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.

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

NASA Technical Reports Server (NTRS)

Church, Curtis K.

1990-01-01

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

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

PubMed Central

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

2013-01-01

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

Failure Mode, Effects, and Criticality Analysis (FMECA)

DTIC Science & Technology

1993-04-01

Preliminary Failure Modes, Effects and Criticality Analysis (FMECA) of the Brayton Isotope Power System Ground Demonstration System, Report No. TID 27301...No. TID/SNA - 3015, Aeroject Nuclear Systems Co., Sacramento, California: 1970. 95. Taylor , J.R. A Formalization of Failure Mode Analysis of Control...Roskilde, Denmark: 1973. 96. Taylor , J.R. A Semi-Automatic Method for Oualitative Failure Mode Analysis. Report No. RISO-M-1707. Available from a

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.

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.

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

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

Schubert, L; Westerly, D; Vinogradskiy, Y

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

[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.

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.

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

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

Xu, Y; Bhatnagar, J; Bednarz, G

2015-06-15

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

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

PubMed Central

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

2017-01-01

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

Failure Mode and Effects Analysis (FMEA) Introductory Overview

DTIC Science & Technology

2012-06-14

Failure Mode and Effects Analysis ( FMEA ) Introductory Overview TARDEC Systems Engineering Risk Management Team POC: Kadry Rizk or Gregor Ratajczak...2. REPORT TYPE Briefing Charts 3. DATES COVERED 01-05-2012 to 23-05-2012 4. TITLE AND SUBTITLE Failure Mode and Effects Analysis ( FMEA ) 5a...18 WELCOME Welcome to “An introductory overview of Failure Mode and Effects Analysis ( FMEA )”, A brief concerning the use and benefits of FMEA

High-throughput sequencing: a failure mode analysis.

PubMed

Yang, George S; Stott, Jeffery M; Smailus, Duane; Barber, Sarah A; Balasundaram, Miruna; Marra, Marco A; Holt, Robert A

2005-01-04

Basic manufacturing principles are becoming increasingly important in high-throughput sequencing facilities where there is a constant drive to increase quality, increase efficiency, and decrease operating costs. While high-throughput centres report failure rates typically on the order of 10%, the causes of sporadic sequencing failures are seldom analyzed in detail and have not, in the past, been formally reported. Here we report the results of a failure mode analysis of our production sequencing facility based on detailed evaluation of 9,216 ESTs generated from two cDNA libraries. Two categories of failures are described; process-related failures (failures due to equipment or sample handling) and template-related failures (failures that are revealed by close inspection of electropherograms and are likely due to properties of the template DNA sequence itself). Preventative action based on a detailed understanding of failure modes is likely to improve the performance of other production sequencing pipelines.

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.

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.

Failure modes and effects analysis for ocular brachytherapy.

PubMed

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

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

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

PubMed

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

2014-10-01

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

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

PubMed

Chen, Ying-Chu; Tsai, Pei-Yi

2017-06-01

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

Failure 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

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

PubMed

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

2008-07-01

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

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

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.

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.

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

Mechanics of dual-mode dilative failure in subaqueous sediment deposits

NASA Astrophysics Data System (ADS)

You, Yao; Flemings, Peter; Mohrig, David

2014-07-01

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

On a common critical state in localized and diffuse failure modes

NASA Astrophysics Data System (ADS)

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

2016-10-01

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

Prediction of mode of death in heart failure: the Seattle Heart Failure Model.

PubMed

Mozaffarian, Dariush; Anker, Stefan D; Anand, Inder; Linker, David T; Sullivan, Mark D; Cleland, John G F; Carson, Peter E; Maggioni, Aldo P; Mann, Douglas L; Pitt, Bertram; Poole-Wilson, Philip A; Levy, Wayne C

2007-07-24

Prognosis and mode of death in heart failure patients are highly variable in that some patients die suddenly (often from ventricular arrhythmia) and others die of progressive failure of cardiac function (pump failure). Prediction of mode of death may facilitate decisions about specific medications or devices. We used the Seattle Heart Failure Model (SHFM), a validated prediction model for total mortality in heart failure, to assess the mode of death in 10,538 ambulatory patients with New York Heart Association class II to IV heart failure and predominantly systolic dysfunction enrolled in 6 randomized trials or registries. During 16,735 person-years of follow-up, 2014 deaths occurred, which included 1014 sudden deaths and 684 pump-failure deaths. Compared with a SHFM score of 0, patients with a score of 1 had a 50% higher risk of sudden death, patients with a score of 2 had a nearly 3-fold higher risk, and patients with a score of 3 or 4 had a nearly 7-fold higher risk (P<0.001 for all comparisons; 1-year area under the receiver operating curve, 0.68). Stratification of risk of pump-failure death was even more pronounced, with a 4-fold higher risk with a score of 1, a 15-fold higher risk with a score of 2, a 38-fold higher risk with a score of 3, and an 88-fold higher risk with a score of 4 (P<0.001 for all comparisons; 1-year area under the receiver operating curve, 0.85). The proportion of deaths caused by sudden death versus pump-failure death decreased from a ratio of 7:1 with a SHFM score of 0 to a ratio of 1:2 with a SHFM score of 4 (P trend <0.001). The SHFM score provides information about the likely mode of death among ambulatory heart failure patients. Investigation is warranted to determine whether such information might predict responses to or cost-effectiveness of specific medications or devices in heart failure patients.

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

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

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.

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

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

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

2015-06-15

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

Microstructure-failure mode correlations in braided composites

NASA Technical Reports Server (NTRS)

Filatovs, G. J.; Sadler, Robert L.; El-Shiekh, Aly

1992-01-01

Explication of the fracture processes of braided composites is needed for modeling their behavior. Described is a systematic exploration of the relationship between microstructure, loading mode, and micro-failure mechanisms in carbon/epoxy braided composites. The study involved compression and fracture toughness tests and optical and scanning electron fractography, including dynamic in-situ testing. Principal failure mechanisms of low sliding, buckling, and unstable crack growth are correlated to microstructural parameters and loading modes; these are used for defining those microstructural conditions which are strength limiting.

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

PubMed Central

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

2015-01-01

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

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

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

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

Hoisak, J; Manger, R; Dragojevic, I

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

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

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

Howe, J

2015-06-15

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

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

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

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

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

PV Degradation Curves: Non-Linearities and Failure Modes

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

Jordan, Dirk C.; Silverman, Timothy J.; Sekulic, Bill

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,more » 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.« less

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.

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

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

Xie, J; Xiao, Y; Wang, J

2014-06-15

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

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

PubMed

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

2013-12-01

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

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

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

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

2015-04-01

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

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.

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

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

Huq, M.

2015-06-15

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

Optoelectronic Devices with Complex Failure Modes

NASA Technical Reports Server (NTRS)

Johnston, A.

2000-01-01

This part of the NSREC-2000 Short Course discusses radiation effects in basic photonic devices along with effects in more complex optoelectronic devices where the overall radiation response depends on several factors, with the possibility of multiple failure modes.

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

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

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

2012-02-01

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

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.

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

PubMed

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

2018-04-01

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

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

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.

Experimental methods for identifying failure mechanisms

NASA Technical Reports Server (NTRS)

Daniel, I. M.

1983-01-01

Experimental methods for identifying failure mechanisms in fibrous composites are studied. Methods to identify failure in composite materials includes interferometry, holography, fractography and ultrasonics.

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.

An efficient scan diagnosis methodology according to scan failure mode for yield enhancement

NASA Astrophysics Data System (ADS)

Kim, Jung-Tae; Seo, Nam-Sik; Oh, Ghil-Geun; Kim, Dae-Gue; Lee, Kyu-Taek; Choi, Chi-Young; Kim, InSoo; Min, Hyoung Bok

2008-12-01

Yield has always been a driving consideration during fabrication of modern semiconductor industry. Statistically, the largest portion of wafer yield loss is defective scan failure. This paper presents efficient failure analysis methods for initial yield ramp up and ongoing product with scan diagnosis. Result of our analysis shows that more than 60% of the scan failure dies fall into the category of shift mode in the very deep submicron (VDSM) devices. However, localization of scan shift mode failure is very difficult in comparison to capture mode failure because it is caused by the malfunction of scan chain. Addressing the biggest challenge, we propose the most suitable analysis method according to scan failure mode (capture / shift) for yield enhancement. In the event of capture failure mode, this paper describes the method that integrates scan diagnosis flow and backside probing technology to obtain more accurate candidates. We also describe several unique techniques, such as bulk back-grinding solution, efficient backside probing and signal analysis method. Lastly, we introduce blocked chain analysis algorithm for efficient analysis of shift failure mode. In this paper, we contribute to enhancement of the yield as a result of the combination of two methods. We confirm the failure candidates with physical failure analysis (PFA) method. The direct feedback of the defective visualization is useful to mass-produce devices in a shorter time. The experimental data on mass products show that our method produces average reduction by 13.7% in defective SCAN & SRAM-BIST failure rates and by 18.2% in wafer yield rates.

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.

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

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

PubMed

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

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

UAV Swarm Behavior Modeling for Early Exposure of Failure Modes

DTIC Science & Technology

2016-09-01

Systems Center Atlantic, for his patience with me through this two-year process. He worked with my schedule and was very understanding of the...emergence of new failure modes? The MP modeling environment provides a breakdown of all potential event traces. Given that the research questions call...for the revelation of potential failure modes, MP was selected as the modeling environment because it provides a substantial set of results and data

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/

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

PubMed

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

2018-02-01

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

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.

Sounds of Failure: Passive Acoustic Measurements of Excited Vibrational Modes

NASA Astrophysics Data System (ADS)

Brzinski, Theodore A.; Daniels, Karen E.

2018-05-01

Granular materials can fail through spontaneous events like earthquakes or brittle fracture. However, measurements and analytic models which forecast failure in this class of materials, while of both fundamental and practical interest, remain elusive. Materials including numerical packings of spheres, colloidal glasses, and granular materials have been known to develop an excess of low-frequency vibrational modes as the confining pressure is reduced. Here, we report experiments on sheared granular materials in which we monitor the evolving density of excited modes via passive monitoring of acoustic emissions. We observe a broadening of the distribution of excited modes coincident with both bulk and local plasticity, and evolution in the shape of the distribution before and after bulk failure. These results provide a new interpretation of the changing state of the material on its approach to stick-slip failure.

Sounds of Failure: Passive Acoustic Measurements of Excited Vibrational Modes.

PubMed

Brzinski, Theodore A; Daniels, Karen E

2018-05-25

Granular materials can fail through spontaneous events like earthquakes or brittle fracture. However, measurements and analytic models which forecast failure in this class of materials, while of both fundamental and practical interest, remain elusive. Materials including numerical packings of spheres, colloidal glasses, and granular materials have been known to develop an excess of low-frequency vibrational modes as the confining pressure is reduced. Here, we report experiments on sheared granular materials in which we monitor the evolving density of excited modes via passive monitoring of acoustic emissions. We observe a broadening of the distribution of excited modes coincident with both bulk and local plasticity, and evolution in the shape of the distribution before and after bulk failure. These results provide a new interpretation of the changing state of the material on its approach to stick-slip failure.

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

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

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.

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.

WE-H-BRC-01: Failure Mode and Effects Analysis of Skin Electronic Brachytherapy Using Esteya Unit

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

Ibanez-Rosello, B; Bautista-Ballesteros, J; Bonaque, J

Purpose: A failure mode and effect analysis (FMEA) of skin lesions treatment process using Esteya™ device (Elekta Brachyterapy, Veenendaal, The Netherlands) was performed, with the aim of increasing the quality of the treatment and reducing the likelihood of unwanted events. Methods: A multidisciplinary team with experience in the treatment process met to establish the process map, which outlines the flow of various stages for such patients undergoing skin treatment. Potential failure modes (FM) were identified and the value of severity (S), frequency of occurrence (O), and lack of detectability (D) of the proposed FM were scored individually, each on amore » scale of 1 to 10 following TG-100 guidelines of the AAPM. These failure modes were ranked according to our risk priority number (RPN) and S scores. The efficiency of existing quality management tools was analyzed through a reassessment of the O and D made by consensus. Results: 149 FM were identified, 43 of which had RPN ≥ 100 and 30 had S ≥ 7. After introduction of the tools of quality management, only 3 FM had RPN ≥ 100 and 22 FM had RPN ≥ 50. These 22 FM were thoroughly analyzed and new tools for quality management were proposed. The most common cause of highest RPN FM was associated with the heavy patient workload and the continuous and accurate applicator-patient skin contact during the treatment. To overcome this second item, a regular quality control and setup review by a second individual before each treatment session was proposed. Conclusion: FMEA revealed some of the FM potentials that were not predicted during the initial implementation of the quality management tools. This exercise was useful in identifying the need of periodic update of the FMEA process as new potential failures can be identified.« less

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.

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.

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.

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

PubMed Central

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

2013-01-01

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

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.

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

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

PubMed

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

2004-01-01

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

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

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

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

NASA Astrophysics Data System (ADS)

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

2017-12-01

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

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.

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

PubMed

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

2016-01-01

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

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

Photovoltaic failure and degradation modes

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

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

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

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

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.

Weighted Fuzzy Risk Priority Number Evaluation of Turbine and Compressor Blades Considering Failure Mode Correlations

NASA Astrophysics Data System (ADS)

Gan, Luping; Li, Yan-Feng; Zhu, Shun-Peng; Yang, Yuan-Jian; Huang, Hong-Zhong

2014-06-01

Failure mode, effects and criticality analysis (FMECA) and Fault tree analysis (FTA) are powerful tools to evaluate reliability of systems. Although single failure mode issue can be efficiently addressed by traditional FMECA, multiple failure modes and component correlations in complex systems cannot be effectively evaluated. In addition, correlated variables and parameters are often assumed to be precisely known in quantitative analysis. In fact, due to the lack of information, epistemic uncertainty commonly exists in engineering design. To solve these problems, the advantages of FMECA, FTA, fuzzy theory, and Copula theory are integrated into a unified hybrid method called fuzzy probability weighted geometric mean (FPWGM) risk priority number (RPN) method. The epistemic uncertainty of risk variables and parameters are characterized by fuzzy number to obtain fuzzy weighted geometric mean (FWGM) RPN for single failure mode. Multiple failure modes are connected using minimum cut sets (MCS), and Boolean logic is used to combine fuzzy risk priority number (FRPN) of each MCS. Moreover, Copula theory is applied to analyze the correlation of multiple failure modes in order to derive the failure probabilities of each MCS. Compared to the case where dependency among multiple failure modes is not considered, the Copula modeling approach eliminates the error of reliability analysis. Furthermore, for purpose of quantitative analysis, probabilities importance weight from failure probabilities are assigned to FWGM RPN to reassess the risk priority, which generalize the definition of probability weight and FRPN, resulting in a more accurate estimation than that of the traditional models. Finally, a basic fatigue analysis case drawn from turbine and compressor blades in aeroengine is used to demonstrate the effectiveness and robustness of the presented method. The result provides some important insights on fatigue reliability analysis and risk priority assessment of structural

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

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

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

2012-06-25

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

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

NASA Technical Reports Server (NTRS)

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

2011-01-01

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

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.

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).

Statistical analysis of lithium iron sulfide status cell cycle life and failure mode

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

Gay, E.C.; Battles, J.E.; Miller, W.E.

1983-08-01

A statistical model was developed for life cycle testing of electrochemical cell life cycle trials and verified experimentally. The Weibull distribution was selected to predict the end of life for a cell, based on a 20 percent loss of initial stabilized capacity or a decrease to less than 95 percent coulombic efficiency. Groups of 12 or more Li-alloy/FeS cells were cycled to determine the mean time to failure (MTTF) and also to identify the failure modes. The cells were all full size electric vehicle batteries with 150-350 A-hr capacity. The Weibull shape factors were determined and verified in prediction ofmore » the number of cell failures in two 10 cell modules. The short circuit failure in the cells with BN-felt and MgO powder separators were found to be caused by the formation of Li-Al protrusions that penetrated the BN-felt separators, and the extrusion of active material at the edge of the electrodes.« less

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.

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

PubMed

Deng, Xinyang; Jiang, Wen

2017-09-12

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

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

PubMed Central

Deng, Xinyang

2017-01-01

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

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

Fracture Resistance and Mode of Failure of Ceramic versus Titanium Implant Abutments and Single Implant-Supported Restorations.

PubMed

Sghaireen, Mohd G

2015-06-01

The material of choice for implant-supported restorations is affected by esthetic requirements and type of abutment. This study compares the fracture resistance of different types of implant abutments and implant-supported restorations and their mode of failure. Forty-five Oraltronics Pitt-Easy implants (Oraltronics Dental Implant Technology GmbH, Bremen, Germany) (4 mm diameter, 10 mm length) were embedded in clear autopolymerizing acrylic resin. The implants were randomly divided into three groups, A, B and C, of 15 implants each. In group A, titanium abutments and metal-ceramic crowns were used. In group B, zirconia ceramic abutments and In-Ceram Alumina crowns were used. In group C, zirconia ceramic abutments and IPS Empress Esthetic crowns were used. Specimens were tested to failure by applying load at 130° from horizontal plane using an Instron Universal Testing Machine. Subsequently, the mode of failure of each specimen was identified. Fracture resistance was significantly different between groups (p < .05). The highest fracture loads were associated with metal-ceramic crowns supported by titanium abutments (p = .000). IPS Empress crowns supported by zirconia abutments had the lowest fracture loads (p = .000). Fracture modes of metal-ceramic crowns supported by titanium abutments included screw fracture and screw bending. Fracture of both crown and abutment was the dominant mode of failure of In-Ceram/IPS Empress crowns supported by zirconia abutments. Metal-ceramic crowns supported by titanium abutments were more resistant to fracture than In-Ceram crowns supported by zirconia abutments, which in turn were more resistant to fracture than IPS Empress crowns supported by zirconia abutments. In addition, failure modes of restorations supported by zirconia abutments were more catastrophic than those for restorations supported by titanium abutments. © 2013 Wiley Periodicals, Inc.

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.

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

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

Xie, J; Wang, J; P, J

2016-06-15

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

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.

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

NASA Astrophysics Data System (ADS)

Rucitra, A. L.

2018-03-01

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

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.

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

PubMed Central

Li, Xixi; He, Mei; Wang, Haiyan

2017-01-01

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

Relationship Between Unusual High-Temperature Fatigue Crack Growth Threshold Behavior in Superalloys and Sudden Failure Mode Transitions

NASA Technical Reports Server (NTRS)

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

2017-01-01

An investigation of high temperature cyclic fatigue crack growth (FCG) threshold behavior of two advanced nickel disk alloys was conducted. The focus of the study was the unusual crossover effect in the near-threshold region of these type of alloys where conditions which produce higher crack growth rates in the Paris regime, produce higher resistance to crack growth in the near threshold regime. It was shown that this crossover effect is associated with a sudden change in the fatigue failure mode from a predominant transgranular mode in the Paris regime to fully intergranular mode in the threshold fatigue crack growth region. This type of a sudden change in the fracture mechanisms has not been previously reported and is surprising considering that intergranular failure is typically associated with faster crack growth rates and not the slow FCG rates of the near-threshold regime. By characterizing this behavior as a function of test temperature, environment and cyclic frequency, it was determined that both the crossover effect and the onset of intergranular failure are caused by environmentally driven mechanisms which have not as yet been fully identified. A plausible explanation for the observed behavior is proposed.

Ageing and degradation determines failure mode on sea urchin spines.

PubMed

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

2017-09-01

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

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.

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

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.

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.

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

PubMed

Li, Xixi; He, Mei; Wang, Haiyan

2017-12-01

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

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.

