressure melt ejection (HPME), combustion-induced failure and overpressurization are still concerns to varying degrees. As part of this analysis, scoping studies performed in MELCOR show that HPME and the resulting direct containment heating (DCH) do not impose a significant threat to containment integrity. Additional scoping studies regarding the effect of recovery actions on in-vessel hydrogen generation show that reflooding a partially degraded core do not significantly affect hydrogen generation in-vessel, and the NUREG-1150 assumption that insufficient hydrogen is generated in-vessel to produce an energetic deflagration is confirmed. The DET analyses performed in this work show that very late power recovery produces the potential for very energetic combustion events which are capable of failing containment with a non-negligible probability, and that containment cooling systems have a significant impact on core concrete attack, and therefore combustible gas generation ex-vessel. Ultimately, the overall risk of combustion-induced containment failure is low, but its conditional likelihood can have a significant effect on accident mitigation strategies. It is also shown in this work that DETs are particularly well suited to examine low probability events because of their ability to rediscretize CDFs and observe solution convergence.

Health management system for rocket engines

NASA Technical Reports Server (NTRS)

Nemeth, Edward

1990-01-01

The functional framework of a failure detection algorithm for the Space Shuttle Main Engine (SSME) is developed. The basic algorithm is based only on existing SSME measurements. Supplemental measurements, expected to enhance failure detection effectiveness, are identified. To support the algorithm development, a figure of merit is defined to estimate the likelihood of SSME criticality 1 failure modes and the failure modes are ranked in order of likelihood of occurrence. Nine classes of failure detection strategies are evaluated and promising features are extracted as the basis for the failure detection algorithm. The failure detection algorithm provides early warning capabilities for a wide variety of SSME failure modes. Preliminary algorithm evaluation, using data from three SSME failures representing three different failure types, demonstrated indications of imminent catastrophic failure well in advance of redline cutoff in all three cases.

Fault Tree Analysis: An Emerging Methodology for Instructional Science.

ERIC Educational Resources Information Center

Wood, R. Kent; And Others

1979-01-01

Describes Fault Tree Analysis, a tool for systems analysis which attempts to identify possible modes of failure in systems to increase the probability of success. The article defines the technique and presents the steps of FTA construction, focusing on its application to education. (RAO)

Detection of system failures in multi-axes tasks. [pilot monitored instrument approach

NASA Technical Reports Server (NTRS)

Ephrath, A. R.

1975-01-01

The effects of the pilot's participation mode in the control task on his workload level and failure detection performance were examined considering a low visibility landing approach. It is found that the participation mode had a strong effect on the pilot's workload, the induced workload being lowest when the pilot acted as a monitoring element during a coupled approach and highest when the pilot was an active element in the control loop. The effects of workload and participation mode on failure detection were separated. The participation mode was shown to have a dominant effect on the failure detection performance, with a failure in a monitored (coupled) axis being detected significantly faster than a comparable failure in a manually controlled axis.

Simplified analysis of timber rivet connections

Treesearch

Douglas C. Stahl; Marshall. Begel; Ronald W. Wolfe

2000-01-01

Timber rivets, fasteners for glulam and heavy timber construction, have been used in Canada for about thirty years and recently were adopted by the U.S. National Design Specification for Wood Construction (NDS). Rivet connections can exhibit two failure modes, one of which is fundamentally different from those of other dowel fasteners. Failure can occur when a volume...

Analysis for the Progressive Failure Response of Textile Composite Fuselage Frames

NASA Technical Reports Server (NTRS)

Johnson, Eric R.; Boitnott, Richard L. (Technical Monitor)

2002-01-01

A part of aviation accident mitigation is a crashworthy airframe structure, and an important measure of merit for a crashworthy structure is the amount of kinetic energy that can be absorbed in the crush of the structure. Prediction of the energy absorbed from finite element analyses requires modeling the progressive failure sequence. Progressive failure modes may include material degradation, fracture and crack growth, and buckling and collapse. The design of crashworthy airframe components will benefit from progressive failure analyses that have been validated by tests. The subject of this research is the development of a progressive failure analysis for a textile composite, circumferential fuselage frame subjected to a quasi-static, crash-type load. The test data for the frame are reported, and these data are used to develop and to validate methods for the progressive failure response.

Modes of failure in disordered solids

NASA Astrophysics Data System (ADS)

Roy, Subhadeep; Biswas, Soumyajyoti; Ray, Purusattam

2017-12-01

The two principal ingredients determining the failure modes of disordered solids are the strength of heterogeneity and the length scale of the region affected in the solid following a local failure. While the latter facilitates damage nucleation, the former leads to diffused damage—the two extreme natures of the failure modes. In this study, using the random fiber bundle model as a prototype for disordered solids, we classify all failure modes that are the results of interplay between these two effects. We obtain scaling criteria for the different modes and propose a general phase diagram that provides a framework for understanding previous theoretical and experimental attempts of interpolation between these modes. As the fiber bundle model is a long-standing model for interpreting various features of stressed disordered solids, the general phase diagram can serve as a guiding principle in anticipating the responses of disordered solids in general.

Nanowire failure: long = brittle and short = ductile.

PubMed

Wu, Zhaoxuan; Zhang, Yong-Wei; Jhon, Mark H; Gao, Huajian; Srolovitz, David J

2012-02-08

Experimental studies of the tensile behavior of metallic nanowires show a wide range of failure modes, ranging from ductile necking to brittle/localized shear failure-often in the same diameter wires. We performed large-scale molecular dynamics simulations of copper nanowires with a range of nanowire lengths and provide unequivocal evidence for a transition in nanowire failure mode with change in nanowire length. Short nanowires fail via a ductile mode with serrated stress-strain curves, while long wires exhibit extreme shear localization and abrupt failure. We developed a simple model for predicting the critical nanowire length for this failure mode transition and showed that it is in excellent agreement with both the simulation results and the extant experimental data. The present results provide a new paradigm for the design of nanoscale mechanical systems that demarcates graceful and catastrophic failure. © 2012 American Chemical Society

Risk management for outsourcing biomedical waste disposal – Using the failure mode and effects analysis

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

Liao, Ching-Jong; Ho, Chao Chung, E-mail: ho919@pchome.com.tw

Highlights: • This study is based on a real case in hospital in Taiwan. • We use Failure Mode and Effects Analysis (FMEA) as the evaluation method. • We successfully identify the evaluation factors of bio-medical waste disposal risk. - Abstract: Using the failure mode and effects analysis, this study examined biomedical waste companies through risk assessment. Moreover, it evaluated the supervisors of biomedical waste units in hospitals, and factors relating to the outsourcing risk assessment of biomedical waste in hospitals by referring to waste disposal acts. An expert questionnaire survey was conducted on the personnel involved in waste disposalmore » units in hospitals, in order to identify important factors relating to the outsourcing risk of biomedical waste in hospitals. This study calculated the risk priority number (RPN) and selected items with an RPN value higher than 80 for improvement. These items included “availability of freezing devices”, “availability of containers for sharp items”, “disposal frequency”, “disposal volume”, “disposal method”, “vehicles meeting the regulations”, and “declaration of three lists”. This study also aimed to identify important selection factors of biomedical waste disposal companies by hospitals in terms of risk. These findings can serve as references for hospitals in the selection of outsourcing companies for biomedical waste disposal.« less

Failure mode and effects analysis of the universal anaesthesia machine in two tertiary care hospitals in Sierra Leone

PubMed Central

Rosen, M. A.; Sampson, J. B.; Jackson, E. V.; Koka, R.; Chima, A. M.; Ogbuagu, O. U.; Marx, M. K.; Koroma, M.; Lee, B. H.

2014-01-01

Background Anaesthesia care in developed countries involves sophisticated technology and experienced providers. However, advanced machines may be inoperable or fail frequently when placed into the austere medical environment of a developing country. Failure mode and effects analysis (FMEA) is a method for engaging local staff in identifying real or potential breakdowns in processes or work systems and to develop strategies to mitigate risks. Methods Nurse anaesthetists from the two tertiary care hospitals in Freetown, Sierra Leone, participated in three sessions moderated by a human factors specialist and an anaesthesiologist. Sessions were audio recorded, and group discussion graphically mapped by the session facilitator for analysis and commentary. These sessions sought to identify potential barriers to implementing an anaesthesia machine designed for austere medical environments—the universal anaesthesia machine (UAM)—and also engaging local nurse anaesthetists in identifying potential solutions to these barriers. Results Participating Sierra Leonean clinicians identified five main categories of failure modes (resource availability, environmental issues, staff knowledge and attitudes, and workload and staffing issues) and four categories of mitigation strategies (resource management plans, engaging and educating stakeholders, peer support for new machine use, and collectively advocating for needed resources). Conclusions We identified factors that may limit the impact of a UAM and devised likely effective strategies for mitigating those risks. PMID:24833727

Failure Behavior Characterization of Mo-Modified Ti Surface by Impact Test and Finite Element Analysis

NASA Astrophysics Data System (ADS)

Ma, Yong; Qin, Jianfeng; Zhang, Xiangyu; Lin, Naiming; Huang, Xiaobo; Tang, Bin

2015-07-01

Using the impact test and finite element simulation, the failure behavior of the Mo-modified layer on pure Ti was investigated. In the impact test, four loads of 100, 300, 500, and 700 N and 104 impacts were adopted. The three-dimensional residual impact dents were examined using an optical microscope (Olympus-DSX500i), indicating that the impact resistance of the Ti surface was improved. Two failure modes cohesive and wearing were elucidated by electron backscatter diffraction and energy-dispersive spectrometer performed in a field-emission scanning electron microscope. Through finite element forward analysis performed at a typical impact load of 300 N, stress-strain distributions in the Mo-modified Ti were quantitatively determined. In addition, the failure behavior of the Mo-modified layer was determined and an ideal failure model was proposed for high-load impact, based on the experimental and finite element forward analysis results.

Analysis and Test Correlation of Proof of Concept Box for Blended Wing Body-Low Speed Vehicle

NASA Technical Reports Server (NTRS)

Spellman, Regina L.

2003-01-01

The Low Speed Vehicle (LSV) is a 14.2% scale remotely piloted vehicle of the revolutionary Blended Wing Body concept. The design of the LSV includes an all composite airframe. Due to internal manufacturing capability restrictions, room temperature layups were necessary. An extensive materials testing and manufacturing process development effort was underwent to establish a process that would achieve the high modulus/low weight properties required to meet the design requirements. The analysis process involved a loads development effort that incorporated aero loads to determine internal forces that could be applied to a traditional FEM of the vehicle and to conduct detailed component analyses. A new tool, Hypersizer, was added to the design process to address various composite failure modes and to optimize the skin panel thickness of the upper and lower skins for the vehicle. The analysis required an iterative approach as material properties were continually changing. As a part of the material characterization effort, test articles, including a proof of concept wing box and a full-scale wing, were fabricated. The proof of concept box was fabricated based on very preliminary material studies and tested in bending, torsion, and shear. The box was then tested to failure under shear. The proof of concept box was also analyzed using Nastran and Hypersizer. The results of both analyses were scaled to determine the predicted failure load. The test results were compared to both the Nastran and Hypersizer analytical predictions. The actual failure occurred at 899 lbs. The failure was predicted at 1167 lbs based on the Nastran analysis. The Hypersizer analysis predicted a lower failure load of 960 lbs. The Nastran analysis alone was not sufficient to predict the failure load because it does not identify local composite failure modes. This analysis has traditionally been done using closed form solutions. Although Hypersizer is typically used as an optimizer for the design process, the failure prediction was used to help gain acceptance and confidence in this new tool. The correlated models and process were to be used to analyze the full BWB-LSV airframe design. The analysis and correlation with test results of the proof of concept box is presented here, including the comparison of the Nastran and Hypersizer results.

WE-G-BRC-02: Risk Assessment for HDR Brachytherapy

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

Mayadev, J.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

WE-G-BRC-01: Risk Assessment for Radiosurgery

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

Kim, G.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

WE-G-BRC-03: Risk Assessment for Physics Plan Review

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

Parker, S.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

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

NONE

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

Failure mode and effects analysis to reduce risk of anticoagulation levels above the target range during concurrent antimicrobial therapy.

