Operational Interventions to Maintenance Error
NASA Technical Reports Server (NTRS)
Kanki, Barbara G.; Walter, Diane; Dulchinos, VIcki
1997-01-01
A significant proportion of aviation accidents and incidents are known to be tied to human error. However, research of flight operational errors has shown that so-called pilot error often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the team7 concept for maintenance operations and in tailoring programs to fit the needs of technical opeRAtions. Nevertheless, there remains a dual challenge: 1) to develop human factors interventions which are directly supported by reliable human error data, and 2) to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.
Reduction of Maintenance Error Through Focused Interventions
NASA Technical Reports Server (NTRS)
Kanki, Barbara G.; Walter, Diane; Rosekind, Mark R. (Technical Monitor)
1997-01-01
It is well known that a significant proportion of aviation accidents and incidents are tied to human error. In flight operations, research of operational errors has shown that so-called "pilot error" often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the "team" concept for maintenance operations and in tailoring programs to fit the needs of technical operations. Nevertheless, there remains a dual challenge: to develop human factors interventions which are directly supported by reliable human error data, and to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.
The contributions of human factors on human error in Malaysia aviation maintenance industries
NASA Astrophysics Data System (ADS)
Padil, H.; Said, M. N.; Azizan, A.
2018-05-01
Aviation maintenance is a multitasking activity in which individuals perform varied tasks under constant pressure to meet deadlines as well as challenging work conditions. These situational characteristics combined with human factors can lead to various types of human related errors. The primary objective of this research is to develop a structural relationship model that incorporates human factors, organizational factors, and their impact on human errors in aviation maintenance. Towards that end, a questionnaire was developed which was administered to Malaysian aviation maintenance professionals. Structural Equation Modelling (SEM) approach was used in this study utilizing AMOS software. Results showed that there were a significant relationship of human factors on human errors and were tested in the model. Human factors had a partial effect on organizational factors while organizational factors had a direct and positive impact on human errors. It was also revealed that organizational factors contributed to human errors when coupled with human factors construct. This study has contributed to the advancement of knowledge on human factors effecting safety and has provided guidelines for improving human factors performance relating to aviation maintenance activities and could be used as a reference for improving safety performance in the Malaysian aviation maintenance companies.
Chiu, Ming-Chuan; Hsieh, Min-Chih
2016-05-01
The purposes of this study were to develop a latent human error analysis process, to explore the factors of latent human error in aviation maintenance tasks, and to provide an efficient improvement strategy for addressing those errors. First, we used HFACS and RCA to define the error factors related to aviation maintenance tasks. Fuzzy TOPSIS with four criteria was applied to evaluate the error factors. Results show that 1) adverse physiological states, 2) physical/mental limitations, and 3) coordination, communication, and planning are the factors related to airline maintenance tasks that could be addressed easily and efficiently. This research establishes a new analytic process for investigating latent human error and provides a strategy for analyzing human error using fuzzy TOPSIS. Our analysis process complements shortages in existing methodologies by incorporating improvement efficiency, and it enhances the depth and broadness of human error analysis methodology. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.
Associations between errors and contributing factors in aircraft maintenance
NASA Technical Reports Server (NTRS)
Hobbs, Alan; Williamson, Ann
2003-01-01
In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.
Identifying Human Factors Issues in Aircraft Maintenance Operations
NASA Technical Reports Server (NTRS)
Veinott, Elizabeth S.; Kanki, Barbara G.; Shafto, Michael G. (Technical Monitor)
1995-01-01
Maintenance operations incidents submitted to the Aviation Safety Reporting System (ASRS) between 1986-1992 were systematically analyzed in order to identify issues relevant to human factors and crew coordination. This exploratory analysis involved 95 ASRS reports which represented a wide range of maintenance incidents. The reports were coded and analyzed according to the type of error (e.g, wrong part, procedural error, non-procedural error), contributing factors (e.g., individual, within-team, cross-team, procedure, tools), result of the error (e.g., aircraft damage or not) as well as the operational impact (e.g., aircraft flown to destination, air return, delay at gate). The main findings indicate that procedural errors were most common (48.4%) and that individual and team actions contributed to the errors in more than 50% of the cases. As for operational results, most errors were either corrected after landing at the destination (51.6%) or required the flight crew to stop enroute (29.5%). Interactions among these variables are also discussed. This analysis is a first step toward developing a taxonomy of crew coordination problems in maintenance. By understanding what variables are important and how they are interrelated, we may develop intervention strategies that are better tailored to the human factor issues involved.
NASA Technical Reports Server (NTRS)
Mattson, Marifran; Petrin, Donald A.; Young, John P.
2001-01-01
The study of human factors has had a decisive impact on the aviation industry. However, the entire aviation system often is not considered in researching, training, and evaluating human factors issues especially with regard to safety. In both conceptual and practical terms, we argue for the proactive management of human error from both an individual and organizational systems perspective. The results of a multidisciplinary research project incorporating survey data from professional pilots and maintenance technicians and an exploratory study integrating students from relevant disciplines are reported. Survey findings suggest that latent safety errors may occur during the maintenance discrepancy reporting process because pilots and maintenance technicians do not effectively interact with one another. The importance of interdepartmental or cross-disciplinary training for decreasing these errors and increasing safety is discussed as a primary implication.
Spacecraft and propulsion technician error
NASA Astrophysics Data System (ADS)
Schultz, Daniel Clyde
Commercial aviation and commercial space similarly launch, fly, and land passenger vehicles. Unlike aviation, the U.S. government has not established maintenance policies for commercial space. This study conducted a mixed methods review of 610 U.S. space launches from 1984 through 2011, which included 31 failures. An analysis of the failure causal factors showed that human error accounted for 76% of those failures, which included workmanship error accounting for 29% of the failures. With the imminent future of commercial space travel, the increased potential for the loss of human life demands that changes be made to the standardized procedures, training, and certification to reduce human error and failure rates. Several recommendations were made by this study to the FAA's Office of Commercial Space Transportation, space launch vehicle operators, and maintenance technician schools in an effort to increase the safety of the space transportation passengers.
A circadian rhythm in skill-based errors in aviation maintenance.
Hobbs, Alan; Williamson, Ann; Van Dongen, Hans P A
2010-07-01
In workplaces where activity continues around the clock, human error has been observed to exhibit a circadian rhythm, with a characteristic peak in the early hours of the morning. Errors are commonly distinguished by the nature of the underlying cognitive failure, particularly the level of intentionality involved in the erroneous action. The Skill-Rule-Knowledge (SRK) framework of Rasmussen is used widely in the study of industrial errors and accidents. The SRK framework describes three fundamental types of error, according to whether behavior is under the control of practiced sensori-motor skill routines with minimal conscious awareness; is guided by implicit or explicit rules or expertise; or where the planning of actions requires the conscious application of domain knowledge. Up to now, examinations of circadian patterns of industrial errors have not distinguished between different types of error. Consequently, it is not clear whether all types of error exhibit the same circadian rhythm. A survey was distributed to aircraft maintenance personnel in Australia. Personnel were invited to anonymously report a safety incident and were prompted to describe, in detail, the human involvement (if any) that contributed to it. A total of 402 airline maintenance personnel reported an incident, providing 369 descriptions of human error in which the time of the incident was reported and sufficient detail was available to analyze the error. Errors were categorized using a modified version of the SRK framework, in which errors are categorized as skill-based, rule-based, or knowledge-based, or as procedure violations. An independent check confirmed that the SRK framework had been applied with sufficient consistency and reliability. Skill-based errors were the most common form of error, followed by procedure violations, rule-based errors, and knowledge-based errors. The frequency of errors was adjusted for the estimated proportion of workers present at work/each hour of the day, and the 24 h pattern of each error type was examined. Skill-based errors exhibited a significant circadian rhythm, being most prevalent in the early hours of the morning. Variation in the frequency of rule-based errors, knowledge-based errors, and procedure violations over the 24 h did not reach statistical significance. The results suggest that during the early hours of the morning, maintenance technicians are at heightened risk of "absent minded" errors involving failures to execute action plans as intended.
Wiegmann, D A; Shappell, S A
2001-11-01
The Human Factors Analysis and Classification System (HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing the human causes of aviation accidents. Based on Reason's (1990) model of latent and active failures, HFACS addresses human error at all levels of the system, including the condition of aircrew and organizational factors. The purpose of the present study was to assess the utility of the HFACS framework as an error analysis and classification tool outside the military. The HFACS framework was used to analyze human error data associated with aircrew-related commercial aviation accidents that occurred between January 1990 and December 1996 using database records maintained by the NTSB and the FAA. Investigators were able to reliably accommodate all the human causal factors associated with the commercial aviation accidents examined in this study using the HFACS system. In addition, the classification of data using HFACS highlighted several critical safety issues in need of intervention research. These results demonstrate that the HFACS framework can be a viable tool for use within the civil aviation arena. However, additional research is needed to examine its applicability to areas outside the flight deck, such as aircraft maintenance and air traffic control domains.
The Development and Deployment of a Maintenance Operations Safety Survey.
Langer, Marie; Braithwaite, Graham R
2016-11-01
Based on the line operations safety audit (LOSA), two studies were conducted to develop and deploy an equivalent tool for aircraft maintenance: the maintenance operations safety survey (MOSS). Safety in aircraft maintenance is currently measured reactively, based on the number of audit findings, reportable events, incidents, or accidents. Proactive safety tools designed for monitoring routine operations, such as flight data monitoring and LOSA, have been developed predominantly for flight operations. In Study 1, development of MOSS, 12 test peer-to-peer observations were collected to investigate the practicalities of this approach. In Study 2, deployment of MOSS, seven expert observers collected 56 peer-to-peer observations of line maintenance checks at four stations. Narrative data were coded and analyzed according to the threat and error management (TEM) framework. In Study 1, a line check was identified as a suitable unit of observation. Communication and third-party data management were the key factors in gaining maintainer trust. Study 2 identified that on average, maintainers experienced 7.8 threats (operational complexities) and committed 2.5 errors per observation. The majority of threats and errors were inconsequential. Links between specific threats and errors leading to 36 undesired states were established. This research demonstrates that observations of routine maintenance operations are feasible. TEM-based results highlight successful management strategies that maintainers employ on a day-to-day basis. MOSS is a novel approach for safety data collection and analysis. It helps practitioners understand the nature of maintenance errors, promote an informed culture, and support safety management systems in the maintenance domain. © 2016, Human Factors and Ergonomics Society.
Unsafe acts and unsafe outcomes in aircraft maintenance
NASA Technical Reports Server (NTRS)
Hobbs, Alan; Williamson, Ann
2002-01-01
Road safety studies using the Driver Behaviour Questionnaire (DBQ) have provided support for a three-way distinction between violations, skill-based errors and mistakes, and have indicated that a tendency to commit driving violations is associated with an increased risk of accident involvement. The aims of this study were to examine whether the three-way distinction of unsafe acts is applicable in the context of aircraft maintenance, and whether involvement in maintenance safety occurrences can be predicted on the basis of self-reported unsafe acts. A Maintenance Behaviour Questionnaire (MBQ) was developed to explore patterns of unsafe acts committed by aircraft maintenance mechanics. The MBQ was completed anonymously by over 1300 Australian aviation mechanics, who also provided information on their involvement in workplace accidents and incidents. Four factors were identified: routine violations, skill-based errors, mistakes and exceptional violations. Violations and mistakes were related significantly to the occurrence of incidents that jeopardized the quality of aircraft maintenance, but were not related to workplace injuries. Skill-based errors, while not related to work quality incidents, were related to workplace injuries. The results are consistent with the three-way typology of unsafe acts described by Reason et al. (1990) and with the DBQ research indicating an association between self-reported violations and accidents. The current findings suggest that interventions addressed at maintenance quality incidents should take into account the role of violations and mistakes, and the factors that promote them. In contrast, interventions directed at reducing workplace injury are likely to require a focus on skill-based errors.
EHR Improvement Using Incident Reports.
Teame, Tesfay; Stålhane, Tor; Nytrø, Øystein
2017-01-01
This paper discusses reactive improvement of clinical software using methods for incident analysis. We used the "Five Whys" method because we had only descriptive data and depended on a domain expert for the analysis. The analysis showed that there are two major root causes for EHR software failure, and that they are related to human and organizational errors. A main identified improvement is allocating more resources to system maintenance and user training.
Neural evidence for enhanced error detection in major depressive disorder.
Chiu, Pearl H; Deldin, Patricia J
2007-04-01
Anomalies in error processing have been implicated in the etiology and maintenance of major depressive disorder. In particular, depressed individuals exhibit heightened sensitivity to error-related information and negative environmental cues, along with reduced responsivity to positive reinforcers. The authors examined the neural activation associated with error processing in individuals diagnosed with and without major depression and the sensitivity of these processes to modulation by monetary task contingencies. The error-related negativity and error-related positivity components of the event-related potential were used to characterize error monitoring in individuals with major depressive disorder and the degree to which these processes are sensitive to modulation by monetary reinforcement. Nondepressed comparison subjects (N=17) and depressed individuals (N=18) performed a flanker task under two external motivation conditions (i.e., monetary reward for correct responses and monetary loss for incorrect responses) and a nonmonetary condition. After each response, accuracy feedback was provided. The error-related negativity component assessed the degree of anomaly in initial error detection, and the error positivity component indexed recognition of errors. Across all conditions, the depressed participants exhibited greater amplitude of the error-related negativity component, relative to the comparison subjects, and equivalent error positivity amplitude. In addition, the two groups showed differential modulation by task incentives in both components. These data implicate exaggerated early error-detection processes in the etiology and maintenance of major depressive disorder. Such processes may then recruit excessive neural and cognitive resources that manifest as symptoms of depression.
A Grounded Theory Study of Aircraft Maintenance Technician Decision-Making
NASA Astrophysics Data System (ADS)
Norcross, Robert
Aircraft maintenance technician decision-making and actions have resulted in aircraft system errors causing aircraft incidents and accidents. Aircraft accident investigators and researchers examined the factors that influence aircraft maintenance technician errors and categorized the types of errors in an attempt to prevent similar occurrences. New aircraft technology introduced to improve aviation safety and efficiency incur failures that have no information contained in the aircraft maintenance manuals. According to the Federal Aviation Administration, aircraft maintenance technicians must use only approved aircraft maintenance documents to repair, modify, and service aircraft. This qualitative research used a grounded theory approach to explore the decision-making processes and actions taken by aircraft maintenance technicians when confronted with an aircraft problem not contained in the aircraft maintenance manuals. The target population for the research was Federal Aviation Administration licensed aircraft and power plant mechanics from across the United States. Nonprobability purposeful sampling was used to obtain aircraft maintenance technicians with the experience sought in the study problem. The sample population recruitment yielded 19 participants for eight focus group sessions to obtain opinions, perceptions, and experiences related to the study problem. All data collected was entered into the Atlas ti qualitative analysis software. The emergence of Aircraft Maintenance Technician decision-making themes regarding Aircraft Maintenance Manual content, Aircraft Maintenance Technician experience, and legal implications of not following Aircraft Maintenance Manuals surfaced. Conclusions from this study suggest Aircraft Maintenance Technician decision-making were influenced by experience, gaps in the Aircraft Maintenance Manuals, reliance on others, realizing the impact of decisions concerning aircraft airworthiness, management pressures, and legal concerns related to decision-making. Recommendations included an in-depth systematic review of the Aircraft Maintenance Manuals, development of a Federal Aviation Administration approved standardized Aircraft Maintenance Technician decision-making flow diagram, and implementation of risk based decision-making training. The benefit of this study is to save the airline industry revenue by preventing poor decision-making practices that result in inefficient maintenance actions and aircraft incidents and accidents.
Skills, rules and knowledge in aircraft maintenance: errors in context
NASA Technical Reports Server (NTRS)
Hobbs, Alan; Williamson, Ann
2002-01-01
Automatic or skill-based behaviour is generally considered to be less prone to error than behaviour directed by conscious control. However, researchers who have applied Rasmussen's skill-rule-knowledge human error framework to accidents and incidents have sometimes found that skill-based errors appear in significant numbers. It is proposed that this is largely a reflection of the opportunities for error which workplaces present and does not indicate that skill-based behaviour is intrinsically unreliable. In the current study, 99 errors reported by 72 aircraft mechanics were examined in the light of a task analysis based on observations of the work of 25 aircraft mechanics. The task analysis identified the opportunities for error presented at various stages of maintenance work packages and by the job as a whole. Once the frequency of each error type was normalized in terms of the opportunities for error, it became apparent that skill-based performance is more reliable than rule-based performance, which is in turn more reliable than knowledge-based performance. The results reinforce the belief that industrial safety interventions designed to reduce errors would best be directed at those aspects of jobs that involve rule- and knowledge-based performance.
ERIC Educational Resources Information Center
Yordanova, Juliana; Albrecht, Bjorn; Uebel, Henrik; Kirov, Roumen; Banaschewski, Tobias; Rothenberger, Aribert; Kolev, Vasil
2011-01-01
The maintenance of stable goal-directed behaviour is a hallmark of conscious executive control in humans. Notably, both correct and error human actions may have a subconscious activation-based determination. One possible source of subconscious interference may be the default mode network that, in contrast to attentional network, manifests…
Integration of MSFC Usability Lab with Usability Testing
NASA Technical Reports Server (NTRS)
Cheng, Yiwei; Richardson, Sally
2010-01-01
As part of the Stage Analysis Branch, human factors engineering plays an important role in relating humans to the systems of hardware and structure designs of the new launch vehicle. While many branches are involved in the technical aspects of creating a launch vehicle, human factors connects humans to the scientific systems with the goal of improving operational performance and safety while reducing operational error and damage to the hardware. Human factors engineers use physical and computerized models to visualize possible areas for improvements to ensure human accessibility to components requiring maintenance and that the necessary maintenance activities can be accomplished with minimal risks to human and hardware. Many methods of testing are used to fulfill this goal, such as physical mockups, computerized visualization, and usability testing. In this analysis, a usability test is conducted to test how usable a website is to users who are and are not familiar with it. The testing is performed using participants and Morae software to record and analyze the results. This analysis will be a preliminary test of the usability lab in preparation for use in new spacecraft programs, NASA Enterprise, or other NASA websites. The usability lab project is divided into two parts: integration of the usability lab and a preliminary test of the usability lab.
Identification of the human factors contributing to maintenance failures in a petroleum operation.
Antonovsky, Ari; Pollock, Clare; Straker, Leon
2014-03-01
This research aimed to identify the most frequently occurring human factors contributing to maintenance-related failures within a petroleum industry organization. Commonality between failures will assist in understanding reliability in maintenance processes, thereby preventing accidents in high-hazard domains. Methods exist for understanding the human factors contributing to accidents. Their application in a maintenance context mainly has been advanced in aviation and nuclear power. Maintenance in the petroleum industry provides a different context for investigating the role that human factors play in influencing outcomes. It is therefore worth investigating the contributing human factors to improve our understanding of both human factors in reliability and the factors specific to this domain. Detailed analyses were conducted of maintenance-related failures (N = 38) in a petroleum company using structured interviews with maintenance technicians. The interview structure was based on the Human Factor Investigation Tool (HFIT), which in turn was based on Rasmussen's model of human malfunction. A mean of 9.5 factors per incident was identified across the cases investigated.The three most frequent human factors contributing to the maintenance failures were found to be assumption (79% of cases), design and maintenance (71%), and communication (66%). HFIT proved to be a useful instrument for identifying the pattern of human factors that recurred most frequently in maintenance-related failures. The high frequency of failures attributed to assumptions and communication demonstrated the importance of problem-solving abilities and organizational communication in a domain where maintenance personnel have a high degree of autonomy and a wide geographical distribution.
Dawson, Drew; Cleggett, Courtney; Thompson, Kirrilly; Thomas, Matthew J W
2017-02-01
In the military or emergency services, operational requirements and/or community expectations often preclude formal prescriptive working time arrangements as a practical means of reducing fatigue-related risk. In these environments, workers sometimes employ adaptive or protective behaviours informally to reduce the risk (i.e. likelihood or consequence) associated with a fatigue-related error. These informal behaviours enable employees to reduce risk while continuing to work while fatigued. In this study, we documented the use of informal protective behaviours in a group of defence aviation personnel including flight crews. Semi-structured interviews were conducted to determine whether and which protective behaviours were used to mitigate fatigue-related error. The 18 participants were from aviation-specific trades and included aircrew (pilots and air-crewman) and aviation maintenance personnel (aeronautical engineers and maintenance personnel). Participants identified 147 ways in which they and/or others act to reduce the likelihood or consequence of a fatigue-related error. These formed seven categories of fatigue-reduction strategies. The two most novel categories are discussed in this paper: task-related and behaviour-based strategies. Broadly speaking, these results indicate that fatigued military flight and maintenance crews use protective 'fatigue-proofing' behaviours to reduce the likelihood and/or consequence of fatigue-related error and were aware of the potential benefits. It is also important to note that these behaviours are not typically part of the formal safety management system. Rather, they have evolved spontaneously as part of the culture around protecting team performance under adverse operating conditions. When compared with previous similar studies, aviation personnel were more readily able to understand the idea of fatigue proofing than those from a fire-fighting background. These differences were thought to reflect different cultural attitudes toward error and formal training using principles of Crew Resource Management and Threat and Error Management. Copyright © 2015 Elsevier Ltd. All rights reserved.
Human Factors in Aircraft Maintenance
2001-03-01
795 - 3-798. Reason, J . (1990). Human Error. Cambridge: Cambridge University Press. Schmidt, J ., Schmorrow, D . and Figlock, R. (2000). Human factors...and so on. When each step is described in sufficient detail, the task description is complete and task analysis can begin (e.g. Drury, Paramore , Van... Paramore , B., Van Cott, H.P., Grey, S.M. and Corlett, E.M.(1987). Task analysis. In G. Salvendy (Ed) Handbook of Human Factors, Chapter 3.4. New
Architecture and Key Techniques of Augmented Reality Maintenance Guiding System for Civil Aircrafts
NASA Astrophysics Data System (ADS)
hong, Zhou; Wenhua, Lu
2017-01-01
Augmented reality technology is introduced into the maintenance related field for strengthened information in real-world scenarios through integration of virtual assistant maintenance information with real-world scenarios. This can lower the difficulty of maintenance, reduce maintenance errors, and improve the maintenance efficiency and quality of civil aviation crews. Architecture of augmented reality virtual maintenance guiding system is proposed on the basis of introducing the definition of augmented reality and analyzing the characteristics of augmented reality virtual maintenance. Key techniques involved, such as standardization and organization of maintenance data, 3D registration, modeling of maintenance guidance information and virtual maintenance man-machine interaction, are elaborated emphatically, and solutions are given.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Lon N. Haney; David I. Gertman
2003-04-01
Beginning in the 1980s a primary focus of human reliability analysis was estimation of human error probabilities. However, detailed qualitative modeling with comprehensive representation of contextual variables often was lacking. This was likely due to the lack of comprehensive error and performance shaping factor taxonomies, and the limited data available on observed error rates and their relationship to specific contextual variables. In the mid 90s Boeing, America West Airlines, NASA Ames Research Center and INEEL partnered in a NASA sponsored Advanced Concepts grant to: assess the state of the art in human error analysis, identify future needs for human errormore » analysis, and develop an approach addressing these needs. Identified needs included the need for a method to identify and prioritize task and contextual characteristics affecting human reliability. Other needs identified included developing comprehensive taxonomies to support detailed qualitative modeling and to structure meaningful data collection efforts across domains. A result was the development of the FRamework Assessing Notorious Contributing Influences for Error (FRANCIE) with a taxonomy for airline maintenance tasks. The assignment of performance shaping factors to generic errors by experts proved to be valuable to qualitative modeling. Performance shaping factors and error types from such detailed approaches can be used to structure error reporting schemes. In a recent NASA Advanced Human Support Technology grant FRANCIE was refined, and two new taxonomies for use on space missions were developed. The development, sharing, and use of error taxonomies, and the refinement of approaches for increased fidelity of qualitative modeling is offered as a means to help direct useful data collection strategies.« less
ERIC Educational Resources Information Center
Miller, A. Eve; Watson, Jason M.; Strayer, David L.
2012-01-01
Neuroscience suggests that the anterior cingulate cortex (ACC) is responsible for conflict monitoring and the detection of errors in cognitive tasks, thereby contributing to the implementation of attentional control. Though individual differences in frontally mediated goal maintenance have clearly been shown to influence outward behavior in…
Distinct brain networks for adaptive and stable task control in humans
Dosenbach, Nico U. F.; Fair, Damien A.; Miezin, Francis M.; Cohen, Alexander L.; Wenger, Kristin K.; Dosenbach, Ronny A. T.; Fox, Michael D.; Snyder, Abraham Z.; Vincent, Justin L.; Raichle, Marcus E.; Schlaggar, Bradley L.; Petersen, Steven E.
2007-01-01
Control regions in the brain are thought to provide signals that configure the brain's moment-to-moment information processing. Previously, we identified regions that carried signals related to task-control initiation, maintenance, and adjustment. Here we characterize the interactions of these regions by applying graph theory to resting state functional connectivity MRI data. In contrast to previous, more unitary models of control, this approach suggests the presence of two distinct task-control networks. A frontoparietal network included the dorsolateral prefrontal cortex and intraparietal sulcus. This network emphasized start-cue and error-related activity and may initiate and adapt control on a trial-by-trial basis. The second network included dorsal anterior cingulate/medial superior frontal cortex, anterior insula/frontal operculum, and anterior prefrontal cortex. Among other signals, these regions showed activity sustained across the entire task epoch, suggesting that this network may control goal-directed behavior through the stable maintenance of task sets. These two independent networks appear to operate on different time scales and affect downstream processing via dissociable mechanisms. PMID:17576922
Nelson, Richard E; Angelovic, Aaron W; Nelson, Scott D; Gleed, Jeremy R; Drews, Frank A
2015-05-01
Adherence engineering applies human factors principles to examine non-adherence within a specific task and to guide the development of materials or equipment to increase protocol adherence and reduce human error. Central line maintenance (CLM) for intensive care unit (ICU) patients is a task through which error or non-adherence to protocols can cause central line-associated bloodstream infections (CLABSIs). We conducted an economic analysis of an adherence engineering CLM kit designed to improve the CLM task and reduce the risk of CLABSI. We constructed a Markov model to compare the cost-effectiveness of the CLM kit, which contains each of the 27 items necessary for performing the CLM procedure, compared with the standard care procedure for CLM, in which each item for dressing maintenance is gathered separately. We estimated the model using the cost of CLABSI overall ($45,685) as well as the excess LOS (6.9 excess ICU days, 3.5 excess general ward days). Assuming the CLM kit reduces the risk of CLABSI by 100% and 50%, this strategy was less costly (cost savings between $306 and $860) and more effective (between 0.05 and 0.13 more quality-adjusted life-years) compared with not using the pre-packaged kit. We identified threshold values for the effectiveness of the kit in reducing CLABSI for which the kit strategy was no longer less costly. An adherence engineering-based intervention to streamline the CLM process can improve patient outcomes and lower costs. Patient safety can be improved by adopting new approaches that are based on human factors principles.
2001-09-01
of MEIMS was programmed in Microsoft Access 97 using Visual Basic for Applications ( VBA ). This prototype had very little documentation. The FAA...using Acess 2000 as an interface and SQL server as the database engine. Question 1: Did you have any problems accessing the program? Y / N
Recent Advances in Thermoregulation
ERIC Educational Resources Information Center
Tansey, Etain A.; Johnson, Christopher D.
2015-01-01
Thermoregulation is the maintenance of a relatively constant core body temperature. Humans normally maintain a body temperature at 37°C, and maintenance of this relatively high temperature is critical to human survival. This concept is so important that control of thermoregulation is often the principal example cited when teaching physiological…
Garrison, Laurel E; Kunz, Jasen M; Cooley, Laura A; Moore, Matthew R; Lucas, Claressa; Schrag, Stephanie; Sarisky, John; Whitney, Cynthia G
2016-06-10
The number of reported cases of Legionnaires' disease, a severe pneumonia caused by the bacterium Legionella, is increasing in the United States. During 2000-2014, the rate of reported legionellosis cases increased from 0.42 to 1.62 per 100,000 persons; 4% of reported cases were outbreak-associated. Legionella is transmitted through aerosolization of contaminated water. A new industry standard for prevention of Legionella growth and transmission in water systems in buildings was published in 2015. CDC investigated outbreaks of Legionnaires' disease to identify gaps in building water system maintenance and guide prevention efforts. Information from summaries of CDC Legionnaires' disease outbreak investigations during 2000-2014 was systematically abstracted, and water system maintenance deficiencies from land-based investigations were categorized as process failures, human errors, equipment failures, or unmanaged external changes. During 2000-2014, CDC participated in 38 field investigations of Legionnaires' disease. Among 27 land-based outbreaks, the median number of cases was 10 (range = 3-82) and median outbreak case fatality rate was 7% (range = 0%-80%). Sufficient information to evaluate maintenance deficiencies was available for 23 (85%) investigations. Of these, all had at least one deficiency; 11 (48%) had deficiencies in ≥2 categories. Fifteen cases (65%) were linked to process failures, 12 (52%) to human errors, eight (35%) to equipment failures, and eight (35%) to unmanaged external changes. Multiple common preventable maintenance deficiencies were identified in association with disease outbreaks, highlighting the importance of comprehensive water management programs for water systems in buildings. Properly implemented programs, as described in the new industry standard, could reduce Legionella growth and transmission, preventing Legionnaires' disease outbreaks and reducing disease.
The Development and Deployment of a Maintenance Operations Safety Survey
Langer, Marie; Braithwaite, Graham R.
2016-01-01
Objective: Based on the line operations safety audit (LOSA), two studies were conducted to develop and deploy an equivalent tool for aircraft maintenance: the maintenance operations safety survey (MOSS). Background: Safety in aircraft maintenance is currently measured reactively, based on the number of audit findings, reportable events, incidents, or accidents. Proactive safety tools designed for monitoring routine operations, such as flight data monitoring and LOSA, have been developed predominantly for flight operations. Method: In Study 1, development of MOSS, 12 test peer-to-peer observations were collected to investigate the practicalities of this approach. In Study 2, deployment of MOSS, seven expert observers collected 56 peer-to-peer observations of line maintenance checks at four stations. Narrative data were coded and analyzed according to the threat and error management (TEM) framework. Results: In Study 1, a line check was identified as a suitable unit of observation. Communication and third-party data management were the key factors in gaining maintainer trust. Study 2 identified that on average, maintainers experienced 7.8 threats (operational complexities) and committed 2.5 errors per observation. The majority of threats and errors were inconsequential. Links between specific threats and errors leading to 36 undesired states were established. Conclusion: This research demonstrates that observations of routine maintenance operations are feasible. TEM-based results highlight successful management strategies that maintainers employ on a day-to-day basis. Application: MOSS is a novel approach for safety data collection and analysis. It helps practitioners understand the nature of maintenance errors, promote an informed culture, and support safety management systems in the maintenance domain. PMID:27411354
NASA Astrophysics Data System (ADS)
Moan, T.
2017-12-01
An overview of integrity management of offshore structures, with emphasis on the oil and gas energy sector, is given. Based on relevant accident experiences and means to control the associated risks, accidents are categorized from a technical-physical as well as human and organizational point of view. Structural risk relates to extreme actions as well as structural degradation. Risk mitigation measures, including adequate design criteria, inspection, repair and maintenance as well as quality assurance and control of engineering processes, are briefly outlined. The current status of risk and reliability methodology to aid decisions in the integrity management is briefly reviewed. Finally, the need to balance the uncertainties in data, methods and computational efforts and the cautious use and quality assurance and control in applying high fidelity methods to avoid human errors, is emphasized, and with a plea to develop both high fidelity as well as efficient, simplified methods for design.
The concept of lifestyle factors, based on the teaching of avicenna (ibn sina).
Choopani, Rasool; Emtiazy, Majid
2015-01-01
According to the definition stated in the beginning of the "Al-Qanun fi al-Tibb" (the Qanun of Medicine); medicine is a science, from which one learns the states of the human body; health and disease and what causes them, in order to preserve good health when it exists, and restore it when it is lacking. Based on this issue, Avicenna believes that medical science belongs to all human without any limitation, and maintenance of health is one of its prime objectives. He states that many disorders are related to errors in the 6 factors, which are essential for maintaining health and preventing diseases. Avicenna described these six essential factors (lifestyle factors) in his masterpiece, Qanun of Medicine, as "Asbab-e-Settah-e-Zaruriah." Based on the teaching of Avicenna, the first step for maintaining health and approaches to treatment is modification of lifestyle factors, including of nutrition, physical activity, etc.
Predictive models of safety based on audit findings: Part 1: Model development and reliability.
Hsiao, Yu-Lin; Drury, Colin; Wu, Changxu; Paquet, Victor
2013-03-01
This consecutive study was aimed at the quantitative validation of safety audit tools as predictors of safety performance, as we were unable to find prior studies that tested audit validity against safety outcomes. An aviation maintenance domain was chosen for this work as both audits and safety outcomes are currently prescribed and regulated. In Part 1, we developed a Human Factors/Ergonomics classification framework based on HFACS model (Shappell and Wiegmann, 2001a,b), for the human errors detected by audits, because merely counting audit findings did not predict future safety. The framework was tested for measurement reliability using four participants, two of whom classified errors on 1238 audit reports. Kappa values leveled out after about 200 audits at between 0.5 and 0.8 for different tiers of errors categories. This showed sufficient reliability to proceed with prediction validity testing in Part 2. Copyright © 2012 Elsevier Ltd and The Ergonomics Society. All rights reserved.
A rose by any other name: Certification seen as process rather than content
NASA Technical Reports Server (NTRS)
Wilson, John R.
1994-01-01
Green (1990) believes that the two main factors safeguarding flying from human error are both related to certification and regulation. First is the increasingly proceduralized nature of flying whereby as much as possible is reduced to a rule-based activity. Second is the emphasis placed upon training and competency checking of aircrew in simulators and in the air, both generally and for all particular types of aircraft flown. This leaves, believes Green, other human factors that are relatively unaddressed as yet and which can give rise to human reliability problems. These include: hardware factors and especially pilot/co-pilot relationships; and system factors including fatigue and cost/safety trade-offs. He also, importantly, identifies problems with the integration of the 'electronic crew member' following increased automation. Human reliability failures with artificial intelligence and automation, due to over-reliance on the system fail-safe mechanisms, or to operator under- confidence in the integrity or self-regulating capacity of the system, or to out-of-loop effects, are widely accepted as being due to deficiencies in plant design, planning, management and maintenance more than to 'operator error' - Reason's (1990) latent error or organization pathogens argument. Reliability failures in complex systems are well enough documented to give cause for concern and at least promote a debate on the merits of a full certification program. The purpose of this short paper is to seek out and explore what is valuable in certification, at the least to show that the benefits outweigh the disadvantages and at best to identify positive outcomes perhaps not obtainable in other ways. On both sides of the debate on certification there is general agreement on the need for a better human factors perspective and effort in complex aviation systems design. What is at issue is how this is to be promoted. It is incumbent upon opponents of certification to say how else such promotion be enabled. This is an exploratory and philosophical review, not a focused and specific one, and it will draw upon much that is not firmly in the domain of complex aviation systems.
Völker, Martin; Fiederer, Lukas D J; Berberich, Sofie; Hammer, Jiří; Behncke, Joos; Kršek, Pavel; Tomášek, Martin; Marusič, Petr; Reinacher, Peter C; Coenen, Volker A; Helias, Moritz; Schulze-Bonhage, Andreas; Burgard, Wolfram; Ball, Tonio
2018-06-01
Error detection in motor behavior is a fundamental cognitive function heavily relying on local cortical information processing. Neural activity in the high-gamma frequency band (HGB) closely reflects such local cortical processing, but little is known about its role in error processing, particularly in the healthy human brain. Here we characterize the error-related response of the human brain based on data obtained with noninvasive EEG optimized for HGB mapping in 31 healthy subjects (15 females, 16 males), and additional intracranial EEG data from 9 epilepsy patients (4 females, 5 males). Our findings reveal a multiscale picture of the global and local dynamics of error-related HGB activity in the human brain. On the global level as reflected in the noninvasive EEG, the error-related response started with an early component dominated by anterior brain regions, followed by a shift to parietal regions, and a subsequent phase characterized by sustained parietal HGB activity. This phase lasted for more than 1 s after the error onset. On the local level reflected in the intracranial EEG, a cascade of both transient and sustained error-related responses involved an even more extended network, spanning beyond frontal and parietal regions to the insula and the hippocampus. HGB mapping appeared especially well suited to investigate late, sustained components of the error response, possibly linked to downstream functional stages such as error-related learning and behavioral adaptation. Our findings establish the basic spatio-temporal properties of HGB activity as a neural correlate of error processing, complementing traditional error-related potential studies. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.
The use of fault reporting of medical equipment to identify latent design flaws.
Flewwelling, C J; Easty, A C; Vicente, K J; Cafazzo, J A
2014-10-01
Poor device design that fails to adequately account for user needs, cognition, and behavior is often responsible for use errors resulting in adverse events. This poor device design is also often latent, and could be responsible for "No Fault Found" (NFF) reporting, in which medical devices sent for repair by clinical users are found to be operating as intended. Unresolved NFF reports may contribute to incident under reporting, clinical user frustration, and biomedical engineering technologist inefficacy. This study uses human factors engineering methods to investigate the relationship between NFF reporting frequency and device usability. An analysis of medical equipment maintenance data was conducted to identify devices with a high NFF reporting frequency. Subsequently, semi-structured interviews and heuristic evaluations were performed in order to identify potential usability issues. Finally, usability testing was conducted in order to validate that latent usability related design faults result in a higher frequency of NFF reporting. The analysis of medical equipment maintenance data identified six devices with a high NFF reporting frequency. Semi-structured interviews, heuristic evaluations and usability testing revealed that usability issues caused a significant portion of the NFF reports. Other factors suspected to contribute to increased NFF reporting include accessory issues, intermittent faults and environmental issues. Usability testing conducted on three of the devices revealed 23 latent usability related design faults. These findings demonstrate that latent usability related design faults manifest themselves as an increase in NFF reporting and that devices containing usability related design faults can be identified through an analysis of medical equipment maintenance data. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.
NASA Technical Reports Server (NTRS)
Alexander, Tiffaney Miller
2017-01-01
Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.
NASA Technical Reports Server (NTRS)
Alexander, Tiffaney Miller
2017-01-01
Research results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.
NASA Technical Reports Server (NTRS)
Alexander, Tiffaney Miller
2017-01-01
Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Quality within space exploration ground processing operations, the identification and or classification of underlying contributors and causes of human error must be identified, in order to manage human error.This presentation will provide a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.
45 CFR 1310.13 - Maintenance of vehicles.
Code of Federal Regulations, 2010 CFR
2010-10-01
... 45 Public Welfare 4 2010-10-01 2010-10-01 false Maintenance of vehicles. 1310.13 Section 1310.13 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION FOR CHILDREN, YOUTH AND FAMILIES, HEAD START...
45 CFR 1310.13 - Maintenance of vehicles.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 4 2011-10-01 2011-10-01 false Maintenance of vehicles. 1310.13 Section 1310.13 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION FOR CHILDREN, YOUTH AND FAMILIES, HEAD START...
Federal Register 2010, 2011, 2012, 2013, 2014
2010-06-03
... published in the Federal Register on May 12, 2006. The error resulted in an incorrect component maintenance... related investigative and corrective actions if necessary. DATES: This correction is effective June 3... wall-mounted cabin attendant seat, and related investigative and corrective actions if necessary. As...
Research on measurement of aviation magneto ignition strength and balance
NASA Astrophysics Data System (ADS)
Gao, Feng; He, Zhixiang; Zhang, Dingpeng
2017-12-01
Aviation magneto ignition system failure accounted for two-thirds of the total fault aviation piston engine and above. At present the method used for this failure diagnosis is often depended on the visual inspections in the civil aviation maintenance field. Due to human factors, the visual inspections cannot provide ignition intensity value and ignition equilibrium deviation value among the different spark plugs in the different cylinder of aviation piston engine. So air magneto ignition strength and balance testing has become an aviation piston engine maintenance technical problem needed to resolve. In this paper, the ultraviolet sensor with detection wavelength of 185~260nm and driving voltage of 320V DC is used as the core of ultraviolet detection to detect the ignition intensity of Aviation magneto ignition system and the balance deviation of the ignition intensity of each cylinder. The experimental results show that the rotational speed within the range 0 to 3500 RPM test error less than 0.34%, ignition strength analysis and calculation error is less than 0.13%, and measured the visual inspection is hard to distinguish between high voltage wire leakage failure of deviation value of 200 pulse ignition strength balance/Sec. The method to detect aviation piston engine maintenance of magneto ignition system fault has a certain reference value.
Human Error: The Stakes Are Raised.
ERIC Educational Resources Information Center
Greenberg, Joel
1980-01-01
Mistakes related to the operation of nuclear power plants and other technologically complex systems are discussed. Recommendations are given for decreasing the chance of human error in the operation of nuclear plants. The causes of the Three Mile Island incident are presented in terms of the human error element. (SA)
Software for marine ecological environment comprehensive monitoring system based on MCGS
NASA Astrophysics Data System (ADS)
Wang, X. H.; Ma, R.; Cao, X.; Cao, L.; Chu, D. Z.; Zhang, L.; Zhang, T. P.
2017-08-01
The automatic integrated monitoring software for marine ecological environment based on MCGS configuration software is designed and developed to realize real-time automatic monitoring of many marine ecological parameters. The DTU data transmission terminal performs network communication and transmits the data to the user data center in a timely manner. The software adopts the modular design and has the advantages of stable and flexible data structure, strong portability and scalability, clear interface, simple user operation and convenient maintenance. Continuous site comparison test of 6 months showed that, the relative error of the parameters monitored by the system such as temperature, salinity, turbidity, pH, dissolved oxygen was controlled within 5% with the standard method and the relative error of the nutrient parameters was within 15%. Meanwhile, the system had few maintenance times, low failure rate, stable and efficient continuous monitoring capabilities. The field application shows that the software is stable and the data communication is reliable, and it has a good application prospect in the field of marine ecological environment comprehensive monitoring.
NASA Astrophysics Data System (ADS)
Prashanth, B. N.; Roy, Kingshuk
2017-07-01
Three Dimensional (3D) maintenance data provides a link between design and technical documentation creating interactive 3D graphical training and maintenance material. It becomes difficult for an operator to always go through huge paper manuals or come running to the computer for doing maintenance of a machine which makes the maintenance work fatigue. Above being the case, a 3D animation makes maintenance work very simple since, there is no language barrier. The research deals with the generation of 3D maintenance data of any given machine. The best tool for obtaining the 3D maintenance is selected and the tool is analyzed. Using the same tool, a detailed process for extracting the 3D maintenance data for any machine is set. This project aims at selecting the best tool for obtaining 3D maintenance data and to select the detailed process for obtaining 3D maintenance data. 3D maintenance reduces use of big volumes of manuals which creates human errors and makes the work of an operator fatiguing. Hence 3-D maintenance would help in training and maintenance and would increase productivity. 3Dvia when compared with Cortona 3D and Deep Exploration proves to be better than them. 3Dvia is good in data translation and it has the best renderings compared to the other two 3D maintenance software. 3Dvia is very user friendly and it has various options for creating 3D animations. Its Interactive Electronic Technical Publication (IETP) integration is also better than the other two software. Hence 3Dvia proves to be the best software for obtaining 3D maintenance data of any machine.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu; Harris, Kendra M.; Ford, Eric
Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface,more » (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.« less
Technical documentation challenges in aviation maintenance : a proceedings report.
DOT National Transportation Integrated Search
2012-11-01
The 2012 Technical Documentation workshop addressed both problems and solutions associated with technical : documentation for maintenance. These issues are known to cause errors, rework, maintenance delays, other : safety hazards, and FAA administrat...
NASA Astrophysics Data System (ADS)
Shukri, S. Ahmad; Millar, R.; Gratton, G.; Garner, M.; Noh, H. Mohd
2017-12-01
Documentation errors and human errors are often claimed to be the contributory factors for aircraft maintenance mistakes. This paper highlights the preliminary results of the third phase of a four-phased research on communication media that are utilised in an aircraft maintenance organisation. The second phase has looked into the probability of success and failure in completing a task by 60 subjects while in this third phase, the same subjects have been interviewed immediately after completing the task by using Root Cause Analysis (RCA) method. It is discovered that the root cause of their inability to finish the task while using only written manual is the absence of diagrams. However, haste is identified to be the root cause for the incompletion of the task when both manual and diagram are given to the participants. It is observed that those who are able to complete the task is due to their reference to both manual and diagram, simultaneously.
Weaver, Sallie J; Newman-Toker, David E; Rosen, Michael A
2012-01-01
Missed, delayed, or wrong diagnoses can have a severe impact on patients, providers, and the entire health care system. One mechanism implicated in such diagnostic errors is the deterioration of cognitive diagnostic skills that are used rarely or not at all over a prolonged period of time. Existing evidence regarding maintenance of effective cognitive reasoning skills in the clinical education, organizational training, and human factors literatures suggest that continuing education plays a critical role in mitigating and managing diagnostic skill decay. Recent models also underscore the role of system level factors (eg, cognitive decision support tools, just-in-time training opportunities) in supporting clinical reasoning process. The purpose of this manuscript is to offer a multidisciplinary review of cognitive models of clinical decision making skills in order to provide a list of best practices for supporting continuous improvement and maintenance of cognitive diagnostic processes through continuing education. Copyright © 2012 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.
Brennan, Peter A; Mitchell, David A; Holmes, Simon; Plint, Simon; Parry, David
2016-01-01
Human error is as old as humanity itself and is an appreciable cause of mistakes by both organisations and people. Much of the work related to human factors in causing error has originated from aviation where mistakes can be catastrophic not only for those who contribute to the error, but for passengers as well. The role of human error in medical and surgical incidents, which are often multifactorial, is becoming better understood, and includes both organisational issues (by the employer) and potential human factors (at a personal level). Mistakes as a result of individual human factors and surgical teams should be better recognised and emphasised. Attitudes and acceptance of preoperative briefing has improved since the introduction of the World Health Organization (WHO) surgical checklist. However, this does not address limitations or other safety concerns that are related to performance, such as stress and fatigue, emotional state, hunger, awareness of what is going on situational awareness, and other factors that could potentially lead to error. Here we attempt to raise awareness of these human factors, and highlight how they can lead to error, and how they can be minimised in our day-to-day practice. Can hospitals move from being "high risk industries" to "high reliability organisations"? Copyright © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
10-MWe solar-thermal central-receiver pilot plant. Operating and maintenance manual
DOE Office of Scientific and Technical Information (OSTI.GOV)
Not Available
1979-08-01
Information required to perform the initial program loading and operation of the Heliostat Array Controller (HAC) is provided. Operating activities are described as required for heliostat control. All computer console command steps, from power up to power down are described. Detailed steps are provided to wake up the system and direct heliostat beams to standby, on target, standby to stow and power down. Maintenance requirements (preventive and corrective), reparability (reparable - non-reparable decisions), spares identification, spares storage location, replacement levels, replacement location and repair location are established. Individual system breakdown block diagrams are provided for each system/assembly/subassembly. Maintenance and repairmore » description sheets are provided for each maintenance significant item. The manual provides support of the following equipment: (a) helostat assembly; (b) heliostat control assembly; and (c) maintenance and installation equipment. The safety requirements for the operating and maintenance functions are established. These procedures will assist in eliminating or controlling the accident potentials caused by human error, environment, or component malfunctions or interactions that could result in major injury or fatality to operating or visiting personnel, or damage to subsystem components or support equipment. These procedures are for normal and test operating conditions and emergency situations, and apply to all Martin Marietta Corporation, governmental, operating and visitor personnel. (LEW)« less
An optimized ensemble local mean decomposition method for fault detection of mechanical components
NASA Astrophysics Data System (ADS)
Zhang, Chao; Li, Zhixiong; Hu, Chao; Chen, Shuai; Wang, Jianguo; Zhang, Xiaogang
2017-03-01
Mechanical transmission systems have been widely adopted in most of industrial applications, and issues related to the maintenance of these systems have attracted considerable attention in the past few decades. The recently developed ensemble local mean decomposition (ELMD) method shows satisfactory performance in fault detection of mechanical components for preventing catastrophic failures and reducing maintenance costs. However, the performance of ELMD often heavily depends on proper selection of its model parameters. To this end, this paper proposes an optimized ensemble local mean decomposition (OELMD) method to determinate an optimum set of ELMD parameters for vibration signal analysis. In OELMD, an error index termed the relative root-mean-square error (Relative RMSE) is used to evaluate the decomposition performance of ELMD with a certain amplitude of the added white noise. Once a maximum Relative RMSE, corresponding to an optimal noise amplitude, is determined, OELMD then identifies optimal noise bandwidth and ensemble number based on the Relative RMSE and signal-to-noise ratio (SNR), respectively. Thus, all three critical parameters of ELMD (i.e. noise amplitude and bandwidth, and ensemble number) are optimized by OELMD. The effectiveness of OELMD was evaluated using experimental vibration signals measured from three different mechanical components (i.e. the rolling bearing, gear and diesel engine) under faulty operation conditions.
Development of the segment alignment maintenance system (SAMS) for the Hobby-Eberly Telescope
NASA Astrophysics Data System (ADS)
Booth, John A.; Adams, Mark T.; Ames, Gregory H.; Fowler, James R.; Montgomery, Edward E.; Rakoczy, John M.
2000-07-01
A sensing and control system for maintaining optical alignment of ninety-one 1-meter mirror segments forming the Hobby-Eberly Telescope (HET) primary mirror array is now under development. The Segment Alignment Maintenance System (SAMS) is designed to sense relative shear motion between each segment edge pair and calculated individual segment tip, tilt, and piston position errors. Error information is sent to the HET primary mirror control system, which corrects the physical position of each segment as often as once per minute. Development of SAMS is required to meet optical images quality specifications for the telescope. Segment misalignment over time is though to be due to thermal inhomogeneity within the steel mirror support truss. Challenging problems of sensor resolution, dynamic range, mechanical mounting, calibration, stability, robust algorithm development, and system integration must be overcome to achieve a successful operational solution.
Prediction of human errors by maladaptive changes in event-related brain networks.
Eichele, Tom; Debener, Stefan; Calhoun, Vince D; Specht, Karsten; Engel, Andreas K; Hugdahl, Kenneth; von Cramon, D Yves; Ullsperger, Markus
2008-04-22
Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve approximately 30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations.
Prediction of human errors by maladaptive changes in event-related brain networks
Eichele, Tom; Debener, Stefan; Calhoun, Vince D.; Specht, Karsten; Engel, Andreas K.; Hugdahl, Kenneth; von Cramon, D. Yves; Ullsperger, Markus
2008-01-01
Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve ≈30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations. PMID:18427123
NASA Astrophysics Data System (ADS)
Khanam, Mosammat Samia; Biswas, Debasish; Rashid, Mohsina; Salam, Md Abdus
2017-12-01
Safety is one of the most important factors in the field of aviation. Though, modern aircraft are equipped with many instruments/devices to enhance the flight safety but it is seen that accidents/incidents are never reduced to zero. Analysis of the statistical summary of Commercial Jet Airplane accidents highlights that fatal accidents that occurred worldwide from 2006 through 2015 is 11% during taxing, loading/unloading, parking and towing. Human, handling the aircrafts is one of the most important links in aircraft maintenance and hence play a significant role in aviation safety. Effort has been made in this paper to obviate human error in aviation and outline an affordable system that monitors the uneven surface &obstacles for safe "towing in" and "towing out" of an aircraft by the ground crew. The system revolves around implementation of sonar technology by microcontroller. Ultrasonic sensors can be installed on aircraft wings and tail section to identify the uneven surface &obstacles ahead and provide early warning to the maintenance ground crews.
Human reliability in petrochemical industry: an action research.
Silva, João Alexandre Pinheiro; Camarotto, João Alberto
2012-01-01
This paper aims to identify conflicts and gaps between the operators' strategies and actions and the organizational managerial approach for human reliability. In order to achieve these goals, the research approach adopted encompasses literature review, mixing action research methodology and Ergonomic Workplace Analysis in field research. The result suggests that the studied company has a classical and mechanistic point of view focusing on error identification and building barriers through procedures, checklists and other prescription alternatives to improve performance in reliability area. However, it was evident the fundamental role of the worker as an agent of maintenance and construction of system reliability during the action research cycle.
Risk-based maintenance of ethylene oxide production facilities.
Khan, Faisal I; Haddara, Mahmoud R
2004-05-20
This paper discusses a methodology for the design of an optimum inspection and maintenance program. The methodology, called risk-based maintenance (RBM) is based on integrating a reliability approach and a risk assessment strategy to obtain an optimum maintenance schedule. First, the likely equipment failure scenarios are formulated. Out of many likely failure scenarios, the ones, which are most probable, are subjected to a detailed study. Detailed consequence analysis is done for the selected scenarios. Subsequently, these failure scenarios are subjected to a fault tree analysis to determine their probabilities. Finally, risk is computed by combining the results of the consequence and the probability analyses. The calculated risk is compared against known acceptable criteria. The frequencies of the maintenance tasks are obtained by minimizing the estimated risk. A case study involving an ethylene oxide production facility is presented. Out of the five most hazardous units considered, the pipeline used for the transportation of the ethylene is found to have the highest risk. Using available failure data and a lognormal reliability distribution function human health risk factors are calculated. Both societal risk factors and individual risk factors exceeded the acceptable risk criteria. To determine an optimal maintenance interval, a reverse fault tree analysis was used. The maintenance interval was determined such that the original high risk is brought down to an acceptable level. A sensitivity analysis is also undertaken to study the impact of changing the distribution of the reliability model as well as the error in the distribution parameters on the maintenance interval.
Rong, Hao; Tian, Jin; Zhao, Tingdi
2016-01-01
In traditional approaches of human reliability assessment (HRA), the definition of the error producing conditions (EPCs) and the supporting guidance are such that some of the conditions (especially organizational or managerial conditions) can hardly be included, and thus the analysis is burdened with incomprehensiveness without reflecting the temporal trend of human reliability. A method based on system dynamics (SD), which highlights interrelationships among technical and organizational aspects that may contribute to human errors, is presented to facilitate quantitatively estimating the human error probability (HEP) and its related variables changing over time in a long period. Taking the Minuteman III missile accident in 2008 as a case, the proposed HRA method is applied to assess HEP during missile operations over 50 years by analyzing the interactions among the variables involved in human-related risks; also the critical factors are determined in terms of impact that the variables have on risks in different time periods. It is indicated that both technical and organizational aspects should be focused on to minimize human errors in a long run. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.
Hird, Megan A; Vesely, Kristin A; Fischer, Corinne E; Graham, Simon J; Naglie, Gary; Schweizer, Tom A
2017-01-01
The areas of driving impairment characteristic of mild cognitive impairment (MCI) remain unclear. This study compared the simulated driving performance of 24 individuals with MCI, including amnestic single-domain (sd-MCI, n = 11) and amnestic multiple-domain MCI (md-MCI, n = 13), and 20 age-matched controls. Individuals with MCI committed over twice as many driving errors (20.0 versus 9.9), demonstrated difficulty with lane maintenance, and committed more errors during left turns with traffic compared to healthy controls. Specifically, individuals with md-MCI demonstrated greater driving difficulty compared to healthy controls, relative to those with sd-MCI. Differentiating between different subtypes of MCI may be important when evaluating driving safety.
Maneuver Recovery Analysis for the Magnetospheric Multiscale Mission
NASA Technical Reports Server (NTRS)
Gramling, Cheryl; Carpenter, Russell; Volle, Michael; Lee, Taesul; Long, Anne
2007-01-01
The use of spacecraft formations creates new and more demanding requirements for orbit determination accuracy. In addition to absolute navigation requirements, there are typically relative navigation requirements that are based on the size or shape of the formation. The difficulty in meeting these requirements is related to the relative dynamics of the spacecraft orbits and the frequency of the formation maintenance maneuvers. This paper examines the effects of bi-weekly formation maintenance maneuvers on the absolute and relative orbit determination accuracy for the four-spacecraft Magnetospheric Multiscale (MMS) formation. Results are presented from high fidelity simulations that include the effects of realistic orbit determination errors in the maneuver planning process. Solutions are determined using a high accuracy extended Kalman filter designed for onboard navigation. Three different solutions are examined, considering the effects of process noise and measurement rate on the solutions.
DOT National Transportation Integrated Search
2011-06-01
The unregulated hours and frequent night work characteristic of maintenance can produce significant levels of : employee fatigue, with a resultant risk of maintenance error. Fatigue Risk Management Systems (FRMS) are : widely used to manage fatigue a...
Cost effective nuclear commercial grade dedication
DOE Office of Scientific and Technical Information (OSTI.GOV)
Maletz, J.J.; Marston, M.J.
1991-01-01
This paper describes a new computerized database method to create/edit/view specification technical data sheets (mini-specifications) for procurement of spare parts for nuclear facility maintenance and to develop information that could support possible future facility life extension efforts. This method may reduce cost when compared with current manual methods. The use of standardized technical data sheets (mini-specifications) for items of the same category improves efficiency. This method can be used for a variety of tasks, including: Nuclear safety-related procurement; Non-safety related procurement; Commercial grade item procurement/dedication; Evaluation of replacement items. This program will assist the nuclear facility in upgrading its procurementmore » activities consistent with the recent NUMARC Procurement Initiative. Proper utilization of the program will assist the user in assuring that the procured items are correct for the applications, provide data to assist in detecting fraudulent materials, minimize human error in withdrawing database information, improve data retrievability, improve traceability, and reduce long-term procurement costs.« less
Code of Federal Regulations, 2010 CFR
2010-10-01
... assistance payments, related foster care and adoption administrative and training expenditures, and the... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE...
Code of Federal Regulations, 2012 CFR
2012-10-01
..., adoption assistance payments, related foster care and adoption administrative and training expenditures... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE...
Code of Federal Regulations, 2014 CFR
2014-10-01
..., adoption assistance payments, related foster care and adoption administrative and training expenditures... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE...
Code of Federal Regulations, 2011 CFR
2011-10-01
... assistance payments, related foster care and adoption administrative and training expenditures, and the... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE...
Code of Federal Regulations, 2013 CFR
2013-10-01
..., adoption assistance payments, related foster care and adoption administrative and training expenditures... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE...
Information systems and human error in the lab.
Bissell, Michael G
2004-01-01
Health system costs in clinical laboratories are incurred daily due to human error. Indeed, a major impetus for automating clinical laboratories has always been the opportunity it presents to simultaneously reduce cost and improve quality of operations by decreasing human error. But merely automating these processes is not enough. To the extent that introduction of these systems results in operators having less practice in dealing with unexpected events or becoming deskilled in problemsolving, however new kinds of error will likely appear. Clinical laboratories could potentially benefit by integrating findings on human error from modern behavioral science into their operations. Fully understanding human error requires a deep understanding of human information processing and cognition. Predicting and preventing negative consequences requires application of this understanding to laboratory operations. Although the occurrence of a particular error at a particular instant cannot be absolutely prevented, human error rates can be reduced. The following principles are key: an understanding of the process of learning in relation to error; understanding the origin of errors since this knowledge can be used to reduce their occurrence; optimal systems should be forgiving to the operator by absorbing errors, at least for a time; although much is known by industrial psychologists about how to write operating procedures and instructions in ways that reduce the probability of error, this expertise is hardly ever put to use in the laboratory; and a feedback mechanism must be designed into the system that enables the operator to recognize in real time that an error has occurred.
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.
Galashan, Daniela; Fehr, Thorsten; Kreiter, Andreas K; Herrmann, Manfred
2014-07-11
Initially, human area MT+ was considered a visual area solely processing motion information but further research has shown that it is also involved in various different cognitive operations, such as working memory tasks requiring motion-related information to be maintained or cognitive tasks with implied or expected motion.In the present fMRI study in humans, we focused on MT+ modulation during working memory maintenance using a dynamic shape-tracking working memory task with no motion-related working memory content. Working memory load was systematically varied using complex and simple stimulus material and parametrically increasing retention periods. Activation patterns for the difference between retention of complex and simple memorized stimuli were examined in order to preclude that the reported effects are caused by differences in retrieval. Conjunction analysis over all delay durations for the maintenance of complex versus simple stimuli demonstrated a wide-spread activation pattern. Percent signal change (PSC) in area MT+ revealed a pattern with higher values for the maintenance of complex shapes compared to the retention of a simple circle and with higher values for increasing delay durations. The present data extend previous knowledge by demonstrating that visual area MT+ presents a brain activity pattern usually found in brain regions that are actively involved in working memory maintenance.
An Empirical Investigation of USAF Logistics Readiness Officer Mission Sets
2013-03-01
parts, engine repair and 7 spare utilization, fuel cell and fuel system related repairs, heavy maintenance and inspection functions, and aircraft...provide additional mission sets. Fuels Management, Program Management, Acquisitions Management, and Depot Maintenance were suggested once each as...being mentioned by 2.5 percent ( Fuels Management, Program Management, Acquisitions Management, and Depot Maintenance) and 5 percent (Human Capital
The precision segmented reflectors: Moderate mission figure control subsystem
NASA Technical Reports Server (NTRS)
Sevaston, G.; Redding, D.; Lau, K.; Breckenridge, W.; Levine, B.; Nerheim, N.; Sirlin, S.; Kadogawa, H.
1991-01-01
A system concept for a space based segmented reflector telescope figure control subsystem is described. The concept employs a two phase architecture in which figure initialization and figure maintenance are independent functions. Figure initialization is accomplished by image sharpening using natural reference targets. Figure maintenance is performed by monitoring the relative positions and alignments of the telescope components using an optical truss. Actuation is achieved using precision positioners. Computer simulation results of figure initialization by pairwise segment coalignment/cophasing and simulated annealing are presented along with figure maintenance results using a wavefront error regulation algorithm. Both functions are shown to perform at acceptable levels for the class of submillimeter telescopes that are serving as the focus of this technology development effort. Component breadboard work as well as plans for a system testbed are discussed.
Management Aspects of Software Maintenance.
1984-09-01
educated in * the complex nature of software maintenance to be able to properly evaluate and manage the software maintenance effort. In this...maintenance and improvement may be called "software evolution". The soft- ware manager must be Educated in the complex nature cf soft- Iware maintenance to be...complaint of error or request for modification is also studied in order to determine what action needs tc be taken. 2. Define Objective and Approach :
Oppold, P; Rupp, M; Mouloua, M; Hancock, P A; Martin, J
2012-01-01
Unmanned (UAVs, UCAVs, and UGVs) systems still have major human factors and ergonomic challenges related to the effective design of their control interface systems, crucial to their efficient operation, maintenance, and safety. Unmanned system interfaces with a human centered approach promote intuitive interfaces that are easier to learn, and reduce human errors and other cognitive ergonomic issues with interface design. Automation has shifted workload from physical to cognitive, thus control interfaces for unmanned systems need to reduce mental workload on the operators and facilitate the interaction between vehicle and operator. Two-handed video game controllers provide wide usability within the overall population, prior exposure for new operators, and a variety of interface complexity levels to match the complexity level of the task and reduce cognitive load. This paper categorizes and provides taxonomy for 121 haptic interfaces from the entertainment industry that can be utilized as control interfaces for unmanned systems. Five categories of controllers were based on the complexity of the buttons, control pads, joysticks, and switches on the controller. This allows the selection of the level of complexity needed for a specific task without creating an entirely new design or utilizing an overly complex design.
Development of the updating executive function: From 7-year-olds to young adults.
Carriedo, Nuria; Corral, Antonio; Montoro, Pedro R; Herrero, Laura; Rucián, Mercedes
2016-04-01
Updating information in working memory (WM) is a critical executive function responsible both for continuously replacing outdated information with new relevant data and to suppress or inhibit content that is no longer relevant according to task demands. The goal of the present research is twofold: First, we aimed to study updating development in 548 participants of 4 different age ranges--7-, 11-, and 15-year-olds and young adults--using the updating task devised by R. De Beni and P. Palladino (2004), which allows differentiating maintenance and inhibition processes. Second, we attempted to determine the relation between these processes across development as well as the differentiation among different types of inhibition processes tapped by this task. Results showed that there was an improvement of memory performance with age along with an upgrading of inhibitory efficiency. However, whereas in memory performance, a progressive increase was observed until the age of 15 years followed by stabilization, in inhibition, a continuous progressive increase was observed until young adulthood. Importantly, results showed that development of the different inhibitory mechanisms does not progress equally. All the groups committed more errors related to inefficient suppression mechanisms in WM than errors related to control of long-term memory interference. Principal component analysis showed that updating implies different subprocesses: active maintenance/suppression of information in WM and control of proactive interference. Developmental trajectories showed that the maintenance/suppression of information in the WM component continues to develop far beyond adolescence but that proactive interference control is responsible for variations in updating across development. (c) 2016 APA, all rights reserved).
Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant
Jahangiri, Mehdi; Hoboubi, Naser; Rostamabadi, Akbar; Keshavarzi, Sareh; Hosseini, Ali Akbar
2015-01-01
Background A permit to work (PTW) is a formal written system to control certain types of work which are identified as potentially hazardous. However, human error in PTW processes can lead to an accident. Methods This cross-sectional, descriptive study was conducted to estimate the probability of human errors in PTW processes in a chemical plant in Iran. In the first stage, through interviewing the personnel and studying the procedure in the plant, the PTW process was analyzed using the hierarchical task analysis technique. In doing so, PTW was considered as a goal and detailed tasks to achieve the goal were analyzed. In the next step, the standardized plant analysis risk-human (SPAR-H) reliability analysis method was applied for estimation of human error probability. Results The mean probability of human error in the PTW system was estimated to be 0.11. The highest probability of human error in the PTW process was related to flammable gas testing (50.7%). Conclusion The SPAR-H method applied in this study could analyze and quantify the potential human errors and extract the required measures for reducing the error probabilities in PTW system. Some suggestions to reduce the likelihood of errors, especially in the field of modifying the performance shaping factors and dependencies among tasks are provided. PMID:27014485
WE-G-BRA-04: Common Errors and Deficiencies in Radiation Oncology Practice
DOE Office of Scientific and Technical Information (OSTI.GOV)
Kry, S; Dromgoole, L; Alvarez, P
Purpose: Dosimetric errors in radiotherapy dose delivery lead to suboptimal treatments and outcomes. This work reviews the frequency and severity of dosimetric and programmatic errors identified by on-site audits performed by the IROC Houston QA center. Methods: IROC Houston on-site audits evaluate absolute beam calibration, relative dosimetry data compared to the treatment planning system data, and processes such as machine QA. Audits conducted from 2000-present were abstracted for recommendations, including type of recommendation and magnitude of error when applicable. Dosimetric recommendations corresponded to absolute dose errors >3% and relative dosimetry errors >2%. On-site audits of 1020 accelerators at 409 institutionsmore » were reviewed. Results: A total of 1280 recommendations were made (average 3.1/institution). The most common recommendation was for inadequate QA procedures per TG-40 and/or TG-142 (82% of institutions) with the most commonly noted deficiency being x-ray and electron off-axis constancy versus gantry angle. Dosimetrically, the most common errors in relative dosimetry were in small-field output factors (59% of institutions), wedge factors (33% of institutions), off-axis factors (21% of institutions), and photon PDD (18% of institutions). Errors in calibration were also problematic: 20% of institutions had an error in electron beam calibration, 8% had an error in photon beam calibration, and 7% had an error in brachytherapy source calibration. Almost all types of data reviewed included errors up to 7% although 20 institutions had errors in excess of 10%, and 5 had errors in excess of 20%. The frequency of electron calibration errors decreased significantly with time, but all other errors show non-significant changes. Conclusion: There are many common and often serious errors made during the establishment and maintenance of a radiotherapy program that can be identified through independent peer review. Physicists should be cautious, particularly in areas highlighted herein that show a tendency for errors.« less
Code of Federal Regulations, 2010 CFR
2010-07-01
... relating to sickle cell anemia or infection with the human immunodeficiency virus. 1.478 Section 1.478... treatment programs; not applicable to records relating to sickle cell anemia or infection with the human...
Code of Federal Regulations, 2011 CFR
2011-07-01
... relating to sickle cell anemia or infection with the human immunodeficiency virus. 1.478 Section 1.478... treatment programs; not applicable to records relating to sickle cell anemia or infection with the human...
Code of Federal Regulations, 2012 CFR
2012-07-01
... relating to sickle cell anemia or infection with the human immunodeficiency virus. 1.478 Section 1.478... treatment programs; not applicable to records relating to sickle cell anemia or infection with the human...
Code of Federal Regulations, 2014 CFR
2014-07-01
... relating to sickle cell anemia or infection with the human immunodeficiency virus. 1.478 Section 1.478... treatment programs; not applicable to records relating to sickle cell anemia or infection with the human...
Code of Federal Regulations, 2013 CFR
2013-07-01
... relating to sickle cell anemia or infection with the human immunodeficiency virus. 1.478 Section 1.478... treatment programs; not applicable to records relating to sickle cell anemia or infection with the human...
Logic-based assessment of the compatibility of UMLS ontology sources
2011-01-01
Background The UMLS Metathesaurus (UMLS-Meta) is currently the most comprehensive effort for integrating independently-developed medical thesauri and ontologies. UMLS-Meta is being used in many applications, including PubMed and ClinicalTrials.gov. The integration of new sources combines automatic techniques, expert assessment, and auditing protocols. The automatic techniques currently in use, however, are mostly based on lexical algorithms and often disregard the semantics of the sources being integrated. Results In this paper, we argue that UMLS-Meta’s current design and auditing methodologies could be significantly enhanced by taking into account the logic-based semantics of the ontology sources. We provide empirical evidence suggesting that UMLS-Meta in its 2009AA version contains a significant number of errors; these errors become immediately apparent if the rich semantics of the ontology sources is taken into account, manifesting themselves as unintended logical consequences that follow from the ontology sources together with the information in UMLS-Meta. We then propose general principles and specific logic-based techniques to effectively detect and repair such errors. Conclusions Our results suggest that the methodologies employed in the design of UMLS-Meta are not only very costly in terms of human effort, but also error-prone. The techniques presented here can be useful for both reducing human effort in the design and maintenance of UMLS-Meta and improving the quality of its contents. PMID:21388571
45 CFR 400.28 - Maintenance of records and reports.
Code of Federal Regulations, 2010 CFR
2010-10-01
... 400.28 Public Welfare Regulations Relating to Public Welfare OFFICE OF REFUGEE RESETTLEMENT, ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES REFUGEE RESETTLEMENT PROGRAM... maintenance of such operational records as are necessary for Federal monitoring of the State's refugee...
Krigolson, Olav E; Hassall, Cameron D; Handy, Todd C
2014-03-01
Our ability to make decisions is predicated upon our knowledge of the outcomes of the actions available to us. Reinforcement learning theory posits that actions followed by a reward or punishment acquire value through the computation of prediction errors-discrepancies between the predicted and the actual reward. A multitude of neuroimaging studies have demonstrated that rewards and punishments evoke neural responses that appear to reflect reinforcement learning prediction errors [e.g., Krigolson, O. E., Pierce, L. J., Holroyd, C. B., & Tanaka, J. W. Learning to become an expert: Reinforcement learning and the acquisition of perceptual expertise. Journal of Cognitive Neuroscience, 21, 1833-1840, 2009; Bayer, H. M., & Glimcher, P. W. Midbrain dopamine neurons encode a quantitative reward prediction error signal. Neuron, 47, 129-141, 2005; O'Doherty, J. P. Reward representations and reward-related learning in the human brain: Insights from neuroimaging. Current Opinion in Neurobiology, 14, 769-776, 2004; Holroyd, C. B., & Coles, M. G. H. The neural basis of human error processing: Reinforcement learning, dopamine, and the error-related negativity. Psychological Review, 109, 679-709, 2002]. Here, we used the brain ERP technique to demonstrate that not only do rewards elicit a neural response akin to a prediction error but also that this signal rapidly diminished and propagated to the time of choice presentation with learning. Specifically, in a simple, learnable gambling task, we show that novel rewards elicited a feedback error-related negativity that rapidly decreased in amplitude with learning. Furthermore, we demonstrate the existence of a reward positivity at choice presentation, a previously unreported ERP component that has a similar timing and topography as the feedback error-related negativity that increased in amplitude with learning. The pattern of results we observed mirrored the output of a computational model that we implemented to compute reward prediction errors and the changes in amplitude of these prediction errors at the time of choice presentation and reward delivery. Our results provide further support that the computations that underlie human learning and decision-making follow reinforcement learning principles.
Passing the Baton: An Experimental Study of Shift Handover
NASA Technical Reports Server (NTRS)
Parke, Bonny; Hobbs, Alan; Kanki, Barbara
2010-01-01
Shift handovers occur in many safety-critical environments, including aviation maintenance, medicine, air traffic control, and mission control for space shuttle and space station operations. Shift handovers are associated with increased risk of communication failures and human error. In dynamic industries, errors and accidents occur disproportionately after shift handover. Typical shift handovers involve transferring information from an outgoing shift to an incoming shift via written logs, or in some cases, face-to-face briefings. The current study explores the possibility of improving written communication with the support modalities of audio and video recordings, as well as face-to-face briefings. Fifty participants participated in an experimental task which mimicked some of the critical challenges involved in transferring information between shifts in industrial settings. All three support modalities, face-to-face, video, and audio recordings, reduced task errors significantly over written communication alone. The support modality most preferred by participants was face-to-face communication; the least preferred was written communication alone.
45 CFR 205.60 - Reports and maintenance of records.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 2 2012-10-01 2012-10-01 false Reports and maintenance of records. 205.60 Section 205.60 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY ASSISTANCE (ASSISTANCE PROGRAMS), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL...
45 CFR 205.60 - Reports and maintenance of records.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 2 2014-10-01 2012-10-01 true Reports and maintenance of records. 205.60 Section 205.60 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY ASSISTANCE (ASSISTANCE PROGRAMS), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL...
45 CFR 205.60 - Reports and maintenance of records.
Code of Federal Regulations, 2013 CFR
2013-10-01
... 45 Public Welfare 2 2013-10-01 2012-10-01 true Reports and maintenance of records. 205.60 Section 205.60 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY ASSISTANCE (ASSISTANCE PROGRAMS), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL...
45 CFR 205.60 - Reports and maintenance of records.
Code of Federal Regulations, 2010 CFR
2010-10-01
... 45 Public Welfare 2 2010-10-01 2010-10-01 false Reports and maintenance of records. 205.60 Section 205.60 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY ASSISTANCE (ASSISTANCE PROGRAMS), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL...
45 CFR 205.60 - Reports and maintenance of records.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 2 2011-10-01 2011-10-01 false Reports and maintenance of records. 205.60 Section 205.60 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY ASSISTANCE (ASSISTANCE PROGRAMS), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL...
DOE Office of Scientific and Technical Information (OSTI.GOV)
Able, CM; Baydush, AH; Nguyen, C
Purpose: To determine the effectiveness of SPC analysis for a model predictive maintenance process that uses accelerator generated parameter and performance data contained in trajectory log files. Methods: Each trajectory file is decoded and a total of 131 axes positions are recorded (collimator jaw position, gantry angle, each MLC, etc.). This raw data is processed and either axis positions are extracted at critical points during the delivery or positional change over time is used to determine axis velocity. The focus of our analysis is the accuracy, reproducibility and fidelity of each axis. A reference positional trace of the gantry andmore » each MLC is used as a motion baseline for cross correlation (CC) analysis. A total of 494 parameters (482 MLC related) were analyzed using Individual and Moving Range (I/MR) charts. The chart limits were calculated using a hybrid technique that included the use of the standard 3σ limits and parameter/system specifications. Synthetic errors/changes were introduced to determine the initial effectiveness of I/MR charts in detecting relevant changes in operating parameters. The magnitude of the synthetic errors/changes was based on: TG-142 and published analysis of VMAT delivery accuracy. Results: All errors introduced were detected. Synthetic positional errors of 2mm for collimator jaw and MLC carriage exceeded the chart limits. Gantry speed and each MLC speed are analyzed at two different points in the delivery. Simulated Gantry speed error (0.2 deg/sec) and MLC speed error (0.1 cm/sec) exceeded the speed chart limits. Gantry position error of 0.2 deg was detected by the CC maximum value charts. The MLC position error of 0.1 cm was detected by the CC maximum value location charts for every MLC. Conclusion: SPC I/MR evaluation of trajectory log file parameters may be effective in providing an early warning of performance degradation or component failure for medical accelerator systems.« less
26 CFR 1.1311(b)-1 - Maintenance of an inconsistent position.
Code of Federal Regulations, 2010 CFR
2010-04-01
..., or nonrecognition, as the case may be, in the year of the error, and (ii) such inconsistent position... 26 Internal Revenue 11 2010-04-01 2010-04-01 true Maintenance of an inconsistent position. 1.1311....1311(b)-1 Maintenance of an inconsistent position. (a) In general. Under the circumstances stated in...
Vilà-Balló, Adrià; Hdez-Lafuente, Prado; Rostan, Carles; Cunillera, Toni; Rodriguez-Fornells, Antoni
2014-10-01
Performance monitoring is crucial for well-adapted behavior. Offenders typically have a pervasive repetition of harmful-impulsive behaviors, despite an awareness of the negative consequences of their actions. However, the link between performance monitoring and aggressive behavior in juvenile offenders has not been closely investigated. Event-related brain potentials (ERPs) were used to investigate performance monitoring in juvenile non-psychopathic violent offenders compared with a well-matched control group. Two ERP components associated with error monitoring, error-related negativity (ERN) and error-positivity (Pe), and two components related to inhibitory processing, the stop-N2 and stop-P3 components, were evaluated using a combined flanker-stop-signal task. The results showed that the amplitudes of the ERN, the stop-N2, the stop-P3, and the standard P3 components were clearly reduced in the offenders group. Remarkably, no differences were observed for the Pe. At the behavioral level, slower stop-signal reaction times were identified for offenders, which indicated diminished inhibitory processing. The present results suggest that the monitoring of one's own behavior is affected in juvenile violent offenders. Specifically, we determined that different aspects of executive function were affected in the studied offenders, including error processing (reduced ERN) and response inhibition (reduced N2 and P3). However, error awareness and compensatory post-error adjustment processes (error correction) were unaffected. The current pattern of results highlights the role of performance monitoring in the acquisition and maintenance of externalizing harmful behavior that is frequently observed in juvenile offenders. Copyright © 2014 Elsevier B.V. All rights reserved.
Henneman, Elizabeth A; Roche, Joan P; Fisher, Donald L; Cunningham, Helene; Reilly, Cheryl A; Nathanson, Brian H; Henneman, Philip L
2010-02-01
This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance. Copyright 2010 Elsevier Inc. All rights reserved.
45 CFR 149.350 - Maintenance of records.
Code of Federal Regulations, 2010 CFR
2010-10-01
... 45 Public Welfare 1 2010-10-01 2010-10-01 false Maintenance of records. 149.350 Section 149.350 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS... (but not limited to) the use of electronic media. (d) The sponsor must require its health insurance...
45 CFR 149.350 - Maintenance of records.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 1 2011-10-01 2011-10-01 false Maintenance of records. 149.350 Section 149.350 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS... (but not limited to) the use of electronic media. (d) The sponsor must require its health insurance...
Human Temporal Cortical Single Neuron Activity During Working Memory Maintenance
Zamora, Leona; Corina, David; Ojemann, George
2016-01-01
The Working Memory model of human memory, first introduced by Baddeley and Hitch (1974), has been one of the most influential psychological constructs in cognitive psychology and human neuroscience. However the neuronal correlates of core components of this model have yet to be fully elucidated. Here we present data from two studies where human temporal cortical single neuron activity was recorded during tasks differentially affecting the maintenance component of verbal working memory. In Study One we vary the presence or absence of distracting items for the entire period of memory storage. In Study Two we vary the duration of storage so that distractors filled all, or only one-third of the time the memory was stored. Extracellular single neuron recordings were obtained from 36 subjects undergoing awake temporal lobe resections for epilepsy, 25 in Study one, 11 in Study two. Recordings were obtained from a total of 166 lateral temporal cortex neurons during performance of one of these two tasks, 86 study one, 80 study two. Significant changes in activity with distractor manipulation were present in 74 of these neurons (45%), 38 Study one, 36 Study two. In 48 (65%) of those there was increased activity during the period when distracting items were absent, 26 Study One, 22 Study Two. The magnitude of this increase was greater for Study One, 47.6%, than Study Two, 8.1%, paralleling the reduction in memory errors in the absence of distracters, for Study One of 70.3%, Study Two 26.3% These findings establish that human lateral temporal cortex is part of the neural system for working memory, with activity during maintenance of that memory that parallels performance, suggesting it represents active rehearsal. In 31 of these neurons (65%) this activity was an extension of that during working memory encoding that differed significantly from the neural processes recorded during overt and silent language tasks without a recent memory component, 17 Study one, 14 Study two. Contrary to the Baddeley model, that activity during verbal working memory maintenance often represented activity specific to working memory rather than speech or language. PMID:27059210
DOE Office of Scientific and Technical Information (OSTI.GOV)
Callan, J.R.; Kelly, R.T.; Quinn, M.L.
1995-05-01
Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices usedmore » in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error.« less
Code of Federal Regulations, 2012 CFR
2012-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... receive Federal reimbursement at the 50 percent level for expenditures related to the planning, design...
Code of Federal Regulations, 2014 CFR
2014-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... receive Federal reimbursement at the 50 percent level for expenditures related to the planning, design...
Code of Federal Regulations, 2013 CFR
2013-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... receive Federal reimbursement at the 50 percent level for expenditures related to the planning, design...
Souvestre, P A; Landrock, C K; Blaber, A P
2008-08-01
Human factors centered aviation accident analyses report that skill based errors are known to be cause of 80% of all accidents, decision making related errors 30% and perceptual errors 6%1. In-flight decision making error is a long time recognized major avenue leading to incidents and accidents. Through the past three decades, tremendous and costly efforts have been developed to attempt to clarify causation, roles and responsibility as well as to elaborate various preventative and curative countermeasures blending state of the art biomedical, technological advances and psychophysiological training strategies. In-flight related statistics have not been shown significantly changed and a significant number of issues remain not yet resolved. Fine Postural System and its corollary, Postural Deficiency Syndrome (PDS), both defined in the 1980's, are respectively neurophysiological and medical diagnostic models that reflect central neural sensory-motor and cognitive controls regulatory status. They are successfully used in complex neurotraumatology and related rehabilitation for over two decades. Analysis of clinical data taken over a ten-year period from acute and chronic post-traumatic PDS patients shows a strong correlation between symptoms commonly exhibited before, along side, or even after error, and sensory-motor or PDS related symptoms. Examples are given on how PDS related central sensory-motor control dysfunction can be correctly identified and monitored via a neurophysiological ocular-vestibular-postural monitoring system. The data presented provides strong evidence that a specific biomedical assessment methodology can lead to a better understanding of in-flight adaptive neurophysiological, cognitive and perceptual dysfunctional status that could induce in flight-errors. How relevant human factors can be identified and leveraged to maintain optimal performance will be addressed.
Updating expected action outcome in the medial frontal cortex involves an evaluation of error type.
Maier, Martin E; Steinhauser, Marco
2013-10-02
Forming expectations about the outcome of an action is an important prerequisite for action control and reinforcement learning in the human brain. The medial frontal cortex (MFC) has been shown to play an important role in the representation of outcome expectations, particularly when an update of expected outcome becomes necessary because an error is detected. However, error detection alone is not always sufficient to compute expected outcome because errors can occur in various ways and different types of errors may be associated with different outcomes. In the present study, we therefore investigate whether updating expected outcome in the human MFC is based on an evaluation of error type. Our approach was to consider an electrophysiological correlate of MFC activity on errors, the error-related negativity (Ne/ERN), in a task in which two types of errors could occur. Because the two error types were associated with different amounts of monetary loss, updating expected outcomes on error trials required an evaluation of error type. Our data revealed a pattern of Ne/ERN amplitudes that closely mirrored the amount of monetary loss associated with each error type, suggesting that outcome expectations are updated based on an evaluation of error type. We propose that this is achieved by a proactive evaluation process that anticipates error types by continuously monitoring error sources or by dynamically representing possible response-outcome relations.
Action errors, error management, and learning in organizations.
Frese, Michael; Keith, Nina
2015-01-03
Every organization is confronted with errors. Most errors are corrected easily, but some may lead to negative consequences. Organizations often focus on error prevention as a single strategy for dealing with errors. Our review suggests that error prevention needs to be supplemented by error management--an approach directed at effectively dealing with errors after they have occurred, with the goal of minimizing negative and maximizing positive error consequences (examples of the latter are learning and innovations). After defining errors and related concepts, we review research on error-related processes affected by error management (error detection, damage control). Empirical evidence on positive effects of error management in individuals and organizations is then discussed, along with emotional, motivational, cognitive, and behavioral pathways of these effects. Learning from errors is central, but like other positive consequences, learning occurs under certain circumstances--one being the development of a mind-set of acceptance of human error.
2001-09-01
groupwork # table (rd int identity primary key,agrp varchar(150),bgrp varchar(150),ard int,brd int) -- declare @trans# table (rd int identity,agg varchar(300...8217 */ -- Store field and associated fields within it. insert @ groupwork #(agrp,bgrp,ard,brd) select a.grp,b.grp,a.rd,b.rd --select a.rd as a_rd,cast(a.grp as...8217 end +’#rac.’+bgrp, @str1=agrp from @ groupwork # where ard<@k /* don’t want last field */ order by rd -- Fields set @mgrpsupdate5= ’ case when #rac.cgrps
Clustering and Recurring Anomaly Identification: Recurring Anomaly Detection System (ReADS)
NASA Technical Reports Server (NTRS)
McIntosh, Dawn
2006-01-01
This viewgraph presentation reviews the Recurring Anomaly Detection System (ReADS). The Recurring Anomaly Detection System is a tool to analyze text reports, such as aviation reports and maintenance records: (1) Text clustering algorithms group large quantities of reports and documents; Reduces human error and fatigue (2) Identifies interconnected reports; Automates the discovery of possible recurring anomalies; (3) Provides a visualization of the clusters and recurring anomalies We have illustrated our techniques on data from Shuttle and ISS discrepancy reports, as well as ASRS data. ReADS has been integrated with a secure online search
Yordanova, Juliana; Albrecht, Björn; Uebel, Henrik; Kirov, Roumen; Banaschewski, Tobias; Rothenberger, Aribert; Kolev, Vasil
2011-06-01
The maintenance of stable goal-directed behaviour is a hallmark of conscious executive control in humans. Notably, both correct and error human actions may have a subconscious activation-based determination. One possible source of subconscious interference may be the default mode network that, in contrast to attentional network, manifests intrinsic oscillations at very low (<0.1 Hz) frequencies. In the present study, we analyse the time dynamics of performance accuracy to search for multisecond periodic fluctuations of error occurrence. Attentional lapses in attention deficit/hyperactivity disorder are proposed to originate from interferences from intrinsically oscillating networks. Identifying periodic error fluctuations with a frequency<0.1 Hz in patients with attention deficit/hyperactivity disorder would provide a behavioural evidence for such interferences. Performance was monitored during a visual flanker task in 92 children (7- to 16-year olds), 47 with attention deficit/hyperactivity disorder, combined type and 45 healthy controls. Using an original approach, the time distribution of error occurrence was analysed in the frequency and time-frequency domains in order to detect rhythmic periodicity. Major results demonstrate that in both patients and controls, error behaviour was characterized by multisecond rhythmic fluctuations with a period of ∼12 s, appearing with a delay after transition to task. Only in attention deficit/hyperactivity disorder, was there an additional 'pathological' oscillation of error generation, which determined periodic drops of performance accuracy each 20-30 s. Thus, in patients, periodic error fluctuations were modulated by two independent oscillatory patterns. The findings demonstrate that: (i) attentive behaviour of children is determined by multisecond regularities; and (ii) a unique additional periodicity guides performance fluctuations in patients. These observations may re-conceptualize the understanding of attentive behaviour beyond the executive top-down control and may reveal new origins of psychopathological behaviours in attention deficit/hyperactivity disorder.
Hooper, Brionny J; O'Hare, David P A
2013-08-01
Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classification System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identification of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the influence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fixed-wing and rotary-wing operations. This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008. Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fixed wing (23%) incidents. Both classificatory systems showed significant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors. Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.
Huber, A R; Méndez, A; Brunner-Agten, S
2013-01-01
Automatia, an ancient Greece goddess of luck who makes things happen by themselves and on her own will without human engagement, is present in our daily life in the medical laboratory. Automation has been introduced and perfected by clinical chemistry and since then expanded into other fields such as haematology, immunology, molecular biology and also coagulation testing. The initial small and relatively simple standalone instruments have been replaced by more complex systems that allow for multitasking. Integration of automated coagulation testing into total laboratory automation has become possible in the most recent years. