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Sample records for failure modes analysis

  1. Failure mode analysis to predict product reliability.

    NASA Technical Reports Server (NTRS)

    Zemanick, P. P.

    1972-01-01

    The failure mode analysis (FMA) is described as a design tool to predict and improve product reliability. The objectives of the failure mode analysis are presented as they influence component design, configuration selection, the product test program, the quality assurance plan, and engineering analysis priorities. The detailed mechanics of performing a failure mode analysis are discussed, including one suggested format. Some practical difficulties of implementation are indicated, drawn from experience with preparing FMAs on the nuclear rocket engine program.

  2. Failure Mode Identification Through Clustering Analysis

    NASA Technical Reports Server (NTRS)

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

    2002-01-01

    Research has shown that nearly 80% of the costs and problems are created in product development and that cost and quality are essentially designed into products in the conceptual stage. Currently, failure identification procedures (such as FMEA (Failure Modes and Effects Analysis), FMECA (Failure Modes, Effects and Criticality Analysis) and FTA (Fault Tree Analysis)) and design of experiments are being used for quality control and for the detection of potential failure modes during the detail design stage or post-product launch. Though all of these methods have their own advantages, they do not give information as to what are the predominant failures that a designer should focus on while designing a product. This work uses a functional approach to identify failure modes, which hypothesizes that similarities exist between different failure modes based on the functionality of the product/component. In this paper, a statistical clustering procedure is proposed to retrieve information on the set of predominant failures that a function experiences. The various stages of the methodology are illustrated using a hypothetical design example.

  3. 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.

  4. 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.

  5. A streamlined failure mode and effects analysis

    SciTech Connect

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

    2014-06-15

    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 used 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.

  6. 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.

  7. Is failure mode and effect analysis reliable?

    PubMed

    Shebl, Nada Atef; Franklin, Bryony Dean; Barber, Nick

    2009-06-01

    To test the reliability of failure mode and effect analysis (FMEA) within a hospital setting in the United Kingdom. Two multidisciplinary groups were recruited, within 2 hospitals from the same National Health Services (NHS) Trust, to conduct separate FMEAs in parallel on the same topic. Each group conducted an FMEA for the use of vancomycin and gentamicin. The groups followed the basic FMEA steps, which included mapping the process of care; identifying potential failures within the process; determining the severity, probability, and detectability scores for these failures; and finally making recommendations to decrease these failures. Both groups described the process with 5 major steps: starting vancomycin or gentamicin, prescribing the antibiotics, administering the antibiotics, monitoring the antibiotics, and finally stopping or continuing the treatment. Although each group identified 50 failures, only 17 (17%) of them were common to both. Furthermore, the severity, detectability, and risk priority number scores for both groups differed markedly resulting in their failures being prioritized differently. Failure mode and effect analysis is a useful tool to aid multidisciplinary groups in understanding a process of care and identifying errors that may occur. However, the results of this study call into question the reliability of the FMEA process that was tested. The 2 groups identified similar steps in the process of care but different potential failures with very different risk priority numbers. Such discrepancies make it impossible to identify reliably those failures that should be prioritized and thus where money, time, and effort should be allocated to avoid these failures. Health care organizations should not solely depend on FMEA findings to improve patient safety.

  8. Failure-Modes-And-Effects Analysis Of Software Logic

    NASA Technical Reports Server (NTRS)

    Garcia, Danny; Hartline, Thomas; Minor, Terry; Statum, David; Vice, David

    1996-01-01

    Rigorous analysis applied early in design effort. Method of identifying potential inadequacies and modes and effects of failures caused by inadequacies (failure-modes-and-effects analysis or "FMEA" for short) devised for application to software logic.

  9. 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.

  10. Mod 1 wind turbine generator failure modes and effects analysis

    NASA Technical Reports Server (NTRS)

    1979-01-01

    A failure modes and effects analysis (FMEA) was directed primarily at identifying those critical failure modes that would be hazardous to life or would result in major damage to the system. Each subsystem was approached from the top down, and broken down to successive lower levels where it appeared that the criticality of the failure mode warranted more detail analysis. The results were reviewed by specialists from outside the Mod 1 program, and corrective action taken wherever recommended.

  11. [Failure mode effect analysis applied to preparation of intravenous cytostatics].

    PubMed

    Santos-Rubio, M D; Marín-Gil, R; Muñoz-de la Corte, R; Velázquez-López, M D; Gil-Navarro, M V; Bautista-Paloma, F J

    2016-01-01

    To proactively identify risks in the preparation of intravenous cytostatic drugs, and to prioritise and establish measures to improve safety procedures. Failure Mode Effect Analysis methodology was used. A multidisciplinary team identified potential failure modes of the procedure through a brainstorming session. The impact associated with each failure mode was assessed with the Risk Priority Number (RPN), which involves three variables: occurrence, severity, and detectability. Improvement measures were established for all identified failure modes, with those with RPN>100 considered critical. The final RPN (theoretical) that would result from the proposed measures was also calculated and the process was redesigned. A total of 34 failure modes were identified. The initial accumulated RPN was 3022 (range: 3-252), and after recommended actions the final RPN was 1292 (range: 3-189). RPN scores >100 were obtained in 13 failure modes; only the dispensing sub-process was free of critical points (RPN>100). A final reduction of RPN>50% was achieved in 9 failure modes. This prospective risk analysis methodology allows the weaknesses of the procedure to be prioritised, optimize use of resources, and a substantial improvement in the safety of the preparation of cytostatic drugs through the introduction of double checking and intermediate product labelling. Copyright © 2015 SECA. Published by Elsevier Espana. All rights reserved.

  12. 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.

  13. 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.

  14. 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.

  15. 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.

  16. Failure mode analysis of a spacecraft power system

    SciTech Connect

    Lee, J.R.

    1995-12-31

    For the spacecraft power system`s dynamic analyses, dc/dc converters are usually modeled with a linearized model using the state space averaging technique. The linearized model can be used for small-signal ac and transient analyses. However, since the linearized model has limitations in its accuracies, certain types of transient analyses including a failure mode must be performed by using a more accurate cycle-by-cycle model. In this paper, a failure mode analysis is presented with a small-signal analysis and corresponding transient simulations.

  17. Failure Mode Effects Analysis for an Accelerator Control System

    SciTech Connect

    Hartman, Steven M

    2009-01-01

    Failure mode effects analysis (FMEA) has been used in industry for design, manufacturing and assembly process quality control. It describes a formal approach for categorizing how a process may fail and for prioritizing failures based on their severity, frequency and likelihood of detection. Experience conducting a partial FMEA of an accelerator subsystem and its related control system will be reviewed. The applicability of the FMEA process to an operational accelerator control system will be discussed.

  18. Cycles till failure of silver-zinc cells with competing failure modes - Preliminary data analysis

    NASA Technical Reports Server (NTRS)

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

    1980-01-01

    The data analysis of cycles to failure of silver-zinc electrochemical cells with competing failure modes is presented. The test ran 129 cells through charge-discharge cycles until failure; preliminary data analysis consisted of response surface estimate of life. Batteries fail through low voltage condition and an internal shorting condition; a competing failure modes analysis was made using maximum likelihood estimation for the extreme value life distribution. Extensive residual plotting and probability plotting were used to verify data quality and selection of model.

  19. Propofol sedation Quality and safety. Failure mode and effects analysis.

    PubMed

    Huergo Fernández, Adrián; Amor Martín, Pedro; Fernández Cadenas, Fernando

    2017-08-01

    Sedation is a key component of digestive endoscopy. While ensuring procedural safety and quality represents a primary goal, a detailed assessment of patient-focused risks and improvements is lacking on most occasions. Failure mode and effect analysis (FMEA) is a useful tool in this context as a means of raising barriers and defense mechanisms to prevent adverse events from developing.

  20. Failure Mode, Effects, and Criticality Analysis (FMECA)

    DTIC Science & Technology

    1993-04-01

    necessary to effect repair. Indenture Levels: The levels which identify or describe the relative complexity of an assembly or function. Local Effect...FMECA 9 3.0 FMEA ANALYSIS TECHNIQUES The FMEA can be implemented using a hardware or functional approach. Often, due to system complexity , the FMEA...will be performed as a combination of the two types. The complexity of each design, its state of development and the data available, will dictate the

  1. Failure modes and effects analysis (RADL Item 2-23)

    SciTech Connect

    1980-04-01

    The Pilot Plant is a central receiver design concept. It is comprised of five major subsystems as shown schematically, plus a set of equipment (Plant Support Subsystem) used to support total plant operation. The failure modes and effects analysis (FMEA) is a bottom-up analysis used to identify the failure characteristics of the system (total equipment used to produce electrical power), that is, the failure of a single component is assumed and the effect of that failure upon the system is determined. The FMEA is concerned with the plant from an operational standpoint (i.e., the production of electrical power). This analysis was performed to the component level. This was interpreted as a valve, computer, measurement sensor and its associated signal conditioning, an electronic black box, etc.

  2. On Automating Failure Mode Analysis and Enforcing its Integrity

    NASA Technical Reports Server (NTRS)

    Tai, Ann T.; Tso, Kam S.; Chau, Savio N.

    2005-01-01

    This paper reports our experience on the development of a design-for-safety (DFS) workbench called Risk Assessment and Management Environment (RAME) for microelectronic avionics systems. Our objective is to transform DFS practice from an ad-hoc, inefficient, error-prone approach to a stringent engineering process such that DFS can keep up with the rapidly growing complexity of avionics systems. In particular, RAME is built upon an information infrastructure that comprises a fault model, a knowledge base, and a failure reporting/tracking system. This infrastructure permits systematic learning from prior projects and enables the automation of failure modes, effects and criticality analysis (FMECA). Among other unique features, the most important advantage of RAME is its capability of directly accepting design source code in hardware description languages (HDLs) for automated failure mode analysis, which enables RAME to be compatible and to evolve with most electronic-computer-aided-design systems. Through an initial experimental evaluation of the RAME prototype, we show that our approach to FMECA automation improves failure mode analysis turn-around-time, completeness, and accuracy.

  3. Failure modes and effects analysis of fusion magnet systems

    SciTech Connect

    Zimmermann, M; Kazimi, M S; Siu, N O; Thome, R J

    1988-12-01

    A failure modes and consequence analysis of fusion magnet system is an important contributor towards enhancing the design by improving the reliability and reducing the risk associated with the operation of magnet systems. In the first part of this study, a failure mode analysis of a superconducting magnet system is performed. Building on the functional breakdown and the fault tree analysis of the Toroidal Field (TF) coils of the Next European Torus (NET), several subsystem levels are added and an overview of potential sources of failures in a magnet system is provided. The failure analysis is extended to the Poloidal Field (PF) magnet system. Furthermore, an extensive analysis of interactions within the fusion device caused by the operation of the PF magnets is presented in the form of an Interaction Matrix. A number of these interactions may have significant consequences for the TF magnet system particularly interactions triggered by electrical failures in the PF magnet system. In the second part of this study, two basic categories of electrical failures in the PF magnet system are examined: short circuits between the terminals of external PF coils, and faults with a constant voltage applied at external PF coil terminals. An electromagnetic model of the Compact Ignition Tokamak (CIT) is used to examine the mechanical load conditions for the PF and the TF coils resulting from these fault scenarios. It is found that shorts do not pose large threats to the PF coils. Also, the type of plasma disruption has little impact on the net forces on the PF and the TF coils. 39 refs., 30 figs., 12 tabs.

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

    SciTech Connect

    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 a 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

  5. [Failure mode and effect analysis: application in chemotherapy].

    PubMed

    Chuang, Ching-Hui; Chuang, Sheu-Wen

    2009-08-01

    Medical institutions are increasingly concerned about ensuring the safety of patients under their care. Failure mode and effect analysis (FMEA) is a qualitative approach based on a proactive process. Strongly promoted by the Joint Commission Accredited of Health Organization (JCAHO) since 2002, FMEA has since been adopted and widely practiced in healthcare organizations to assess and analyze clinical error events. FMEA has proven to be an effective method of minimizing errors in both manufacturing and healthcare industries. It predicts failure points in systems and allows an organization to address proactively the causes of problems and prioritize improvement strategies. The application of FMEA in chemotherapy at our department identified three main failure points: (1) inappropriate chemotherapy standard operating procedures (SOPs), (2) communication barriers, and (3) insufficient training of nurses. The application of FMEA in chemotherapy is expected to enhance the sensitivity and proactive abilities of healthcare practitioners during potentially risky situations as well as to improve levels of patient care safety.

  6. Letter report seismic shutdown system failure mode and effect analysis

    SciTech Connect

    KECK, R.D.

    1999-09-01

    The Supply Ventilation System Seismic Shutdown ensures that the 234-52 building supply fans, the dry air process fans and vertical development calciner are shutdown following a seismic event. This evaluates the failure modes and determines the effects of the failure modes.

  7. 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.

  8. Failure mode and effects analysis outputs: are they valid?

    PubMed

    Shebl, Nada Atef; Franklin, Bryony Dean; Barber, Nick

    2012-06-10

    Failure Mode and Effects Analysis (FMEA) is a prospective risk assessment tool that has been widely used within the aerospace and automotive industries and has been utilised within healthcare since the early 1990s. The aim of this study was to explore the validity of FMEA outputs within a hospital setting in the United Kingdom. Two multidisciplinary teams each conducted an FMEA for the use of vancomycin and gentamicin. Four different validity tests were conducted: Face validity: by comparing the FMEA participants' mapped processes with observational work. Content validity: by presenting the FMEA findings to other healthcare professionals. Criterion validity: by comparing the FMEA findings with data reported on the trust's incident report database. Construct validity: by exploring the relevant mathematical theories involved in calculating the FMEA risk priority number. Face validity was positive as the researcher documented the same processes of care as mapped by the FMEA participants. However, other healthcare professionals identified potential failures missed by the FMEA teams. Furthermore, the FMEA groups failed to include failures related to omitted doses; yet these were the failures most commonly reported in the trust's incident database. Calculating the RPN by multiplying severity, probability and detectability scores was deemed invalid because it is based on calculations that breach the mathematical properties of the scales used. There are significant methodological challenges in validating FMEA. It is a useful tool to aid multidisciplinary groups in mapping and understanding a process of care; however, the results of our study cast doubt on its validity. FMEA teams are likely to need different sources of information, besides their personal experience and knowledge, to identify potential failures. As for FMEA's methodology for scoring failures, there were discrepancies between the teams' estimates and similar incidents reported on the trust's incident

  9. Failure modes and effects analysis in clinical engineering.

    PubMed

    Willis, G

    1992-01-01

    Failure modes and effects analysis (FMEA) is a proactive quality assurance procedure that has been commonly used to address potential design flaws and product misuses during the design stage of a product's life. FMEA is becoming commonplace among manufacturing companies but is relatively unknown outside of manufacturing circles. One potential new application of FMEA is by medical device end-users who could address design or functional concerns specific to their situation. The continued increase in the amount and complexity of medical instrumentation necessitates an aggressive stance towards safety in each hospital, such as is recommended in this paper.

  10. Failure modes and effects analysis for ocular brachytherapy.

    PubMed

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

    2017-08-18

    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.

  11. 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.

  12. The Worker Exposure Failure Modes and Effects Analysis

    SciTech Connect

    Cadwallader, L.C.

    2005-05-15

    The Worker Exposure Failure Modes and Effects Analysis (WE-FMEA) is a new approach to quantitatively evaluate worker risks from possible failures of co-located equipment in the complex environment of a magnetic or inertial fusion experiment. For next-step experiments such as the International Thermonuclear Experimental Reactor (ITER) or the National Ignition Facility (NIF), the systems and equipment will be larger, handle more throughput or power, and will, in general, be more robust than past experiments. These systems and equipment are necessary to operate the machine, but the rooms are congested with equipment, piping, and cables, which poses a new level of hazard for workers who will perform hands-on maintenance. The WE-FMEA systematically analyzes the nearby equipment and the work environment for equipment failure or inherent hazards, and then develops exposure scenarios. Once identified, the exposure scenarios are evaluated for the worker hazards and quantitative worker risk is calculated. Then risk scenarios are quantitatively compared to existing statistical data on worker injuries; high-risk scenarios can be identified and addressed in more detail to determine the proper means to reduce, mitigate, or protect against the hazard. The WE-FMEA approach is described and a cooling system maintenance example is given.

  13. Failure mode and effects analysis outputs: are they valid?

    PubMed Central

    2012-01-01

    Background Failure Mode and Effects Analysis (FMEA) is a prospective risk assessment tool that has been widely used within the aerospace and automotive industries and has been utilised within healthcare since the early 1990s. The aim of this study was to explore the validity of FMEA outputs within a hospital setting in the United Kingdom. Methods Two multidisciplinary teams each conducted an FMEA for the use of vancomycin and gentamicin. Four different validity tests were conducted: · Face validity: by comparing the FMEA participants’ mapped processes with observational work. · Content validity: by presenting the FMEA findings to other healthcare professionals. · Criterion validity: by comparing the FMEA findings with data reported on the trust’s incident report database. · Construct validity: by exploring the relevant mathematical theories involved in calculating the FMEA risk priority number. Results Face validity was positive as the researcher documented the same processes of care as mapped by the FMEA participants. However, other healthcare professionals identified potential failures missed by the FMEA teams. Furthermore, the FMEA groups failed to include failures related to omitted doses; yet these were the failures most commonly reported in the trust’s incident database. Calculating the RPN by multiplying severity, probability and detectability scores was deemed invalid because it is based on calculations that breach the mathematical properties of the scales used. Conclusion There are significant methodological challenges in validating FMEA. It is a useful tool to aid multidisciplinary groups in mapping and understanding a process of care; however, the results of our study cast doubt on its validity. FMEA teams are likely to need different sources of information, besides their personal experience and knowledge, to identify potential failures. As for FMEA’s methodology for scoring failures, there were discrepancies between the teams’ estimates

  14. Failure mode and effects analysis: A community practice perspective.

    PubMed

    Schuller, Bradley W; Burns, Angi; Ceilley, Elizabeth A; King, Alan; LeTourneau, Joan; Markovic, Alexander; Sterkel, Lynda; Taplin, Brigid; Wanner, Jennifer; Albert, Jeffrey M

    2017-09-25

    To report our early experiences with failure mode and effects analysis (FMEA) in a community practice setting. The FMEA facilitator received extensive training at the AAPM Summer School. Early efforts focused on department education and emphasized the need for process evaluation in the context of high profile radiation therapy accidents. A multidisciplinary team was assembled with representation from each of the major department disciplines. Stereotactic radiosurgery (SRS) was identified as the most appropriate treatment technique for the first FMEA evaluation, as it is largely self-contained and has the potential to produce high impact failure modes. Process mapping was completed using breakout sessions, and then compiled into a simple electronic format. Weekly sessions were used to complete the FMEA evaluation. Risk priority number (RPN) values > 100 or severity scores of 9 or 10 were considered high risk. The overall time commitment was also tracked. The final SRS process map contained 15 major process steps and 183 subprocess steps. Splitting the process map into individual assignments was a successful strategy for our group. The process map was designed to contain enough detail such that another radiation oncology team would be able to perform our procedures. Continuous facilitator involvement helped maintain consistent scoring during FMEA. Practice changes were made responding to the highest RPN scores, and new resulting RPN scores were below our high-risk threshold. The estimated person-hour equivalent for project completion was 258 hr. This report provides important details on the initial steps we took to complete our first FMEA, providing guidance for community practices seeking to incorporate this process into their quality assurance (QA) program. Determining the feasibility of implementing complex QA processes into different practice settings will take on increasing significance as the field of radiation oncology transitions into the new TG-100 QA

  15. Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

    PubMed

    Steinberger, Dina M; Douglas, Stephen V; Kirschbaum, Mark S

    2009-09-01

    A multidisciplinary team from the University of Wisconsin Hospital and Clinics transplant program used failure mode and effects analysis to proactively examine opportunities for communication and handoff failures across the continuum of care from organ procurement to transplantation. The team performed a modified failure mode and effects analysis that isolated the multiple linked, serial, and complex information exchanges occurring during the transplantation of one solid organ. Failure mode and effects analysis proved effective for engaging a diverse group of persons who had an investment in the outcome in analysis and discussion of opportunities to improve the system's resilience for avoiding errors during a time-pressured and complex process.

  16. Analysis of standby and demand stress failures modes

    SciTech Connect

    Lofgren, E.V.; Thaggard, M. )

    1992-10-01

    This report describes work to develop and demonstrates methods for partitioning standby component failure modes into causes that fail the component while it is in standby, and when it changes state, during testing or from other demands. Failure of the component from standby stresses is modeled using a model that explicitly contains the length of the test interval. Failure of the component from demand stresses such as vibration, wind, etc., is modeled using the probability of failure on demand model. Misuse of these models in PRAS, could lead to PRAs that, give misleading results, or that are more useful for decision purposes. A method was developed and demonstrated to partition standby/demand stresses. The method was used on the work maintenance records from two Nuclear Power Plants (NPPs) to estimate reliability parameters for Motor Operated Valves And Emergency Diesel Generators (EDGs).

  17. 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.

  18. FMEA, the alternative process hazard method. [Failure Mode Effects Analysis

    SciTech Connect

    Goyal, R.K. )

    1993-05-01

    Failure mode effects analysis (FMEA) is an old reliability/assurance tool finding its way into the HPI. Not popular yet, this hazard technique has some viable applications that can improve hazard assessment data. Notably, FMEA studies can identify possible areas for improvement that may have not been discovered using other methods. Also, FMEA is not as labor intensive and costly as other process hazard analysis (PHA) methods. PSHA 1910.119 set in place an informational structure whose main purpose is the reduction of potential accidents and minimizing risks in the event of an accident. Consequently, HPI operators must evaluate their process systems and identify potential major hazards, such as fires, explosions and accidental release of toxic/hazardous chemicals, and protect their facilities, employees, the public and the environment. But, which PHA method(s) apply to a particular plant or process still remains a difficult question. This paper describes what FMEA is; types of FMEA; how to conduct a FMEA study; comparison with HAZOP (hazard and operability study); computer software; applicability of FMEA; and examples of its use.

  19. [Failure mode and effects analysis on computerized drug prescriptions].

    PubMed

    Paredes-Atenciano, J A; Roldán-Aviña, J P; González-García, Mercedes; Blanco-Sánchez, M C; Pinto-Melero, M A; Pérez-Ramírez, C; Calvo Rubio-Burgos, Miguel; Osuna-Navarro, F J; Jurado-Carmona, A M

    2015-01-01

    To identify and analyze errors in drug prescriptions of patients treated in a "high resolution" hospital by applying a Failure mode and effects analysis (FMEA).Material and methods A multidisciplinary group of medical specialties and nursing analyzed medical records where drug prescriptions were held in free text format. An FMEA was developed in which the risk priority index (RPI) was obtained from a cross-sectional observational study using an audit of the medical records, carried out in 2 phases: 1) Pre-intervention testing, and (2) evaluation of improvement actions after the first analysis. An audit sample size of 679 medical records from a total of 2,096 patients was calculated using stratified sampling and random selection of clinical events. Prescription errors decreased by 22.2% in the second phase. FMEA showed a greater RPI in "unspecified route of administration" and "dosage unspecified", with no significant decreases observed in the second phase, although it did detect, "incorrect dosing time", "contraindication due to drug allergy", "wrong patient" or "duplicate prescription", which resulted in the improvement of prescriptions. Drug prescription errors have been identified and analyzed by FMEA methodology, improving the clinical safety of these prescriptions. This tool allows updates of electronic prescribing to be monitored. To avoid such errors would require the mandatory completion of all sections of a prescription. Copyright © 2014 SECA. Published by Elsevier Espana. All rights reserved.

  20. 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

  1. Analysis of the shearout failure mode in composite bolted joints

    NASA Technical Reports Server (NTRS)

    Wilson, D. W.; Pipes, R. B.

    1981-01-01

    A semi-empirical shearout strength model has been formulated for the analysis of composite bolted joints with allowance for the effects of joint geometry. The model employs a polynomial stress function in conjunction with a point stress failure criterion to predict strength as a function of fastener size, edge distance, and half spacing. The stress function is obtained by two-dimensional plane-stress finite element analysis using quadrilateral elements with orthotropic material properties. Comparison of experimentally determined shearout strength data with model predicted failures has substantiated the accuracy of the model.

  2. 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.

  3. 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

  4. Constructing an effective prevention mechanism for MSW lifecycle using failure mode and effects analysis.

    PubMed

    Chen, Ying-Chu; Wu, Wen-Fang

    2015-12-01

    Municipal solid waste in Taiwan is a valuable source of renewable energy. Phases of municipal solid waste lifecycle (classification, disposal, storage, collection and transportation) before incineration or landfilled face various potential failures. Applying a proper technique to eliminate or decrease potential failures is desirable and needed. Failure Modes and Effects Analysis to municipal solid waste lifecycle was found in literature. This study utilized the Failure Modes and Effects Analysis as a convenient technique for determining, classifying and analyzing common failures in the municipal solid waste lifecycle. As a result, an appropriate risk scoring of severity, occurrence, and detection of failure modes and computing the Risk Priority Number for identifying the high potential failure modes were made. Nineteen failure modes were identified, and nine of them were ranked as the priority items for improvement. Recommended actions for all failure modes were suggested. Occurrences of failures were remarkably reduced after implementing the procedure for six months. The results of this study have minimized potential failures and brought continuous improvement, thus achieving a better protection of the environment. Copyright © 2015 Elsevier Ltd. All rights reserved.

  5. A failure modes, mechanisms, and effects analysis (FMMEA) of lithium-ion batteries

    NASA Astrophysics Data System (ADS)

    Hendricks, Christopher; Williard, Nick; Mathew, Sony; Pecht, Michael

    2015-11-01

    Lithium-ion batteries are popular energy storage devices for a wide variety of applications. As batteries have transitioned from being used in portable electronics to being used in longer lifetime and more safety-critical applications, such as electric vehicles (EVs) and aircraft, the cost of failure has become more significant both in terms of liability as well as the cost of replacement. Failure modes, mechanisms, and effects analysis (FMMEA) provides a rigorous framework to define the ways in which lithium-ion batteries can fail, how failures can be detected, what processes cause the failures, and how to model failures for failure prediction. This enables a physics-of-failure (PoF) approach to battery life prediction that takes into account life cycle conditions, multiple failure mechanisms, and their effects on battery health and safety. This paper presents an FMMEA of battery failure and describes how this process enables improved battery failure mitigation control strategies.

  6. The use of failure mode effect and criticality analysis in a medication error subcommittee.

    PubMed

    Williams, E; Talley, R

    1994-04-01

    Failure Mode Effect and Criticality Analysis (FMECA) is the systematic assessment of a process or product that enables one to determine the location and mechanism of potential failures. It has been used by engineers, particularly in the aerospace industry, to identify and prioritize potential failures during product development when there is a lack of data but an abundance of expertise. The Institute for Safe Medication Practices has recommended its use in analyzing the medication administration process in hospitals and in drug product development in the pharamceutical industry. A medication error subcommittee adopted and modified FMECA to identify and prioritize significant failure modes in its specific medication administration process. Based on this analysis, the subcommittee implemented solutions to four of the five highest ranked failure modes. FMECA provided a method for a multidisciplinary group to address the most important medication error concerns based upon the expertise of the group members. It also facilitated consensus building in a group with varied perceptions.

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

    SciTech Connect

    Xu, Y; Bhatnagar, J; Bednarz, G; Flickinger, J; Arai, Y; Huq, M Saiful; Vacsulka, J; Monaco, E; Niranjan, A; Lunsford, L Dade; Feng, W

    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 detection (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

  8. A Tool To Support Failure Mode And Effects Analysis Based On Causal Modelling And Reasoning

    NASA Astrophysics Data System (ADS)

    Underwood, W. E.; Laib, S. L.

    1987-05-01

    A prototype knowledge-based system has been developed that supports Failure Mode & Effects Analysis (FMEA). The knowledge base consists of causal models of components and a representation for coupling these components into assemblies and systems. The causal models are qualitative models. They allow reasoning as to whether variables are increasing, decreasing or steady. The analysis strategies used by the prototype allow it to determine the effects of failure modes on the function of the part, the failure effect on the assembly the part is contained in, and the effect on the subsystem containing the assembly.

  9. Preliminary Failure Modes and Effects Analysis of the US Massive Gas Injection Disruption Mitigation System Design

    SciTech Connect

    Lee C. Cadwallader

    2013-10-01

    This report presents the results of a preliminary failure modes and effects analysis (FMEA) of a candidate design for the ITER Disruption Mitigation System. This candidate is the Massive Gas Injection System that provides machine protection in a plasma disruption event. The FMEA was quantified with “generic” component failure rate data as well as some data calculated from operating facilities, and the failure events were ranked for their criticality to system operation.

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

    SciTech Connect

    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.

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

    SciTech Connect

    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.

  12. 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, Al

  13. Evaluation of Safety in a Radiation Oncology Setting Using Failure Mode and Effects Analysis

    SciTech Connect

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

    2009-07-01

    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.

  14. Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.

    PubMed

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

    2009-07-01

    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. 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. 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. 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.

  15. 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

  16. 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.

  17. 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.

  18. Failure Mode and Effects Analysis (FMEA) Introductory Overview

    DTIC Science & Technology

    2012-06-14

    effects based on how severe they are, how often they might occur, and how easily we can find them. 3. Effects: the consequences of failure. The...Actions ! 0 l!1 .. requirE-ments ~ l=ailure 1-’rP.vP.ntion .., llP.tP.c::tion Completion Dato Action• Taken P. il "’ ; · .. "’ = 0 i;r= ~ ~ " S pnrg

  19. [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.

  20. Failure mode analysis of a post-tension anchored dam using linear finite element analysis

    NASA Astrophysics Data System (ADS)

    Corn, Aimee

    There are currently over 84,000 dams in the United States, and the average age of those dams is 52 years. Concrete gravity dams are the second most common dam type, with more than 3,000 in the United States. Current engineering technology and technical understanding of hydrologic and seismic events has resulted in significant increases to the required design loads for most dams; therefore, many older dams do not have adequate safety for extreme loading events. Concrete gravity dams designed and constructed in the early 20th century did not consider uplift pressures beneath the dam, which reduces the effective weight of the structure. One method that has been used to enhance the stability of older concrete gravity dams includes the post-tension anchor (PTA) system. Post-tensioning infers modifying cured concrete and using self-equilibrating elements to increase the weight of the section, which provides added stability. There is a lack of historical evidence regarding the potential failure mechanisms for PTA concrete gravity dams. Of particular interest, is how these systems behave during large seismic events. The objective of this thesis is to develop a method by which the potential failure modes during a seismic event for a PTA dam can be evaluated using the linear elastic finite element method of analysis. The most likely potential failure modes (PFM) for PTA designs are due to tensile failure and shear failure. A numerical model of a hypothetical project was developed to simulate PTAs in the dam. The model was subjected to acceleration time-history motions that simulated the seismic loads. The results were used to evaluate the likelihood of tendon failure due to both tension and shear. The results from the analysis indicated that the PTA load increased during the seismic event; however, the peak load in the tendons was less than the gross ultimate tensile strength (GUTS) and would not be expected to result in tensile failure at the assumed project. The analysis

  1. 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.

  2. 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.

  3. 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.

  4. Damage mechanics - failure modes

    SciTech Connect

    Krajcinovic, D.; Vujosevic, M.

    1996-12-31

    The present study summarizes the results of the DOE sponsored research program focused on the brittle failure of solids with disordered microstructure. The failure is related to the stochastic processes on the microstructural scale; namely, the nucleation and growth of microcracks. The intrinsic failure modes, such as the percolation, localization and creep rupture, are studied by emphasizing the effect of the micro-structural disorder. A rich spectrum of physical phenomena and new concepts that emerges from this research demonstrates the reasons behind the limitations of traditional, deterministic, and local continuum models.

  5. 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.

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

    SciTech Connect

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

    2010-12-15

    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 {approx}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 {approx}35 min, while that taken for comprehensive testing was {approx}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

  7. 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

  8. 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.

  9. 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.

  10. Structured LSA Task 301. Functional Requirements Icentification. Subtask 301.2.4.1. Failure Mode, Effect & Criticality Analysis (FMECA)

    DTIC Science & Technology

    1988-04-01

    DEVELOP GROuE RULES AND ASSUMPTIONS) ITK/FUN ITEM ACRONYMS: FMlA - FAILURE MODE AND EFFECT ANALYSIS FUNCTION L8AR - LOGISTIC SUPPORT ANALYSIS RECORD...Fiu/BLK/DIA FUNCTIONAL ACRONM: FMLA ...FAILURE MODE AND EFFECTS ANALYSIS BLOCK DIAGRAM PURPOSE OF DATA: ALLOW TUE ANALYST ACCESS TO THE FUNCTIONAL BLOCK DIAGRAMS NEEDED TO COPLETE TUE FMlA

  11. Performance improvement through proactive risk assessment: Using failure modes and effects analysis

    PubMed Central

    Yarmohammadian, Mohammad Hossein; Abadi, Tahereh Naseri Boori; Tofighi, Shahram; Esfahani, Sekine Saghaeiannejad

    2014-01-01

    Introduction: Cognizance of any error-prone professional activities has a great impact on the continuity of professional organizations in the competitive atmosphere, particularly in health care industry where every second has critical value in patients’ life saving. Considering invaluable functions of medical record department — as legal document and continuity of health care — “failure mode and effects analysis (FMEA)” utilized to identify the ways a process can fail, and how it can be made safer. Materials and Methods: The structured approach involved assembling a team of experts, employing a trained facilitator, introducing the rating scales and process during team orientation and collectively scoring failure modes. The probability of the failure-effect combination was related to the frequency of occurrence, potential severity, and likelihood of detection before causing any harm to the staff or patients. Frequency, severity and detectability were each given a score from 1 to 10. Risk priority numbers were calculated. Results: In total 56 failure modes were identified and in subsets of Medical Record Department including admission unit dividing emergency, outpatient and inpatient classes, statististic, health data organizing and data processing and Medical Coding units. Although most failure modes were classified as a high risk group, limited resources were, as an impediment to implement recommended actions at the same time. Conclusion: Proactive risk assessment methods, such as FMEA enable health care administrators to identify where and what safeguards are needed to protect against a bad outcome even when an error does occur. PMID:25013821

  12. 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.

  13. 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

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

    PubMed

    Magnezi, Racheli; Hemi, Asaf; Hemi, Rina

    2016-01-01

    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. 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. 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). 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.

  15. 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.

  16. Failure modes and effects analysis of a coal-slurry preheater

    SciTech Connect

    Mitchell, H.A.; Parsly, L.F.; Smith, A.N.

    1981-09-01

    The Fossil Energy performance assurance program is concerned with the application of reliability, safety, and quality assurance techniques in the design and operation of the pilot plants and demonstration plants that exist or are being planned as part of the US Department of Energy fossil energy conversion programs. This report involves the application of one technique, failure modes and effects analysis (FMEA), on the safety and reliability analysis of the coal slurry preheater, a critical component in a typical coal direct liquefaction plant. The analysis identifies 55 potential failure modes. Fourteen of these events, if they should occur, would result in losses of sufficient magnitude to require special consideration in the design or operating phase to assure control of risk at an acceptable level. The report concludes that the FMEA could be a valuable tool in the identification of critical components for coal conversion systems. For maximum effect, FMEA needs to be used during the initial design phase. Its principal value is to determine high-risk failure modes, which could have unacceptable impacts on system safety and reliability/availability. The usefulness of FMEA will be improved if it is supplemented by the development of a failure data base; this data base could also be of value in selected cases as input to a more detaled technique such as fault-tree analysis.

  17. Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward

    PubMed Central

    van Tilburg, C M; Leistikow, I P; Rademaker, C M A; Bierings, M B; van Dijk, A T H

    2006-01-01

    Background Pediatric inpatient settings are known for their high medication error rate. The aim of this study was to investigate whether the Health Care Failure Mode and Effect Analysis (HFMEA) is a valid proactive method to evaluate circumscribed health care processes like prescription up to and including administration of chemotherapy (vincristine) in the pediatric oncology inpatient setting. Methods A multidisciplinary team consisting of a team leader, pharmacy, nursing and medical staff and a patient's parent was assembled in a pediatric oncology ward with a computerized physician order entry system. A flow diagram of the process was made and potential failure modes were identified and evaluated using a hazard scoring matrix. Using a decision tree, it was determined for which failure mode recommendations had to be made. Results The process was divided into three main parts: prescription, processing by the pharmacy, and administration. Fourteen out of 61 failure modes were classified as high risk, 10 of which were sufficiently covered by current protocols. For the other four failure modes, five recommendations were made. Four additional recommendations were made concerning non‐high risk failure modes. Most of them were implemented by the hospital management. The whole process took seven meetings and a total of 140 man‐hours. Conclusions The systematic approach of HFMEA by a multidisciplinary team is a useful method for detecting failure modes. A patient or a parent of a patient contributes to the multidisciplinarity of the team. PMID:16456212

  18. 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

  19. 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

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

    PubMed

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

    2013-12-01

    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. 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. 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

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

    SciTech Connect

    Ciocca, Mario; Cantone, Marie-Claire; Veronese, Ivan; Cattani, Federica; Pedroli, Guido; Molinelli, Silvia; Vitolo, Viviana; Orecchia, Roberto

    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, 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

  2. MO-D-BRB-07: Failure-Mode and Effects Analysis Study for CyberKnife Stereotactic Radiosurgery.

    PubMed

    Dieterich, S; Ford, E; Halasz, C

    2012-06-01

    The purpose of this study is to conduct a Failure Modes and Effect Analysis (FMEA) for CyberKnife Stereotactic Radiosurgery to determine the sensitivity of existing QA procedures and determine in which areas new QA procedures needed to be implemented. Members from each professional team providing service for CyberKnife radiosurgery (Medical Physicists, Nurses, Physicians, Radiation Therapists, and Administrators) were interviewed to gather potential failure modes. A patient flow chart was developed from patient consult to conclusion of last treatment. Failure modes were mapped to nodes in the flow charts to identify potential high-risk areas. A matrix was created to correlate existing QA procedures with failure modes to identify failure modes that were not covered by any QA as well as identify the sensitivity of QA procedures to prevent failures. 180 failure modes were identified. Current AAPM QA recommendations were found to focus preferentially on technical failure modes (15%), while the majority of failure modes found are process failures and human errors (85%). Creating a Venn diagram of CyberKnife and Gamma Knife failure modes revealed a large overlap area. The most effective QA checks are checklists for physics second chart review and pre- treatment time-out checklists. Existing checklists were modified and new checklists added to address high-ranked failure modes. New procedure guidelines, e.g. for contouring workflow and add-on simulations, were developed as QC to address clusters of failure modes. An ARIA-CyberKnife DICOM interface is being implemented to resolve failure modes centering around multiple fraction, multiple plan treatments and total dose tracking. This work is the first FMEA study for the CyberKnife stereotactic radiosurgery. It will facilitate medical physicists using the CyberKnife to deliver SRS/SBRT treatments to transition from experience-based technical QA to a comprehensive new quality paradigm including technical, process, and human

  3. Failure mode and effects analysis: a comparison of two common risk prioritisation methods.

    PubMed

    McElroy, Lisa M; Khorzad, Rebeca; Nannicelli, Anna P; Brown, Alexandra R; Ladner, Daniela P; Holl, Jane L

    2016-05-01

    Failure mode and effects analysis (FMEA) is a method of risk assessment increasingly used in healthcare over the past decade. The traditional method, however, can require substantial time and training resources. The goal of this study is to compare a simplified scoring method with the traditional scoring method to determine the degree of congruence in identifying high-risk failures. An FMEA of the operating room (OR) to intensive care unit (ICU) handoff was conducted. Failures were scored and ranked using both the traditional risk priority number (RPN) and criticality-based method, and a simplified method, which designates failures as 'high', 'medium' or 'low' risk. The degree of congruence was determined by first identifying those failures determined to be critical by the traditional method (RPN≥300), and then calculating the per cent congruence with those failures designated critical by the simplified methods (high risk). In total, 79 process failures among 37 individual steps in the OR to ICU handoff process were identified. The traditional method yielded Criticality Indices (CIs) ranging from 18 to 72 and RPNs ranging from 80 to 504. The simplified method ranked 11 failures as 'low risk', 30 as medium risk and 22 as high risk. The traditional method yielded 24 failures with an RPN ≥300, of which 22 were identified as high risk by the simplified method (92% agreement). The top 20% of CI (≥60) included 12 failures, of which six were designated as high risk by the simplified method (50% agreement). These results suggest that the simplified method of scoring and ranking failures identified by an FMEA can be a useful tool for healthcare organisations with limited access to FMEA expertise. However, the simplified method does not result in the same degree of discrimination in the ranking of failures offered by the traditional method. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  4. Using Healthcare Failure Mode and Effect Analysis to Reduce Intravenous Chemotherapy Errors in Chinese Hospitalized Patients.

    PubMed

    Li, Gui; Xu, Bo; He, Rui-Xian; Zhang, Shu-Xiang

    Intravenous chemotherapy administration is a high-risk process; attention must be paid to preventing errors that might occur during the administration of chemotherapy. The aim of this study is to investigate whether the healthcare failure mode and effect analysis (HFMEA) is a valid proactive method to apply to chemotherapy administration in the Chinese oncology inpatient setting. A multidisciplinary team created a flow diagram of the chemotherapy administration process and potential failure modes were identified and evaluated using a hazard-scoring matrix. Using a decision tree, failure mode recommendations were made. Chemotherapy error rates before and after the HFMEA were compared. A total of 5 failure modes were identified with high hazard scores, and 15 recommendations were made. After the intervention, the chemotherapy error rate decreased significantly from 2.05% to 0.17%. The complexity of intravenous chemotherapy makes it vulnerable to error, and with serious consequences. Multiple errors can occur during ordering, preparing, compounding, dispensing, and administering the chemotherapy. The process of HFMEA helped reduce the chemotherapy error rate in Chinese hospitalized patients. Clinicians in oncology can take effective measures to avoid chemotherapy errors using the HFMEA.

  5. Risk assessment of the emergency processes: Healthcare failure mode and effect analysis

    PubMed Central

    Taleghani, Yasamin Molavi; Rezaei, Fatemeh; Sheikhbardsiri, Hojat

    2016-01-01

    BACKGROUND: Ensuring about the patient’s safety is the first vital step in improving the quality of care and the emergency ward is known as a high-risk area in treatment health care. The present study was conducted to evaluate the selected risk processes of emergency surgery department of a treatment-educational Qaem center in Mashhad by using analysis method of the conditions and failure effects in health care. METHODS: In this study, in combination (qualitative action research and quantitative cross-sectional), failure modes and effects of 5 high-risk procedures of the emergency surgery department were identified and analyzed according to Healthcare Failure Mode and Effects Analysis (HFMEA). To classify the failure modes from the “nursing errors in clinical management model (NECM)”, the classification of the effective causes of error from “Eindhoven model” and determination of the strategies to improve from the “theory of solving problem by an inventive method” were used. To analyze the quantitative data of descriptive statistics (total points) and to analyze the qualitative data, content analysis and agreement of comments of the members were used. RESULTS: In 5 selected processes by “voting method using rating”, 23 steps, 61 sub-processes and 217 potential failure modes were identified by HFMEA. 25 (11.5%) failure modes as the high risk errors were detected and transferred to the decision tree. The most and the least failure modes were placed in the categories of care errors (54.7%) and knowledge and skill (9.5%), respectively. Also, 29.4% of preventive measures were in the category of human resource management strategy. CONCLUSION: “Revision and re-engineering of processes”, “continuous monitoring of the works”, “preparation and revision of operating procedures and policies”, “developing the criteria for evaluating the performance of the personnel”, “designing a suitable educational content for needs of employee”,

  6. 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.

  7. Model OA Wind Turbine Generator FEMA (Failure Modes and Effects Analysis)

    SciTech Connect

    Klein, W.E. . Plum Brook Station); Lalli, V.R. . Lewis Research Center)

    1989-10-01

    This report presents the results of Failure Modes and Effects Analysis (FMEA) conducted for the Wind Turbine Generators. 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. 2 refs., 3 figs.

  8. Using causal reasoning for automated failure modes and effects analysis (FMEA)

    NASA Astrophysics Data System (ADS)

    Bell, Daniel; Cox, Lisa; Jackson, Steve; Schaefer, Phil

    The authors have developed a tool that automates the reasoning portion of a failure modes and effects analysis (FMEA). It is built around a flexible causal reasoning module that has been adapted to the FMEA procedure. The approach and software architecture have been proven. A prototype tool has been created and successfully passed a test and evaluation program. The authors are expanding the operational capability and adapting the tool to various CAD/CAE (computer-aided design and engineering) platforms.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

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

    SciTech Connect

    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 number 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.

  14. Common Cause Failure Modes

    NASA Technical Reports Server (NTRS)

    Wetherholt, Jon; Heimann, Timothy J.; Anderson, Brenda

    2011-01-01

    High technology industries with high failure costs commonly use redundancy as a means to reduce risk. Redundant systems, whether similar or dissimilar, are susceptible to Common Cause Failures (CCF). CCF is not always considered in the design effort and, therefore, can be a major threat to success. There are several aspects to CCF which must be understood to perform an analysis which will find hidden issues that may negate redundancy. This paper will provide definition, types, a list of possible causes and some examples of CCF. Requirements and designs from NASA projects will be used in the paper as examples.

  15. 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

  16. 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

  17. 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

  18. 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.

  19. Anticipating risk for human subjects participating in clinical research: application of Failure Mode and Effects Analysis.

    PubMed

    Cody, Robert J

    2006-03-01

    Failure Mode and Effects Analysis (FMEA) is a method applied in various industries to anticipate and mitigate risk. This methodology can be more systematically applied to the protection of human subjects in research. The purpose of FMEA is simple: prevent problems before they occur. By applying FMEA process analysis to the elements of a specific research protocol, the failure severity, occurrence, and detection rates can be estimated for calculation of a "risk priority number" (RPN). Methods can then be identified to reduce the RPN to levels where the risk/benefit ratio favors human subject benefit, to a greater magnitude than existed in the pre-analysis risk profile. At the very least, the approach provides a checklist of issues that can be individualized for specific research protocols or human subject populations.

  20. 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.

  1. 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.

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

    SciTech Connect

    Perks, Julian R.; Stanic, Sinisa; Stern, Robin L.; Henk, Barbara; Nelson, Marsha S.; Harse, Rick D.; Mathai, Mathew; Purdy, James A.; Valicenti, Richard K.; Siefkin, Allan D.; Chen, Allen M.

    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). 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.

  3. 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.

  4. Poster - Thur Eve - 19: Risk assessment of clinical radiation processes using failure modes and effect analysis.

    PubMed

    Angers, C; Studinski, R; La Russa, D; Bahm, J; Renaud, J; Clark, B G

    2012-07-01

    The aim of this work was to apply failure modes and effect analysis (FMEA) to assess risk in two radiation planning and treatment processes; our on-call (out-of-clinical hours) process and our tomotherapy process. The motivation was provided by analysis of 2506 adverse incidents reported over a 5 year period, the on-call process for giving rise to a higher than expected number of incidents and our tomotherapy process for the reverse. For the on-call scenario, three separate processes were analysed: our current process, our current process incorporating a software upgrade eliminating several planning steps and a fully integrated process in which the patient is imaged, planned and treated on a single platform (TomoTherapy Hi Art, Accuray Incorporated, Sunnyvale, CA). After construction of a detailed process map for each case, a multidisciplinary group identified potential failure modes for each process step, the effects of each failure and existing controls. Risk probability numbers were determined from severity, frequency of occurrence and detectability scores assigned to each failure mode according to a standard scale. The results were analysed to identify and prioritise feasible and effective process improvements. For the on-call process, our current workflow was identified as incurring the highest risk of the three processes analysed, demonstrating quantitatively the value of the software upgrade and providing a clear rationale for the associated expense. In summary, we have found FMEA to be a feasible tool for assessing relative risk in a clinical process. However, operational and resource issues must be considered separately. © 2012 American Association of Physicists in Medicine.

  5. 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

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

    PubMed

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

    2014-07-15

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

  7. Modular titanium alloy neck adapter failures in hip replacement - failure mode analysis and influence of implant material

    PubMed Central

    2010-01-01

    Background Modular neck adapters for hip arthroplasty stems allow the surgeon to modify CCD angle, offset and femoral anteversion intraoperatively. Fretting or crevice corrosion may lead to failure of such a modular device due to high loads or surface contamination inside the modular coupling. Unfortunately we have experienced such a failure of implants and now report our clinical experience with the failures in order to advance orthopaedic material research and joint replacement surgery. The failed neck adapters were implanted between August 2004 and November 2006 a total of about 5000 devices. After this period, the titanium neck adapters were replaced by adapters out of cobalt-chromium. Until the end of 2008 in total 1.4% (n = 68) of the implanted titanium alloy neck adapters failed with an average time of 2.0 years (0.7 to 4.0 years) postoperatively. All, but one, patients were male, their average age being 57.4 years (36 to 75 years) and the average weight 102.3 kg (75 to 130 kg). The failures of neck adapters were divided into 66% with small CCD of 130° and 60% with head lengths of L or larger. Assuming an average time to failure of 2.8 years, the cumulative failure rate was calculated with 2.4%. Methods A series of adapter failures of titanium alloy modular neck adapters in combination with a titanium alloy modular short hip stem was investigated. For patients having received this particular implant combination risk factors were identified which were associated with the occurence of implant failure. A Kaplan-Meier survival-failure-analysis was conducted. The retrieved implants were analysed using microscopic and chemical methods. Modes of failure were simulated in biomechanical tests. Comparative tests included modular neck adapters made of titanium alloy and cobalt chrome alloy material. Results Retrieval examinations and biomechanical simulation revealed that primary micromotions initiated fretting within the modular tapered neck connection. A continuous

  8. Modular titanium alloy neck adapter failures in hip replacement--failure mode analysis and influence of implant material.

    PubMed

    Grupp, Thomas M; Weik, Thomas; Bloemer, Wilhelm; Knaebel, Hanns-Peter

    2010-01-04

    Modular neck adapters for hip arthroplasty stems allow the surgeon to modify CCD angle, offset and femoral anteversion intraoperatively. Fretting or crevice corrosion may lead to failure of such a modular device due to high loads or surface contamination inside the modular coupling. Unfortunately we have experienced such a failure of implants and now report our clinical experience with the failures in order to advance orthopaedic material research and joint replacement surgery.The failed neck adapters were implanted between August 2004 and November 2006 a total of about 5000 devices. After this period, the titanium neck adapters were replaced by adapters out of cobalt-chromium. Until the end of 2008 in total 1.4% (n = 68) of the implanted titanium alloy neck adapters failed with an average time of 2.0 years (0.7 to 4.0 years) postoperatively. All, but one, patients were male, their average age being 57.4 years (36 to 75 years) and the average weight 102.3 kg (75 to 130 kg). The failures of neck adapters were divided into 66% with small CCD of 130 degrees and 60% with head lengths of L or larger. Assuming an average time to failure of 2.8 years, the cumulative failure rate was calculated with 2.4%. A series of adapter failures of titanium alloy modular neck adapters in combination with a titanium alloy modular short hip stem was investigated. For patients having received this particular implant combination risk factors were identified which were associated with the occurRence of implant failure. A Kaplan-Meier survival-failure-analysis was conducted. The retrieved implants were analysed using microscopic and chemical methods. Modes of failure were simulated in biomechanical tests. Comparative tests included modular neck adapters made of titanium alloy and cobalt chrome alloy material. Retrieval examinations and biomechanical simulation revealed that primary micromotions initiated fretting within the modular tapered neck connection. A continuous abrasion and

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

    SciTech Connect

    Xie, J; Xiao, Y; Wang, J; Peng, J; Lu, S; Hu, W

    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 of 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.

  10. 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

  11. Failure mode and effects analysis of skin electronic brachytherapy using Esteya(®) unit.

    PubMed

    Ibanez-Rosello, Blanca; Bautista-Ballesteros, Juan Antonio; Bonaque, Jorge; Celada, Francisco; Lliso, Françoise; Carmona, Vicente; Gimeno-Olmos, Jose; Ouhib, Zoubir; Rosello, Joan; Perez-Calatayud, Jose

    2016-12-01

    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). 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. 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. 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.

  12. 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

  13. 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

  14. Cost Based Failure Modes and Effects Analysis (FMEA) for Systems of Accelerator Magnets.

    SciTech Connect

    Spencer, Cherrill M

    2003-06-02

    The proposed Next Linear Collider (NLC) has a proposed 85% overall availability goal, the availability specifications for all its 7200 magnets and their 6167 power supplies are 97.5% each. Thus all of the electromagnets and their power supplies must be highly reliable or quickly repairable. Improved reliability or repairability comes at a higher cost. We have developed a set of analysis procedures for magnet designers to use as they decide how much effort to exert, i.e. how much money to spend, to improve the reliability of a particular style of magnet. We show these procedures being applied to a standard SLAC electromagnet design in order to make it reliable enough to meet the NLC availability specs. First, empirical data from SLAC's accelerator failure database plus design experience are used to calculate MTBF for failure modes identified through a FMEA. Availability for one particular magnet can be calculated. Next, labor and material costs to repair magnet failures are used in a Monte Carlo simulation to calculate the total cost of all failures over a 30-year lifetime. Opportunity costs are included. Engineers choose from amongst various designs by comparing lifecycle costs.

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

    SciTech Connect

    Younge, Kelly Cooper; Wang, Yizhen; Thompson, John; Giovinazzo, Julia; Finlay, Marisa

    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 total 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.

  16. 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.

  17. 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.

  18. Risk management for outsourcing biomedical waste disposal – Using the failure mode and effects analysis

    SciTech Connect

    Liao, Ching-Jong; Ho, Chao Chung

    2014-07-15

    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 disposal 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.

  19. Failure mode and effects analysis of witnessing protocols for ensuring traceability during PGD/PGS cycles.

    PubMed

    Cimadomo, Danilo; Ubaldi, Filippo Maria; Capalbo, Antonio; Maggiulli, Roberta; Scarica, Catello; Romano, Stefania; Poggiana, Cristina; Zuccarello, Daniela; Giancani, Adriano; Vaiarelli, Alberto; Rienzi, Laura

    2016-09-01

    Preimplantation genetic diagnosis and aneuploidy testing (PGD/PGS) use is constantly growing in IVF, and embryo/biopsy traceability during the additional laboratory procedures needed is pivotal. An electronic witnessing system (EWS), which showed a significant value in decreasing mismatch occurrence and increasing detection possibilities during standard care IVF, still does not guarantee the same level of efficiency during PGD/PGS cycles. Specifically, EWS cannot follow single embryos throughout the procedure. This is however critical when an unambiguous diagnosis corresponds to each embryo. Failure Mode and Effects Analysis (FMEA) is a proactive method generally adopted to define tools ensuring safety along a procedure. Due to the implementation of a large quantitative PCR (qPCR)-based blastocyst stage PGD/PGS programme in our centre, and to evaluate the potential procedural risks, a FMEA was performed in September 2014. Forty-four failure modes were identified, among which six were given a moderate risk priority number (>15) (RPN; product of estimated occurrence, severity and detection). Specific corrective measures were then introduced and implemented, and a second evaluation performed six months later. The meticulous and careful application of such measures allowed the risks to be decreased along the whole protocol, by reducing their estimated occurrence and/or increasing detection possibilities. Copyright © 2016 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

  20. 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

    2017-03-28

    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.

  1. [Failure mode and effects analysis (FMEA) of insulin in a mother-child university-affiliated health center].

    PubMed

    Berruyer, M; Atkinson, S; Lebel, D; Bussières, J-F

    2016-01-01

    Insulin is a high-alert drug. The main objective of this descriptive cross-sectional study was to evaluate the risks associated with insulin use in healthcare centers. The secondary objective was to propose corrective measures to reduce the main risks associated with the most critical failure modes in the analysis. We conducted a failure mode and effects analysis (FMEA) in obstetrics-gynecology, neonatology and pediatrics. Five multidisciplinary meetings occurred in August 2013. A total of 44 out of 49 failure modes were analyzed. Nine out of 44 (20%) failure modes were deemed critical, with a criticality score ranging from 540 to 720. Following the multidisciplinary meetings, everybody agreed that an FMEA was a useful tool to identify failure modes and their relative importance. This approach identified many corrective measures. This shared experience increased awareness of safety issues with insulin in our mother-child center. This study identified the main failure modes and associated corrective measures. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

  2. A blackboard model of an expert system for failure mode and effects analysis

    NASA Astrophysics Data System (ADS)

    Russomanno, David J.; Bonnell, Ronald D.; Bowles, John B.

    The design of an expert system to assist in performing a failure mode and effects analysis (FMEA) is approached from a knowledge-use-level perspective to provide a thorough understanding of the problem and insight into the knowledge and expertise needed to automate the FMEA process. A blackboard model is a conceptual model that provides the organizational principles required for the design of an expert system without actually specifying its realization. In the blackboard model of an intelligent FMEA, the system is functionally decomposed into a set of knowledge sources, each containing the knowledge associated with a subfunction of the FMEA process. The conceptual model derived can be used to evaluate attempts to automate the FMEA process, and it can serve as the foundation for further research into automating the FMEA process. An example is presented illustrating the interaction among the knowledge sources in the blackboard model to construct a FMEA for a domestic hot water heater.

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

    NASA Technical Reports Server (NTRS)

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

  4. 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.

  5. SU-F-P-07: Applying Failure Modes and Effects Analysis to Treatment Planning System QA

    SciTech Connect

    Mathew, D; Alaei, P

    2016-06-15

    Purpose: A small-scale implementation of Failure Modes and Effects Analysis (FMEA) for treatment planning system QA by utilizing methodology of AAPM TG-100 report. Methods: FMEA requires numerical values for severity (S), occurrence (O) and detectability (D) of each mode of failure. The product of these three values gives a risk priority number (RPN). We have implemented FMEA for the treatment planning system (TPS) QA for two clinics which use Pinnacle and Eclipse TPS. Quantitative monthly QA data dating back to 4 years for Pinnacle and 1 year for Eclipse have been used to determine values for severity (deviations from predetermined doses at points or volumes), and occurrence of such deviations. The TPS QA protocol includes a phantom containing solid water and lung- and bone-equivalent heterogeneities. Photon and electron plans have been evaluated in both systems. The dose values at multiple distinct points of interest (POI) within the solid water, lung, and bone-equivalent slabs, as well as mean doses to several volumes of interest (VOI), have been re-calculated monthly using the available algorithms. Results: The computed doses vary slightly month-over-month. There have been more significant deviations following software upgrades, especially if the upgrade involved re-modeling of the beams. TG-100 guidance and the data presented here suggest an occurrence (O) of 2 depending on the frequency of re-commissioning the beams, severity (S) of 3, and detectability (D) of 2, giving an RPN of 12. Conclusion: Computerized treatment planning systems could pose a risk due to dosimetric errors and suboptimal treatment plans. The FMEA analysis presented here suggests that TPS QA should immediately follow software upgrades, but does not need to be performed every month.

  6. Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

    PubMed Central

    Kapur, Ajay; Goode, Gina; Riehl, Catherine; Zuvic, Petrina; Joseph, Sherin; Adair, Nilda; Interrante, Michael; Bloom, Beatrice; Lee, Lucille; Sharma, Rajiv; Sharma, Anurag; Antone, Jeffrey; Riegel, Adam; Vijeh, Lili; Zhang, Honglai; Cao, Yijian; Morgenstern, Carol; Montchal, Elaine; Cox, Brett; Potters, Louis

    2013-01-01

    By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice. PMID:24380074

  7. Comparison Study of Electromagnet and Permanent Magnet Systems for an Accelerator Using Cost-Based Failure Modes and Effects Analysis.

    SciTech Connect

    Spencer, C

    2004-02-19

    The next generation of particle accelerators will be one-of-a-kind facilities, and to meet their luminosity goals they must have guaranteed availability over their several decade lifetimes. The Next Linear Collider (NLC) is one viable option for a 1 TeV electron-positron linear collider, it has an 85% overall availability goal. We previously showed how a traditional Failure Modes and Effects Analysis (FMEA) of a SLAC electromagnet leads to reliability-enhancing design changes. Traditional FMEA identifies failure modes with high risk but does not consider the consequences in terms of cost, which could lead to unnecessarily expensive components. We have used a new methodology, ''Life Cost-Based FMEA'', which measures risk of failure in terms of cost, in order to evaluate and compare two different technologies that might be used for the 8653 NLC magnets: electromagnets or permanent magnets. The availabilities for the two different types of magnet systems have been estimated using empirical data from SLAC's accelerator failure database plus expert opinion on permanent magnet failure modes and industry standard failure data. Labor and material costs to repair magnet failures are predicted using a Monte Carlo simulation of all possible magnet failures over a 30-year lifetime. Our goal is to maximize up-time of the NLC through magnet design improvements and the optimal combination of electromagnets and permanent magnets, while reducing magnet system lifecycle costs.

  8. Failure Modes Effects and Criticality Analysis, an Underutilized Safety, Reliability, Project Management and Systems Engineering Tool

    NASA Astrophysics Data System (ADS)

    Mullin, Daniel Richard

    2013-09-01

    The majority of space programs whether manned or unmanned for science or exploration require that a Failure Modes Effects and Criticality Analysis (FMECA) be performed as part of their safety and reliability activities. This comes as no surprise given that FMECAs have been an integral part of the reliability engineer's toolkit since the 1950s. The reasons for performing a FMECA are well known including fleshing out system single point failures, system hazards and critical components and functions. However, in the author's ten years' experience as a space systems safety and reliability engineer, findings demonstrate that the FMECA is often performed as an afterthought, simply to meet contract deliverable requirements and is often started long after the system requirements allocation and preliminary design have been completed. There are also important qualitative and quantitative components often missing which can provide useful data to all of project stakeholders. These include; probability of occurrence, probability of detection, time to effect and time to detect and, finally, the Risk Priority Number. This is unfortunate as the FMECA is a powerful system design tool that when used effectively, can help optimize system function while minimizing the risk of failure. When performed as early as possible in conjunction with writing the top level system requirements, the FMECA can provide instant feedback on the viability of the requirements while providing a valuable sanity check early in the design process. It can indicate which areas of the system will require redundancy and which areas are inherently the most risky from the onset. Based on historical and practical examples, it is this author's contention that FMECAs are an immense source of important information for all involved stakeholders in a given project and can provide several benefits including, efficient project management with respect to cost and schedule, system engineering and requirements management

  9. Failure Mode and Effects Analysis: views of hospital staff in the UK.

    PubMed

    Shebl, Nada; Franklin, Bryony; Barber, Nick; Burnett, Susan; Parand, Anam

    2012-01-01

    To explore health care professionals' experiences and perceptions of Failure Mode and Effects Analysis (FMEA), a team-based, prospective risk analysis technique. Semi-structured interviews were conducted with 21 operational leads (20 pharmacists, one nurse) in medicines management teams of hospitals participating in a national quality improvement programme. Interviews were transcribed, coded and emergent themes identified using framework analysis. Themes identified included perceptions and experiences of participants with FMEA, validity and reliability issues, and FMEA's use in practice. FMEA was considered to be a structured but subjective process that helps health care professionals get together to identify high risk areas of care. Both positive and negative opinions were expressed, with the majority of interviewees expressing positive views towards FMEA in relation to its structured nature and the use of a multidisciplinary team. Other participants criticised FMEA for being subjective and lacking validity. Most likely to restrict its widespread use were its time consuming nature and its perceived lack of validity and reliability. FMEA is a subjective but systematic tool that helps identify high risk areas, but its time consuming nature, difficulty with the scores and perceived lack of validity and reliability may limit its widespread use.

  10. Evaluating the application of failure mode and effects analysis technique in hospital wards: a systematic review

    PubMed Central

    Asgari Dastjerdi, Hoori; Khorasani, Elahe; Yarmohammadian, Mohammad Hossein; Ahmadzade, Mahdiye Sadat

    2017-01-01

    Abstract: Background: Medical errors are one of the greatest problems in any healthcare systems. The best way to prevent such problems is errors identification and their roots. Failure Mode and Effects Analysis (FMEA) technique is a prospective risk analysis method. This study is a review of risk analysis using FMEA technique in different hospital wards and departments. Methods: This paper has systematically investigated the available databases. After selecting inclusion and exclusion criteria, the related studies were found. This selection was made in two steps. First, the abstracts and titles were investigated by the researchers and, after omitting papers which did not meet the inclusion criteria, 22 papers were finally selected and the text was thoroughly examined. At the end, the results were obtained. Results: The examined papers had focused mostly on the process and had been conducted in the pediatric wards and radiology departments, and most participants were nursing staffs. Many of these papers attempted to express almost all the steps of model implementation; and after implementing the strategies and interventions, the Risk Priority Number (RPN) was calculated to determine the degree of the technique’s effect. However, these papers have paid less attention to the identification of risk effects. Conclusions: The study revealed that a small number of studies had failed to show the FMEA technique effects. In general, however, most of the studies recommended this technique and had considered it a useful and efficient method in reducing the number of risks and improving service quality. PMID:28039688

  11. Analysis of standby and demand stress failures modes. Methodology and applications to EDGs and MOVs

    SciTech Connect

    Lofgren, E.V.; Thaggard, M.

    1992-10-01

    This report describes work to develop and demonstrates methods for partitioning standby component failure modes into causes that fail the component while it is in standby, and when it changes state, during testing or from other demands. Failure of the component from standby stresses is modeled using a model that explicitly contains the length of the test interval. Failure of the component from demand stresses such as vibration, wind, etc., is modeled using the probability of failure on demand model. Misuse of these models in PRAS, could lead to PRAs that, give misleading results, or that are more useful for decision purposes. A method was developed and demonstrated to partition standby/demand stresses. The method was used on the work maintenance records from two Nuclear Power Plants (NPPs) to estimate reliability parameters for Motor Operated Valves And Emergency Diesel Generators (EDGs).

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

    SciTech Connect

    Teixeira, Flavia C.

    2016-01-15

    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 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. 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

  13. Risk Management in Magnetic Resonance: Failure Mode, Effects, and Criticality Analysis

    PubMed Central

    Granata, Vincenza; Filice, Salvatore; Raiano, Nicola; Amato, Daniela Maria; Zirpoli, Maria; di Finizio, Alessandro; Sansone, Mario; Russo, Anna; Covelli, Eugenio Maria; Pedicini, Tonino; Triassi, Maria

    2013-01-01

    The aim of the study was to perform a risk management procedure in “Magnetic Resonance Examination” process in order to identify the critical phases and sources of radiological errors and to identify potential improvement projects including procedures, tests, and checks to reduce the error occurrence risk. In this study we used the proactive analysisFailure Mode Effects Criticality Analysis,” a qualitative and quantitative risk management procedure; has calculated Priority Risk Index (PRI) for each activity of the process; have identified, on the PRI basis, the most critical activities and, for them, have defined improvement projects; and have recalculated the PRI after implementation of improvement projects for each activity. Time stop and audits are performed in order to control the new procedures. The results showed that the most critical tasks of “Magnetic Resonance Examination” process were the reception of the patient, the patient schedule drafting, the closing examination, and the organization of activities. Four improvement projects have been defined and executed. PRI evaluation after improvement projects implementation has shown that the risk decreased significantly following the implementation of procedures and controls defined in improvement projects, resulting in a reduction of the PRI between 43% and 100%. PMID:24171173

  14. 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

  15. Failure Mode/Mechanism Distributions

    DTIC Science & Technology

    1991-09-01

    Boards: Flashover (24996-000,NR) Broken NR Terminal Boards: Mechanical Breakage (24996-000,NR) Cortact Failure MR Terminals: (Intermittent contact... mechanism data on of various discrete semiconductor device types. The data has been compiled from reports of reliability demonstration tests conducted in...Room 3C0, Fnrbes Bu ilinn. Order No. FMD-91 Failure Mode/ Mechanism Distributions DTiC QUALIi INSPECTED 5 1991 Ace 94taa Yor SNTTS ai Prepared by: ,= t

  16. 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.

  17. Failure mode and effects analysis applied to the maintenance and repair of anesthetic equipment in an austere medical environment.

    PubMed

    Rosen, Michael A; Lee, Benjamin H; Sampson, John B; Koka, Rahul; Chima, Adaora M; Ogbuagu, Onyebuchi U; Marx, Megan K; Kamara, Thaim B; Koroma, Michael; Jackson, Eric V

    2014-08-01

    Medical technology designed for Western settings frequently does not function adequately or as intended when placed in an austere clinical environment because of issues such as the instability of the electrical grid, environmental conditions, access to replacement parts, level of provider training and general absence of biomedical engineering support. The purpose of this study was to demonstrate the feasibility of applying failure mode and effects analysis as part of an implementation strategy for medical devices in austere medical settings. Observational case-study. SETTING/PARTICIPANTS/INTERVENTION: We conducted failure mode and effects analysis sessions with 16 biomedical engineering technicians at two tertiary-care hospitals in Freetown, Sierra Leone. The sessions focused on maintenance and repair processes for the Universal Anaesthesia Machine. Participating biomedical engineers detailed local maintenance and repair processes and failure modes, including resource availability, communication challenges, use errors and physical access to the machine. Qualitative descriptive themes in barriers perceived and solutions generated by biomedical engineers. Solutions generated involved redesigned work processes to increase the efficiency of identifying machine malfunctions, clinician engagement strategies, a formal plan for acquiring spare parts and plans for improving access to the machine. Follow-up interviews indicated solutions generated were implemented and perceived to be effective. This study demonstrates the feasibility of using the failure mode and effects analysis approach to improve implementation of technology in austere medical environments. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

  18. Using Failure Mode Effects and Criticality Analysis for High-Risk Processes at Three Community Hospitals

    SciTech Connect

    Coles, Garill A.; Fuller, Becky; Nordquist, Kathleen; Kongslie, Anita

    2005-03-01

    The staff at three Washington State hospitals and Battelle Pacific Northwest Division have been collaborating to apply Failure Mode Effects and Criticality Analysis (FMECA) to assess several hospital processes. The staff from Kadlec Medical Center (KMC), located in Richland, Washington; Kennewick General Hospital (KGH), located in Kennewick, Washington; and Lourdes Medical Center (LMC), located in Pasco, Washington, along with staff from Battelle, which is located in Richland, Washington have been working together successfully for two and a half years. Tri-Cities Shared Services, a local organization which implements shared hospital services, has provided the forum for joint activity. This effort was initiated in response to the new JCAHO patient safety standards implemented in July 2001, and the hospitals’ desire to be more proactive in improving patient safety. As a result of performing FMECAs the weaknesses of six medical processes have been characterized and corresponding system improvements implemented. Based on this collective experience, insights about the benefits of applying FMECAs to healthcare processes have been identified.

  19. Leveraging electronic health record documentation for Failure Mode and Effects Analysis team identification

    PubMed Central

    Carson, Matthew B; Lee, Young Ji; Benacka, Corrine; Mutharasan, R. Kannan; Ahmad, Faraz S; Kansal, Preeti; Yancy, Clyde W; Anderson, Allen S; Soulakis, Nicholas D

    2017-01-01

    Objective: Using Failure Mode and Effects Analysis (FMEA) as an example quality improvement approach, our objective was to evaluate whether secondary use of orders, forms, and notes recorded by the electronic health record (EHR) during daily practice can enhance the accuracy of process maps used to guide improvement. We examined discrepancies between expected and observed activities and individuals involved in a high-risk process and devised diagnostic measures for understanding discrepancies that may be used to inform quality improvement planning. Methods: Inpatient cardiology unit staff developed a process map of discharge from the unit. We matched activities and providers identified on the process map to EHR data. Using four diagnostic measures, we analyzed discrepancies between expectation and observation. Results: EHR data showed that 35% of activities were completed by unexpected providers, including providers from 12 categories not identified as part of the discharge workflow. The EHR also revealed sub-components of process activities not identified on the process map. Additional information from the EHR was used to revise the process map and show differences between expectation and observation. Conclusion: Findings suggest EHR data may reveal gaps in process maps used for quality improvement and identify characteristics about workflow activities that can identify perspectives for inclusion in an FMEA. Organizations with access to EHR data may be able to leverage clinical documentation to enhance process maps used for quality improvement. While focused on FMEA protocols, findings from this study may be applicable to other quality activities that require process maps. PMID:27589944

  20. Effectiveness and cost of failure mode and effects analysis methodology to reduce neurosurgical site infections.

    PubMed

    Hover, Alexander R; Sistrunk, William W; Cavagnol, Robert M; Scarrow, Alan; Finley, Phillip J; Kroencke, Audrey D; Walker, Judith L

    2014-01-01

    Mercy Hospital Springfield is a tertiary care facility with 32 000 discharges and 15 000 inpatient surgeries in 2011. From June 2009 through January 2011, a stable inpatient elective neurosurgery infection rate of 2.15% was observed. The failure mode and effects analysis (FMEA) methodology to reduce inpatient neurosurgery infections was utilized. Following FMEA implementation, overall elective neurosurgery infection rates were reduced to 1.51% and sustained through May 2012. Compared with baseline, the post-FMEA deep-space and organ infection rate was reduced by 41% (P = .052). Overall hospital inpatient clean surgery infection rates for the same time frame did not decrease to the same extent, suggesting a specific effect of the FMEA. The study team believes that the FMEA interventions resulted in 14 fewer expected infections, $270 270 in savings, a 168-day reduction in expected length of stay, and 22 fewer readmissions. Given the serious morbidity and cost of health care-associated infections, the study team concludes that FMEA implementation was clinically cost-effective. © 2013 by the American College of Medical Quality.

  1. Failure modes and effects analysis of total skin electron irradiation technique.

    PubMed

    Ibanez-Rosello, B; Bautista, J A; Bonaque, J; Perez-Calatayud, J; Gonzalez-Sanchis, A; Lopez-Torrecilla, J; Brualla-Gonzalez, L; Garcia-Hernandez, T; Vicedo-Gonzalez, A; Granero, D; Serrano, A; Borderia, B; Solera, C; Rosello, J

    2017-08-04

    Total skin electron irradiation (TSEI) is a radiotherapy technique which consists of an homogeneous body surface irradiation by electrons. This treatment requires very strict technical and dosimetric conditions, requiring the implementation of multiple controls. Recently, the Task Group 100 report of the AAPM has recommended adapting the quality assurance program of the facility to the risks of their processes. A multidisciplinary team evaluated the potential failure modes (FMs) of every process step, regardless of the management tools applied in the installation. For every FM, occurrence (O), severity (S) and detectability (D) by consensus was evaluated, which resulted in the risk priority number (RPN), which permitted the ranking of the FMs. Subsequently, all the management tools used, related to the TSEI process, were examined and the FMs were reevaluated, to analyze the effectiveness of these tools and to propose new management tools to cover the greater risk FMs. 361 FMs were identified, 103 of which had RPN ≥80, initially, and 41 had S ≥ 8. Taking this into account the quality management tools FMs were reevaluated and only 30 FMs had RPN ≥80. The study of these 30 FMs emphasized that the FMs that involved greater risk were related to the diffuser screen placement and the patient's position during treatment. The quality assurance program of the facility has been adapted to the risk of this treatment process, following the guidelines proposed by the TG-100. However, clinical experience continually reveals new FMs, so the need for periodic risk analysis is required.

  2. Analyzing planned maintenance (PM) inspection data by failure mode and effect analysis methodology.

    PubMed

    Ridgway, Malcolm

    2003-01-01

    There is no question that medical devices are becoming more reliable. However, we have had some difficulty finding a satisfactory method for providing persuasive documentary evidence that this improved reliability will allow us to relax our traditional planned maintenance (PM) practices without compromising patient safety. The acceptance and increasing use of Failure Mode and Effect Analysis (FMEA) by several of the oversight agencies, including the Joint Commission on Accreditation of Healthcare Organizations, provides us with an important opportunity to take another shot at this vexing problem. Using this proven FMEA methodology and some relatively simple rules to quantify the results of the routine PM inspections that all healthcare providers are still performing in considerable abundance, we have developed a method that allows us to reduce the test results to a simple, single measure (the Risk Score) that can be used to characterize the effectiveness and levels of safety of our current PM regimens. When tested on theoretical data and a sample of real PM inspection results, the method provides answers that seem reasonable. Although it will probably require some modification as we begin the standardized data gathering and gain working experience, it is our hope that this new approach will become generally accepted within the industry. This kind of positive response should enable us to persuade the various accrediting and licensing agencies to similarly accept the concept.

  3. Risk management for outsourcing biomedical waste disposal - using the failure mode and effects analysis.

    PubMed

    Liao, Ching-Jong; Ho, Chao Chung

    2014-07-01

    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 disposal 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.

  4. Failure mode and effects analysis as a performance improvement tool in trauma.

    PubMed

    Day, Suzanne; Dalto, Joseph; Fox, Jolene; Turpin, Melinda

    2006-01-01

    Performance improvement (PI) in the multiple systems injured patient frequently highlights areas for improvement in overall hospital care processes. Failure mode effects analysis (FMEA) is an effective tool to assess and prioritize areas of risk in clinical practice. Failure mode effects analysis is often initiated by a "near-miss" or concern for risk as opposed to a root cause analysis that is initiated solely after a sentinel event. In contrast to a root cause analysis, the FMEA looks more broadly at processes involved in the delivery of care. The purpose of this abstract was to demonstrate the usefulness of FMEA as a PI tool by describing an event and following the event through the healthcare delivery PI processes involved. During routine chart abstraction, a trauma registrar found that an elderly trauma patient admitted with a subdural hematoma inadvertently received heparin during the course of a dialysis treatment. Although heparin use was contraindicated in this patient, there were no sequelae as a result of the error. This case was reviewed by the trauma service PI committee and the quality improvement team, which initiated FMEA. An FMEA of inpatient dialysis process was conducted following this incident. The process included physician, nursing, and allied health representatives involved in dialysis. As part of the process, observations of dialysis treatments and staff interviews were conducted. Observation revealed that nurses generally left the patient's room and did not involve themselves in the dialysis process. A formal patient "pass-off" report was not done. Nurses did not review dialysis orders or reevaluate the treatment plan before treatment. We found that several areas of our current practice placed our patients at risk. 1. The nephrology consult/dialysis communication process was inconsistent. 2. Scheduling of treatments for chronic dialysis patients could occur without a formal consult or order. 3. RNs were not consistently involved in dialysis

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

    SciTech Connect

    Younge, K C; Lee, C I; Feng, M; Novelli, P; Moran, J M; Prisciandaro, J I

    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. 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

  6. 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).

  7. 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

  8. 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.

  9. Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessment.

    PubMed

    Shaqdan, Khalid; Aran, Shima; Daftari Besheli, Laleh; Abujudeh, Hani

    2014-06-01

    In this review article, the authors provide a detailed series of guidelines for effectively performing root-cause analysis (RCA) and health failure mode and effect analysis (HFMEA). RCA is a retrospective approach used to ascertain the "root cause" of a problem that has already occurred, whereas HFMEA is a prospective risk assessment tool whose aim is to recognize risks to patient safety. RCA and HFMEA are used for the prevention of errors or recurring errors to create a safer workplace, maintain high standards in health care quality, and incorporate time-saving and cost-saving modifications to favorably affect the patient care environment. The principles and techniques provided here should allow reviewers to better understand the features of RCA and HFMEA and how to apply these processes appropriately. These principles include how to organize a team, identify root causes, seed out proximate causes, graphically describe the process, conduct a hazard analysis, and develop and implement potential action plans.

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

    DTIC Science & Technology

    1980-03-24

    CHART NATIONAL BUREAU Of STANDARDS- 1963-.1 I C2~ LEYE IAFVAL AIR EIWM MET j REPORT NAEC-9L-7958 I-LAKENU RST. N.J. 00733 I 0 HAZARDS/FAILURE MODES AND... Io c-c "I 3. oi As SS1- ;=__ __ _ _ __ _ _ __ _ _ =a -C4 ~Ow~ _________________________- w. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ nhvJ...LJ A.. 45hM 4 hS i~ to .. C zU .4. 0C4ca00c- IL -o to Is - io - WIZJM=1FA - eCA 7.1~1 1. -1. w 14 gap 01- 03 z - . I’d H W _ V_

  11. Modes of implant failure after hip resurfacing: morphological and wear analysis of 267 retrieval specimens.

    PubMed

    Morlock, Michael M; Bishop, Nick; Zustin, Jozef; Hahn, Michael; Rüther, Wolfgang; Amling, Michael

    2008-08-01

    Resurfacing of the hip joint is experiencing a revival due to improvements in materials, design, and manufacturing techniques. Despite good midterm outcomes, the high early rate of failure and concerns about metal debris require a detailed morphological and wear analysis of retrieved resurfacing implants in order to understand failure mechanisms. A worldwide collection of hip resurfacing revision devices was initiated, and 267 components were received. Devices were analyzed by patient demographics, radiographic positioning, and wear, as well as morphologically and histologically. Specimens were grouped into four different failure types. They were also stratified into rim-loaded or non-rim-loaded groups. Failures were also assessed by surgeon learning-curve effects. Time to failure was significantly different between the four revision-type groups: Specimens with fractures involving the implant rim were most common (46%) and failed earliest after surgery (mean of ninety-nine days), followed by fractures inside the femoral head (20%, 262 days) and loose cups (9%, 423 days). Revisions not due to fractures or cup loosening (25%) occurred at a mean of 722 days after surgery. Rim-loaded implants exhibited an average twenty-one to twenty-sevenfold higher wear rate than implants without rim-loading. Rim-loaded implants also showed a steeper mean cup inclination than their non-rim-loaded counterparts (59 degrees compared with 50 degrees ). Most failures occurred during the learning curve of the surgeon (the first fifty to 100 implantations). Failures on the femoral side usually occur within the first nine months after surgery and appear to be most directly related to the implantation technique or patient selection. Later failures are observed mainly due to acetabular problems, either due to dramatically increased wear or poor cup anchorage. Improper cup anteversion may be similar to or more important than cup inclination in producing excessive wear.

  12. 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.

  13. Failure modes of electrospun nanofibers

    NASA Astrophysics Data System (ADS)

    Zussman, E.; Rittel, D.; Yarin, A. L.

    2003-06-01

    Failure modes of electrospun polymer nanofibers are reported. The nanofibers have diameters in the range of 80-400 nm and lengths greater then several centimeters. The nanofibers fail by a multiple necking mechanism, sometimes followed by the development of a fibriliar structure. This phenomenon is attributed to a strong stretching of solidified nanofibers by the tapered accumulating wheel (electrostatic lens), if its rotation speed becomes too high. Necking has not been observed in the nanofibers collected on a grounded plate.

  14. 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.

  15. 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.

  16. Risk Assessment of Using Entonox for the Relief of Labor Pain: A Healthcare Failure Modes and Effects Analysis Approach

    PubMed Central

    Najafi, Tahereh Fathi; Bahri, Narjes; Ebrahimipour, Hosein; Najar, Ali Vafaee; Taleghani, Yasamin Molavi

    2016-01-01

    Introduction In order to prevent medical errors, it is important to know why they occur and to identify their causes. Healthcare failure modes and effects analysis (HFMEA) is a type of qualitative descriptive that is used to evaluate the risk. The aim of this study was to assess the risks of using Entonox for labor pain by HFMEA. Methods A mixed-methods design (qualitative action research and quantitative cross-sectional research) was used. The modes and effects of failures in the process of using Entonox were detected and analyzed during 2013–2014 at Hefdahe Shahrivar Hospital, Mashhad, Iran. Overall, 52 failure modes were identified, with 25 being recognized as high-risk modes. Results The results revealed that 48.5% of these errors fall into the care process type, 22.05% belong to the communicative type, 19.1% fall into the administrative type, and 10.2% are of the knowledge and skills type. Strategies were presented in the forms of acceptance (3.2%), control (90.3%), and elimination (6.4%). Conclusion The following actions are suggested for improving the process of using Entonox: Close supervision by the midwife, precise recording of all the stages of the process in the woman’s medical record, the necessity of the presence of the anesthesiologist at the woman’s bedside during labor, confirming the indications for use of Entonox, and close monitoring to ensure the safety of the gas cylinder guards. PMID:27123224

  17. Failure mode analysis of degraded InGaAs-AlGaAs strained quantum well multi-mode vertical-cavity surface-emitting lasers

    NASA Astrophysics Data System (ADS)

    Sin, Yongkun; Lingley, Zachary; Brodie, Miles; Huang, Michael; Bushmaker, Adam; Theiss, Jesse; Presser, Nathan; Foran, Brendan; Moss, Steven C.

    2016-03-01

    Remarkable progress made in vertical cavity surface emitting lasers (VCSELs) emitting at 850 and 980 nm has led them to find an increasing number of applications in high speed data communications as well as in potential space satellite systems. However, little has been reported on reliability and failure modes of InGaAs VCSELs emitting at ~980 nm although it is crucial to understand failure modes and underlying degradation mechanisms in developing these VCSELs that exceed lifetime requirements for space missions. The active layer of commercial VCSELs that we studied consisted of two or three InGaAs quantum wells. The laser structures were fabricated into deep mesas followed by a steam oxidation process to form oxide-apertures for current and optical confinements. Our multi- mode VCSELs showed a laser threshold of ~ 0.5 mA at RT. Failures were generated via accelerated life-testing of VCSELs. For the present study, we report on failure mode analysis of degraded oxide-VCSELs using various techniques. We employed nondestructive techniques including electroluminescence (EL), optical beam induced current (OBIC), and electron beam induced current (EBIC) techniques as well as destructive techniques including focused ion beam (FIB) and high-resolution TEM techniques to study VCSELs that showed different degradation behaviors. Especially, we employed FIB systems to locally remove a portion of top-DBR mirrors of degraded VCSELs, which made it possible for our subsequent EBIC and OBIC techniques to locate damaged areas that were generated as a result of degradation processes and also for our HR-TEM technique to prepare TEM cross sections from damaged areas. Our nondestructive and destructive physical analysis results are reported including defect and structural analysis results from pre-aged VCSELs as well as from degraded VCSELs life-tested under different test conditions.

  18. Design of a safer approach to intravenous drug infusions: failure mode effects analysis

    PubMed Central

    Apkon, M; Leonard, J; Probst, L; DeLizio, L; Vitale, R

    2004-01-01

    Objectives: A set of standard processes was developed for delivering continuous drug infusions in order to improve (1) patient safety; (2) efficiency in staff workflow; (3) hemodynamic stability during infusion changes, and (4) efficient use of resources. Failure modes effects analysis (FMEA) was used to examine the impact of process changes on the reliability of delivering drug infusions. Setting: An 11 bed multidisciplinary pediatric ICU in the children's hospital of an academic medical center staffed by board certified pediatric intensivists. The hospital uses computerized physician order entry for all medication orders. Methods: A multidisciplinary team characterized key elements of the drug infusion process. The process was enhanced to increase overall reliability and the original and revised processes were compared using FMEA. Resource consumption was estimated by reviewing purchasing and pharmacy records for the calendar year after full implementation of the revised process. Staff satisfaction was evaluated using an anonymous questionnaire administered to staff nurses in the ICU and pediatric residents who had rotated through the ICU. Results: The original process was characterized by six elements: selecting the drug; selecting a dose; selecting an infusion rate; calculating and ordering the infusion; preparing the infusion; programming the infusion pump and delivering the infusion. The following practice changes were introduced: standardizing formulations for all infusions; developing database driven calculators; extending infusion hang times from 24 to 72 hours; changing from bedside preparation by nurses to pharmacy prepared or premanufactured solutions. FMEA showed that the last three elements of the original process had high risk priority numbers (RPNs) of >225 whereas the revised process had no elements with RPNs >100. The combined effect of prolonging infusion hang times, preparation in the pharmacy, and purchasing premanufactured solutions resulted

  19. Photovoltaic failure and degradation modes: PV failure and degradation modes

    DOE PAGES

    Jordan, Dirk C.; Silverman, Timothy J.; Wohlgemuth, John H.; ...

    2017-01-30

    The extensive photovoltaic field reliability literature was analyzed and reviewed. Future work is prioritized based upon information assembled from recent installations, and inconsistencies in degradation mode identification are discussed to help guide future publication on this subject. Reported failure rates of photovoltaic modules fall mostly in the range of other consumer products; however, the long expected useful life of modules may not allow for direct comparison. In general, degradation percentages are reported to decrease appreciably in newer installations that are deployed after the year 2000. However, these trends may be convoluted with varying manufacturing and installation quality world-wide. Modules inmore » hot and humid climates show considerably higher degradation modes than those in desert and moderate climates, which warrants further investigation. Delamination and diode/j-box issues are also more frequent in hot and humid climates than in other climates. The highest concerns of systems installed in the last 10 years appear to be hot spots followed by internal circuitry discoloration. Encapsulant discoloration was the most common degradation mode, particularly in older systems. In newer systems, encapsulant discoloration appears in hotter climates, but to a lesser degree. Thin-film degradation modes are dominated by glass breakage and absorber corrosion, although the breadth of information for thin-film modules is much smaller than for x-Si.« less

  20. Fracture - An Unforgiving Failure Mode

    NASA Technical Reports Server (NTRS)

    Goodin, James Ronald

    2006-01-01

    During the 2005 Conference for the Advancement for Space Safety, after a typical presentation of safety tools, a Russian in the audience simply asked, "How does that affect the hardware?" Having participated in several International System Safety Conferences, I recalled that most attention is dedicated to safety tools and little, if any, to hardware. The intent of this paper on the hazard of fracture and failure modes associated with fracture is my attempt to draw attention to the grass roots of system safety - improving hardware robustness and resilience.

  1. Photovoltaic failure and degradation modes

    DOE PAGES

    Jordan, Dirk C.; Silverman, Timothy J.; Wohlgemuth, John H.; ...

    2017-01-30

    The extensive photovoltaic field reliability literature was analyzed and reviewed. Future work is prioritized based upon information assembled from recent installations, and inconsistencies in degradation mode identification are discussed to help guide future publication on this subject. Reported failure rates of photovoltaic modules fall mostly in the range of other consumer products; however, the long expected useful life of modules may not allow for direct comparison. In general, degradation percentages are reported to decrease appreciably in newer installations that are deployed after the year 2000. However, these trends may be convoluted with varying manufacturing and installation quality world-wide. Modules inmore » hot and humid climates show considerably higher degradation modes than those in desert and moderate climates, which warrants further investigation. Delamination and diode/j-box issues are also more frequent in hot and humid climates than in other climates. The highest concerns of systems installed in the last 10 years appear to be hot spots followed by internal circuitry discoloration. Encapsulant discoloration was the most common degradation mode, particularly in older systems. In newer systems, encapsulant discoloration appears in hotter climates, but to a lesser degree. Lastly, thin-film degradation modes are dominated by glass breakage and absorber corrosion, although the breadth of information for thin-film modules is much smaller than for x-Si.« less

  2. 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.

  3. Defense against common mode failures in protection system design

    SciTech Connect

    Wyman, R.H.; Johnson, G.L.

    1997-08-27

    The introduction of digital instrumentation and control into reactor safety systems creates a heightened concern about common-mode failure. This paper discusses the concern and methods to cope with the concern. Common-mode failures have been a ``fact-of-life`` in existing systems. The informal introduction of defense-in-depth and diversity (D-in-D&D)-coupled with the fact that hardware common-mode failures are often distributed in time-has allowed systems to deal with past common-mode failures. However, identical software operating in identical redundant systems presents the potential for simultaneous failure. Consequently, the use of digital systems raises the concern about common-mode failure to a new level. A more methodical approach to mitigating common-mode failure is needed to address these concerns. Purposeful introduction of D-in-D&D has been used as a defense against common-mode failure in reactor protection systems. At least two diverse systems are provided to mitigate any potential initiating event. Additionally, diverse displays and controls are provided to allow the operator to monitor plant status and manually initiate engineered safety features. A special form of conimon-mode failure analysis called ``defense-in-depth and diversity analysis`` has been developed to identify possible conimon-mode failure vulnerabilities in digital systems. An overview of this analysis technique is provided.

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

    SciTech Connect

    Ho, Chao Chung; Liao, Ching-Jong

    2011-12-15

    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 quality 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.

  5. 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.

  6. Use of risk assessment analysis by failure mode, effects, and criticality to reduce door-to-balloon time.

    PubMed

    Khare, Rahul K; Nannicelli, Anna P; Powell, Emilie S; Seivert, Nicholas P; Adams, James G; Holl, Jane L

    2013-10-01

    The Centers for Medicare & Medicaid Services currently endorses a door-to-balloon time of 90 minutes or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction. Recent evidence shows that a door-to-balloon time of 60 minutes significantly decreases inhospital mortality. We seek to use a proactive risk assessment method of failure mode, effects, and criticality analysis (FMECA) to evaluate door-to-balloon time process, to investigate how each component failure may affect the performance of a system, and to evaluate the frequency and the potential severity of harm of each failure. We conducted a 2-part study: FMECA of the door-to-balloon time system and process of care, and evaluation of a single institution's door-to-balloon time operational data using a retrospective observational cohort design. A multidisciplinary group of FMECA participants described the door-to-balloon time process to then create a comprehensive map and table listing all process steps and identified process failures, including their frequency, consequence, and causes. Door-to-balloon time operational data were assessed by "on" versus "off" hours. Fifty-one failure points were identified across 4 door-to-balloon time phases. Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. Total door-to-balloon time during on hours had a median time of 55 minutes (95% confidence interval 46 to 60 minutes) compared with 77 minutes (95% confidence interval 68 to 83 minutes) during off hours. The FMECA revealed clear areas of potential delay and vulnerability that can be addressed to decrease door-to-balloon time from 90 to 60 minutes. FMECAs can provide a robust assessment of potential risks and can serve as the platform for significant process improvement and system redesign for door-to-balloon time. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

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

    SciTech Connect

    Hoisak, J; Manger, R; Dragojevic, I

    2015-06-15

    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 of 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

  8. 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.

  9. 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

  10. Failure mode and effects analysis of the universal anaesthesia machine in two tertiary care hospitals in Sierra Leone.

    PubMed

    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

    2014-09-01

    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. 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. 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). We identified factors that may limit the impact of a UAM and devised likely effective strategies for mitigating those risks. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

  11. Analysis of functional failure mode of commercial deep sub-micron SRAM induced by total dose irradiation

    NASA Astrophysics Data System (ADS)

    Zheng, Qi-Wen; Cui, Jiang-Wei; Zhou, Hang; Yu, De-Zhao; Yu, Xue-Feng; Lu, Wu; Guo, Qi; Ren, Di-Yuan

    2015-10-01

    Functional failure mode of commercial deep sub-micron static random access memory (SRAM) induced by total dose irradiation is experimentally analyzed and verified by circuit simulation. We extensively characterize the functional failure mode of the device by testing its electrical parameters and function with test patterns covering different functional failure modes. Experimental results reveal that the functional failure mode of the device is a temporary function interruption caused by peripheral circuits being sensitive to the standby current rising. By including radiation-induced threshold shift and off-state leakage current in memory cell transistors, we simulate the influence of radiation on the functionality of the memory cell. Simulation results reveal that the memory cell is tolerant to irradiation due to its high stability, which agrees with our experimental result.

  12. Preliminary Analysis of Perfusionists’ Strategies for Managing Routine and Failure Mode Scenarios in Cardiopulmonary Bypass

    PubMed Central

    Power, Gerald; Miller, Anne

    2007-01-01

    Abstract: Cardiopulmonary bypass (CPB) is a complex task requiring high levels of practitioner expertise. Although some education standards exist, few are based on an analysis of perfusionists’ problem-solving needs. This study shows the efficacy of work domain analysis (WDA) as a framework for analyzing perfusionists’ conceptualization and problem-solving strategies. A WDA model of a CPB circuit was developed. A high-fidelity CPB simulator (Manbit) was used to present routine and oxygenator failure scenarios to six proficient perfusionists. The video-cued recall technique was used to elicit perfusionists’ conceptualization strategies. The resulting recall transcripts were coded using the WDA model and analyzed for associations between task completion times and patterns of conceptualization. The WDA model developed was successful in being able to account for and describe the thought process followed by each participant. It was also shown that, although there was no correlation between experience with CPB and ability to change an oxygenator, there was a link between the between specific thought patterns and the efficiency in undertaking this task. Simulators are widely used in many fields of human endeavor, and in this research, the attempt was made to use WDA to gain insights into the complexities of the human thought process when engaged in the complex task of conducting CPB. The assumption that experience equates with ability is challenged, and rather, it is shown that thought process is a more significant determinant of success when engaged in complex tasks. WDA analysis in combination with a CPB simulator may be used to elucidate successful strategies for completing complex tasks. PMID:17972450

  13. MO-D-213-02: Quality Improvement Through a Failure Mode and Effects Analysis of Pediatric External Beam Radiotherapy

    SciTech Connect

    Gray, J; Lukose, R; Bronson, J; Chandler, B; Merchant, T; Farr, J

    2015-06-15

    Purpose: To conduct a failure mode and effects analysis (FMEA) as per AAPM Task Group 100 on clinical processes associated with teletherapy, and the development of mitigations for processes with identified high risk. Methods: A FMEA was conducted on clinical processes relating to teletherapy treatment plan development and delivery. Nine major processes were identified for analysis. These steps included CT simulation, data transfer, image registration and segmentation, treatment planning, plan approval and preparation, and initial and subsequent treatments. Process tree mapping was utilized to identify the steps contained within each process. Failure modes (FM) were identified and evaluated with a scale of 1–10 based upon three metrics: the severity of the effect, the probability of occurrence, and the detectability of the cause. The analyzed metrics were scored as follows: severity – no harm = 1, lethal = 10; probability – not likely = 1, certainty = 10; detectability – always detected = 1, undetectable = 10. The three metrics were combined multiplicatively to determine the risk priority number (RPN) which defined the overall score for each FM and the order in which process modifications should be deployed. Results: Eighty-nine procedural steps were identified with 186 FM accompanied by 193 failure effects with 213 potential causes. Eighty-one of the FM were scored with a RPN > 10, and mitigations were developed for FM with RPN values exceeding ten. The initial treatment had the most FM (16) requiring mitigation development followed closely by treatment planning, segmentation, and plan preparation with fourteen each. The maximum RPN was 400 and involved target delineation. Conclusion: The FMEA process proved extremely useful in identifying previously unforeseen risks. New methods were developed and implemented for risk mitigation and error prevention. Similar to findings reported for adult patients, the process leading to the initial treatment has an

  14. Proposal on How To Conduct a Biopharmaceutical Process Failure Mode and Effect Analysis (FMEA) as a Risk Assessment Tool.

    PubMed

    Zimmermann, Hartmut F; Hentschel, Norbert

    2011-01-01

    With the publication of the quality guideline ICH Q9 "Quality Risk Management" by the International Conference on Harmonization, risk management has already become a standard requirement during the life cycle of a pharmaceutical product. Failure mode and effect analysis (FMEA) is a powerful risk analysis tool that has been used for decades in mechanical and electrical industries. However, the adaptation of the FMEA methodology to biopharmaceutical processes brings about some difficulties. The proposal presented here is intended to serve as a brief but nevertheless comprehensive and detailed guideline on how to conduct a biopharmaceutical process FMEA. It includes a detailed 1-to-10-scale FMEA rating table for occurrence, severity, and detectability of failures that has been especially designed for typical biopharmaceutical processes. The application for such a biopharmaceutical process FMEA is widespread. It can be useful whenever a biopharmaceutical manufacturing process is developed or scaled-up, or when it is transferred to a different manufacturing site. It may also be conducted during substantial optimization of an existing process or the development of a second-generation process. According to their resulting risk ratings, process parameters can be ranked for importance and important variables for process development, characterization, or validation can be identified. Health authorities around the world ask pharmaceutical companies to manage risk during development and manufacturing of pharmaceuticals. The so-called failure mode and effect analysis (FMEA) is an established risk analysis tool that has been used for decades in mechanical and electrical industries. However, the adaptation of the FMEA methodology to pharmaceutical processes that use modern biotechnology (biopharmaceutical processes) brings about some difficulties, because those biopharmaceutical processes differ from processes in mechanical and electrical industries. The proposal presented here

  15. 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.

  16. Quality risk analysis in a cGMP environment: multiple models for comprehensive failure mode identification during the computer system lifecycle.

    PubMed

    Gervais, Brian; D'Arcy, Deirdre M

    2014-01-01

    Pharmaceutical quality systems use various inputs to ensure product quality and prevent failures that might have patient consequences. These inputs are generally data from failures that have already occurred, for example process deviations or customer complaints. Risk analysis techniques are well-established in certain other industries and have become of interest to pharmaceutical manufacturers because they allow potential quality failures to be predicted and mitigating action taken in advance of their occurring. Failure mode and effects analysis (FMEA) is one such technique, and in this study it was applied to implement a computerized manufacturing execution system in a pharmaceutical manufacturing environment. After introduction, the system was monitored to detect failures that did occur and these were analyzed to determine why the risk analysis method failed to predict them. Application of FMEA in other industries has identified weaknesses in predicting certain error types, specifically its dependence on other techniques to model risk situations and its poor analysis of non-hardware risks, such as human error, and this was confirmed in this study. Hierarchical holographic modeling (HHM), a technique for identifying risk scenarios in wide-scope analyses, was applied subsequently and identified additional potential failure modes. The technique for human error rate prediction (THERP) has previously been used for the quantitative analysis of human error risk and the event tree from this technique was adapted and identified further human error scenarios. These were input to the FMEA for prioritization and mitigation, thereby strengthening the risk analysis in terms of failure modes considered.

  17. 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.

  18. Key Performance Outcomes of Patient Safety Curricula: Root Cause Analysis, Failure Mode and Effects Analysis, and Structured Communications Skills

    PubMed Central

    2011-01-01

    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. PMID:22102754

  19. [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.

  20. Failure modes in surface micromachined microelectromechanical actuators

    SciTech Connect

    Miller, S.L.; Rodgers, M.S.; LaVigne, G.; Sniegowski, J.J.; Clews, P.; Tanner, D.M.; Peterson, K.A.

    1998-03-01

    In order for the rapidly emerging field of MicroElectroMechanical Systems (MEMS) to meet its extraordinary expectations regarding commercial impact, issues pertaining to how they fail must be understood. The authors identify failure modes common to a broad range of MEMS actuators, including adhesion (stiction) and friction induced failures caused by improper operational methods, mechanical instabilities, and electrical instabilities. Demonstrated methods to mitigate these failure modes include implementing optimized designs, model based operational methods, and chemical surface treatments.

  1. 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.

  2. [Applying healthcare failure mode and effect analysis to improve the surgical specimen transportation process and rejection rate].

    PubMed

    Hu, Pao-Hsueh; Hu, Hsiao-Chen; Huang, Hui-Ju; Chao, Hui-Lin; Lei, Ei-Fang

    2014-04-01

    Because surgical pathology specimens are crucial to the diagnosis and treatment of disease, it is critical that they be collected and transported safely and securely. Due to recent near-miss events in our department, we used the healthcare failure model and effect analysis to identify 14 potential perils in the specimen collection and transportation process. Improvement and prevention strategies were developed accordingly to improve quality of care. Using health care failure mode and effect analysis (HFMEA) may improve the surgical specimen transportation process and reduce the rate of surgical specimen rejection. Rectify standard operating procedures for surgical pathology specimen collection and transportation. Create educational videos and posters. Rectify methods of specimen verification. Organize and create an online and instantaneous management system for specimen tracking and specimen rejection. Implementation of the new surgical specimen transportation process effectively eliminated the 14 identified potential perils. In addition, the specimen rejection fell from 0.86% to 0.03%. This project was applied to improve the specimen transportation process, enhance interdisciplinary cooperation, and improve the patient-centered healthcare system. The creation and implementation of an online information system significantly facilitates specimen tracking, hospital cost reductions, and patient safety improvements. The success in our department is currently being replicated across all departments in our hospital that transport specimens. Our experience and strategy may be applied to inter-hospital specimen transportation in the future.

  3. The role of failure modes and effects analysis in showing the benefits of automation in the blood bank.

    PubMed

    Han, Tae Hee; Kim, Moon Jung; Kim, Shinyoung; Kim, Hyun Ok; Lee, Mi Ae; Choi, Ji Seon; Hur, Mina; St John, Andrew

    2013-05-01

    Failure modes and effects analysis (FMEA) is a risk management tool used by the manufacturing industry but now being applied in laboratories. Teams from six South Korean blood banks used this tool to map their manual and automated blood grouping processes and determine the risk priority numbers (RPNs) as a total measure of error risk. The RPNs determined by each of the teams consistently showed that the use of automation dramatically reduced the RPN compared to manual processes. In addition, FMEA showed where the major risks occur in each of the manual processes and where attention should be prioritized to improve the process. Despite no previous experience with FMEA, the teams found the technique relatively easy to use and the subjectivity associated with assigning risk numbers did not affect the validity of the data. FMEA should become a routine technique for improving processes in laboratories. © 2012 American Association of Blood Banks.

  4. 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.

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

    DTIC Science & Technology

    2012-06-01

    that all those cards were used fraudulently, but that credit card information on the cardholders was exposed. Sony Says PlayStation Hacker Got...Personal Data April 26, 2011 Last week, Sony’s online network for the PlayStation suffered a catastrophic failure through a hacking attack. And since...Internet or to download demos of new games. Then, on Tuesday, after several days of near silence, Sony said that as a result of the attack, an

  6. Clinical implementation and failure mode and effects analysis of HDR skin brachytherapy using Valencia and Leipzig surface applicators.

    PubMed

    Sayler, Elaine; Eldredge-Hindy, Harriet; Dinome, Jessie; Lockamy, Virginia; Harrison, Amy S

    2015-01-01

    The planning procedure for Valencia and Leipzig surface applicators (VLSAs) (Nucletron, Veenendaal, The Netherlands) differs substantially from CT-based planning; the unfamiliarity could lead to significant errors. This study applies failure modes and effects analysis (FMEA) to high-dose-rate (HDR) skin brachytherapy using VLSAs to ensure safety and quality. A multidisciplinary team created a protocol for HDR VLSA skin treatments and applied FMEA. Failure modes were identified and scored by severity, occurrence, and detectability. The clinical procedure was then revised to address high-scoring process nodes. Several key components were added to the protocol to minimize risk probability numbers. (1) Diagnosis, prescription, applicator selection, and setup are reviewed at weekly quality assurance rounds. Peer review reduces the likelihood of an inappropriate treatment regime. (2) A template for HDR skin treatments was established in the clinic's electronic medical record system to standardize treatment instructions. This reduces the chances of miscommunication between the physician and planner as well as increases the detectability of an error. (3) A screen check was implemented during the second check to increase detectability of an error. (4) To reduce error probability, the treatment plan worksheet was designed to display plan parameters in a format visually similar to the treatment console display, facilitating data entry and verification. (5) VLSAs are color coded and labeled to match the electronic medical record prescriptions, simplifying in-room selection and verification. Multidisciplinary planning and FMEA increased detectability and reduced error probability during VLSA HDR brachytherapy. This clinical model may be useful to institutions implementing similar procedures. Copyright © 2015 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

  7. WE-H-BRC-03: Failure Mode and Effects Analysis in the First Clinical Implementation of a Novel Stereotactic Breast Radiotherapy Device: GammaPod™

    SciTech Connect

    Mossahebi, S; Feigenberg, S; Nichols, E; Becker, S; Prado, K; Yi, B; Mutaf, Y; Niu, Y; Yu, C

    2016-06-15

    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 higher 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

  8. 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.

  9. 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

  10. Failure modes and effects analysis in image-guided high-dose-rate brachytherapy: Quality control optimization to reduce errors in treatment volume.

    PubMed

    Wadi-Ramahi, Shada; Alnajjar, Waleed; Mahmood, Rana; Jastaniyah, Noha; Moftah, Belal

    2016-01-01

    Analyze the inputs which cause treatment to the wrong volume in high-dose-rate brachytherapy (HDRB), with emphasis on imaging role during implant, planning, and treatment verification. The end purpose is to compare our current practice to the findings of the study and apply changes where necessary. Failure mode and effects analysis was used to study the failure pathways for treating the wrong volume in HDRB. The role of imaging and personnel was emphasized, and subcategories were formed. A quality assurance procedure is proposed for each high-scoring failure mode (FM). Forty FMs were found that lead to treating the wrong volume. Of these, 73% were human failures, 20% were machine failures, and 7% were procedural/guideline failures. The use of imaging was found to resolve 85% of the FMs. We also noted that imaging processes were under used in current practice of HDRB especially in pretreatment verification. Twelve FMs (30%) scored the highest, and for each one of them, we propose clinical/practical solutions that could be applied to reduce the risk by increasing detectability. This work resulted in two conclusions: the role of imaging in improving failure detection and the emphasized role of human-based failures. The majority of FMs are human failures, and imaging increased the ability to detect 85% of all FMs. We proposed quality assurance practices for each high-scoring FM and have implemented some of them in our own practice. Copyright © 2016 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

  11. 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.

  12. Failure mode and effects analysis in designing a virtual reality-based training simulator for bilateral sagittal split osteotomy.

    PubMed

    Sofronia, R E; Knott, T; Davidescu, A; Savii, G G; Kuhlen, T; Gerressen, M

    2013-03-01

    Virtual reality-based simulators offer a cost-effective and efficient alternative to traditional medical training and planning. Developing a simulator that enables the training of medical skills and also supports recognition of errors made by the trainee is a challenge. The first step in developing such a system consists of error identification in the real procedure, in order to ensure that the training environment covers the most significant errors that can occur. This paper focuses on identifying the main system requirements for an interactive simulator for training bilateral sagittal split osteotomy (BSSO). An approach is proposed based on failure mode and effects analysis (FMEA), a risk analysis method that is well structured and already an approved technique in other domains. Based on the FMEA results, a BSSO training simulator is currently being developed, which centres upon the main critical steps of the procedure (sawing and splitting) and their main errors. FMEA seems to be a suitable tool in the design phase of developing medical simulators. Herein, it serves as a communication medium for knowledge transfer between the medical experts and the system developers. The method encourages a reflective process and allows identification of the most important elements and scenarios that need to be trained. Copyright © 2013 John Wiley & Sons, Ltd.

  13. Failure Mode and Effects RHIC Cryogenic Liquid Storage Area

    SciTech Connect

    Gaffney, Michael

    1999-02-16

    The object of a failure mode and effect analysis (FMEA) is to identify all the postulated modes of failure within a system or sub system design so that hazards from the resultant effects can be eliminated or control to an acceptable level of risk at the earliest possible time. The analysis shall be used to assess existing high risk items and the systems or sub-systems, in the design state. The analysis will then provide us with the information needed to minimize hazardous effects due to component failure.

  14. Failure Mode Effects Analysis for the RHIC Cryogenic Distribution System First Sextant Test Configuration

    SciTech Connect

    Kane, S.

    1996-12-26

    The RHIC Cryogenic Distribution System previously has been analyzed and documented in the RHIC Cryogenic System Safety Analysis Report, September 6, 1994 and the RHIC SAD. These reports address the Cryogenic Distribution System for the completed Collider. The Collider is not completed for the First Sextant Test, thus the Cryogenic Distribution System must be modified for the First Sextant Test. Additionally, some components were not identified or designed at the time of the original report, and could not be analyzed. Finally, some minor modifications have been made to the configuration originally analyzed in 1994. This report specifically addresses all of the differences in the Cryogenic Distributio system configuration for the RHIC First Sextant Test and updates the analysis of those components whose design has been finalized or changed from the originally analyzed configuration.

  15. Use of failure modes and effects analysis in design of the tracker system for the HET wide-field upgrade

    NASA Astrophysics Data System (ADS)

    Hayes, Richard; Beets, Tim; Beno, Joseph; Booth, John; Cornell, Mark; Good, John; Heisler, James; Hill, Gary; Kriel, Herman; Penney, Charles; Rafal, Marc; Savage, Richard; Soukup, Ian; Worthington, Michael; Zierer, Joseph

    2012-09-01

    In support of the Hobby-Eberly Telescope Dark Energy Experiment (HETDEX), the Center for Electromechanics at The University of Texas at Austin was tasked with developing the new Tracker and control system to support the HETDEX Wide-Field Upgrade. The tracker carries the 3,100 kg Prime Focus Instrument Package and Wide Field Corrector approximately 13 m above the 10 m diameter primary mirror. Its safe and reliable operation by a sophisticated control system, over a 20 year life time is a paramount requirement for the project. To account for all potential failures and potential hazards, to both the equipment and personnel involved, an extensive Failure Modes and Effects Analysis (FMEA) was completed early in the project. This task required participation of all the stakeholders over a multi-day meeting with numerous follow up exchanges. The event drove a number of significant design decisions and requirements that might not have been identified this early in the project without this process. The result is a system that has multiple layers of active and passive safety systems to protect the tens of millions of dollars of hardware involved and the people who operate it. This paper will describe the background of the FMEA process, how it was utilized on HETDEX, the critical outcomes, how the required safety systems were implemented, and how they have worked in operation. It should be of interest to engineers, designers, and managers engaging in complex multi-disciplinary and parallel engineering projects that involve automated hardware and control systems with potentially hazardous operating scenarios.

  16. Structural system reliability under multiple failure modes

    NASA Technical Reports Server (NTRS)

    Mahadevan, S.; Chamis, C. C.

    1993-01-01

    This paper describes a computational method for system reliability estimation of propulsion structures. The failure domain of the entire structural system is computed through the union of failure regions for various critical system failure modes. The effect of non-critical progressive damage is incorporated through structural reanalysis, resulting in the construction of several linear segments to approximately cover the system failure domain. An adaptive damage imposition scheme is outlined for the sake of computational efficiency. The proposed method is used to construct the system survival cdf (cumulative distribution function) of a two-rotor system.

  17. The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication administration process on the floor.

    PubMed

    Nguyen, Christina; Côté, Justine; Lebel, Denis; Caron, Elaine; Genest, Christine; Mallet, Monia; Phan, Véronique; Bussières, Jean-François

    2013-02-01

    The objective of this article was to critically evaluate the causes of adverse drug events during the nurse medication administration process in paediatric care units in order to identify and prioritize interventions that need to be implemented. This is a failure mode, effects and criticality analysis (FMECA) study. A multidisciplinary committee composed of nurses, pharmacists, physicians and risk managers evaluated through consensus the process of administering medications at the Centre hospitalier universitaire de Sainte-Justine. By mapping the process, all the failure modes were identified and associated with at least one cause each. Using a summary grid, each failure mode was evaluated by rating frequency (from 1 to 9), likelihood of failure detection (from 0 to 100%) and severity (from 1 to 9) using adapted versions of already published scales. A 10-member committee was set up, and it met eight times between January and April 2010. In the two specialized paediatric units selected (n = 38 beds), an average number of approximately 20 000 drug doses was administered monthly from about 400 non-proprietary names. Through consensus, the committee identified 16 processes and 53 failure modes. While frequency and severity were based on perceptions that could be objectivized with local data and scientific documentation, the likelihood of detection was mainly based on individual perception. FMECA is a useful approach to improve the medication process. © 2011 Blackwell Publishing Ltd.

  18. Finite Element Analysis and Failure Mode Characterization of Pyramidal Fin Arrays Produced by Masked Cold Gas Dynamic Spray

    NASA Astrophysics Data System (ADS)

    Cormier, Yannick; Dupuis, Philippe; Jodoin, Bertrand; Ghaei, Abbas

    2015-12-01

    This work evaluates the shear strength of pyramidal fin arrays made from various feedstock materials (cylindrical aluminum, spherical nickel, and cylindrical stainless steel 304 powders) deposited on an Al6061-T6 substrate. Higher shear strength was measured for the nickel fin array followed by the stainless steel 304 and the aluminum arrays. Different failure modes were observed by inspecting the fracture surfaces under Scanning Electron Microscope. Deposition between the cold sprayed nickel and stainless fins was detected whereas dimples were noticed on the substrate between the fins when aluminum is used as the feedstock material. A numerical simulation of normal and angled impacts using the high strain rate Preston-Tonks-Wallace model was carried out in order to have a better understanding of the experimental results. The equivalent plastic strain (PEEQ) obtained from the finite element analysis at normal impact correlates with the different shear strengths measured experimentally. Furthermore, even if a higher PEEQ was observed for angled impacts compared to its normal collision counterpart, it is suggested that the particles may not bond because of the rotational restitution momentum caused by the tangential friction generated during angled impacts. This rotational restitution momentum was not detected for particle impacts normal to the substrate surface.

  19. Failure Mode and Effect Analysis (FMEA) Applications to Identify Iron Sand Reject and Losses in Cement Industry : A Case Study

    NASA Astrophysics Data System (ADS)

    Helia, V. N.; Wijaya, W. N.

    2017-06-01

    One of the main raw materials required in the manufacture of cement is iron sand. Data from the Procurement Department on XYZ Company shows that the number of defective iron sand (reject) fluctuates every month. Iron sand is an important raw material in the cement production process, so that the amount of iron sand reject and losses got financial and non-financial impact. This study aims to determine the most dominant activity as the cause of rejection and losses of iron sands and suggest improvements that can be made by using the approach of FMEA (Failure Mode and Effect Analysis). Data collection techniques in this study was using the method of observation, interviews, and focus group discussion (FGD) as well as the assessment of the experts to identify it. Results from this study is there are four points of the most dominant cause of the defect of iron sand (mining activities, acceptance, examination and delivery). Recommendation for overcoming these problem is presented (vendor improvement).

  20. 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.

  1. A Framework for Creating a Function-based Design Tool for Failure Mode Identification

    NASA Technical Reports Server (NTRS)

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

    2002-01-01

    Knowledge of potential failure modes during design is critical for prevention of failures. Currently industries use procedures such as Failure Modes and Effects Analysis (FMEA), Fault Tree analysis, or Failure Modes, Effects and Criticality analysis (FMECA), as well as knowledge and experience, to determine potential failure modes. When new products are being developed there is often a lack of sufficient knowledge of potential failure mode and/or a lack of sufficient experience to identify all failure modes. This gives rise to a situation in which engineers are unable to extract maximum benefits from the above procedures. This work describes a function-based failure identification methodology, which would act as a storehouse of information and experience, providing useful information about the potential failure modes for the design under consideration, as well as enhancing the usefulness of procedures like FMEA. As an example, the method is applied to fifteen products and the benefits are illustrated.

  2. Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critical patients.

    PubMed

    Viejo Moreno, R; Sánchez-Izquierdo Riera, J Á; Molano Álvarez, E; Barea Mendoza, J A; Temprano Vázquez, S; Díaz Castellano, L; Montejo González, J C

    2016-11-01

    To improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. A contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact. Patients admitted to the adult polyvalent ICU of a third-level hospital center. A total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. A series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. Indication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. A total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures. The failure mode and effects analysis allowed us to identify improvements in the prevention of

  3. Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children.

    PubMed

    Daverio, Marco; Fino, Giuliana; Luca, Brugnaro; Zaggia, Cristina; Pettenazzo, Andrea; Parpaiola, Antonella; Lago, Paola; Amigoni, Angela

    2015-12-01

    Errors in are estimated to occur with an incidence of 3.7-16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU). The aim of our study was to describe the trend of IR in a PICU and evaluate the effect of FMEA application on the number and severity of the errors detected. With this prospective observational study, we evaluated the frequency IR documented in standard IR forms completed from January 2009 to December 2012 in the PICU of Woman's and Child's Health Department of Padova. On the basis of their severity, errors were classified as: without outcome (55%), with minor outcome (16%), with moderate outcome (10%), and with major outcome (3%); 16% of reported incidents were 'near misses'. We compared the data before and after the introduction of FMEA. Sixty-nine errors were registered, 59 (86%) concerning drug therapy (83% during prescription). Compared to 2009-2010, in 2011-2012, we noted an increase of reported errors (43 vs 26) with a reduction of their severity (21% vs 8% 'near misses' and 65% vs 38% errors with no outcome). With the introduction of FMEA, we obtained an increased awareness in error reporting. Application of these systems will improve the quality of healthcare services. © 2015 John Wiley & Sons Ltd.

  4. Administrative risk quantification of subcutaneous and intravenous therapies in Italian centers utilizing the Failure Mode and Effects Analysis approach

    PubMed Central

    Ponzetti, Clemente; Canciani, Monica; Farina, Massimo; Era, Sara; Walzer, Stefan

    2016-01-01

    Background In oncology, an important parameter of safety is the potential treatment error in hospitals. The analyzed hypothesis is that of subcutaneous therapies would provide a superior safety benefit over intravenous therapies through fixed-dose administrations, when analyzed with trastuzumab and rituximab. Methods For the calculation of risk levels, the Failure Mode and Effect Analysis approach was applied. Within this approach, the critical treatment path is followed and risk classification for each individual step is estimated. For oncology and hematology administration, 35 different risk steps were assessed. The study was executed in 17 hematology and 16 breast cancer centers in Italy. As intravenous and subcutaneous were the only injection routes in medical available for trastuzumab and rituximab in oncology at the time of the study, these two therapies were chosen. Results When the risk classes were calculated, eight high-risk areas were identified for the administration of an intravenous therapy in hematology or oncology; 13 areas would be defined as having a median-risk classification and 14 areas as having a low-risk classification (total risk areas: n=35). When the new subcutaneous formulation would be applied, 23 different risk levels could be completely eliminated (65% reduction). Important high-risk classes such as dose calculation, preparation and package labeling, preparation of the access to the vein, pump infusion preparation, and infusion monitoring were included in the eliminations. The overall risk level for the intravenous administration was estimated to be 756 (ex-ante) and could be reduced by 70% (ex-post). The potential harm compensation for errors related to pharmacy would be decreased from eight risk classes to only three risk classes. Conclusion The subcutaneous administration of trastuzumab (breast cancer) and rituximab (hematology) might lower the risk of administration and treatment errors for patients and could hence indirectly have

  5. Fracture Analysis of Competing Failure Modes of Aluminum-CFRP Joints Using Three-Layer Titanium Laminates as Transition

    NASA Astrophysics Data System (ADS)

    Woizeschke, P.; Vollertsen, F.

    2015-09-01

    The structural properties of lightweight constructions can be adapted to specific local requirements using multi-material designs. Aluminum alloys and carbon fiber-reinforced plastics (CFRP) are materials of great interest requiring suitable joining techniques in order to transfer the advantages of combining the materials to structural benefits. Thus, the research group "Schwarz-Silber" investigates novel concepts to enable frontal aluminum-CFRP joints using transition structures. In the foil concept titanium foils are used as transition elements. Specimens have been produced using three-layer titanium laminates. In tensile tests, three failure locations have been observed: (1) Al-Ti seam, (2) Ti-CFRP hybrid laminate, and (3) CFRP laminate. In this paper, the fracture mechanisms of these failure modes are investigated by analyzing metallographic micrographs and fracture surfaces as well as by correlating load-displacement curves to video imaging of tensile tests. The results show that the cracking of the CFRP layers can be traced back to an assembly error. The laminate character of the titanium part tends to reduce the Al-Ti seam strength. However, two sub-joint tests demonstrate that the Al-Ti seam can endure loads up to 9.5 kN. The ductile failure behavior of the Ti-CFRP hybrid laminates is caused by plastic deformations of the titanium laminate liners.

  6. Utilization of Failure Mode and Effects Analysis (FMEA) Method in Increasing the Revenue of Emergency Department; a Prospective Cohort Study.

    PubMed

    Shahrami, Ali; Rahmati, Farhad; Kariman, Hamid; Hashemi, Behrooz; Rahmati, Majid; Baratloo, Alireza; Forouzanfar, Mohammad Mehdi; Safari, Saeed

    2013-01-01

    The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED) are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA) method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided into one main system and six subsystems, based on FMEA. The study was divided into two phases. In the first phase, the problems leading to the loss of revenue in each subsystem were identified and weighted into four groups using risk priority number (RPN), and the solutions for fixing them were planned. Then, in the second phase, discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after intervention using the repeated measure ANOVA test. 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousand US dollars/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousand US dollars/month after solving first, second, third, and fourth priority problems, respectively (337.75% increase in two years) (p<0.001). 111.0% increase in the ED revenue after solving of first priority problems revealed that they were extremely indispensable in decreasing the revenue (p<0.0001). The

  7. Utilization of Failure Mode and Effects Analysis (FMEA) Method in Increasing the Revenue of Emergency Department; a Prospective Cohort Study

    PubMed Central

    Shahrami, Ali; Rahmati, Farhad; Kariman, Hamid; Hashemi, Behrooz; Rahmati, Majid; Baratloo, Alireza; Forouzanfar, Mohammad Mehdi; Safari, Saeed

    2013-01-01

    Introduction: The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED) are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA) method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. Methods: This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided into one main system and six subsystems, based on FMEA. The study was divided into two phases. In the first phase, the problems leading to the loss of revenue in each subsystem were identified and weighted into four groups using risk priority number (RPN), and the solutions for fixing them were planned. Then, in the second phase, discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after intervention using the repeated measure ANOVA test. Results: 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousand US dollars/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousand US dollars/month after solving first, second, third, and fourth priority problems, respectively (337.75% increase in two years) (p<0.001). 111.0% increase in the ED revenue after solving of first priority problems revealed that they were extremely indispensable in

  8. TSS-1R Failure Mode Evaluation

    NASA Technical Reports Server (NTRS)

    Vaughn, Jason A.; McCollum, Matthew B.; Kamenetzky, Rachel R.

    1997-01-01

    Soon after the break of the tether during the Tethered Satellite System (TSS-1R) mission in February, 1996, a Tiger Team was assembled at the George C. Marshall Space Flight Center to determine the tether failure mode. One possible failure scenario was the Kevlar' strength member of the tether failed because of degradation due to electrical discharge or electrical arcing. During the next several weeks, extensive electrical discharge testing in low vacuum and plasma environments was conducted in an attempt to reproduce the electrical activity recorded by on-board science instruments during the mission. The results of these tests are presented in this paper.

  9. 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.

  10. Analysis of possibilities for carbon removal from porous anode of solid oxide fuel cells after different failure modes

    NASA Astrophysics Data System (ADS)

    Subotić, Vanja; Schluckner, Christoph; Schroettner, Hartmuth; Hochenauer, Christoph

    2016-01-01

    This study focuses on the investigation of possibilities for carbon removal from the fuel electrode of anode supported solid oxide fuel cells (ASC-SOFCs) after different degradation modes. To design the conditions which generally lead the cell in the range of carbon depositions the performed thermodynamic calculations show that the SOFC operating temperature range seems to be appropriate for formation of elemental carbon in various types. Concerning this the loaded large planar single SOFCs are fed with synthetic diesel reformate thus simulating realistic operating conditions and enabling the formation and deposition of carbon on the anode side. A mixture of hydrogen/water vapor/nitrogen is used to remove the detected carbon depositions in a cell-protecting manner. For the purpose of this investigation several failure modes are induced after which determination the already defined regeneration strategy is applied. The cathode degradation is first induced and secondly the fuel supply is interrupted to induce re-oxidation of nickel (Ni) on the anode side. The undertaken investigations determine that carbon can be fully removed from the anode surface after nickel oxidation, while cathode degradation disables the complete cell regeneration.

  11. Metal matrix composites: Testing, analysis, and failure modes; Proceedings of the Symposium, Sparks, NV, Apr. 25, 26, 1988

    NASA Technical Reports Server (NTRS)

    Johnson, W. S. (Editor)

    1989-01-01

    The present conference discusses the tension and compression testing of MMCs, the measurement of advanced composites' thermal expansion, plasticity theory for fiber-reinforced composites, a deformation analysis of boron/aluminum specimens by moire interferometry, strength prediction methods for MMCs, and the analysis of notched MMCs under tensile loading. Also discussed are techniques for the mechanical and thermal testing of Ti3Al/SCS-6 MMCs, damage initiation and growth in fiber-reinforced MMCs, the shear testing of MMCs, the crack growth and fracture of continuous fiber-reinforced MMCs in view of analytical and experimental results, and MMC fiber-matrix interface failures.

  12. Metal matrix composites: Testing, analysis, and failure modes; Proceedings of the Symposium, Sparks, NV, Apr. 25, 26, 1988

    NASA Technical Reports Server (NTRS)

    Johnson, W. S. (Editor)

    1989-01-01

    The present conference discusses the tension and compression testing of MMCs, the measurement of advanced composites' thermal expansion, plasticity theory for fiber-reinforced composites, a deformation analysis of boron/aluminum specimens by moire interferometry, strength prediction methods for MMCs, and the analysis of notched MMCs under tensile loading. Also discussed are techniques for the mechanical and thermal testing of Ti3Al/SCS-6 MMCs, damage initiation and growth in fiber-reinforced MMCs, the shear testing of MMCs, the crack growth and fracture of continuous fiber-reinforced MMCs in view of analytical and experimental results, and MMC fiber-matrix interface failures.

  13. Failure modes and conditions of Itokawa

    NASA Astrophysics Data System (ADS)

    Hirabayashi, Masatoshi; Scheeres, Daniel J.

    2015-11-01

    The YORP effect has been found to play a crucial role in the rotational evolution of small bodies. Recent studies have argued that the YORP effect is very sensitive to the shape of an asteroid (Statler, 2015, Icarus 202, 502) and, as the shape deforms, can possibly change (McMahon, 2015, DDA meeting #301.04). Such sensitivity has been considered to affect the orbital evolution of an asteroid (Bottke et al., 2015, Icarus 247, 191). As a result, this mysterious effect could make fast and slow rotators (personal communication with Bill Bottke, 2015). In addition, possible candidates of rotational disruption have also been discovered in the last decades (e.g., Jewitt et al., 2014, ApJ 784, L8). These studies gave rise to the following question: how does the shape of an asteroid change when subject to rotational variations from the YORP effect? Better understandings of asteroid deformation and failure at different spin periods will help us find clues of it. To do this we are surveying the failure modes and conditions of available shape models with detailed mass information. The main technique used is a plastic finite element model by Hirabayashi and Scheeres (2015, ApJ 798, L8). We have analyzed asteroid Itokawa, which is currently spinning at a spin period of 12.1 hours. Itokawa’s failure conditions at different spin periods can be described by using the minimum cohesive strength that ensures stability of the structure. The results show that this minimum cohesive strength increases as the spin period becomes shorter. If the spin period is longer than 4.5 hours, a failure mode caused by a combination of compression and tension occurs at cohesive strength less than 6 Pa. At shorter spin periods, however, tension spreads out across the neck, causing the body to fail even at cohesive strength higher than it. Since Hill’s stability condition is 5.2 hours, once the body fails at spin periods shorter than 4.5 hours, it breaks into two components that eventually escape

  14. Metal Whiskers: Failure Modes and Mitigation Strategies

    NASA Technical Reports Server (NTRS)

    Brusse, Jay A.; Leidecker, Henning

    2007-01-01

    Metal coatings especially tin, zinc and cadmium are unpredictably susceptible to the formation of electrically conductive, crystalline filaments referred to as metal whiskers. The use of such coatings in and around electrical systems presents a risk of electrical shorting. Examples of metal whisker formation are shown with emphasis on optical inspection techniques to improve probability of detection. The failure modes (i.e., electrical shorting behavior) associated with metal whiskers are described. Based on an almost 9- year long study, the benefits of polyurethane conformal coat (namely, Arathane 5750) to protect electrical conductors from whisker-induced short circuit anomalies is discussed.

  15. Life Cost Based FMEA Manual: A Step by Step Guide to Carrying Out a Cost-based Failure Modes and Effects Analysis

    SciTech Connect

    Rhee, Seung; Spencer, Cherrill; /Stanford U. /SLAC

    2009-01-23

    Failure occurs when one or more of the intended functions of a product are no longer fulfilled to the customer's satisfaction. The most critical product failures are those that escape design reviews and in-house quality inspection and are found by the customer. The product may work for a while until its performance degrades to an unacceptable level or it may have not worked even before customer took possession of the product. The end results of failures which may lead to unsafe conditions or major losses of the main function are rated high in severity. Failure Modes and Effects Analysis (FMEA) is a tool widely used in the automotive, aerospace, and electronics industries to identify, prioritize, and eliminate known potential failures, problems, and errors from systems under design, before the product is released (Stamatis, 1997). Several industrial FMEA standards such as those published by the Society of Automotive Engineers, US Department of Defense, and the Automotive Industry Action Group employ the Risk Priority Number (RPN) to measure risk and severity of failures. The Risk Priority Number (RPN) is a product of 3 indices: Occurrence (O), Severity (S), and Detection (D). In a traditional FMEA process design engineers typically analyze the 'root cause' and 'end-effects' of potential failures in a sub-system or component and assign penalty points through the O, S, D values to each failure. The analysis is organized around categories called failure modes, which link the causes and effects of failures. A few actions are taken upon completing the FMEA worksheet. The RPN column generally will identify the high-risk areas. The idea of performing FMEA is to eliminate or reduce known and potential failures before they reach the customers. Thus, a plan of action must be in place for the next task. Not all failures can be resolved during the product development cycle, thus prioritization of actions must be made within the design group. One definition of detection

  16. 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.

  17. Tools for Developing a Quality Management Program: Proactive Tools (Process Mapping, Value Stream Mapping, Fault Tree Analysis, and Failure Mode and Effects Analysis)

    SciTech Connect

    Rath, Frank

    2008-05-01

    This article examines the concepts of quality management (QM) and quality assurance (QA), as well as the current state of QM and QA practices in radiotherapy. A systematic approach incorporating a series of industrial engineering-based tools is proposed, which can be applied in health care organizations proactively to improve process outcomes, reduce risk and/or improve patient safety, improve through-put, and reduce cost. This tool set includes process mapping and process flowcharting, failure modes and effects analysis (FMEA), value stream mapping, and fault tree analysis (FTA). Many health care organizations do not have experience in applying these tools and therefore do not understand how and when to use them. As a result there are many misconceptions about how to use these tools, and they are often incorrectly applied. This article describes these industrial engineering-based tools and also how to use them, when they should be used (and not used), and the intended purposes for their use. In addition the strengths and weaknesses of each of these tools are described, and examples are given to demonstrate the application of these tools in health care settings.

  18. Tools for developing a quality management program: proactive tools (process mapping, value stream mapping, fault tree analysis, and failure mode and effects analysis).

    PubMed

    Rath, Frank

    2008-01-01

    This article examines the concepts of quality management (QM) and quality assurance (QA), as well as the current state of QM and QA practices in radiotherapy. A systematic approach incorporating a series of industrial engineering-based tools is proposed, which can be applied in health care organizations proactively to improve process outcomes, reduce risk and/or improve patient safety, improve through-put, and reduce cost. This tool set includes process mapping and process flowcharting, failure modes and effects analysis (FMEA), value stream mapping, and fault tree analysis (FTA). Many health care organizations do not have experience in applying these tools and therefore do not understand how and when to use them. As a result there are many misconceptions about how to use these tools, and they are often incorrectly applied. This article describes these industrial engineering-based tools and also how to use them, when they should be used (and not used), and the intended purposes for their use. In addition the strengths and weaknesses of each of these tools are described, and examples are given to demonstrate the application of these tools in health care settings.

  19. Modelling the failure modes in geobag revetments.

    PubMed

    Akter, A; Crapper, M; Pender, G; Wright, G; Wong, W S

    2012-01-01

    In recent years, sand filled geotextile bags (geobags) have been used as a means of long-term riverbank revetment stabilization. However, despite their deployment in a significant number of locations, the failure modes of such structures are not well understood. Three interactions influence the geobag performance, i.e. geobag-geobag, geobag-water flow and geobag-water flow-river bank. The aim of the research reported here is to develop a detailed understanding of the failure mechanisms in a geobag revetment using a discrete element model (DEM) validated by laboratory data. The laboratory measured velocity data were used for preparing a mapped velocity field for a coupled DEM simulation of geobag revetment failure. The validated DEM model could identify well the critical bag location in varying water depths. Toe scour, one of the major instability factors in revetments, and its influence on the bottom-most layer of the bags were also reasonably represented in this DEM model. It is envisaged that the use of a DEM model will provide more details on geobag revetment performance in riverbanks.

  20. 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

  1. An Investigation of Digital Instrumentation and Control System Failure Modes

    SciTech Connect

    Korsah, Kofi; Cetiner, Mustafa Sacit; Muhlheim, Michael David; Poore III, Willis P

    2010-01-01

    A study sponsored by the Nuclear Regulatory Commission study was conducted to investigate digital instrumentation and control (DI&C) systems and module-level failure modes using a number of databases both in the nuclear and non-nuclear industries. The objectives of the study were to obtain relevant operational experience data to identify generic DI&C system failure modes and failure mechanisms, and to obtain generic insights, with the intent of using results to establish a unified framework for categorizing failure modes and mechanisms. Of the seven databases studied, the Equipment Performance Information Exchange database was found to contain the most useful data relevant to the study. Even so, the general lack of quality relative to the objectives of the study did not allow the development of a unified framework for failure modes and mechanisms of nuclear I&C systems. However, an attempt was made to characterize all the failure modes observed (i.e., without regard to the type of I&C equipment under consideration) into common categories. It was found that all the failure modes identified could be characterized as (a) detectable/preventable before failures, (b) age-related failures, (c) random failures, (d) random/sudden failures, or (e) intermittent failures. The percentage of failure modes characterized as (a) was significant, implying that a significant reduction in system failures could be achieved through improved online monitoring, exhaustive testing prior to installation, adequate configuration control or verification and validation, etc.

  2. An evaluation of mixed-mode delamination failure criteria

    NASA Technical Reports Server (NTRS)

    Reeder, J. R.

    1992-01-01

    Many different failure criteria have been suggested for mixed mode delamination toughness, but few sets of mixed mode data exist that are consistent over the full mode I opening to mode II shear load range. The mixed mode bending (MMB) test was used to measure the delamination toughness of a brittle epoxy composite, a state of the art toughened epoxy composite, and a tough thermoplastic composite over the full mixed mode range. To gain insight into the different failure responses of the different materials, the delamination fracture surfaces were also examined. An evaluation of several failure criteria which have been reported in the literature was performed, and the range of responses modeled by each criterion was analyzed. A new bilinear failure criterion was analyzed. A new bilinear failure criterion was developed based on a change in the failure mechanism observed from the delamination surfaces. The different criteria were compared to the failure criterion. The failure response of the tough thermoplastic composite could be modeled well with the bilinear criterion but could also be modeled with the more simple linear failure criterion. Since the materials differed in their mixed mode failure response, mixed mode delamination testing will be needed to characterize a composite material. A critical evaluation is provided of the mixed mode failure criteria and should provide general guidance for selecting an appropriate criterion for other materials.

  3. Failure modes of lead/acid batteries

    NASA Astrophysics Data System (ADS)

    Culpin, B.; Rand, D. A. J.

    , have been afforded little discussion. Progressive life-limiting factors encountered with flooded-electrolyte batteries are discussed in detail. These are mainly associated with degradation of the positive plate, the negative plate and the separator. The technology of valve-regulated (i.e., immobilized-electrolyte) batteries is still at an early stage compared with that of flooded designs and, consequently, published information on failure modes is very limited. Nevertheless, based on the reports that are available and the authors' own knowledge, it is possible to make estimates of the major and minor causes of failure (note, these will also occur in flooded systems, but with shifted emphasis). Grid corrosion and growth are generally considered to be of major importance. Both negative-plate sulphation and water loss are also of concern, particularly in cycling applications. By contrast, the traditional problems associated mossing and dendritic growth of the active material should be reduced in valve-regulated batteries.

  4. Global Failure Modes in Composite Structures

    NASA Technical Reports Server (NTRS)

    Knauss, W. G.; Gonzalez, Luis

    2001-01-01

    Composite materials provide well-known advantages for space and aeronautical applications in terms of strength and rigidity to weight ratios and other mechanical properties. As a consequence, their use has experienced a constant increase in the past decades and it is anticipated that this trend will be maintained in the near future. At the same time, being these materials relatively new compared to metals, and having failure characteristics completely different from them, their damage growth and their failure mechanisms are not as well understood in a predictive sense. For example, while in metals fracture produces "clean" cracks with their well defined analytically stress fields at the crack tip, composite fracture is a more complex phenomenon. Instead of a crack, we confront a "damage zone" that may include fiber breakage, fiber microbuckling, fiber pullout, matrix cracking, delamination, debonding or any combination of all these different mechanisms. These phenomena are prevalent in any failure process through an aircraft structure, whether one addresses a global failure such as the ripping of a fuselage or wing section, or whether one is concerned with the failure initiation near a thickness change at stringers or other reinforcement. Thus the topic that has been under consideration has wide application in any real structure and is considered an essential contribution to the predictive failure analysis capability for aircraft containing composite components. The heterogeneity and the anisotropy of composites are not only advantageous but essential characteristics, yet these same features provide complex stress fields, especially in the presence of geometrical discontinuities such as notches, holes or cutouts or structural elements such as stiffeners, stringers, etc. To properly address the interaction between a damage/crack front and a hole with a stringer it is imperative that the stress and deformation fields of the former be (sufficiently well) characterized

  5. Gearbox Typical Failure Modes, Detection, and Mitigation Methods (Presentation)

    SciTech Connect

    Sheng, S.

    2014-01-01

    This presentation was given at the AWEA Operations & Maintenance and Safety Seminar and focused on what the typical gearbox failure modes are, how to detect them using detection techniques, and strategies that help mitigate these failures.

  6. Failure mode interaction in fiber reinforced laminated composites

    NASA Astrophysics Data System (ADS)

    Prabhakar, Pavana

    A novel computational modeling framework to predict the compressive strength of fiber reinforced polymer matrix composite (FRPC) laminates has been presented. The model development has been motivated by a set of experimental results on the compression response of two different FRPCs. The model accounts for failure mode interaction between kink-banding and interface fracture (or delamination), which are observed in the experimental results. To reduce the size of the computational model, those interfaces that are most susceptible to delamination are first determined through a free-edge stress analysis. Furthermore, 0-axis layers, which are passive in the failure process are represented through an equivalent homogenized model, but the microstructural features of the on-axis layers (zero plies) are retained in the computational model. The predictions of the model matched well with the experimental observations, and they were found to accurately account for failure mechanism interactions. Therefore, this model has the potential to replace the need to carry out large numbers of tests to obtain the compressive strength allowable for FRPC laminates, the latter allowable being an essential element in the design of lightweight FRPC aerostructures. Furthermore, the thesis presents a new computational model to predict fiber/matrix splitting failure, a failure mode that is frequently observed in in-plane tensile failure of FRPC's. By considering a single lamina, this failure mechanism was seamlessly modeled through the development of a continuum-decohesive nite element (CDFE). The CDFE was motivated by the variational multiscale cohesive method (VMCM) presented earlier by Rudraraju et al. (2010) at the University of Michigan. In the CDFE, the transition from a continuum to a non-continuum is modeled directly (physically) without resorting to enrichment of the shape functions of the element. Thus, the CDFE is a natural merger between cohesive elements and continuum elements. The

  7. Equipment Failure Analysis

    NASA Technical Reports Server (NTRS)

    1980-01-01

    Tennessee Eastman uses NASTRAN to minimize lost production by pinpointing the causes of equipment failures and preventing recurrences. An example of the program's utility involves a large centrifugal fan which developed cracks during start-ups and shutdowns. This information prompted redesign of the fan. Tennessee Eastman has made extensive use of NASTRAN, both as failure analysis tool and as an aid in redesigning production hardware.

  8. Failure Mode Analysis of Aluminium Alloy 2024-T3 in Double-Lap Bolted Joints with Single and Double Fasteners; A Numerical and Experimental Study

    PubMed Central

    Fallahnezhad, Khosro; Steele, Andrew; Oskouei, Reza H.

    2015-01-01

    This paper aims to study the mechanical behaviour and failure mode of Al 2024-T3 in double-lap bolted joints. To accomplish this, the effect of geometric parameters was investigated in both configurations of single and double fasteners. Using ABAQUS/Standard, a three-dimensional finite element model was developed and verified against the experimental results of the joints loaded in tension. In general, double bolt joints were found to have greater load carrying capacities than single bolt joints (by 40%–49%). In single bolt joints, the plate width had insignificant effect on the behaviour of the joint under tensile loading; whereas, increasing the distance of the hole from the edge, considerably enhanced the strength of the joint. In double bolt joints, changing the edge distance had almost no effect on the behaviour of the joint. However, increasing the plate width from 25.4 to 30 mm increased the load carrying capacity by 28%. This study showed that in single bolt connections, with increasing the edge distance, the failure mode can favourably shift from shear-out to bearing. Also, double bolt joints with wider plates (increased width) can beneficially shift the failure mode from net-tension to bearing. The geometric parameters were found to play an important role in controlling the failure mode so that catastrophic failure modes of net-tension and shear-out can be prevented in bolted joint.

  9. Integration of Value Stream Map and Healthcare Failure Mode and Effect Analysis into Six Sigma Methodology to Improve Process of Surgical Specimen Handling.

    PubMed

    Hung, Sheng-Hui; Wang, Pa-Chun; Lin, Hung-Chun; Chen, Hung-Ying; Su, Chao-Ton

    2015-01-01

    Specimen handling is a critical patient safety issue. Problematic handling process, such as misidentification (of patients, surgical site, and specimen counts), specimen loss, or improper specimen preparation can lead to serious patient harms and lawsuits. Value stream map (VSM) is a tool used to find out non-value-added works, enhance the quality, and reduce the cost of the studied process. On the other hand, healthcare failure mode and effect analysis (HFMEA) is now frequently employed to avoid possible medication errors in healthcare process. Both of them have a goal similar to Six Sigma methodology for process improvement. This study proposes a model that integrates VSM and HFMEA into the framework, which mainly consists of define, measure, analyze, improve, and control (DMAIC), of Six Sigma. A Six Sigma project for improving the process of surgical specimen handling in a hospital was conducted to demonstrate the effectiveness of the proposed model.

  10. Applicability of NASA contract quality management and failure mode effect analysis procedures to the USGS Outer Continental Shelf oil and gas lease management program

    NASA Technical Reports Server (NTRS)

    Dyer, M. K.; Little, D. G.; Hoard, E. G.; Taylor, A. C.; Campbell, R.

    1972-01-01

    An approach that might be used for determining the applicability of NASA management techniques to benefit almost any type of down-to-earth enterprise is presented. A study was made to determine the following: (1) the practicality of adopting NASA contractual quality management techniques to the U.S. Geological Survey Outer Continental Shelf lease management function; (2) the applicability of failure mode effects analysis to the drilling, production, and delivery systems in use offshore; (3) the impact on industrial offshore operations and onshore management operations required to apply recommended NASA techniques; and (4) the probable changes required in laws or regulations in order to implement recommendations. Several management activities that have been applied to space programs are identified, and their institution for improved management of offshore and onshore oil and gas operations is recommended.

  11. Failure mode and effect analysis oriented to risk-reduction interventions in intraoperative electron radiation therapy: the specific impact of patient transportation, automation, and treatment planning availability.

    PubMed

    López-Tarjuelo, Juan; Bouché-Babiloni, Ana; Santos-Serra, Agustín; Morillo-Macías, Virginia; Calvo, Felipe A; Kubyshin, Yuri; Ferrer-Albiach, Carlos

    2014-11-01

    Industrial companies use failure mode and effect analysis (FMEA) to improve quality. Our objective was to describe an FMEA and subsequent interventions for an automated intraoperative electron radiotherapy (IOERT) procedure with computed tomography simulation, pre-planning, and a fixed conventional linear accelerator. A process map, an FMEA, and a fault tree analysis are reported. The equipment considered was the radiance treatment planning system (TPS), the Elekta Precise linac, and TN-502RDM-H metal-oxide-semiconductor-field-effect transistor in vivo dosimeters. Computerized order-entry and treatment-automation were also analyzed. Fifty-seven potential modes and effects were identified and classified into 'treatment cancellation' and 'delivering an unintended dose'. They were graded from 'inconvenience' or 'suboptimal treatment' to 'total cancellation' or 'potentially wrong' or 'very wrong administered dose', although these latter effects were never experienced. Risk priority numbers (RPNs) ranged from 3 to 324 and totaled 4804. After interventions such as double checking, interlocking, automation, and structural changes the final total RPN was reduced to 1320. FMEA is crucial for prioritizing risk-reduction interventions. In a semi-surgical procedure like IOERT double checking has the potential to reduce risk and improve quality. Interlocks and automation should also be implemented to increase the safety of the procedure. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  12. 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.

  13. A bilinear failure criterion for mixed-mode delamination

    NASA Technical Reports Server (NTRS)

    Reeder, James R.

    1993-01-01

    Many different failure criteria have been suggested for mixed-mode delamination toughness, but few sets of mixed-mode data exist that are consistent over the full range of Mode 1 opening load to Mode 2 shear load range. The mixed-mode bending (MMB) test was used to measure the delamination toughness of a brittle epoxy composite, a state-of-the-art toughened epoxy composite, and a tough thermoplastic composite over the full mixed-mode range. To gain insight into the different failure responses of the different materials, the delamination fracture surfaces were also examined. An evaluation of several failure criteria that have been reported in the literature was performed, and the range of responses modeled by each criterion was analyzed. A bilinear failure criterion was introduced based on a change in the failure mechanism observed from the delamination surfaces. The different criteria were compared to the failure response of the three materials tested. The responses of the two epoxies were best modeled with the new bilinear failure criterion. The failure response of the tough thermoplastic composite could be modeled well with the bilinear criterion but could also be modeled with the more simple linear failure criterion. Since the materials differed in their mixed-mode failure response, mixed-mode delamination testing will be needed to characterize a composite material. This paper presents consistent sets of mixed-mode data, provides a critical evaluation of the mixed-mode failure criteria, and should provide general guidance for selecting an appropriate criterion for other materials.

  14. SU-C-BRD-02: A Team Focused Clinical Implementation and Failure Mode and Effects Analysis of HDR Skin Brachytherapy Using Valencia and Leipzig Surface Applicators

    SciTech Connect

    Sayler, E; Harrison, A; Eldredge-Hindy, H; Dinome, J; Munro, S; Anne, R; Comber, E; Lockamy, V

    2014-06-15

    Purpose: and Leipzig applicators (VLAs) are single-channel brachytherapy surface applicators used to treat skin lesions up to 2cm diameter. Source dwell times can be calculated and entered manually after clinical set-up or ultrasound. This procedure differs dramatically from CT-based planning; the novelty and unfamiliarity could lead to severe errors. To build layers of safety and ensure quality, a multidisciplinary team created a protocol and applied Failure Modes and Effects Analysis (FMEA) to the clinical procedure for HDR VLA skin treatments. Methods: team including physicists, physicians, nurses, therapists, residents, and administration developed a clinical procedure for VLA treatment. The procedure was evaluated using FMEA. Failure modes were identified and scored by severity, occurrence, and detection. The clinical procedure was revised to address high-scoring process nodes. Results: Several key components were added to the clinical procedure to minimize risk probability numbers (RPN): -Treatments are reviewed at weekly QA rounds, where physicians discuss diagnosis, prescription, applicator selection, and set-up. Peer review reduces the likelihood of an inappropriate treatment regime. -A template for HDR skin treatments was established in the clinical EMR system to standardize treatment instructions. This reduces the chances of miscommunication between the physician and planning physicist, and increases the detectability of an error during the physics second check. -A screen check was implemented during the second check to increase detectability of an error. -To reduce error probability, the treatment plan worksheet was designed to display plan parameters in a format visually similar to the treatment console display. This facilitates data entry and verification. -VLAs are color-coded and labeled to match the EMR prescriptions, which simplifies in-room selection and verification. Conclusion: Multidisciplinary planning and FMEA increased delectability and

  15. Failure mode analysis and a mechanism for hot-ductility improvement in the Nb-microalloyed steel

    NASA Astrophysics Data System (ADS)

    Zarandi, Faramarz; Yue, Steven

    2004-12-01

    Loss of hot ductility at the straightening stage of the continuous casting of high-strength low-alloy steel is attributed to different microalloying elements, in particular, Nb. However, such elements are essential for the desired mechanical characteristics of the final product. Since the chemistry cannot be altered to alleviate the problem, thermomechanical processing was studied in order to improve the hot ductility. Two Nb-microalloyed steels, one also containing B, were examined. The thermal history occurring in the continuous casting process was taken into account as well. First, it was noticed that the steel with B has a higher hot ductility than the other after being subjected to in-situ melting followed by the thermal schedule. Grain boundary sliding was recognized as the failure mechanism. Then, the effect of deformation applied in the vicinity of the δ→ γ transformation, while the thermal schedule was being executed, was investigated. Such deformation appeared to improve the hot ductility remarkably. Finally, the mechanism of such improvement in the hot ductility was elaborated.

  16. Light water reactor lower head failure analysis

    SciTech Connect

    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 broader 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.

  17. Wind Turbine Gearbox Failure Modes - A Brief (Presentation)

    SciTech Connect

    Sheng, S.; McDade, M.; Errichello, R.

    2011-10-01

    Wind turbine gearboxes are not always meeting 20-year design life. Premature failure of gearboxes increases cost of energy, turbine downtime, unplanned maintenance, gearbox replacement and rebuild, and increased warranty reserves. The problem is widespread, affects most Original Equipment Manufacturers, and is not caused by manufacturing practices. There is a need to improve gearbox reliability and reduce turbine downtime. The topics of this presentation are: GRC (Gearbox Reliability Collaborative) technical approach; Gearbox failure database; Recorded incidents summary; Top failure modes for bearings; Top failure modes for gears; GRC test gearbox; Bearing nomenclature; Test history; Real damage; Gear sets; Bearings; Observations; and Summary. 5 refs.

  18. Identification and assessment of common errors in the admission process of patients in Isfahan Fertility and Infertility Center based on "failure modes and effects analysis".

    PubMed

    Dehghan, Ashraf; Abumasoudi, Rouhollah Sheikh; Ehsanpour, Soheila

    2016-01-01

    Infertility and errors in the process of its treatment have a negative impact on infertile couples. The present study was aimed to identify and assess the common errors in the reception process by applying the approach of "failure modes and effects analysis" (FMEA). In this descriptive cross-sectional study, the admission process of fertility and infertility center of Isfahan was selected for evaluation of its errors based on the team members' decision. At first, the admission process was charted through observations and interviewing employees, holding multiple panels, and using FMEA worksheet, which has been used in many researches all over the world and also in Iran. Its validity was evaluated through content and face validity, and its reliability was evaluated through reviewing and confirmation of the obtained information by the FMEA team, and eventually possible errors, causes, and three indicators of severity of effect, probability of occurrence, and probability of detection were determined and corrective actions were proposed. Data analysis was determined by the number of risk priority (RPN) which is calculated by multiplying the severity of effect, probability of occurrence, and probability of detection. Twenty-five errors with RPN ≥ 125 was detected through the admission process, in which six cases of error had high priority in terms of severity and occurrence probability and were identified as high-risk errors. The team-oriented method of FMEA could be useful for assessment of errors and also to reduce the occurrence probability of errors.

  19. Investigation of successive failure modes in graphite/epoxy laminated composite beams

    NASA Astrophysics Data System (ADS)

    Greif, R.; Chapon, E.

    1993-05-01

    A theoretical and experimental investigation is conducted for the successive failure modes of graphite-epoxy laminated beams, on the basis of the Tsai-Wu and maximum stress failure theories, giving attention to behavior beyond the first failure. It is assumed that, once a ply fails in a laminate, it can carry no further load and its elastic properties are set to zero. The failure analysis is then repeated with the modified laminae on updated matrices, until the next failure point is reached. Theoretical results are compared with experimental ones, and it is found that theory-based failures occur at substantially lower loads than those of actual fracture.

  20. Safety Management of a Clinical Process Using Failure Mode and Effect Analysis: Continuous Renal Replacement Therapies in Intensive Care Unit Patients.

    PubMed

    Sanchez-Izquierdo-Riera, Jose Angel; Molano-Alvarez, Esteban; Saez-de la Fuente, Ignacio; Maynar-Moliner, Javier; Marín-Mateos, Helena; Chacón-Alves, Silvia

    2016-01-01

    The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases: 1) Retrospective observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p < 0.05); less patients suffered circuit coagulation with inability to return the blood to the patient (25 patients [46.3%] vs. 16 patients [22.2%]; p < 0.05); 54 patients (100%) versus 5 (6.94%) did not get phosphorus levels monitoring (p < 0.05); in 14 patients (25.9%) versus 0 (0%), the CRRT prescription did not appear on medical orders. As a measure of improvement, we adopt a dynamic dosage management. After the process FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.

  1. Failure Modes Experienced on Spacecraft Nicd Batteries

    NASA Technical Reports Server (NTRS)

    Gross, S.

    1985-01-01

    A review was made of failures and irregularities experienced on nickel cadmium batteries for 31 spacecraft. Only rarely did batteries fail completely. In many cases, poorly performing batteries were compensated for by a reduction in loads or by continuing to operate in spite of out-of-voltage conditions. Low discharge voltage was the most common problem observed in flight spacecraft (42%). Spacecraft batteries are often designed to protect against cell shorts, but cell shorts accounted for only 16% of the failures. Other causes of problems were high charge voltage (16%), battery problems caused by other elements of the spacecraft (10%), and open circuit failures (6%). Problems of miscellaneous or unknown causes occurred in 10% of the cases.

  2. Circuit breaker operation and potential failure modes during an earthquake

    SciTech Connect

    Lambert, H.E.; Budnitz, R.J.

    1987-01-01

    This study addresses the effect of a strong-motion earthquake on circuit breaker operation. It focuses on the loss of offsite power (LOSP) transient caused by a strong-motion earthquake at the Zion Nuclear Power Plant. This paper also describes the operator action necessary to prevent core melt if the above circuit breaker failure modes occur simultaneously on three 4.16 KV buses. Numerous circuit breakers important to plant safety, such as circuit breakers to diesel generators and engineered safety systems (ESS), must open and/or close during this transient while strong motion is occurring. Potential seismically-induced circuit-breaker failures modes were uncovered while the study was conducted. These failure modes include: circuit breaker fails to close; circuit breaker trips inadvertently; circuit breaker fails to reclose after trip. The causes of these failure modes include: Relay chatter causes the circuit breaker to trip; Relay chatter causes anti-pumping relays to seal-in which prevents automatic closure of circuit breakers; Load sequencer failures. The incorporation of these failure modes as well as other instrumentation and control failures into a limited scope seismic probabilistic risk assessment is also discussed in this paper.

  3. Predicting Modes and Displacements of Seismic Rock Slope Failures

    NASA Astrophysics Data System (ADS)

    Gibson, M. D.; Wartman, J.; Keefer, D. K.; Maclaughlin, M.; Arnold, L.; Applegate, K. N.; Smith, S.; Adams, S.

    2013-12-01

    Seismically induced rock slope failures have resulted in billions of dollars of economic damage and enormous loss of life throughout the world. Accurate prediction of the triggering and run out of these failures is elusive for a variety of reasons, including knowledge of the physical modes of failure. Our research explores the potential failure modes of an idealized rigid rock block and expands the modes typically considered to include not only sliding but also toppling (pure forward rotation) and slumping (combined backward rotation and translation). The yield acceleration (or minimum inertial acceleration to cause block movement) for slumping, similar to toppling, is found to be lower than for pure translational sliding. These yield accelerations indicate the initial modes of rock block failure; however, they do not always predict the ultimate failure mode. To predict the final failure modes, the results of discrete element numerical analyses were compared to pseudo static yield acceleration to develop a seismic failure mode decision-making chart based on block geometry and interface friction. With regard to seismic displacement predictions, current simplified models predicting ultimate displacement of a mass under seismic conditions are limited to purely translating, sliding blocks (i.e. Newmark's sliding block method). Our modeling introduces additional simplified analyses to predict ultimate displacement in toppling and slumping modes as well. Important findings from these new methods are that the magnitude of seismically-induced displacement is dependent on the size of the block (or failure mass) and that as the yield acceleration decreases the seismically induced displacements increase. We plan to map these tools into analyses that evaluate rock slope systems with complex geology and geotechnical characteristics. It is envisioned that the decision chart, which predicts the initial and ultimate modes of failure based on block geometry and interface friction

  4. SU-E-T-119: Analysis the Efficacy of Different Radiotherapy Methods and Failure Mode in No-Metastasis Esophageal Squamous Cell Carcinoma

    SciTech Connect

    Yankun, C; Zhihui, T; Runxiao, L; Shen, W

    2015-06-15

    Purpose: To evaluate the curative effect of radio (chemo) therapy and mode of treatment failure in no-metastasis and lesion length ≤ 5.0cm esophageal squamous cell carcinoma (ESCC). Methods: There were 158 eligible patients were retrospectively analyzed, to analysis the curative effect of radio (chemo) therapy, prognosis factors, toxicity and prognostic index model. Results: To all patients the 1, 3, 5 overall survival rate were 83.54%, 52.53%, 32.58%, the local recurrence rate were 15.08%, 33.60% and 38.14%; distant metastasis rate were 10.64%, 25.21% and 36.06%; tumor specific survival rate were 76.64%, 54.07% and 44.51%. Multivariate analysis showed that patients with ECOG grade (χ2=13.945, P=0.000), short-term effect (χ2=19.360, P=0.000) and different radiotherapy methods (χ2=9.866, P=0.002) as the independent prognostic factors. Prognostic index model showed that the survival rate was significantly higher in the lower value of PI group than in the larger value of PI group (χ2=49.19, P=0.0000). In our whole group, there were simple locoregional recurrence (LR) 40 cases (25.3%), simple Distant metastasis (DM) 31 cases (19.6%), LR and DM in 14 cases (8.9%) after treatment. The chi-square test showed that there were no significant difference in the incidence of Elective Nodal Irradiation (ENI )and Involved Field Irradiation (IFI) patients with LR and DM ( χ2=2.363, 2.950, P=0.124, 0.085). Conclusion: Radio (chemo) therapy has a good curative effect in no-metastasis and lesion length ≤ 5.0cm ESCC patients.

  5. Failure modes for pipelines in landslide areas

    SciTech Connect

    Bruschi, R.; Spinazze, M.; Tomassini, D.; Cuscuna, S.; Venzi, S.

    1995-12-31

    In recent years a number of incidences of pipelines affected by slow soil movements have been reported in the relevant literature. Further related issues such as soil-pipe interaction have been studied both theoretically and through experimental surveys, along with the environmental conditions which are responsible for hazard to the pipeline integrity. A suitable design criteria under these circumstances has been discussed by several authors, in particular in relation to a limit state approach and hence a strain based criteria. The scope of this paper is to describe the failure mechanisms which may affect the pipeline in the presence of slow soil movements impacting on the pipeline, both in the longitudinal and transverse direction. Particular attention is paid to environmental, geometric and structural parameters which steer the process towards one or other failure mechanism. Criteria for deciding upon remedial measures required to guarantee the structural integrity of the pipeline, both in the short and in the long term, are discussed.

  6. Failure analysis of surface-micromachined microengines

    SciTech Connect

    Peterson, K.A.; Tangyunyong, P.; Pimentel, A.A.

    1998-11-01

    Microelectronic failure analysis (FA) has been an integral part of the development of state-of-the-art integrated circuits. FA of MicroElectroMechanical Systems (MEMS) is moving from its infancy stage to assume an important role in the successful design, fabrication, performance and reliability analysis for this new technology. In previous work, the authors focused on the application of several techniques developed for integrated circuit analysis to an earlier version of a surface micromachined microengine fabricated at Sandia. Recently, they have identified important new failure modes in binary counters that incorporate a newer design of the microengine, using a subset of integrated circuit failure analysis techniques including optical microscopy, focused ion beam (FIB) techniques, atomic force microscopy (AFM), and scanning electron microscopy (SEM). The primary failure mode they have identified is directly related to visible wear on bearing surfaces. In this paper, they describe in detail the characteristics of the failure modes in binary counters. They also compare the failure characteristics with those of an earlier version of the microengine.

  7. A practical guide to failure mode and effects analysis in health care: making the most of the team and its meetings.

    PubMed

    Ashley, Laura; Armitage, Gerry; Neary, Maria; Hollingsworth, Gillian

    2010-08-01

    Failure Mode and Effects Analysis (FMEA) is a proactive risk assessment tool used to identify potential vulnerabilities in complex, high-risk processes and to generate remedial actions before the processes result in adverse events. FMEA is increasingly used to proactively assess and improve the safety of complex health care processes such as drug administration and blood transfusion. A central feature of FMEA is that it is undertaken by a multidisciplinary team, and because it entails numerous analytical steps, it takes a series of several meetings. Composing a team of busy health care professionals with the appropriate knowledge, skill mix, and logistical availability for regular meetings is, however, a serious challenge. Despite this, information and advice on FMEA team assembly and meetings scheduling are scarce and diffuse and often presented without the accompanying rationale. Assemble an eight-member team composed of clinically active health care staff, from every profession involved in delivery of the process-and who regularly perform it; staff from a range of seniority levels; outsider(s) to the process-and perhaps even to health care; a leader (and facilitator); and researchers. Plan for 10-15 hours of team meeting time for first-time, narrowly defined FMEAs, scheduled as four to six meetings lasting 2 to 3 hours each, spaced weekly to biweekly. Meet in a venue that seats the team around one table and is off the hospital floor but within its grounds. FMEA, generally acknowledged to be a useful addition to the patient safety toolkit, is a meticulous and time- and resource-intensive methodology, and its successful completion is highly dependent on the team members' aptitude and on the facility's and team members' commitment to hold regular, productive meetings.

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

    PubMed

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

    2013-01-01

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

  9. Failure modes and materials design for biomechanical layer structures

    NASA Astrophysics Data System (ADS)

    Deng, Yan

    Ceramic materials are finding increasing usage in the area of biomechanical replacements---dental crowns, hip and bone implants, etc.---where strength, wear resistance, biocompatibility, chemical durability and even aesthetics are critical issues. Aesthetic ceramic crowns have been widely used in dentistry to replace damaged or missing teeth. However, the failure rates of ceramic crowns, especially all-ceramic crowns, can be 1%˜6% per year, which is not satisfactory to patients. The materials limitations and underlying fracture mechanisms of these prostheses are not well understood. In this thesis, fundamental fracture and damage mechanisms in model dental bilayer and trilayer structures are studied. Principle failure modes are identified from in situ experimentation and confirmed by fracture mechanics analysis. In bilayer structures of ceramic/polycarbonate (representative of ceramic crown/dentin structure), three major damage sources are identified: (i) top-surface cone cracks or (ii) quasiplasticity, dominating in thick ceramic bilayers; (iii) bottom-surface radial cracks, dominating in thin ceramic bilayers. Critical load P for each damage mode are measured in six dental ceramics: Y-TZP zirconia, glass-infiltrated zirconia and alumina (InCeram), glass-ceramic (Empress II), Porcelain (Mark II and Empress) bonded to polymer substrates, as a function of ceramic thickness d in the range of 100 mum to 10 mm. P is found independent of d for mode (i) and (ii), but has a d 2 relations for mode (iii)---bottom surface radial cracking. In trilayer structures of glass/core-ceramic/polycarbonate (representing veneer porcelain/core/dentin structures), three inner fracture origins are identified: radial cracks from the bottom surface in the (i) first and (ii) second layers; and (iii) quasiplasticity in core-ceramic layer. The role of relative veneer/core thickness, d1/d 2 and materials properties is investigated for three core materials with different modulus (114--270GPa

  10. RAB-plate versus sliding hip screw for unstable trochanteric hip fractures: stability of the fixation and modes of failure--radiographic analysis of 218 fractures.

    PubMed

    Buciuto, R; Hammer, R

    2001-03-01

    The sliding hip screw has gained considerable acceptance in the treatment of unstable trochanteric fractures. However, the new type of 120 degrees fixed angle blade-plate with a buttress rod (RAB-plate) showed encouraging clinical results. The purpose of this study was to assess stability of fixation and analyze modes of failure in unstable trochanteric hip fractures treated with these devices. A retrospective radiographic review of 218 unstable fractures was performed. Linear and angular displacements of the major fragments and implant migration into the femoral head during healing were assessed. Additionally, adequacy of the reduction and the location of the implant within the femoral head as predictors of fixation failure were evaluated. The postreduction neck-shaft angle was maintained in the majority of the fractures in both groups. However, there was a significantly higher incidence of varus angulation by 10 degrees or more by the completion of healing among fractures treated with the sliding hip screw (p = 0.04). There was no statistically significant difference in vertical migration of the device into the femoral head between the implants used (p = 0.3). There was a significant relationship between failure of the fixation and varus reduction (p = 0.04) as well as screw/neck angle deviation more than 20 degrees in the lateral projection (p = 0.005) or if the implant was in a superior or posterior position (p = 0.02). The RAB-plate provided a more stable fixation, especially with regard to maintained postoperative alignment. However, positive predictors for fixation failure were identical for both devices. Here, the screw/neck angle deviation has had the strongest significance for prediction of fixation failure.

  11. The study of typical failure modes and failure mechanism of polymer materials

    NASA Astrophysics Data System (ADS)

    Xu, Huanxiang; Tang, Yanhuang; Liu, Zilian; Cai, Yingying; Wang, Youliang

    2017-09-01

    Polymer materials are widely used because of their unique properties such as light, easy processing, various performance and so on. However, due to the structural characteristics of polymer materials, some conditions such as light, heat, solvents and so on will cause polymer materials failure. In this paper, the typical failure modes and failure mechanism of polymer materials such as cracking, discoloration, bulging, precipitates and so on are analyzed and discussed.

  12. Failure modes at room and elevated temperatures. Technical report

    SciTech Connect

    Braun, L.M.

    1995-04-01

    Successful development of reliable ceramic composites will depend on an understanding of matrix cracking and damage mechanisms in these materials. Therefore, the objective of the Failure Models subtask is to investigate failure and damage mechanisms in fiber reinforced ceramic composites. Issues such as how fiber coatings, the fiber/matrix interface, residual stresses, and fiber volume fraction affect frictional stresses, fiber debonding, fiber pull-out and failure modes will be examined. The effect of these microstructural parameters on matrix crack initiation, propagation and damage will also be determined. The resulting observations and measurements data will be used to develop theoretical models for damage mechanisms in fiber reinforced composites. This report presents results concerning the effect of temperature on the failure modes of continuous fiber ceramic composites performed during the last quarter of FY 1993 and FY 1994. The Raman stress measurements and calculations were performed during the last quarter of FY 1994 and the first quarter of FY 1995.

  13. Recent performance, lifetime, and failure modes of the 5045 klystron population at SLAC

    SciTech Connect

    Koontz, R.F.; Lee, T.G.; Pearson, C.; Vlieks, A.E.

    1992-08-01

    The 65 MW S-Band klystrons (5045) used to power SLC have been in service for over seven years. Currently, 244 of these tubes are in place on the accelerator, operating full power at 120 pulses per second. Enough tubes have now reached end of life, or experienced other failures to allow a good analysis of failure modes, and to project average lifetime for this type of tube. This paper describes the various modes of failure seen in klystrons rammed from SLC service, and provides data on expected lifetime from current production based on accumulated SLC operating experience.

  14. Effects of Failure Modes on Strength of Aluminum Resistance Spot Welds

    SciTech Connect

    Sun, Xin; Stephens, Elizabeth V.; Davies, Richard W.; Khaleel, Mohammad A.; Spinella, Donald J.

    2005-04-01

    This paper examines the effects of failure modes on the static strength and total energy absorption of aluminum spot-welded samples using experimental, statistical, and analytical approaches. The main failure modes for aluminum spot welds are nugget pullout and interfacial fracture. Two populations of aluminum spot welds were studied. Within each population, coupon configurations of lap shear, cross tension and coach peel were considered. Thirty replicate static strength tests were performed for each coupon configuration. The resulted peak load and energy absorption level associated with each failure mode was studied using statistical models. Next, an analytical model was developed to determine the failure mode of an aluminum resistance spot weld based on stress analysis. It is found that weld size, sheet thickness, and level of weld porosity and defects are the main factors determining the cross tension failure mode for an aluminum spot weld. The peak load and energy absorption levels for the cross tension and coach peel samples tested are found not to be very sensitive to the failure modes under static loading.

  15. 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.

  16. Transition among failure modes of the bending system with a stiff film on a soft substrate

    SciTech Connect

    Dai, Longchao; Huang, Yin; Chen, Hang; Feng, Xue; Fang, Daining

    2015-01-12

    Growing interest is being attracted by stretchable and flexible electronics recently due to their attractive characteristics, commercial potentials, and engineering challenges. In comparison with the system on a macroscopic scale, different failure modes are observed in a system with a thin film bonded on an elastomeric substrate. Furthermore, the experimental observations reveal that failure modes occur in turn with the increasing of thickness ratio of the film to substrate. In this paper, theoretical analysis is performed on the failure mechanism in this system with the focus on transitions among these failure modes based on the theory of fracture mechanics. The present theoretical predictions are coincident with related experiment results and can be used to guide the related structural design.

  17. PV Degradation Curves: Non-Linearities and Failure Modes

    SciTech Connect

    Jordan, Dirk C.; Silverman, Timothy J.; Sekulic, Bill; Kurtz, Sarah R.

    2016-09-03

    Photovoltaic (PV) reliability and durability have seen increased interest in recent years. Historically, and as a preliminarily reasonable approximation, linear degradation rates have been used to quantify long-term module and system performance. The underlying assumption of linearity can be violated at the beginning of the life, as has been well documented, especially for thin-film technology. Additionally, non-linearities in the wear-out phase can have significant economic impact and appear to be linked to different failure modes. In addition, associating specific degradation and failure modes with specific time series behavior will aid in duplicating these degradation modes in accelerated tests and, eventually, in service life prediction. In this paper, we discuss different degradation modes and how some of these may cause approximately linear degradation within the measurement uncertainty (e.g., modules that were mainly affected by encapsulant discoloration) while other degradation modes lead to distinctly non-linear degradation (e.g., hot spots caused by cracked cells or solder bond failures and corrosion). The various behaviors are summarized with the goal of aiding in predictions of what may be seen in other systems.

  18. Scanning microscopy in microcircuit failure analysis

    NASA Technical Reports Server (NTRS)

    Nicolas, D. P.

    1978-01-01

    A three-phase microcircuit failure analysis procedure is presented. In the first phase, the device is nondestructively tested and the data obtained is correlated with the circumstances surrounding the failure event. The device is then subjected to a limited nondestructive analysis dominated by optical and scanning electron microscopy (SEM). Knowing that microcircuits usually fail from manufacturing defects or misuse, the analyst looks for one of the probable mechanisms. The SEM has two special operating modes that provide unique data for nondestructive analysis: voltage contrast and conductive current. These are used with other SEM modes and surface analysis techniques to analyze complicated microcircuits. The last phase includes the destructive procedures. The end product of these analyses is a corrective action that will yield a highly reliable system.

  19. Failure analysis of high performance ballistic fibers

    NASA Astrophysics Data System (ADS)

    Spatola, Jennifer S.

    High performance fibers have a high tensile strength and modulus, good wear resistance, and a low density, making them ideal for applications in ballistic impact resistance, such as body armor. However, the observed ballistic performance of these fibers is much lower than the predicted values. Since the predictions assume only tensile stress failure, it is safe to assume that the stress state is affecting fiber performance. The purpose of this research was to determine if there are failure mode changes in the fiber fracture when transversely loaded by indenters of different shapes. An experimental design mimicking transverse impact was used to determine any such effects. Three different indenters were used: round, FSP, and razor blade. The indenter height was changed to change the angle of failure tested. Five high performance fibers were examined: KevlarRTM KM2, SpectraRTM 130d, DyneemaRTM SK-62 and SK-76, and ZylonRTM 555. Failed fibers were analyzed using an SEM to determine failure mechanisms. The results show that the round and razor blade indenters produced a constant failure strain, as well as failure mechanisms independent of testing angle. The FSP indenter produced a decrease in failure strain as the angle increased. Fibrillation was the dominant failure mechanism at all angles for the round indenter, while through thickness shearing was the failure mechanism for the razor blade. The FSP indenter showed a transition from fibrillation at low angles to through thickness shearing at high angles, indicating that the round and razor blade indenters are extreme cases of the FSP indenter. The failure mechanisms observed with the FSP indenter at various angles correlated with the experimental strain data obtained during fiber testing. This indicates that geometry of the indenter tip in compression is a contributing factor in lowering the failure strain of the high performance fibers. TEM analysis of the fiber failure mechanisms was also attempted, though without

  20. BIOASSAY VESSEL FAILURE ANALYSIS

    SciTech Connect

    Vormelker, P

    2008-09-22

    Two high-pressure bioassay vessels failed at the Savannah River Site during a microwave heating process for biosample testing. Improper installation of the thermal shield in the first failure caused the vessel to burst during microwave heating. The second vessel failure is attributed to overpressurization during a test run. Vessel failure appeared to initiate in the mold parting line, the thinnest cross-section of the octagonal vessel. No material flaws were found in the vessel that would impair its structural performance. Content weight should be minimized to reduce operating temperature and pressure. Outer vessel life is dependent on actual temperature exposure. Since thermal aging of the vessels can be detrimental to their performance, it was recommended that the vessels be used for a limited number of cycles to be determined by additional testing.

  1. 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.

  2. 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.

  3. Reliability and failure modes of internal conical dental implant connections.

    PubMed

    Freitas-Júnior, Amilcar C; Almeida, Erika O; Bonfante, Estevam A; Silva, Nelson R F A; Coelho, Paulo G

    2013-02-01

    Biological and mechanical implant-abutment connection complications and failures are still present in clinical practice, frequently compromising oral function. The purpose of this study was to evaluate the reliability and failure modes of anterior single-unit restorations in internal conical interface (ICI) implants using step-stress accelerated life testing (SSALT). Forty-two ICI implants were distributed in two groups (n = 21 each): group AT-OsseoSpeed(™) TX (Astra Tech, Waltham, MA, USA); group SV-Duocon System Line, Morse Taper (Signo Vinces Ltda., Campo Largo, PR, Brazil). The corresponding abutments were screwed to the implants and standardized maxillary central incisor metal crowns were cemented and subjected to SSALT in water. Use-level probability Weibull curves and reliability for a mission of 50,000 cycles at 200 N were calculated. Differences between groups were assessed by Kruskal-Wallis along with Bonferroni's post-hoc tests. Polarized-light and scanning electron microscopes were used for failure analyses. The Beta (β) value derived from use level probability Weibull calculation was 1.62 (1.01-2.58) for group AT and 2.56 (1.76-3.74) for group SV, indicating that fatigue was an accelerating factor for failure of both groups. The reliability for group AT was 0.95 and for group SV was 0.88. Kruskal-Wallis along with Bonferroni's post-hoc tests showed no significant difference between the groups tested (P > 0.27). In all specimens of both groups, the chief failure mode was abutment fracture at the conical joint region and screw fracture at neck's region. Reliability was not different between investigated ICI connections supporting maxillary incisor crowns. Failure modes were similar. © 2012 John Wiley & Sons A/S.

  4. 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.

  5. New understandings of failure modes in SSL luminaires

    SciTech Connect

    Shepherd, Sarah D; Mills, Karmann C; Yaga, Robert; Johnson, Cortina; Davis, J Lynn

    2014-09-18

    As SSL products are being rapidly introduced into the market, there is a need to develop standard screening and testing protocols that can be performed quickly and provide data surrounding product lifetime and performance. These protocols, derived from standard industry tests, are known as ALTs (accelerated life tests) and can be performed in a timeframe of weeks to months instead of years. Accelerated testing utilizes a combination of elevated temperature and humidity conditions as well as electrical power cycling to control aging of the luminaires. In this study, we report on the findings of failure modes for two different luminaire products exposed to temperature-humidity ALTs. LEDs are typically considered the determining component for the rate of lumen depreciation. However, this study has shown that each luminaire component can independently or jointly influence system performance and reliability. Material choices, luminaire designs, and driver designs all have significant impacts on the system reliability of a product. From recent data, it is evident that the most common failure modes are not within the LED, but instead occur within resistors, capacitors, and other electrical components of the driver. Insights into failure modes and rates as a result of ALTs are reported with emphasis on component influence on overall system reliability.

  6. New understandings of failure modes in SSL luminaires

    NASA Astrophysics Data System (ADS)

    Shepherd, Sarah D.; Mills, Karmann C.; Yaga, Robert; Johnson, Cortina; Davis, J. Lynn

    2014-09-01

    As SSL products are being rapidly introduced into the market, there is a need to develop standard screening and testing protocols that can be performed quickly and provide data surrounding product lifetime and performance. These protocols, derived from standard industry tests, are known as ALTs (accelerated life tests) and can be performed in a timeframe of weeks to months instead of years. Accelerated testing utilizes a combination of elevated temperature and humidity conditions as well as electrical power cycling to control aging of the luminaires. In this study, we report on the findings of failure modes for two different luminaire products exposed to temperature-humidity ALTs. LEDs are typically considered the determining component for the rate of lumen depreciation. However, this study has shown that each luminaire component can independently or jointly influence system performance and reliability. Material choices, luminaire designs, and driver designs all have significant impacts on the system reliability of a product. From recent data, it is evident that the most common failure modes are not within the LED, but instead occur within resistors, capacitors, and other electrical components of the driver. Insights into failure modes and rates as a result of ALTs are reported with emphasis on component influence on overall system reliability.

  7. Investigation of failure mode transition in ceramics under confinement

    SciTech Connect

    Ravichandran, G.; Chen, W.; Ortiz, M.

    1995-12-31

    A newly developed experimental technique is used to investigate the failure behavior of ceramics in multi-axial compression. The axial loading is provided by a split Kolsky (Hopkinson) compression bar and the radial confinement is provided by shrink fit sleeves on the cylindrical specimens. Confinement pressures on the order of 1 GPa have been achieved. As the confinement is increased on the specimen, the failure mode changes from axial splitting under no confinement to conical faulting under moderate confinement. Experimental data have been obtained for several engineering ceramics in the strain rate range of 10{sup -3} to 10{sup 3} s{sup -1}. The peak or failure strength increases with increasing confinement. The increase in strength over its unconfined strength for a given level of confinement remains independent of the strain rate. The data from multiaxial loading experiments suggest that the engineering ceramics follow the Drucker-Prager model for pressure sensitive dilatant materials. This model is used to predict the localization modes in axi-symmetric geometries. The predictions are compared with experimental results for the limit load and the geometry of the fault. The implications of the proposed constitutive and failure model for the performance of engineering ceramics under multi-axial loading are discussed.

  8. System Reliability Assessment for a Rock Tunnel with Multiple Failure Modes

    NASA Astrophysics Data System (ADS)

    Lü, Qing; Chan, Chin Loong; Low, Bak Kong

    2013-07-01

    This paper presents a practical procedure for assessing the system reliability of a rock tunnel. Three failure modes, namely, inadequate support capacity, excessive tunnel convergence, and insufficient rockbolt length, are considered and investigated using a deterministic model of ground-support interaction analysis based on the convergence-confinement method (CCM). The failure probability of each failure mode is evaluated from the first-order reliability method (FORM) and the response surface method (RSM) via an iterative procedure. The system failure probability bounds are estimated using the bimodal bounds approach suggested by Ditlevsen (1979), based on the reliability index and design point inferred from the FORM. The proposed approach is illustrated with an example of a circular rock tunnel. The computed system failure probability bounds compare favorably with those generated from Monte Carlo simulations. The results show that the relative importance of different failure modes to the system reliability of the tunnel mainly depends on the timing of support installation relative to the advancing tunnel face. It is also shown that reliability indices based on the second-order reliability method (SORM) can be used to achieve more accurate bounds on the system failure probability for nonlinear limit state surfaces. The system reliability-based design for shotcrete thickness is also demonstrated.

  9. Characterization of mode 1 and mixed-mode failure of adhesive bonds between composite adherends

    NASA Technical Reports Server (NTRS)

    Mall, S.; Johnson, W. S.

    1985-01-01

    A combined experimental and analytical investigation of an adhesively bonded composite joint was conducted to characterize both the static and fatigue beyond growth mechanism under mode 1 and mixed-mode 1 and 2 loadings. Two bonded systems were studied: graphite/epoxy adherends bonded with EC 3445 and FM-300 adhesives. For each bonded system, two specimen types were tested: a double-cantilever-beam specimen for mode 1 loading and a cracked-lapshear specimen for mixed-mode 1 and 2 loading. In all specimens tested, failure occurred in the form of debond growth. Debonding always occurred in a cohesive manner with EC 3445 adhesive. The FM-300 adhesive debonded in a cohesive manner under mixed-mode 1 and 2 loading, but in a cohesive, adhesive, or combined cohesive and adhesive manner under mode 1 loading. Total strain-energy release rate appeared to be the driving parameter for debond growth under static and fatigue loadings.

  10. Study of electrical breakdown and secondary pull-in failure modes for NEM relays

    NASA Astrophysics Data System (ADS)

    Ramezani, M.; Severi, S.; Tilmans, H. A. C.; De Meyer, K.

    2017-01-01

    In this work, two common failure modes of nano-electro-mechanical (NEM) relays: (1) electrical breakdown and (2) stiction due to secondary pull-in were analyzed. These effects are dominant when dimensions of the device are scaled to the sub-micrometer scale. Like MEMS devices, design adjustments, such as introduction of dimples, cannot provide a solution. The geometrical parameters and working environment drive directly the occurrence of these failure modes. The beam length is the key parameter in driving the electrical breakdown while the distance of the gate to the drain, the beam thickness, and the actuation gap set the limits for secondary pull-in voltage. The analysis shows that these failure modes could be mitigated and a physical parameters design space could be identified to achieve NEM devices for high speed operation.

  11. Failure environment analysis tool applications

    NASA Technical Reports Server (NTRS)

    Pack, Ginger L.; Wadsworth, David B.

    1994-01-01

    Understanding risks and avoiding failure are daily concerns for the women and men of NASA. Although NASA's mission propels us to push the limits of technology, and though the risks are considerable, the NASA community has instilled within it, the determination to preserve the integrity of the systems upon which our mission and, our employees lives and well-being depend. One of the ways this is being done is by expanding and improving the tools used to perform risk assessment. The Failure Environment Analysis Tool (FEAT) was developed to help engineers and analysts more thoroughly and reliably conduct risk assessment and failure analysis. FEAT accomplishes this by providing answers to questions regarding what might have caused a particular failure; or, conversely, what effect the occurrence of a failure might have on an entire system. Additionally, FEAT can determine what common causes could have resulted in other combinations of failures. FEAT will even help determine the vulnerability of a system to failures, in light of reduced capability. FEAT also is useful in training personnel who must develop an understanding of particular systems. FEAT facilitates training on system behavior, by providing an automated environment in which to conduct 'what-if' evaluation. These types of analyses make FEAT a valuable tool for engineers and operations personnel in the design, analysis, and operation of NASA space systems.

  12. Failure environment analysis tool applications

    NASA Technical Reports Server (NTRS)

    Pack, Ginger L.; Wadsworth, David B.

    1993-01-01

    Understanding risks and avoiding failure are daily concerns for the women and men of NASA. Although NASA's mission propels us to push the limits of technology, and though the risks are considerable, the NASA community has instilled within, the determination to preserve the integrity of the systems upon which our mission and, our employees lives and well-being depend. One of the ways this is being done is by expanding and improving the tools used to perform risk assessment. The Failure Environment Analysis Tool (FEAT) was developed to help engineers and analysts more thoroughly and reliably conduct risk assessment and failure analysis. FEAT accomplishes this by providing answers to questions regarding what might have caused a particular failure; or, conversely, what effect the occurrence of a failure might have on an entire system. Additionally, FEAT can determine what common causes could have resulted in other combinations of failures. FEAT will even help determine the vulnerability of a system to failures, in light of reduced capability. FEAT also is useful in training personnel who must develop an understanding of particular systems. FEAT facilitates training on system behavior, by providing an automated environment in which to conduct 'what-if' evaluation. These types of analyses make FEAT a valuable tool for engineers and operations personnel in the design, analysis, and operation of NASA space systems.

  13. Structural integrity and potential failure modes of hanford high-level waste tanks

    SciTech Connect

    Han, F.C.

    1996-09-30

    Structural Integrity of the Hanford High-Level Waste Tanks were evaluated based on the existing Design and Analysis Documents. All tank structures were found adequate for the normal operating and seismic loads. Potential failure modes of the tanks were assessed by engineering interpretation and extrapolation of the existing engineering documents.

  14. Strength reliability analysis of stiffened cylindrical shells considering failure correlation

    NASA Astrophysics Data System (ADS)

    Bai, Xu; Sun, Liping; Qin, Wei; Lv, Yongkun

    2014-03-01

    The stiffened cylindrical shell is commonly used for the pressure hull of submersibles and the legs of offshore platforms. There are various failure modes because of uncertainty with the structural size and material properties, uncertainty of the calculation model and machining errors. Correlations among failure modes must be considered with the structural reliability of stiffened cylindrical shells. However, the traditional method cannot consider the correlations effectively. The aim of this study is to present a method of reliability analysis for stiffened cylindrical shells which considers the correlations among failure modes. Firstly, the joint failure probability calculation formula of two related failure modes is derived through use of the 2D joint probability density function. Secondly, the full probability formula of the tandem structural system is given with consideration to the correlations among failure modes. At last, the accuracy of the system reliability calculation is verified through use of the Monte Carlo simulation. Result of the analysis shows the failure probability of stiffened cylindrical shells can be gained through adding the failure probability of each mode.

  15. Mud pump failure analysis

    SciTech Connect

    Lewis, E.C. II

    1981-10-01

    Extrusion, the primary cause of piston failure, is the degradation of a seal caused by the seal material moving into the interface between the two parts being sealed. It is shown that operational dynamics of the mud piston lead to an aggravated extrusion condition. As both the liner wall and the piston OD lose material, the clearance gap between liner and piston increases. This gap provides the piston seal a space to move into when pressurized. This movement, called extrusion, is undesirable because the piston rubber is then subjected to abnormal stresses which it cannot tolerate. As the piston moves forward, this extruded material is gradually nibbled away. Extrusion and nibble action continue on each stroke of the pump as additional rubber moves away from the high-pressure side of the piston toward the low-pressure side. A discussion is presented of extrusion rates and seal leakage.

  16. SU-E-T-128: Applying Failure Modes and Effects Analysis to a Risk-Based Quality Management for Stereotactic Radiosurgery in Brazil

    SciTech Connect

    Teixeira, F; Almeida, C de; Huq, M

    2015-06-15

    Purpose: The goal of the present work was to evaluate the process maps for stereotactic radiosurgery (SRS) treatment at three radiotherapy centers in Brazil and apply the FMEA technique to evaluate similarities and differences, if any, of the hazards and risks associated with these processes. Methods: A team, consisting of professionals from different disciplines and involved in the SRS treatment, was formed at each center. Each team was responsible for the development of the process map, and performance of FMEA and FTA. A facilitator knowledgeable in these techniques led the work at each center. The TG100 recommended scales were used for the evaluation of hazard and severity for each step for the major process “treatment planning”. Results: Hazard index given by the Risk Priority Number (RPN) is found to range from 4–270 for various processes and the severity (S) index is found to range from 1–10. The RPN values > 100 and severity value ≥ 7 were chosen to flag safety improvement interventions. Number of steps with RPN ≥100 were found to be 6, 59 and 45 for the three centers. The corresponding values for S ≥ 7 are 24, 21 and 25 respectively. The range of RPN and S values for each center belong to different process steps and failure modes. Conclusion: These results show that interventions to improve safety is different for each center and it is associated with the skill level of the professional team as well as the technology used to provide radiosurgery treatment. The present study will very likely be a model for implementation of risk-based prospective quality management program for SRS treatment in Brazil where currently there are 28 radiotherapy centers performing SRS. A complete FMEA for SRS for these three radiotherapy centers is currently under development.

  17. First passage failure: Analysis alternatives

    SciTech Connect

    PAEZ,THOMAS L.; NGUYEN,H.P.; WIRSCHING,PAUL H.

    2000-04-17

    Most mechanical and structural failures can be formulated as first passage problems. The traditional approach to first passage analysis models barrier crossings as Poisson events. The crossing rate is established and used in the Poisson framework to approximate the no-crossing probability. While this approach is accurate in a number of situations, it is desirable to develop analysis alternatives for those situations where traditional analysis is less accurate and situations where it is difficult to estimate parameters of the traditional approach. This paper develops an efficient simulation approach to first passage failure analysis. It is based on simulation of segments of complex random processes with the Karhunen-Loeve expansion, use of these simulations to estimate the parameters of a Markov chain, and use of the Markov chain to estimate the probability of first passage failure. Some numerical examples are presented.

  18. MEMS Reliability: Infrastructure, Test Structures, Experiments, and Failure Modes

    SciTech Connect

    TANNER,DANELLE M.; SMITH,NORMAN F.; IRWIN,LLOYD W.; EATON,WILLIAM P.; HELGESEN,KAREN SUE; CLEMENT,J. JOSEPH; MILLER,WILLIAM M.; MILLER,SAMUEL L.; DUGGER,MICHAEL T.; WALRAVEN,JEREMY A.; PETERSON,KENNETH A.

    2000-01-01

    The burgeoning new technology of Micro-Electro-Mechanical Systems (MEMS) shows great promise in the weapons arena. We can now conceive of micro-gyros, micro-surety systems, and micro-navigators that are extremely small and inexpensive. Do we want to use this new technology in critical applications such as nuclear weapons? This question drove us to understand the reliability and failure mechanisms of silicon surface-micromachined MEMS. Development of a testing infrastructure was a crucial step to perform reliability experiments on MEMS devices and will be reported here. In addition, reliability test structures have been designed and characterized. Many experiments were performed to investigate failure modes and specifically those in different environments (humidity, temperature, shock, vibration, and storage). A predictive reliability model for wear of rubbing surfaces in microengines was developed. The root causes of failure for operating and non-operating MEMS are discussed. The major failure mechanism for operating MEMS was wear of the polysilicon rubbing surfaces. Reliability design rules for future MEMS devices are established.

  19. Maximum likelihood estimation for life distributions with competing failure modes

    NASA Technical Reports Server (NTRS)

    Sidik, S. M.

    1979-01-01

    Systems which are placed on test at time zero, function for a period and die at some random time were studied. Failure may be due to one of several causes or modes. The parameters of the life distribution may depend upon the levels of various stress variables the item is subject to. Maximum likelihood estimation methods are discussed. Specific methods are reported for the smallest extreme-value distributions of life. Monte-Carlo results indicate the methods to be promising. Under appropriate conditions, the location parameters are nearly unbiased, the scale parameter is slight biased, and the asymptotic covariances are rapidly approached.

  20. Aligning Demand for Spare Parts with their Underlying Failure Mode.

    DTIC Science & Technology

    1995-09-01

    5095 11 3 55.6 44 3091.36 1936 2446.4 5096 11 0 328.5 91 107912.3 8281 29893.5 5097 11 0 514 129 264196 16641 66306 5098 11 2 151.6 128 22982.56...Special I »X\\! 0 h\\ 1 < ,i ^ 3 ALIGNING DEMAND FOR SPARE PARTS WITH THEIR UNDERLYING FAILURE MODES THESIS Steven D. Kephart, B.S. Captain...of Tables viii List of Acronyms ix Abstract x I. Introduction 1-1 Background 1-2 Indentured Component Structure 1- 3 Consumables and Reparables

  1. Root Cause Analysis - A Diagnostic Failure Analysis Technique for Managers

    DTIC Science & Technology

    1975-03-26

    sources of data -There are many additional sources of data which may produce facts useful during a root cause analysis. Each fact can be applied to the...supporting or refuting data columns of the root cause analysis chart. to help establish the root cause mode of failure. Some of the sources of data are as...facts when performing a root cause analysis. Use verified data from all available sources . Take steps to verify all data used as rapidly as possible

  2. Failure Analysis of Fencing Blades

    NASA Astrophysics Data System (ADS)

    Kibaroglu, D.; Baydogan, M.; Cimenoglu, H.; Bas, B.; Yagsi, C.; Aliyeva, N.

    2017-05-01

    This study deals with the failure analysis of broken fencing blades (one épée and one foil). For the characterization of the broken blades, metallographic examinations, chemical analysis, hardness measurements, fracture surface examinations and tensile tests were performed. Maximum stress occurred at the outer fibres of the blades was estimated as high as 1456 MPa and 1298 MPa for épée and foil, respectively. Results showed that failure of the blades was initiated from a notch, which has been formed as the result of an impact action during training, or from the groove machined along the blade for inserting an electrical wire. In order to increase resistance of the blades against such failures, alternative blade material, modified blade geometry and a surface hardening treatment were proposed.

  3. Damage mechanisms and failure modes of cortical bone under components of physiological loading.

    PubMed

    George, W T; Vashishth, D

    2005-09-01

    Fatigue damage development in cortical bone was investigated in vitro under different mechanical components of physiological loading including tension, compression, and torsion. During each test, stress and strain data were collected continuously to monitor and statistically determine the occurrence of the primary, secondary, and tertiary stages associated with fatigue and/or creep failure of bone. The resultant microdamage and failure modes were identified by histological and fractographic analysis, respectively. The tensile group demonstrated Mode I cracking and the three classic stages of fatigue and creep suggesting a low crack initiation threshold, steady crack propagation and final failure by coalescence of microcracks. In contrast, the compressive group displayed Mode II cracking and a two-stage fatigue behavior with limited creep suggesting a high crack initiation threshold followed by a sudden fracture. The torsion group also displayed a two-stage fatigue profile but demonstrated extensive damage from mixed mode (Modes II and III) microcracking and predominant time-dependent damage. Thus, fatigue behavior of bone was found to be uniquely related to the individual mechanical components of physiological loading and the latter determined the specific damage mechanisms associated with fatigue fracture.

  4. Failure mode and weakening effect of water on sandstone

    NASA Astrophysics Data System (ADS)

    Baud, Patrick; Zhu, Wenlu; Wong, Teng-Fong

    2000-07-01

    Previous studies have shown that brittle strength of a rock is generally reduced in the presence of water. However, for siliciclastic rocks, there is a paucity of data on the waterweakening behavior in the cataclastic flow regime. To compare the weakening effect of water in the brittle faulting and cataclastic flow regime, triaxial compression experiments were conducted on the Berea, Boise, Darley Dale, and Gosford sandstones (with nominal porosities ranging from 11% to 35%) under nominally dry and saturated conditions at room temperature. Inelastic behavior and failure mode of the nominal dry samples were qualitatively similar to those of water-saturated samples. At elevated pressures, shear localization was inhibited, and all the samples failed by strain hardening. The compactive yield strengths (associated with the onset of shear-enhanced compaction) in the saturated samples were lower than those in the dry samples deformed under comparable pressure conditions by 20% to 70%. The reductions of brittle strength in the presence of water ranged from 5% to 17%. The water-weakening effects were most and least significant in the Gosford and Berea sandstones, respectively. The relation between water weakening and failure mode is consistently explained by micromechanical models formulated on the basis that the specific surface energy in the presence of water is lowered than that in vacuum by the ratio λ. In accordance with the Hertzian fracture model the initial yield stress in the compactive cataclastic flow regime scales with the grain-crushing pressure, which is proportional to λ3/2. In the brittle faulting regime, damage mechanics models predict that the uniaxial compressive strength scales with λ1/2. In the presence of water the confined brittle strength is lower due to reductions of both the specific surface energy and friction coefficient.

  5. Flexural strength and failure modes of layered ceramic structures

    PubMed Central

    Borba, Márcia; de Araújo, Maico D.; de Lima, Erick; Yoshimura, Humberto N.; Cesar, Paulo F.; Griggs, Jason A.; Bona, Álvaro Della

    2011-01-01

    Objective to evaluate the effect of the specimen design on the flexural strength (σf) and failure mode of ceramic structures, testing the hypothesis that the ceramic material under tension controls the mechanical performance of the structure. Methods Three ceramics used as framework materials for fixed partial dentures (YZ - Vita In-Ceram YZ; IZ - Vita In-Ceram Zirconia; AL - Vita In-Ceram AL) and two veneering porcelains (VM7 and VM9) were studied. Bar-shaped specimens were produced in three different designs (n=10): monolithic, two layers (porcelain-framework) and three layers (TRI) (porcelain-framework-porcelain). Specimens were tested for three-point flexural strength at 1 MPa/s in 37°C artificial saliva. For bi-layered design, the specimens were tested in both conditions: with porcelain (PT) or framework ceramic (FT) layer under tension. Fracture surfaces were analyzed using stereomicroscope and scanning electron microscopy (SEM). Young’s modulus (E) and Poisson’s ratio (ν) were determined using ultrasonic pulse-echo method. Results were statistically analyzed by Kruskal-Wallis and Student-Newman-Keuls tests. Results Except for VM7 and VM9, significant differences were observed for E values among the materials. YZ showed the highest ν value followed by IZ and AL. YZ presented the highest σf. There was no statistical difference in the σf value between IZ and IZ-FT and between AL and AL-FT. σf values for YZ-PT, IZ-PT, IZ-TRI, AL-PT, AL-TRI were similar to the results obtained for VM7 and VM9. Two types of fracture mode were identified: total and partial failure. Significance The mechanical performance of the specimens was determined by the material under tension during testing, confirming the study hypothesis. PMID:21982199

  6. Energy dissipation due to various failure modes in axial compression of unidirectional PMC tubes

    SciTech Connect

    Ghouri, M.I.A.; Newaz, G.M.

    1997-12-31

    Composite materials exhibit high energy absorption compared to conventional materials because of the progressive nature of the damage process. Progressive crushing in a polymer matrix composite (PMC) tube is a complex process involving different failure modes and delamination is one of the dominant damage mode. Computational simulation of the progressive crushing process is performed to understand the role of delamination in progressive crushing. The energy contribution of the delamination mode of failure in the overall energy absorption is predicted. A six ply unidirectional graphite/polyester composite tube is considered for this study. Quasi-static finite element analysis is performed in the non-linear FE code, ABAQUS, by simulating the dominant failure modes. The critical stress criterion is used to propagate the central delamination crack. The critical stress is determined by virtual crack extension method (VCEM). The energy absorption due to friction is also predicted. The prediction of the overall load-deflection response and energy absorption with this model correlates well with the experimental data.

  7. Failure of the ERBE scanner instrument aboard NOAA 10 spacecraft and results of failure analysis

    NASA Technical Reports Server (NTRS)

    Miller, J. B.; Weaver, W. L.; Kopia, L. P.; Howerton, C. E.; Payton, M. G.; Harris, C. J.

    1990-01-01

    The Earth Radiation Budget Experiment (ERBE) scanner instrument on the NOAA 10 spacecraft malfunctioned on May 22, 1989, after more than 4 years of in-flight operation. After the failure, all instrument operational mode commands were tested and the resulting data analyzed. Details of the tests and analysis of output data are discussed therein. The radiometric and housekeeping data appear to be valid. However, the instrument will not correctly execute operational scan mode commands or the preprogrammed calibration sequences. The data indicate the problem is the result of a failure in the internal address decoding circuity in one of the ROM (read only memory) chips of the instrument computer.

  8. ATM CMG bearing failure analysis

    NASA Technical Reports Server (NTRS)

    1975-01-01

    The cause or causes for the failure of ATM CMG S/N 5 (Skylab 1) and the anomalies associated with ATM CMG S/N 6 (Skylab 2) were investigated. Skylab telemetry data were reviewed and presented in the form of parameter distributions. The theory that the problems were caused by marginal bearing lubrication was studied along with the effects of orbital conditions on lubricants. Bearing tests were performed to investigate the effect of lubricant or lack of lubricant in the ATM CMG bearings and the dispersion and migration of the lubricant. The vacuum and weightless conditions of space were simulated in the bearing tests. Analysis of the results of the tests conducted points to inadequate lubrication as the predominant factor causing the failure of ATM CMG S/N 5 (Skylab 1) and the anomalies associated with ATM CMG S/N 6 (Skylab 2).

  9. Integrated Circuit Failure Analysis Hypertext Help System

    SciTech Connect

    Henderson, Christopher L.; Barton, Daniel L.; Campbell, Ann N.; Cole, Edward I; Mikawa, Russell E.; Peterson, Kenneth A.; Rife, James L.; Soden, Jerry M.

    1995-02-23

    This software assists a failure analyst performing failure analysis on integrated circuits. The software can also be used to train inexperienced failure analysts. The software also provides a method for storing information and making it easily available to experienced failure analysts.

  10. Failure analysis: Status and future trends

    SciTech Connect

    Anderson, R.E.; Soden, J.M.; Henderson, C.L.

    1995-02-01

    Failure analysis is a critical element in the integrated circuit manufacturing industry. This paper reviews the changing role of failure analysis and describes major techniques employed in the industry today. Several advanced failure analysis techniques that meet the challenges imposed by advancements in integrated circuit technology are described and their applications are discussed. Future trends in failure analysis needed to keep pace with the continuing advancements in integrated circuit technology are anticipated.

  11. Reliability, failure modes, and degradation mechanisms in high power single- and multi-mode InGaAs-AlGaAs strained quantum well lasers

    NASA Astrophysics Data System (ADS)

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

    2016-03-01

    High power single-mode (SM) and multi-mode (MM) InGaAs-AlGaAs strained quantum well (QW) lasers are critical components for both telecommunications and potential space satellite communications systems. However, little has been reported on failure modes of state-of-the-art SM 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 under different test conditions 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. To the best of our knowledge, this is the first report demonstrating that the dominant failure mode of both SM and MM InGaAs-AlGaAs strained QW lasers is the bulk failure. 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 SM and MM lasers. Our long-term life test results and FMA results are reported.

  12. Failure Analysis and Mechanisms of Failure of Fibrous Composite Structures

    NASA Technical Reports Server (NTRS)

    Noor, A. K. (Compiler); Shuart, M. J. (Compiler); Starnes, J. H., Jr. (Compiler); Williams, J. G. (Compiler)

    1983-01-01

    The state of the art of failure analysis and current design practices, especially as applied to the use of fibrous composite materials in aircraft structures is discussed. Deficiencies in these technologies are identified, as are directions for future research.

  13. Graphical Displays Assist In Analysis Of Failures

    NASA Technical Reports Server (NTRS)

    Pack, Ginger; Wadsworth, David; Razavipour, Reza

    1995-01-01

    Failure Environment Analysis Tool (FEAT) computer program enables people to see and better understand effects of failures in system. Uses digraph models to determine what will happen to system if set of failure events occurs and to identify possible causes of selected set of failures. Digraphs or engineering schematics used. Also used in operations to help identify causes of failures after they occur. Written in C language.

  14. 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.

  15. Distinct failure modes in bio-inspired 3D-printed staggered composites under non-aligned loadings

    NASA Astrophysics Data System (ADS)

    Slesarenko, Viacheslav; Kazarinov, Nikita; Rudykh, Stephan

    2017-03-01

    The superior mechanical properties of biological materials originate in their complex hierarchical microstructures, combining stiff and soft constituents at different length scales. In this work, we employ a three-dimensional multi-materials printing to fabricate the bio-inspired staggered composites, and study their mechanical properties and failure mechanisms. We observe that bio-inspired staggered composites with inclined stiff tablets are able to undergo two different failure modes, depending on the inclination angle. We find that such artificial structure demonstrates high toughness only under loading applied at relatively small angle to the tablets stacking direction, while for higher angles the composites fail catastrophically. This aspect of the failure behavior was captured experimentally as well as by means of the finite element analysis. We show that even a relatively simple failure model with a strain energy limiter, can be utilized to qualitatively distinguish these two different modes of failure, occurring in the artificial bio-inspired composites.

  16. European Extremely Large Telescope (E-ELT) availability stochastic model: integrating failure mode and effect analysis (FMEA), influence diagram, and Bayesian network together

    NASA Astrophysics Data System (ADS)

    Verzichelli, Gianluca

    2016-08-01

    An Availability Stochastic Model for the E-ELT has been developed in GeNIE. The latter is a Graphical User Interface (GUI) for the Structural Modeling, Inference, and Learning Engine (SMILE), originally distributed by the Decision Systems Laboratory from the University of Pittsburgh, and now being a product of Bayes Fusion, LLC. The E-ELT will be the largest optical/near-infrared telescope in the world. Its design comprises an Alt-Azimuth mount reflecting telescope with a 39-metre-diameter segmented primary mirror, a 4-metre-diameter secondary mirror, a 3.75-metre-diameter tertiary mirror, adaptive optics and multiple instruments. This paper highlights how a Model has been developed for an earlier on assessment of the Telescope Avail- ability. It also describes the modular structure and the underlying assumptions that have been adopted for developing the model and demonstrates the integration of FMEA, Influence Diagram and Bayesian Network elements. These have been considered for a better characterization of the Model inputs and outputs and for taking into account Degraded-based Reliability (DBR). Lastly, it provides an overview of how the information and knowledge captured in the model may be used for an earlier on definition of the Failure, Detection, Isolation and Recovery (FDIR) Control Strategy and the Telescope Minimum Master Equipment List (T-MMEL).

  17. Common-Cause Failure Analysis in Event Assessment

    SciTech Connect

    Dana L. Kelly; Dale M. Rasmuson

    2008-09-01

    This paper describes the approach taken by the U. S. Nuclear Regulatory Commission to the treatment of common-cause failure in probabilistic risk assessment of operational events. The approach is based upon the Basic Parameter Model for common-cause failure, and examples are illustrated using the alpha-factor parameterization, the approach adopted by the NRC in their Standardized Plant Analysis Risk (SPAR) models. The cases of a failed component (with and without shared common-cause failure potential) and a component being unavailable due to preventive maintenance or testing are addressed. The treatment of two related failure modes (e.g., failure to start and failure to run) is a new feature of this paper. These methods are being applied by the NRC in assessing the risk significance of operational events for the Significance Determination Process (SDP) and the Accident Sequence Precursor (ASP) program.

  18. Fabric Controls on the Failure Mode of Strongly Deformed Metamorphic Rocks with Multiple Anisotropies

    NASA Astrophysics Data System (ADS)

    Agliardi, F.; Zanchetta, S.; Crosta, G. B.; Barberini, V.; Fusi, N.; De Ponti, E.

    2012-12-01

    resolutions (MicroCT: 40-60 μm; medical CT: 625 μm) and micro-structural analysis of thin sections. Investigation results suggest that the failure of strongly deformed metamorphic rocks is controlled by the occurrence of multiple anisotropies related to micro-fabric, not always characterised by clear meso-scale expression, including crenulation folding, shape preferred orientation, intracrystalline deformation microstructure. Different failure modes dominate depending on the geometrical arrangement of both foliation and fold axial surfaces, in turn affecting the values of rock strength and deformability. The results of this study point to the need of accounting for the effects of multiple, geometrically complex anisotropies in setting up realistic models of rock fracturing at different scale and for different geological and engineering applications.

  19. Reliability and fatigue failure modes of implant-supported aluminum-oxide fixed dental prostheses

    PubMed Central

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

    2012-01-01

    Objectives To investigate failure modes and reliability of implant-supported aluminum-oxide three-unit fixed-dental-prostheses (FDPs) using two different veneering porcelains. Material and methods Thirty-six aluminum-oxide FDP-frameworks were CAD/CAM fabricated and either hand-veneered(n=18) or over-pressed(n=18). All FDPs were adhesively luted to custom-made zirconium-oxide-abutments attached to dental implant fixtures (RP-4×13mm). Specimens were stored in water prior to mechanical testing. A Step-Stress-Accelerated-Life-Test (SSALT) with three load/cycles varying profiles was developed based on initial single-load-to-failure testing. Failure was defined by veneer chipping or chipping in combination with framework fracture. SSALT was performed on each FDP inclined 30° with respect to the applied load direction. For all specimens, failure modes were analyzed using polarized-reflected-light-microscopy and scanning-electron-microscopy (SEM). Reliability was computed using Weibull analysis software (Reliasoft). Results The dominant failure mode for the over-pressed FDPs was buccal chipping of the porcelain in the loading area of the pontic, while hand-veneered specimens failed mainly by combined failure modes in the veneering porcelain, framework and abutments. Chipping of the porcelain occurred earlier in the over-pressed specimens (350 N/85k, load/cycles) than in the hand-veneered (600 N/110k)(profile I). Given a mission at 300 N load and 100k or 200 K cycles the computed Weibull reliability (2-sided at 90.0 % confidence bounds) was 0.99(1/0.98) and 0.99(1/0.98) for hand-veneered FDPs, and 0.45(0.76/0.10) and 0.05(0.63/0) for over-pressed FDPs, respectively. Conclusions In the range of average clinical loads (300–700 N), hand-veneered aluminum-oxide FDPs showed significantly less failure by chipping of the veneer than the over-pressed. Hand-veneered FDPs under fatigue loading failed at loads ≥ 600N. PMID:22093019

  20. Failure Analysis of Sapphire Refractive Secondary Concentrators

    NASA Technical Reports Server (NTRS)

    Salem, Jonathan A.; Quinn, George D.

    2009-01-01

    Failure analysis was performed on two sapphire, refractive secondary concentrators (RSC) that failed during elevated temperature testing. Both concentrators failed from machining/handling damage on the lens face. The first concentrator, which failed during testing to 1300 C, exhibited a large r-plane twin extending from the lens through much of the cone. The second concentrator, which was an attempt to reduce temperature gradients and failed during testing to 649 C, exhibited a few small twins on the lens face. The twins were not located at the origin, but represent another mode of failure that needs to be considered in the design of sapphire components. In order to estimate the fracture stress from fractographic evidence, branching constants were measured on sapphire strength specimens. The fractographic analysis indicated radial tensile stresses of 44 to 65 MPa on the lens faces near the origins. Finite element analysis indicated similar stresses for the first RSC, but lower stresses for the second RSC. Better machining and handling might have prevented the fractures, however, temperature gradients and resultant thermal stresses need to be reduced to prevent twinning.

  1. Manufacturing quality from electronic failure analysis results

    NASA Astrophysics Data System (ADS)

    Dobbs, B.

    The Electronic Failure Analysis Group of the AFWAL/Materials Laboratory Systems Support Division has investigated numerous electronic device failures that resulted from manufacturing process defects. The electronic failure analysis program that verifies the device failure, locates the failure site, establishes the cause of failure and recommends corrective actions is discussed in relation to improving the quality of electronic devices; performing electronic failure analysis is a high-payoff activity. Corrective actions usually involve very small costs to the manufacturer and provide the user with a large return on investment. Brief case histories are presented in regard to packaging, die attachment, solder flux removal, package moisture content, IC metallization processes, potted modules, and handling procedures affecting device cleanliness. Situations are identified where better quality control could eliminate many device defects that lead to premature part failure.

  2. 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

  3. Failure Analysis at the Kennedy Space Center

    NASA Technical Reports Server (NTRS)

    Salazar, Victoria L.; Wright, Clara

    2010-01-01

    History has shown that failures occur in every engineering endeavor, and what we learn from those failures contributes to the knowledge base to safely complete future missions. The necessity of failure analysis is at its apex at the end of one aged program (i.e. Shuttle) and at the beginning of a new and untested program (i.e. Constellation). The information that we gain through failure analysis corrects the deficiencies in the current vehicle to make the next generation of vehicles more efficient and safe. The Failure Analysis and Materials Evaluation section in the Materials Science Division at the Kennedy Space Center performs metallurgical, mechanical, electrical, and non-metallic failure analysis and accident investigations on both flight hardware and ground support equipment (GSE) for the Shuttle, International Space Station, Constellation, and Launch Services Programs. This presentation will explore a variety of failure case studies at KSC and the lessons learned that can be applied in future programs.

  4. SNS STRIPPER FOIL FAILURE MODES AND THEIR CURES

    SciTech Connect

    Galambos, John D; Luck, Chris; Plum, Michael A; Shaw, Robert W; Ladd, Peter; Raparia, Deepak; Macek, Robert James; Kim, Sang-Ho; Peters, Charles C; Polsky, Yarom

    2010-01-01

    The diamond stripper foils in use at the Spallation Neutron Source worked successfully with no failures until May 3, 2009, when we started experiencing a rash of foil system failures after increasing the beam power to ~840 kW. The main contributors to the failures are thought to be 1) convoy electrons, stripped from the incoming H beam, that strike the foil bracket and may also reflect back from the electron catcher, and 2) vacuum breakdown from the charge developed on the foil by secondary electron emission. In this paper we will detail these and other failure mechanisms, and describe the improvements we have made to mitigate them.

  5. Predicting Ductility and Failure Modes of TRIP Steels under Different Loading Conditions

    SciTech Connect

    Choi, Kyoo Sil; Liu, Wenning N.; Sun, Xin; Khaleel, Mohammad A.

    2010-06-12

    We study the ultimate ductility and failure modes of a TRIP (TRansformation-Induced Plasticity) 800 steel under different loading conditions with an advanced micromechanics-based finite element analysis. The representative volume element (RVE) for the TRIP800 under examination is developed based on an actual microstructure obtained from scanning electron microscopy (SEM). The evolution of retained austenite during deformation process and the mechanical properties of the constituent phases of the TRIP800 steel are obtained from the synchrotron-based in-situ high-energy X-ray diffraction (HEXRD) experiments and a self-consistent (SC) model. The ductile failure of the TRIP800 under different loading conditions is predicted in the form of plastic strain localization without any prescribed failure criteria for the individual phases. Comparisons of the computational results with experimental measurements suggest that the microstructure-based finite element analysis can well capture the overall macroscopic behavior of the TRIP800 steel under different loading conditions. The methodology described in this study may be extended for studying the ultimate ductile failure mechanisms of TRIP steels as well as the effects of the various processing parameters on the macroscopic behaviors of TRIP steels.

  6. 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

  7. Wind Turbine Failures - Tackling current Problems in Failure Data Analysis

    NASA Astrophysics Data System (ADS)

    Reder, M. D.; Gonzalez, E.; Melero, J. J.

    2016-09-01

    The wind industry has been growing significantly over the past decades, resulting in a remarkable increase in installed wind power capacity. Turbine technologies are rapidly evolving in terms of complexity and size, and there is an urgent need for cost effective operation and maintenance (O&M) strategies. Especially unplanned downtime represents one of the main cost drivers of a modern wind farm. Here, reliability and failure prediction models can enable operators to apply preventive O&M strategies rather than corrective actions. In order to develop these models, the failure rates and downtimes of wind turbine (WT) components have to be understood profoundly. This paper is focused on tackling three of the main issues related to WT failure analyses. These are, the non-uniform data treatment, the scarcity of available failure analyses, and the lack of investigation on alternative data sources. For this, a modernised form of an existing WT taxonomy is introduced. Additionally, an extensive analysis of historical failure and downtime data of more than 4300 turbines is presented. Finally, the possibilities to encounter the lack of available failure data by complementing historical databases with Supervisory Control and Data Acquisition (SCADA) alarms are evaluated.

  8. Failure Analysis at the Kennedy Space Center

    NASA Technical Reports Server (NTRS)

    Salazar, Victoria L.; Wright, M. Clara

    2010-01-01

    History has shown that failures occur in every engineering endeavor, and what we learn from those failures contributes to the knowledge base to safely complete future missions. The necessity of failure analysis is at its apex at the end of one aged program and at the beginning of a new and untested program. The information that we gain through failure analysis corrects the deficiencies in the current vehicle to make the next generation of vehicles more efficient and safe. The Failure Analysis and Materials Evaluation Branch in the Materials Science Division at the Kennedy Space Center performs metallurgical, mechanical, electrical, and non-metallic materials failure analyses and accident investigations on both flight hardware and ground support equipment for the Space Shuttle, International Space Station, Constellation, and Launch Services Programs. This paper will explore a variety of failure case studies at the Kennedy Space Center and the lessons learned that can be applied in future programs.

  9. Future technology challenges for failure analysis

    SciTech Connect

    Anderson, R.E.; Soden, J.M.; Henderson, C.L.

    1995-08-01

    Failure analysis is a critical element in the integrated circuit manufacturing industry. This paper explores the challenges for IC failure analysis in the environment of present and future silicon IC technology trends, using the 1994 National Technology Roadmap for Semiconductors as a technology guide. Advanced failure analysis techniques that meet the challenges of state-of-the-art IC technology are described and their applications are discussed. New paradigms will be required for failure analysis to keep pace with future advancements in IC technology.

  10. Lunar Module Electrical Power System Design Considerations and Failure Modes

    NASA Technical Reports Server (NTRS)

    Interbartolo, Michael

    2009-01-01

    This slide presentation reviews the design and redesign considerations of the Apollo lunar module electrical power system. Included in the work are graphics showing the lunar module power system. It describes the in-flight failures, and the lessons learned from these failures.

  11. Failure analysis of PB-1 (EBTS Be/Cu mockup)

    SciTech Connect

    Odegard, B.C. Jr.; Cadden, C.H.

    1996-11-01

    Failure analysis was done on PB-1 (series of Be tiles joined to Cu alloy) following a tile failure during a high heat flux experiment in EBTS (electron beam test system). This heat flux load simulated ambient conditions inside ITER; the Be tiles were bonded to the Cu alloy using low-temperature diffusion bonding, which is being considered for fabricating plasma facing components in ITER. Results showed differences between the EBTS failure and a failure during a room temperature tensile test. The latter occurred at the Cu-Be interface in an intermetallic phase formed by reaction of the two metals at the bonding temperature. Fracture strengths measured by these tests were over 300 MPa. The high heat flux specimens failed at the Cu-Cu diffusion bond. Fracture morphology in both cases was a mixed mode of dimple rupture and transgranular cleavage. Several explanations for this difference in failure mechanism are suggested.

  12. 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.

  13. Global Failure Modes in Composite Structures for High Altitudes

    NASA Technical Reports Server (NTRS)

    Knauss, W. G.

    2004-01-01

    This report summarizes the accomplishments under the referenced grant. The work described was started under the guidance and supervision of the late Dr. James Stames as the technical contact. It was aimed at investigating the development of analysis tools to deal with the problem of rupture in reinforced structural skin of future composites-based aircraft. It was of particular interest to assess methods by which failure features reminiscent of cracks in metallic structures would develop and propagate in fiber reinforced structures in interaction with the reinforcing frame. To eventually achieve that goal it was necessary to first understand the stress or strain distribution at the front of such features so that interactions between such features and reinforcing agents could be assessed computationally. Thus the major emphasis here was on the assessment of damage front and methods on how to assess or characterize it. During the conduct of this research program Dr. Stames changed to a different NASA- internal assignment, which divorced him of the direct supervision of this grant. A student who was approximately % into the completion of his Ph.D. research needed to finish this work, and NASA funds were made available under Dr. Damodar Ambur, the successor Branch Manager for Dr. James Starnes, for the completion of this work. The current grant was the thus a new and fmal support increment for completion of the started research. Final reports for previous funding have been completed and submitted. Because of the interconnection of this last phase of the investigation with previous work it is deemed useful to make the Ph.D. thesis by Luis Gonzales the body of this report.

  14. Failure modes of a concrete nuclear-containment building subjected to hydrogen detonation

    SciTech Connect

    Fugelso, L.E.; Butler, T.A.

    1983-01-01

    Calculated response for the Indian Point reactor containment building to static internal pressure and one case of a dynamic pressure representing hydrogen combustion and detonation are presented. Comparison of the potential failure modes is made. 9 figures.

  15. Effects of Fusion Zone Size on Failure Modes and Performance of Advanced High Strength Steel Spot Welds

    SciTech Connect

    Sun, Xin; Stephens, Elizabeth V.; Khaleel, Mohammad A.

    2006-04-28

    This paper examines the effects of fusion zone size on failure modes, static strength and energy absorption of resistance spot welds (RSW) of advanced high strength steels (AHSS). DP800 and TRIP800 spot welds are considered. The main failure modes for spot welds are nugget pullout and interfacial fracture. Partial interfacial fracture is also observed. The critical fusion zone sizes to ensure nugget pull-out failure mode are developed for both DP800 and TRIP800 using the limit load based analytical model and the micro-hardness measurements of the weld cross sections. Static weld strength tests using cross tension samples were performed on the joint populations with controlled fusion zone sizes. The resulted peak load and energy absorption levels associated with each failure mode were studied using statistical data analysis tools. The results in this study show that the conventional weld size of 4 t can not produce nugget pullout mode for both the DP800 and TRIP800 materials. The results also suggest that performance based spot weld acceptance criteria should be developed for different AHSS spot welds.

  16. Life Prediction and Classification of Failure Modes in Solid State Luminaires Using Bayesian Probabilistic Models

    SciTech Connect

    Lall, Pradeep; Wei, Junchao; Sakalaukus, Peter

    2014-05-27

    A new method has been developed for assessment of the onset of degradation in solid state luminaires to classify failure mechanisms by using metrics beyond lumen degradation that are currently used for identification of failure. Luminous Flux output, Correlated Color Temperature Data on Philips LED Lamps has been gathered under 85°C/85%RH till lamp failure. The acquired data has been used in conjunction with Bayesian Probabilistic Models to identify luminaires with onset of degradation much prior to failure through identification of decision boundaries between lamps with accrued damage and lamps beyond the failure threshold in the feature space. In addition luminaires with different failure modes have been classified separately from healthy pristine luminaires. It is expected that, the new test technique will allow the development of failure distributions without testing till L70 life for the manifestation of failure.

  17. Microstructurally Based Prediction of High Strain Failure Modes in Crystalline Solids

    DTIC Science & Technology

    2016-07-05

    methodologies, and in-situ experiments to predict how combinations of ductile failure modes initiate and evolve, at different physical scales, to complete...different interrelated physical mechanisms, such as a myriad of representative dislocation-density 1. REPORT DATE (DD-MM-YYYY) 4. TITLE AND SUBTITLE...and in-situ experiments to predict how combinations of ductile failure modes initiate and evolve, at different physical scales, to complete rupture in

  18. The Failure Analysis in Traction Power System

    NASA Astrophysics Data System (ADS)

    Kim, Hyungchul; Heo, Guk-bum; Lee, Hyungwoo; Kim, Dong Jin; Kim, Jin O.

    2008-10-01

    This paper presents a failure analysis of traction power systems. The electric railway consists of traction power systems, various vehicles, operating equipment, track, overhead line and electric equipment. It is a fundamental function of traction power systems that they supply customers with acceptable reliability and high quality power. Perhaps the most commonly used reliability assessment for railway systems has been the failure analysis of the traction signal system. The reliability assessment of traction power systems has also been an indispensable issue for reliability assessment. This paper deals with the classification of railway accidents caused by electrification problems, the estimation of failure rate in power equipments and failure analysis using fault trees. In study cases, the fault tree method for failure analysis is applied to railway substations in South Korea.

  19. Failure modes and durability of Kevlar/epoxy composites

    SciTech Connect

    Morgan, R.J.; Mones, E.T.; Steele, W.J.; Deutscher, S.B.

    1980-06-04

    The fracture topographies of Kevlar 49/epoxy composite strands and multilayer composites in the form of pressure vessels are discussed in terms of the microscopic deformation and failure processes of the composites. The effect of resin ductility and fiber-matrix interfacial bond strength on mechanisms of fiber damage are considered. The failure of the Kevlar 49 fibers by a splitting process and the parameters, such as fiber fibrillation and macromolecular chain scission, that control such a process, are discussed in relation to fiber and composite performance.

  20. Failure modes and durability of kevlar/epoxy composites

    SciTech Connect

    Morgan, R.J.; Mones, E.T.; Steele, W.J.; Deutscher, S.B.

    1981-04-01

    The fracture topographies of Kevlar 49/epoxy composite strands and multilayer composites in the form of pressure vessels are discussed in terms of the microscopic deformation and failure processes of the composites. The effect of resin ductility and fiber-matrix interfacial bond strength on mechanisms of fiber damage are considered. The failure of the Kevlar 49 fibers by a splitting process and the parameters, such as fiber fibrillation and macromolecular chain scission, that control such a process are discussed in relation to fiber and composite performance.

  1. Ambulatory heart rate range predicts mode-specific mortality and hospitalisation in chronic heart failure.

    PubMed

    Cubbon, Richard M; Ruff, Naomi; Groves, David; Eleuteri, Antonio; Denby, Christine; Kearney, Lorraine; Ali, Noman; Walker, Andrew M N; Jamil, Haqeel; Gierula, John; Gale, Chris P; Batin, Phillip D; Nolan, James; Shah, Ajay M; Fox, Keith A A; Sapsford, Robert J; Witte, Klaus K; Kearney, Mark T

    2016-02-01

    We aimed to define the prognostic value of the heart rate range during a 24 h period in patients with chronic heart failure (CHF). Prospective observational cohort study of 791 patients with CHF associated with left ventricular systolic dysfunction. Mode-specific mortality and hospitalisation were linked with ambulatory heart rate range (AHRR; calculated as maximum minus minimum heart rate using 24 h Holter monitor data, including paced and non-sinus complexes) in univariate and multivariate analyses. Findings were then corroborated in a validation cohort of 408 patients with CHF with preserved or reduced left ventricular ejection fraction. After a mean 4.1 years of follow-up, increasing AHRR was associated with reduced risk of all-cause, sudden, non-cardiovascular and progressive heart failure death in univariate analyses. After accounting for characteristics that differed between groups above and below median AHRR using multivariate analysis, AHRR remained strongly associated with all-cause mortality (HR 0.991/bpm increase in AHRR (95% CI 0.999 to 0.982); p=0.046). AHRR was not associated with the risk of any non-elective hospitalisation, but was associated with heart-failure-related hospitalisation. AHRR was modestly associated with the SD of normal-to-normal beats (R(2)=0.2; p<0.001) and with peak exercise-test heart rate (R(2)=0.33; p<0.001). Analysis of the validation cohort revealed AHRR to be associated with all-cause and mode-specific death as described in the derivation cohort. AHRR is a novel and readily available prognosticator in patients with CHF, which may reflect autonomic tone and exercise capacity. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  2. Ambulatory heart rate range predicts mode-specific mortality and hospitalisation in chronic heart failure

    PubMed Central

    Cubbon, Richard M; Ruff, Naomi; Groves, David; Eleuteri, Antonio; Denby, Christine; Kearney, Lorraine; Ali, Noman; Walker, Andrew M N; Jamil, Haqeel; Gierula, John; Gale, Chris P; Batin, Phillip D; Nolan, James; Shah, Ajay M; Fox, Keith A A; Sapsford, Robert J; Witte, Klaus K; Kearney, Mark T

    2016-01-01

    Objective We aimed to define the prognostic value of the heart rate range during a 24 h period in patients with chronic heart failure (CHF). Methods Prospective observational cohort study of 791 patients with CHF associated with left ventricular systolic dysfunction. Mode-specific mortality and hospitalisation were linked with ambulatory heart rate range (AHRR; calculated as maximum minus minimum heart rate using 24 h Holter monitor data, including paced and non-sinus complexes) in univariate and multivariate analyses. Findings were then corroborated in a validation cohort of 408 patients with CHF with preserved or reduced left ventricular ejection fraction. Results After a mean 4.1 years of follow-up, increasing AHRR was associated with reduced risk of all-cause, sudden, non-cardiovascular and progressive heart failure death in univariate analyses. After accounting for characteristics that differed between groups above and below median AHRR using multivariate analysis, AHRR remained strongly associated with all-cause mortality (HR 0.991/bpm increase in AHRR (95% CI 0.999 to 0.982); p=0.046). AHRR was not associated with the risk of any non-elective hospitalisation, but was associated with heart-failure-related hospitalisation. AHRR was modestly associated with the SD of normal-to-normal beats (R2=0.2; p<0.001) and with peak exercise-test heart rate (R2=0.33; p<0.001). Analysis of the validation cohort revealed AHRR to be associated with all-cause and mode-specific death as described in the derivation cohort. Conclusions AHRR is a novel and readily available prognosticator in patients with CHF, which may reflect autonomic tone and exercise capacity. PMID:26674986

  3. Effect of Different Groundwater Levels on Seismic Dynamic Response and Failure Mode of Sandy Slope.

    PubMed

    Huang, Shuai; Lv, Yuejun; Peng, Yanju; Zhang, Lifang; Xiu, Liwei

    2015-01-01

    Heavy seismic damage tends to occur in slopes when groundwater is present. The main objectives of this paper are to determine the dynamic response and failure mode of sandy slope subjected simultaneously to seismic forces and variable groundwater conditions. This paper applies the finite element method, which is a fast and efficient design tool in modern engineering analysis, to evaluate dynamic response of the slope subjected simultaneously to seismic forces and variable groundwater conditions. Shaking table test is conducted to analyze the failure mode and verify the accuracy of the finite element method results. The research results show that dynamic response values of the slope have different variation rules under near and far field earthquakes. And the damage location and pattern of the slope are different in varying groundwater conditions. The destruction starts at the top of the slope when the slope is in no groundwater, which shows that the slope appears obvious whipping effect under the earthquake. The destruction starts at the toe of the slope when the slope is in the high groundwater levels. Meanwhile, the top of the slope shows obvious seismic subsidence phenomenon after earthquake. Furthermore, the existence of the groundwater has a certain effect of damping.

  4. Effect of Different Groundwater Levels on Seismic Dynamic Response and Failure Mode of Sandy Slope

    PubMed Central

    Huang, Shuai; Lv, Yuejun; Peng, Yanju; Zhang, Lifang; Xiu, Liwei

    2015-01-01

    Heavy seismic damage tends to occur in slopes when groundwater is present. The main objectives of this paper are to determine the dynamic response and failure mode of sandy slope subjected simultaneously to seismic forces and variable groundwater conditions. This paper applies the finite element method, which is a fast and efficient design tool in modern engineering analysis, to evaluate dynamic response of the slope subjected simultaneously to seismic forces and variable groundwater conditions. Shaking table test is conducted to analyze the failure mode and verify the accuracy of the finite element method results. The research results show that dynamic response values of the slope have different variation rules under near and far field earthquakes. And the damage location and pattern of the slope are different in varying groundwater conditions. The destruction starts at the top of the slope when the slope is in no groundwater, which shows that the slope appears obvious whipping effect under the earthquake. The destruction starts at the toe of the slope when the slope is in the high groundwater levels. Meanwhile, the top of the slope shows obvious seismic subsidence phenomenon after earthquake. Furthermore, the existence of the groundwater has a certain effect of damping. PMID:26560103

  5. Deformation and Brittle Failure of Folded Gneiss in Triaxial Compression: Failure Modes, Acoustic Signatures and Microfabric Controls

    NASA Astrophysics Data System (ADS)

    Agliardi, F.; Vinciguerra, S.; Dobbs, M. R.; Zanchetta, S.

    2014-12-01

    Fabric anisotropy is a key control of rock behavior in different geological settings and over different timescales. However, the effect of tectonically folded fabrics on the brittle strength and failure mode of metamorphic rocks is poorly understood. Recent data, obtained from uniaxial compression experiments on folded gneiss (Agliardi et al., 2014), demonstrated that their brittle failure modes depend upon the arrangement of two anisotropies (i.e. foliation and fold axial planes) and that rock strength correlates with failure mode. Since lithostatic pressure may significantly affect this rock behavior, we investigated its effect in triaxial compression experiments. We tested the Monte Canale Gneiss (Italian Alps), characterized by low phyllosilicate content and compositional layering folded at the cm-scale. We used a servo-controlled hydraulic loading system to test 19 air-dry cylindrical specimens (ø = 54 mm) that were characterized both in terms of fold geometry and orientation of foliation and fold axial planes to the axial load direction. The specimens were instrumented with direct contact axial and circumferential strain gauges. Acoustic emissions and P- and S-wave velocities were measured by piezoelectric transducers mounted in the compression platens. The tests were performed at confining pressures of 40 MPa and axial strain rates of 5*10-6 s-1. Post-failure study of fracture mechanisms and related microfabric controls was undertaken using X-ray CT, optical microscopy and SEM. Samples failed in three distinct brittle modes produced by different combinations of fractures parallel to foliation, fractures parallel to fold axial planes, or mm-scale shear bands. The failure modes, consistent with those described in uniaxial compression experiments, were found to be associated with distinct stress-strain and acoustic emission signatures. Failure modes involving quartz-dominated axial plane anisotropy correspond to higher peak strength and axial strain, less

  6. An assessment of BWR (boiling water reactor) Mark III containment challenges, failure modes, and potential improvements in performance

    SciTech Connect

    Schroeder, J.A.; Pafford, D.J.; Kelly, D.L.; Jones, K.R.; Dallman, F.J. )

    1991-01-01

    This report describes risk-significant challenges posed to Mark III containment systems by severe accidents as identified for Grand Gulf. Design similarities and differences between the Mark III plants that are important to containment performance are summarized. The accident sequences responsible for the challenges and the postulated containment failure modes associated with each challenge are identified and described. Improvements are discussed that have the potential either to prevent or delay containment failure, or to mitigate the offsite consequences of a fission product release. For each of these potential improvements, a qualitative analysis is provided. A limited quantitative risk analysis is provided for selected potential improvements. 21 refs., 5 figs., 46 tabs.

  7. Survey of failure modes from 122 residential solar water heaters

    SciTech Connect

    Not Available

    1984-10-01

    This report describes the results of a survey on the operation of active solar heating and cooling systems and their components. Questionnaires were sent to homeowners and installers, covering 122 systems. Results were categorized according to problem severity, location, system type, length of system operation, and time of the year. Approximately 47% of the systems had at least one reliability problem over a two-year period. Flat-plate collector and storage systems were highly reliable. Improper operation of these components was attributed to installation problems. Drainback designs also had the greatest reliability; draindown systems were the least reliable, largely because of the failure of draindown valves. Differential controllers caused the largest number of failures that resulted in a repair cost in excess of $50 to the homeowner.

  8. Analysis of failure in manufacturing machinery

    NASA Astrophysics Data System (ADS)

    Sulaiman, S.; Abidin Ismail, N.

    2013-12-01

    This paper presents information about how to interpret the machine failure in suitable ways. The concept in this paper focuses on the methodology and creates active thinking with positive attitude to solve the machine failure. It is also described few topic on elaborate the technique towards investigate and develop a better understanding of using this concept in manufacturing industry. Failure analysis (FA) in manufacturing has its own value for each characteristic and to communicate, it needs specific data. Two methods were discussed to perform FA i.e. Why-why analysis and PM analysis (is a philosophy which aims to clarify the mechanism behind the chronically defective phenomena by analyzing the phenomena in terms of physical principle). For Why-why analysis, it is mainly effective in preventing the recurrence of failures that occur at the initial period. Whereas PM analysis is mainly effective for resolving on a fundamental problem that occur in the accidental period.

  9. Global Failure Modes in High Temperature Composite Structures

    NASA Technical Reports Server (NTRS)

    Knauss, W. G.

    1998-01-01

    Composite materials have been considered for many years as the major advance in the construction of energy efficient aerospace structures. Notable advances have been made in understanding the special design considerations that set composites apart from the usual "isotropic" engineering materials such as the metals. As a result, a number of significant engineering designs have been accomplished. However, one shortcoming of the currently favored composites is their relatively unforgiving behavior with respect to failure (brittleness) under seemingly mild impact conditions and large efforts are underway to rectify that situation, much along the lines of introducing thermoplastic matrix materials. Because of their relatively more pronounced (thermo) viscoelastic behavior these materials respond with "toughness" in fracture situations. From the point of view of applications requiring material strength, this property is highly desirable. This feature impacts several important and distinct engineering problems which have been' considered under this grant and cover the 1) effect of impact damage on structural (buckling) stability of composite panels, the 2) effect of time dependence on the progression of buckling instabilities, and the 3) evolution of damage and fracture at generic thickness discontinuities in structures. The latter topic has serious implications for structural stability problems (buckling failure in reinforced shell structures) as well as failure progression in stringer-reinforced shell structures. This grant has dealt with these issues. Polymer "toughness" is usually associated with uncrosslinked or thermo-plastic polymers. But, by comparison with their thermoset counterparts they tend to exhibit more pronounced time dependent material behavior; also, that time dependence can occur at lower temperatures which places restriction in the high temperature use of these "newer and tougher" materials that are not quite so serious with the thermoset matrix

  10. Progressive Failure Analysis of Composite Stiffened Panels

    NASA Technical Reports Server (NTRS)

    Bednarcyk, Brett A.; Yarrington, Phillip W.; Collier, Craig S.; Arnold, Steven M.

    2006-01-01

    A new progressive failure analysis capability for stiffened composite panels has been developed based on the combination of the HyperSizer stiffened panel design/analysis/optimization software with the Micromechanics Analysis Code with Generalized Method of Cells (MAC/GMC). MAC/GMC discretizes a composite material s microstructure into a number of subvolumes and solves for the stress and strain state in each while providing the homogenized composite properties as well. As a result, local failure criteria may be employed to predict local subvolume failure and the effects of these local failures on the overall composite response. When combined with HyperSizer, MAC/GMC is employed to represent the ply level composite material response within the laminates that constitute a stiffened panel. The effects of local subvolume failures can then be tracked as loading on the stiffened panel progresses. Sample progressive failure results are presented at both the composite laminate and the composite stiffened panel levels. Deformation and failure model predictions are compared with experimental data from the World Wide Failure Exercise for AS4/3501-6 graphite/epoxy laminates.

  11. Principal elementary mode analysis (PEMA).

    PubMed

    Folch-Fortuny, Abel; Marques, Rodolfo; Isidro, Inês A; Oliveira, Rui; Ferrer, Alberto

    2016-03-01

    Principal component analysis (PCA) has been widely applied in fluxomics to compress data into a few latent structures in order to simplify the identification of metabolic patterns. These latent structures lack a direct biological interpretation due to the intrinsic constraints associated with a PCA model. Here we introduce a new method that significantly improves the interpretability of the principal components with a direct link to metabolic pathways. This method, called principal elementary mode analysis (PEMA), establishes a bridge between a PCA-like model, aimed at explaining the maximum variance in flux data, and the set of elementary modes (EMs) of a metabolic network. It provides an easy way to identify metabolic patterns in large fluxomics datasets in terms of the simplest pathways of the organism metabolism. The results using a real metabolic model of Escherichia coli show the ability of PEMA to identify the EMs that generated the different simulated flux distributions. Actual flux data of E. coli and Pichia pastoris cultures confirm the results observed in the simulated study, providing a biologically meaningful model to explain flux data of both organisms in terms of the EM activation. The PEMA toolbox is freely available for non-commercial purposes on http://mseg.webs.upv.es.

  12. Achieving Resiliency by Eliminating Common Mode Failures in the Smart Grid

    SciTech Connect

    Dagle, Jeffery E.

    2012-01-19

    Abstract—This panel presentation will provide perspectives of resiliency as it relates to smart grids. As smart grid technologies are deployed, the interconnected nature of these systems is becoming more prevalent and more complex, and while resilience is expected to be enhanced, the presence of common mode failures will thwart the ability of the smart grid to achieve full levels of resilience. Studying system behavior in the face of failures (e.g., cyber attacks) allows a characterization of the systems’ response to failure scenarios, loss of communications, and other changes in system environment (such as the need for emergent updates and rapid reconfiguration). The impact of such failures on the availability of the system can be assessed and mitigation strategies considered. This panel will consider measures to identify and eliminate common mode failure mechanisms that might be present in the deployment of smart grid systems.

  13. Corrosion, failure analysis and metallography

    SciTech Connect

    Shiels, S.A.; Bagnall, C.; Witkowski, R.E.; Van der Voort, G.F.

    1985-01-01

    This book describes various aspects of microhardness testing and some of its many applications. Sixteen papers are devoted to a wide range of physical metallurgy, microstructural and metallographic topics concerning materials such as stainless steels, aluminum, zirconium, irons and steels, thoria fuels, dental amalgams, Ni4Mo, and vanadium. Also covered are corrosion problems and failures of materials ranging from semiconductors to a tantalum heat exchanger.

  14. Failure modes of current total ankle replacement systems.

    PubMed

    Pappas, Michael J; Buechel, Frederick F

    2013-04-01

    Methodology for evaluation of total ankle replacements is described. Fusion and its problems are discussed as are those of total ankle joint replacement. Fusion is an imperfect solution because it reduces ankle functionality and has significant complications. Early fixed-bearing total ankles were long-term failures and abandoned. Currently available fixed-bearing ankles have proved inferior to fusion or are equivalent to earlier devices. Only mobile-bearing devices have been shown reasonably safe and effective. One such device, the STAR, has been approved by the Food and Drug Administration after a rigorous controlled clinical trial and is available for use in the United States.

  15. Analysis of the Causes and Consequences of Submarine Slope Failure

    DTIC Science & Technology

    1997-09-30

    ANALYSIS OF THE CAUSES AND CONSEQUENCES OF SUBMARINE SLOPE FAILURE Lincoln F. Pratson Institute of Arctic and Alpine Research University of Colorado...and stratigraphy. SCIENTIFIC OBJECTIVES • Use estimates of the state of stress in a submarine slope to constrain the likelihood and potential mode of...analytical solution for the state of stress in two dimensions in a simple, homogeneous, submarine slope; and second, a numerical solution of the state of

  16. Failure mode and ageing of steel/epoxy joints

    NASA Astrophysics Data System (ADS)

    De'Nève, B.; Delamar, M.; Nguyen, T. T.; Shanahan, M. E. R.

    1998-09-01

    Torsional adhesive joints were made using a filled DGEBA based epoxy resin cured with dicyandiamide (DDA). Ageing, both of the joints and the bulk adhesive, was effected at 40, 55 and 70°C at ca. 98% relative humidity. Joint strength was monitored after various ageing periods. Auger electron spectroscopy (AES) and X-ray photoelectron spectroscopy (XPS) were used to analyze the adhesive and joint fracture surfaces. It was found that the adhesive composition near the adherent (zinc-electrocoated and bare steel) was modified compared with the bulk material. Before ageing there appeared to be an enrichment in hardener (DDA) near the adherent/adhesive interface and apparently adhesive failures were indeed interfacial. During ageing, the formation of ester groups subsequently transformed into carboxylates was observed. After ageing for up to 11 000 h, joints using a zinc electrocoated steel adherent showed fracture near the interface brought about by the modification of the adhesive. For longer ageing periods, failure occurred in a corrosion layer mixed with adhesive. A slightly better performance observed with the zinc electrocoated adherents has been attributed to the migration of Zn or Zn species into the adhesive during ageing.

  17. Failure modes of plasma-sprayed thermal barrier coatings

    NASA Astrophysics Data System (ADS)

    Schlichting, Kevin Walter

    Conventional plasma-sprayed thermal barrier coatings (TBCs) are known to fail by spallation of the yttria-stabilized zirconia (YSZ) topcoat exposing the underlying metal to high temperatures. Failure takes place by crack propagation in the YSZ just above the YSZ/thermally grown oxide (TGO) interface. Compressive stress in the TGO due to thermal expansion coefficient mismatch and oxidation is believed to play a key role in the failure. However, non-destructive measurement of the compressive stress in the TGO has been challenging due to the overlying ceramic top layer. In this study, TBC samples coated to current industrial specifications were thermally cycled to various fractions of their life to determine the failure mechanisms. The technique of Cr3+ piezospectroscopy was successfully applied to the plasma-sprayed samples for the first time in an effort to measure compressive stress in the TGO through the ceramic top layer. In addition, a new nano-grained plasma-sprayed TBC was studied in order to develop a next generation TBC with enhanced properties. Results from observations on cross-sections and spalled surfaces have identified two competing failure mechanisms for TBCs: (1) cracking along asperity tips at the TGO/bond coat interface, and (2) cracking in the ceramic between the asperity tips. TGO residual compressive stress was found to increase in the first 1 to 10 cycles and then decrease with increasing number of cycles. The standard deviation of the stress measurement, which is a measure of damage accumulation in the TGO layer, was found to increase at higher numbers of cycles. Measurement of compressive stress in the TGO using Cr3+ piezo-spectroscopy was limited to YSZ thicknesses of <50 mum due to an impurity present in the YSZ layer. When no impurity was present the limiting thickness was <170 mum due to scattering by microstructural defects such as solute, porosity, and most importantly splat boundaries. A new nano-grained TBC was fabricated with a

  18. Launch Vehicle Failure Dynamics and Abort Triggering Analysis

    NASA Technical Reports Server (NTRS)

    Hanson, John M.; Hill, Ashely D.; Beard, Bernard B.

    2011-01-01

    Launch vehicle ascent is a time of high risk for an on-board crew. There are many types of failures that can kill the crew if the crew is still on-board when the failure becomes catastrophic. For some failure scenarios, there is plenty of time for the crew to be warned and to depart, whereas in some there is insufficient time for the crew to escape. There is a large fraction of possible failures for which time is of the essence and a successful abort is possible if the detection and action happens quickly enough. This paper focuses on abort determination based primarily on data already available from the GN&C system. This work is the result of failure analysis efforts performed during the Ares I launch vehicle development program. Derivation of attitude and attitude rate abort triggers to ensure that abort occurs as quickly as possible when needed, but that false positives are avoided, forms a major portion of the paper. Some of the potential failure modes requiring use of these triggers are described, along with analysis used to determine the success rate of getting the crew off prior to vehicle demise.

  19. Failure analysis of thick composite cylinders under external pressure

    NASA Technical Reports Server (NTRS)

    Caiazzo, A.; Rosen, B. W.

    1992-01-01

    Failure of thick section composites due to local compression strength and overall structural instability is treated. Effects of material nonlinearity, imperfect fiber architecture, and structural imperfections upon anticipated failure stresses are determined. Comparisons with experimental data for a series of test cylinders are described. Predicting the failure strength of composite structures requires consideration of stability and material strength modes of failure using linear and nonlinear analysis techniques. Material strength prediction requires the accurate definition of the local multiaxial stress state in the material. An elasticity solution for the linear static analysis of thick anisotropic cylinders and rings is used herein to predict the axisymmetric stress state in the cylinders. Asymmetric nonlinear behavior due to initial cylinder out of roundness and the effects of end closure structure are treated using finite element methods. It is assumed that local fiber or ply waviness is an important factor in the initiation of material failure. An analytical model for the prediction of compression failure of fiber composites, which includes the effects of fiber misalignments, matrix inelasticity, and multiaxial applied stresses is used for material strength calculations. Analytical results are compared to experimental data for a series of glass and carbon fiber reinforced epoxy cylinders subjected to external pressure. Recommendations for pretest characterization and other experimental issues are presented. Implications for material and structural design are discussed.

  20. Temperature effect on the performance of a dissipative dielectric elastomer generator with failure modes

    NASA Astrophysics Data System (ADS)

    Chen, S. E.; Deng, L.; He, Z. C.; Li, Eric; Li, G. Y.

    2016-05-01

    Research on dielectric elastomer generators (DEGs) which can be utilized to convert mechanical energy to electrical energy has gained wide attention lately. However, very few works account for the operating temperature, viscoelasticity and current leakage in the analysis of DEGs simultaneously. In this study, under several compound four-stroke conversion cycles, the electromechanical performance and energy conversion of a dissipative DEG made of a very-high-bond (VHB) elastomer are investigated at different operating temperatures. The performance parameters such as energy density and conversion efficiency are calculated under different temperatures. Moreover, the common failure modes of the generator are considered: material rupture, loss of tension, electrical breakdown and electromechanical instability. The numerical results have distinctly shown that the operating temperature plays an important role in the performance of DEGs, which could possibly make a larger conversion efficiency for the DEG.

  1. Specific Energy as an Index to Identify the Critical Failure Mode Transition Depth in Rock Cutting

    NASA Astrophysics Data System (ADS)

    He, Xianqun; Xu, Chaoshui

    2016-04-01

    Rock cutting typically involves driving a rigid cutter across the rock surface at certain depth of cut and is used to remove rock material in various engineering applications. It has been established that there exist two distinct failure modes in rock cutting, i.e. ductile mode and brittle mode. The ductile mode takes precedence when the cut is shallow and the increase in the depth of cut leads to rock failure gradually shifted to brittle-dominant mode. The threshold depth or the critical transition depth, at which rock failure under cutting changes from the ductile to the brittle mode, is associated with not only the rock properties but also the cutting operational parameters and the understanding of this threshold is important to optimise the tool design and operational parameters. In this study, a new method termed the specific cutting energy transition model is proposed from an energy perspective which is demonstrated to be much more effective in identifying the critical transition depth compared with existing approaches. In the ductile failure cutting mode, the specific cutting energy is found to be independent of the depth of cut; but in the brittle failure cutting mode, the specific cutting energy is found to be dependent on the depth of cut following a power-law relationship. The critical transition depth is identified as the intersection point between these two relationships. Experimental tests on two types of rocks with different combinations of cutting velocity, depth of cut and back rake angle are conducted and the application of the proposed model on these cutting datasets has demonstrated that the model can provide a very effective tool to analyse the cutting mechanism and to identify the critical transition depth.

  2. DELPHI expert panel evaluation of Hanford high level waste tank failure modes and release quantities

    SciTech Connect

    Dunford, G.L.; Han, F.C.

    1996-09-30

    The Failure Modes and Release Quantities of the Hanford High Level Waste Tanks due to postulated accident loads were established by a DELPHI Expert Panel consisting of both on-site and off-site experts in the field of Structure and Release. The Report presents the evaluation process, accident loads, tank structural failure conclusion reached by the panel during the two-day meeting.

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

    NASA Technical Reports Server (NTRS)

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

    1991-01-01

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

  4. Analysis of a Memory Device Failure

    NASA Technical Reports Server (NTRS)

    Nicolas, David P.; Devaney, John; Gores, Mark; Dicken, Howard

    1998-01-01

    The recent failure of a vintage memory device presented a unique challenge to failure analysts. Normally device layouts, fabrication parameters and other technical information were available to assist the analyst in the analysis. However, this device was out of production for many years and the manufacturer was no longer in business, so the information was not available. To further complicate this analysis, the package leads were all but removed making additional electrical testing difficult. Under these conditions, new and innovative methods were used to analyze the failure. The external visual exam, radiography, PIND, and leak testing were performed with nominal results. Since electrical testing was precluded by the short lead lengths, the device was delidded to expose the internal structures for microscopic examination. No failure mechanism was identified. The available electrical data suggested an ESD or low level EOS type mechanism which left no visible surface damage. Due to parallel electrical paths, electrical probing on the chip failed to locate the failure site. Two non-destructive Scanning Electron Microscopy techniques, CIVA (Charge Induced Voltage Alteration) and EBIC (Electron Beam Induced Current), and a liquid crystal decoration technique which detects localized heating were employed to aid in the analysis. CIVA and EBIC isolated two faults in the input circuitry, and the liquid crystal technique further localized two hot spots in regions on two input gates. Removal of the glassivation and metallization revealed multiple failure sites located in the gate oxide of two input transistors suggesting machine (testing) induced damage.

  5. Effects of soil-engineering properties on the failure mode of shallow landslides

    USGS Publications Warehouse

    McKenna, Jonathan Peter; Santi, Paul Michael; Amblard, Xavier; Negri, Jacquelyn

    2012-01-01

    Some landslides mobilize into flows, while others slide and deposit material immediately down slope. An index based on initial dry density and fine-grained content of soil predicted failure mode of 96 landslide initiation sites in Oregon and Colorado with 79% accuracy. These material properties can be used to identify potential sources for debris flows and for slides. Field data suggest that loose soils can evolve from dense soils that dilate upon shearing. The method presented herein to predict failure mode is most applicable for shallow (depth 8), with few to moderate fines (fine-grained content <18%), and with liquid limits <40.

  6. 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.

  7. Plastic and Failure Analysis of Composites

    NASA Technical Reports Server (NTRS)

    Bigelow, C. A.; Johnson, W. S.

    1985-01-01

    Three-dimensional finite-element computer program called PAFAC (Plastic and Failure Analysis of Composites) developed for elastic/plastic analysis of fiber-reinforced composite materials and structures. PAFAC written in FORTRAN IV for batch execution. Particularly suited for analyzing laminated metal-matrix composites.

  8. Interface failure modes explain non-monotonic size-dependent mechanical properties in bioinspired nanolaminates.

    PubMed

    Song, Z Q; Ni, Y; Peng, L M; Liang, H Y; He, L H

    2016-03-31

    Bioinspired discontinuous nanolaminate design becomes an efficient way to mitigate the strength-ductility tradeoff in brittle materials via arresting the crack at the interface followed by controllable interface failure. The analytical solution and numerical simulation based on the nonlinear shear-lag model indicates that propagation of the interface failure can be unstable or stable when the interfacial shear stress between laminae is uniform or highly localized, respectively. A dimensionless key parameter defined by the ratio of two characteristic lengths governs the transition between the two interface-failure modes, which can explain the non-monotonic size-dependent mechanical properties observed in various laminate composites.

  9. Interface failure modes explain non-monotonic size-dependent mechanical properties in bioinspired nanolaminates

    NASA Astrophysics Data System (ADS)

    Song, Z. Q.; Ni, Y.; Peng, L. M.; Liang, H. Y.; He, L. H.

    2016-03-01

    Bioinspired discontinuous nanolaminate design becomes an efficient way to mitigate the strength-ductility tradeoff in brittle materials via arresting the crack at the interface followed by controllable interface failure. The analytical solution and numerical simulation based on the nonlinear shear-lag model indicates that propagation of the interface failure can be unstable or stable when the interfacial shear stress between laminae is uniform or highly localized, respectively. A dimensionless key parameter defined by the ratio of two characteristic lengths governs the transition between the two interface-failure modes, which can explain the non-monotonic size-dependent mechanical properties observed in various laminate composites.

  10. Molecular dynamics study on the failure modes of aluminium under decaying shock loading

    NASA Astrophysics Data System (ADS)

    Shao, Jian-Li; Wang, Pei; He, An-Min; Duan, Su-Qing; Qin, Cheng-Sen

    2013-04-01

    We have investigated the failure modes of single crystal aluminium under decaying shock loading by using molecular dynamics simulations. The microstructure evolution during the failure is presented in terms of the central symmetry parameter, and the corresponding pressure and temperature profiles are calculated and discussed. These results explain the failure morphology and mechanical properties under dynamic tension and especially the difference between solid and melted states. In addition, the fracture strength of aluminium is analyzed from surface velocity within acoustic approximation and virial theorem.

  11. Common failure modes for composite aircraft structures due to secondary loads

    NASA Astrophysics Data System (ADS)

    Rubin, A. M.

    The most common examples of composite laminate failure in typical aircraft structures are discussed, with particular consideration given to the effects of out-of-plane loads (and the resulting interlaminar shear/interlaminar tension) and bolted joint failure modes on the composite substructure and skins. It is noted that design allowables and environmental strength reduction factors for these types of failure model can be easily developed by performing simple element tests under RT/Dry and worst-case environmental conditions. The strength/stiffness factors identified during these tests may then be used to modify data obtained during full-scale RT/Dry tests.

  12. Interface failure modes explain non-monotonic size-dependent mechanical properties in bioinspired nanolaminates

    PubMed Central

    Song, Z. Q.; Ni, Y.; Peng, L. M.; Liang, H. Y.; He, L. H.

    2016-01-01

    Bioinspired discontinuous nanolaminate design becomes an efficient way to mitigate the strength-ductility tradeoff in brittle materials via arresting the crack at the interface followed by controllable interface failure. The analytical solution and numerical simulation based on the nonlinear shear-lag model indicates that propagation of the interface failure can be unstable or stable when the interfacial shear stress between laminae is uniform or highly localized, respectively. A dimensionless key parameter defined by the ratio of two characteristic lengths governs the transition between the two interface-failure modes, which can explain the non-monotonic size-dependent mechanical properties observed in various laminate composites. PMID:27029955

  13. Small Fatigue Crack Growth and Failure Mode Transitions in a Ni-Base Superalloy at Elevated Temperature (Preprint)

    DTIC Science & Technology

    2010-02-01

    AFRL-RX-WP-TP-2010-4070 SMALL FATIGUE CRACK GROWTH AND FAILURE MODE TRANSITIONS IN A Ni-BASE SUPERALLOY AT ELEVATED TEMPERATURE (Preprint...CRACK GROWTH AND FAILURE MODE TRANSITIONS IN A Ni-BASE SUPERALLOY AT ELEVATED TEMPERATURE (Preprint) 5a. CONTRACT NUMBER IN HOUSE 5b. GRANT...by ANSI Std. Z39-18 Page 1 of 28 Small Fatigue Crack Growth and Failure Mode Transitions in a Ni-Base Superalloy at Elevated Temperature M. J

  14. Beam and shell modes of buckling of buried pipes induced by compressive ground failure

    SciTech Connect

    Chiou, Y.J.; Chi, S.Y.

    1995-12-31

    The buckling of buried pipeline induced by compressive ground failure was investigated. Both the beam mode of buckling and local shell mode of buckling, and their interactions were studied. The pipeline response was analyzed numerically. The results agree qualitatively with past researches and possess satisfactory comparisons with actual case histories. The relations of critical buried depth versus ratio of pipe diameter to thickness for buried pipe with different imperfections and various soil foundations were established.

  15. Finite element modelling of woven composite failure modes at the mesoscopic scale: deterministic versus stochastic approaches

    NASA Astrophysics Data System (ADS)

    Roirand, Q.; Missoum-Benziane, D.; Thionnet, A.; Laiarinandrasana, L.

    2017-09-01

    Textile composites are composed of 3D complex architecture. To assess the durability of such engineering structures, the failure mechanisms must be highlighted. Examinations of the degradation have been carried out thanks to tomography. The present work addresses a numerical damage model dedicated to the simulation of the crack initiation and propagation at the scale of the warp yarns. For the 3D woven composites under study, loadings in tension and combined tension and bending were considered. Based on an erosion procedure of broken elements, the failure mechanisms have been modelled on 3D periodic cells by finite element calculations. The breakage of one element was determined using a failure criterion at the mesoscopic scale based on the yarn stress at failure. The results were found to be in good agreement with the experimental data for the two kinds of macroscopic loadings. The deterministic approach assumed a homogeneously distributed stress at failure all over the integration points in the meshes of woven composites. A stochastic approach was applied to a simple representative elementary periodic cell. The distribution of the Weibull stress at failure was assigned to the integration points using a Monte Carlo simulation. It was shown that this stochastic approach allowed more realistic failure simulations avoiding the idealised symmetry due to the deterministic modelling. In particular, the stochastic simulations performed have shown several variations of the stress as well as strain at failure and the failure modes of the yarn.

  16. Finite element modelling of woven composite failure modes at the mesoscopic scale: deterministic versus stochastic approaches

    NASA Astrophysics Data System (ADS)

    Roirand, Q.; Missoum-Benziane, D.; Thionnet, A.; Laiarinandrasana, L.

    2017-01-01

    Textile composites are composed of 3D complex architecture. To assess the durability of such engineering structures, the failure mechanisms must be highlighted. Examinations of the degradation have been carried out thanks to tomography. The present work addresses a numerical damage model dedicated to the simulation of the crack initiation and propagation at the scale of the warp yarns. For the 3D woven composites under study, loadings in tension and combined tension and bending were considered. Based on an erosion procedure of broken elements, the failure mechanisms have been modelled on 3D periodic cells by finite element calculations. The breakage of one element was determined using a failure criterion at the mesoscopic scale based on the yarn stress at failure. The results were found to be in good agreement with the experimental data for the two kinds of macroscopic loadings. The deterministic approach assumed a homogeneously distributed stress at failure all over the integration points in the meshes of woven composites. A stochastic approach was applied to a simple representative elementary periodic cell. The distribution of the Weibull stress at failure was assigned to the integration points using a Monte Carlo simulation. It was shown that this stochastic approach allowed more realistic failure simulations avoiding the idealised symmetry due to the deterministic modelling. In particular, the stochastic simulations performed have shown several variations of the stress as well as strain at failure and the failure modes of the yarn.

  17. Fatigue resistance and failure mode of adhesively restored custom metal-composite resin premolar implant abutments.

    PubMed

    Boff, Luís Leonildo; Oderich, Elisa; Cardoso, Antônio Carlos; Magne, Pascal

    2014-01-01

    To evaluate the fatigue resistance and failure mode of composite resin and porcelain onlays and crowns bonded to premolar custom metal-composite resin premolar implant abutments. Sixty composite resin mesostructures were fabricated with computer assistance with two preparation designs (crown vs onlay) and bonded to a metal implant abutment. Following insertion into an implant with a tapered abutment interface (Titamax CM), each metal-composite resin abutment was restored with either composite resin (Paradigm MZ100) or ceramic (Paradigm C) (n = 15) and attached with adhesive resin (Optibond FL) and a preheated light-curing composite resin (Filtek Z100). Cyclic isometric chewing (5 Hz) was then simulated, starting with 5,000 cycles at a load of 50 N, followed by stages of 200, 400, 600, 800, 1,000, 1,200, and 1,400 N (25,000 cycles each). Samples were loaded until fracture or to a maximum of 180,000 cycles. The four groups were compared using life table survival analysis (log-rank test). Previously published data using zirconia abutments of the same design were included for comparison. Paradigm C and MZ100 specimens fractured at average loads of 1,133 N and 1,266 N, respectively. Survival rates ranged from 20% to 33.3% (ceramic crowns and onlays) to 60% (composite resin crowns and onlays) and were significantly different (pooled data for restorative material). There were no restoration failures, but there were adhesive failures at the connection between the abutment and the mesostructure. The survival of the metal-composite resin premolar abutments was inferior to that of identical zirconia abutments from a previous study (pooled data for abutment material). Composite resin onlays/crowns bonded to metal-composite resin premolar implant abutments presented higher survival rates than comparable ceramic onlays/crowns. Zirconia abutments outperformed the metal-composite resin premolar abutments.

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

    SciTech Connect

    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.

  19. Automatic tools for microprocessor failure analysis

    NASA Astrophysics Data System (ADS)

    Conard, Didier; Laurent, J.; Velazco, Raoul; Ziade, Haissam; Cabestany, J.; Sala, F.

    A new approach for fault location when testing microprocessors is presented. The startpoint for the backtracing analysis converging to the failure is constituted by the automatic localization of a reduced area. Automatic image comparison based on pattern recognition is performed by means of an electron beam tester. The developed hardware and software tools allow large circuit areas to be covered offering powerful diagnosis capabilities to the user. The validation of this technique was performed on faulty 68000 microprocessors. It shows the feasibility of the automation of the first and most important step of failure analysis: fault location at the chip surface.

  20. Early failure of bioabsorbable anterior cervical fusion plates: case report and failure analysis.

    PubMed

    Brkaric, Mario; Baker, Kevin C; Israel, Raj; Harding, Trevor; Montgomery, David M; Herkowitz, Harry N

    2007-05-01

    Case report with forensic failure analysis. To determine the failure modes of 3 explanted 70:30 PLDLA Mystique (Medtronic Sofamor Danek, Memphis, TN) graft containment plates retrieved from revision surgery for early device failure. To reduce the problems of stress-shielding and radiopacity associated with metallic systems, bioabsorbable polymers have been used in anterior cervical discectomy and fusion procedures. Degradation of mechanical properties in vivo is a major concern when using bioabsorbable systems. Three of 6 patients who underwent anterior cervical discectomy with instrumented fusion, using Mystique graft containment systems experienced early failure requiring revision to alternate hardware. Devices were retrieved after failure and analyzed by light microscopy and environmental scanning electron microscopy. Simulations were performed with an unused plating system to induce damage for comparison with the retrieved devices. A detailed case review was performed to identify possible sources of extraordinary loading or damage. One plating system failed at 6 weeks postimplantation due to fatigue fracture of the screws. Crack initiation sites were identified at the interface of the thread root and mold line of the screw. Another plating system failed at 16 weeks postimplantation due to the coalescence of radial microcracking between holes in the plate, leading to catastrophic failure of the plate. The final plating system failed during the implantation surgery, when the screw fractured in torsion. Stress concentrations at the screw head-shaft interface and thread-shaft interface reduce the fatigue performance of bioabsorbable screws. Hydrolysis of the polymer may also play a role in the reduction of resistance to crack initiation and propagation.

  1. Dynamic Failure Mode Transitions in 7075Al Expanding rings driven by Electromagnetic loading

    NASA Astrophysics Data System (ADS)

    Liu, Mingtao; Tang, Tiegang; Guo, Zhaoliang; Fan, Cheng

    Dynamic failure mode transitions are observed in 7075Al electromagnetic expanding rings with a typical size of 3mm in thickness and 0.5mm in height. The rings are driven to maximum expanding velocities ranged from 60m/s to 180m/s, corresponding to strain rates of about 3000 to 9000 per second. At lower strain rates, the fractures of the rings are dominated by the hoop tensile stress, and the cracks are along the radial direction. At higher strain rates, the fractures of the rings are dominated by the maximum shear stress, and the cracks are lie along with an angle of about 45 degree with the radial direction. While the rings deform at medium strain rates, a mixed failure mode is observed, which simultaneously consists of tensile fracture and shear fracture. The failure strains of the specimen and the numbers of the fragmentations were measured after testing. The failure strains show a maximum value as the strain rate increasing, but the numbers of the fragmentations increase firstly, then decrease and then increase again. These phenomena were found to have a close relationship with the dynamic failure mode transitions.

  2. Failure Analysis of Ceramic Components

    SciTech Connect

    B.W. Morris

    2000-06-29

    Ceramics are being considered for a wide range of structural applications due to their low density and their ability to retain strength at high temperatures. The inherent brittleness of monolithic ceramics requires a departure from the deterministic design philosophy utilized to analyze metallic structural components. The design program ''Ceramic Analysis and Reliability Evaluation of Structures Life'' (CARES/LIFE) developed by NASA Lewis Research Center uses a probabilistic approach to predict the reliability of monolithic components under operational loading. The objective of this study was to develop an understanding of the theories used by CARES/LIFE to predict the reliability of ceramic components and to assess the ability of CARES/LIFE to accurately predict the fast fracture behavior of monolithic ceramic components. A finite element analysis was performed to determine the temperature and stress distribution of a silicon carbide O-ring under diametral compression. The results of the finite element analysis were supplied as input into CARES/LIFE to determine the fast fracture reliability of the O-ring. Statistical material strength parameters were calculated from four-point flexure bar test data. The predicted reliability showed excellent correlation with O-ring compression test data indicating that the CARES/LIFE program can be used to predict the reliability of ceramic components subjected to complicated stress states using material properties determined from simple uniaxial tensile tests.

  3. Failure Modes and Diagnostic Signatures Working Group - Ignition Diagnostics Requirements Update

    SciTech Connect

    Cerjan, C; Haan, S; Hatchett, S; Koch, J

    2007-03-26

    We have performed an initial assessment of the sensitivity of various expected ignition diagnostic signatures to ignition failure modes using one and two-dimensional hydrodynamics simulations and post-processed simulated diagnostic output. As a result of this assessment, we recommend several changes to the current requirements for the ignition diagnostic suite. These recommendations are summarized in Table 1.

  4. A Study of Energy Management Systems and its Failure Modes in Smart Grid Power Distribution

    NASA Astrophysics Data System (ADS)

    Musani, Aatif

    The subject of this thesis is distribution level load management using a pricing signal in a smart grid infrastructure. The project relates to energy management in a spe-cialized distribution system known as the Future Renewable Electric Energy Delivery and Management (FREEDM) system. Energy management through demand response is one of the key applications of smart grid. Demand response today is envisioned as a method in which the price could be communicated to the consumers and they may shift their loads from high price periods to the low price periods. The development and deployment of the FREEDM system necessitates controls of energy and power at the point of end use. In this thesis, the main objective is to develop the control model of the Energy Management System (EMS). The energy and power management in the FREEDM system is digitally controlled therefore all signals containing system states are discrete. The EMS is modeled as a discrete closed loop transfer function in the z-domain. A breakdown of power and energy control devices such as EMS components may result in energy con-sumption error. This leads to one of the main focuses of the thesis which is to identify and study component failures of the designed control system. Moreover, H-infinity ro-bust control method is applied to ensure effectiveness of the control architecture. A focus of the study is cyber security attack, specifically bad data detection in price. Test cases are used to illustrate the performance of the EMS control design, the effect of failure modes and the application of robust control technique. The EMS was represented by a linear z-domain model. The transfer function be-tween the pricing signal and the demand response was designed and used as a test bed. EMS potential failure modes were identified and studied. Three bad data detection meth-odologies were implemented and a voting policy was used to declare bad data. The run-ning mean and standard deviation analysis method proves to be

  5. FAILURE ANALYSIS: WASTEWATER DRUM BULGING

    SciTech Connect

    Vormelker, P

    2008-09-15

    A 55 gallon wastewater drum lid was found to be bulged during storage in a remote area. Drum samples were obtained for analysis. The interior surface of these samples revealed blistering and holes in the epoxy phenolic drum liner and corrosion of the carbon steel drum. It is suspected that osmotic pressure drove permeation of the water through the epoxy phenolic coating which was weakened from exposure to low pH water. The coating failed at locations throughout the drum interior. Subsequent corrosion of the carbon steel released hydrogen which pressurized the drum causing deformation of the drum lid. Additional samples from other wastewater drums on the same pallet were also evaluated and limited corrosion was visible on the interior surfaces. It is suspected that, with time, the corrosion would have advanced to cause pressurization of these sealed drums.

  6. Nonlinear Temperature Dependent Failure Analysis of Finite Width Composite Laminates.

    DTIC Science & Technology

    1979-12-01

    tangent modulii obtained by Ramberg-Osgood parameters. It is shown that a’ring stresses and stresses due to tensile loading are significant as edge ... effect in all types of laminate studies. The tensor polynomial failure criterion is used to predict the initiation of failure. The mode of failure is

  7. Failure analysis of fuze power supply

    SciTech Connect

    Menke, J.T.

    1996-10-01

    Batteries in storage which were used in electronic fuzes were found to be leaking after 5 years. The leaking battery ampules were made of copper and contained mixture of fluoboric acid and methylene bromide. The corrosion mechanism is described along with the testing/analysis required to simulate the field failures.

  8. Comparison of fracture strength and failure mode of different ceramic implant abutments.

    PubMed

    Elsayed, Adham; Wille, Sebastian; Al-Akhali, Majed; Kern, Matthias

    2017-04-01

    The whitish color of zirconia (ZrO2) abutments offers favorable esthetics compared with the grayish color of titanium (Ti) abutments. Nonetheless, ZrO2 has greater opacity, making it difficult to achieve natural tooth color. Therefore, lithium disilicate (LaT) abutments have been suggested to replace metal abutments. The purpose of this in vitro study was to evaluate the fracture strength and failure mode of single-tooth implant restorations using ZrO2 and LaT abutments, and to compare them with titanium (Ti) abutments. Five different types of abutments, Ti; ZrO2 with no metal base; ZrO2 with a metal base (ZrT); LaT; and LaT combination abutment and crown (LcT) were assembled on 40 Ti implants and restored with LaT crowns. Specimens were subjected to quasistatic loading using a universal testing machine, until the implant-abutment connection failed. As bending of the metal would be considered a clinical failure, the values of force (N) at which the plastic deformation of the metal occurred were calculated, and the rate of deformation was analyzed. Statistical analysis was done using the Mann-Whitney U test (α=.05). Group ZrO2 revealed the lowest resistance to failure with a mean of 202 ±33 N. Groups ZrT, LaT, and LaC withstood higher forces without fracture or debonding of the ceramic suprastructure, and failure was due to deformation of metal bases, with no statistically significant differences between these groups regarding the bending behavior. Within the limitations of this in vitro study, it was concluded that LaT abutments have the potential to withstand the physiological occlusal forces that occur in the anterior region and that ZrO2 abutments combined with Ti inserts have much higher fracture strength than pure ZrO2 abutments. Copyright © 2016 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.

  9. 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

  10. Failure analysis for micro-electrical-mechanical systems (MEMS)

    SciTech Connect

    Peterson, K.A.; Tangyunyong, P.; Barton, D.L.

    1997-10-01

    Micro-Electrical Mechanical Systems (MEMS) is an emerging technology with demonstrated potential for a wide range of applications including sensors and actuators for medical, industrial, consumer, military, automotive and instrumentation products. Failure analysis (FA) of MEMS is critically needed for the successful design, fabrication, performance analysis and reliability assurance of this new technology. Many devices have been examined using techniques developed for integrated circuit analysis, including optical inspection, scanning laser microscopy (SLM), scanning electron microscopy (SEM), focused ion beam (FIB) techniques, atomic force microscopy (AFM), infrared (IR) microscopy, light emission (LE) microscopy, acoustic microscopy and acoustic emission analysis. For example, the FIB was used to microsection microengines that developed poor performance characteristics. Subsequent SEM analysis clearly demonstrated the absence of wear on gear, hub, and pin joint bearing surfaces, contrary to expectations. Another example involved the use of infrared microscopy for thermal analysis of operating microengines. Hot spots were located, which did not involve the gear or hub, but indicated contact between comb structures which drive microengines. Voltage contrast imaging proved useful on static and operating MEMS in both the SEM and the FIB and identified electrostatic clamping as a potentially significant contributor to failure mechanisms in microengines. This work describes MEMS devices, FA techniques, failure modes, and examples of FA of MEMS.

  11. Comprehensive characterization and failure modes of tungsten microwire arrays in chronic neural implants

    NASA Astrophysics Data System (ADS)

    Prasad, Abhishek; Xue, Qing-Shan; Sankar, Viswanath; Nishida, Toshikazu; Shaw, Gerry; Streit, Wolfgang J.; Sanchez, Justin C.

    2012-10-01

    activated microglia were present near the electrode tracks in all non-acute animals studied, thus indicating presence of a neuroinflammatory response regardless of post-implantation survival times and electrode performance. Conversely, dystrophic microglia detectable as fragmented cells were found almost exclusively in acute animals surviving only few hours after implantation. While there was no consistent relationship between microglial cell responses and electrode performance, we noticed co-occurrence of high ferritin expression, intraparenchymal bleeding, and microglial degeneration suggesting presence of excessive oxidative stress via Fenton chemistry. Biochemical analysis indicated that these electrodes always caused a persistent release of axonal injury biomarkers even several months after implantation suggesting persistent tissue damage. Our study suggests that mechanisms of electrode failure are multi-factorial involving both abiotic and biotic parameters. Since these failure modes occur concurrently and cannot be isolated from one another, the lack of consistent relationship between electrode performance and microglial responses in our results suggest that one or more of the abiotic factors were equally responsible for degradation in electrode performance over long periods of time.

  12. Analysis of cascading failure in gene networks.

    PubMed

    Sun, Longxiao; Wang, Shudong; Li, Kaikai; Meng, Dazhi

    2012-01-01

    It is an important subject to research the functional mechanism of cancer-related genes make in formation and development of cancers. The modern methodology of data analysis plays a very important role for deducing the relationship between cancers and cancer-related genes and analyzing functional mechanism of genome. In this research, we construct mutual information networks using gene expression profiles of glioblast and renal in normal condition and cancer conditions. We investigate the relationship between structure and robustness in gene networks of the two tissues using a cascading failure model based on betweenness centrality. Define some important parameters such as the percentage of failure nodes of the network, the average size-ratio of cascading failure, and the cumulative probability of size-ratio of cascading failure to measure the robustness of the networks. By comparing control group and experiment groups, we find that the networks of experiment groups are more robust than that of control group. The gene that can cause large scale failure is called structural key gene. Some of them have been confirmed to be closely related to the formation and development of glioma and renal cancer respectively. Most of them are predicted to play important roles during the formation of glioma and renal cancer, maybe the oncogenes, suppressor genes, and other cancer candidate genes in the glioma and renal cancer cells. However, these studies provide little information about the detailed roles of identified cancer genes.

  13. Failure modes and conditions of a cohesive, spherical body due to YORP spin-up

    NASA Astrophysics Data System (ADS)

    Hirabayashi, Masatoshi

    2015-12-01

    This paper presents transition of the failure mode of a cohesive, spherical body due to The Yarkovsky-O'Keefe-Radzievskii-Paddack (YORP) spin-up. On the assumption that the distribution of materials in the body is homogeneous, failed regions first appearing in the body at different spin rates are predicted by comparing the yield condition of an elastic stress in the body. It is found that as the spin rate increases, the locations of the failed regions move from the equatorial surface to the central region. To avoid such failure modes, the body should have higher cohesive strength. The results by this model are consistent with those by a plastic finite element model. Then, this model and a two-layered-cohesive model first proposed by Hirabayashi et al. are used to classify possible evolution and disruption of a spherical body. There are three possible pathways to disruption. First, because of a strong structure, failure of the central region is dominant and eventually leads to a breakup into multiple components. Secondly, a weak surface and a weak interior make the body oblate. Thirdly, a strong internal core prevents the body from failing and only allows surface shedding. This implies that observed failure modes may highly depend on the internal structure of an asteroid, which could provide crucial information for giving constraints on the physical properties.

  14. Shift in failure modes in foam core sandwich composites subject to repeated slamming on water

    NASA Astrophysics Data System (ADS)

    Figueroa, Evaristo; Shafiq, Basir

    2013-06-01

    A test program designed and carried out to mimic the repeated impact of the bow section of fast-moving small boats on the ocean surface provided some unique observations in terms of failure mode transition. Damage progression and modes of failure were evaluated for two types of sandwich composites with comparable global strength and stiffness but different foam density and facesheet strength. Testing was performed on flat rectangular specimens that contained symmetric semi-elliptical edge flaws produced near the end of the specimen held by the rotating cam. Type 1 specimens (softer core/stronger facesheet) consistently failed by interface and through-the-thickness core shear, independent of the flaw size. In contrast, a gradual decrease in flaw size in Type 2 specimens (denser core/weaker facesheet) produced a striking transition in the mode of failure from local buckling in the vicinity of the flaw site along with exponentially increasing lifetime, to interface shear failure at the free end accompanied by a dramatic drop in lifetime. The lifetime of Type 2 specimens was more than two orders of magnitude greater than that of Type 1 specimens.

  15. Failure analysis of resin composite bonded to ceramic.

    PubMed

    Della Bona, Alvaro; Anusavice, Kenneth J; Mecholsky, John J

    2003-12-01

    To use fractographic principles to classify the mode of failure of resin composite bonded to ceramic specimens after microtensile testing. A leucite-based ceramic (IPS Empress)-E1) and a lithia disilicate-based ceramic (IPS Empress2)-E2) were selected for the study. Fifteen blocks of E1 and E2 were polished through 1 microm alumina abrasive. The following ceramic surface treatments were applied to three blocks of each ceramic: (1) 9.5% hydrofluoric acid (HF) for 2 min; (2) 4% acidulated phosphate fluoride (APF) for 2 min; (3) Silane coating (S); (4) HF+S; (5) APF+S. An adhesive resin and a resin composite were applied to all treated surfaces and light cured. Twenty bar specimens for each group were prepared from the composite-ceramic blocks and stored in 37 degrees C distilled water for 30 days before loading to failure under tension in an Instron testing machine. Fracture surfaces were examined using scanning electron microscopy and X-ray dot mapping. Statistical analysis was performed using one-way ANOVA, Duncan's multiple range test, and Weibull analyses. Similar surface treatments were associated with significantly different bond strengths and modes of failures for E1 and E2. All fractures occurred within the adhesion zone. The microstructural difference between etched E1 and E2 ceramics was a major controlling factor on adhesion. The quality of the bond should not be assessed based on bond strength data alone. Mode of failure and fractographic analyses should provide important information leading to predictions of clinical performance limits.

  16. Rapid repair of severely earthquake-damaged bridge piers with flexural-shear failure mode

    NASA Astrophysics Data System (ADS)

    Sun, Zhiguo; Wang, Dongsheng; Du, Xiuli; Si, Bingjun

    2011-12-01

    An experimental study was conducted to investigate the feasibility of a proposed rapid repair technique for severely earthquake-damaged bridge piers with flexural-shear failure mode. Six circular pier specimens were first tested to severe damage in flexural-shear mode and repaired using early-strength concrete with high-fluidity and carbon fiber reinforced polymers (CFRP). After about four days, the repaired specimens were tested to failure again. The seismic behavior of the repaired specimens was evaluated and compared to the original specimens. Test results indicate that the proposed repair technique is highly effective. Both shear strength and lateral displacement of the repaired piers increased when compared to the original specimens, and the failure mechanism of the piers shifted from flexural-shear failure to ductile flexural failure. Finally, a simple design model based on the Seible formulation for post-earthquake repair design was compared to the experimental results. It is concluded that the design equation for bridge pier strengthening before an earthquake could be applicable to seismic repairs after an earthquake if the shear strength contribution of the spiral bars in the repaired piers is disregarded and 1.5 times more FRP sheets is provided.

  17. Data Collection Plan to Populate the Light Water Reactor Sustainability Failure Mode Degradation Library

    SciTech Connect

    Magdy S. Tawfik; Binh T. Pham; Vivek Agarwal; Nancy J. Lybeck

    2011-09-01

    Interest in implementing advanced Prognostic Health Management (PHM) systems in commercial nuclear power plants (NPPs) has increased rapidly in recent years, with an overarching goal of implementing of improving the safety, reliability, and economics/profitability of the aging nuclear fleet and extending their service life in the most cost-effective manner. The PHM system utilizes prognostic tools to estimate the remaining useful life (RUL) of a component or system of components based on current and predicted operating conditions. An effective implementation of the PHM system will anticipate and identify unique age-dependent degradation modes to provide early warning of emerging problems. Selection of the components and structures to be monitored is a crucial step for successful PHM implementation in NPPs. A selection framework is recommended for risk significant components (both safety-related and non-safety related) based on the Fussell-Vesely (F-V) Importance Measure and the Risk Achievement Worth (RAW) measure. For the selected components, a failure mode degradation library will be developed consisting of data corresponding to different failure/degradation modes. In lieu of constructing an expensive scaled test facility, several data sources are identified for populating the failure mode degradation library, including various national laboratories, universities, agencies, and industries.

  18. Progressive Failure Analysis Methodology for Laminated Composite Structures

    NASA Technical Reports Server (NTRS)

    Sleight, David W.

    1999-01-01

    A progressive failure analysis method has been developed for predicting the failure of laminated composite structures under geometrically nonlinear deformations. The progressive failure analysis uses C(exp 1) shell elements based on classical lamination theory to calculate the in-plane stresses. Several failure criteria, including the maximum strain criterion, Hashin's criterion, and Christensen's criterion, are used to predict the failure mechanisms and several options are available to degrade the material properties after failures. The progressive failure analysis method is implemented in the COMET finite element analysis code and can predict the damage and response of laminated composite structures from initial loading to final failure. The different failure criteria and material degradation methods are compared and assessed by performing analyses of several laminated composite structures. Results from the progressive failure method indicate good correlation with the existing test data except in structural applications where interlaminar stresses are important which may cause failure mechanisms such as debonding or delaminations.

  19. Post Buckling Progressive Failure Analysis of Composite Laminated Stiffened Panels

    NASA Astrophysics Data System (ADS)

    Anyfantis, Konstantinos N.; Tsouvalis, Nicholas G.

    2012-06-01

    The present work deals with the numerical prediction of the post buckling progressive and final failure response of stiffened composite panels based on structural nonlinear finite element methods. For this purpose, a progressive failure model (PFM) is developed and applied to predict the behaviour of an experimentally tested blade-stiffened panel found in the literature. Failure initiation and propagation is calculated, owing to the accumulation of the intralaminar failure modes induced in fibre reinforced composite materials. Hashin failure criteria have been employed in order to address the fiber and matrix failure modes in compression and tension. On the other hand, the Tsai-Wu failure criterion has been utilized for addressing shear failure. Failure detection is followed with the introduction of corresponding material degradation rules depending on the individual failure mechanisms. Failure initiation and failure propagation as well as the post buckling ultimate attained load have been numerically evaluated. Final failure behaviour of the simulated stiffened panel is due to sudden global failure, as concluded from comparisons between numerical and experimental results being in good agreement.

  20. Electrical power requirements analysis. Single failure tolerant entry

    NASA Technical Reports Server (NTRS)

    Pipher, M. D.; Green, P. A.; Wolfgram, D. F.

    1977-01-01

    The results of an analysis of the orbiter electrical power system for the case of a single failure tolerant (SFT) entry are presented. The analysis was performed using the shuttle electrical power system analysis computer program. It was performed to permit assessment of the capability of the orbiter systems to support the proposed entry configuration and to provide the data necessary to identify potential constraints and limitations. Three contingency modes have been identified which would require an SFT entry. This analysis addresses an SFT entry resulting from the loss of two fuel cell powerplants, while on orbit. The results of the analysis indicate that, even under near optimum conditions, the fuel cell power demand will exceed the tested operating capacity of 16 kw, and that various electrical components may experience voltages below 24 VDC.

  1. Sliding Mode Control of the X-33 with an Engine Failure

    NASA Technical Reports Server (NTRS)

    Shtessel, Yuri B.; Hall, Charles E.

    2000-01-01

    Ascent flight control of the X-3 is performed using two XRS-2200 linear aerospike engines. in addition to aerosurfaces. The baseline control algorithms are PID with gain scheduling. Flight control using an innovative method. Sliding Mode Control. is presented for nominal and engine failed modes of flight. An easy to implement, robust controller. requiring no reconfiguration or gain scheduling is demonstrated through high fidelity flight simulations. The proposed sliding mode controller utilizes a two-loop structure and provides robust. de-coupled tracking of both orientation angle command profiles and angular rate command profiles in the presence of engine failure, bounded external disturbances (wind gusts) and uncertain matrix of inertia. Sliding mode control causes the angular rate and orientation angle tracking error dynamics to be constrained to linear, de-coupled, homogeneous, and vector valued differential equations with desired eigenvalues. Conditions that restrict engine failures to robustness domain of the sliding mode controller are derived. Overall stability of a two-loop flight control system is assessed. Simulation results show that the designed controller provides robust, accurate, de-coupled tracking of the orientation angle command profiles in the presence of external disturbances and vehicle inertia uncertainties, as well as the single engine failed case. The designed robust controller will significantly reduce the time and cost associated with flying new trajectory profiles or orbits, with new payloads, and with modified vehicles

  2. Availability and Failure Modes of the BaBar Superconducting Solenoid

    SciTech Connect

    Knodel, M.

    2004-09-29

    A 1.5 T thin superconducting solenoid has been in operation as part of the BaBar detector since 1999. This magnet is a critical component of the BaBar experiment. A significant amount of magnet operating experience has been gathered. The average availability of this magnet currently approaches 99 percent. This paper describes the historical frequency and modes of unplanned magnet ramp downs and quenches. It also describes steps that have been taken to mitigate these failure modes as well as planned future improvements.

  3. Failure Analysis of Composite Structure Materials.

    DTIC Science & Technology

    1987-05-27

    starting point of the investigation. Such techniques included flow charts describing the logical arrangement of investigative operations along with...to determine the causes of failure in continuous fiber reinforced composite materials. Such techniques included flow charts describing the logical...sub-FALN’s were developed to describe the logical flow of analysis in greater detail for each major discipline (see section 6.0). To aid investigators

  4. Experimental and failure analysis of the prosthetic finger joint implants

    NASA Astrophysics Data System (ADS)

    Naidu, Sanjiv H.

    Small joint replacement arthroplasty of the hand is a well accepted surgical procedure to restore function and cosmesis in an individual with a crippled hand. Silicone elastomers have been used as prosthetic material in various small hand joints for well over three decades. Although the clinical science aspects of silicone elastomer failure are well known, the physical science aspects of prosthetic failure are scant and vague. In the following thesis, using both an animal model, and actual retrieved specimens which have failed in human service, experimental and failure analysis of silicone finger joints are presented. Fractured surfaces of retrieved silicone trapezial implants, and silicone finger joint implants were studied with both FESEM and SEM; the mode of failure for silicone trapezium is by wear polishing, whereas the finger joint implants failed either by fatigue fracture or tearing of the elastomer, or a combination of both. Thermal analysis revealed that the retrieved elastomer implants maintained its viscoelastic properties throughout the service period. In order to provide for a more functional and physiologic arthroplasty a novel finger joint (Rolamite prosthesis) is proposed using more recently developed thermoplastic polymers. The following thesis also addresses the outcome of the experimental studies of the Rolamite prosthesis in a rabbit animal model, in addition to the failure analysis of the thermoplastic polymers while in service in an in vivo synovial environment. Results of retrieved Rolamite specimens suggest that the use for thermoplastic elastomers such as block copolymer based elastomers in a synovial environment such as a mammalian joint may very well be limited.

  5. [Primary failure of eruption (PFE). Clinical and molecular genetics analysis].

    PubMed

    Stellzig-Eisenhauer, Angelika; Decker, Eva; Meyer-Marcotty, Philipp; Rau, Christiane; Fiebig, Britta S; Kress, Wolfram; Saar, Kathrin; Rüschendorf, Franz; Hubner, Norbert; Grimm, Tiemo; Witt, Emil; Weber, Bernhard H F

    2013-09-01

    The term "primary failure of eruption" (PFE) refers to the complete or partial failure of a primary non-ankylosed tooth to erupt due to a disturbance of the eruption mechanism. Up to now, the molecular basis for this failure was unknown. Four families were studied in whom at least two members were affected by non-syndromic PFE as part of a clinical and molecular genetics study. Radiological diagnostics (OPTs) were carried out in all patients and their unaffected relatives (control group). The genetic analysis included a genomewide linkage analysis followed by direct DNA sequencing of positional candidate genes. Starting from the index patients, we were able to reconstruct pedigrees over two and/or three generations in the families that indicated an autosomal-dominant mode of inheritance of non-syndromic PFE. Fifteen patients were diagnosed with PFE. Gender distribution was nearly equal (7 female, 8 male). Molecular genetic analysis of the PTHR1 gene revealed three distinct heterozygous mutations (c.1050-3C>G; c.543 + 1G>A; c.463G>T). Unaffected persons exhibited no mutations. Knowledge of the genetic causes of non-syndromic PFE can now be used for the differential diagnosis of eruption failure. It permits affected family members to be identified early and may lead to new treatment possibilities in the long term. The genetically-verified diagnosis of "primary failure of eruption" can protect patients and orthodontists from years of futile treatment, because orthodontic treatment alone does not lead to success. Moreover, it has a negative influence on unaffected teeth and areas of the jaw. © EDP Sciences, SFODF, 2013.

  6. Memories and NASA Spacecraft: A Description of Memories, Radiation Failure Modes, and System Design Considerations

    NASA Technical Reports Server (NTRS)

    LaBel, Kenneth A.; Ladbury, Ray; Oldhamm, Timothy

    2010-01-01

    As NASA has evolved it's usage of spaceflight computing, memory applications have followed as well. In this slide presentation, the history of NASA's memories from magnetic core and tape recorders to current semiconductor approaches is discussed. There is a brief description of current functional memory usage in NASA space systems followed by a description of potential radiation-induced failure modes along with considerations for reliable system design.

  7. Lunar Module ECS (Environmental Control System) - Design Considerations and Failure Modes. Part 1

    NASA Technical Reports Server (NTRS)

    Interbartolo, Michael

    2009-01-01

    Design considerations and failure modes for the Lunar Module (LM) Environmental Control System (ECS) are described. An overview of the the oxygen supply and cabin pressurization, atmosphere revitalization, water management and heat transport systems are provided. Design considerations including reliability, flight instrumentation, modularization and the change to the use of batteries instead of fuel cells are discussed. A summary is provided for the LM ECS general testing regime.

  8. Factors Influencing Progressive Failure Analysis Predictions for Laminated Composite Structure

    NASA Technical Reports Server (NTRS)

    Knight, Norman F., Jr.

    2008-01-01

    Progressive failure material modeling methods used for structural analysis including failure initiation and material degradation are presented. Different failure initiation criteria and material degradation models are described that define progressive failure formulations. These progressive failure formulations are implemented in a user-defined material model for use with a nonlinear finite element analysis tool. The failure initiation criteria include the maximum stress criteria, maximum strain criteria, the Tsai-Wu failure polynomial, and the Hashin criteria. The material degradation model is based on the ply-discounting approach where the local material constitutive coefficients are degraded. Applications and extensions of the progressive failure analysis material model address two-dimensional plate and shell finite elements and three-dimensional solid finite elements. Implementation details are described in the present paper. Parametric studies for laminated composite structures are discussed to illustrate the features of the progressive failure modeling methods that have been implemented and to demonstrate their influence on progressive failure analysis predictions.

  9. Evaluation of a fracture failure mode in the Space Shuttle hydrogen pressurization system flow control valves

    NASA Astrophysics Data System (ADS)

    Hauver, S. E.; Sueme, D. R.

    1992-07-01

    During acceptance testing of the Space Shuttle Endeavor hydrogen flow control valves, which are used in the Orbiter's fuel tank pressurization system, two of the valves experienced fracture of the poppet flange. The poppets are made of 440 C, a high strength, wear-resistant, low ductility, martensitic stainless steel. The investigation which was initiated to determine the cause of these failures is traced. All aspects of the poppet processing that may have introduced a defect were assessed. This included machining, heat treating, passivation, assembly, and test. In addition, several potential failure modes were investigated. The extensive investigation revealed no obvious cause of the failures, but did result in a recommendation for a different material application.

  10. Different failure modes for V-containing and V-free AB2 metal hydride alloys

    NASA Astrophysics Data System (ADS)

    Young, K.; Wong, D. F.; Yasuoka, S.; Ishida, J.; Nei, J.; Koch, J.

    2014-04-01

    Failure modes of a V-containing and a V-free AB2 Laves phase-based metal hydride alloy were studied by the combination of X-ray diffractometer, scanning electron microscope, X-ray energy dispersive spectroscopy, inductively coupled plasma, Soxhlet extraction, and magnetic susceptibility measurement. Cells with the V-containing alloy exhibited less capacity degradation up until venting occurred in the cells, after which the capacity rapidly degraded. Cells with the V-free alloy remained linear in capacity degradation throughout the cycle life test. The failure mechanism for the V-containing alloy is related to the formation of an oxide layer that penetrates deeper into the alloy particles due to high V leaching and impedes gas recombination, while the failure mechanism for the V-free alloy is related to the continuous pulverization of the main AB2 phase.

  11. Cardiac and Hemodynamic Benefits: Mode of Action of Ivabradine in Heart Failure.

    PubMed

    Pereira-Barretto, Antonio Carlos

    2015-10-01

    Heart failure has seen a number of therapeutic advances in recent years. Despite this, heart failure is still related to increasing rates of morbidity, repeated hospitalizations, and mortality. Ivabradine is a recent treatment option for heart failure. It has a mode of action that includes reduction in heart rate, and leads to improvement in outcomes related to heart failure mortality and morbidity, as demonstrated by the results of the SHIFT trial in patients with systolic heart failure, functional classes II and III on the New York Heart Association classification, and left ventricular ejection fraction ≤ 35%. These results are intriguing since many heart failure drugs reduce heart rate without such benefits, or with quite different effects, making it more difficult to understand the novelty of ivabradine in this setting. Many of the drugs used in heart failure modify heart rate, but most have other pathophysiological effects beyond their chronotropic action, which affect their efficacy in preventing morbidity and mortality outcomes. For instance, heart rate reduction at rest or exercise with ivabradine prolongs diastolic perfusion time, improves coronary blood flow, and increases exercise capacity. Another major difference is the increase in stroke volume observed with ivabradine, which may underlie its beneficial cardiac effects. Finally, there is mounting evidence from both preclinical and clinical studies that ivabradine has an anti-remodeling effect, improving left ventricular structures and functions. All together, these mechanisms have a positive impact on the prognosis of ivabradine-treated patients with heart failure, making a compelling argument for use of ivabradine in combination with other treatments.

  12. Stick-slip failure in granular experiments: the role of low-frequency vibrational modes

    NASA Astrophysics Data System (ADS)

    Brzinski, T., III; Daniels, K.

    2014-12-01

    The intermittent nature of strain at geological faults is a consequence of the loss of rigidity of the gouge. Due to the granular nature of the gouge, we take insight from granular physics in order to characterize the role of gouge in the generation of seismic events. In static granular packings, the loss of rigidity has been observed to be associated with an excess in low-frequency vibrational modes. The same holds true in both molecular and colloidal glasses, suggesting that excess low-frequency vibrational modes are a general feature in the failure of disordered solids. Therefore, we seek a relationship between these low-frequency modes and spatiotemporal patterns of failure by studying an experimental analog to a geological fault. Specifically, we measure the acoustic emissions from jammed, quasi-2D granular packings under shear. We use a split-bottom annular shear geometry, driven with a linear-ramp torque in order to generate stick-slip behavior, and observe intervals of both periodic and aperiodic slip. We investigate how low-frequency emissions are associated with both local and global slip events of various magnitudes and directions. Twelve piezoelectric acoustic receivers, an imaging system, and high-resolution stress/strain sensors enable direct comparison of acoustic properties as the system approaches failure. The use of photoelastic grains enables local measurement of changes to the internal stresses.

  13. Recent Advances In Structural Vibration And Failure Mode Control In Mainland China: Theory, Experiments And Applications

    SciTech Connect

    Li Hui; Ou Jinping

    2008-07-08

    A number of researchers have been focused on structural vibration control in the past three decades over the world and fruit achievements have been made. This paper introduces the recent advances in structural vibration control including passive, active and semiactive control in mainland China. Additionally, the co-author extends the structural vibration control to failure mode control. The research on the failure mode control is also involved in this paper. For passive control, this paper introduces full scale tests of buckling-restrained braces conducted to investigate the performance of the dampers and the second-editor of the Code of Seismic Design for Buildings. For active control, this paper introduces the HMD system for wind-induced vibration control of the Guangzhou TV tower. For semiactive control, the smart damping devices, algorithms for semi-active control, design methods and applications of semi-active control for structures are introduced in this paper. The failure mode control for bridges is also introduced.

  14. Precursory changes in seismic velocity for the spectrum of earthquake failure modes.

    PubMed

    Scuderi, M M; Marone, C; Tinti, E; Di Stefano, G; Collettini, C

    2016-09-01

    Temporal changes in seismic velocity during the earthquake cycle have the potential to illuminate physical processes associated with fault weakening and connections between the range of fault slip behaviors including slow earthquakes, tremor and low frequency earthquakes1. Laboratory and theoretical studies predict changes in seismic velocity prior to earthquake failure2, however tectonic faults fail in a spectrum of modes and little is known about precursors for those modes3. Here we show that precursory changes of wave speed occur in laboratory faults for the complete spectrum of failure modes observed for tectonic faults. We systematically altered the stiffness of the loading system to reproduce the transition from slow to fast stick-slip and monitored ultrasonic wave speed during frictional sliding. We find systematic variations of elastic properties during the seismic cycle for both slow and fast earthquakes indicating similar physical mechanisms during rupture nucleation. Our data show that accelerated fault creep causes reduction of seismic velocity and elastic moduli during the preparatory phase preceding failure, which suggests that real time monitoring of active faults may be a means to detect earthquake precursors.

  15. Precursory changes in seismic velocity for the spectrum of earthquake failure modes

    PubMed Central

    Scuderi, M.M.; Marone, C.; Tinti, E.; Di Stefano, G.; Collettini, C.

    2016-01-01

    Temporal changes in seismic velocity during the earthquake cycle have the potential to illuminate physical processes associated with fault weakening and connections between the range of fault slip behaviors including slow earthquakes, tremor and low frequency earthquakes1. Laboratory and theoretical studies predict changes in seismic velocity prior to earthquake failure2, however tectonic faults fail in a spectrum of modes and little is known about precursors for those modes3. Here we show that precursory changes of wave speed occur in laboratory faults for the complete spectrum of failure modes observed for tectonic faults. We systematically altered the stiffness of the loading system to reproduce the transition from slow to fast stick-slip and monitored ultrasonic wave speed during frictional sliding. We find systematic variations of elastic properties during the seismic cycle for both slow and fast earthquakes indicating similar physical mechanisms during rupture nucleation. Our data show that accelerated fault creep causes reduction of seismic velocity and elastic moduli during the preparatory phase preceding failure, which suggests that real time monitoring of active faults may be a means to detect earthquake precursors. PMID:27597879

  16. A molecular dynamics study of the failure modes of a glassy polymer confined between rigid walls

    NASA Astrophysics Data System (ADS)

    Kulmi, Udit; Basu, Sumit

    2006-09-01

    Adhesion is a complex and multifaceted phenomenon which is controlled by various factors such as the loading rate, interface toughness, temperature and geometric and molecular properties. The mode of failure of adhesive joints (adhesive or cohesive) is decided through a complex interplay between these factors. In this work, we study the failure under tensile loading of a thin layer of a polymeric material confined between two rigid walls using molecular dynamics simulations. The strength of the interface is controlled by the interaction potential between the polymer and wall atoms. The polymer modelled is a simple linear chain of 'united atoms' having a fixed bond length but contributions to the energy arise from bending and torsion of bonds as well as from non-bonded interactions between the 'united atoms'. The results indicate that even when the adhesion between the wall and the polymer is weak, a short chained polymer is more likely to fail by a mixed adhesive cohesive mode. A long chained polymer, with the same interface strength, fails in a pure adhesive manner. However, when the interface is sufficiently strengthened, the long chained polymer fails cohesively and it can bear a much higher load. The failure mode is somewhat modulated by the rate at which deformation occurs. Moreover, when the polymer is confined such that the spacing between the walls is comparable to the end-to-end distance of the polymer chain, strength of the joint increases significantly. In such a situation, even polymers with weak interfacial adhesion might fail cohesively.

  17. Precursory changes in seismic velocity for the spectrum of earthquake failure modes

    NASA Astrophysics Data System (ADS)

    Scuderi, M. M.; Marone, C.; Tinti, E.; di Stefano, G.; Collettini, C.

    2016-09-01

    Temporal changes in seismic velocity during the earthquake cycle have the potential to illuminate physical processes associated with fault weakening and connections between the range of fault slip behaviours including slow earthquakes, tremor and low-frequency earthquakes. Laboratory and theoretical studies predict changes in seismic velocity before earthquake failure; however, tectonic faults fail in a spectrum of modes and little is known about precursors for those modes. Here we show that precursory changes of wave speed occur in laboratory faults for the complete spectrum of failure modes observed for tectonic faults. We systematically altered the stiffness of the loading system to reproduce the transition from slow to fast stick-slip and monitored ultrasonic wave speed during frictional sliding. We find systematic variations of elastic properties during the seismic cycle for both slow and fast earthquakes indicating similar physical mechanisms during rupture nucleation. Our data show that accelerated fault creep causes reduction of seismic velocity and elastic moduli during the preparatory phase preceding failure, which suggests that real-time monitoring of active faults may be a means to detect earthquake precursors.

  18. Long-term lumen depreciation behavior and failure modes of multi-die array LEDs

    NASA Astrophysics Data System (ADS)

    Jayawardena, Asiri; Marcus, Daniel; Prugue, Ximena; Narendran, Nadarajah

    2013-09-01

    One of the main advantages of multi-die array light-emitting diodes (LEDs) is their high flux density. However, a challenge for using such a product in lighting fixture applications is the heat density and the need for thermal management to keep the junction temperatures of all the dies low for long-term reliable performance. Ten multi-die LED array samples for each product from four different manufacturers were subjected to lumen maintenance testing (as described in IES-LM-80-08), and their resulting lumen depreciation and failure modes were studied. The products were tested at the maximum case (or pin) temperature reported by the respective manufacturer by appropriately powering the LEDs. In addition, three samples for each product from two different manufacturers were subjected to rapid thermal cycling, and the resulting lumen depreciation and failure modes were studied. The results showed that the exponential lumen decay model using long-term lumen maintenance data as recommended in IES TM-21 does not fit for all package types. The failure of a string of dies and single die failure in a string were observed in some of the packages.

  19. Effect of ferrule height and glass fibre post length on fracture resistance and failure mode of endodontically treated teeth.

    PubMed

    Abdulrazzak, Shurooq S; Sulaiman, Eshamsul; Atiya, Basim K; Jamaludin, Marhazlinda

    2014-08-01

    The purpose of this study was to evaluate the combined effect of ferrule height and post length on fracture resistance and failure mode of endodontically treated teeth restored with glass fibre posts, composite resin cores and crowns. Ninety human maxillary central incisors were endodontically treated and divided into three groups (n = 30) according to the ferrule heights: 4, 2 and 0 mm, respectively. Post spaces in each group were prepared at 2/3, 1/2 and 1/3 of the root length (n = 10). The specimens were received fibre posts, composite resin core build up and cast metal crowns. After thermocycling, compressive static load was applied at an angle of 135° to the crowns. Two-way analysis of variance showed significant differences in the failure load in the ferrule height groups, no significant differences in post length groups and no significant interaction between ferrule heights and post lengths. More restorable failure modes were observed. © 2013 Australian Society of Endodontology.

  20. Failure Analysis of Worn Surface Micromachined Microengines

    SciTech Connect

    Walraven, Jeremy A.; Headley, Thomas J.; Campbell, Ann N.; Tanner, Danelle M.

    1999-07-21

    Failure analysis (FA) tools have been applied to analyze failing polysilicon microengines. These devices were stressed to failure under accelerated conditions in both oxidizing and non-oxidizing environments. The dominant failure mechanism of these microengines was identified as wear of rubbing surfaces. This often results in either seized microengines or microengines with broken pin joints. Analysis of these failed polysilicon devices found that wear debris was produced in both oxidizing and non-oxidizing environments. By varying the relative percent humidity (%RH), they observed an increase in the amount of wear debris with decreasing humidity. Plan view imaging using scanning electron microscopy revealed build-up of wear debris on the surface of microengines. Focused ion beam (FIB) cross sections revealed the location and build-up of wear debris on the surface of microengines. Focused ion beam (FIB) cross sections revealed the location and build-up of wear debris within the microengine. Seized regions were also observed in the pin joint area using FIB processing. By using transmission electron microscopy in conjunction with energy dispersive x-ray spectroscopy (EDX) and electron energy loss spectroscopy (EELS), they were able to identify wear debris produced in low (1.8% RH), medium and high (39% RH) humidities.

  1. FASTHELP. Integrated Circuit Failure Analysis Hypertext Help System

    SciTech Connect

    Henderson, C; Barton, D; Campbell, A; Cole, E; Mikawa, R E; Peterson, K A; Rife, J L; Soden, J M

    1994-09-30

    This software assists a failure analyst performing failure analysis on integrated circuits. The software can also be used to train inexperienced failure analysts. The software also provides a method for storing information and making it easily available to experienced failure analysts.

  2. Effects of Fusion Zone Size and Failure Mode on Peak Load and Energy Absorption of Advanced High Strength Steel Spot Welds under Lap Shear Loading Conditions

    SciTech Connect

    Sun, Xin; Stephens, Elizabeth V.; Khaleel, Mohammad A.

    2008-06-01

    This paper examines the effects of fusion zone size on failure modes, static strength and energy absorption of resistance spot welds (RSW) of advanced high strength steels (AHSS) under lap shear loading condition. DP800 and TRIP800 spot welds are considered. The main failure modes for spot welds are nugget pullout and interfacial fracture. Partial interfacial fracture is also observed. Static weld strength tests using lap shear samples were performed on the joint populations with various fusion zone sizes. The resulted peak load and energy absorption levels associated with each failure mode were studied for all the weld populations using statistical data analysis tools. The results in this study show that AHSS spot welds with conventionally required fusion zone size of can not produce nugget pullout mode for both the DP800 and TRIP800 welds under lap shear loading. Moreover, failure mode has strong influence on weld peak load and energy absorption for all the DP800 welds and the TRIP800 small welds: welds failed in pullout mode have statistically higher strength and energy absorption than those failed in interfacial fracture mode. For TRIP800 welds above the critical fusion zone level, the influence of weld failure modes on peak load and energy absorption diminishes. Scatter plots of peak load and energy absorption versus weld fusion zone size were then constructed, and the results indicate that fusion zone size is the most critical factor in weld quality in terms of peak load and energy absorption for both DP800 and TRIP800 spot welds.

  3. Cyclic loading of endodontically treated teeth restored with glass fibre and titanium alloy posts: fracture resistance and failure modes.

    PubMed

    Abdul Salam, Saridatun Nur; Banerjee, Avijit; Mannocci, Francesco; Pilecki, Peter; Watson, Timothy F

    2006-09-01

    The aims of this in-vitro investigation were to compare the fracture resistance and the failure modes of endodontically treated teeth restored with glass fibre-reinforced posts with those of teeth restored with titanium-alloy posts. A total of 60 single-rooted human mandibular premolars were endodontically treated. The teeth were divided into two experimental and one control group. Post spaces 9mm long were prepared in the roots of the experimental groups in which glass fibre-reinforced posts (Group A) and titanium-alloy posts (Group B) were cemented. In the control group (Group C), no post was inserted. The specimens were stored in normal saline for a period of three weeks before being intermittently loaded at an angle of 30 degrees degrees to the long axis of the tooth at a frequency of two loads of 40N per second. Log-rank test used for the overall analysis revealed that there was no significant difference of fracture resistance between teeth restored with glass fibre-reinforced posts (Group A) and titanium-alloy posts (Group B). The survival of the control group was found to be significantly inferior to that of the experimental groups. There was no significant difference in the number of failures between the two experimental groups. There was significantly more core and post failure for the glass fibre-reinforced posts, root and core failure for the titanium-alloy posts and core failure for the control group. The results suggest that post failures are more frequent in teeth restored with quartz fibre posts and root fractures are more frequent in teeth restored with titanium posts.

  4. Failure analysis of lattice tower like structures

    NASA Astrophysics Data System (ADS)

    Ramalingam, Raghavan

    2017-07-01

    The Experimental investigations have revealed significant mismatches between analytical estimates and experimentally measured deflections of tower structures. Conductor and groundwire tension and sag are influenced by the peak and cross-arm deflections and hence accurate estimates of the tower deflections at service loads are of key interest. This paper presents a nonlinear formulation for analysis of tower structures in an attempt to close the mismatch. The analysis includes geometric nonlinear behaviour of the tower, material nonlinearity as well as leg member buckling in compression. The nonlinear analysis reveals that the ultimate collapse loads of the towers tested to failure can be predicted. However the, deflections continue to have a mismatch despite nonlinear analysis. This demonstrates the need for inclusion of other parameters to be able to reduce the error of analytical deflection estimates.

  5. Timing analysis of PWR fuel pin failures

    SciTech Connect

    Jones, K.R.; Wade, N.L.; Katsma, K.R.; Siefken, L.J. ); Straka, M. )

    1992-09-01

    Research has been conducted to develop and demonstrate a methodology for calculation of the time interval between receipt of the containment isolation signals and the first fuel pin failure for loss-of-coolant accidents (LOCAs). Demonstration calculations were performed for a Babcock and Wilcox (B W) design (Oconee) and a Westinghouse (W) four-loop design (Seabrook). Sensitivity studies were performed to assess the impacts of fuel pin bumup, axial peaking factor, break size, emergency core cooling system availability, and main coolant pump trip on these times. The analysis was performed using the following codes: FRAPCON-2, for the calculation of steady-state fuel behavior; SCDAP/RELAP5/MOD3 and TRACPF1/MOD1, for the calculation of the transient thermal-hydraulic conditions in the reactor system; and FRAP-T6, for the calculation of transient fuel behavior. In addition to the calculation of fuel pin failure timing, this analysis provides a comparison of the predicted results of SCDAP/RELAP5/MOD3 and TRAC-PFL/MOD1 for large-break LOCA analysis. Using SCDAP/RELAP5/MOD3 thermal-hydraulic data, the shortest time intervals calculated between initiation of containment isolation and fuel pin failure are 10.4 seconds and 19.1 seconds for the B W and W plants, respectively. Using data generated by TRAC-PF1/MOD1, the shortest intervals are 10.3 seconds and 29.1 seconds for the B W and W plants, respectively. These intervals are for a double-ended, offset-shear, cold leg break, using the technical specification maximum peaking factor and applied to fuel with maximum design bumup. Using peaking factors commensurate widi actual bumups would result in longer intervals for both reactor designs. This document also contains appendices A through J of this report.

  6. Failure mode, strain localization and permeability evolution in porous sedimentary rocks

    NASA Astrophysics Data System (ADS)

    Vajdova, Veronika

    Laboratory study was undertaken to investigate failure mode, strain localization and permeability evolution in the brittle-ductile transition of porous sandstone and limestone. Conventional triaxial compression experiments and permeability measurements were conducted at high pressure and room temperature, and microstructural observations were performed on failed samples using optical microscopy. Strain localization was investigated on Bentheim sandstone where besides shear localization, a new failure mode represented by discrete compaction bands was recently reported. To study the effect of stress heterogeneity on initiation and propagation of the compaction bands, triaxial experiments were conducted on dry cylindrical samples with a circumferential notch as a stress concentrator. Acoustic emission data were recorded to underscore the temporal aspect. Mechanical and microstructural data revealed sensitivity of initiation of compaction bands to stress concentration at the notch. The band propagated by sequential increments as "anti-crack" in direction perpendicular to the maximum principal stress. With increasing axial strain an array formed of parallel compaction bands. The effect of strain localization on hydraulic permeability was studied on cylindrical samples in triaxial compression for fluid flow parallel to maximum principal stress. The permeability decreased with deformation for both failure modes, shear and compaction bands. A dramatic decrease of more than one order of magnitude occurred over a relatively narrow range of axial strain when the first few compaction bands developed. Motivated by microstructural observations, the failed sample was modeled as a layered medium with permeability contrast between the compaction bands and the relatively undeformed matrix. Unlike in sandstone, the failure in the brittle-ductile transition in limestone is affected by crystal plasticity of calcite. The interplay of crystal plastic and cataclastic mechanisms was

  7. Stability Analysis and the Stabilisation of Flexural Toppling Failure

    NASA Astrophysics Data System (ADS)

    Amini, Mehdi; Majdi, Abbas; Aydan, Ömer

    2009-10-01

    Flexural toppling is a mode of failure that may occur in a wide range of layered rock strata in both rock slopes and large underground excavations. Whenever rock mass is composed of a set of parallel discontinuities dipping steeply against the excavated face plane, the rock mass will have the potential of flexural toppling failure as well. In such cases, the rock mass behaves like inclined superimposed cantilever beams that bend under their own weight while transferring the load to the underlying strata. If the bending stress exceeds the rock column’s tensile strength, flexural toppling failure will be initiated. Since the rock columns are “statically indeterminate,” thus, their factors of safety may not be determined solely by equations of equilibrium. The paper describes an analytical model with a sequence of inclined superimposed cantilever rock columns with a potential of flexural topping failure. The model is based on the principle of compatibility equations and leads to a new method by which the magnitudes and points of application of intercolumn forces are determined. On the basis of the proposed model, a safety factor for each rock column can be computed independently. Hence, every rock column will have a unique factor of safety. The least factor of safety that exists in any rock column is selected as the rock mass representative safety factor based on which simple equations are proposed for a conservative rock mass stability analysis and design. As a result, some new relations are established in order to design the length, cross-sectional area and pattern of fully grouted rock bolts for the stabilisation of such rock mass. Finally, the newly proposed equations are compared with the results of existing experimental flexural toppling failure models (base friction and centrifuge tests) for further verification.

  8. Interactive multi-mode blade impact analysis

    NASA Technical Reports Server (NTRS)

    Alexander, A.; Cornell, R. W.

    1978-01-01

    The theoretical methodology used in developing an analysis for the response of turbine engine fan blades subjected to soft-body (bird) impacts is reported, and the computer program developed using this methodology as its basis is described. This computer program is an outgrowth of two programs that were previously developed for the purpose of studying problems of a similar nature (a 3-mode beam impact analysis and a multi-mode beam impact analysis). The present program utilizes an improved missile model that is interactively coupled with blade motion which is more consistent with actual observations. It takes into account local deformation at the impact area, blade camber effects, and the spreading of the impacted missile mass on the blade surface. In addition, it accommodates plate-type mode shapes. The analysis capability in this computer program represents a significant improvement in the development of the methodology for evaluating potential fan blade materials and designs with regard to foreign object impact resistance.

  9. Predictions of High Strain Rate Failure Modes in Layered Aluminum Composites

    NASA Astrophysics Data System (ADS)

    Khanikar, Prasenjit; Zikry, M. A.

    2014-01-01

    A dislocation density-based crystalline plasticity formulation, specialized finite-element techniques, and rational crystallographic orientation relations were used to predict and characterize the failure modes associated with the high strain rate behavior of aluminum layered composites. Two alloy layers, a high strength alloy, aluminum 2195, and an aluminum alloy 2139, with high toughness, were modeled with representative microstructures that included precipitates, dispersed particles, and different grain boundary distributions. Different layer arrangements were investigated for high strain rate applications and the optimal arrangement was with the high toughness 2139 layer on the bottom, which provided extensive shear strain localization, and the high strength 2195 layer on the top for high strength resistance The layer thickness of the bottom high toughness layer also affected the bending behavior of the roll-bonded interface and the potential delamination of the layers. Shear strain localization, dynamic cracking, and delamination are the mutually competing failure mechanisms for the layered metallic composite, and control of these failure modes can be used to optimize behavior for high strain rate applications.

  10. Notch strengthening or weakening governed by transition of shear failure to normal mode fracture.

    PubMed

    Lei, Xianqi; Li, Congling; Shi, Xinghua; Xu, Xianghong; Wei, Yujie

    2015-05-29

    It is generally observed that the existence of geometrical discontinuity like notches in materials will lead to strength weakening, as a resultant of local stress concentration. By comparing the influence of notches to the strength of three typical materials, aluminum alloys with intermediate tensile ductility, metallic glasses with no tensile ductility, and brittle ceramics, we observed strengthening in aluminum alloys and metallic glasses: Tensile strength of the net section in circumferentially notched cylinders increases with the constraint quantified by the ratio of notch depth over notch root radius; in contrast, the ceramic exhibit notch weakening. The strengthening in the former two is due to resultant deformation transition: Shear failure occurs in intact samples while samples with deep notches break in normal mode fracture. No such deformation transition was observed in the ceramic, and stress concentration leads to its notch weakening. The experimental results are confirmed by theoretical analyses and numerical simulation. The results reported here suggest that the conventional criterion to use brittleness and/or ductility to differentiate notch strengthening or weakening is not physically sound. Notch strengthening or weakening relies on the existence of failure mode transition and materials exhibiting shear failure while subjected to tension will notch strengthen.

  11. Notch strengthening or weakening governed by transition of shear failure to normal mode fracture

    PubMed Central

    Lei, Xianqi; Li, Congling; Shi, Xinghua; Xu, Xianghong; Wei, Yujie

    2015-01-01

    It is generally observed that the existence of geometrical discontinuity like notches in materials will lead to strength weakening, as a resultant of local stress concentration. By comparing the influence of notches to the strength of three typical materials, aluminum alloys with intermediate tensile ductility, metallic glasses with no tensile ductility, and brittle ceramics, we observed strengthening in aluminum alloys and metallic glasses: Tensile strength of the net section in circumferentially notched cylinders increases with the constraint quantified by the ratio of notch depth over notch root radius; in contrast, the ceramic exhibit notch weakening. The strengthening in the former two is due to resultant deformation transition: Shear failure occurs in intact samples while samples with deep notches break in normal mode fracture. No such deformation transition was observed in the ceramic, and stress concentration leads to its notch weakening. The experimental results are confirmed by theoretical analyses and numerical simulation. The results reported here suggest that the conventional criterion to use brittleness and/or ductility to differentiate notch strengthening or weakening is not physically sound. Notch strengthening or weakening relies on the existence of failure mode transition and materials exhibiting shear failure while subjected to tension will notch strengthen. PMID:26022892

  12. Fatigue Failure Modes of the Grain Size Transition Zone in a Dual Microstructure Disk

    NASA Technical Reports Server (NTRS)

    Gabb, Timothy P.; Kantzos, Pete T.; Palsa, Bonnie; Telesman, Jack; Gayda, John; Sudbrack, Chantal K.

    2012-01-01

    Mechanical property requirements vary with location in nickel-based superalloy disks. In order to maximize the associated mechanical properties, heat treatment methods have been developed for producing tailored grain microstructures. In this study, fatigue failure modes of a grain size transition zone in a dual microstructure disk were evaluated. A specialized heat treatment method was applied to produce varying grain microstructure in the bore to rim portions of a powder metallurgy processed nickel-based superalloy disk. The transition in grain size was concentrated in a zone of the disk web, between the bore and rim. Specimens were extracted parallel and transversely across this transition zone, and multiple fatigue tests were performed at 427 C and 704 C. Grain size distributions were characterized in the specimens, and related to operative failure initiation modes. Mean fatigue life decreased with increasing maximum grain size, going out through the transition zone. The scatter in limited tests of replicates was comparable for failures of uniform gage specimens in all transition zone locations examined.

  13. Current modes of failure in TKA: infection, instability, and stiffness predominate.

    PubMed

    Le, David H; Goodman, Stuart B; Maloney, William J; Huddleston, James I

    2014-07-01

    Historically, polyethylene wear and its sequelae (osteolysis, late instability, aseptic loosening) were common causes for revision total knee arthroplasty (TKA). Recently, polyethylene manufacturing has become more consistent; furthermore, a clearer understanding of the importance of oxidation on polyethylene performance led to packaging of the polyethylene bearings in an inert environment. This improved the quality and consistency of polyethylene used in TKA, raising the question of whether different failure modes now predominate after TKA. The purpose of this study was to determine the current reasons for (1) early and (2) late failures after TKA at one high-volume arthroplasty center. We reviewed all first-time revision TKAs performed between 2001 and 2011 at one institution, yielding a group of 253 revision TKAs in 251 patients. Mean age at the time of revision was 64 years (SD 10 years). Mean time to revision was 35 months (SD 23 months). Preoperative evaluations, laboratory data, radiographs, and intraoperative findings were used to determine causes for revision. Early failure was defined as revision within 2 years of the index procedure. The primary failure mechanism was determined by the operating surgeon. Early failure accounted for 46% (116 of 253) of all revisions with infection (28 of 116 [24%]), instability (30 of 116 [26%]), and stiffness (21 of 116 [18%]) being the leading causes. Late failure accounted for 54% (137 of 253) of all revisions with the most common causes including infection (34 of 137 [25%]), instability (24 of 137 [18%]), and stiffness (19 of 253 [14%]). Polyethylene wear was implicated as the failure mechanism in 2% of early cases (two of 116) and 9% of late cases (13 of 137). In contrast to previous studies, wear-related implant failure in TKA was relatively uncommon in this series. Changes in polyethylene manufacturing, sterilization, and storage may have accounted for some of this difference; however, longer-term followup will

  14. Effects of Fusion Zone Size on Failure Modes and Performance of Advanced High Strength Steel Spot Welds (2006-01-0531)

    SciTech Connect

    Sun, Xin; Stephens, Elizabeth V.; Khaleel, Mohammad A.

    2007-03-01

    This paper examines the effects of fusion zone size on failure modes, static strength and energy absorption of resistance spot welds (RSW) of advanced high strength steels (AHSS). DP800 and TRIP800 spot welds are considered. The main failure modes for spot welds are nugget pullout and interfacial fracture. Partial interfacial fracture is also observed. The critical fusion zone sizes to ensure nugget pull-out failure mode are developed for both DP800 and TRIP800 using the limit load based analytical model and the micro-hardness measurements of the weld cross sections. Static weld strength tests using cross tension samples were performed on the joint populations with controlled fusion zone sizes. The resulted peak load and energy absorption levels associated with each failure mode were studied using statistical data analysis tools. The results in this study show that the conventional weld size of 4 t1/2 can not produce nugget pullout mode for both the DP800 and TRIP800 materials. The results also suggest that performance based spot weld acceptance criteria should be developed for different AHSS spot welds.

  15. Effects of Fusion Zone Size and Failure Mode on Peak Load and Energy Absorption of Advanced High Strength Steel Spot Welds

    SciTech Connect

    Sun, Xin; Stephens, Elizabeth V.; Khaleel, Mohammad A.

    2007-01-01

    This paper examines the effects of fusion zone size on failure modes, static strength and energy absorption of resistance spot welds (RSW) of advanced high strength steels (AHSS). DP800 and TRIP800 spot welds are considered. The main failure modes for spot welds are nugget pullout and interfacial fracture. Partial interfacial fracture is also observed. The critical fusion zone sizes to ensure nugget pull-out failure mode are developed for both DP800 and TRIP800 using limit load based analytical model and micro-hardness measurements of the weld cross sections. Static weld strength tests using cross tension samples were performed on the joint populations with controlled fusion zone sizes. The resulted peak load and energy absorption levels associated with each failure mode were studied for all the weld populations using statistical data analysis tools. The results in this study show that AHSS spot welds with fusion zone size of can not produce nugget pullout mode for both the DP800 and TRIP800 materials examined. The critical fusion zone size for nugget pullout shall be derived for individual materials based on different base metal properties as well as different heat affected zone (HAZ) and weld properties resulted from different welding parameters.

  16. Initial Failure Analysis of Ceramic Filters

    SciTech Connect

    Huque, Z.; Mei, D.; Zhou, J.

    1996-12-31

    Effective high temperature ceramic filters are indispensable in the advanced, coal based power systems (IGCC and PFBC). To meet the environmental particulate emission requirements and improve thermal efficiency, ceramic filters are utilized to cleanup the hot gas particulate to protect downstream heat exchanger and gas turbine components from fouling and corrosion. The mechanical integrity of ceramic filters and an efficient dust cake removal system are the key issues for hot gas cleanup systems. The filters must survive combined stresses due to mechanical, thermal, chemical and steam attack throughout normal operations (cold back pulse cleaning jets), unexpected excessive ash accumulation, and the start up and shut down conditions. To evaluate the design and performance of ceramic filters, different long term filter testing programs were conducted. To fulfill this purpose, two Advanced Particle Filter (APF) systems were complete at Tidd PFBC Demonstration Plant in Brilliant, Ohio in late 1990 as part of the Department of Energy`s (DOE) Clean Coal Technology Program. However, many filter failures 1649 were reported prior to its desired life time. In Tidd APF vessel, 28 filters failed one time, The objectives of this program were to provide an understanding of the factors pertinent to the failures of ceramic filters by characterizing filter properties and the dust cake removal mechanism, Researches were emphasized on understanding of changes of filter properties and back pulse cleaning mechanism to resolve the issues relating to filter permeability variations, ash bridging and micro-thermal cracks induced during cold back pulse cleaning. To perform failure analysis of ceramic filters, thermal numerical simulation, material laboratory analysis on filter materials and dust cake, and measurements on filter properties and back pulse intensity along filter axis within a bench scale filter chamber were conducted.

  17. Modes of deformation and failure of Kevlar 49 fibers and composites

    SciTech Connect

    Pruneda, C.O.; Morgan, R.J.; Kong, F.M.; Hodson, J.A.; Kershaw, R.P.; Casey, A.W.

    1983-12-05

    Fracture-topography and stress-optical-microscopy are utilized to study the deformation and failure modes of Kevlar 49 fibers and their epoxy composites. Fracture topographies of bare yarns, composite strands, and pressure vessels reveal Kevlar 49 fibers fail in tension by axially splitting 20 to 50 times their diameter D (20 to 50D) along their lengths. This type of fiber failure involves shear-induced microvoid growth throughout the fiber which occurs principally along the fiber axis, followed by macroscopic crack propagation through such microscopic crack propagation through such microvoids. Fiber splitting in the fracture of single filaments is < 5D because of the absence of external shear stresses. The topographies observed in fractured single filaments are described in terms of longitudinal and transverse fiber crack propagation paths in the fiber skin and core. Hydrolytically-degraded Kevlar 49 fibers exhibit lower fiber split lengths in composites. There is a correlation between the percentage of fibers that exhibit transverse failure without splitting and the composite strength. Stress-optical-microscopy studies of the deformation and failure processes of simple composite laminates are reported as a function of laminate geometry, temperature, and fiber surface treatment.

  18. Mechanical failure modes of chronically implanted planar silicon-based neural probes for laminar recording.

    PubMed

    Kozai, Takashi D Y; Catt, Kasey; Li, Xia; Gugel, Zhannetta V; Olafsson, Valur T; Vazquez, Alberto L; Cui, X Tracy

    2015-01-01

    Penetrating intracortical electrode arrays that record brain activity longitudinally are powerful tools for basic neuroscience research and emerging clinical applications. However, regardless of the technology used, signals recorded by these electrodes degrade over time. The failure mechanisms of these electrodes are understood to be a complex combination of the biological reactive tissue response and material failure of the device over time. While mechanical mismatch between the brain tissue and implanted neural electrodes have been studied as a source of chronic inflammation and performance degradation, the electrode failure caused by mechanical mismatch between different material properties and different structural components within a device have remained poorly characterized. Using Finite Element Model (FEM) we simulate the mechanical strain on a planar silicon electrode. The results presented here demonstrate that mechanical mismatch between iridium and silicon leads to concentrated strain along the border of the two materials. This strain is further focused on small protrusions such as the electrical traces in planar silicon electrodes. These findings are confirmed with chronic in vivo data (133-189 days) in mice by correlating a combination of single-unit electrophysiology, evoked multi-unit recordings, electrochemical impedance spectroscopy, and scanning electron microscopy from traces and electrode sites with our modeling data. Several modes of mechanical failure of chronically implanted planar silicon electrodes are found that result in degradation and/or loss of recording. These findings highlight the importance of strains and material properties of various subcomponents within an electrode array. Copyright © 2014 Elsevier Ltd. All rights reserved.

  19. Mechanical failure modes of chronically implanted planar silicon-based neural probes for laminar recording

    PubMed Central

    Kozai, Takashi D. Y.; Catt, Kasey; Li, Xia; Gugel, Zhannetta V.; Olafsson, Valur T.; Vazquez, Alberto L.; Cui, X. Tracy

    2014-01-01

    Penetrating intracortical electrode arrays that record brain activity longitudinally are powerful tools for basic neuroscience research and emerging clinical applications. However, regardless of the technology used, signals recorded by these electrodes degrade over time. The failure mechanisms of these electrodes are understood to be a complex combination of the biological reactive tissue response and material failure of the device over time. While mechanical mismatch between the brain tissue and implanted neural electrodes have been studied as a source of chronic inflammation and performance degradation, the electrode failure caused by mechanical mismatch between different material properties and different structural components within a device have remained poorly characterized. Using Finite Element Model (FEM) we simulate the mechanical strain on a planar silicon electrode. The results presented here demonstrate that mechanical mismatch between iridium and silicon leads to concentrated strain along the border of the two materials. This strain is further focused on small protrusions such as the electrical traces in planar silicon electrodes. These findings are confirmed with chronic in vivo data (133–189 days) in mice by correlating a combination of single-unit electrophysiology, evoked multi-unit recordings, electrochemical impedance spectroscopy, and scanning electron microscopy from traces and electrode sites with our modeling data. Several modes of mechanical failure of chronically implanted planar silicon electrodes are found that result in degradation and/or loss of recording. These findings highlight the importance of strains and material properties of various subcomponents within an electrode array. PMID:25453935

  20. Failure Mode of the Water-filled Fractures under Hydraulic Pressure in Karst Tunnels

    NASA Astrophysics Data System (ADS)

    Dong, Xin; Lu, Hao; Huang, Houxu; Hao, Yiqing; Xia, Yuanpu

    2017-06-01

    Water-filled fractures continue to grow after the excavation of karst tunnels, and the hydraulic pressure in these fractures changes along with such growth. This paper simplifies the fractures in the surrounding rock as flat ellipses and then identifies the critical hydraulic pressure values required for the occurrence of tensile-shear and compression-shear failures in water-filled fractures in the case of plane stress. The occurrence of tensile-shear fracture requires a larger critical hydraulic pressure than compression-shear failure in the same fracture. This paper examines the effects of fracture strike and lateral pressure coefficient on critical hydraulic pressure, and identifies compression-shear failure as the main failure mode of water-filled fractures. This paper also analyses the hydraulic pressure distribution in fractures with different extensions, and reveals that hydraulic pressure decreases along with the continuous growth of fractures and cannot completely fill a newly formed fracture with water. Fracture growth may be interrupted under the effect of hydraulic tensile shear.

  1. Reliability and mode of failure of bonded monolithic and multilayer ceramics.

    PubMed

    Alessandretti, Rodrigo; Borba, Marcia; Benetti, Paula; Corazza, Pedro Henrique; Ribeiro, Raissa; Della Bona, Alvaro

    2017-02-01

    To evaluate the reliability of monolithic and multilayer ceramic structures used in the CAD-on technique (Ivoclar), and the mode of failure produced in ceramic structures bonded to a dentin analog material (NEMA-G10). Ceramic specimens were fabricated as follows (n=30): CAD-on- trilayer structure (IPS e.max ZirCAD/IPS e.max Crystall./Connect/IPS e.max CAD); YLD- bilayer structure (IPS e.max ZirCAD/IPS e.max Ceram); LDC- monolithic structure (IPS e.max CAD); and YZW- monolithic structure (Zenostar Zr Translucent). All ceramic specimens were bonded to G10 and subjected to compressive load in 37°C distilled water until the sound of the first crack, monitored acoustically. Failure load (Lf) values were recorded (N) and statistically analyzed using Weibull distribution, Kruskal-Wallis test, and Student-Newman-Keuls test (α=0.05). Lf values of CAD-on and YZW structures were statistically similar (p=0.917), but higher than YLD and LDC (p<0.01). Weibull modulus (m) values were statistically similar for all experimental groups. Monolithic structures (LDC and YZW) failed from radial cracks. Failures in the CAD-on and YLD groups showed, predominantly, both radial and cone cracks. Monolithic zirconia (YZW) and CAD-on structures showed similar failure resistance and reliability, but a different fracture behavior. Copyright © 2016 The Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

  2. FEAT - FAILURE ENVIRONMENT ANALYSIS TOOL (UNIX VERSION)

    NASA Technical Reports Server (NTRS)

    Pack, G.

    1994-01-01

    The Failure Environment Analysis Tool, FEAT, enables people to see and better understand the effects of failures in a system. FEAT uses digraph models to determine what will happen to a system if a set of failure events occurs and to identify the possible causes of a selected set of failures. Failures can be user-selected from either engineering schematic or digraph model graphics, and the effects or potential causes of the failures will be color highlighted on the same schematic or model graphic. As a design tool, FEAT helps design reviewers understand exactly what redundancies have been built into a system and where weaknesses need to be protected or designed out. A properly developed digraph will reflect how a system functionally degrades as failures accumulate. FEAT is also useful in operations, where it can help identify causes of failures after they occur. Finally, FEAT is valuable both in conceptual development and as a training aid, since digraphs can identify weaknesses in scenarios as well as hardware. Digraphs models for use with FEAT are generally built with the Digraph Editor, a Macintosh-based application which is distributed with FEAT. The Digraph Editor was developed specifically with the needs of FEAT users in mind and offers several time-saving features. It includes an icon toolbox of components required in a digraph model and a menu of functions for manipulating these components. It also offers FEAT users a convenient way to attach a formatted textual description to each digraph node. FEAT needs these node descriptions in order to recognize nodes and propagate failures within the digraph. FEAT users store their node descriptions in modelling tables using any word processing or spreadsheet package capable of saving data to an ASCII text file. From within the Digraph Editor they can then interactively attach a properly formatted textual description to each node in a digraph. Once descriptions are attached to them, a selected set of nodes can be

  3. FEAT - FAILURE ENVIRONMENT ANALYSIS TOOL (UNIX VERSION)

    NASA Technical Reports Server (NTRS)

    Pack, G.

    1994-01-01

    The Failure Environment Analysis Tool, FEAT, enables people to see and better understand the effects of failures in a system. FEAT uses digraph models to determine what will happen to a system if a set of failure events occurs and to identify the possible causes of a selected set of failures. Failures can be user-selected from either engineering schematic or digraph model graphics, and the effects or potential causes of the failures will be color highlighted on the same schematic or model graphic. As a design tool, FEAT helps design reviewers understand exactly what redundancies have been built into a system and where weaknesses need to be protected or designed out. A properly developed digraph will reflect how a system functionally degrades as failures accumulate. FEAT is also useful in operations, where it can help identify causes of failures after they occur. Finally, FEAT is valuable both in conceptual development and as a training aid, since digraphs can identify weaknesses in scenarios as well as hardware. Digraphs models for use with FEAT are generally built with the Digraph Editor, a Macintosh-based application which is distributed with FEAT. The Digraph Editor was developed specifically with the needs of FEAT users in mind and offers several time-saving features. It includes an icon toolbox of components required in a digraph model and a menu of functions for manipulating these components. It also offers FEAT users a convenient way to attach a formatted textual description to each digraph node. FEAT needs these node descriptions in order to recognize nodes and propagate failures within the digraph. FEAT users store their node descriptions in modelling tables using any word processing or spreadsheet package capable of saving data to an ASCII text file. From within the Digraph Editor they can then interactively attach a properly formatted textual description to each node in a digraph. Once descriptions are attached to them, a selected set of nodes can be

  4. Failure mechanics of fiber composite notched charpy specimens. [stress analysis

    NASA Technical Reports Server (NTRS)

    Chamis, C. C.

    1976-01-01

    A finite element stress analysis was performed to determine the stress variation in the vicinity of the notch and far field of fiber composites Charpy specimens (ASTM Standard). NASTRAN was used for the finite element analysis assuming linear behavior and equivalent static load. The unidirectional composites investigated ranged from Thornel 75 Epoxy to S-Glass/Epoxy with the fiber direction parallel to the long dimension of the specimen. The results indicate a biaxial stress state exists in (1) the notch vicinity which is dominated by transverse tensile and interlaminar shear and (2) near the load application point which is dominated by transverse compression and interlaminar shear. The results also lead to the postulation of hypotheses for the predominant failure modes, the fracture initiation, and the fracture process. Finally, the results indicate that the notched Charpy test specimen is not suitable for assessing the impact resistance of nonmetallic fiber composites directly.

  5. Influence of surface finishing on fracture load and failure mode of glass ceramic crowns.

    PubMed

    Mores, Rafael Tagliari; Borba, Márcia; Corazza, Pedro Henrique; Della Bona, Álvaro; Benetti, Paula

    2017-03-23

    Ceramic restorations often require adjustments using diamond rotary instruments, which damage the glazed surface. The effect of these adjustments on the fracture behavior of these restorations is unclear. The purpose of this in vitro study was to evaluate the influence of induced surface defects on the fracture load and mode of failure of lithium disilicate-based (LDS) glass ceramic restorations. Premolar crowns were obtained from LDS computer-aided design and computer-aided manufacturing blocks (n=60) and glazed. The crowns were bonded to dentin analog dies and divided into 5 groups (n=12), as follows: glaze; abrasion (diamond rotary instrument 2135); abrasion and reglaze; abrasion and polishing (diamond rotary instrument 2135F, 2135 FF, and polishing devices); and polishing. The topography of the crowns was examined by scanning electron microscopy, and roughness was measured. A compressive load (0.5 mm/min) was applied by a piston to the center of the lingual cusp until fracture. The fracture load was recorded and data were statistically analyzed by ANOVA and the Tukey HSD test (α=.05). Fractured crowns were examined to determine the fracture origin. Polishing and/or reglazing resulted in lower roughness than for the abraded group (P<.05), which did not affect the fracture loads (P=.696). Catastrophic fracture with origin at the intaglio surface was the mode of failure for all the crowns. The experiment design successfully submitted the crowns to a clinical stress state, resulting in a clinically relevant failure. Reglazing or polishing were effective in reducing surface defects. Surface treatments had no effect on the immediate catastrophic failure of LDS crowns. Copyright © 2017 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.

  6. Capacities and failure modes of suction bucket foundation with internal bulkheads

    NASA Astrophysics Data System (ADS)

    Xiao, Zhong; Ge, Borui; Wang, Yan

    2017-08-01

    Suction bucket foundations can be divided into four compartments by cruciform internal bulkheads, thereby yielding better capacity in certain conditions than those without internal bulkheads. As yet, no systematic study has been conducted regarding the effects of cruciform internal bulkheads on the capacities of suction bucket foundations. In this study, we established a large number of finite element models of suction bucket foundations with and without cruciform internal bulkheads and of solid embedded circular foundations. We found the uniaxial capacities and failure modes of suction bucket foundations with various depth ratios to remain basically unaffected by internal bulkheads in uniform clays. However, in inhomogeneous clay with high strength heterogeneity, we observed the uniaxial moment and horizontal capacities and corresponding failure modes of suction bucket foundations with a low depth ratio to be obviously affected by internal bulkheads. In this case, the uniaxial moment capacities, in particular, as well as the horizontal capacities of suction bucket foundations with cruciform internal bulkheads become obviously greater than those without internal bulkheads. Under combined loading, we found the failure envelopes of suction bucket foundations with and without cruciform internal bulkheads and of solid circular foundation to also be basically consistent in uniform clays. However, in inhomogeneous clay with high strength heterogeneity, cruciform internal bulkheads can obviously change the shapes of the failure envelopes of bucket foundations with a small depth ratio. We conclude that when the acting vertical load or foundation depth is relatively small, suction bucket foundations with cruciform internal bulkheads can be subjected to larger moment and horizontal loads in soft clays with high strength heterogeneity.

  7. Predicting the occurrence of mixed mode failure associated with hydraulic fracturing, part 2 water saturated tests

    SciTech Connect

    Bauer, Stephen J.; Broome, Scott Thomas; Choens, Charles; Barrow, Perry Carl

    2015-09-14

    Seven water-saturated triaxial extension experiments were conducted on four sedimentary rocks. This experimental condition was hypothesized more representative of that existing for downhole hydrofracture and thus it may improve our understanding of the phenomena. In all tests the pore pressure was 10 MPa and confirming pressure was adjusted to achieve tensile and transitional failure mode conditions. Using previous work in this LDRD for comparison, the law of effective stress is demonstrated in extension using this sample geometry. In three of the four lithologies, no apparent chemo-mechanical effect of water is apparent, and in the fourth lithology test results indicate some chemo-mechanical effect of water.

  8. Common-Cause Failure Analysis in Event Assessment

    SciTech Connect

    D. M. Rasmuson; D. L. Kelly

    2008-06-01

    This paper reviews the basic concepts of modelling common-cause failures (CCFs) in reliability and risk studies and then applies these concepts to the treatment of CCF in event assessment. The cases of a failed component (with and without shared CCF potential) and a component being unavailable due to preventive maintenance or testing are addressed. The treatment of two related failure modes (e.g. failure to start and failure to run) is a new feature of this paper, as is the treatment of asymmetry within a common-cause component group.

  9. PAFAC- PLASTIC AND FAILURE ANALYSIS OF COMPOSITES

    NASA Technical Reports Server (NTRS)

    Bigelow, C. A.

    1994-01-01

    The increasing number of applications of fiber-reinforced composites in industry demands a detailed understanding of their material properties and behavior. A three-dimensional finite-element computer program called PAFAC (Plastic and Failure Analysis of Composites) has been developed for the elastic-plastic analysis of fiber-reinforced composite materials and structures. The evaluation of stresses and deformations at edges, cut-outs, and joints is essential in understanding the strength and failure for metal-matrix composites since the onset of plastic yielding starts very early in the loading process as compared to the composite's ultimate strength. Such comprehensive analysis can only be achieved by a finite-element program like PAFAC. PAFAC is particularly suited for the analysis of laminated metal-matrix composites. It can model the elastic-plastic behavior of the matrix phase while the fibers remain elastic. Since the PAFAC program uses a three-dimensional element, the program can also model the individual layers of the laminate to account for thickness effects. In PAFAC, the composite is modeled as a continuum reinforced by cylindrical fibers of vanishingly small diameter which occupy a finite volume fraction of the composite. In this way, the essential axial constraint of the phases is retained. Furthermore, the local stress and strain fields are uniform. The PAFAC finite-element solution is obtained using the displacement method. Solution of the nonlinear equilibrium equations is obtained with a Newton-Raphson iteration technique. The elastic-plastic behavior of composites consisting of aligned, continuous elastic filaments and an elastic-plastic matrix is described in terms of the constituent properties, their volume fractions, and mutual constraints between phases indicated by the geometry of the microstructure. The program uses an iterative procedure to determine the overall response of the laminate, then from the overall response determines the stress

  10. PAFAC- PLASTIC AND FAILURE ANALYSIS OF COMPOSITES

    NASA Technical Reports Server (NTRS)

    Bigelow, C. A.

    1994-01-01

    The increasing number of applications of fiber-reinforced composites in industry demands a detailed understanding of their material properties and behavior. A three-dimensional finite-element computer program called PAFAC (Plastic and Failure Analysis of Composites) has been developed for the elastic-plastic analysis of fiber-reinforced composite materials and structures. The evaluation of stresses and deformations at edges, cut-outs, and joints is essential in understanding the strength and failure for metal-matrix composites since the onset of plastic yielding starts very early in the loading process as compared to the composite's ultimate strength. Such comprehensive analysis can only be achieved by a finite-element program like PAFAC. PAFAC is particularly suited for the analysis of laminated metal-matrix composites. It can model the elastic-plastic behavior of the matrix phase while the fibers remain elastic. Since the PAFAC program uses a three-dimensional element, the program can also model the individual layers of the laminate to account for thickness effects. In PAFAC, the composite is modeled as a continuum reinforced by cylindrical fibers of vanishingly small diameter which occupy a finite volume fraction of the composite. In this way, the essential axial constraint of the phases is retained. Furthermore, the local stress and strain fields are uniform. The PAFAC finite-element solution is obtained using the displacement method. Solution of the nonlinear equilibrium equations is obtained with a Newton-Raphson iteration technique. The elastic-plastic behavior of composites consisting of aligned, continuous elastic filaments and an elastic-plastic matrix is described in terms of the constituent properties, their volume fractions, and mutual constraints between phases indicated by the geometry of the microstructure. The program uses an iterative procedure to determine the overall response of the laminate, then from the overall response determines the stress

  11. Failure analysis of laminated composites by using iterative three-dimensional finite element method

    NASA Astrophysics Data System (ADS)

    Hwang, W. C.; Sun, C. T.

    1989-05-01

    A failure analysis of laminated composites is accomplished by using an iterative three-dimensional finite element method. Based on Tsai-Wu failure theory, three different modes of failure are proposed: fiber breakage, matrix cracking, and delamination. The first ply failure load is then evaluated. As the applied load exceeds the first ply failure load, localized structural failure occurs and the global structural stiffness should change. The global stiffness matrix is modified by taking nonlinearity due to partial failures within a laminate into consideration. The first ply failure load is analyzed by using a iterative mixed field method in solving the linear part of the finite element equations. The progressive failure problem is solved numerically by using Newton-Raphson iterative schemes for the solution of nonlinear finite element equations. Numerical examples include angle-ply symmetric Thornel 300 graphite/934 resin epoxy laminates under uniaxial tension. First ply failure loads as well as the final failure loads are evaluated. Good correlation between analytical results and experimental data are observed. Numerical results also include the investigation of composite specimens with a centered hole, under uniaxial tension. Excellent correlation with the experimental data is observed.

  12. 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

  13. Effect of post-space treatments on the push-out bond strength and failure modes of glass fibre posts.

    PubMed

    Arisu, Hacer Deniz; Kivanç, Bağdagül Helvacioğlu; Sağlam, Baran C; Şimşek, Eser; Görgül, Güliz

    2013-04-01

    The aim of this study was to evaluate the effect of different post-space treatments on the push-out bond strength and failure modes of glass fibre posts. Forty mandibular premolar roots were cut and endodontically treated. Post spaces were prepared and roots were divided into four groups. In group 1 distilled water irrigation (control), in group 2 2.25% NaOCl irrigation, in group 3 2.25% NaOCl + 17% EDTA irrigation were done and in group 4 diode laser was applied to the prepared post spaces. Scanning electron microscope (SEM) analysis was made for each group. Fibre posts were then luted with resin cement. Each root was prepared for push-out test. Data were statistically analysed with anova (P = 0.05). After push-out test, the failure modes were observed but not statistically analysed. There were statistically significant differences between Group 3 and Group 2 in both regions (P < 0.05), also in the middle region of Group 4 and Group 2 (P < 0.05). Cervical root segments showed higher bond strengths than middle ones in all groups (P < 0.05). The highest bond strength values were obtained from NaOCl/EDTA and the lowest bond strength values were obtained from NaOCl for both regions. © 2010 The Authors. Australian Endodontic Journal © 2010 Australian Society of Endodontology.

  14. Statistical analysis of failure data on controllers and SSME turbine blade failures

    NASA Technical Reports Server (NTRS)

    Patil, S. A.

    1986-01-01

    The expressions for the maximum likelihood functions are given when the failure data are censored at a given point or at multiple points, or when the data come in groups. Different models applicable to failure data are presented with their characteristics. A graphical method of distinguishing different models by using cumulative hazard fucnction is discussed. For the failure data on controllers the model is determined by cumulative hazard function and chi-square goodness of fit. Using the Weibull Model the maximum likelihood estimators of the shape parameter and the failure rate parameter are obtained. The confidence intervals, meantime between failures, and B1 are determined. Similarly, for the data on Space Shuttle Main Engine (SSME) blade failures the maximum likelihood estimators are obtained for the Weibull parameters. The variances, confidence intervals, meantime between failures, and reliability are determined. The analysis is performed under assumption of grouped data as well as randomly placed data.

  15. Dynamic Response and Dynamic Failure Mode of a Weak Intercalated Rock Slope Using a Shaking Table

    NASA Astrophysics Data System (ADS)

    Fan, Gang; Zhang, Jianjing; Wu, Jinbiao; Yan, Kongming

    2016-08-01

    A large-scale shaking table test was performed to study the dynamic response of slopes parallel to geological bedding (bedding slopes) and slopes that cross-cut geological bedding (counter-bedding slopes). The test results show that the acceleration amplification coefficients increase with increasing elevation and, when the input earthquake amplitude is greater than 0.3 g, both bedding and counter-bedding slopes begin to show nonlinear dynamic response characteristics. With increasing elevation, the displacement of the bedding slope surface increases greatly. Conversely, the displacement of the counter-bedding slope surface increases first and then decreases; the slope develops a bulge at the relative elevation of 0.85. The displacement of the bedding slope surface is greater than that of the counter-bedding slope. The counter-bedding slope is more seismically stable compared with the bedding slope. Based on the Hilbert-Huang transform and marginal spectrum theories, the processes that develop dynamic damage of the bedding and counter-bedding slopes are identified. It is shown that the dynamic failure mode of the bedding slope is mainly represented by vertical tensile cracks at the rear of the slope, bedding slide of the strata along the weak intercalation, and rock collapse from the slope crest. However, the dynamic failure mode of the counter-bedding slope is mainly represented by staggered horizontal and vertical fissures, extrusion of the weak intercalation, and breakage at the slope crest.

  16. Rapid repair techniques for severely earthquake-damaged circular bridge piers with flexural failure mode

    NASA Astrophysics Data System (ADS)

    Sun, Zhiguo; Li, Hongnan; Bi, Kaiming; Si, Bingjun; Wang, Dongsheng

    2017-04-01

    In this study, three rapid repair techniques are proposed to retrofit circular bridge piers that are severely damaged by the flexural failure mode in major earthquakes. The quasi-static tests on three 1:2.5 scaled circular pier specimens are conducted to evaluate the efficiency of the proposed repair techniques. For the purpose of rapid repair, the repair procedure for all the specimens is conducted within four days, and the behavior of the repaired specimens is evaluated and compared with the original ones. A finite element model is developed to predict the cyclic behavior of the repaired specimens and the numerical results are compared with the test data. It is found that all the repaired specimens exhibit similar or larger lateral strength and deformation capacity than the original ones. The initial lateral stiffness of all the repaired specimens is lower than that of the original ones, while they show a higher lateral stiffness at the later stage of the test. No noticeable difference is observed for the energy dissipation capacity between the original and repaired pier specimens. It is suggested that the repair technique using the early-strength concrete jacket confined by carbon fiber reinforced polymer (CFRP) sheets can be an optimal method for the rapid repair of severely earthquake-damaged circular bridge piers with flexural failure mode.

  17. Failure modes and fracture origins of porcelain veneers on bilayer dental crowns.

    PubMed

    Liu, Yihong; Liu, Guanghua; Wang, Yong; Shen, James Zhijian; Feng, Hailan

    2014-01-01

    The aims of this study were to determine the fracture origins and crack paths in the porcelain of clinically failed bilayer ceramic restorations and to reveal the correlation between the porcelain failures and material properties. Three clinically failed crowns of each material (bilayer zirconia crowns, galvano-ceramic crowns, and porcelain-fused-to-metal crowns) were collected and underwent failure analysis. The fractures found in porcelain veneers showed several characteristics including wear, Hertzian cone crack, chipping off, and delamination. The results indicated that the fracture origins and features of the porcelain in bilayer ceramic restorations might be affected by the rigidity of core materials and thickness of copings.

  18. Factors influencing survival and mode of death in severe chronic ischaemic cardiac failure.

    PubMed Central

    Glover, D R; Littler, W A

    1987-01-01

    An evaluation of factors which may influence survival and mode of death was conducted over a three year period in a consecutive series of 50 patients with severe chronic ischaemic cardiac failure for more than three months. At the initial assessment all patients were already receiving intensive medical treatment. During follow up four patients successfully underwent cardiac surgery and medical treatment was modified in most patients, with four patients receiving antiarrhythmic drugs. Twenty six patients died: 17 suddenly within one hour of onset of symptoms and nine of progressive cardiac failure. The mortality by one year was 26% and by two years it was 62%. Comparison of those who survived with those who died within one year of follow up showed that a very low left ventricular ejection fraction, severe ventricular arrhythmias, the presence of gallop rhythm, and New York Heart Association class IV were the variables that predicted mortality. By two years left ventricular ejection fraction, ventricular arrhythmias, and pulmonary capillary wedge pressure were the variables that were significantly different in survivors and patients who died. No differences were found in any of the recorded variables between those who died suddenly and those who did not. Thus in patients with chronic ischaemic cardiac failure determination of the left ventricular ejection fraction and the severity of ventricular arrhythmia on the ambulatory electrocardiogram are the best ways to predict prognosis. The presence of gallop rhythm and New York Heart Association class IV status predict early death. PMID:3814447

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

    SciTech Connect

    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 learning 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.

  20. SU-E-T-179: Clinical Impact of IMRT Failure Modes at Or Near TG-142 Tolerance Criteria Levels

    SciTech Connect

    Faught, J Tonigan; Balter, P; Johnson, J; Kry, S; Court, L; Stingo, F; Followill, D

    2015-06-15

    Purpose: Quantitatively assess the clinical impact of 11 critical IMRT dose delivery failure modes. Methods: Eleven step-and-shoot IMRT failure modes (FMs) were introduced into twelve Pinnacle v9.8 treatment plans. One standard and one highly modulated plan on the IROC IMRT phantom and ten previous H&N patient treatment plans were used. FMs included physics components covered by basic QA near tolerance criteria levels (TG-142) such as beam energy, MLC positioning, and MLC modeling. Resultant DVHs were compared to those of failure-free plans and the severity of plan degradation was assessed considering PTV coverage and OAR and normal tissue tolerances and used for FMEA severity scoring. Six of these FMs were physically simulated and phantom irradiations performed. TLD and radiochromic film results are used for comparison to treatment planning studies. Results: Based on treatment planning studies, the largest clinical impact from the phantom cases was induced by 2 mm systematic MLC shift in one bank with the combination of a D95% target under dose near 16% and OAR overdose near 8%. Cord overdoses of 5%–11% occurred with gantry angle, collimator angle, couch angle, MLC leaf end modeling, and MLC transmission and leakage modeling FMs. PTV coverage and/or OAR sparing was compromised in all FMs introduced in phantom plans with the exception of CT number to electron density tables, MU linearity, and MLC tongue-and-groove modeling. Physical measurements did not entirely agree with treatment planning results. For example, symmetry errors resulted in the largest physically measured discrepancies of up to 3% in the PTVs while a maximum of 0.5% deviation was seen in the treatment planning studies. Patient treatment plan study results are under analysis. Conclusion: Even in the simplistic anatomy of the IROC phantom, some basic physics FMs, just outside of TG-142 tolerance criteria, appear to have the potential for large clinical implications.

  1. 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

  2. SDO Delta H Mode Design and Analysis

    NASA Technical Reports Server (NTRS)

    Mason, Paul A.; Starin, Scott R.

    2007-01-01

    While on orbit, disturbance torques on a three axis stabilized spacecraft tend to increase the system momentum, which is stored in the reaction wheels. Upon reaching the predefined momentum capacity (or maximum wheel speed) of the reaction wheel, an external torque must be used to unload the momentum. The purpose of the Delta H mode is to manage the system momentum. This is accomplished by driving the reaction wheels to a target momentum state while the attitude thrusters, which provide an external torque, are used to maintain the attitude. The Delta H mode is designed to meet the mission requirements and implement the momentum management plan. Changes in the requirements or the momentum management plan can lead to design changes in the mode. The momentum management plan defines the expected momentum buildup trend, the desired momentum state and how often the system is driven to the desired momentum state (unloaded). The desired momentum state is chosen based on wheel capacity, wheel configuration, thruster layout and thruster sizing. For the Solar Dynamics Observatory mission, the predefined wheel momentum capacity is a function of the jitter requirements, power, and maximum momentum capacity. Changes in jitter requirements or power limits can lead to changes in the desired momentum state. These changes propagate into the changes in the momentum management plan and therefore the Delta H mode design. This paper presents the analysis and design performed for the Solar Dynamics Observatory Delta H mode. In particular, the mode logic and processing needed to meet requirements is described along with the momentum distribution formulation. The Delta H mode design is validated using the Solar Dynamics Observatory High Fidelity simulator. Finally, a summary of the design is provided along with concluding remarks.

  3. An assessment of BWR (boiling water reactor) Mark-II containment challenges, failure modes, and potential improvements in performance

    SciTech Connect

    Kelly, D.L.; Jones, K.R.; Dallman, R.J. ); Wagner, K.C. )

    1990-07-01

    This report assesses challenges to BWR Mark II containment integrity that could potentially arise from severe accidents. Also assessed are some potential improvements that could prevent core damage or containment failure, or could mitigate the consequences of such failure by reducing the release of fission products to the environment. These challenges and improvements are analyzed via a limited quantitative risk/benefit analysis of a generic BWR/4 reactor with Mark II containment. Point estimate frequencies of the dominant core damage sequences are obtained and simple containment event trees are constructed to evaluate the response of the containment to these severe accident sequences. The resulting containment release modes are then binned into source term release categories, which provide inputs to the consequence analysis. The output of the consequences analysis is used to construct an overall base case risk profile. Potential improvements and sensitivities are evaluated by modifying the event tree spilt fractions, thus generating a revised risk profile. Several important sensitivity cases are examined to evaluate the impact of phenomenological uncertainties on the final results. 75 refs., 25 figs., 65 tabs.

  4. Evaluation of shear bond strength of porcelain bonded to laser welded titanium surface and determination of mode of bond failure.

    PubMed

    Patil, Narendra P; Dandekar, Minal; Nadiger, Ramesh K; Guttal, Satyabodh S

    2010-09-01

    The aim of this study was to evaluate the shear bond strength of porcelain to laser welded titanium surface and to determine the mode of bond failure through scanning electron microscopy (SEM) and energy dispersive spectrophotometry (EDS). Forty five cast rectangular titanium specimens with the dimension of 10 mm x 8 mm x 1 mm were tested. Thirty specimens had a perforation of 2 mm diameter in the centre. These were randomly divided into Group A and B. The perforations in the Group B specimens were repaired by laser welding using Cp Grade II titanium wire. The remaining 15 specimens were taken as control group. All the test specimens were layered with low fusing porcelain and tested for shear bond strength. The debonded specimens were subjected to SEM and EDS. Data were analysed with 1-way analysis of variance and Student's t-test for comparison among the different groups. One-way analysis of variance (ANOVA) showed no statistically significant difference in shear bond strength values at a 5% level of confidence. The mean shear bond strength values for control group, Group A and B was 8.4 +/- 0.5 Mpa, 8.1 +/- 0.4 Mpa and 8.3 +/- 0.3 Mpa respectively. SEM/EDS analysis of the specimens showed mixed and cohesive type of bond failure. Within the limitations of the study laser welding did not have any effect on the shear bond strength of porcelain bonded to titanium.

  5. Mechanical behavior and localized failure modes in a porous basalt from the Azores

    NASA Astrophysics Data System (ADS)

    Loaiza, S.; Fortin, J.; Schubnel, A.; Guéguen, Y.; Moreira, M.; Vinciguerra, S.

    2012-04-01

    Basaltic rocks are the main component of the oceanic upper crust. This is of potential interest for water and geothermal resources, or for storage of CO2. The aim of our work is to investigate experimentally the mechanical behavior and the failure modes of porous basalt as well as the permeability evolution during deformation. Cylindrical basalt samples, from the Azores, of 30 mm in diameter and 60 mm in length were deformed the triaxial cell of the Laboratoire de Geologie at the Ecole Normale Supérieure (Paris) at room temperature and at a constant axial strain rate of 10-5 s-1. The initial porosity of the sample was 18%. The Geodesign triaxial cell can reach 300MPa confining pressure; axial load is performed through a piston and can reach 900 MPa (for a 30mm diameter sample); maximum pore pressure is 100MPa (applied using two precision volumetric pumps). In our study, a set of experiments were performed at confining pressure in the range of 25-290 MPa. The samples were deformed under saturated conditions at a constant pore pressure of 5MPa. Two volumetric pumps kept the pore pressure constant, and the pore volume variations were recorded. The evolution of the porosity was calculated from the total volume variation inside the volumetric pumps. Permeability measurements were performed using the steady-state technique. Our result shows that two modes of deformation can be highlighted in this basalt. At low confining pressure (Pc < 50 MPa), the differential stress attains a peak before the sample undergoes strain softening; the failure of sample occurs by shear localization. Yet, the brittle regime is commonly observed in this low Pc range, the experiments performed at confining pressure higher than 50 MPa, show a totally different mode of deformation. In this second mode of deformation, an appreciable inelastic porosity reduction is observed. Comparing to the hydrostatic loading, the rock sample started to compact beyond a critical stress state; and from then

  6. Reliability measurement for mixed mode failures of 33/11 kilovolt electric power distribution stations.

    PubMed

    Alwan, Faris M; Baharum, Adam; Hassan, Geehan S

    2013-01-01

    The reliability of the electrical distribution system is a contemporary research field due to diverse applications of electricity in everyday life and diverse industries. However a few research papers exist in literature. This paper proposes a methodology for assessing the reliability of 33/11 Kilovolt high-power stations based on average time between failures. The objective of this paper is to find the optimal fit for the failure data via time between failures. We determine the parameter estimation for all components of the station. We also estimate the reliability value of each component and the reliability value of the system as a whole. The best fitting distribution for the time between failures is a three parameter Dagum distribution with a scale parameter [Formula: see text] and shape parameters [Formula: see text] and [Formula: see text]. Our analysis reveals that the reliability value decreased by 38.2% in each 30 days. We believe that the current paper is the first to address this issue and its analysis. Thus, the results obtained in this research reflect its originality. We also suggest the practicality of using these results for power systems for both the maintenance of power systems models and preventive maintenance models.

  7. Reliability Measurement for Mixed Mode Failures of 33/11 Kilovolt Electric Power Distribution Stations

    PubMed Central

    Alwan, Faris M.; Baharum, Adam; Hassan, Geehan S.

    2013-01-01

    The reliability of the electrical distribution system is a contemporary research field due to diverse applications of electricity in everyday life and diverse industries. However a few research papers exist in literature. This paper proposes a methodology for assessing the reliability of 33/11 Kilovolt high-power stations based on average time between failures. The objective of this paper is to find the optimal fit for the failure data via time between failures. We determine the parameter estimation for all components of the station. We also estimate the reliability value of each component and the reliability value of the system as a whole. The best fitting distribution for the time between failures is a three parameter Dagum distribution with a scale parameter and shape parameters and . Our analysis reveals that the reliability value decreased by 38.2% in each 30 days. We believe that the current paper is the first to address this issue and its analysis. Thus, the results obtained in this research reflect its originality. We also suggest the practicality of using these results for power systems for both the maintenance of power systems models and preventive maintenance models. PMID:23936346

  8. The effects of ethylene oxide and gas-plasma sterilization on failure strength and failure mode of pre-tied monofilament ligature loops.

    PubMed

    Trostle, Steven S; Hendrickson, Dean A; Franke, Chad

    2002-01-01

    To evaluate the effects of ethylene oxide and gas-plasma sterilization on the failure strength and failure mode of pre-tied monofilament ligature loops. A randomized block design was used by blocking for suture (size 1 polyglyconate, size 2 polydioxanone) and sterilization technique (control, ethylene oxide, gas plasma). Twenty replicates of each suture-sterilization technique combination. Ligature loops were pre-tied using a 4S-modified Roeder knot then exposed to 1 of 3 treatments (control, ethylene oxide, or gas-plasma sterilization). Ligature loops were mounted onto a mechanical testing machine to evaluate the effects of sterilization on failure strength and failure mode (disruption, untying). There were no differences between polydioxanone and polyglyconate suture materials in failure strength or mode within sterilization methods. Both sterilization methods significantly increased the likelihood that suture loops would untie compared with controls subjects. Ligature loops that disrupted had a greater breaking strength than those that untied, regardless of sterilization method or suture type. Sterilization with either ethylene oxide or gas plasma of pre-tied, polyglyconate, or polydioxanone ligature loops significantly increases the in vitro likelihood of a modified Roeder knot untying. Further studies need to be conducted to determine the in vivo requirements for ligature loops. Copyright 2002 by The American College of Veterinary Surgeons

  9. 14 CFR 417.224 - Probability of failure analysis.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Probability of failure analysis. 417.224..., DEPARTMENT OF TRANSPORTATION LICENSING LAUNCH SAFETY Flight Safety Analysis § 417.224 Probability of failure analysis. (a) General. All flight safety analyses for a launch, regardless of hazard or phase of...

  10. Extensive risk analysis of mechanical failure for an epiphyseal hip prothesis: a combined numerical-experimental approach.

    PubMed

    Martelli, S; Taddei, F; Cristofolini, L; Gill, H S; Viceconti, M

    2011-02-01

    There has been recent renewed interest in proximal femur epiphyseal replacement as an alternative to conventional total hip replacement. In many branches of engineering, risk analysis has proved to be an efficient tool for avoiding premature failures of innovative devices. An extensive risk analysis procedure has been developed for epiphyseal hip prostheses and the predictions of this method have been compared to the known clinical outcomes of a well-established contemporary design, namely hip resurfacing devices. Clinical scenarios leading to revision (i.e. loosening, neck fracture and failure of the prosthetic component) were associated with potential failure modes (i.e. overload, fatigue, wear, fibrotic tissue differentiation and bone remodelling). Driving parameters of the corresponding failure mode were identified together with their safe thresholds. For each failure mode, a failure criterion was identified and studied under the most relevant physiological loading conditions. All failure modes were investigated with the most suitable investigation tool, either numerical or experimental. Results showed a low risk for each failure scenario either in the immediate postoperative period or in the long term. These findings are in agreement with those reported by the majority of clinical studies for correctly implanted devices. Although further work is needed to confirm the predictions of this method, it was concluded that the proposed risk analysis procedure has the potential to increase the efficacy of preclinical validation protocols for new epiphyseal replacement devices.

  11. Dilatancy, compaction, and failure mode in andesite: the transition from brittle faulting to shear-enhanced compaction in volcanic edifices

    NASA Astrophysics Data System (ADS)

    Heap, M. J.; Lavallee, Y.; David, E. C.; Petrakova, L.; Baud, P.; Dingwell, D. B.; Reuschle, T.

    2011-12-01

    Andesite is an extrusive volcanic rock of intermediate composition (i.e., SiO2 varies between 52-63%). Andesitic volcanoes, typical of convergent plate margin settings, represent about 25% of volcanoes worldwide. However, our understanding of the physical and mechanical properties of andesites, important for volcanic hazard mitigation, remains sparse. We have therefore embarked on a systematic study on the mechanical properties of a suite of andesites collected from Volcán de Colima, one of the most active volcanoes on the Trans-Mexican volcanic belt, Mexico. Our andesite samples (ranging from 8 to 18% porosity) had high initial crack densities (as inferred from both a newly-devised sliding crack model and from more traditional stereological techniques), corroborated by low ultrasonic wave velocities (P-wave velocities were about 2.5 km/s for all samples). Bulk geochemical analysis showed that all samples were compositionally identical. Compressive strength experiments, performed at room temperature and under a constant strain rate of 10-5 s-1, were performed under a range of effective confining pressures (representative of those within a volcanic edifice). When rock is exposed to an applied differential stress, it can react in two different ways. The void space (a combination of cracks and pores) within the rock can either demonstrate net dilatation or net compaction. The resultant behaviour of the rock is governed by the competition between micromechanical processes, namely dilatational microcracking versus grain crushing and pore collapse. The potency of these competing processes is dependent on both the initial physical properties of the rock, such as porosity and grain size, and the conditions under which the rock deforms. In our experiments, all of the andesites displayed dilatancy and/or dilatant modes of failure, either axial splitting (restricted to the uniaxial experiments) or shear faulting at low effective confining pressures. Under uniaxial conditions

  12. 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.

  13. 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.

  14. 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.

  15. 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.

  16. 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.

  17. 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.

  18. 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.

  19. Physicochemical characterization and failure analysis of military coating systems

    NASA Astrophysics Data System (ADS)

    Keene, Lionel Thomas

    Modern military coating systems, as fielded by all branches of the U.S. military, generally consist of a diverse array of organic and inorganic components that can complicate their physicochemical analysis. These coating systems consist of VOC-solvent/waterborne automotive grade polyurethane matrix containing a variety of inorganic pigments and flattening agents. The research presented here was designed to overcome the practical difficulties regarding the study of such systems through the combined application of several cross-disciplinary techniques, including vibrational spectroscopy, electron microscopy, microtomy, ultra-fast laser ablation and optical interferometry. The goal of this research has been to determine the degree and spatial progression of weathering-induced alteration of military coating systems as a whole, as well as to determine the failure modes involved, and characterizing the impact of these failures on the physical barrier performance of the coatings. Transmission-mode Fourier Transform Infrared (FTIR) spectroscopy has been applied to cross-sections of both baseline and artificially weathered samples to elucidate weathering-induced spatial gradients to the baseline chemistry of the coatings. A large discrepancy in physical durability (as indicated by the spatial progression of these gradients) has been found between older and newer generation coatings. Data will be shown implicating silica fillers (previously considered inert) as the probable cause for this behavioral divergence. A case study is presented wherein the application of the aforementioned FTIR technique fails to predict the durability of the coating system as a whole. The exploitation of the ultra-fast optical phenomenon of femtosecond (10-15S) laser ablation is studied as a potential tool to facilitate spectroscopic depth profiling of composite materials. Finally, the interferometric technique of Phase Shifting was evaluated as a potential high-sensitivity technique applied to the

  20. Comparison of Failure Modes in 2-D and 3-D Woven Carbon Phenolic Systems

    NASA Technical Reports Server (NTRS)

    Rossman, Grant A.; Stackpoole, Mairead; Feldman, Jay; Venkatapathy, Ethiraj; Braun, Robert D.

    2013-01-01

    NASA Ames Research Center is developing Woven Thermal Protection System (WTPS) materials as a new class of heatshields for entry vehicles (Stackpoole). Currently, there are few options for ablative entry heatshield materials, none of which is ideally suited to the planetary probe missions currently of interest to NASA. While carbon phenolic was successfully used for the missions Pioneer Venus and Galileo (to Jupiter), the heritage constituents are no longer available. An alternate carbon phenolic would need to be qualified for probe missions, which is most efficient at heat fluxes greater than those currently of interest. Additional TPS materials such as Avcoat and PICA are not sufficiently robust for the heat fluxes required. As a result, there is a large TPS gap between the materials efficient at very high conditions (carbon phenolic) and those that are effective at low-moderate conditions (all others). Development of 3D Woven TPS is intended to fill this gap, targeting mid-density weaves that could with withstand mid-range heat fluxes between 1100 W/sq cm and 8000 W/sq cm (Venkatapathy (2012). Preliminary experimental studies have been performed to show the feasibility of WTPS as a future mid-range TPS material. One study performed in the mARC Jet Facility at NASA Ames Research Center characterized the performance of a 3D Woven TPS sample and compared it to 2D carbon phenolic samples at ply angles of 0deg, 23.5deg, and 90deg. Each sample contained similar compositions of phenolic and carbon fiber volume fractions for experimental consistency. The goal of this study was to compare the performance of the TPS materials by evaluating resulting recession and failure modes. After exposing both samples to similar heat flux and pressure conditions, the 2D carbon phenolic laminate was shown to experience significant delamination between layers and further pocketing underneath separated layers. The 3D Woven TPS sample did not experience the delamination or pocketing