PubMed

Daniels, Lisa M; Barreto, Jason N; Kuth, John C; Anderson, Jeremy R; Zhang, Beilei; Majka, Andrew J; Morgenthaler, Timothy I; Tosh, Pritish K

2015-07-15

A failure mode and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to above-target International Normalized Ratios (INRs) in warfarin-treated patients receiving concurrent antimicrobial therapy. The INRs of patients on long-term warfarin therapy who received a course of trimethoprim-sulfamethoxazole, metronidazole, fluconazole, miconazole, or voriconazole (highly potentiating antimicrobials, or HPAs) between September 1 and December 31, 2011, were compared with patients on long-term warfarin therapy who did not receive any antimicrobial during the same period. A multidisciplinary team of physicians, pharmacists, and a systems analyst was then formed to complete a step-by-step outline of the processes involved in warfarin management and concomitant HPA therapy, followed by an FMEA. Patients taking trimethoprim-sulfamethoxazole, metronidazole, or fluconazole demonstrated a significantly increased risk of having an INR of >4.5. The FMEA identified 134 failure modes. The most common failure modes were as follows: (1) electronic medical records did not identify all patients receiving warfarin, (2) HPA prescribers were unaware of recommended warfarin therapy when HPAs were prescribed, (3) HPA prescribers were unaware that a patient was taking warfarin and that the drug interaction is significant, and (4) warfarin managers were unaware that an HPA had been prescribed for a patient. An FMEA determined that the risk of adverse events caused by concomitantly administering warfarin and HPAs can be decreased by preemptively identifying patients receiving warfarin, having a care process in place, alerting providers about the patient's risk status, and notifying providers at the anticoagulation clinic. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

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.

Improving Attachments of Non-Invasive (Type III) Electronic Data Loggers to Cetaceans

DTIC Science & Technology

2015-09-30

animals in human care will be performed to test and validate this approach. The cadaver trials will enable controlled testing to failure or with both...quantitative metrics and analysis tools to assess the impact of a tag on the animal . Here we will present: 1) the characterization of the mechanical...fine scale motion analysis for swimming animals . 2 APPROACH Our approach is divided into four subtasks: Task 1: Forces and failure modes

WE-H-BRC-01: Failure Mode and Effects Analysis of Skin Electronic Brachytherapy Using Esteya Unit

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

Ibanez-Rosello, B; Bautista-Ballesteros, J; Bonaque, J

Purpose: A failure mode and effect analysis (FMEA) of skin lesions treatment process using Esteya™ device (Elekta Brachyterapy, Veenendaal, The Netherlands) was performed, with the aim of increasing the quality of the treatment and reducing the likelihood of unwanted events. Methods: A multidisciplinary team with experience in the treatment process met to establish the process map, which outlines the flow of various stages for such patients undergoing skin treatment. Potential failure modes (FM) were identified and the value of severity (S), frequency of occurrence (O), and lack of detectability (D) of the proposed FM were scored individually, each on amore » scale of 1 to 10 following TG-100 guidelines of the AAPM. These failure modes were ranked according to our risk priority number (RPN) and S scores. The efficiency of existing quality management tools was analyzed through a reassessment of the O and D made by consensus. Results: 149 FM were identified, 43 of which had RPN ≥ 100 and 30 had S ≥ 7. After introduction of the tools of quality management, only 3 FM had RPN ≥ 100 and 22 FM had RPN ≥ 50. These 22 FM were thoroughly analyzed and new tools for quality management were proposed. The most common cause of highest RPN FM was associated with the heavy patient workload and the continuous and accurate applicator-patient skin contact during the treatment. To overcome this second item, a regular quality control and setup review by a second individual before each treatment session was proposed. Conclusion: FMEA revealed some of the FM potentials that were not predicted during the initial implementation of the quality management tools. This exercise was useful in identifying the need of periodic update of the FMEA process as new potential failures can be identified.« less

Roles of Shape and Internal Structure in Rotational Disruption of Asteroids

NASA Astrophysics Data System (ADS)

Hirabayashi, Masatoshi; Scheeres, Daniel Jay

2015-08-01

An active research area over the last decade has been to explore configuration changes of rubble pile asteroids due to rotationally induced disruption, initially driven by the remarkable fact that there is a spin period threshold of 2 hr for asteroids larger than a few hundred meters in size. Several different disruption modes due to rapid rotation can be identified, as surface shedding, fission and failure of the internal structure. Relevant to these discussions are many observations of asteroid shapes that have revealed a diversity of forms such as oblate spheroids with equatorial ridges, strongly elongated shapes and contact binaries, to say nothing of multi-body systems. With consideration that rotationally induced deformation is one of the primary drivers of asteroid evolution, we have been developing two techniques for investigating the structure of asteroids, while accounting for their internal mechanical properties through plastic theory. The first technique developed is an analytical model based on limit analysis, which provides rigorous bounds on the asteroid mechanical properties for their shapes to remain stable. The second technique applies finite element model analysis that accounts for plastic deformation. Combining these models, we have explored the correlation between unique shape features and failure modes. First, we have been able to show that contact binary asteroids preferentially fail at their narrow necks at a relatively slow spin period, due to stress concentration. Second, applying these techniques to the breakup event of active asteroid P/2013 R3, we have been able to develop explicit constraints on the cohesion within rubble pile asteroids. Third, by probing the effect of inhomogeneous material properties, we have been able to develop conditions for whether an oblate body will fail internally or through surface shedding. These different failure modes can be tested by measuring the density distribution within a rubble pile body through determination of its gravity field. This talk will explore these different modes of failure and motivate divergent theories of failure that depend on properties of rubble piles.

Thermal barrier coating life prediction model

NASA Technical Reports Server (NTRS)

Hillery, R. V.; Pilsner, B. H.; Cook, T. S.; Kim, K. S.

1986-01-01

This is the second annual report of the first 3-year phase of a 2-phase, 5-year program. The objectives of the first phase are to determine the predominant modes of degradation of a plasma sprayed thermal barrier coating system and to develop and verify life prediction models accounting for these degradation modes. The primary TBC system consists of an air plasma sprayed ZrO-Y2O3 top coat, a low pressure plasma sprayed NiCrAlY bond coat, and a Rene' 80 substrate. Task I was to evaluate TBC failure mechanisms. Both bond coat oxidation and bond coat creep have been identified as contributors to TBC failure. Key property determinations have also been made for the bond coat and the top coat, including tensile strength, Poisson's ratio, dynamic modulus, and coefficient of thermal expansion. Task II is to develop TBC life prediction models for the predominant failure modes. These models will be developed based on the results of thermmechanical experiments and finite element analysis. The thermomechanical experiments have been defined and testing initiated. Finite element models have also been developed to handle TBCs and are being utilized to evaluate different TBC failure regimes.

TU-FG-201-11: Evaluating the Validity of Prospective Risk Analysis Methods: A Comparison of Traditional FMEA and Modified Healthcare FMEA

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

Lah, J; Manger, R; Kim, G

Purpose: To examine the ability of traditional Failure mode and effects analysis (FMEA) and a light version of Healthcare FMEA (HFMEA), called Scenario analysis of FMEA (SAFER) by comparing their outputs in terms of the risks identified and their severity rankings. Methods: We applied two prospective methods of the quality management to surface image guided, linac-based radiosurgery (SIG-RS). For the traditional FMEA, decisions on how to improve an operation are based on risk priority number (RPN). RPN is a product of three indices: occurrence, severity and detectability. The SAFER approach; utilized two indices-frequency and severity-which were defined by a multidisciplinarymore » team. A criticality matrix was divided into 4 categories; very low, low, high and very high. For high risk events, an additional evaluation was performed. Based upon the criticality of the process, it was decided if additional safety measures were needed and what they comprise. Results: Two methods were independently compared to determine if the results and rated risks were matching or not. Our results showed an agreement of 67% between FMEA and SAFER approaches for the 15 riskiest SIG-specific failure modes. The main differences between the two approaches were the distribution of the values and the failure modes (No.52, 54, 154) that have high SAFER scores do not necessarily have high FMEA RPN scores. In our results, there were additional risks identified by both methods with little correspondence. In the SAFER, when the risk score is determined, the basis of the established decision tree or the failure mode should be more investigated. Conclusion: The FMEA method takes into account the probability that an error passes without being detected. SAFER is inductive because it requires the identification of the consequences from causes, and semi-quantitative since it allow the prioritization of risks and mitigation measures, and thus is perfectly applicable to clinical parts of radiotherapy.« less

Failure mode and effects analysis of skin electronic brachytherapy using Esteya® unit

PubMed Central

Bautista-Ballesteros, Juan Antonio; Bonaque, Jorge; Celada, Francisco; Lliso, Françoise; Carmona, Vicente; Gimeno-Olmos, Jose; Ouhib, Zoubir; Rosello, Joan; Perez-Calatayud, Jose

2016-01-01

Purpose Esteya® (Nucletron, an Elekta company, Elekta AB, Stockholm, Sweden) is an electronic brachytherapy device used for skin cancer lesion treatment. In order to establish an adequate level of quality of treatment, a risk analysis of the Esteya treatment process has been done, following the methodology proposed by the TG-100 guidelines of the American Association of Physicists in Medicine (AAPM). Material and methods A multidisciplinary team familiar with the treatment process was formed. This team developed a process map (PM) outlining the stages, through which a patient passed when subjected to the Esteya treatment. They identified potential failure modes (FM) and each individual FM was assessed for the severity (S), frequency of occurrence (O), and lack of detection (D). A list of existing quality management tools was developed and the FMs were consensually reevaluated. Finally, the FMs were ranked according to their risk priority number (RPN) and their S. Results 146 FMs were identified, 106 of which had RPN ≥ 50 and 30 had S ≥ 7. After introducing the quality management tools, only 21 FMs had RPN ≥ 50. The importance of ensuring contact between the applicator and the surface of the patient’s skin was emphasized, so the setup was reviewed by a second individual before each treatment session with periodic quality control to ensure stability of the applicator pressure. Some of the essential quality management tools are already being implemented in the installation are the simple templates for reproducible positioning of skin applicators, that help marking the treatment area and positioning of X-ray tube. Conclusions New quality management tools have been established as a result of the application of the failure modes and effects analysis (FMEA) treatment. However, periodic update of the FMEA process is necessary, since clinical experience has suggested occurring of further new possible potential failure modes. PMID:28115958

Optimisation of shock absorber process parameters using failure mode and effect analysis and genetic algorithm

NASA Astrophysics Data System (ADS)

Mariajayaprakash, Arokiasamy; Senthilvelan, Thiyagarajan; Vivekananthan, Krishnapillai Ponnambal

2013-07-01

The various process parameters affecting the quality characteristics of the shock absorber during the process were identified using the Ishikawa diagram and by failure mode and effect analysis. The identified process parameters are welding process parameters (squeeze, heat control, wheel speed, and air pressure), damper sealing process parameters (load, hydraulic pressure, air pressure, and fixture height), washing process parameters (total alkalinity, temperature, pH value of rinsing water, and timing), and painting process parameters (flowability, coating thickness, pointage, and temperature). In this paper, the process parameters, namely, painting and washing process parameters, are optimized by Taguchi method. Though the defects are reasonably minimized by Taguchi method, in order to achieve zero defects during the processes, genetic algorithm technique is applied on the optimized parameters obtained by Taguchi method.

Application of ISO 22000 and Failure Mode and Effect Analysis (FMEA) for industrial processing of salmon: a case study.

PubMed

Arvanitoyannis, Ioannis S; Varzakas, Theodoros H

2008-05-01

The Failure Mode and Effect Analysis (FMEA) model was applied for risk assessment of salmon manufacturing. A tentative approach of FMEA application to the salmon industry was attempted in conjunction with ISO 22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (salmon processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points were identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram and fishbone diagram). In this work, a comparison of ISO 22000 analysis with HACCP is carried out over salmon processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the RPN per identified processing hazard. Fish receiving, casing/marking, blood removal, evisceration, filet-making cooling/freezing, and distribution were the processes identified as the ones with the highest RPN (252, 240, 210, 210, 210, 210, 200 respectively) and corrective actions were undertaken. After the application of corrective actions, a second calculation of RPN values was carried out resulting in substantially lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO 22000 system of a salmon processing industry is anticipated to prove advantageous to industrialists, state food inspectors, and consumers.

Independent Orbiter Assessment (IOA): Analysis of the electrical power generation/power reactant storage and distribution subsystem

NASA Technical Reports Server (NTRS)

Gotch, S. M.

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 NAA FMEA/CIL documentation. The independent analysis results corresponding to the Orbiter Electrical Power Generation (EPG)/Power Reactants Storage and Distribution (PRSD) System Hardware is documented. The EPG/PRSD hardware is required for performing critical functions of cryogenic hydrogen and oxygen storage and distribution to the Fuel Cell Powerplants (FCP) and Atmospheric Revitalization Pressure Control Subsystem (ARPCS). Specifically, the EPG/PRSD hardware consists of the following: Hydryogen (H2) tanks; Oxygen (O2) tanks; H2 Relief Valve/Filter Packages (HRVFP); O2 Relief Valve/Filter Packages (ORVFP); H2 Valve Modules (HVM); O2 Valve Modules (OVM); and O2 and H2 lines, components, and fittings.

MO-G-BRE-05: Clinical Process Improvement and Billing in Radiation Oncology: A Case Study of Applying FMEA for CPT Code 77336 (continuing Medical Physics Consultation)

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

Spirydovich, S; Huq, M

2014-06-15

Purpose: The improvement of quality in healthcare can be assessed by Failure Mode and Effects Analysis (FMEA). In radiation oncology, FMEA, as applied to the billing CPT code 77336, can improve both charge capture and, most importantly, quality of the performed services. Methods: We created an FMEA table for the process performed under CPT code 77336. For a given process step, each member of the assembled team (physicist, dosimetrist, and therapist) independently assigned numerical values for: probability of occurrence (O, 1–10), severity (S, 1–10), and probability of detection (D, 1–10) for every failure mode cause and effect combination. The riskmore » priority number, RPN, was then calculated as a product of O, S and D from which an average RPN was calculated for each combination mentioned above. A fault tree diagram, with each process sorted into 6 categories, was created with linked RPN. For processes with high RPN recommended actions were assigned. 2 separate R and V systems (Lantis and EMR-based ARIA) were considered. Results: We identified 9 potential failure modes and corresponding 19 potential causes of these failure modes all resulting in unjustified 77336 charge and compromised quality of care. In Lantis, the range of RPN was 24.5–110.8, and of S values – 2–10. The highest ranking RPN of 110.8 came from the failure mode described as “end-of-treatment check not done before the completion of treatment”, and the highest S value of 10 (RPN=105) from “overrides not checked”. For the same failure modes, within ARIA electronic environment with its additional controls, RPN values were significantly lower (44.3 for end-of-treatment missing check and 20.0 for overrides not checked). Conclusion: Our work has shown that when charge capture was missed that also resulted in some services not being performed. Absence of such necessary services may result in sub-optimal quality of care rendered to patients.« less

Reliability analysis based on the losses from failures.

PubMed

Todinov, M T

2006-04-01

The conventional reliability analysis is based on the premise that increasing the reliability of a system will decrease the losses from failures. On the basis of counterexamples, it is demonstrated that this is valid only if all failures are associated with the same losses. In case of failures associated with different losses, a system with larger reliability is not necessarily characterized by smaller losses from failures. Consequently, a theoretical framework and models are proposed for a reliability analysis, linking reliability and the losses from failures. Equations related to the distributions of the potential losses from failure have been derived. It is argued that the classical risk equation only estimates the average value of the potential losses from failure and does not provide insight into the variability associated with the potential losses. Equations have also been derived for determining the potential and the expected losses from failures for nonrepairable and repairable systems with components arranged in series, with arbitrary life distributions. The equations are also valid for systems/components with multiple mutually exclusive failure modes. The expected losses given failure is a linear combination of the expected losses from failure associated with the separate failure modes scaled by the conditional probabilities with which the failure modes initiate failure. On this basis, an efficient method for simplifying complex reliability block diagrams has been developed. Branches of components arranged in series whose failures are mutually exclusive can be reduced to single components with equivalent hazard rate, downtime, and expected costs associated with intervention and repair. A model for estimating the expected losses from early-life failures has also been developed. For a specified time interval, the expected losses from early-life failures are a sum of the products of the expected number of failures in the specified time intervals covering the early-life failures region and the expected losses given failure characterizing the corresponding time intervals. For complex systems whose components are not logically arranged in series, discrete simulation algorithms and software have been created for determining the losses from failures in terms of expected lost production time, cost of intervention, and cost of replacement. Different system topologies are assessed to determine the effect of modifications of the system topology on the expected losses from failures. It is argued that the reliability allocation in a production system should be done to maximize the profit/value associated with the system. Consequently, a method for setting reliability requirements and reliability allocation maximizing the profit by minimizing the total cost has been developed. Reliability allocation that maximizes the profit in case of a system consisting of blocks arranged in series is achieved by determining for each block individually the reliabilities of the components in the block that minimize the sum of the capital, operation costs, and the expected losses from failures. A Monte Carlo simulation based net present value (NPV) cash-flow model has also been proposed, which has significant advantages to cash-flow models based on the expected value of the losses from failures per time interval. Unlike these models, the proposed model has the capability to reveal the variation of the NPV due to different number of failures occurring during a specified time interval (e.g., during one year). The model also permits tracking the impact of the distribution pattern of failure occurrences and the time dependence of the losses from failures.

Independent Orbiter Assessment (IOA): Assessment of the life support and airlock support systems, volume 2

NASA Technical Reports Server (NTRS)

Barickman, K.

1988-01-01

The McDonnell Douglas Astronautics Company (MDAC) was selected in June 1986 to perform an Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL). The IOA effort first completed an analysis of the Life Support and Airlock Support Systems (LSS and ALSS) 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. The discrepancies were flagged for potential future resolution. This report documents the results of that comparison for the Orbiter LSS and ALSS hardware. Volume 2 continues the presentation of IOA worksheets and contains the critical items list and NASA FMEA to IOA worksheet cross reference and recommendations.

Comprehensive protocol of traceability during IVF: the result of a multicentre failure mode and effect analysis.

PubMed

Rienzi, L; Bariani, F; Dalla Zorza, M; Albani, E; Benini, F; Chamayou, S; Minasi, M G; Parmegiani, L; Restelli, L; Vizziello, G; Costa, A Nanni

2017-08-01

Can traceability of gametes and embryos be ensured during IVF? The use of a simple and comprehensive traceability system that includes the most susceptible phases during the IVF process minimizes the risk of mismatches. Mismatches in IVF are very rare but unfortunately possible with dramatic consequences for both patients and health care professionals. Traceability is thus a fundamental aspect of the treatment. A clear process of patient and cell identification involving witnessing protocols has to be in place in every unit. To identify potential failures in the traceability process and to develop strategies to mitigate the risk of mismatches, previously failure mode and effects analysis (FMEA) has been used effectively. The FMEA approach is however a subjective analysis, strictly related to specific protocols and thus the results are not always widely applicable. To reduce subjectivity and to obtain a widespread comprehensive protocol of traceability, a multicentre centrally coordinated FMEA was performed. Seven representative Italian centres (three public and four private) were selected. The study had a duration of 21 months (from April 2015 to December 2016) and was centrally coordinated by a team of experts: a risk analysis specialist, an expert embryologist and a specialist in human factor. Principal investigators of each centre were first instructed about proactive risk assessment and FMEA methodology. A multidisciplinary team to perform the FMEA analysis was then formed in each centre. After mapping the traceability process, each team identified the possible causes of mistakes in their protocol. A risk priority number (RPN) for each identified potential failure mode was calculated. The results of the FMEA analyses were centrally investigated and consistent corrective measures suggested. The teams performed new FMEA analyses after the recommended implementations. In each centre, this study involved: the laboratory director, the Quality Control & Quality Assurance responsible, Embryologist(s), Gynaecologist(s), Nurse(s) and Administration. The FMEA analyses were performed according to the Joint Commission International. The FMEA teams identified seven main process phases: oocyte collection, sperm collection, gamete processing, insemination, embryo culture, embryo transfer and gamete/embryo cryopreservation. A mean of 19.3 (SD ± 5.8) associated process steps and 41.9 (SD ± 12.4) possible failure modes were recognized per centre. A RPN ≥15 was calculated in a mean of 6.4 steps (range 2-12, SD ± 3.60). A total of 293 failure modes were centrally analysed 45 of which were considered at medium/high risk. After consistent corrective measures implementation and re-evaluation, a significant reduction in the RPNs in all centres (RPN <15 for all steps) was observed. A simple and comprehensive traceability system was designed as the result of the seven FMEA analyses. The validity of FMEA is in general questionable due to the subjectivity of the judgments. The design of this study has however minimized this risk by introducing external experts for the analysis of the FMEA results. Specific situations such as sperm/oocyte donation, import/export and pre-implantation genetic testing were not taken into consideration. Finally, this study is only limited to the analysis of failure modes that may lead to mismatches, other possible procedural mistakes are not accounted for. Every single IVF centre should have a clear and reliable protocol for identification of patients and traceability of cells during manipulation. The results of this study can support IVF groups in better recognizing critical steps in their protocols, understanding identification and witnessing process, and in turn enhancing safety by introducing validated corrective measures. This study was designed by the Italian Society of Embryology Reproduction and Research (SIERR) and funded by the Italian National Transplant Centre (CNT) of the Italian National Institute of Health (ISS). The authors have no conflicts of interest. N/A. © The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com

Compendium of Mechanical Limit-States

NASA Technical Reports Server (NTRS)

Kowal, Michael

1996-01-01

A compendium was compiled and is described to provide a diverse set of limit-state relationships for use in demonstrating the application of probabilistic reliability methods to mechanical systems. The different limit-state relationships can be used to analyze the reliability of a candidate mechanical system. In determining the limit-states to be included in the compendium, a comprehensive listing of the possible failure modes that could affect mechanical systems reliability was generated. Previous literature defining mechanical modes of failure was studied, and cited failure modes were included. From this, classifications for failure modes were derived and are described in some detail.

Fabric controls on the brittle failure of folded gneiss and schist

NASA Astrophysics Data System (ADS)

Agliardi, Federico; Zanchetta, Stefano; Crosta, Giovanni B.

2014-12-01

We experimentally studied the brittle failure behaviour of folded gneiss and schist. Rock fabric and petrography were characterised by meso-structural analyses, optical microscopy, X-ray diffraction, and SEM imaging. Uniaxial compression, triaxial compression and indirect tension laboratory tests were performed to characterise their strength and stress-strain behaviour. Fracture patterns generated in compression were resolved in 3D through X-ray computed tomography at different resolutions (30 to 625 μm). Uniaxial compression tests revealed relatively low and scattered values of unconfined compressive strength (UCS) and Young's modulus, with no obvious relationships with the orientation of foliation. Samples systematically failed in four brittle modes, involving different combinations of shear fractures along foliation or parallel to fold axial planes, or the development of cm-scale shear zones. Fracture quantification and microstructural analysis show that different failure modes occur depending on the mutual geometrical arrangement and degree of involvement of two distinct physical anisotropies, i.e. the foliation and the fold axial planes. The Axial Plane Anisotropy (APA) is related to micro-scale grain size reduction and shape preferred orientation within quartz-rich domains, and to mechanical rotation or initial crenulation cleavage within phyllosilicate-rich domains at fold hinge zones. In quartz-rich rocks (gneiss), fracture propagation through quartz aggregates forming the APA corresponds to higher fracture energy and strength than found for fracture through phyllosilicate-rich domains. This results in a strong dependence of strength on the failure mode. Conversely, in phyllosilicate-rich rocks (schist), all the failure modes are dominated by the strength of phyllosilicates, resulting in a sharp reduction of strength anisotropy.

Characterization of the Edge Crack Torsion (ECT) Test for Mode III Fracture Toughness Measurement of Laminated Composites

NASA Technical Reports Server (NTRS)

Ratcliffe, James G.

2004-01-01

The edge crack torsion (ECT) test is designed to initiate mode III delamination growth in composite laminates. An ECT specimen is a rectangular laminate, containing an edge delamination at the laminate mid-plane. Torsion load is applied to the specimens, resulting in relative transverse shear sliding of the delaminated faces. The test data reduction schemes are intended to yield initiation values of critical mode III strain energy release rate, G(sub IIIc), that are constant with delamination length. The test has undergone several design changes during its development. The objective of this paper was to determine the suitability of the current ECT test design as a mode III fracture test. To this end, ECT tests were conducted on specimens manufactured from IM7/8552 and specimens made from S2/8552 tape laminates. Several specimens, each with different delamination lengths are tested. Detailed, three-dimensional finite element analyses of the specimens were performed. The analysis results were used to calculate the distribution of mode I, mode II, and mode III strain energy release rate along the delamination front. The results indicated that mode III-dominated delamination growth would be initiated from the specimen center. However, in specimens of both material types, the measured values of G(sub IIIc) exhibited significant dependence on delamination length. Furthermore, there was a large amount of scatter in the data. Load-displacement response of the specimens exhibited significant deviation from linearity before specimen failure. X-radiographs of a sample of specimens revealed that damage was initiated in the specimens prior to failure. Further inspection of the failure surfaces is required to identify the damage and determine that mode III delamination is initiated in the specimens.

[THE FAILURE MODES AND EFFECTS ANALYSIS FACILITATES A SAFE, TIME AND MONEY SAVING OPEN ACCESS COLONOSCOPY SERVICE].

PubMed

Gingold-Belfer, Rachel; Niv, Yaron; Horev, Nehama; Gross, Shuli; Sahar, Nadav; Dickman, Ram

2017-04-01

Failure modes and effects analysis (FMEA) is used for the identification of potential risks in health care processes. We used a specific FMEA - based form for direct referral for colonoscopy and assessed it for procedurerelated perforations. Ten experts in endoscopy evaluated and computed the entire referral process, modes of preparation for the endoscopic procedure, the endoscopic procedure itself and the discharge process. We used FMEA assessing for likelihood of occurrence, detection and severity and calculated the risk profile number (RPN) for each of the above points. According to the highest RPN results we designed a specific open access referral form and then compared the occurrence of colonic perforations (between 2010 and 2013) in patients who were referred through the open access arm (Group 1) to those who had a prior clinical consultation (non-open access, Group 2). Our experts in endoscopy (5 physicians and 5 nurses) identified 3 categories of failure modes that, on average, reached the highest RPNs. We identified 9,558 colonoscopies in group 1, and 12,567 in group 2. Perforations were identified in three patients from the open access group (1:3186, 0.03%) and in 10 from group 2 (1:1256, 0.07%) (p = 0.024). Direct referral for colonoscopy saved 9,558 pre-procedure consultations and the sum of $850,000. The FMEA tool-based specific referral form facilitates a safe, time and money saving open access colonoscopy service. Our form may be adopted by other gastroenterological clinics in Israel.

Nonlinear temperature dependent failure analysis of finite width composite laminates

NASA Technical Reports Server (NTRS)

Nagarkar, A. P.; Herakovich, C. T.

1979-01-01

A quasi-three dimensional, nonlinear elastic finite element stress analysis of finite width composite laminates including curing stresses is presented. Cross-ply, angle-ply, and two quasi-isotropic graphite/epoxy laminates are studied. Curing stresses are calculated using temperature dependent elastic properties that are input as percent retention curves, and stresses due to mechanical loading in the form of an axial strain are calculated using tangent modulii obtained by Ramberg-Osgood parameters. It is shown that curing stresses and stresses due to tensile loading are significant as edge effects in all types of laminate studies. The tensor polynomial failure criterion is used to predict the initiation of failure. The mode of failure is predicted by examining individual stress contributions to the tensor polynomial.

Composite Interlaminar Shear Fracture Toughness, G(sub 2c): Shear Measurement of Sheer Myth?

NASA Technical Reports Server (NTRS)

OBrien, T. Kevin

1997-01-01

The concept of G2c as a measure of the interlaminar shear fracture toughness of a composite material is critically examined. In particular, it is argued that the apparent G2c as typically measured is inconsistent with the original definition of shear fracture. It is shown that interlaminar shear failure actually consists of tension failures in the resin rich layers between plies followed by the coalescence of ligaments created by these failures and not the sliding of two planes relative to one another that is assumed in fracture mechanics theory. Several strain energy release rate solutions are reviewed for delamination in composite laminates and structural components where failures have been experimentally documented. Failures typically occur at a location where the mode 1 component accounts for at least one half of the total G at failure. Hence, it is the mode I and mixed-mode interlaminar fracture toughness data that will be most useful in predicting delamination failure in composite components in service. Although apparent G2c measurements may prove useful for completeness of generating mixed-mode criteria, the accuracy of these measurements may have very little influence on the prediction of mixed-mode failures in most structural components.

Analysis for the Progressive Failure Response of Textile Composite Fuselage Frames

NASA Technical Reports Server (NTRS)

Johnson, Eric R.; Boitnott, Richard L. (Technical Monitor)

2002-01-01

A part of aviation accident mitigation is a crash worthy airframe structure, and an important measure of merit for a crash worthy structure is the amount of kinetic energy that can be absorbed in the crush of the structure. Prediction of the energy absorbed from finite element analyses requires modeling the progressive failure sequence. Progressive failure modes may include material degradation, fracture and crack growth, and buckling and collapse. The design of crash worthy airframe components will benefit from progressive failure analyses that have been validated by tests. The subject of this research is the development of a progressive failure analysis for textile composite. circumferential fuselage frames subjected to a quasi-static, crash-type load. The test data for these frames are reported, and these data, along with stub column test data, are to be used to develop and to validate methods for the progressive failure response.

A multiscale structural investigation of the annulus-endplate anchorage system and its mechanisms of failure.

PubMed

Rodrigues, Samantha A; Thambyah, Ashvin; Broom, Neil D

2015-03-01

The annulus-endplate anchorage system performs a critical role in the disc, creating a strong structural link between the compliant annulus and the rigid vertebrae. Endplate failure is thought to be associated with disc herniation, a recent study indicating that this failure mode occurs more frequently than annular rupture. The aim was to investigate the structural principles governing annulus-endplate anchorage and the basis of its strength and mechanisms of failure. Loading experiments were performed on ovine lumbar motion segments designed to induce annulus-endplate failure, followed by macro- to micro- to fibril-level structural analyses. The study was funded by a doctoral scholarship from our institution. Samples were loaded to failure in three modes: torsion using intact motion segments, in-plane tension of the anterior annulus-endplate along one of the oblique fiber angles, and axial tension of the anterior annulus-endplate. The anterior region was chosen for its ease of access. Decalcification was used to investigate the mechanical influence of the mineralized component. Structural analysis was conducted on both the intact and failed samples using differential interference contrast optical microscopy and scanning electron microscopy. Two main modes of anchorage failure were observed--failure at the tidemark or at the cement line. Samples subjected to axial tension contained more tidemark failures compared with those subjected to torsion and in-plane tension. Samples decalcified before testing frequently contained damage at the cement line, this being more extensive than in fresh samples. Analysis of the intact samples at their anchorage sites revealed that annular subbundle fibrils penetrate beyond the cement line to a limited depth and appear to merge with those in the vertebral and cartilaginous endplates. Annulus-endplate anchorage is more vulnerable to failure in axial tension compared with both torsion and in-plane tension and is probably due to acute fiber bending at the soft-hard interface of the tidemark. This finding is consistent with evidence showing that flexion, which induces a similar pattern of axial tension, increases the risk of herniation involving endplate failure. The study also highlights the important strengthening role of calcification at this junction and provides new evidence of a fibril-based form of structural integration across the cement line. Copyright © 2015 Elsevier Inc. All rights reserved.

Fault Tree Analysis as a Planning and Management Tool: A Case Study

ERIC Educational Resources Information Center

Witkin, Belle Ruth

1977-01-01

Fault Tree Analysis is an operations research technique used to analyse the most probable modes of failure in a system, in order to redesign or monitor the system more closely in order to increase its likelihood of success. (Author)

Fatigue crack growth in an aluminum alloy-fractographic study

NASA Astrophysics Data System (ADS)

Salam, I.; Muhammad, W.; Ejaz, N.

2016-08-01

A two-fold approach was adopted to understand the fatigue crack growth process in an Aluminum alloy; fatigue crack growth test of samples and analysis of fractured surfaces. Fatigue crack growth tests were conducted on middle tension M(T) samples prepared from an Aluminum alloy cylinder. The tests were conducted under constant amplitude loading at R ratio 0.1. The stress applied was from 20,30 and 40 per cent of the yield stress of the material. The fatigue crack growth data was recorded. After fatigue testing, the samples were subjected to detailed scanning electron microscopic (SEM) analysis. The resulting fracture surfaces were subjected to qualitative and quantitative fractographic examinations. Quantitative fracture analysis included an estimation of crack growth rate (CGR) in different regions. The effect of the microstructural features on fatigue crack growth was examined. It was observed that in stage II (crack growth region), the failure mode changes from intergranular to transgranular as the stress level increases. In the region of intergranular failure the localized brittle failure was observed and fatigue striations are difficult to reveal. However, in the region of transgranular failure the crack path is independent of the microstructural features. In this region, localized ductile failure mode was observed and well defined fatigue striations were present in the wake of fatigue crack. The effect of interaction of growing fatigue crack with microstructural features was not substantial. The final fracture (stage III) was ductile in all the cases.

75 FR 51931 - Airworthiness Directives; Dassault-Aviation Model FALCON 7X Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-24

... root cause: A leakage failure mode of Transient Voltage Suppressor (TVS) diodes used on Power... condition is a leakage failure mode of TVS diodes used on PDCU cards or GCU cards in the PPDB, which in... discovery of a common root cause: A leakage failure mode of Transient Voltage Suppressor (TVS) diodes used...

Combining System Safety and Reliability to Ensure NASA CoNNeCT's Success

NASA Technical Reports Server (NTRS)

Havenhill, Maria; Fernandez, Rene; Zampino, Edward

2012-01-01

Hazard Analysis, Failure Modes and Effects Analysis (FMEA), the Limited-Life Items List (LLIL), and the Single Point Failure (SPF) List were applied by System Safety and Reliability engineers on NASA's Communications, Navigation, and Networking reConfigurable Testbed (CoNNeCT) Project. The integrated approach involving cross reviews of these reports by System Safety, Reliability, and Design engineers resulted in the mitigation of all identified hazards. The outcome was that the system met all the safety requirements it was required to meet.

Unified continuum damage model for matrix cracking in composite rotor blades

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

Pollayi, Hemaraju; Harursampath, Dineshkumar

This paper deals with modeling of the first damage mode, matrix micro-cracking, in helicopter rotor/wind turbine blades and how this effects the overall cross-sectional stiffness. The helicopter/wind turbine rotor system operates in a highly dynamic and unsteady environment leading to severe vibratory loads present in the system. Repeated exposure to this loading condition can induce damage in the composite rotor blades. These rotor/turbine blades are generally made of fiber-reinforced laminated composites and exhibit various competing modes of damage such as matrix micro-cracking, delamination, and fiber breakage. There is a need to study the behavior of the composite rotor system undermore » various key damage modes in composite materials for developing Structural Health Monitoring (SHM) system. Each blade is modeled as a beam based on geometrically non-linear 3-D elasticity theory. Each blade thus splits into 2-D analyzes of cross-sections and non-linear 1-D analyzes along the beam reference curves. Two different tools are used here for complete 3-D analysis: VABS for 2-D cross-sectional analysis and GEBT for 1-D beam analysis. The physically-based failure models for matrix in compression and tension loading are used in the present work. Matrix cracking is detected using two failure criterion: Matrix Failure in Compression and Matrix Failure in Tension which are based on the recovered field. A strain variable is set which drives the damage variable for matrix cracking and this damage variable is used to estimate the reduced cross-sectional stiffness. The matrix micro-cracking is performed in two different approaches: (i) Element-wise, and (ii) Node-wise. The procedure presented in this paper is implemented in VABS as matrix micro-cracking modeling module. Three examples are presented to investigate the matrix failure model which illustrate the effect of matrix cracking on cross-sectional stiffness by varying the applied cyclic load.« less

Acousto-Ultrasonic analysis of failure in ceramic matrix composite tensile specimens

NASA Technical Reports Server (NTRS)

Kautz, Harold E.; Chulya, Abhisak

1993-01-01

Three types of acousto-ultrasonic (AU) measurements, stress-wave factor (SWF), lowest antisymmetric plate mode group velocity (VS), and lowest symmetric plate mode group velocity (VL), were performed on specimens before and after tensile failure. Three different Nicalon fiber architectures with ceramic matrices were tested. These composites were categorized as 1D (unidirectional fiber orientation) SiC/CAS glass ceramic, and 2D and 3D woven SiC/SiC ceramic matrix materials. SWF was found to be degraded after tensile failure in all three material categories. VS was found to be degraded only in the 1D SiC/CAS. VL was difficult to determine on the irregular specimen surfaces but appeared unchanged on all failed specimens. 3D woven specimens with heat-treatment at high temperature exhibited degradation only in SWF.

Fatigue behavior of a cross-ply metal matrix composite at elevated temperature under strain controlled mode. Master`s thesis

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

Dennis, L.B.

1994-12-01

This research extends the existing knowledge of cross-ply metal matrix composites (MMC) to include fatigue behavior under strain-controlled fully reversed loading. This study investigated fatigue life, failure modes and damage mechanisms of the SCS-6/Ti-15-3, (O/9O)2s, MMC. The laminate was subjected to fully reversed fatigue at elevated temperature (427 deg C) at various strain levels. Stress, strain and modulus data were analyzed to characterize the macro-mechanical behavior of the composite. Microscopy and fractography were accomplished to identify and characterize the damage mechanisms at the microscopic level. Failure modes varied according to the maximum applied strain level showing either mixed mode (i.e.more » combination of both fiber and matrix dominated modes) or matrix dominated fatigue failures. As expected, higher strain loadings resulted in more ductility of the matrix at failure, evidenced by fracture surface features. For testing of the same composite laminate, the fatigue life under strain controlled mode slightly increased, compared to its load-controlled mode counterpart, using the effective strain range comparison basis. However, the respective fatigue life curves converged in the high cycle region, suggesting that the matrix dominated failure mode produces equivalent predicted fatigue lives for both control modes.« less

Probabilistic framework for product design optimization and risk management

NASA Astrophysics Data System (ADS)

Keski-Rahkonen, J. K.

2018-05-01

Probabilistic methods have gradually gained ground within engineering practices but currently it is still the industry standard to use deterministic safety margin approaches to dimensioning components and qualitative methods to manage product risks. These methods are suitable for baseline design work but quantitative risk management and product reliability optimization require more advanced predictive approaches. Ample research has been published on how to predict failure probabilities for mechanical components and furthermore to optimize reliability through life cycle cost analysis. This paper reviews the literature for existing methods and tries to harness their best features and simplify the process to be applicable in practical engineering work. Recommended process applies Monte Carlo method on top of load-resistance models to estimate failure probabilities. Furthermore, it adds on existing literature by introducing a practical framework to use probabilistic models in quantitative risk management and product life cycle costs optimization. The main focus is on mechanical failure modes due to the well-developed methods used to predict these types of failures. However, the same framework can be applied on any type of failure mode as long as predictive models can be developed.

Biomarkers of Myocardial Stress and Fibrosis as Predictors of Mode of Death in Patients with Chronic Heart Failure

PubMed Central

Ahmad, Tariq; Fiuzat, Mona; Neely, Ben; Neely, Megan; Pencina, Michael J.; Kraus, William E.; Zannad, Faiez; Whellan, David J.; Donahue, Mark; Piña, Ileana L.; Adams, Kirkwood; Kitzman, Dalane W.; O’Connor, Christopher M.; Felker, G. Michael

2014-01-01

Objective To determine whether biomarkers of myocardial stress and fibrosis improve prediction of mode of death in patients with chronic heart failure. Background The two most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of mode of death may facilitate treatment decisions. The relationship between NT-proBNP, galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown. Methods HF-ACTION was a randomized controlled trial of exercise training vs. usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (LVEF<35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox-proportional hazards modeling, and interaction testing was used to measure differential association between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP. Results After a median follow up of 2.5 years, there were 155 deaths: 49 from pump failure 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk of both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death but this relationship was attenuated after adjustment for clinical risk factors. Clinical variables along with NT-proBNP levels were stronger predictors of pump failure (C statistic: 0.87) than sudden cardiac death (C statistic: 0.73). Addition of ST2 and galectin-3 led to improved net risk classification of 11% for sudden cardiac death, but not pump failure. Conclusions Clinical predictors along with NT-proBNP levels were strong predictors of pump failure risk, with insignificant incremental contributions of ST2 and galectin-3. Predictability of sudden cardiac death risk was less robust and enhanced by information provided by novel biomarkers. PMID:24952693

Management of reliability and maintainability; a disciplined approach to fleet readiness

NASA Technical Reports Server (NTRS)

Willoughby, W. J., Jr.

1981-01-01

Material acquisition fundamentals were reviewed and include: mission profile definition, stress analysis, derating criteria, circuit reliability, failure modes, and worst case analysis. Military system reliability was examined with emphasis on the sparing of equipment. The Navy's organizational strategy for 1980 is presented.

Test and Analysis of Sub-Components of Aluminum-Lithium Alloy Cylinders

NASA Technical Reports Server (NTRS)

Haynie, Waddy T.; Chunchu, Prasad B.; Satyanarayana, Arunkumar; Hilburger, Mark W.; Smith, Russell W.

2012-01-01

Integrally machined blade-stiffened panels subjected to an axial compressive load were tested and analyzed to observe the buckling, crippling, and postcrippling response of the panels. The panels were fabricated from aluminum-lithium alloys 2195 and 2050, and both alloys have reduced material properties in the short transverse material direction. The tests were designed to capture a failure mode characterized by the stiffener separating from the panel in the postbuckling range. This failure mode is attributed to the reduced properties in the short transverse direction. Full-field measurements of displacements and strains using three-dimensional digital image correlation systems and local measurements using strain gages were used to capture the deformation of the panel leading up to the failure of the panel for specimens fabricated from 2195. High-speed cameras were used to capture the initiation of the failure. Finite element models were developed using an isotropic strain-hardening material model. Good agreement was observed between the measured and predicted responses for both alloys.

Crack classification and evolution in anisotropic shale during cyclic loading tests by acoustic emission

NASA Astrophysics Data System (ADS)

Wang, Miaomiao; Tan, Chengxuan; Meng, Jing; Yang, Baicun; Li, Yuan

2017-08-01

Characterization and evolution of the cracking mode in shale formation is significant, as fracture networks are an important element in shale gas exploitation. In this study we determine the crack modes and evolution in anisotropic shale under cyclic loading using the acoustic emission (AE) parameter-analysis method based on the average frequency and RA (rise-time/amplitude) value. Shale specimens with bedding-plane orientations parallel and perpendicular to the axial loading direction were subjected to loading cycles with increasing peak values until failure occurred. When the loading was parallel to the bedding plane, most of the cracks at failure were shear cracks, while tensile cracks were dominant in the specimens that were loaded normal to the bedding direction. The evolution of the crack mode in the shale specimens observed in the loading-unloading sequence except for the first cycle can be divided into three stages: (I) no or several cracks (AE events) form as a result of the Kaiser effect, (II) tensile and shear cracks increase steadily at nearly equal proportions, (III) tensile cracks and shear cracks increase abruptly, with more cracks forming in one mode than in the other. As the dominant crack motion is influenced by the bedding, the failure mechanism is discussed based on the evolution of the different crack modes. Our conclusions can increase our understanding of the formation mechanism of fracture networks in the field.

Solid Propellant Grain Structural Integrity Analysis

NASA Technical Reports Server (NTRS)

1973-01-01

The structural properties of solid propellant rocket grains were studied to determine the propellant resistance to stresses. Grain geometry, thermal properties, mechanical properties, and failure modes are discussed along with design criteria and recommended practices.

16 CFR 1211.5 - General testing parameters.

Code of Federal Regulations, 2010 CFR

2010-01-01

... condition flow chart shown in figure 1 shall be used: (1) To conduct a failure-mode and effect analysis (FMEA); (2) In investigating the performance during the Environmental Stress Tests; and (3) During the...

Savannah River Site generic data base development

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

Blanton, C.H.; Eide, S.A.

This report describes the results of a project to improve the generic component failure data base for the Savannah River Site (SRS). A representative list of components and failure modes for SRS risk models was generated by reviewing existing safety analyses and component failure data bases and from suggestions from SRS safety analysts. Then sources of data or failure rate estimates were identified and reviewed for applicability. A major source of information was the Nuclear Computerized Library for Assessing Reactor Reliability, or NUCLARR. This source includes an extensive collection of failure data and failure rate estimates for commercial nuclear powermore » plants. A recent Idaho National Engineering Laboratory report on failure data from the Idaho Chemical Processing Plant was also reviewed. From these and other recent sources, failure data and failure rate estimates were collected for the components and failure modes of interest. This information was aggregated to obtain a recommended generic failure rate distribution (mean and error factor) for each component failure mode.« less

Study on the effect of the infill walls on the seismic performance of a reinforced concrete frame

NASA Astrophysics Data System (ADS)

Zhang, Cuiqiang; Zhou, Ying; Zhou, Deyuan; Lu, Xilin

2011-12-01

Motivated by the seismic damage observed to reinforced concrete (RC) frame structures during the Wenchuan earthquake, the effect of infill walls on the seismic performance of a RC frame is studied in this paper. Infill walls, especially those made of masonry, offer some amount of stiffness and strength. Therefore, the effect of infill walls should be considered during the design of RC frames. In this study, an analysis of the recorded ground motion in the Wenchuan earthquake is performed. Then, a numerical model is developed to simulate the infill walls. Finally, nonlinear dynamic analysis is carried out on a RC frame with and without infill walls, respectively, by using CANNY software. Through a comparative analysis, the following conclusions can be drawn. The failure mode of the frame with infill walls is in accordance with the seismic damage failure pattern, which is strong beam and weak column mode. This indicates that the infill walls change the failure pattern of the frame, and it is necessary to consider them in the seismic design of the RC frame. The numerical model presented in this paper can effectively simulate the effect of infill walls on the RC frame.

Interlaminar shear stress effects on the postbuckling response of graphite-epoxy panels

NASA Technical Reports Server (NTRS)

Engelstad, S. P.; Knight, N. F., Jr.; Reddy, J. N.

1990-01-01

The influence of shear flexibility on overall postbuckling response was assessed, and transverse shear stress distributions in relation to panel failure were examined. Nonlinear postbuckling results are obtained for finite element models based on classical laminated plate theory and first-order shear deformation theory. Good correlation between test and analysis is obtained. The results presented analytically substantiate the experimentally observed failure mode.

Reliability Estimation of Aero-engine Based on Mixed Weibull Distribution Model

NASA Astrophysics Data System (ADS)

Yuan, Zhongda; Deng, Junxiang; Wang, Dawei

2018-02-01

Aero-engine is a complex mechanical electronic system, based on analysis of reliability of mechanical electronic system, Weibull distribution model has an irreplaceable role. Till now, only two-parameter Weibull distribution model and three-parameter Weibull distribution are widely used. Due to diversity of engine failure modes, there is a big error with single Weibull distribution model. By contrast, a variety of engine failure modes can be taken into account with mixed Weibull distribution model, so it is a good statistical analysis model. Except the concept of dynamic weight coefficient, in order to make reliability estimation result more accurately, three-parameter correlation coefficient optimization method is applied to enhance Weibull distribution model, thus precision of mixed distribution reliability model is improved greatly. All of these are advantageous to popularize Weibull distribution model in engineering applications.

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.

User's guide to the Reliability Estimation System Testbed (REST)

NASA Technical Reports Server (NTRS)

Nicol, David M.; Palumbo, Daniel L.; Rifkin, Adam

1992-01-01

The Reliability Estimation System Testbed is an X-window based reliability modeling tool that was created to explore the use of the Reliability Modeling Language (RML). RML was defined to support several reliability analysis techniques including modularization, graphical representation, Failure Mode Effects Simulation (FMES), and parallel processing. These techniques are most useful in modeling large systems. Using modularization, an analyst can create reliability models for individual system components. The modules can be tested separately and then combined to compute the total system reliability. Because a one-to-one relationship can be established between system components and the reliability modules, a graphical user interface may be used to describe the system model. RML was designed to permit message passing between modules. This feature enables reliability modeling based on a run time simulation of the system wide effects of a component's failure modes. The use of failure modes effects simulation enhances the analyst's ability to correctly express system behavior when using the modularization approach to reliability modeling. To alleviate the computation bottleneck often found in large reliability models, REST was designed to take advantage of parallel processing on hypercube processors.

Quality Issues in Propulsion

NASA Technical Reports Server (NTRS)

McCarty, John P.; Lyles, Garry M.

1997-01-01

Propulsion system quality is defined in this paper as having high reliability, that is, quality is a high probability of within-tolerance performance or operation. Since failures are out-of-tolerance performance, the probability of failures and their occurrence is the difference between high and low quality systems. Failures can be described at 3 levels: the system failure (which is the detectable end of a failure), the failure mode (which is the failure process), and the failure cause (which is the start). Failure causes can be evaluated & classified by type. The results of typing flight history failures shows that most failures are in unrecognized modes and result from human error or noise, i.e. failures are when engineers learn how things really work. Although the study based on US launch vehicles, a sampling of failures from other countries indicates the finding has broad application. The parameters of the design of a propulsion system are not single valued, but have dispersions associated with the manufacturing of parts. Many tests are needed to find failures, if the dispersions are large relative to tolerances, which could contribute to the large number of failures in unrecognized modes.

A multidimensional anisotropic strength criterion based on Kelvin modes

NASA Astrophysics Data System (ADS)

Arramon, Yves Pierre

A new theory for the prediction of multiaxial strength of anisotropic elastic materials was proposed by Biegler and Mehrabadi (1993). This theory is based on the premise that the total elastic strain energy of an anisotropic material subjected to multiaxial stress can be decomposed into dilatational and deviatoric modes. A multidimensional strength criterion may thus be formulated by postulating that the failure would occur when the energy stored in one of these modes has reached a critical value. However, the logic employed by these authors to formulate a failure criterion based on this theory could not be extended to multiaxial stress. In this thesis, an alternate criterion is presented which redresses the biaxial restriction by reformulating the surfaces of constant modal energy as surfaces of constant eigenstress magnitude. The resulting failure envelope, in a multidimensional stress space, is piecewise smooth. Each facet of the envelope is expected to represent the locus of failure data by a particular Kelvin mode. It is further shown that the Kelvin mode theory alone provides an incomplete description of the failure of some materials, but that this weakness can be addressed by the introduction of a set of complementary modes. A revised theory which combines both Kelvin and complementary modes is thus proposed and applied seven example materials: an isotropic concrete, tetragonal paperboard, two orthotropic softwoods, two orthotropic hardwoods and an orthotropic cortical bone. The resulting failure envelopes for these examples were plotted and, with the exception of concrete, shown to produce intuitively correct failure predictions.

Evaluating the Effect of Minimizing Screws on Stabilization of Symphysis Mandibular Fracture by 3D Finite Element Analysis.

PubMed

Kharmanda, Ghias; Kharma, Mohamed-Yaser

2017-06-01

The objective of this work is to integrate structural optimization and reliability concepts into mini-plate fixation strategy used in symphysis mandibular fractures. The structural reliability levels are next estimated when considering a single failure mode and multiple failure modes. A 3-dimensional finite element model is developed in order to evaluate the ability of reducing the negative effect due to the stabilization of the fracture. Topology optimization process is considered in the conceptual design stage to predict possible fixation layouts. In the detailed design stage, suitable mini-plates are selected taking into account the resulting topology and different anatomical considerations. Several muscle forces are considered in order to obtain realistic predictions. Since some muscles can be cut or harmed during the surgery and cannot operate at its maximum capacity, there is a strong motivation to introduce the loading uncertainties in order to obtain reliable designs. The structural reliability is carried out for a single failure mode and multiple failure modes. The different results are validated with a clinical case of a male patient with symphysis fracture. In this case while use of the upper plate fixation with four holes, only two screws were applied to protect adjacent vital structure. This behavior does not affect the stability of the fracture. The proposed strategy to optimize bone plates leads to fewer complications and second surgeries, less patient discomfort, and shorter time of healing.

Failure Mode Analysis of V-Shaped Pyrotechnically Actuated Valves

NASA Technical Reports Server (NTRS)

Sachdev, Jai S.; Hosangadi, A.; Chenoweth, James D.; Saulsberry, Regor L.; McDougle, Stephen H.

2012-01-01

Current V-shaped stainless steel pyrovalve initiators have rectified many of the deficiencies of the heritage Y-shaped aluminum design. However, a credible failure mode still exists for dual simultaneous initiator (NSI) firings in which low temperatures were detected at the booster cap and less consistent ignition was observed than when a single initiator was fired. In order to asses this issue, a numerical framework has been developed for predicting the flow through pyrotechnically actuated valves. This framework includes a fully coupled solution of the gas-phase equation with a non-equilibrium dispersed phase for solid particles as well as the capability to model conjugate gradient heat transfer to the booster cap. Through a hierarchy of increasingly complex simulations, a hypothesis for the failure mode of the nearly simultaneous dual NSI firings has been proven. The simulations indicate that the failure mode for simultaneous dual NSI firings may be caused by flow interactions between the flame channels. The shock waves from each initiator interact in the booster cavity resulting in a high pressure that prevents the gas and particulate velocity from rising in the booster cap region. This impedes the bulk of the particulate phase from impacting the booster cap and reduces the heat transfer to the booster cap since the particles do not impact it. Heat transfer calculations to the solid metal indicate that gas-phase convective heat transfer may not be adequate by itself and that energy transfer from the particulate phase may be crucial for the booster cap burn through.

Failure mode and effects analysis: too little for too much?

PubMed

Dean Franklin, Bryony; Shebl, Nada Atef; Barber, Nick

2012-07-01

Failure mode and effects analysis (FMEA) is a structured prospective risk assessment method that is widely used within healthcare. FMEA involves a multidisciplinary team mapping out a high-risk process of care, identifying the failures that can occur, and then characterising each of these in terms of probability of occurrence, severity of effects and detectability, to give a risk priority number used to identify failures most in need of attention. One might assume that such a widely used tool would have an established evidence base. This paper considers whether or not this is the case, examining the evidence for the reliability and validity of its outputs, the mathematical principles behind the calculation of a risk prioirty number, and variation in how it is used in practice. We also consider the likely advantages of this approach, together with the disadvantages in terms of the healthcare professionals' time involved. We conclude that although FMEA is popular and many published studies have reported its use within healthcare, there is little evidence to support its use for the quantitative prioritisation of process failures. It lacks both reliability and validity, and is very time consuming. We would not recommend its use as a quantitative technique to prioritise, promote or study patient safety interventions. However, the stage of FMEA involving multidisciplinary mapping process seems valuable and work is now needed to identify the best way of converting this into plans for action.

Investigation of advanced fault insertion and simulator methods

NASA Technical Reports Server (NTRS)

Dunn, W. R.; Cottrell, D.

1986-01-01

The cooperative agreement partly supported research leading to the open-literature publication cited. Additional efforts under the agreement included research into fault modeling of semiconductor devices. Results of this research are presented in this report which is summarized in the following paragraphs. As a result of the cited research, it appears that semiconductor failure mechanism data is abundant but of little use in developing pin-level device models. Failure mode data on the other hand does exist but is too sparse to be of any statistical use in developing fault models. What is significant in the failure mode data is that, unlike classical logic, MSI and LSI devices do exhibit more than 'stuck-at' and open/short failure modes. Specifically they are dominated by parametric failures and functional anomalies that can include intermittent faults and multiple-pin failures. The report discusses methods of developing composite pin-level models based on extrapolation of semiconductor device failure mechanisms, failure modes, results of temperature stress testing and functional modeling. Limitations of this model particularly with regard to determination of fault detection coverage and latency time measurement are discussed. Indicated research directions are presented.

A New Rock Strength Criterion from Microcracking Mechanisms Which Provides Theoretical Evidence of Hybrid Failure

NASA Astrophysics Data System (ADS)

Zhu, Qi-Zhi

2017-02-01

A proper criterion describing when material fails is essential for deep understanding and constitutive modeling of rock damage and failure by microcracking. Physically, such a criterion should be the global effect of local mechanical response and microstructure evolution inside the material. This paper aims at deriving a new mechanisms-based failure criterion for brittle rocks, based on micromechanical unilateral damage-friction coupling analyses rather than on the basic results from the classical linear elastic fracture mechanics. The failure functions respectively describing three failure modes (purely tensile mode, tensile-shear mode as well as compressive-shear mode) are achieved in a unified upscaling framework and illustrated in the Mohr plane and also in the plane of principal stresses. The strength envelope is proved to be continuous and smooth with a compressive to tensile strength ratio dependent on material properties. Comparisons with experimental data are finally carried out. By this work, we also provide a theoretical evidence on the hybrid failure and the smooth transition from tensile failure to compressive-shear failure.

Application of ISO22000, failure mode, and effect analysis (FMEA) cause and effect diagrams and pareto in conjunction with HACCP and risk assessment for processing of pastry products.

PubMed

Varzakas, Theodoros H

2011-09-01

The Failure Mode and Effect Analysis (FMEA) model has been applied for the risk assessment of pastry processing. A tentative approach of FMEA application to the pastry industry was attempted in conjunction with ISO22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (pastry processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram, and fishbone diagram). In this work a comparison of ISO22000 analysis with HACCP is carried out over pastry processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the Risk Priority Number (RPN) per identified processing hazard. Storage of raw materials and storage of final products at -18°C followed by freezing were the processes identified as the ones with the highest RPN (225, 225, and 144 respectively) and corrective actions were undertaken. Following the application of corrective actions, a second calculation of RPN values was carried out leading to considerably lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO22000 system of a pastry processing industry is considered imperative.

Failure analysis of fuel cell electrodes using three-dimensional multi-length scale X-ray computed tomography

NASA Astrophysics Data System (ADS)

Pokhrel, A.; El Hannach, M.; Orfino, F. P.; Dutta, M.; Kjeang, E.

2016-10-01

X-ray computed tomography (XCT), a non-destructive technique, is proposed for three-dimensional, multi-length scale characterization of complex failure modes in fuel cell electrodes. Comparative tomography data sets are acquired for a conditioned beginning of life (BOL) and a degraded end of life (EOL) membrane electrode assembly subjected to cathode degradation by voltage cycling. Micro length scale analysis shows a five-fold increase in crack size and 57% thickness reduction in the EOL cathode catalyst layer, indicating widespread action of carbon corrosion. Complementary nano length scale analysis shows a significant reduction in porosity, increased pore size, and dramatically reduced effective diffusivity within the remaining porous structure of the catalyst layer at EOL. Collapsing of the structure is evident from the combination of thinning and reduced porosity, as uniquely determined by the multi-length scale approach. Additionally, a novel image processing based technique developed for nano scale segregation of pore, ionomer, and Pt/C dominated voxels shows an increase in ionomer volume fraction, Pt/C agglomerates, and severe carbon corrosion at the catalyst layer/membrane interface at EOL. In summary, XCT based multi-length scale analysis enables detailed information needed for comprehensive understanding of the complex failure modes observed in fuel cell electrodes.

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.

Numerical Model for the Study of the Strength and Failure Modes of Rock Containing Non-Persistent Joints

NASA Astrophysics Data System (ADS)

Vergara, Maximiliano R.; Van Sint Jan, Michel; Lorig, Loren

2016-04-01

The mechanical behavior of rock containing parallel non-persistent joint sets was studied using a numerical model. The numerical analysis was performed using the discrete element software UDEC. The use of fictitious joints allowed the inclusion of non-persistent joints in the model domain and simulating the progressive failure due to propagation of existing fractures. The material and joint mechanical parameters used in the model were obtained from experimental results. The results of the numerical model showed good agreement with the strength and failure modes observed in the laboratory. The results showed the large anisotropy in the strength resulting from variation of the joint orientation. Lower strength of the specimens was caused by the coalescence of fractures belonging to parallel joint sets. A correlation was found between geometrical parameters of the joint sets and the contribution of the joint sets strength in the global strength of the specimen. The results suggest that for the same dip angle with respect to the principal stresses; the uniaxial strength depends primarily on the joint spacing and the angle between joints tips and less on the length of the rock bridges (persistency). A relation between joint geometrical parameters was found from which the resulting failure mode can be predicted.

Failure detection and fault management techniques for flush airdata sensing systems

NASA Technical Reports Server (NTRS)

Whitmore, Stephen A.; Moes, Timothy R.; Leondes, Cornelius T.

1992-01-01

Methods based on chi-squared analysis are presented for detecting system and individual-port failures in the high-angle-of-attack flush airdata sensing system on the NASA F-18 High Alpha Research Vehicle. The HI-FADS hardware is introduced, and the aerodynamic model describes measured pressure in terms of dynamic pressure, angle of attack, angle of sideslip, and static pressure. Chi-squared analysis is described in the presentation of the concept for failure detection and fault management which includes nominal, iteration, and fault-management modes. A matrix of pressure orifices arranged in concentric circles on the nose of the aircraft indicate the parameters which are applied to the regression algorithms. The sensing techniques are applied to the F-18 flight data, and two examples are given of the computed angle-of-attack time histories. The failure-detection and fault-management techniques permit the matrix to be multiply redundant, and the chi-squared analysis is shown to be useful in the detection of failures.

Reliability analysis of the F-8 digital fly-by-wire system

NASA Technical Reports Server (NTRS)

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

1981-01-01

The F-8 Digital Fly-by-Wire (DFBW) flight test program intended to provide the technology for advanced control systems, giving aircraft enhanced performance and operational capability is addressed. A detailed analysis of the experimental system was performed to estimated the probabilities of two significant safety critical events: (1) loss of primary flight control function, causing reversion to the analog bypass system; and (2) loss of the aircraft due to failure of the electronic flight control system. The analysis covers appraisal of risks due to random equipment failure, generic faults in design of the system or its software, and induced failure due to external events. A unique diagrammatic technique was developed which details the combinatorial reliability equations for the entire system, promotes understanding of system failure characteristics, and identifies the most likely failure modes. The technique provides a systematic method of applying basic probability equations and is augmented by a computer program written in a modular fashion that duplicates the structure of these equations.

Biomarkers of myocardial stress and fibrosis as predictors of mode of death in patients with chronic heart failure.

PubMed

Ahmad, Tariq; Fiuzat, Mona; Neely, Benjamin; Neely, Megan L; Pencina, Michael J; Kraus, William E; Zannad, Faiez; Whellan, David J; Donahue, Mark P; Piña, Ileana L; Adams, Kirkwood F; Kitzman, Dalane W; O'Connor, Christopher M; Felker, G Michael

2014-06-01

The aim of this study was to determine whether biomarkers of myocardial stress and fibrosis improve prediction of the mode of death in patients with chronic heart failure. The 2 most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of the mode of death may facilitate treatment decisions. The relationship between amino-terminal pro-brain natriuretic peptide (NT-proBNP), galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown. HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) was a randomized controlled trial of exercise training versus usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox proportional hazards modeling, and interaction testing was used to measure differential associations between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP. After a median follow-up period of 2.5 years, there were 155 deaths: 49 from pump failure, 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk for both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death, but this relationship was attenuated after adjustment for clinical risk factors. Clinical variables along with NT-proBNP levels were stronger predictors of pump failure (C statistic: 0.87) than sudden cardiac death (C statistic: 0.73). Addition of ST2 and galectin-3 led to improved net risk classification of 11% for sudden cardiac death, but not pump failure. Clinical predictors along with NT-proBNP levels were strong predictors of pump failure risk, with insignificant incremental contributions of ST2 and galectin-3. Predictability of sudden cardiac death risk was less robust and enhanced by information provided by novel biomarkers. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Argonne National Laboratory Li-alloy/FeS cell testing and R and D programs

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

Gay, E.C.

1982-01-01

Groups of 12 or more identical Li-alloy/FeS cells fabricated by Eagle-Picher Industries, Inc. and Gould Inc. were operated at Argonne National Laboratory (ANL) in the status cell test program to obtain data for statistical analysis of cell cycle life and failure modes. The cells were full-size electric vehicle battery cells (150 to 350 Ah capacity) and they were cycled at the 4-h discharge rate and 8-h charge rate. The end of life was defined as a 20% loss of capacity or a decrease in the coulombic efficiency to less than 95%. Seventy-four cells (six groups of identical cells) were cycle-lifemore » tested and the results were analyzed statistically. The ultimate goal of this analysis was to predict cell and battery reliability. Testing of groups of identical cells also provided a means of identifying common failure modes which were eliminated by cell design changes. Mean time to failure (MTTF) for the cells based on the Weibull distribution is presented.« less

A systems engineering approach to automated failure cause diagnosis in space power systems

NASA Technical Reports Server (NTRS)

Dolce, James L.; Faymon, Karl A.

1987-01-01

Automatic failure-cause diagnosis is a key element in autonomous operation of space power systems such as Space Station's. A rule-based diagnostic system has been developed for determining the cause of degraded performance. The knowledge required for such diagnosis is elicited from the system engineering process by using traditional failure analysis techniques. Symptoms, failures, causes, and detector information are represented with structured data; and diagnostic procedural knowledge is represented with rules. Detected symptoms instantiate failure modes and possible causes consistent with currently held beliefs about the likelihood of the cause. A diagnosis concludes with an explanation of the observed symptoms in terms of a chain of possible causes and subcauses.

Analysis, testing, and evaluation of faulted and unfaulted Wye, Delta, and open Delta connected electromechanical actuators

NASA Technical Reports Server (NTRS)

Nehl, T. W.; Demerdash, N. A.

1983-01-01

Mathematical models capable of simulating the transient, steady state, and faulted performance characteristics of various brushless dc machine-PSA (power switching assembly) configurations were developed. These systems are intended for possible future use as primemovers in EMAs (electromechanical actuators) for flight control applications. These machine-PSA configurations include wye, delta, and open-delta connected systems. The research performed under this contract was initially broken down into the following six tasks: development of mathematical models for various machine-PSA configurations; experimental validation of the model for failure modes; experimental validation of the mathematical model for shorted turn-failure modes; tradeoff study; and documentation of results and methodology.

Prediction of Composite Laminate Strength Properties Using a Refined Zigzag Plate Element

NASA Technical Reports Server (NTRS)

Barut, Atila; Madenci, Erdogan; Tessler, Alexander

2013-01-01

This study presents an approach that uses the refined zigzag element, RZE(exp2,2) in conjunction with progressive failure criteria to predict the ultimate strength of composite laminates based on only ply-level strength properties. The methodology involves four major steps: (1) Determination of accurate stress and strain fields under complex loading conditions using RZE(exp2,2)-based finite element analysis, (2) Determination of failure locations and failure modes using the commonly accepted Hashin's failure criteria, (3) Recursive degradation of the material stiffness, and (4) Non-linear incremental finite element analysis to obtain stress redistribution until global failure. The validity of this approach is established by considering the published test data and predictions for (1) strength of laminates under various off-axis loading, (2) strength of laminates with a hole under compression, and (3) strength of laminates with a hole under tension.

Investigation of short-circuit failure mechanisms of SiC MOSFETs by varying DC bus voltage

NASA Astrophysics Data System (ADS)

Namai, Masaki; An, Junjie; Yano, Hiroshi; Iwamuro, Noriyuki

2018-07-01

In this study, the experimental evaluation and numerical analysis of short-circuit mechanisms of 1200 V SiC planar and trench MOSFETs were conducted at various DC bus voltages from 400 to 800 V. Investigation of the impact of DC bus voltage on short-circuit capability yielded results that are extremely useful for many existing power electronics applications. Three failure mechanisms were identified in this study: thermal runaway, MOS channel current following device turn-off, and rupture of the gate oxide layer (gate oxide layer damage). The SiC MOSFETs experienced lattice temperatures exceeding 1000 K during the short-circuit transient; as Si insulated gate bipolar transistors (IGBTs) are not typically subject to such temperatures, the MOSFETs experienced distinct failure modes, and the mode experienced was significantly influenced by the DC bus voltage. In conclusion, suggestions regarding the SiC MOSFET design and operation methods that would enhance device robustness are proposed.

Robust failure detection filters. M.S. Thesis

NASA Technical Reports Server (NTRS)

Sanmartin, A. M.

1985-01-01

The robustness of detection filters applied to the detection of actuator failures on a free-free beam is analyzed. This analysis is based on computer simulation tests of the detection filters in the presence of different types of model mismatch, and on frequency response functions of the transfers corresponding to the model mismatch. The robustness of detection filters based on a model of the beam containing a large number of structural modes varied dramatically with the placement of some of the filter poles. The dynamics of these filters were very hard to analyze. The design of detection filters with a number of modes equal to the number of sensors was trivial. They can be configured to detect any number of actuator failure events. The dynamics of these filters were very easy to analyze and their robustness properties were much improved. A change of the output transformation allowed the filter to perform satisfactorily with realistic levels of model mismatch.

Product Quality Improvement Using FMEA for Electric Parking Brake (EPB)

NASA Astrophysics Data System (ADS)

Dumitrescu, C. D.; Gruber, G. C.; Tişcă, I. A.

2016-08-01

One of the most frequently used methods to improve product quality is complex FMEA. (Failure Modes and Effects Analyses). In the literature various FMEA is known, depending on the mode and depending on the targets; we mention here some of these names: Failure Modes and Effects Analysis Process, or analysis Failure Mode and Effects Reported (FMECA). Whatever option is supported by the work team, the goal of the method is the same: optimize product design activities in research, design processes, implementation of manufacturing processes, optimization of mining product to beneficiaries. According to a market survey conducted on parts suppliers to vehicle manufacturers FMEA method is used in 75%. One purpose of the application is that after the research and product development is considered resolved, any errors which may be detected; another purpose of applying the method is initiating appropriate measures to avoid mistakes. Achieving these two goals leads to a high level distribution in applying, to avoid errors already in the design phase of the product, thereby avoiding the emergence and development of additional costs in later stages of product manufacturing. During application of FMEA method using standardized forms; with their help will establish the initial assemblies of product structure, in which all components will be viewed without error. The work is an application of the method FMEA quality components to optimize the structure of the electrical parking brake (Electric Parching Brake - E.P.B). This is a component attached to the roller system which ensures automotive replacement of conventional mechanical parking brake while ensuring its comfort, functionality, durability and saves space in the passenger compartment. The paper describes the levels at which they appealed in applying FMEA, working arrangements in the 4 distinct levels of analysis, and how to determine the number of risk (Risk Priority Number); the analysis of risk factors and established authors who have imposed measures to reduce / eliminate risk completely exploiting this complex product.

Probabilistic finite elements for fracture and fatigue analysis

NASA Technical Reports Server (NTRS)

Liu, W. K.; Belytschko, T.; Lawrence, M.; Besterfield, G. H.

1989-01-01

The fusion of the probabilistic finite element method (PFEM) and reliability analysis for probabilistic fracture mechanics (PFM) is presented. A comprehensive method for determining the probability of fatigue failure for curved crack growth was developed. The criterion for failure or performance function is stated as: the fatigue life of a component must exceed the service life of the component; otherwise failure will occur. An enriched element that has the near-crack-tip singular strain field embedded in the element is used to formulate the equilibrium equation and solve for the stress intensity factors at the crack-tip. Performance and accuracy of the method is demonstrated on a classical mode 1 fatigue problem.

Basic failure mechanisms in advanced composites

NASA Technical Reports Server (NTRS)

Mullin, J. V.; Mazzio, V. F.; Mehan, R. L.

1972-01-01

Failure mechanisms in carbon-epoxy composites are identified as a basis for more reliable prediction of the performance of these materials. The approach involves both the study of local fracture events in model specimens containing small groups of filaments and fractographic examination of high fiber content engineering composites. Emphasis is placed on the correlation of model specimen observations with gross fracture modes. The effects of fiber surface treatment, resin modification and fiber content are studied and acoustic emission methods are applied. Some effort is devoted to analysis of the failure process in composite/metal specimens.

Researchers at NREL Find Fewer Failures of PV Panels and Different

Science.gov Websites

10, 2017 Overall failure rates for photovoltaic (PV) solar panels have fallen dramatically when Failures of PV Panels and Different Degradation Modes in Systems Installed after 2000 Researchers at NREL Find Fewer Failures of PV Panels and Different Degradation Modes in Systems Installed after 2000 April

14 CFR 25.1309 - Equipment, systems, and installations.

Code of Federal Regulations, 2014 CFR

2014-01-01

... airplane or the ability of the crew to cope with adverse operating conditions is improbable. (c) Warning... requirements of paragraph (b) of this section must be shown by analysis, and where necessary, by appropriate ground, flight, or simulator tests. The analysis must consider— (1) Possible modes of failure, including...

14 CFR 29.1309 - Equipment, systems, and installations.

Code of Federal Regulations, 2012 CFR

2012-01-01

... rotorcraft or the ability of the crew to cope with adverse operating conditions is improbable. (c) Warning... requirements of paragraph (b)(2) of this section must be shown by analysis and, where necessary, by appropriate ground, flight, or simulator tests. The analysis must consider— (1) Possible modes of failure, including...

14 CFR 25.1309 - Equipment, systems, and installations.

Code of Federal Regulations, 2013 CFR

2013-01-01

... airplane or the ability of the crew to cope with adverse operating conditions is improbable. (c) Warning... requirements of paragraph (b) of this section must be shown by analysis, and where necessary, by appropriate ground, flight, or simulator tests. The analysis must consider— (1) Possible modes of failure, including...

14 CFR 25.1309 - Equipment, systems, and installations.

Code of Federal Regulations, 2011 CFR

2011-01-01

... airplane or the ability of the crew to cope with adverse operating conditions is improbable. (c) Warning... requirements of paragraph (b) of this section must be shown by analysis, and where necessary, by appropriate ground, flight, or simulator tests. The analysis must consider— (1) Possible modes of failure, including...

14 CFR 29.1309 - Equipment, systems, and installations.

Code of Federal Regulations, 2013 CFR

2013-01-01

... rotorcraft or the ability of the crew to cope with adverse operating conditions is improbable. (c) Warning... requirements of paragraph (b)(2) of this section must be shown by analysis and, where necessary, by appropriate ground, flight, or simulator tests. The analysis must consider— (1) Possible modes of failure, including...

14 CFR 29.1309 - Equipment, systems, and installations.

Code of Federal Regulations, 2014 CFR

2014-01-01

... rotorcraft or the ability of the crew to cope with adverse operating conditions is improbable. (c) Warning... requirements of paragraph (b)(2) of this section must be shown by analysis and, where necessary, by appropriate ground, flight, or simulator tests. The analysis must consider— (1) Possible modes of failure, including...

14 CFR 25.1309 - Equipment, systems, and installations.

Code of Federal Regulations, 2012 CFR

2012-01-01

... airplane or the ability of the crew to cope with adverse operating conditions is improbable. (c) Warning... requirements of paragraph (b) of this section must be shown by analysis, and where necessary, by appropriate ground, flight, or simulator tests. The analysis must consider— (1) Possible modes of failure, including...

Foresight begins with FMEA. Delivering accurate risk assessments.

PubMed

Passey, R D

1999-03-01

If sufficient factors are taken into account and two- or three-stage analysis is employed, failure mode and effect analysis represents an excellent technique for delivering accurate risk assessments for products and processes, and for relating them to legal liability. This article describes a format that facilitates easy interpretation.

Risk-based planning analysis for a single levee

NASA Astrophysics Data System (ADS)

Hui, Rui; Jachens, Elizabeth; Lund, Jay

2016-04-01

Traditional risk-based analysis for levee planning focuses primarily on overtopping failure. Although many levees fail before overtopping, few planning studies explicitly include intermediate geotechnical failures in flood risk analysis. This study develops a risk-based model for two simplified levee failure modes: overtopping failure and overall intermediate geotechnical failure from through-seepage, determined by the levee cross section represented by levee height and crown width. Overtopping failure is based only on water level and levee height, while through-seepage failure depends on many geotechnical factors as well, mathematically represented here as a function of levee crown width using levee fragility curves developed from professional judgment or analysis. These levee planning decisions are optimized to minimize the annual expected total cost, which sums expected (residual) annual flood damage and annualized construction costs. Applicability of this optimization approach to planning new levees or upgrading existing levees is demonstrated preliminarily for a levee on a small river protecting agricultural land, and a major levee on a large river protecting a more valuable urban area. Optimized results show higher likelihood of intermediate geotechnical failure than overtopping failure. The effects of uncertainty in levee fragility curves, economic damage potential, construction costs, and hydrology (changing climate) are explored. Optimal levee crown width is more sensitive to these uncertainties than height, while the derived general principles and guidelines for risk-based optimal levee planning remain the same.

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.

Identification and classification of failure modes in laminated composites by using a multivariate statistical analysis of wavelet coefficients

NASA Astrophysics Data System (ADS)

Baccar, D.; Söffker, D.

2017-11-01

Acoustic Emission (AE) is a suitable method to monitor the health of composite structures in real-time. However, AE-based failure mode identification and classification are still complex to apply due to the fact that AE waves are generally released simultaneously from all AE-emitting damage sources. Hence, the use of advanced signal processing techniques in combination with pattern recognition approaches is required. In this paper, AE signals generated from laminated carbon fiber reinforced polymer (CFRP) subjected to indentation test are examined and analyzed. A new pattern recognition approach involving a number of processing steps able to be implemented in real-time is developed. Unlike common classification approaches, here only CWT coefficients are extracted as relevant features. Firstly, Continuous Wavelet Transform (CWT) is applied to the AE signals. Furthermore, dimensionality reduction process using Principal Component Analysis (PCA) is carried out on the coefficient matrices. The PCA-based feature distribution is analyzed using Kernel Density Estimation (KDE) allowing the determination of a specific pattern for each fault-specific AE signal. Moreover, waveform and frequency content of AE signals are in depth examined and compared with fundamental assumptions reported in this field. A correlation between the identified patterns and failure modes is achieved. The introduced method improves the damage classification and can be used as a non-destructive evaluation tool.

Stiffness and strength of fiber reinforced polymer composite bridge deck systems

NASA Astrophysics Data System (ADS)

Zhou, Aixi

This research investigates two principal characteristics that are of primary importance in Fiber Reinforced Polymer (FRP) bridge deck applications: STIFFNESS and STRENGTH. The research was undertaken by investigating the stiffness and strength characteristics of the multi-cellular FRP bridge deck systems consisting of pultruded FRP shapes. A systematic analysis procedure was developed for the stiffness analysis of multi-cellular FRP deck systems. This procedure uses the Method of Elastic Equivalence to model the cellular deck as an equivalent orthotropic plate. The procedure provides a practical method to predict the equivalent orthotropic plate properties of cellular FRP decks. Analytical solutions for the bending analysis of single span decks were developed using classical laminated plate theory. The analysis procedures can be extended to analyze continuous FRP decks. It can also be further developed using higher order plate theories. Several failure modes of the cellular FRP deck systems were recorded and analyzed through laboratory and field tests and Finite Element Analysis (FEA). Two schemes of loading patches were used in the laboratory test: a steel patch made according to the ASSHTO's bridge testing specifications; and a tire patch made from a real truck tire reinforced with silicon rubber. The tire patch was specially designed to simulate service loading conditions by modifying real contact loading from a tire. Our research shows that the effects of the stiffness and contact conditions of loading patches are significant in the stiffness and strength testing of FRP decks. Due to the localization of load, a simulated tire patch yields larger deflection than the steel patch under the same loading level. The tire patch produces significantly different failure compared to the steel patch: a local bending mode with less damage for the tire patch; and a local punching-shear mode for the steel patch. A deck failure function method is proposed for predicting the failure of FRP decks. Using developed laminated composite theories and FEA techniques, a strength analysis procedure containing ply-level information was proposed and detailed for FRP deck systems. The behavior of the deck's unsupported (free) edges was also investigated using ply-level FEA.

Signature analysis of acoustic emission from graphite/epoxy composites

NASA Technical Reports Server (NTRS)

Russell, S. S.; Henneke, E. G., II

1977-01-01

Acoustic emissions were monitored for crack extension across and parallel to the fibers in a single ply and multiply laminates of graphite epoxy composites. Spectrum analysis was performed on the transient signal to ascertain if the fracture mode can be characterized by a particular spectral pattern. The specimens were loaded to failure quasistatically in a tensile machine. Visual observations were made via either an optical microscope or a television camera. The results indicate that several types of characteristics in the time and frequency domain correspond to different types of failure.

A statistical overview of mass movement characteristics on the North American Atlantic outer continental margin

USGS Publications Warehouse

Booth, James S.; O'Leary, Dennis W.

1992-01-01

An analysis of 179 mass movements on the North American Atlantic continental slope and upper rise shows that slope failures have occurred throughout the geographic extent of the outer margin. Although the slope failures show no striking affinity for a particular depth as an origination level, there is a broad, primary mode centered at about 900 m. The resulting slides terminate at almost all depths and have a primary mode at 1100 m, but the slope/rise boundary (at 2200 m) also is an important mode. Slope failures have occurred at declivities ranging from 1° to 30° (typically, 4°); the resultant mass movement deposits vary in width from 0.2 to 50 km (typically, 1-2 km) and in length from 0.3 to 380 km (typically, 2–4 km), and they have been reported to be as thick as 650 m. On a numeric basis, mass movements are slightly more prevalent on open slopes than in other physiographic settings, and both translational and rotational failure surfaces are common. The typical mass movement is disintegrative in nature. Open slope slides tend to occur at lower slope angles and are larger than canyon slides. Further, large‐scale slides rather than small‐scale slides tend to originate on gentle slopes (≍ 3-4°). Rotational slope failures appear to have a slightly greater chance of occurring in canyons, but there is no analogous bias associated with translational failures. Similarly, disintegrative slides seem more likely to be associated with rotational slope failures than translational ones and are longer than their nondisintegrative counterparts. The occurrence of such a variety of mass movements at low declivities implies that a regional failure mechanism has prevailed. We suggest that earthquakes or, perhaps in some areas, gas hydrates are the most likely cause of the slope failures.

The role of shear and tensile failure in dynamically triggered landslides

USGS Publications Warehouse

Gipprich, T.L.; Snieder, R.K.; Jibson, R.W.; Kimman, W.

2008-01-01

Dynamic stresses generated by earthquakes can trigger landslides. Current methods of landslide analysis such as pseudo-static analysis and Newmark's method focus on the effects of earthquake accelerations on the landslide mass to characterize dynamic landslide behaviour. One limitation of these methods is their use Mohr-Coulomb failure criteria, which only accounts for shear failure, but the role of tensile failure is not accounted for. We develop a limit-equilibrium model to investigate the dynamic stresses generated by a given ground motion due to a plane wave and use this model to assess the role of shear and tensile failure in the initiation of slope instability. We do so by incorporating a modified Griffith failure envelope, which combines shear and tensile failure into a single criterion. Tests of dynamic stresses in both homogeneous and layered slopes demonstrate that two modes of failure exist, tensile failure in the uppermost meters of a slope and shear failure at greater depth. Further, we derive equations that express the dynamic stress in the near-surface in the acceleration measured at the surface. These equations are used to approximately define the depth range for each mechanism of failure. The depths at which these failure mechanisms occur suggest that shear and tensile failure might collaborate in generating slope failure. ?? 2007 The Authors Journal compilation ?? 2007 RAS.

Failure modes for compression loaded angle-ply plates with holes

NASA Technical Reports Server (NTRS)

Burns, S. W.; Herakovich, C. T.; Williams, J. G.

1987-01-01

A combined theoretical-experimental investigation of failure in notched, graphite-epoxy, angle-ply laminates subjected to far-field compression loading indicates that failure generally initiates on the hole boundary and propagates along a line parallel to the fiber orientation of the laminate. The strength of notched laminates with specimen width-to-hole diameter ratios of 5 and 10 are compared to the strength of unnotched laminates. The experimental results are complemented by a three-dimensional finite element stress analysis that includes interlaminar stresses around holes in (+/- theta)s laminates. The finite element predictions indicate that failure is initiated by shear stresses at the hole boundary.