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

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

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

Highlights: • This study is based on a real case in hospital in Taiwan. • We use Failure Mode and Effects Analysis (FMEA) as the evaluation method. • We successfully identify the evaluation factors of bio-medical waste disposal risk. - Abstract: Using the failure mode and effects analysis, this study examined biomedical waste companies through risk assessment. Moreover, it evaluated the supervisors of biomedical waste units in hospitals, and factors relating to the outsourcing risk assessment of biomedical waste in hospitals by referring to waste disposal acts. An expert questionnaire survey was conducted on the personnel involved in waste disposalmore » units in hospitals, in order to identify important factors relating to the outsourcing risk of biomedical waste in hospitals. This study calculated the risk priority number (RPN) and selected items with an RPN value higher than 80 for improvement. These items included “availability of freezing devices”, “availability of containers for sharp items”, “disposal frequency”, “disposal volume”, “disposal method”, “vehicles meeting the regulations”, and “declaration of three lists”. This study also aimed to identify important selection factors of biomedical waste disposal companies by hospitals in terms of risk. These findings can serve as references for hospitals in the selection of outsourcing companies for biomedical waste disposal.« less

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

PubMed

Giardina, M; Castiglia, F; Tomarchio, E

2014-12-01

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

Failure 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

[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.

Flexural strength and failure modes of layered ceramic structures.

PubMed

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

2011-12-01

To evaluate the effect of the specimen design on the flexural strength (σ(f)) and failure mode of ceramic structures, testing the hypothesis that the ceramic material under tension controls the mechanical performance of the structure. 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 1MPa/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. 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 σ(f). There was no statistical difference in the σ(f) value between IZ and IZ-FT and between AL and AL-FT. σ(f) 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. The mechanical performance of the specimens was determined by the material under tension during testing, confirming the study hypothesis. Copyright © 2011 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

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

NASA Astrophysics Data System (ADS)

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

2018-06-01

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

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

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.

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

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.

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.

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.

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.

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

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

Gray, J; Lukose, R; Bronson, 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 amore » 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

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

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.

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).

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

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

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.

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

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.

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

2017-11-01

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

Mechanics of Unidirectional Fiber-Reinforced Composites: Buckling Modes and Failure Under Compression Along Fibers

NASA Astrophysics Data System (ADS)

Paimushin, V. N.; Kholmogorov, S. A.; Gazizullin, R. K.

2018-01-01

One-dimensional linearized problems on the possible buckling modes of an internal or peripheral layer of unidirectional multilayer composites with rectilinear fibers under compression in the fiber direction are considered. The investigations are carried out using the known Kirchhoff-Love and Timoshenko models for the layers. The binder, modeled as an elastic foundation, is described by the equations of elasticity theory, which are simplified in accordance to the model of a transversely soft layer and are integrated along the transverse coordinate considering the kinematic coupling relations for a layer and foundation layers. Exact analytical solutions of the problems formulated are found, which are used to calculate a composite made of an HSE 180 REM prepreg based on a unidirectional carbon fiber tape. The possible buckling modes of its internal and peripheral layers are identified. Calculation results are compared with experimental data obtained earlier. It is concluded that, for the composite studied, the flexural buckling of layers in the uniform axial compression of specimens along fibers is impossible — the failure mechanism is delamination with buckling of a fiber bundle according to the pure shear mode. It is realized (due to the low average transverse shear modulus) at the value of the ultimate compression stress equal to the average shear modulus. It is shown that such a shear buckling mode can be identified only on the basis of equations constructed using the Timoshenko shear model to describe the deformation process of layers.

Biomarkers of myocardial stress and fibrosis as predictors of mode of death in patients with chronic heart failure.

PubMed

Ahmad, Tariq; Fiuzat, Mona; Neely, Benjamin; Neely, Megan L; Pencina, Michael J; Kraus, William E; Zannad, Faiez; Whellan, David J; Donahue, Mark P; Piña, Ileana L; Adams, Kirkwood F; Kitzman, Dalane W; O'Connor, Christopher M; Felker, G Michael

2014-06-01

The aim of this study was to determine whether biomarkers of myocardial stress and fibrosis improve prediction of the mode of death in patients with chronic heart failure. The 2 most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of the mode of death may facilitate treatment decisions. The relationship between amino-terminal pro-brain natriuretic peptide (NT-proBNP), galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown. HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) was a randomized controlled trial of exercise training versus usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox proportional hazards modeling, and interaction testing was used to measure differential associations between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP. After a median follow-up period of 2.5 years, there were 155 deaths: 49 from pump failure, 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk for both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death, but this relationship was attenuated after adjustment for clinical risk factors. Clinical

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

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

Lee C. Cadwallader

2010-06-01

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

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

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

Lee C. Cadwallader

2007-08-01

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

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

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

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

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

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

NASA Astrophysics Data System (ADS)

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

2015-02-01

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

Failure Modes in Capacitors When Tested Under a Time-Varying Stress

NASA Technical Reports Server (NTRS)

Liu, David (Donhang)

2011-01-01

Steady step surge testing (SSST) is widely applied to screen out potential power-on failures in solid tantalum capacitors. The test simulates the power supply's on and off characteristics. Power-on failure has been the prevalent failure mechanism for solid tantalum capacitors for decoupling applications. On the other hand, the SSST can also be reviewed as an electrically destructive test under a time-varying stress. It consists of rapidly charging the capacitor with incremental voltage increases, through a low resistance in series, until the capacitor under test is electrically shorted. Highly accelerated life testing (HALT) is usually a time-efficient method for determining the failure mechanism in capacitors; however, a destructive test under a time-varying stress like SSST is even more effective. It normally takes days to complete a HALT test, but it only takes minutes for a time-varying stress test to produce failures. The advantage of incorporating specific time-varying stress into a statistical model is significant in providing an alternative life test method for quickly revealing the failure modes in capacitors. In this paper, a time-varying stress has been incorporated into the Weibull model to characterize the failure modes. The SSST circuit and transient conditions to correctly test the capacitors is discussed. Finally, the SSST was applied for testing polymer aluminum capacitors (PA capacitors), Ta capacitors, and multi-layer ceramic capacitors with both precious metal electrode (PME) and base-metal-electrodes (BME). It appears that testing results are directly associated to the dielectric layer breakdown in PA and Ta capacitors and are independent on the capacitor values, the way the capacitors being built, and the manufactures. The testing results also reveal that ceramic capacitors exhibit breakdown voltages more than 20 times the rated voltage, and the breakdown voltages are inverse proportional to the dielectric layer thickness. The possibility of

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.

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.

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.

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.

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

PubMed

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

2017-06-01

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

Folded fabric tunes rock deformation and failure mode in the upper crust.

PubMed

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

2017-11-10

The micro-mechanisms of brittle failure affect the bulk mechanical behaviour and permeability of crustal rocks. In low-porosity crystalline rocks, these mechanisms are related to mineralogy and fabric anisotropy, while confining pressure, temperature and strain rates regulate the transition from brittle to ductile behaviour. However, the effects of folded anisotropic fabrics, widespread in orogenic settings, on the mechanical behaviour of crustal rocks are largely unknown. Here we explore the deformation and failure behaviour of a representative folded gneiss, by combining the results of triaxial deformation experiments carried out while monitoring microseismicity with microstructural and damage proxies analyses. We show that folded crystalline rocks in upper crustal conditions exhibit dramatic strength heterogeneity and contrasting failure modes at identical confining pressure and room temperature, depending on the geometrical relationships between stress and two different anisotropies associated to the folded rock fabric. These anisotropies modulate the competition among quartz- and mica-dominated microscopic damage processes, resulting in transitional brittle to semi-brittle modes under P and T much lower than expected. This has significant implications on scales relevant to seismicity, energy resources, engineering applications and geohazards.

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

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

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

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

[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.

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

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

NASA Astrophysics Data System (ADS)

Li, Hui; Ou, Jinping

2008-07-01

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.

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.

Some failure modes and analysis techniques for terrestrial solar cell modules

NASA Technical Reports Server (NTRS)

Shumka, A.; Stern, K. H.

1978-01-01

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

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.

Carbon Fiber Strand Tensile Failure Dynamic Event Characterization

NASA Technical Reports Server (NTRS)

Johnson, Kenneth L.; Reeder, James

2016-01-01

There are few if any clear, visual, and detailed images of carbon fiber strand failures under tension useful for determining mechanisms, sequences of events, different types of failure modes, etc. available to researchers. This makes discussion of physics of failure difficult. It was also desired to find out whether the test article-to-test rig interface (grip) played a part in some failures. These failures have nothing to do with stress rupture failure, thus representing a source of waste for the larger 13-00912 investigation into that specific failure type. Being able to identify or mitigate any competing failure modes would improve the value of the 13-00912 test data. The beginnings of the solution to these problems lay in obtaining images of strand failures useful for understanding physics of failure and the events leading up to failure. Necessary steps include identifying imaging techniques that result in useful data, using those techniques to home in on where in a strand and when in the sequence of events one should obtain imaging data.

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

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

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

2012-07-15

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

Failure mode prediction for composite structural insulated panels with MgO board facings

NASA Astrophysics Data System (ADS)

Smakosz, Łukasz; Kreja, Ireneusz

2018-01-01

Sandwich panels are readily used in civil engineering due to their high strength to weight ratio and the ease and speed of assembly. The idea of a sandwich section is to combine thin and durable facings with a light-weight core and the choice of materials used allows obtaining the desired behaviour. Panels in consideration consist of MgO (magnesium oxide) board facings and expanded polystyrene core and are characterized by immunity to biological corrosion, a high thermal insulation and a relatively low impact on environment. Customizing the range of panels to meet market needs requires frequent size changes, leading to different failure modes, which are identified in a series of costly full-scale laboratory tests. A nonlinear numerical model was created with a use of a commercial ABAQUS code and a user-defined procedure, which is able to reproduce observed failure mechanisms; its parameters were established on the basis of small-scale tests and numerical experiments. The model was validated by a comparison with the results of the full-scale bending and compression tests. The results obtained were in satisfactory agreement with the test data.

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

PubMed

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

2003-01-01

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

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

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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.

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.

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

Critical laboratory value notification: a failure mode effects and criticality analysis.

PubMed

Saxena, Sunita; Kempf, Raymond; Wilcox, Susan; Shulman, Ira A; Wong, Louise; Cunningham, Glenn; Vega, Elaine; Hall, Stephanie

2005-09-01

The Failure Mode Effects and Criticality Analysis (FMECA) was applied to improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver of critical laboratory values (CLVs) for outpatients and non-critical care inpatients. Through a risk prioritization process, the most important areas for improvement, including contacting the provider, assisting the provider in contacting the patient, and educating the provider in follow-up options available during off hours, were identified. A variety of systemic improvements were made; for example, the CLV notification process was centralized in the customer service center, with databases to help providers select options and make arrangements for follow-up care and an electronic abstract form to document the CLV notification process. Review of documentation and appropriateness of CLV follow-up care was integrated into the quality monitoring process to detect any variations or problems. The average CLV notification time for the month steadily declined during an eight-month period. Compliance was 100% for the "read-back" requirement and documentation in patient's health record. This proactive risk assessment project successfully modified the CLV notification program from a high- to a low-risk process, identified activities to further improve the process, and helped ensure compliance with a variety of requirements.

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

PubMed

Kolich, Mike

2014-07-01

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

A 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

Shear Fracture of Dual Phase AHSS in the Process of Stamping: Macroscopic Failure Mode and Micro-level Metallographical Observation

NASA Astrophysics Data System (ADS)

Wang, Wurong; Wei, Xicheng; Yang, Jun; Shi, Gang

2011-08-01

Due to its excellent strength and formability combinations, dual phase (DP) steels offer the potential to improve the vehicle crashworthiness performance without increasing car body weight and have been increasingly used into new vehicles. However, a new type of crack mode termed as shear fracture is accompanied with the application of these high strength DP steel sheets. With the cup drawing experiment to identify the limit drawing ratio (LDR) of three DP AHSS with strength level from 600 MPa to 1000 MPa, the study compared and categorized the macroscopic failure mode of these three types of materials. The metallographical observation along the direction of crack was conducted for the DP steels to discover the micro-level propagation mechanism of the fracture.

Identifying the binding mode of a molecular scaffold

NASA Astrophysics Data System (ADS)

Chema, Doron; Eren, Doron; Yayon, Avner; Goldblum, Amiram; Zaliani, Andrea

2004-01-01

We describe a method for docking of a scaffold-based series and present its advantages over docking of individual ligands, for determining the binding mode of a molecular scaffold in a binding site. The method has been applied to eight different scaffolds of protein kinase inhibitors (PKI). A single analog of each of these eight scaffolds was previously crystallized with different protein kinases. We have used FlexX to dock a set of molecules that share the same scaffold, rather than docking a single molecule. The main mode of binding is determined by the mode of binding of the largest cluster among the docked molecules that share a scaffold. Clustering is based on our `nearest single neighbor' method [J. Chem. Inf. Comput. Sci., 43 (2003) 208-217]. Additional criteria are applied in those cases in which more than one significant binding mode is found. Using the proposed method, most of the crystallographic binding modes of these scaffolds were reconstructed. Alternative modes, that have not been detected yet by experiments, could also be identified. The method was applied to predict the binding mode of an additional molecular scaffold that was not yet reported and the predicted binding mode has been found to be very similar to experimental results for a closely related scaffold. We suggest that this approach be used as a virtual screening tool for scaffold-based design processes.

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.

Comparative Evaluation of Fracture Resistance and Mode of Failure of Zirconia and Titanium Abutments with Different Diameters.

PubMed

Shabanpour, Reza; Mousavi, Niloufar; Ghodsi, Safoura; Alikhasi, Marzieh

2015-08-01

The purpose of the current study was to compare the fracture resistance and mode of failure of zirconia and titanium abutments with different diameters. Fourteen groups of abutments including prefabricated zirconia, copy-milled zirconia and titanium abutments of an implant system (XiVE, Dentsply) were prepared in different diameters. An increasing vertical load was applied to each specimen until failure occurred. Fracture resistance was measured in each group using the universal testing machine. Moreover, the failure modes were studied and categorized as abutment screw fracture, connection area fracture, abutment body fracture, abutment body distortion, screw distortion and connection area distortion. Groups were statistically compared using univariate and post-hoc tests. The level of statistical significance was set at 5%. Fabrication method (p = 0.03) and diameter (p < 0.001) had significant effect on the fracture resistance of abutments. Fracture resistance of abutments with 5.5 mm diameter was higher than other diameters (p < 0.001). The observed modes of failure were dependent on the abutment material as well. All of the prefabricated titanium abutments fractured within the abutment screw. Abutment screw distortion, connection area fracture, and abutment body fracture were the common failure type in other groups. Diameter had a significant effect on fracture resistance of implant abutments, as abutments with greater diameters were more resistant to static loads. Copy-milled abutments showed lower fracture resistance as compared to other experimental groups. Although zirconia abutments have received great popularity among clinicians and even patients selecting them for narrow implants should be with caution.

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

PubMed

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

2012-08-01

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

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.

Mode I Failure of Armor Ceramics: Experiments and Modeling

NASA Astrophysics Data System (ADS)

Meredith, Christopher; Leavy, Brian

2017-06-01

The pre-notched edge on impact (EOI) experiment is a technique for benchmarking the damage and fracture of ceramics subjected to projectile impact. A cylindrical projectile impacts the edge of a thin rectangular plate with a pre-notch on the opposite edge. Tension is generated at the notch tip resulting in the initiation and propagation of a mode I crack back toward the impact edge. The crack can be quantitatively measured using an optical method called Digital Gradient Sensing, which measures the crack-tip deformation by simultaneously quantifying two orthogonal surface slopes via measuring small deflections of light rays from a specularly reflective surface around the crack. The deflections in ceramics are small so the high speed camera needs to have a very high pixel count. This work reports on the results from pre-crack EOI experiments of SiC and B4 C plates. The experimental data are quantitatively compared to impact simulations using an advanced continuum damage model. The Kayenta ceramic model in Alegra will be used to compare fracture propagation speeds, bifurcations and inhomogeneous initiation of failure will be compared. This will provide insight into the driving mechanisms required for the macroscale failure modeling of ceramics.

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

Failure modes of vacuum plasma spray tungsten coating created on carbon fibre composites under thermal loads

NASA Astrophysics Data System (ADS)

Hirai, T.; Bekris, N.; Coad, J. P.; Grisolia, C.; Linke, J.; Maier, H.; Matthews, G. F.; Philipps, V.; Wessel, E.

2009-07-01

Vacuum plasma spray tungsten (VPS-W) coating created on a carbon fibre reinforced composite (CFC) was tested under two thermal load schemes in the electron beam facility to examine the operation limits and failure modes. In cyclic ELM-like short transient thermal loads, the VPS-W coating was destroyed sub-layer by sub-layer at 0.33 GW/m 2 for 1 ms pulse duration. At longer single pulses, simulating steady-state thermal loads, the coating was destroyed at surface temperatures above 2700 °C by melting of the rhenium containing multilayer at the interface between VPS-W and CFC. The operation limits and failure modes of the VPS-W coating in the thermal load schemes are discussed in detail.

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. Copyright © 2014 Elsevier Ltd. All rights reserved.

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.

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.

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

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

Spacecraft Parachute Recovery System Testing from a Failure Rate Perspective

NASA Technical Reports Server (NTRS)

Stewart, Christine E.

2013-01-01

Spacecraft parachute recovery systems, especially those with a parachute cluster, require testing to identify and reduce failures. This is especially important when the spacecraft in question is human-rated. Due to the recent effort to make spaceflight affordable, the importance of determining a minimum requirement for testing has increased. The number of tests required to achieve a mature design, with a relatively constant failure rate, can be estimated from a review of previous complex spacecraft recovery systems. Examination of the Apollo parachute testing and the Shuttle Solid Rocket Booster recovery chute system operation will clarify at which point in those programs the system reached maturity. This examination will also clarify the risks inherent in not performing a sufficient number of tests prior to operation with humans on-board. When looking at complex parachute systems used in spaceflight landing systems, a pattern begins to emerge regarding the need for a minimum amount of testing required to wring out the failure modes and reduce the failure rate of the parachute system to an acceptable level for human spaceflight. Not only a sufficient number of system level testing, but also the ability to update the design as failure modes are found is required to drive the failure rate of the system down to an acceptable level. In addition, sufficient data and images are necessary to identify incipient failure modes or to identify failure causes when a system failure occurs. In order to demonstrate the need for sufficient system level testing prior to an acceptable failure rate, the Apollo Earth Landing System (ELS) test program and the Shuttle Solid Rocket Booster Recovery System failure history will be examined, as well as some experiences in the Orion Capsule Parachute Assembly System will be noted.

True Triaxial Strength and Failure Modes of Cubic Rock Specimens with Unloading the Minor Principal Stress

NASA Astrophysics Data System (ADS)

Li, Xibing; Du, Kun; Li, Diyuan

2015-11-01

True triaxial tests have been carried out on granite, sandstone and cement mortar using cubic specimens with the process of unloading the minor principal stress. The strengths and failure modes of the three rock materials are studied in the processes of unloading σ 3 and loading σ 1 by the newly developed true triaxial test system under different σ 2, aiming to study the mechanical responses of the rock in underground excavation at depth. It shows that the rock strength increases with the raising of the intermediate principal stress σ 2 when σ 3 is unloaded to zero. The true triaxial strength criterion by the power-law relationship can be used to fit the testing data. The "best-fitting" material parameters A and n ( A > 1.4 and n < 1.0) are almost located in the same range as expected by Al-Ajmi and Zimmerman (Int J Rock Mech Min Sci 563 42(3):431-439, 2005). It indicates that the end effect caused by the height-to-width ratio of the cubic specimens will not significantly affect the testing results under true triaxial tests. Both the strength and failure modes of cubic rock specimens under true triaxial unloading condition are affected by the intermediate principal stress. When σ 2 increases to a critical value for the strong and hard rocks (R4, R5 and R6), the rock failure mode may change from shear to slabbing. However, for medium strong and weak rocks (R3 and R2), even with a relatively high intermediate principal stress, they tend to fail in shear after a large amount of plastic deformation. The maximum extension strain criterion Stacey (Int J Rock Mech Min Sci Geomech Abstr 651 18(6):469-474, 1981) can be used to explain the change of failure mode from shear to slabbing for strong and hard rocks under true triaxial unloading test condition.

Deformation modes in an Icelandic basalt: From brittle failure to localized deformation bands

NASA Astrophysics Data System (ADS)

Adelinet, M.; Fortin, J.; Schubnel, A.; Guéguen, Y.

2013-04-01

According to the stress state, deformation mode observed in rocks may be very different. Even in the brittle part of the crust a differential stress can induce shear failure but also localized compacting deformation, such as compaction bands in porous sedimentary rocks. The mode of deformation controls many hydrodynamic factors, such as permeability and porosity. We investigate in this paper two different modes of deformation in an Icelandic basalt by using laboratory seismological tools (elastic waves and acoustic emissions) and microstructural observations. First of all, we show that at low effective confining pressure (Peff = 5 MPa) an axial loading induces a shear failure in the basalt with an angle of about 30° with respect to the main stress direction. On the contrary, at high effective confining pressure (Peff ≥ 75 MPa and more) an increase of the axial stress induces a localization of the deformation in the form of subhorizontal bands again with respect to the main stress direction. In this second regime, focal mechanisms of the acoustic emissions reveal an important number of compression events suggesting pore collapse mechanisms. Microstructural observations confirm this assumption. Similar compaction structures are usually obtained for porous sedimentary rocks (20-25%). However, the investigated basalt has an initial total porosity of only about 10% so that compaction structures were not expected. The pore size and the ratio of pore to grain size are likely to be key factors for the particular observed mechanical behavior.

Identification and classification of failure modes in laminated composites by using a multivariate statistical analysis of wavelet coefficients

NASA Astrophysics Data System (ADS)

Baccar, D.; Söffker, D.

2017-11-01

Acoustic Emission (AE) is a suitable method to monitor the health of composite structures in real-time. However, AE-based failure mode identification and classification are still complex to apply due to the fact that AE waves are generally released simultaneously from all AE-emitting damage sources. Hence, the use of advanced signal processing techniques in combination with pattern recognition approaches is required. In this paper, AE signals generated from laminated carbon fiber reinforced polymer (CFRP) subjected to indentation test are examined and analyzed. A new pattern recognition approach involving a number of processing steps able to be implemented in real-time is developed. Unlike common classification approaches, here only CWT coefficients are extracted as relevant features. Firstly, Continuous Wavelet Transform (CWT) is applied to the AE signals. Furthermore, dimensionality reduction process using Principal Component Analysis (PCA) is carried out on the coefficient matrices. The PCA-based feature distribution is analyzed using Kernel Density Estimation (KDE) allowing the determination of a specific pattern for each fault-specific AE signal. Moreover, waveform and frequency content of AE signals are in depth examined and compared with fundamental assumptions reported in this field. A correlation between the identified patterns and failure modes is achieved. The introduced method improves the damage classification and can be used as a non-destructive evaluation tool.

Light water reactor lower head failure analysis

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

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

1993-10-01

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

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

Fracture resistance and primary failure mode of endodontically treated teeth restored with a carbon fiber-reinforced resin post system in vitro.

PubMed

Raygot, C G; Chai, J; Jameson, D L

2001-01-01

This study was undertaken to characterize the fracture resistance and mode of fracture of endodontically treated incisors restored with cast post-and-core, prefabricated stainless steel post, or carbon fiber-reinforced composite post systems. Ten endodontically treated teeth restored with each technique were subjected to a compressive load delivered at a 130-degree angle to the long axis until the first sign of failure was noted. The fracture load and the mode of fracture were recorded. The failure loads registered in the three groups were not significantly different. Between 70%, and 80% of teeth from any of the three groups displayed fractures that were located above the simulated bone level. The use of carbon fiber-reinforced composite posts did not change the fracture resistance or the failure mode of endodontically treated central incisors compared to the use of metallic posts.

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 (L f ) values were recorded (N) and statistically analyzed using Weibull distribution, Kruskal-Wallis test, and Student-Newman-Keuls test (α=0.05). L f 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.

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

Failure detection system risk reduction assessment

NASA Technical Reports Server (NTRS)

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

2012-01-01

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

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

Fatigue failure of metal components as a factor in civil aircraft accidents

NASA Technical Reports Server (NTRS)

Holshouser, W. L.; Mayner, R. D.

1972-01-01

A review of records maintained by the National Transportation Safety Board showed that 16,054 civil aviation accidents occurred in the United States during the 3-year period ending December 31, 1969. Material failure was an important factor in the cause of 942 of these accidents. Fatigue was identified as the mode of the material failures associated with the cause of 155 accidents and in many other accidents the records indicated that fatigue failures might have been involved. There were 27 fatal accidents and 157 fatalities in accidents in which fatigue failures of metal components were definitely identified. Fatigue failures associated with accidents occurred most frequently in landing-gear components, followed in order by powerplant, propeller, and structural components in fixed-wing aircraft and tail-rotor and main-rotor components in rotorcraft. In a study of 230 laboratory reports on failed components associated with the cause of accidents, fatigue was identified as the mode of failure in more than 60 percent of the failed components. The most frequently identified cause of fatigue, as well as most other types of material failures, was improper maintenance (including inadequate inspection). Fabrication defects, design deficiencies, defective material, and abnormal service damage also caused many fatigue failures. Four case histories of major accidents are included in the paper as illustrations of some of the factors invovled in fatigue failures of aircraft components.

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.

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.

Field failure mechanisms for photovoltaic modules

NASA Technical Reports Server (NTRS)

Dumas, L. N.; Shumka, A.

1981-01-01

Beginning in 1976, Department of Energy field centers have installed and monitored a number of field tests and application experiments using current state-of-the-art photovoltaic modules. On-site observations of module physical and electrical degradation, together with in-depth laboratory analysis of failed modules, permits an overall assessment of the nature and causes of early field failures. Data on failure rates are presented, and key failure mechanisms are analyzed with respect to origin, effect, and prospects for correction. It is concluded that all failure modes identified to date are avoidable or controllable through sound design and production practices.

Margins Associated with Loss of Assured Safety for Systems with Multiple Time-Dependent Failure Modes.

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

Helton, Jon C.; Brooks, Dusty Marie; Sallaberry, Cedric Jean-Marie.

Representations for margins associated with loss of assured safety (LOAS) for weak link (WL)/strong link (SL) systems involving multiple time-dependent failure modes are developed. The following topics are described: (i) defining properties for WLs and SLs, (ii) background on cumulative distribution functions (CDFs) for link failure time, link property value at link failure, and time at which LOAS occurs, (iii) CDFs for failure time margins defined by (time at which SL system fails) – (time at which WL system fails), (iv) CDFs for SL system property values at LOAS, (v) CDFs for WL/SL property value margins defined by (property valuemore » at which SL system fails) – (property value at which WL system fails), and (vi) CDFs for SL property value margins defined by (property value of failing SL at time of SL system failure) – (property value of this SL at time of WL system failure). Included in this presentation is a demonstration of a verification strategy based on defining and approximating the indicated margin results with (i) procedures based on formal integral representations and associated quadrature approximations and (ii) procedures based on algorithms for sampling-based approximations.« less

Failure modes in electroactive polymer thin films with elastic electrodes

NASA Astrophysics Data System (ADS)

De Tommasi, D.; Puglisi, G.; Zurlo, G.

2014-02-01

Based on an energy minimization approach, we analyse the elastic deformations of a thin electroactive polymer (EAP) film sandwiched by two elastic electrodes with non-negligible stiffness. We analytically show the existence of a critical value of the electrode voltage for which non-homogeneous solutions bifurcate from the homogeneous equilibrium state, leading to the pull-in phenomenon. This threshold strongly decreases the limit value proposed in the literature considering only homogeneous deformations. We explicitly discuss the influence of geometric and material parameters together with boundary conditions in the attainment of the different failure modes observed in EAP devices. In particular, we obtain the optimum values of these parameters leading to the maximum activation performances of the device.

[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.

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

2017-10-01

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.

Failure and Degradation Modes of PV modules in a Hot Dry Climate: Results after 4 and 12 years of field exposure

NASA Astrophysics Data System (ADS)

Mallineni, Jaya krishna

This study evaluates two photovoltaic (PV) power plants based on electrical performance measurements, diode checks, visual inspections and infrared scanning. The purpose of this study is to measure degradation rates of performance parameters (Pmax, Isc, Voc, Vmax, Imax and FF) and to identify the failure modes in a "hot-dry desert" climatic condition along with quantitative determination of safety failure rates and reliability failure rates. The data obtained from this study can be used by module manufacturers in determining the warranty limits of their modules and also by banks, investors, project developers and users in determining appropriate financing or decommissioning models. In addition, the data obtained in this study will be helpful in selecting appropriate accelerated stress tests which would replicate the field failures for the new modules and would predict the lifetime for new PV modules. The study was conducted at two, single axis tracking monocrystalline silicon (c-Si) power plants, Site 3 and Site 4c of Salt River Project (SRP). The Site 3 power plant is located in Glendale, Arizona and the Site 4c power plant is located in Mesa, Arizona both considered a "hot-dry" field condition. The Site 3 power plant has 2,352 modules (named as Model-G) which was rated at 250 kW DC output. The mean and median degradation of these 12 years old modules are 0.95%/year and 0.96%/year, respectively. The major cause of degradation found in Site 3 is due to high series resistance (potentially due to solder-bond thermo-mechanical fatigue) and the failure mode is ribbon-ribbon solder bond failure/breakage. The Site 4c power plant has 1,280 modules (named as Model-H) which provide 243 kW DC output. The mean and median degradation of these 4 years old modules are 0.96%/year and 1%/year, respectively. At Site 4c, practically, none of the module failures are observed. The average soiling loss is 6.9% in Site 3 and 5.5% in Site 4c. The difference in soiling level is attributed

Common Cause Failures and Ultra Reliability

NASA Technical Reports Server (NTRS)

Jones, Harry W.

2012-01-01

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

Identifying the necessary and sufficient number of risk factors for predicting academic failure.

PubMed

Lucio, Robert; Hunt, Elizabeth; Bornovalova, Marina

2012-03-01

Identifying the point at which individuals become at risk for academic failure (grade point average [GPA] < 2.0) involves an understanding of which and how many factors contribute to poor outcomes. School-related factors appear to be among the many factors that significantly impact academic success or failure. This study focused on 12 school-related factors. Using a thorough 5-step process, we identified which unique risk factors place one at risk for academic failure. Academic engagement, academic expectations, academic self-efficacy, homework completion, school relevance, school safety, teacher relationships (positive relationship), grade retention, school mobility, and school misbehaviors (negative relationship) were uniquely related to GPA even after controlling for all relevant covariates. Next, a receiver operating characteristic curve was used to determine a cutoff point for determining how many risk factors predict academic failure (GPA < 2.0). Results yielded a cutoff point of 2 risk factors for predicting academic failure, which provides a way for early identification of individuals who are at risk. Further implications of these findings are discussed. PsycINFO Database Record (c) 2012 APA, all rights reserved.

Reliability and Failure Modes of a Hybrid Ceramic Abutment Prototype.

PubMed

Silva, Nelson Rfa; Teixeira, Hellen S; Silveira, Lucas M; Bonfante, Estevam A; Coelho, Paulo G; Thompson, Van P

2018-01-01

A ceramic and metal abutment prototype was fatigue tested to determine the probability of survival at various loads. Lithium disilicate CAD-milled abutments (n = 24) were cemented to titanium sleeve inserts and then screw attached to titanium fixtures. The assembly was then embedded at a 30° angle in polymethylmethacrylate. Each (n = 24) was restored with a resin-cemented machined lithium disilicate all-ceramic central incisor crown. Single load (lingual-incisal contact) to failure was determined for three specimens. Fatigue testing (n = 21) was conducted employing the step-stress method with lingual mouth motion loading. Failures were recorded, and reliability calculations were performed using proprietary software. Probability Weibull curves were calculated with 90% confidence bounds. Fracture modes were classified with a stereomicroscope, and representative samples imaged with scanning electron microscopy. Fatigue results indicated that the limiting factor in the current design is the fatigue strength of the abutment screw, where screw fracture often leads to failure of the abutment metal sleeve and/or cracking in the implant fixture. Reliability for completion of a mission at 200 N load for 50K cycles was 0.38 (0.52% to 0.25 90% CI) and for 100K cycles was only 0.12 (0.26 to 0.05)-only 12% predicted to survive. These results are similar to those from previous studies on metal to metal abutment/fixture systems where screw failure is a limitation. No ceramic crown or ceramic abutment initiated fractures occurred, supporting the research hypothesis. The limiting factor in performance was the screw failure in the metal-to-metal connection between the prototyped abutment and the fixture, indicating that this configuration should function clinically with no abutment ceramic complications. The combined ceramic with titanium sleeve abutment prototype performance was limited by the fatigue degradation of the abutment screw. In fatigue, no ceramic crown or ceramic

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

A bivariate model for analyzing recurrent multi-type automobile failures

NASA Astrophysics Data System (ADS)

Sunethra, A. A.; Sooriyarachchi, M. R.

2017-09-01

The failure mechanism in an automobile can be defined as a system of multi-type recurrent failures where failures can occur due to various multi-type failure modes and these failures are repetitive such that more than one failure can occur from each failure mode. In analysing such automobile failures, both the time and type of the failure serve as response variables. However, these two response variables are highly correlated with each other since the timing of failures has an association with the mode of the failure. When there are more than one correlated response variables, the fitting of a multivariate model is more preferable than separate univariate models. Therefore, a bivariate model of time and type of failure becomes appealing for such automobile failure data. When there are multiple failure observations pertaining to a single automobile, such data cannot be treated as independent data because failure instances of a single automobile are correlated with each other while failures among different automobiles can be treated as independent. Therefore, this study proposes a bivariate model consisting time and type of failure as responses adjusted for correlated data. The proposed model was formulated following the approaches of shared parameter models and random effects models for joining the responses and for representing the correlated data respectively. The proposed model is applied to a sample of automobile failures with three types of failure modes and up to five failure recurrences. The parametric distributions that were suitable for the two responses of time to failure and type of failure were Weibull distribution and multinomial distribution respectively. The proposed bivariate model was programmed in SAS Procedure Proc NLMIXED by user programming appropriate likelihood functions. The performance of the bivariate model was compared with separate univariate models fitted for the two responses and it was identified that better performance is secured by

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

DTIC Science & Technology

2012-06-01

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

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

PubMed

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

2017-06-30

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

A method to identify the main mode of machine tool under operating conditions

NASA Astrophysics Data System (ADS)

Wang, Daming; Pan, Yabing

2017-04-01

The identification of the modal parameters under experimental conditions is the most common procedure when solving the problem of machine tool structure vibration. However, the influence of each mode on the machine tool vibration in real working conditions remains unknown. In fact, the contributions each mode makes to the machine tool vibration during machining process are different. In this article, an active excitation modal analysis is applied to identify the modal parameters in operational condition, and the Operating Deflection Shapes (ODS) in frequencies of high level vibration that affect the quality of machining in real working conditions are obtained. Then, the ODS is decomposed by the mode shapes which are identified in operational conditions. So, the contributions each mode makes to machine tool vibration during machining process are got by decomposition coefficients. From the previous steps, we can find out the main modes which effect the machine tool more significantly in working conditions. This method was also verified to be effective by experiments.

Association between bilirubin and mode of death in severe systolic heart failure.

PubMed

Wu, Audrey H; Levy, Wayne C; Welch, Kathleen B; Neuberg, Gerald W; O'Connor, Christopher M; Carson, Peter E; Miller, Alan B; Ghali, Jalal K

2013-04-15

The bilirubin level has been associated with worse outcomes, but it has not been studied as a predictor for the mode of death in patients with systolic heart failure. The Prospective Randomized Amlodipine Evaluation Study (PRAISE) cohort (including New York Heart Association class IIIB-IV patients with left ventricular ejection fraction <30%, n = 1,135) was analyzed, divided by bilirubin level: ≤0.6 mg/dl, group 1; >0.6 to 1.2 mg/dl, group 2; and >1.2 mg/dl, group 3. Multivariate Cox proportional hazards models were used to determine the association of bilirubin with the risk of sudden or pump failure death. Total bilirubin was entered as a base 2 log-transformed variable (log2 bilirubin), indicating doubling of the bilirubin level corresponding to each increase in variable value. The higher bilirubin groups had a lower ejection fraction (range 19% to 21%), sodium (range 138 to 139 mmol/L), and systolic blood pressure (range 111 to 120 mm Hg), a greater heart rate (range 79 to 81 beats/min), and greater diuretic dosages (range 86 to 110 furosemide-equivalent total daily dose in mg). The overall survival rates declined with increasing bilirubin (24.3, 31.3, and 44.3 deaths per 100 person-years, respectively, for groups 1, 2, and 3). Although a positive relation was seen between log2 bilirubin and both pump failure risk and sudden death risk, the relation in multivariate modeling was significant only for pump failure mortality (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82, p = 0.0004), not for sudden death mortality (hazard ratio 1.21, 95% confidence interval 0.98 to 1.49, p = 0.08). In conclusion, an increasing bilirubin level was significantly associated with the risk of pump failure death but not for sudden death in patients with severe systolic heart failure. Copyright © 2013 Elsevier Inc. All rights reserved.

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.

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

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.

How to apply clinical cases and medical literature in the framework of a modified "failure mode and effects analysis" as a clinical reasoning tool--an illustration using the human biliary system.

PubMed

Wong, Kam Cheong

2016-04-06

Clinicians use various clinical reasoning tools such as Ishikawa diagram to enhance their clinical experience and reasoning skills. Failure mode and effects analysis, which is an engineering methodology in origin, can be modified and applied to provide inputs into an Ishikawa diagram. The human biliary system is used to illustrate a modified failure mode and effects analysis. The anatomical and physiological processes of the biliary system are reviewed. Failure is defined as an abnormality caused by infective, inflammatory, obstructive, malignancy, autoimmune and other pathological processes. The potential failures, their effect(s), main clinical features, and investigation that can help a clinician to diagnose at each anatomical part and physiological process are reviewed and documented in a modified failure mode and effects analysis table. Relevant medical and surgical cases are retrieved from the medical literature and weaved into the table. A total of 80 clinical cases which are relevant to the modified failure mode and effects analysis for the human biliary system have been reviewed and weaved into a designated table. The table is the backbone and framework for further expansion. Reviewing and updating the table is an iterative and continual process. The relevant clinical features in the modified failure mode and effects analysis are then extracted and included in the relevant Ishikawa diagram. This article illustrates an application of engineering methodology in medicine, and it sows the seeds of potential cross-pollination between engineering and medicine. Establishing a modified failure mode and effects analysis can be a teamwork project or self-directed learning process, or a mix of both. Modified failure mode and effects analysis can be deployed to obtain inputs for an Ishikawa diagram which in turn can be used to enhance clinical experiences and clinical reasoning skills for clinicians, medical educators, and students.

Detailed investigation of causes of avionics field failures

NASA Astrophysics Data System (ADS)

Kallis, J. M.; Buechler, D. W.; Richardson, Z. C.; Backes, P. G.; Lopez, S. B.; Erickson, J. J.; van Westerhuyzen, D. H.

A detailed analysis of digital and analog modules from the F-15 AN/APG-63 Radar was performed to identify the kinds, types, and number of life models based on observed failure modes, mechanisms, locations, and characteristics needed to perform a Failure Free Operating Period prediction for these items. It is found that a significant fraction of the failures of the analog module and a small fraction of those of the digital module resulted from the exacerbation of latent defects by environmental stresses. It is also found that the fraction of failures resulting from thermal cycling and vibration is small.

Improving FMEA risk assessment through reprioritization of failures

NASA Astrophysics Data System (ADS)

Ungureanu, A. L.; Stan, G.

2016-08-01

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

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.

Numerical Model for the Study of the Strength and Failure Modes of Rock Containing Non-Persistent Joints

NASA Astrophysics Data System (ADS)

Vergara, Maximiliano R.; Van Sint Jan, Michel; Lorig, Loren

2016-04-01

The mechanical behavior of rock containing parallel non-persistent joint sets was studied using a numerical model. The numerical analysis was performed using the discrete element software UDEC. The use of fictitious joints allowed the inclusion of non-persistent joints in the model domain and simulating the progressive failure due to propagation of existing fractures. The material and joint mechanical parameters used in the model were obtained from experimental results. The results of the numerical model showed good agreement with the strength and failure modes observed in the laboratory. The results showed the large anisotropy in the strength resulting from variation of the joint orientation. Lower strength of the specimens was caused by the coalescence of fractures belonging to parallel joint sets. A correlation was found between geometrical parameters of the joint sets and the contribution of the joint sets strength in the global strength of the specimen. The results suggest that for the same dip angle with respect to the principal stresses; the uniaxial strength depends primarily on the joint spacing and the angle between joints tips and less on the length of the rock bridges (persistency). A relation between joint geometrical parameters was found from which the resulting failure mode can be predicted.

Fracture resistance and failure mode of posterior fixed dental prostheses fabricated with two zirconia CAD/CAM systems

PubMed Central

López-Suárez, Carlos; Gonzalo, Esther; Peláez, Jesús; Rodríguez, Verónica

2015-01-01

Background In recent years there has been an improvement of zirconia ceramic materials to replace posterior missing teeth. To date little in vitro studies has been carried out on the fracture resistance of zirconia veneered posterior fixed dental prostheses. This study investigated the fracture resistance and the failure mode of 3-unit zirconia-based posterior fixed dental prostheses fabricated with two CAD/CAM systems. Material and Methods Twenty posterior fixed dental prostheses were studied. Samples were randomly divided into two groups (n=10 each) according to the zirconia ceramic analyzed: Lava and Procera. Specimens were loaded until fracture under static load. Data were analyzed using Wilcoxon´s rank sum test and Wilcoxon´s signed-rank test (P<0.05). Results Partial fracture of the veneering porcelain occurred in 100% of the samples. Within each group, significant differences were shown between the veneering and the framework fracture resistance (P=0.002). The failure occurred in the connector cervical area in 80% of the cases. Conclusions All fracture load values of the zirconia frameworks could be considered clinically acceptable. The connector area is the weak point of the restorations. Key words:Fixed dental prostheses, zirconium-dioxide, zirconia, fracture resistance, failure mode. PMID:26155341

Mode of action and effects of standardized collaborative disease management on mortality and morbidity in patients with systolic heart failure: the Interdisciplinary Network for Heart Failure (INH) study.

PubMed

Angermann, Christiane E; Störk, Stefan; Gelbrich, Götz; Faller, Hermann; Jahns, Roland; Frantz, Stefan; Loeffler, Markus; Ertl, Georg

2012-01-01

Trials investigating efficacy of disease management programs (DMP) in heart failure reported contradictory results. Features rendering specific interventions successful are often ill defined. We evaluated the mode of action and effects of a nurse-coordinated DMP (HeartNetCare-HF, HNC). Patients hospitalized for systolic heart failure were randomly assigned to HNC or usual care (UC). Besides telephone-based monitoring and education, HNC addressed individual problems raised by patients, pursued networking of health care providers and provided training for caregivers. End points were time to death or rehospitalization (combined primary), heart failure symptoms, and quality of life (SF-36). Of 1007 consecutive patients, 715 were randomly assigned (HNC: n=352; UC: n=363; age, 69±12 years; 29% female; 40% New York Heart Association class III-IV). Within 180 days, 130 HNC and 137 UC patients reached the primary end point (hazard ratio, 1.02; 95% confidence interval, 0.81-1.30; P=0.89), since more HNC patients were readmitted. Overall, 32 HNC and 52 UC patients died (1 UC patient and 4 HNC patients after dropout); thus, uncensored hazard ratio was 0.62 (0.40-0.96; P=0.03). HNC patients improved more regarding New York Heart Association class (P=0.05), physical functioning (P=0.03), and physical health component (P=0.03). Except for HNC, health care utilization was comparable between groups. However, HNC patients requested counseling for noncardiac problems even more frequently than for cardiovascular or heart-failure-related issues. The primary end point of this study was neutral. However, mortality risk and surrogates of well-being improved significantly. Quantitative assessment of patient requirements suggested that besides (tele)monitoring individualized care considering also noncardiac problems should be integrated in efforts to achieve more sustainable improvement in heart failure outcomes. URL: http://www.controlled-trials.com. Unique identifier: ISRCTN23325295.

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.

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

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/

Decentralized Sliding Mode Observer Based Dual Closed-Loop Fault Tolerant Control for Reconfigurable Manipulator against Actuator Failure.

PubMed

Zhao, Bo; Li, Chenghao; Liu, Derong; Li, Yuanchun

2015-01-01

This paper considers a decentralized fault tolerant control (DFTC) scheme for reconfigurable manipulators. With the appearance of norm-bounded failure, a dual closed-loop trajectory tracking control algorithm is proposed on the basis of the Lyapunov stability theory. Characterized by the modularization property, the actuator failure is estimated by the proposed decentralized sliding mode observer (DSMO). Moreover, the actuator failure can be treated in view of the local joint information, so its control performance degradation is independent of other normal joints. In addition, the presented DFTC scheme is significantly simplified in terms of the structure of the controller due to its dual closed-loop architecture, and its feasibility is highly reflected in the control of reconfigurable manipulators. Finally, the effectiveness of the proposed DFTC scheme is demonstrated using simulations.

Decentralized Sliding Mode Observer Based Dual Closed-Loop Fault Tolerant Control for Reconfigurable Manipulator against Actuator Failure

PubMed Central

Zhao, Bo; Li, Yuanchun

2015-01-01

This paper considers a decentralized fault tolerant control (DFTC) scheme for reconfigurable manipulators. With the appearance of norm-bounded failure, a dual closed-loop trajectory tracking control algorithm is proposed on the basis of the Lyapunov stability theory. Characterized by the modularization property, the actuator failure is estimated by the proposed decentralized sliding mode observer (DSMO). Moreover, the actuator failure can be treated in view of the local joint information, so its control performance degradation is independent of other normal joints. In addition, the presented DFTC scheme is significantly simplified in terms of the structure of the controller due to its dual closed-loop architecture, and its feasibility is highly reflected in the control of reconfigurable manipulators. Finally, the effectiveness of the proposed DFTC scheme is demonstrated using simulations. PMID:26181826

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

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

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

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)more » 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

Accuracy of a Rationally Derived Method for Identifying Treatment Failure in Children and Adolescents

ERIC Educational Resources Information Center

Bishop, Matthew J.; Bybee, Taige S.; Lambert, Michael J.; Burlingame, Gary M.; Wells, M. Gawain; Poppleton, Landon E.

2005-01-01

Psychotherapy outcome can be enhanced by early identification of potential treatment failures before they leave treatment. In adults, compelling data are emerging that provide evidence that an early warning system that identifies potential treatment failures can be developed and applied to enhance outcome. The present study reports an analysis of…

Basic failure mechanisms in advanced composites

NASA Technical Reports Server (NTRS)

Mullin, J. V.; Mazzio, V. F.; Mehan, R. L.

1972-01-01

Failure mechanisms in carbon-epoxy composites are identified as a basis for more reliable prediction of the performance of these materials. The approach involves both the study of local fracture events in model specimens containing small groups of filaments and fractographic examination of high fiber content engineering composites. Emphasis is placed on the correlation of model specimen observations with gross fracture modes. The effects of fiber surface treatment, resin modification and fiber content are studied and acoustic emission methods are applied. Some effort is devoted to analysis of the failure process in composite/metal specimens.

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.

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.

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

NASA Astrophysics Data System (ADS)

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

2018-06-01

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

Tensile failure criteria for fiber composite materials

NASA Technical Reports Server (NTRS)

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

1972-01-01

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

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.

Performance degradation mechanisms and modes in terrestrial photovoltaic arrays and technology for their diagnosis

NASA Technical Reports Server (NTRS)

Noel, G. T.; Sliemers, F. A.; Derringer, G. C.; Wood, V. E.; Wilkes, K. E.; Gaines, G. B.; Carmichael, D. C.

1978-01-01

Accelerated life-prediction test methodologies have been developed for the validation of a 20-year service life for low-cost photovoltaic arrays. Array failure modes, relevant materials property changes, and primary degradation mechanisms are discussed as a prerequisite to identifying suitable measurement techniques and instruments. Measurements must provide sufficient confidence to permit selection among alternative designs and materials and to stimulate widespread deployment of such arrays. Furthermore, the diversity of candidate materials and designs, and the variety of potential environmental stress combinations, degradation mechanisms and failure modes require that combinations of measurement techniques be identified which are suitable for the characterization of various encapsulation system-cell structure-environment combinations.

Nanowire failure: long = brittle and short = ductile.

PubMed

Wu, Zhaoxuan; Zhang, Yong-Wei; Jhon, Mark H; Gao, Huajian; Srolovitz, David J

2012-02-08

Experimental studies of the tensile behavior of metallic nanowires show a wide range of failure modes, ranging from ductile necking to brittle/localized shear failure-often in the same diameter wires. We performed large-scale molecular dynamics simulations of copper nanowires with a range of nanowire lengths and provide unequivocal evidence for a transition in nanowire failure mode with change in nanowire length. Short nanowires fail via a ductile mode with serrated stress-strain curves, while long wires exhibit extreme shear localization and abrupt failure. We developed a simple model for predicting the critical nanowire length for this failure mode transition and showed that it is in excellent agreement with both the simulation results and the extant experimental data. The present results provide a new paradigm for the design of nanoscale mechanical systems that demarcates graceful and catastrophic failure. © 2012 American Chemical Society

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

Application of Function-Failure Similarity Method to Rotorcraft Component Design

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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

An unusual mode of failure of a tripolar constrained acetabular liner: a case report.

PubMed

Banks, Louisa N; McElwain, John P

2010-04-01

Dislocation after primary total hip arthroplasty (THA) is the most commonly encountered complication and is unpleasant for both the patient and the surgeon. Constrained acetabular components can be used to treat or prevent instability after primary total hip arthroplasty. We present the case of a 42-year-old female with a BMI of 41. At 18 months post-primary THA the patient underwent further revision hip surgery after numerous (more than 20) dislocations. She had a tripolar Trident acetabular cup (Stryker-Howmedica-Osteonics, Rutherford, New Jersey) inserted. Shortly afterwards the unusual mode of failure of the constrained acetabular liner was noted from radiographs in that the inner liner had dissociated from the outer. The reinforcing ring remained intact and in place. We believe that the patient's weight, combined with poor abductor musculature caused excessive demand on the device leading to failure at this interface when the patient flexed forward. Constrained acetabular components are useful implants to treat instability but have been shown to have up to 42% long-term failure rates with problems such as dissociated inserts, dissociated constraining rings and dissociated femoral rings being sited. Sometimes they may be the only option left in difficult cases such as illustrated here, but still unfortunately have the capacity to fail in unusual ways.

Fatigue behavior of a cross-ply metal matrix composite at elevated temperature under strain controlled mode. Master`s thesis

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

Dennis, L.B.

1994-12-01

This research extends the existing knowledge of cross-ply metal matrix composites (MMC) to include fatigue behavior under strain-controlled fully reversed loading. This study investigated fatigue life, failure modes and damage mechanisms of the SCS-6/Ti-15-3, (O/9O)2s, MMC. The laminate was subjected to fully reversed fatigue at elevated temperature (427 deg C) at various strain levels. Stress, strain and modulus data were analyzed to characterize the macro-mechanical behavior of the composite. Microscopy and fractography were accomplished to identify and characterize the damage mechanisms at the microscopic level. Failure modes varied according to the maximum applied strain level showing either mixed mode (i.e.more » combination of both fiber and matrix dominated modes) or matrix dominated fatigue failures. As expected, higher strain loadings resulted in more ductility of the matrix at failure, evidenced by fracture surface features. For testing of the same composite laminate, the fatigue life under strain controlled mode slightly increased, compared to its load-controlled mode counterpart, using the effective strain range comparison basis. However, the respective fatigue life curves converged in the high cycle region, suggesting that the matrix dominated failure mode produces equivalent predicted fatigue lives for both control modes.« less

SNS STRIPPER FOIL FAILURE MODES AND THEIR CURES

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

Galambos, John D; Luck, Chris; Plum, Michael A

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 themore » improvements we have made to mitigate them.« less

Leveraging Client-Side DNS Failure Patterns to Identify Malicious Behaviors

DTIC Science & Technology

2015-09-28

malicious behavior found in our dataset and (ii) to create ground truth to evaluate the system proposed in Section V. We begin by removing those cases that...2011. [10] S. Hao, N. Feamster, and R. Pandrangi, “Monitoring the Initial DNS Behavior of Malicious Domains,” in ACM IMC , 2011. [11] R. Perdisci et...distribution is unlimited. Leveraging Client-Side DNS Failure Patterns to Identify Malicious Behaviors The views, opinions and/or findings contained in

Compression failure of composite laminates

NASA Technical Reports Server (NTRS)

Pipes, R. B.

1983-01-01

This presentation attempts to characterize the compressive behavior of Hercules AS-1/3501-6 graphite-epoxy composite. The effect of varying specimen geometry on test results is examined. The transition region is determined between buckling and compressive failure. Failure modes are defined and analytical models to describe these modes are presented.

Failure mode and bending moment of canine pancarpal arthrodesis constructs stabilized with two different implant systems.

PubMed

Wininger, Fred A; Kapatkin, Amy S; Radin, Alex; Shofer, Frances S; Smith, Gail K

2007-12-01

To compare failure mode and bending moment of a canine pancarpal arthrodesis construct using either a 2.7 mm/3.5 mm hybrid dynamic compression plate (HDCP) or a 3.5 mm dynamic compression plate (DCP). Paired in vitro biomechanical testing of canine pancarpal arthrodesis constructs stabilized with either a 2.7/3.5 HDCP or 3.5 DCP. Paired cadaveric canine antebrachii (n=5). Pancarpal arthrodesis constructs were loaded to failure (point of maximum load) in 4-point bending using a materials-testing machine. Using this point of failure, bending moments were calculated from system variables for each construct and the 2 plating systems compared using a paired t-test. To examine the relationship between metacarpal diameter and screw diameter failure loads, linear regression was used and Pearson' correlation coefficient was calculated. Significance was set at P<.05. HDCP failed at higher loads than DCP for 9 of 10 constructs. The absolute difference in failure rates between the 2 plates was 0.552+/-0.182 N m, P=.0144 (95% confidence interval: -0.58 to 1.68). This is an 8.1% mean difference in bending strength. There was a significant linear correlation r=0.74 (P-slope=.014) and 0.8 (P-slope=.006) between metacarpal diameter and failure loads for the HDCP and 3.5 DCP, respectively. There was a small but significant difference between bending moment at failure between 2.7/3.5 HDCP and 3.5 DCP constructs; however, the difference may not be clinically evident in all patients. The 2.7/3.5 HDCP has physical and mechanical properties making it a more desirable plate for pancarpal arthrodesis.

Analysis of Gas Turbine Engine Failure Modes.

DTIC Science & Technology

1974-01-01

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

Influence of remaining coronal tooth structure on fracture resistance and failure mode of restored endodontically treated maxillary incisors.

PubMed

Santos Pantaleón, Domingo; Morrow, Brian R; Cagna, David R; Pameijer, Cornelis H; Garcia-Godoy, Franklin

2018-03-01

Limited information is available on the effect of an incomplete ferrule because of the varying residual axial wall heights and the volume of residual tooth structure on the fracture resistance of endodontically treated and restored maxillary incisors. The purpose of this in vitro investigation was to examine the effect of varying residual axial wall heights, residual coronal tooth structure, and the absence of 1 proximal axial wall on the fracture resistance and failure mode of endodontically treated teeth restored with metal posts. Sixty intact human maxillary central incisors were divided into 6 groups (n=10): no ferrule (NF), 2-mm complete ferrule (CF2), 2-mm (IF2), 3-mm (IF3), and 4-mm (IF4) incomplete ferrules missing a single interproximal wall, and a control group that had a 6-mm incomplete ferrule (IF6). Cast metal post-and-cores were placed in all experimental specimens except for controls. Control specimens received 1 interproximal cavity preparation extending to the root canal access and a composite resin restoration. Complete metal crowns were then cemented on all specimens. Completed specimens were subjected to thermocycling (6000 cycles, 5°C/55°C) followed by the immediate testing of fracture resistance. Failed specimens were sectioned buccolingually and evaluated to identify the failure mode. The data were analyzed with an analysis of variance (ANOVA) and the Student-Newman-Keuls multiple comparison test (α=.05). An incomplete ferrule (IF2) with 1 interproximal wall missing had significantly reduced fracture resistance (697 N) compared with a complete ferrule (932 N). An increase of 3 to 4 mm of remaining wall height improved fracture resistance, from 844 N (IF3) to 853 N (IF4). Partial decementation was noticed in 8 NF and 5 IF2 specimens. IF3 and IF4 had no decementations. Radicular fractures and cracks (catastrophic failure) were observed in all IF2, IF3, and IF4, 9 CF2, and 6 NF specimens. In 7 specimens without posts (IF6, control

Failure Atlas for Rolling Bearings in Wind Turbines

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

Tallian, T. E.

2006-01-01

This Atlas is structured as a supplement to the book: T.E. Tallian: Failure Atlas for Hertz Contact Machine Elements, 2nd edition, ASME Press New York, (1999). The content of the atlas comprises plate pages from the book that contain bearing failure images, application data, and descriptions of failure mode, image, and suspected failure causes. Rolling bearings are a critical component of the mainshaft system, gearbox and generator in the rapidly developing technology of power generating wind turbines. The demands for long service life are stringent; the design load, speed and temperature regimes are demanding and the environmental conditions including weather,more » contamination, impediments to monitoring and maintenance are often unfavorable. As a result, experience has shown that the rolling bearings are prone to a variety of failure modes that may prevent achievement of design lives. Morphological failure diagnosis is extensively used in the failure analysis and improvement of bearing operation. Accumulated experience shows that the failure appearance and mode of failure causation in wind turbine bearings has many distinguishing features. The present Atlas is a first effort to collect an interpreted database of specifically wind turbine related rolling bearing failures and make it widely available. This Atlas is structured as a supplement to the book: T. E. Tallian: Failure Atlas for Hertz Contact Machine Elements, 2d edition, ASME Press New York, (1999). The main body of that book is a comprehensive collection of self-contained pages called Plates, containing failure images, bearing and application data, and three descriptions: failure mode, image and suspected failure causes. The Plates are sorted by main failure mode into chapters. Each chapter is preceded by a general technical discussion of the failure mode, its appearance and causes. The Plates part is supplemented by an introductory part, describing the appearance classification and failure

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 (ZrO 2 ) abutments offers favorable esthetics compared with the grayish color of titanium (Ti) abutments. Nonetheless, ZrO 2 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 ZrO 2 and LaT abutments, and to compare them with titanium (Ti) abutments. Five different types of abutments, Ti; ZrO 2 with no metal base; ZrO 2 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 ZrO 2 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 ZrO 2 abutments combined with Ti inserts have much higher fracture strength than pure ZrO 2 abutments. Copyright © 2016 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.

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

DTIC Science & Technology

1980-03-24

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

Failure Mode Classification for Life Prediction Modeling of Solid-State Lighting

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

Sakalaukus, Peter Joseph

2015-08-01

Since the passing of the Energy Independence and Security Act of 2007, the U.S. government has mandated greater energy independence which has acted as a catalyst for accelerating and facilitating research efforts toward the development and deployment of market-driven solutions for energy-saving homes, buildings and manufacturing, as well as sustainable transportation and renewable electricity generation. As part of this effort, an emphasis toward advancing solid-state lighting technology through research, development, demonstration, and commercial applications is assisting in the phase out of the common incandescent light bulb, as well as developing a more economical lighting source that is less toxic thanmore » compact fluorescent lighting. This has led lighting manufacturers to pursue SSL technologies for a wide range of consumer lighting applications. An SSL luminaire’s lifetime can be characterized in terms of lumen maintenance life. Lumen maintenance or lumen depreciation is the percentage decrease in the relative luminous flux from that of the original, pristine luminous flux value. Lumen maintenance life is the estimated operating time, in hours, when the desired failure threshold is projected to be reached at normal operating conditions. One accepted failure threshold of SSL luminaires is lumen maintenance of 70% -- a 30% reduction in the light output of the luminaire. Currently, the only approved lighting standard that puts forth a recommendation for long-term luminous flux maintenance projections towards a specified failure threshold of an SSL luminaire is the IES TM-28-14 (TM28) standard. iii TM28 was derived as a means to compare luminaires that have been tested at different facilities, research labs or companies. TM28 recommends the use of the Arrhenius equation to determine SSL device specific reaction rates from thermally driven failure mechanisms used to characterize a single failure mode – the relative change in the luminous flux output or �

Failure Modes in Capacitors When Tested Under a Time-Varying Stress

NASA Technical Reports Server (NTRS)

Liu, David (Donhang)

2011-01-01

Power-on failure has been the prevalent failure mechanism for solid tantalum capacitors in decoupling applications. A surge step stress test (SSST) has been previously applied to identify the critical stress level of a capacitor batch to give some predictability to the power-on failure mechanism [1]. But SSST can also be viewed as an electrically destructive test under a time-varying stress (voltage). It consists of rapidly charging the capacitor with incremental voltage increases, through a low resistance in series, until the capacitor under test is electrically shorted. When the reliability of capacitors is evaluated, a highly accelerated life test (HALT) is usually adopted since it is a time-efficient method of determining the failure mechanism; however, a destructive test under a time-varying stress such as SSST is even more time efficient. It usually takes days or weeks to complete a HALT test, but it only takes minutes for a time-varying stress test to produce failures. The advantage of incorporating a specific time-varying stress profile into a statistical model is significant in providing an alternative life test method for quickly revealing the failure mechanism in capacitors. In this paper, a time-varying stress that mimics a typical SSST has been incorporated into the Weibull model to characterize the failure mechanism in different types of capacitors. The SSST circuit and transient conditions for correctly surge testing capacitors are discussed. Finally, the SSST was applied for testing Ta capacitors, polymer aluminum capacitors (PA capacitors), and multi-layer ceramic (MLC) capacitors with both precious metal electrodes (PME) and base metal electrodes (BME). The test results are found to be directly associated with the dielectric layer breakdown in Ta and PA capacitors and are independent of the capacitor values, the way the capacitors were built, and the capacitors manufacturers. The test results also show that MLC capacitors exhibit surge breakdown

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

NASA Technical Reports Server (NTRS)

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

2001-01-01

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

Development of GENOA Progressive Failure Parallel Processing Software Systems

NASA Technical Reports Server (NTRS)

Abdi, Frank; Minnetyan, Levon

1999-01-01

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

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.

A review of the success and failure characteristics of resin-bonded bridges.

PubMed

Miettinen, M; Millar, B J

2013-07-01

This literature review was designed to assess and compare the success rates and modes of failure of metal-framed, fibre-reinforced composite and all-ceramic resin-bonded bridges. A Medline search (Ovid), supplemented by hand searching, was conducted to identify prospective and retrospective cohort studies on different resin-bonded bridges within the last 16 years. A total of 49 studies met the pre-set inclusion criteria. Success rates of 25 studies on metal-framed, 17 studies on fibre-reinforced composite and 7 studies on all-ceramic resin-bonded bridges were analysed and characteristics of failures were identified. The analysis of the studies indicated an estimation of annual failure rates per year to be 4.6% (±1.3%, 95% CI) for metal-framed, 4.1% (±2.1%, 95% CI) for fibre-reinforced and 11.7% (±1.8%, 95% CI) for all-ceramic resin-bonded bridges. The most frequent complications were: debonding for metal-framed, resin-bonded bridges (93% of all failures); delamination of the composite veneering material for the fibre-reinforced bridges (41%) and fracture of the framework for the all-ceramic bridges (57%). All types of resin-bonded bridges provide an effective short- to medium-term option, with all-ceramic performing least well and having the least favourable mode of failure. The methods of failures were different for different bridges with metal frameworks performing the best over time.

Chemical failure modes of AlQ3-based OLEDs: AlQ3 hydrolysis.

PubMed

Knox, John E; Halls, Mathew D; Hratchian, Hrant P; Schlegel, H Bernhard

2006-03-28

Tris(8-hydroxyquinoline)aluminum(III), AlQ3, is used in organic light-emitting diodes (OLEDs) as an electron-transport material and emitting layer. The reaction of AlQ3 with trace H2O has been implicated as a major failure pathway for AlQ3-based OLEDs. Hybrid density functional calculations have been carried out to characterize the hydrolysis of AlQ3. The thermochemical and atomistic details for this important reaction are reported for both the neutral and oxidized AlQ3/AlQ3+ systems. In support of experimental conclusions, the neutral hydrolysis reaction pathway is found to be a thermally activated process, having a classical barrier height of 24.2 kcal mol(-1). First-principles infrared and electronic absorption spectra are compared to further characterize AlQ3 and the hydrolysis pathway product, AlQ2OH. The activation energy for the cationic AlQ3 hydrolysis pathway is found to be 8.5 kcal mol(-1) lower than for the neutral reaction, which is significant since it suggests a role for charge imbalance in promoting chemical failure modes in OLED devices.

Compression failure of angle-ply laminates

NASA Technical Reports Server (NTRS)

Peel, Larry D.; Hyer, Michael W.; Shuart, Mark J.

1991-01-01

The present work deals with modes and mechanisms of failure in compression of angle-ply laminates. Experimental results were obtained from 42 angle-ply IM7/8551-7a specimens with a lay-up of ((plus or minus theta)/(plus or minus theta)) sub 6s where theta, the off-axis angle, ranged from 0 degrees to 90 degrees. The results showed four failure modes, these modes being a function of off-axis angle. Failure modes include fiber compression, inplane transverse tension, inplane shear, and inplane transverse compression. Excessive interlaminar shear strain was also considered as an important mode of failure. At low off-axis angles, experimentally observed values were considerably lower than published strengths. It was determined that laminate imperfections in the form of layer waviness could be a major factor in reducing compression strength. Previously developed linear buckling and geometrically nonlinear theories were used, with modifications and enhancements, to examine the influence of layer waviness on compression response. The wavy layer is described by a wave amplitude and a wave length. Linear elastic stress-strain response is assumed. The geometrically nonlinear theory, in conjunction with the maximum stress failure criterion, was used to predict compression failure and failure modes for the angle-ply laminates. A range of wave length and amplitudes were used. It was found that for 0 less than or equal to theta less than or equal to 15 degrees failure was most likely due to fiber compression. For 15 degrees less than theta less than or equal to 35 degrees, failure was most likely due to inplane transverse tension. For 35 degrees less than theta less than or equal to 70 degrees, failure was most likely due to inplane shear. For theta less than 70 degrees, failure was most likely due to inplane transverse compression. The fiber compression and transverse tension failure modes depended more heavily on wave length than on wave amplitude. Thus using a single

Evaluation of Window Failure Modes

DTIC Science & Technology

1999-12-01

U.S. Coast Guard Research and Development Center 1082 Shennecossett Road, Groton, CT 06340-6096 Report No. CG-D-08-00 EVALUATION OF WINDOW FAILURE...States Coast Guard Research & Development Center 1082 Shennecossett Road Groton, CT 06340-6096 11 I.Report No. CG-D-08-00 Technical Report...Development Center 1082 Shennecossett Road Groton,CT 06340-6096 12. Sponsoring Organization Name and Address U.S. Department of Transportation United

Mining Clinicians' Electronic Documentation to Identify Heart Failure Patients with Ineffective Self-Management: A Pilot Text-Mining Study.

PubMed

Topaz, Maxim; Radhakrishnan, Kavita; Lei, Victor; Zhou, Li

2016-01-01

Effective self-management can decrease up to 50% of heart failure hospitalizations. Unfortunately, self-management by patients with heart failure remains poor. This pilot study aimed to explore the use of text-mining to identify heart failure patients with ineffective self-management. We first built a comprehensive self-management vocabulary based on the literature and clinical notes review. We then randomly selected 545 heart failure patients treated within Partners Healthcare hospitals (Boston, MA, USA) and conducted a regular expression search with the compiled vocabulary within 43,107 interdisciplinary clinical notes of these patients. We found that 38.2% (n = 208) patients had documentation of ineffective heart failure self-management in the domains of poor diet adherence (28.4%), missed medical encounters (26.4%) poor medication adherence (20.2%) and non-specified self-management issues (e.g., "compliance issues", 34.6%). We showed the feasibility of using text-mining to identify patients with ineffective self-management. More natural language processing algorithms are needed to help busy clinicians identify these patients.

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

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

Identifying novel phenotypes of acute heart failure using cluster analysis of clinical variables.

PubMed

Horiuchi, Yu; Tanimoto, Shuzou; Latif, A H M Mahbub; Urayama, Kevin Y; Aoki, Jiro; Yahagi, Kazuyuki; Okuno, Taishi; Sato, Yu; Tanaka, Tetsu; Koseki, Keita; Komiyama, Kota; Nakajima, Hiroyoshi; Hara, Kazuhiro; Tanabe, Kengo

2018-07-01

Acute heart failure (AHF) is a heterogeneous disease caused by various cardiovascular (CV) pathophysiology and multiple non-CV comorbidities. We aimed to identify clinically important subgroups to improve our understanding of the pathophysiology of AHF and inform clinical decision-making. We evaluated detailed clinical data of 345 consecutive AHF patients using non-hierarchical cluster analysis of 77 variables, including age, sex, HF etiology, comorbidities, physical findings, laboratory data, electrocardiogram, echocardiogram and treatment during hospitalization. Cox proportional hazards regression analysis was performed to estimate the association between the clusters and clinical outcomes. Three clusters were identified. Cluster 1 (n=108) represented "vascular failure". This cluster had the highest average systolic blood pressure at admission and lung congestion with type 2 respiratory failure. Cluster 2 (n=89) represented "cardiac and renal failure". They had the lowest ejection fraction (EF) and worst renal function. Cluster 3 (n=148) comprised mostly older patients and had the highest prevalence of atrial fibrillation and preserved EF. Death or HF hospitalization within 12-month occurred in 23% of Cluster 1, 36% of Cluster 2 and 36% of Cluster 3 (p=0.034). Compared with Cluster 1, risk of death or HF hospitalization was 1.74 (95% CI, 1.03-2.95, p=0.037) for Cluster 2 and 1.82 (95% CI, 1.13-2.93, p=0.014) for Cluster 3. Cluster analysis may be effective in producing clinically relevant categories of AHF, and may suggest underlying pathophysiology and potential utility in predicting clinical outcomes. Copyright © 2018 Elsevier B.V. All rights reserved.

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

NASA Technical Reports Server (NTRS)

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

2017-01-01

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

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.

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

PubMed

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

2014-01-01

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

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

NASA Technical Reports Server (NTRS)

Gibbel, Mark; Larson, Timothy

2000-01-01

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

3D visualization of membrane failures in fuel cells

NASA Astrophysics Data System (ADS)

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

2017-03-01

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

Seismicity, shear failure and modes of deformation in deep subduction zones

NASA Technical Reports Server (NTRS)

Lundgren, Paul R.; Giardini, Domenico

1992-01-01

The joint hypocentral determination method is used to relocate deep seismicity reported in the International Seismological Center catalog for earthquakes deeper than 400 km in the Honshu, Bonin, Mariannas, Java, Banda, and South America subduction zones. Each deep seismic zone is found to display planar features of seismicity parallel to the Harvard centroid-moment tensor nodal planes, which are identified as planes of shear failure. The sense of displacement on these planes is one of resistance to deeper penetration.

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

NASA Technical Reports Server (NTRS)

Ratcliffe, James G.

2004-01-01

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

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

PubMed Central

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

2018-01-01

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

Mode-coupling theory

NASA Astrophysics Data System (ADS)

Reichman, David R.; Charbonneau, Patrick

2005-05-01

In this set of lecture notes we review the mode-coupling theory of the glass transition from several perspectives. First, we derive mode-coupling equations for the description of density fluctuations from microscopic considerations with the use the Mori Zwanzig projection operator technique. We also derive schematic mode-coupling equations of a similar form from a field-theoretic perspective. We review the successes and failures of mode-coupling theory, and discuss recent advances in the applications of the theory.

Processing Mode Causally Influences Emotional Reactivity

PubMed Central

Watkins, Ed; Moberly, Nicholas J.; Moulds, Michelle L.

2008-01-01

Three studies are reported showing that emotional responses to stress can be modified by systematic prior practice in adopting particular processing modes. Participants were induced to think about positive and negative scenarios in a mode either characteristic of or inconsistent with the abstract-evaluative mind-set observed in depressive rumination, via explicit instructions (Experiments 1 and 2) and via implicit induction of interpretative biases (Experiment 3), before being exposed to a failure experience. In all three studies, participants trained into the mode antithetical to depressive rumination demonstrated less emotional reactivity following failure than participants trained into the mode consistent with depressive rumination. These findings provide evidence consistent with the hypothesis that processing mode modifies emotional reactivity and support the processing-mode theory of rumination. PMID:18540752

Register of specialized sources for information on mechanics of structural failure

NASA Technical Reports Server (NTRS)

Carpenter, J. L., Jr.; Denny, F. J.

1973-01-01

Specialized information sources that generate information relative to six problem areas in aerospace mechanics of structural failure are identified. Selection for inclusion was based upon information obtained from the individual knowledge and professional contacts of Martin Marietta Aerospace staff members and the information uncovered by the staff of technical reviewers. Activities listed perform basic or applied research related to the mechanics of structural failure and publish the results of such research. The purpose of the register is to present, in easy reference form, original sources for dependable information regarding failure modes and mechanisms of aerospace structures.

Improved Re-Configurable Sliding Mode Controller for Reusable Launch Vehicle of Second Generation Addressing Aerodynamic Surface Failures and Thrust Deficiencies

NASA Technical Reports Server (NTRS)

Shtessel, Yuri B.

2002-01-01

In this report we present a time-varying sliding mode control (TV-SMC) technique for reusable launch vehicle (RLV) attitude control in ascent and entry flight phases. In ascent flight the guidance commands Euler roll, pitch and yaw angles, and in entry flight it commands the aerodynamic angles of bank, attack and sideslip. The controller employs a body rate inner loop and the attitude outer loop, which are separated in time-scale by the singular perturbation principle. The novelty of the TVSMC is that both the sliding surface and the boundary layer dynamics can be varied in real time using the PD-eigenvalue assignment technique. This salient feature is used to cope with control command saturation and integrator windup in the presence of severe disturbance or control effector failure, which enhances the robustness and fault tolerance of the controller. The TV-SMC is developed and tuned up for the X-33 sub-orbital technology demonstration vehicle in launch and re-entry modes. A variety of nominal, dispersion and failure scenarios have tested via high fidelity 6DOF simulations using MAVERIC/SLIM simulation software.

Are Your Students Ready for Anatomy and Physiology? Developing Tools to Identify Students at Risk for Failure

ERIC Educational Resources Information Center

Gultice, Amy; Witham, Ann; Kallmeyer, Robert

2015-01-01

High failure rates in introductory college science courses, including anatomy and physiology, are common at institutions across the country, and determining the specific factors that contribute to this problem is challenging. To identify students at risk for failure in introductory physiology courses at our open-enrollment institution, an online…

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

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2017-02-01

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

A numerical procedure for failure mode detection of masonry arches reinforced with fiber reinforced polymeric materials

NASA Astrophysics Data System (ADS)

Galassi, S.

2018-05-01

In this paper a mechanical model of masonry arches strengthened with fibre-reinforced composite materials and the relevant numerical procedure for the analysis are proposed. The arch is modelled by using an assemblage of rigid blocks that are connected together and, also to the supporting structures, by mortar joints. The presence of the reinforcement, usually a sheet placed at the intrados or the extrados, prevents the occurrence of cracks that could activate possible collapse mechanisms, due to tensile failure of the mortar joints. Therefore, in a reinforced arch failure generally occurs in a different way from the URM arch. The numerical procedure proposed checks, as a function of an external incremental load, the inner stress state in the arch, in the reinforcement and in the adhesive layer. In so doing, it then provides a prediction of failure modes. Results obtained from experimental tests, carried out on four in-scale models performed in a laboratory, have been compared with those provided by the numerical procedure, implemented in ArchiVAULT, a software developed by the author. In this regard, the numerical procedure is an extension of previous works. Although additional experimental investigations are necessary, these former results confirm that the proposed numerical procedure is promising.

Development of STS/Centaur failure probabilities liftoff to Centaur separation

NASA Technical Reports Server (NTRS)

Hudson, J. M.

1982-01-01

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

A multidimensional anisotropic strength criterion based on Kelvin modes

NASA Astrophysics Data System (ADS)

Arramon, Yves Pierre

A new theory for the prediction of multiaxial strength of anisotropic elastic materials was proposed by Biegler and Mehrabadi (1993). This theory is based on the premise that the total elastic strain energy of an anisotropic material subjected to multiaxial stress can be decomposed into dilatational and deviatoric modes. A multidimensional strength criterion may thus be formulated by postulating that the failure would occur when the energy stored in one of these modes has reached a critical value. However, the logic employed by these authors to formulate a failure criterion based on this theory could not be extended to multiaxial stress. In this thesis, an alternate criterion is presented which redresses the biaxial restriction by reformulating the surfaces of constant modal energy as surfaces of constant eigenstress magnitude. The resulting failure envelope, in a multidimensional stress space, is piecewise smooth. Each facet of the envelope is expected to represent the locus of failure data by a particular Kelvin mode. It is further shown that the Kelvin mode theory alone provides an incomplete description of the failure of some materials, but that this weakness can be addressed by the introduction of a set of complementary modes. A revised theory which combines both Kelvin and complementary modes is thus proposed and applied seven example materials: an isotropic concrete, tetragonal paperboard, two orthotropic softwoods, two orthotropic hardwoods and an orthotropic cortical bone. The resulting failure envelopes for these examples were plotted and, with the exception of concrete, shown to produce intuitively correct failure predictions.

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.

Reliability and failure modes of narrow implant systems.

PubMed

Hirata, Ronaldo; Bonfante, Estevam A; Anchieta, Rodolfo B; Machado, Lucas S; Freitas, Gileade; Fardin, Vinicius P; Tovar, Nick; Coelho, Paulo G

2016-09-01

Narrow implants are indicated in areas of limited bone width or when grafting is nonviable. However, the reduction of implant diameter may compromise their performance. This study evaluated the reliability of several narrow implant systems under fatigue, after restored with single-unit crowns. Narrow implant systems were divided (n = 18 each), as follows: Astra (ASC); BioHorizons (BSC); Straumann Roxolid (SNC), Intra-Lock (IMC), and Intra-Lock one-piece abutment (ILO). Maxillary central incisor crowns were cemented and subjected to step-stress accelerated life testing in water. Use level probability Weibull curves and reliability for a mission of 100,000 cycles at 130- and 180-N loads (90 % two-sided confidence intervals) were calculated. Scanning electron microscopy was used for fractography. Reliability for 100,000 cycles at 130 N was ∼99 % in group ASC, ∼99 % in BSC, ∼96 % in SNC, ∼99 % in IMC, and ∼100 % in ILO. At 180 N, reliability of ∼34 % resulted for the ASC group, ∼91 % for BSC, ∼53 % for SNC, ∼70 % for IMC, and ∼99 % for ILO. Abutment screw fracture was the main failure mode for all groups. Reliability was not different between systems for 100,000 cycles at the 130-N load. A significant decrease was observed at the 180-N load for ASC, SNC, and IMC, whereas it was maintained for BSC and ILO. The investigated narrow implants presented mechanical performance under fatigue that suggests their safe use as single crowns in the anterior region.

Identifying a "default" visual search mode with operant conditioning.

PubMed

Kawahara, Jun-ichiro

2010-09-01

The presence of a singleton in a task-irrelevant domain can impair visual search. This impairment, known as the attentional capture depends on the set of participants. When narrowly searching for a specific feature (the feature search mode), only matching stimuli capture attention. When searching broadly (the singleton detection mode), any oddball captures attention. The present study examined which strategy represents the "default" mode using an operant conditioning approach in which participants were trained, in the absence of explicit instructions, to search for a target in an ambiguous context in which one of two modes was available. The results revealed that participants behaviorally adopted the singleton detection as the default mode but reported using the feature search mode. Conscious strategies did not eliminate capture. These results challenge the view that a conscious set always modulates capture, suggesting that the visual system tends to rely on stimulus salience to deploy attention.

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

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

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 predeterminedmore » 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.« less

A deep-learning classifier identifies patients with clinical heart failure using whole-slide images of H&E tissue

PubMed Central

Peyster, Eliot G.; Frank, Renee; Margulies, Kenneth B.; Feldman, Michael D.

2018-01-01

Over 26 million people worldwide suffer from heart failure annually. When the cause of heart failure cannot be identified, endomyocardial biopsy (EMB) represents the gold-standard for the evaluation of disease. However, manual EMB interpretation has high inter-rater variability. Deep convolutional neural networks (CNNs) have been successfully applied to detect cancer, diabetic retinopathy, and dermatologic lesions from images. In this study, we develop a CNN classifier to detect clinical heart failure from H&E stained whole-slide images from a total of 209 patients, 104 patients were used for training and the remaining 105 patients for independent testing. The CNN was able to identify patients with heart failure or severe pathology with a 99% sensitivity and 94% specificity on the test set, outperforming conventional feature-engineering approaches. Importantly, the CNN outperformed two expert pathologists by nearly 20%. Our results suggest that deep learning analytics of EMB can be used to predict cardiac outcome. PMID:29614076

A deep-learning classifier identifies patients with clinical heart failure using whole-slide images of H&E tissue.

PubMed

Nirschl, Jeffrey J; Janowczyk, Andrew; Peyster, Eliot G; Frank, Renee; Margulies, Kenneth B; Feldman, Michael D; Madabhushi, Anant

2018-01-01

Over 26 million people worldwide suffer from heart failure annually. When the cause of heart failure cannot be identified, endomyocardial biopsy (EMB) represents the gold-standard for the evaluation of disease. However, manual EMB interpretation has high inter-rater variability. Deep convolutional neural networks (CNNs) have been successfully applied to detect cancer, diabetic retinopathy, and dermatologic lesions from images. In this study, we develop a CNN classifier to detect clinical heart failure from H&E stained whole-slide images from a total of 209 patients, 104 patients were used for training and the remaining 105 patients for independent testing. The CNN was able to identify patients with heart failure or severe pathology with a 99% sensitivity and 94% specificity on the test set, outperforming conventional feature-engineering approaches. Importantly, the CNN outperformed two expert pathologists by nearly 20%. Our results suggest that deep learning analytics of EMB can be used to predict cardiac outcome.

Identifying Decadal to Multi-decadal Variability in the Pacific by Empirical Mode Decomposition

NASA Astrophysics Data System (ADS)

Sommers, L. A.; Hamlington, B.; Cheon, S. H.

2016-12-01

Large scale climate variability in the Pacific Ocean like that associated with ENSO and the Pacific Decadal Oscillation (PDO) has been shown to have a significant impact on climate and sea level across a range of timescales. The changes related to these climate signals have worldwide impacts on fisheries, weather, and precipitation patterns among others. Understanding these inter-annual to multi-decadal oscillations is imperative to longer term climate forecasts and understanding how climate will behave, and its effect on changes in sea level. With a 110-year reconstruction of sea level, we examine decadal to multi-decadal variability seen in the sea level fluctuations in the Pacific Ocean. Using empirical mode decomposition (EMD), we break down regional sea level into a series of intrinsic mode functions (IMFs) and attempt attribution of these IMFs to specific climate modes of variability. In particular, and not unexpectedly, we identify IMFs associated with the PDO, finding correlations between the PDO Index and IMFs in the Pacific Ocean upwards of 0.6-0.8 over the 110-year reconstructed record. Perhaps more significantly, we also find evidence of a longer multi-decadal signal ( 50-60 years) in the higher order IMFs. This lower frequency variability has been suggested in previous literature as influencing GMSL, but here we find a regional pattern associated with this multi-decadal signal. By identifying and separating these periodic climate signals, we can gain a better understanding of how the sea level variability associated with these modes can impact sea level on short timescales and serve to exacerbate the effects of long-term sea level change.

Predictions and Experimental Microstructural Characterization of High Strain Rate Failure Modes in Layered Aluminum Composites

NASA Astrophysics Data System (ADS)

Khanikar, Prasenjit

Different aluminum alloys can be combined, as composites, for tailored dynamic applications. Most investigations pertaining to metallic alloy layered composites, however, have been based on quasi-static approaches. The dynamic failure of layered metallic composites, therefore, needs to be characterized in terms of strength, toughness, and fracture response. A dislocation-density based crystalline plasticity formulation, finite-element techniques, rational crystallographic orientation relations and a new fracture methodology were used to predict 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 (GB) distributions. The new fracture methodology, based on an overlap method and phantom nodes, is used with a fracture criteria specialized for fracture on different cleavage planes. One of the objectives of this investigation, therefore, was to determine the optimal arrangements of the 2139 and 2195 aluminum alloys for a metallic layered composite that would combine strength, toughness and fracture resistance for high strain-rate applications. 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-boned interface and the potential delamination of the layers. Shear strain localization, dynamic cracking and delamination were the mutually competing failure mechanisms for the layered metallic composite, and control of these failure modes can be optimized for high strain

Scanning electron microscopy observations of failures of implant overdenture bars: a case series report.

PubMed

Waddell, J Neil; Payne, Alan G T; Swain, Michael V; Kieser, Jules A

2010-03-01

Soldered or cast bars are used as a standard of care in attachment systems supporting maxillary and mandibular implant overdentures. When failures of these bars occur, currently there is a lack of evidence in relation to their specific etiology, location, or nature. To investigate the failure process of a case series of six failed soldered bars, four intact soldered bars, and one intact cast milled bar, which had been supporting implant overdentures. A total of 11 different overdenture bars were removed from patients with different configuration of opposing arches. A failed bar (FB) group (n = 6) had failed soldered overdenture bars, which were recovered from patients following up to 2 years of wear before requiring prosthodontic maintenance and repair. An intact bar (IB) group (n = 5) had both soldered bars and a single cast milled bar, which had been worn by patients for 2 to 5 years prior to receiving other aspects of prosthodontic maintenance. All bars were examined using scanning electron microscopy to establish the possible mode of failure (FB) or to identify evidence of potential failure in the future (IB). Evidence of a progressive failure mode of corrosion fatigue and creep were observed on all the FB and IB usually around the solder areas and nonoxidizing gold cylinder. Fatigue and creep were also observed in all the IB. Where the level of corrosion was substantial, there was no evidence of wear from the matrices of the attachment system. Evidence of an instantaneous failure mode, ductile and brittle overload, was observed on the fracture surfaces of all the FB, within the solder and the nonoxidizing gold cylinders, at the solder/cylinder interface. Corrosion, followed by corrosion fatigue, appears to be a key factor in the onset of the failure process for overdenture bars in this case series of both maxillary and mandibular overdentures. Limited sample size and lack of standardization identify trends only but prevent broad interpretation of the findings.

Effect of DGPS failures on dynamic positioning of mobile drilling units in the North Sea.

PubMed

Chen, Haibo; Moan, Torgeir; Verhoeven, Harry

2009-11-01

Basic features of differential global positioning system (DGPS), and its operational configuration on dynamically positioned (DP) mobile offshore drilling units in the North Sea are described. Generic failure modes of DGPS are discussed, and a critical DGPS failure which has the potential to cause drive-off for mobile drilling units is identified. It is the simultaneous erroneous position data from two DGPS's. Barrier method is used to analyze this critical DGPS failure. Barrier elements to prevent this failure are identified. Deficiencies of each barrier element are revealed based on the incidents and operational experiences in the North Sea. Recommendations to strengthen these barrier elements, i.e. to prevent erroneous position data from DGPS, are proposed. These recommendations contribute to the safety of DP operations of mobile offshore drilling units.

Finite Element Creep-Fatigue Analysis of a Welded Furnace Roll for Identifying Failure Root Cause

NASA Astrophysics Data System (ADS)

Yang, Y. P.; Mohr, W. C.

2015-11-01

Creep-fatigue induced failures are often observed in engineering components operating under high temperature and cyclic loading. Understanding the creep-fatigue damage process and identifying failure root cause are very important for preventing such failures and improving the lifetime of engineering components. Finite element analyses including a heat transfer analysis and a creep-fatigue analysis were conducted to model the cyclic thermal and mechanical process of a furnace roll in a continuous hot-dip coating line. Typically, the roll has a short life, <1 year, which has been a problem for a long time. The failure occurred in the weld joining an end bell to a roll shell and resulted in the complete 360° separation of the end bell from the roll shell. The heat transfer analysis was conducted to predict the temperature history of the roll by modeling heat convection from hot air inside the furnace. The creep-fatigue analysis was performed by inputting the predicted temperature history and applying mechanical loads. The analysis results showed that the failure was resulted from a creep-fatigue mechanism rather than a creep mechanism. The difference of material properties between the filler metal and the base metal is the root cause for the roll failure, which induces higher creep strain and stress in the interface between the weld and the HAZ.

Detection of system failures in multi-axes tasks. [pilot monitored instrument approach

NASA Technical Reports Server (NTRS)

Ephrath, A. R.

1975-01-01

The effects of the pilot's participation mode in the control task on his workload level and failure detection performance were examined considering a low visibility landing approach. It is found that the participation mode had a strong effect on the pilot's workload, the induced workload being lowest when the pilot acted as a monitoring element during a coupled approach and highest when the pilot was an active element in the control loop. The effects of workload and participation mode on failure detection were separated. The participation mode was shown to have a dominant effect on the failure detection performance, with a failure in a monitored (coupled) axis being detected significantly faster than a comparable failure in a manually controlled axis.

Developing a Model for Identifying Students at Risk of Failure in a First Year Accounting Unit

ERIC Educational Resources Information Center

Smith, Malcolm; Therry, Len; Whale, Jacqui

2012-01-01

This paper reports on the process involved in attempting to build a predictive model capable of identifying students at risk of failure in a first year accounting unit in an Australian university. Identifying attributes that contribute to students being at risk can lead to the development of appropriate intervention strategies and support…

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

NASA Technical Reports Server (NTRS)

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

1992-01-01

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

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.

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.

Failure modes for pipelines in landslide areas

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

Bruschi, R.; Spinazze, M.; Tomassini, D.

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 slowmore » 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.« less

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

NASA Astrophysics Data System (ADS)

Loaiza, S.; Fortin, J.; Schubnel, A.; Gueguen, Y.; Vinciguerra, S.; Moreira, M.

2012-10-01

Basaltic rocks are the main component of the oceanic upper crust, thus of potential interest for water and geothermal resources, storage of CO2 and volcanic edifice stability. In this work, we investigated experimentally the mechanical behavior and the failure modes of a porous basalt, with an initial connected porosity of 18%. Results were acquired under triaxial compression experiments at confining pressure in the range of 25-200 MPa on water saturated samples. In addition, a purely hydrostatic test was also performed to reach the pore collapse critical pressure P*. During hydrostatic loading, our results show that the permeability is highly pressure dependent, which suggests that the permeability is mainly controlled by pre-existing cracks. When the sample is deformed at pressure higher than the pore collapse pressure P*, some very small dilatancy develops due to microcracking, and an increase in permeability is observed. Under triaxial loading, two modes of deformation can be highlighted. At low confining pressure (Pc < 50 MPa), the samples are brittle and shear localization occurs. For confining pressure > 50 MPa, the stress-strain curves are characterized by strain hardening and volumetric compaction. Stress drops are also observed, suggesting that compaction may be localized. The presence of compaction bands is confirmed by our microstructure analysis. In addition, the mechanical data allows us to plot the full yield surface for this porous basalt, which follows an elliptic cap as previously observed in high porosity sandstones and limestones.

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.

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

NASA Astrophysics Data System (ADS)

Wessiani, N. A.; Yoshio, F.

2018-04-01

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

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

NASA Technical Reports Server (NTRS)

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

1972-01-01

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

Influence of preparation design and ceramic thicknesses on fracture resistance and failure modes of premolar partial coverage restorations

PubMed Central

Guess, Petra C.; Schultheis, Stefan; Wolkewitz, Martin; Zhang; Strub, Joerg R.

2015-01-01

Statement of problem Preparation designs and ceramic thicknesses are key factors for the long-term success of minimally invasive premolar partial coverage restorations. However, only limited information is presently available on this topic. Purpose The aim of this in vitro study was to evaluate the fracture resistance and failure modes of ceramic premolar partial coverage restorations with different preparation designs and ceramic thicknesses. Material and methods Caries-free human premolars (n= 144) were divided into 9 groups. Palatal onlay preparation comprised reduction of the palatal cusp by 2 mm (Palatal-Onlay-Standard), 1 mm (Palatal-Onlay-Thin), or 0.5 mm (Palatal-Onlay-Ultra-Thin). Complete-coverage onlay preparation additionally included the buccal cusp (Occlusal-Onlay-Standard; Occlusal-Onlay-Thin; Occlusal-Onlay-Ultra-Thin). Labial surface preparations with chamfer reductions of 0.8 mm (Complete-Veneer-Standard), 0.6 mm (Complete-Veneer-Thin) and 0.4 mm (Complete-Veneer-Ultra-Thin) were implemented for complete veneer restorations. Restorations were fabricated from a pressable lithium-disilicate ceramic (IPS-e.max-Press) and cemented adhesively (Syntac-Classic/Variolink-II). All specimens were subjected to cyclic mechanical loading (F= 49 N, 1.2 million cycles) and simultaneous thermocycling (5°C to 55°C) in a mouth-motion simulator. After fatigue, restorations were exposed to single-load-to-failure. Two-way ANOVA was used to identify statistical differences. Pair-wise differences were calculated and P-values were adjusted by the Tukey–Kramer method (α= .05). Results All specimens survived fatigue. Mean (SD) load to failure values (N) were as follows: 837 (320/Palatal-Onlay-Standard), 1055 (369/Palatal-Onlay-Thin), 1192 (342/Palatal-Onlay-Ultra-Thin), 963 (405/Occlusal-Onlay-Standard), 1108 (340/Occlusal-Onlay-Thin), 997 (331/Occlusal-Onlay-Ultra-Thin), 1361 (333/Complete-Veneer-Standard), 1087 (251/Complete-Veneer-Thin), 883 (311/Complete

Researchers at NREL Find Fewer Failures of PV Panels and Different

Science.gov Websites

10, 2017 Overall failure rates for photovoltaic (PV) solar panels have fallen dramatically when Failures of PV Panels and Different Degradation Modes in Systems Installed after 2000 Researchers at NREL Find Fewer Failures of PV Panels and Different Degradation Modes in Systems Installed after 2000 April

Electromigration failure mode concerning negative resistance shift of Cu interconnects buried in porous low-k dielectric

NASA Astrophysics Data System (ADS)

Zheng, Hui; Yin, Binfeng; Yu, Hewei; Chen, Leigang; Gao, Lin; Zhou, Ke; Kuo, Chinte

2017-02-01

Electromigration failure mode concerning a negative resistance shift of 4%-11% and cathode burnout was reported for Cu interconnects buried in porous low-k in this paper. Evidence for oxidation and debonding of Ta/TaN liner at high temperature was revealed, which was demonstrated to have been enabled by the unsealed porous low-k due to moisture uptake. The cathode burnout was thus attributed to severe Joule heating induced in the insulated liner after oxidation. The resistance decay of Cu also exhibited to be mainly consistent with the calculation from specularity recovery of electron scattering at the Cu/Ta interface after oxidation and debonding of the liner, although other factors like strain relaxation may also have some contribution.

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

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

Bauer, Stephen J.; Broome, Scott Thomas; Choens, Charles

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 somemore » chemo-mechanical effect of water.« less

Project Delivery System Mode Decision Based on Uncertain AHP and Fuzzy Sets

NASA Astrophysics Data System (ADS)

Kaishan, Liu; Huimin, Li

2017-12-01

The project delivery system mode determines the contract pricing type, project management mode and the risk allocation among all participants. Different project delivery system modes have different characteristics and applicable scope. For the owners, the selection of the delivery mode is the key point to decide whether the project can achieve the expected benefits, it relates to the success or failure of project construction. Under the precondition of comprehensively considering the influence factors of the delivery mode, the model of project delivery system mode decision was set up on the basis of uncertain AHP and fuzzy sets, which can well consider the uncertainty and fuzziness when conducting the index evaluation and weight confirmation, so as to rapidly and effectively identify the most suitable delivery mode according to project characteristics. The effectiveness of the model has been verified via the actual case analysis in order to provide reference for the construction project delivery system mode.

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.

Abutments with reduced diameter for both cement and screw retentions: analysis of failure modes and misfit of abutment-crown-connections after cyclic loading.

PubMed

Moris, Izabela Cristina Maurício; Faria, Adriana Cláudia Lapria; Ribeiro, Ricardo Faria; Rodrigues, Renata Cristina Silveira

2017-04-01

The aim of this study was to analyze failure modes and misfit of abutments with reduced diameter for both cement and screw retentions after cyclic loading. Forty morse-taper abutment/implant sets of titanium were divided into four groups (N = 10): G4.8S-4.8 abutment with screw-retained crown; G4.8C-4.8 abutment with cemented crown; G3.8S-3.8 abutment with screw-retained crown; and G3.8C-3.8 abutment with cemented crown. Copings were waxed on castable cylinders and cast by oxygen gas flame and injected by centrifugation. After, esthetic veneering ceramic was pressed on these copings for obtaining metalloceramic crowns of upper canine. Cemented crowns were cemented on abutments with provisional cement (Temp Bond NE), and screw-retained crowns were tightened to their abutments with torque recommended by manufacturer (10 N cm). The misfit was measured using a stereomicroscope in a 10× magnification before and after cyclic loading (300,000 cycles). Tests were visually monitored, and failures (decementation, screw loosening and fractures) were registered. Misfit was analyzed by mixed linear model while failure modes by chi-square test (α = 0.05). Cyclic loading affected misfit of 3.8C (P ≤ 0.0001), 3.8S (P = 0.0055) and 4.8C (P = 0.0318), but not of 4.8S (P = 0.1243). No differences were noted between 3.8S with 4.8S before (P = 0.1550) and after (P = 0.9861) cyclic loading, but 3.8C was different from 4.8C only after (P = 0.0015) loading. Comparing different types of retentions at the same diameter abutment, significant difference was noted before and after cyclic loading for 3.8 and 4.8 abutments. Analyzing failure modes, retrievable failures were present at 3.8S and 3.8C groups, while irretrievable were only present at 3.8S. The cyclic loading decreased misfit of cemented and screw-retained crowns on reduced diameter abutments, and misfit of cemented crowns is greater than screw-retained ones. Abutments of reduced diameter failed more than

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

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

Faught, J Tonigan; Balter, P; Johnson, J

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 usedmore » 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.« less

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

NASA Technical Reports Server (NTRS)

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

1992-01-01

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

Construct validity of the Heart Failure Screening Tool (Heart-FaST) to identify heart failure patients at risk of poor self-care: Rasch analysis.

PubMed

Reynolds, Nicholas A; Ski, Chantal F; McEvedy, Samantha M; Thompson, David R; Cameron, Jan

2018-02-14

The aim of this study was to psychometrically evaluate the Heart Failure Screening Tool (Heart-FaST) via: (1) examination of internal construct validity; (2) testing of scale function in accordance with design; and (3) recommendation for change/s, if items are not well adjusted, to improve psychometric credential. Self-care is vital to the management of heart failure. The Heart-FaST may provide a prospective assessment of risk, regarding the likelihood that patients with heart failure will engage in self-care. Psychometric validation of the Heart-FaST using Rasch analysis. The Heart-FaST was administered to 135 patients (median age = 68, IQR = 59-78 years; 105 males) enrolled in a multidisciplinary heart failure management program. The Heart-FaST is a nurse-administered tool for screening patients with HF at risk of poor self-care. A Rasch analysis of responses was conducted which tested data against Rasch model expectations, including whether items serve as unbiased, non-redundant indicators of risk and measure a single construct and that rating scales operate as intended. The results showed that data met Rasch model expectations after rescoring or deleting items due to poor discrimination, disordered thresholds, differential item functioning, or response dependence. There was no evidence of multidimensionality which supports the use of total scores from Heart-FaST as indicators of risk. Aggregate scores from this modified screening tool rank heart failure patients according to their "risk of poor self-care" demonstrating that the Heart-FaST items constitute a meaningful scale to identify heart failure patients at risk of poor engagement in heart failure self-care. © 2018 John Wiley & Sons Ltd.

Effect of Strain Rate on Joint Strength and Failure Mode of Lead-Free Solder Joints

NASA Astrophysics Data System (ADS)

Lin, Jian; Lei, Yongping; Fu, Hanguang; Guo, Fu

2018-03-01

In surface mount technology, the Sn-3.0Ag-0.5Cu solder joint has a shorter impact lifetime than a traditional lead-tin solder joint. In order to improve the impact property of SnAgCu lead-free solder joints and identify the effect of silver content on tensile strength and impact property, impact experiments were conducted at various strain rates on three selected SnAgCu based solder joints. It was found that joint failure mainly occurred in the solder material with large plastic deformation under low strain rate, while joint failure occurred at the brittle intermetallic compound layer without any plastic deformation at a high strain rate. Joint strength increased with the silver content in SnAgCu alloys in static tensile tests, while the impact property of the solder joint decreased with increasing silver content. When the strain rate was low, plastic deformation occurred with failure and the tensile strength of the Sn-3.0Ag-0.5Cu solder joint was higher than that of Sn-0.3Ag-0.7Cu; when the strain rate was high, joint failure mainly occurred at the brittle interface layer and the Sn-0.3Ag-0.7Cu solder joint had a better impact resistance with a thinner intermetallic compound layer.

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

Failure modes for compression loaded angle-ply plates with holes

NASA Technical Reports Server (NTRS)

Burns, S. W.; Herakovich, C. T.; Williams, J. G.

1987-01-01

A combined theoretical-experimental investigation of failure in notched, graphite-epoxy, angle-ply laminates subjected to far-field compression loading indicates that failure generally initiates on the hole boundary and propagates along a line parallel to the fiber orientation of the laminate. The strength of notched laminates with specimen width-to-hole diameter ratios of 5 and 10 are compared to the strength of unnotched laminates. The experimental results are complemented by a three-dimensional finite element stress analysis that includes interlaminar stresses around holes in (+/- theta)s laminates. The finite element predictions indicate that failure is initiated by shear stresses at the hole boundary.

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.

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.

Contact Mechanics and Failure Modes of Compliant Polymeric Bearing Materials for Knee Cartilage Replacement

NASA Astrophysics Data System (ADS)

Tohfafarosh, Mariya Shabbir

failed under tension between 250 - 750% true strain, while those under uniaxial and biaxial compression test sustained compression of 50 - 70% engineering strain (39 - 53% true strain) without any signs of cracking or fracture. The tension was determined to be the primary failure mode for the proposed materials, and the tensile test was used to define the failure criteria of the materials. The unconfined compression tests were used to define the yield stresses and strains under compression, which is the main mode of loading for the knee joint. The results of the plane strain compression were modeled using a finite element model and the maximum principal stress, von Mises stress, maximum shear stress, and maximum principal strain failure criteria were predicted at the corresponding yield strain of each material formulation. Upon comparing the knee model contact stress and strain prediction under normal walking and stair climbing loads with those of the empirical failure criteria at yield, the polycarbonate urethane showed better overall potential for use in compliant knee implants, while the hydrogels exhibited higher potential for delamination or fracture, especially if appropriate implant conformity and thickness are not employed. The outcome of this study and the previous parametric model results helped to determine a niche design space within which designing a knee implant with compliant bearing materials may be feasible. In summary, the potential of compliant bearing materials was thoroughly examined in this thesis, and the results provided a foundation for future testing and development of a compliant cartilage replacement implant. Such an implant would be a promising improvement and alternative to conventional total knee replacements.

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

NASA Technical Reports Server (NTRS)

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

1992-01-01

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

Failure of a laminated composite under tension-compression fatigue loading

NASA Technical Reports Server (NTRS)

Rotem, A.; Nelson, H. G.

1989-01-01

The fatigue behavior of composite laminates under tension-compression loading is analyzed and compared with behavior under tension-tension and compression-compression loading. It is shown that for meaningful fatigue conditions, the tension-compression case is the dominant one. Both tension and compression failure modes can occur under the reversed loading, and failure is dependent on the specific lay-up of the laminate and the difference between the tensile static strength and the absolute value of the compressive static strength. The use of a fatigue failure envelope for determining the fatigue life and mode of failure is proposed and demonstrated.

Peridynamics for failure and residual strength prediction of fiber-reinforced composites

NASA Astrophysics Data System (ADS)

Colavito, Kyle

Peridynamics is a reformulation of classical continuum mechanics that utilizes integral equations in place of partial differential equations to remove the difficulty in handling discontinuities, such as cracks or interfaces, within a body. Damage is included within the constitutive model; initiation and propagation can occur without resorting to special crack growth criteria necessary in other commonly utilized approaches. Predicting damage and residual strengths of composite materials involves capturing complex, distinct and progressive failure modes. The peridynamic laminate theory correctly predicts the load redistribution in general laminate layups in the presence of complex failure modes through the use of multiple interaction types. This study presents two approaches to obtain the critical peridynamic failure parameters necessary to capture the residual strength of a composite structure. The validity of both approaches is first demonstrated by considering the residual strength of isotropic materials. The peridynamic theory is used to predict the crack growth and final failure load in both a diagonally loaded square plate with a center crack, as well as a four-point shear specimen subjected to asymmetric loading. This study also establishes the validity of each approach by considering composite laminate specimens in which each failure mode is isolated. Finally, the failure loads and final failure modes are predicted in a laminate with various hole diameters subjected to tensile and compressive loads.

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

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

Sayler, E; Harrison, A; Eldredge-Hindy, H

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 wasmore » 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

A systematic review of validated methods for identifying acute respiratory failure using administrative and claims data.

PubMed

Jones, Natalie; Schneider, Gary; Kachroo, Sumesh; Rotella, Philip; Avetisyan, Ruzan; Reynolds, Matthew W

2012-01-01

The Food and Drug Administration's (FDA) Mini-Sentinel pilot program initially aims to conduct active surveillance to refine safety signals that emerge for marketed medical products. A key facet of this surveillance is to develop and understand the validity of algorithms for identifying health outcomes of interest (HOIs) from administrative and claims data. This paper summarizes the process and findings of the algorithm review of acute respiratory failure (ARF). PubMed and Iowa Drug Information Service searches were conducted to identify citations applicable to the anaphylaxis HOI. Level 1 abstract reviews and Level 2 full-text reviews were conducted to find articles using administrative and claims data to identify ARF, including validation estimates of the coding algorithms. Our search revealed a deficiency of literature focusing on ARF algorithms and validation estimates. Only two studies provided codes for ARF, each using related yet different ICD-9 codes (i.e., ICD-9 codes 518.8, "other diseases of lung," and 518.81, "acute respiratory failure"). Neither study provided validation estimates. Research needs to be conducted on designing validation studies to test ARF algorithms and estimating their predictive power, sensitivity, and specificity. Copyright © 2012 John Wiley & Sons, Ltd.

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

NASA Technical Reports Server (NTRS)

Bueno, R. A.

1977-01-01

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

Plastic Pipe Failure, Risk, and Threat Analysis

DOT National Transportation Integrated Search

2009-04-29

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

Failure mechanism of hollow tree trunks due to cross-sectional flattening

PubMed Central

Huang, Yan-San; Hsu, Fu-Lan; Lee, Chin-Mei

2017-01-01

Failure of hollow trees in urban areas is a worldwide concern, and it can be caused by different mechanisms, i.e. bending stresses or flattening-related failures. Here we derive a new analytical expression for predicting the bending moment for tangential cracking, and compare the breaking moment of various failure modes, including Brazier buckling, tangential cracking, shear failure and conventional bending failure, as a function of t/R ratio, where t and R are the trunk wall thickness and trunk radius, respectively, of a hollow tree. We use Taiwan red cypress as an example and show that its failure modes and the corresponding t/R ratios are: Brazier buckling (Mode I), tangential cracking followed by longitudinal splitting (Mode II) and conventional bending failure (Mode III) for 0 < t/R < 0.06, 0.06 < t/R < 0.27 and 0.27 < t/R < 1, respectively. The exact values of those ratios may vary within and among species, but the variation is much smaller than individual mechanical properties. Also, shear failure, another type of cracking due to maximum shear stress near the neutral axis of the tree trunk, is unlikely to occur since it requires much larger bending moments. Hence, we conclude that tangential cracking due to cross-sectional flattening, followed by longitudinal splitting, is dominant for hollow trunks. Our equations are applicable to analyse straight hollow tree trunks and plant stems, but are not applicable to those with side openings or those with only heart decay. Our findings provide insights for those managing trees in urban situations and those managing for conservation of hollow-dependent fauna in both urban and rural settings. PMID:28484616

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

NASA Technical Reports Server (NTRS)

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

1992-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1992-01-01

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

Mechanics of rainfall-induced flow failure in unsaturated shallow slopes (Invited)

NASA Astrophysics Data System (ADS)

Buscarnera, G.

2013-12-01

The increase in pore water pressure due to rain infiltration can be a dominant component in the activation of slope instabilities. This work shows an application of the theory of material stability to the triggering analysis of this important class of natural hazards. The goal is to identify the mechanisms through which the process of rain infiltration promotes instabilities of the flow-type in the soil covers. The interplay between increase in pore water pressure and failure mechanisms is investigated at material point level. To account for multiple failure mechanisms, the second-order energy input is linked to the controllability theory and used to define different types of stability indices, each associated with a specific mode of slope failure. It is shown that the theory can be used to assess both shear failure and static liquefaction in saturated and unsaturated soil covers. In particular, it is shown that these instability modes are regulated by the hydro-mechanical characteristics of the soil covers, as well as by their mutual coupling. This finding discloses the importance of the constitutive functions that simulate the interaction between the response of the solid skeleton and the fluid-retention characteristics of the soil. As a consequence, they suggest that even material properties that are not be to directly associated with the shearing resistance (e.g., the potential for wetting compaction) may play a role in the initiation of catastrophic slope failures. According to the proposed interpretation, the process of pore pressure increase can be seen as the trigger of uncontrolled strains, which can anticipate the onset of frictional failure and promote a solid-to-fluid transition.

Mechanism of electromigration failure in Damascene processed copper interconnects

NASA Astrophysics Data System (ADS)

Michael, Nancy Lyn

2002-11-01

A major unresolved issue in Cu interconnect reliability is the interface role in the failure mechanism of real structures. The present study investigates failure in single-level damascene Cu interconnects with variations in interface condition, passivation and barrier, and linewidth. In the first phase, accelerated electromigration testing of 0.25mum Cu interconnects capped with SiN or SiCN, shows that lifetime and failure mode vary with capping layer. The first mode, seen primarily in SiN samples, is characterized by gradual resistance increase and extensive interface damage, believed to result from failure led by interface electromigration. The competing failure mode, found in SiCN capped samples, is characterized by abrupt resistance increase and localized voiding. The second phase fixes SiCN as the capping material and varies barrier material and line width. The three barrier materials, Ta, TaN, and Ta/TaN, produce similar lifetime statistics and failure is abrupt. Line width, however, does have a strong influence on failure time. The line width/grain size ratio ranged from 0.53 to 2.2 but does not correlate with mean time to failure (MTF). The strong dependence on interface fraction, combined with the conclusion from phase one that interface electromigration is not rate controlling, suggests another mechanism related to the interface is a controlling factor. The possibility that contamination and defects at the interface are key to this failure mode was investigated using electro-thermal fatigue (ETF). In ETF, where lines are simultaneously subjected to thermal cycling and constant current, damage caused by thermal stress is accelerated. Tests reveal that in 80 nm lines, transient failure occurs at times far below MTF in electromigration tests at higher temperatures. Failure found in ETF is clearly a result of damage growth due to thermal/mechanical stress rather than electromigration. At the stress levels created by the moderate ETF test conditions, the only

Scale effects in the response and failure of fiber reinforced composite laminates loaded in tension and in flexure

NASA Technical Reports Server (NTRS)

Jackson, Karen E.; Kellas, Sotiris; Morton, John

1992-01-01

The feasibility of using scale model testing for predicting the full-scale behavior of flat composite coupons loaded in tension and beam-columns loaded in flexure is examined. Classical laws of similitude are applied to fabricate and test replica model specimens to identify scaling effects in the load response, strength, and mode of failure. Experiments were performed on graphite-epoxy composite specimens having different laminate stacking sequences and a range of scaled sizes. From the experiments it was deduced that the elastic response of scaled composite specimens was independent of size. However, a significant scale effect in strength was observed. In addition, a transition in failure mode was observed among scaled specimens of certain laminate stacking sequences. A Weibull statistical model and a fracture mechanics based model were applied to predict the strength scale effect since standard failure criteria cannot account for the influence of absolute specimen size on strength.

"Failure-to-Identify" Hunting Incidents: A Resilience Engineering Approach.

PubMed

Bridges, Karl E; Corballis, Paul M; Hollnagel, Erik

2018-03-01

Objective The objective was to develop an understanding, using the Functional Resonance Analysis Method (FRAM), of the factors that could cause a deer hunter to misidentify their intended target. Background Hunting is a popular activity in many communities. However, hunters vary considerably based on training, experience, and expertise. Surprisingly, safety in hunting has not received much attention, especially failure-to-identify hunting incidents. These are incidents in which the hunter, after spotting and targeting their quarry, discharge their firearm only to discover they have been spotting and targeting another human, an inanimate object, or flora by mistake. The hunter must consider environment, target, time of day, weather, and many other factors-continuously evaluating whether the hunt should continue. To understand how these factors can relate to one another is fundamental to begin to understand how incidents happen. Method Workshops with highly experienced and active hunters led to the development of a FRAM model detailing the functions of a "Hunting FRAM." The model was evaluated for correctness based on confidential and anonymous near-miss event submissions by hunters. Results A FRAM model presenting the functions of a hunt was produced, evaluated, and accepted. Using the model, potential sources of incidents or other unintended outcomes were identified, which in turn helped to improve the model. Conclusion Utilizing principles of understanding and visualization tools of the FRAM, the findings create a foundation for safety improvements potentially through training or safety messages based on an increased understanding of the complexity of hunting.

Comprehensive Analysis of Gene Expression Profiles of Sepsis-Induced Multiorgan Failure Identified Its Valuable Biomarkers.

PubMed

Wang, Yumei; Yin, Xiaoling; Yang, Fang

2018-02-01

Sepsis is an inflammatory-related disease, and severe sepsis would induce multiorgan dysfunction, which is the most common cause of death of patients in noncoronary intensive care units. Progression of novel therapeutic strategies has proven to be of little impact on the mortality of severe sepsis, and unfortunately, its mechanisms still remain poorly understood. In this study, we analyzed gene expression profiles of severe sepsis with failure of lung, kidney, and liver for the identification of potential biomarkers. We first downloaded the gene expression profiles from the Gene Expression Omnibus and performed preprocessing of raw microarray data sets and identification of differential expression genes (DEGs) through the R programming software; then, significantly enriched functions of DEGs in lung, kidney, and liver failure sepsis samples were obtained from the Database for Annotation, Visualization, and Integrated Discovery; finally, protein-protein interaction network was constructed for DEGs based on the STRING database, and network modules were also obtained through the MCODE cluster method. As a result, lung failure sepsis has the highest number of DEGs of 859, whereas the number of DEGs in kidney and liver failure sepsis samples is 178 and 175, respectively. In addition, 17 overlaps were obtained among the three lists of DEGs. Biological processes related to immune and inflammatory response were found to be significantly enriched in DEGs. Network and module analysis identified four gene clusters in which all or most of genes were upregulated. The expression changes of Icam1 and Socs3 were further validated through quantitative PCR analysis. This study should shed light on the development of sepsis and provide potential therapeutic targets for sepsis-induced multiorgan failure.

Change Trajectories for the Youth Outcome Questionnaire Self-Report: Identifying Youth at Risk for Treatment Failure

ERIC Educational Resources Information Center

Cannon, Jennifer A. N.; Warren, Jared S.; Nelson, Philip L.; Burlingame, Gary M.

2010-01-01

This study used longitudinal youth outcome data in routine mental health services to test a system for identifying cases at risk for treatment failure. Participants were 2,715 youth (M age = 14) served in outpatient managed care and community mental health settings. Change trajectories were developed using multilevel modeling of archival data.…

Algorithm for Determination of Orion Ascent Abort Mode Achievability

NASA Technical Reports Server (NTRS)

Tedesco, Mark B.

2011-01-01

For human spaceflight missions, a launch vehicle failure poses the challenge of returning the crew safely to earth through environments that are often much more stressful than the nominal mission. Manned spaceflight vehicles require continuous abort capability throughout the ascent trajectory to protect the crew in the event of a failure of the launch vehicle. To provide continuous abort coverage during the ascent trajectory, different types of Orion abort modes have been developed. If a launch vehicle failure occurs, the crew must be able to quickly and accurately determine the appropriate abort mode to execute. Early in the ascent, while the Launch Abort System (LAS) is attached, abort mode selection is trivial, and any failures will result in a LAS abort. For failures after LAS jettison, the Service Module (SM) effectors are employed to perform abort maneuvers. Several different SM abort mode options are available depending on the current vehicle location and energy state. During this region of flight the selection of the abort mode that maximizes the survivability of the crew becomes non-trivial. To provide the most accurate and timely information to the crew and the onboard abort decision logic, on-board algorithms have been developed to propagate the abort trajectories based on the current launch vehicle performance and to predict the current abort capability of the Orion vehicle. This paper will provide an overview of the algorithm architecture for determining abort achievability as well as the scalar integration scheme that makes the onboard computation possible. Extension of the algorithm to assessing abort coverage impacts from Orion design modifications and launch vehicle trajectory modifications is also presented.

A New Rock Strength Criterion from Microcracking Mechanisms Which Provides Theoretical Evidence of Hybrid Failure

NASA Astrophysics Data System (ADS)

Zhu, Qi-Zhi

2017-02-01

A proper criterion describing when material fails is essential for deep understanding and constitutive modeling of rock damage and failure by microcracking. Physically, such a criterion should be the global effect of local mechanical response and microstructure evolution inside the material. This paper aims at deriving a new mechanisms-based failure criterion for brittle rocks, based on micromechanical unilateral damage-friction coupling analyses rather than on the basic results from the classical linear elastic fracture mechanics. The failure functions respectively describing three failure modes (purely tensile mode, tensile-shear mode as well as compressive-shear mode) are achieved in a unified upscaling framework and illustrated in the Mohr plane and also in the plane of principal stresses. The strength envelope is proved to be continuous and smooth with a compressive to tensile strength ratio dependent on material properties. Comparisons with experimental data are finally carried out. By this work, we also provide a theoretical evidence on the hybrid failure and the smooth transition from tensile failure to compressive-shear failure.

Preparation Ferrule Design Effect on Endocrown Failure Resistance.

PubMed

Einhorn, Michael; DuVall, Nicholas; Wajdowicz, Michael; Brewster, John; Roberts, Howard

2017-10-06

To evaluate the effect of preparation ferrule inclusion with fracture resistance of mandibular molar endocrowns. Recently extracted mandibular third molars were randomly divided into 3 groups (n = 12) with the coronal tooth structure removed perpendicular to the root long axis approximately 2 mm above the cemento-enamel junction with a slow-speed diamond saw. The pulp chamber was exposed using a diamond bur in a high-speed handpiece with pulpal remnants removed and canals instrumented using endodontic hand instruments. The chamber floor was restored using a resin core material with a two-step, self-etch adhesive and photopolymerized with a visible light-curing unit to create a 2 mm endocrown preparation pulp chamber extension. One and two millimeter ferrule height groups were prepared using a diamond bur in a high-speed handpiece following CAD/CAM guidelines. Completed preparation surface area was determined using a digital measuring microscope. Scanned preparations were restored with lithium disilicate restorations with a self-adhesive resin luting agent. All manufacturer recommendations were followed. Specimens were stored at 37°C/98% humidity and tested to failure after 24 hours at a 45° angle to the tooth long axis using a universal testing machine. Failure load was converted to MPa using the available bonding surface area with mean data analyzed using Kruskal-Wallis/Dunn (p = 0.05). Calculated failure stress found no difference in failure resistance among the three groups; however, failure load results identified that the endocrown preparations without ferrule had significantly lower fracture load resistance. Failure mode analysis identified that all preparations demonstrated a high number of catastrophic failures. Under the conditions of this study, ferrule-containing endocrown preparations demonstrated significantly greater failure loads than standard endocrown restorations; however, calculated failure stress based on available surface area for adhesive

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

PubMed Central

Ye, Qing; Pan, Hao; Liu, Changhua

2015-01-01

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

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

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

NASA Technical Reports Server (NTRS)

Ratcliffe, James G.

2004-01-01

The edge crack torsion (ECT) test is designed to initiate mode III delamination growth in composite laminates. An ECT specimen is a rectangular laminate, containing an edge delamination at the laminate mid-plane. Torsion load is applied to the specimens, resulting in relative transverse shear sliding of the delaminated faces. The test data reduction schemes are intended to yield initiation values of critical mode III strain energy release rate, G(sub IIIc), that are constant with delamination length. The test has undergone several design changes during its development. The objective of this paper was to determine the suitability of the current ECT test design as a mode III fracture test. To this end, ECT tests were conducted on specimens manufactured from IM7/8552 and specimens made from S2/8552 tape laminates. Several specimens, each with different delamination lengths are tested. Detailed, three-dimensional finite element analyses of the specimens were performed. The analysis results were used to calculate the distribution of mode I, mode II, and mode III strain energy release rate along the delamination front. The results indicated that mode III-dominated delamination growth would be initiated from the specimen center. However, in specimens of both material types, the measured values of G(sub IIIc) exhibited significant dependence on delamination length. Furthermore, there was a large amount of scatter in the data. Load-displacement response of the specimens exhibited significant deviation from linearity before specimen failure. X-radiographs of a sample of specimens revealed that damage was initiated in the specimens prior to failure. Further inspection of the failure surfaces is required to identify the damage and determine that mode III delamination is initiated in the specimens.

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.

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

NASA Technical Reports Server (NTRS)

Howard, Philip M.

2007-01-01

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

Assessment of Crack Path Prediction in Non-Proportional Mixed-Mode Fatigue

NASA Technical Reports Server (NTRS)

Highsmith, Shelby, Jr.; Johnson, Steve; Swanson, Gregory; Sayyah, Tarek; Pettit, Richard

2008-01-01

Non-proportional mixed-mode loading is present in many systems and a growing crack can experience any manner of mixed-mode loading. Prediction of the resulting crack path is important when assessing potential failure modes or when performing a failure investigation. Current crack path selection criteria are presented along with data for Inconel 718 under non-proportional mixed-mode loading. Mixed-mode crack growth can transition between path deflection mechanisms with very different orientations. Non-proportional fatigue loadings lack a single parameter for input to current crack path criteria. Crack growth transitions were observed in proportional and non-proportional FCG tests. Different paths displayed distinct fracture surface morphologies. New crack path drivers & transition criteria must be developed.

Stripper foil failure modes and cures at the Spallation Neutron Source

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

Cousineau, Sarah M; Galambos, John D; Kim, Sang-Ho

2011-01-01

The Spallation Neutron Source comprises a 1 GeV, 1.4 MW linear accelerator followed by an accumulator ring and a liquid mercury target. To manage the beam loss caused by the $H^0$ excited states created during the $H^-$ charge exchange injection into the accumulator ring, the stripper foil is located inside one of the chicane dipoles. This has some interesting consequences that were not fully appreciated until the beam power reached about 840 kW. One consequence was sudden failure of the stripper foil system due to convoy electrons stripped from the incoming $H^-$ beam, which circled around to strike the foilmore » bracket and cause bracket failure. Another consequence is that convoy electrons can reflect back up from the electron catcher and strike the foil and bracket. An additional contributor to foil system failure is vacuum breakdown due to the charge developed on the foil by secondary electron emission. In this paper we detail these and other interesting failure mechanisms and describe the improvements we have made to mitigate them.« less

Identifying core NANDA-I nursing diagnoses, NIC interventions, NOC outcomes, and NNN linkages for heart failure.

PubMed

Park, Hyejin

2014-02-01

The purpose of the study was to identify the core nursing diagnoses, interventions, outcomes, and linkages using standardized nursing terminologies for patients with heart failure (HF). For this study a retrospective descriptive design was used. The frequently used NANDA-I, NIC, NOC, and NNN linkages were identified through 272 inpatient records of patients discharged with HF in a midwestern community. The findings indicate that the top 10 NANDA-I, NIC, and NOC accounted for more than 50% of nursing diagnoses, interventions, and outcomes. The most frequently used top 10 NNN linkages were identified for patients with HF. The identified core NANDA-I, NIC, NOC, and NNN linkages for HF from this study provide scope of practice of nurses working in HF clinics. © 2013 NANDA International, Inc.

A preliminary evaluation of a failure detection filter for detecting and identifying control element failures in a transport aircraft

NASA Technical Reports Server (NTRS)

Bundick, W. T.

1985-01-01

The application of the failure detection filter to the detection and identification of aircraft control element failures was evaluated in a linear digital simulation of the longitudinal dynamics of a B-737 Aircraft. Simulation results show that with a simple correlator and threshold detector used to process the filter residuals, the failure detection performance is seriously degraded by the effects of turbulence.

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

PubMed

Fassett, William E

2011-10-10

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

STRESS AND FAILURE ANALYSIS OF RAPIDLY ROTATING ASTEROID (29075) 1950 DA

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

Hirabayashi, Masatoshi; Scheeres, Daniel J., E-mail: masatoshi.hirabayashi@colorado.edu

Rozitis et al. recently reported that near-Earth asteroid (29075) 1950 DA, whose bulk density ranges from 1.0 g cm{sup –3} to 2.4 g cm{sup –3}, is a rubble pile and requires a cohesive strength of at least 44-76 Pa to keep from failing due to its fast spin period. Since their technique for giving failure conditions required the averaged stress over the whole volume, it discarded information about the asteroid's failure mode and internal stress condition. This paper develops a finite element model and revisits the stress and failure analysis of 1950 DA. For the modeling, we do not consider material hardening andmore » softening. Under the assumption of an associated flow rule and uniform material distribution, we identify the deformation process of 1950 DA when its constant cohesion reaches the lowest value that keeps its current shape. The results show that to avoid structural failure the internal core requires a cohesive strength of at least 75-85 Pa. It suggests that for the failure mode of this body, the internal core first fails structurally, followed by the surface region. This implies that if cohesion is constant over the whole volume, the equatorial ridge of 1950 DA results from a material flow going outward along the equatorial plane in the internal core, but not from a landslide as has been hypothesized. This has additional implications for the likely density of the interior of the body.« less

Development of a Two-Wheel Contingency Mode for the MAP Spacecraft

NASA Technical Reports Server (NTRS)

Starin, Scott R.; ODonnell, James R., Jr.; Bauer, Frank H. (Technical Monitor)

2002-01-01

In the event of a failure of one of MAP's three reaction wheel assemblies (RWAs), it is not possible to achieve three-axis, full-state attitude control using the remaining two wheels. Hence, two of the attitude control algorithms implemented on the MAP spacecraft will no longer be usable in their current forms: Inertial Mode, used for slewing to and holding inertial attitudes, and Observing Mode, which implements the nominal dual-spin science mode. This paper describes the effort to create a complete strategy for using software algorithms to cope with a RWA failure. The discussion of the design process will be divided into three main subtopics: performing orbit maneuvers to reach and maintain an orbit about the second Earth-Sun libration point in the event of a RWA failure, completing the mission using a momentum-bias two-wheel science mode, and developing a new thruster-based mode for adjusting the inertially fixed momentum bias. In this summary, the philosophies used in designing these changes is shown; the full paper will supplement these with algorithm descriptions and testing results.

Causality analysis of leading singular value decomposition modes identifies rotor as the dominant driving normal mode in fibrillation

NASA Astrophysics Data System (ADS)

Biton, Yaacov; Rabinovitch, Avinoam; Braunstein, Doron; Aviram, Ira; Campbell, Katherine; Mironov, Sergey; Herron, Todd; Jalife, José; Berenfeld, Omer

2018-01-01

Cardiac fibrillation is a major clinical and societal burden. Rotors may drive fibrillation in many cases, but their role and patterns are often masked by complex propagation. We used Singular Value Decomposition (SVD), which ranks patterns of activation hierarchically, together with Wiener-Granger causality analysis (WGCA), which analyses direction of information among observations, to investigate the role of rotors in cardiac fibrillation. We hypothesized that combining SVD analysis with WGCA should reveal whether rotor activity is the dominant driving force of fibrillation even in cases of high complexity. Optical mapping experiments were conducted in neonatal rat cardiomyocyte monolayers (diameter, 35 mm), which were genetically modified to overexpress the delayed rectifier K+ channel IKr only in one half of the monolayer. Such monolayers have been shown previously to sustain fast rotors confined to the IKr overexpressing half and driving fibrillatory-like activity in the other half. SVD analysis of the optical mapping movies revealed a hierarchical pattern in which the primary modes corresponded to rotor activity in the IKr overexpressing region and the secondary modes corresponded to fibrillatory activity elsewhere. We then applied WGCA to evaluate the directionality of influence between modes in the entire monolayer using clear and noisy movies of activity. We demonstrated that the rotor modes influence the secondary fibrillatory modes, but influence was detected also in the opposite direction. To more specifically delineate the role of the rotor in fibrillation, we decomposed separately the respective SVD modes of the rotor and fibrillatory domains. In this case, WGCA yielded more information from the rotor to the fibrillatory domains than in the opposite direction. In conclusion, SVD analysis reveals that rotors can be the dominant modes of an experimental model of fibrillation. Wiener-Granger causality on modes of the rotor domains confirms their

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

NASA Technical Reports Server (NTRS)

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

1972-01-01

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

Failure of Non-Circular Composite Cylinders

NASA Technical Reports Server (NTRS)

Hyer, M. W.

2004-01-01

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

Design and Demonstration of Emergency Control Modes for Enhanced Engine Performance

NASA Technical Reports Server (NTRS)

Liu, Yuan; Litt, Jonathan S.; Guo, Ten-Huei

2013-01-01

A design concept is presented for developing control modes that enhance aircraft engine performance during emergency flight scenarios. The benefits of increased engine performance to overall vehicle survivability during these situations may outweigh the accompanied elevated risk of engine failure. The objective involves building control logic that can consistently increase engine performance beyond designed maximum levels based on an allowable heightened probability of failure. This concept is applied to two previously developed control modes: an overthrust mode that increases maximum engine thrust output and a faster response mode that improves thrust response to dynamic throttle commands. This paper describes the redesign of these control modes and presents simulation results demonstrating both enhanced engine performance and robust maintenance of the desired elevated risk level.

A review on mode-I interlaminar fracture toughness of fibre reinforced composites

NASA Astrophysics Data System (ADS)

Nasuha, N.; Azmi, A. I.; Tan, C. L.

2017-10-01

Composite material has been growing rapidly throughout the year for its unique properties in comparisons with metal. Recently, there has been a growth on studying the way to reduce the delamination failure, which is the primary challenge on laminated fibre composite. This failure can degrade the strength of composite materials, hence loses its function. In this review, database search was performed using the keywords search on “interlaminar fracture toughness”, “double cantilever beam”, “delamination resistance” and “Mode-I GIC”. The searches were performed on Google Scholar, Scopus and Web of Science with further cross-referencing with other databases. Most relevant studies were selected for review and referencing by the author. This review paper gives a brief explanation on Mode-I interlaminar fracture toughness of composite material. This fracture mode is the most common modes on studying the delamination failure.

Failure detection and recovery in the assembly/contingency subsystem

NASA Technical Reports Server (NTRS)

Gantenbein, Rex E.

1993-01-01

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

Identifying Students at Risk of School Failure in Luxembourgish Secondary School

ERIC Educational Resources Information Center

Klapproth, Florian; Schaltz, Paule

2013-01-01

If teachers knew in advance whether their students are at risk of school failure, they would have the opportunity to supply these students with additional or special instruction. In Luxembourg, the likelihood of failure in school is particularly high. Taking this result into account, this paper deals with the identification of variables of primary…

Compress knee arthroplasty has 80% 10-year survivorship and novel forms of bone failure.

PubMed

Healey, John H; Morris, Carol D; Athanasian, Edward A; Boland, Patrick J

2013-03-01

Compliant, self-adjusting compression technology is a novel approach for durable prosthetic fixation of the knee. However, the long-term survival of these constructs is unknown. We therefore determined the survival of the Compress prosthesis (Biomet Inc, Warsaw, IN, USA) at 5 and 10 actuarial years and identified the failure modes for this form of prosthetic fixation. We retrospectively reviewed clinical and radiographic records for all 82 patients who underwent Compress knee arthroplasty from 1998 to 2008, as well as one patient who received the device elsewhere but was followed at our institution. Prosthesis survivorship and modes of failure were determined. Followup was for a minimum of 12 months or until implant removal (median, 43 months; range, 6-131 months); 28 patients were followed for more than 5 years. We found a survivorship of 85% at 5 years and 80% at 10 years. Eight patients required prosthetic revision after interface failure due to aseptic loosening alone (n = 3) or aseptic loosening with periprosthetic fracture (n = 5). Additionally, five periprosthetic bone failures occurred that did not require revision: three patients had periprosthetic bone failure without fixation compromise and two exhibited irregular prosthetic osteointegration patterns with concomitant fracture due to mechanical insufficiency. Compress prosthetic fixation after distal femoral tumor resection exhibits long-term survivorship. Implant failure was associated with patient nonadherence to the recommended weightbearing proscription or with bone necrosis and fracture. We conclude this is the most durable FDA-approved fixation method for distal femoral megaprostheses. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

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

NASA Technical Reports Server (NTRS)

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

1988-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1990-01-01

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

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

NASA Technical Reports Server (NTRS)

Ko, William L.

1999-01-01

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

Apollo CSM Power Generation System Design Considerations, Failure Modes and Lessons Learned

NASA Technical Reports Server (NTRS)

Interbartolo, Michael

2009-01-01

The objectives of this slide presentation are to: review the basic design criteria for fuel cells (FC's), review design considerations during developmental phase that affected Block I and Block II vehicles, summarize the conditions that led to the failure of components in the FC's, and state the solution implemented for each failure. It reviews the location of the fuel cells, the fuel cell theory the design criteria going into development phase and coming from the development phase, failures and solutions of Block I and II, and the lessons learned.

Mode 2 fatigue crack growth specimen development

NASA Technical Reports Server (NTRS)

Buzzard, R. J.; Gross, B.; Srawley, J. E.

1983-01-01

A Mode II test specimen was developed which has potential application in understanding phemonena associated with mixed mode fatigue failures in high performance aircraft engine bearing races. The attributes of the specimen are: it contains one single ended notch, which simplifiers data gathering and reduction; the fatigue crack grous in-line with the direction of load application; a single axis test machine is sufficient to perform testing; and the Mode I component is vanishingly small.

Epigenome-Wide Association Study Identifies Cardiac Gene Patterning and a Novel Class of Biomarkers for Heart Failure.

PubMed

Meder, Benjamin; Haas, Jan; Sedaghat-Hamedani, Farbod; Kayvanpour, Elham; Frese, Karen; Lai, Alan; Nietsch, Rouven; Scheiner, Christina; Mester, Stefan; Bordalo, Diana Martins; Amr, Ali; Dietrich, Carsten; Pils, Dietmar; Siede, Dominik; Hund, Hauke; Bauer, Andrea; Holzer, Daniel Benjamin; Ruhparwar, Arjang; Mueller-Hennessen, Matthias; Weichenhan, Dieter; Plass, Christoph; Weis, Tanja; Backs, Johannes; Wuerstle, Maximilian; Keller, Andreas; Katus, Hugo A; Posch, Andreas E

2017-10-17

Biochemical DNA modification resembles a crucial regulatory layer among genetic information, environmental factors, and the transcriptome. To identify epigenetic susceptibility regions and novel biomarkers linked to myocardial dysfunction and heart failure, we performed the first multi-omics study in myocardial tissue and blood of patients with dilated cardiomyopathy and controls. Infinium human methylation 450 was used for high-density epigenome-wide mapping of DNA methylation in left-ventricular biopsies and whole peripheral blood of living probands. RNA deep sequencing was performed on the same samples in parallel. Whole-genome sequencing of all patients allowed exclusion of promiscuous genotype-induced methylation calls. In the screening stage, we detected 59 epigenetic loci that are significantly associated with dilated cardiomyopathy (false discovery corrected P ≤0.05), with 3 of them reaching epigenome-wide significance at P ≤5×10 -8 . Twenty-seven (46%) of these loci could be replicated in independent cohorts, underlining the role of epigenetic regulation of key cardiac transcription regulators. Using a staged multi-omics study design, we link a subset of 517 epigenetic loci with dilated cardiomyopathy and cardiac gene expression. Furthermore, we identified distinct epigenetic methylation patterns that are conserved across tissues, rendering these CpGs novel epigenetic biomarkers for heart failure. The present study provides to our knowledge the first epigenome-wide association study in living patients with heart failure using a multi-omics approach. © 2017 American Heart Association, Inc.

A fuzzy Petri-net-based mode identification algorithm for fault diagnosis of complex systems

NASA Astrophysics Data System (ADS)

Propes, Nicholas C.; Vachtsevanos, George

2003-08-01

Complex dynamical systems such as aircraft, manufacturing systems, chillers, motor vehicles, submarines, etc. exhibit continuous and event-driven dynamics. These systems undergo several discrete operating modes from startup to shutdown. For example, a certain shipboard system may be operating at half load or full load or may be at start-up or shutdown. Of particular interest are extreme or "shock" operating conditions, which tend to severely impact fault diagnosis or the progression of a fault leading to a failure. Fault conditions are strongly dependent on the operating mode. Therefore, it is essential that in any diagnostic/prognostic architecture, the operating mode be identified as accurately as possible so that such functions as feature extraction, diagnostics, prognostics, etc. can be correlated with the predominant operating conditions. This paper introduces a mode identification methodology that incorporates both time- and event-driven information about the process. A fuzzy Petri net is used to represent the possible successive mode transitions and to detect events from processed sensor signals signifying a mode change. The operating mode is initialized and verified by analysis of the time-driven dynamics through a fuzzy logic classifier. An evidence combiner module is used to combine the results from both the fuzzy Petri net and the fuzzy logic classifier to determine the mode. Unlike most event-driven mode identifiers, this architecture will provide automatic mode initialization through the fuzzy logic classifier and robustness through the combining of evidence of the two algorithms. The mode identification methodology is applied to an AC Plant typically found as a component of a shipboard system.

Are your students ready for anatomy and physiology? Developing tools to identify students at risk for failure.

PubMed

Gultice, Amy; Witham, Ann; Kallmeyer, Robert

2015-06-01

High failure rates in introductory college science courses, including anatomy and physiology, are common at institutions across the country, and determining the specific factors that contribute to this problem is challenging. To identify students at risk for failure in introductory physiology courses at our open-enrollment institution, an online pilot survey was administered to 200 biology students. The survey results revealed several predictive factors related to academic preparation and prompted a comprehensive analysis of college records of >2,000 biology students over a 5-yr period. Using these historical data, a model that was 91% successful in predicting student success in these courses was developed. The results of the present study support the use of surveys and similar models to identify at-risk students and to provide guidance in the development of evidence-based advising programs and pedagogies. This comprehensive approach may be a tangible step in improving student success for students from a wide variety of backgrounds in anatomy and physiology courses. Copyright © 2015 The American Physiological Society.

Transient analysis mode participation for modal survey target mode selection using MSC/NASTRAN DMAP

NASA Technical Reports Server (NTRS)

Barnett, Alan R.; Ibrahim, Omar M.; Sullivan, Timothy L.; Goodnight, Thomas W.

1994-01-01

Many methods have been developed to aid analysts in identifying component modes which contribute significantly to component responses. These modes, typically targeted for dynamic model correlation via a modal survey, are known as target modes. Most methods used to identify target modes are based on component global dynamic behavior. It is sometimes unclear if these methods identify all modes contributing to responses important to the analyst. These responses are usually those in areas of hardware design concerns. One method used to check the completeness of target mode sets and identify modes contributing significantly to important component responses is mode participation. With this method, the participation of component modes in dynamic responses is quantified. Those modes which have high participation are likely modal survey target modes. Mode participation is most beneficial when it is used with responses from analyses simulating actual flight events. For spacecraft, these responses are generated via a structural dynamic coupled loads analysis. Using MSC/NASTRAN DMAP, a method has been developed for calculating mode participation based on transient coupled loads analysis results. The algorithm has been implemented to be compatible with an existing coupled loads methodology and has been used successfully to develop a set of modal survey target modes.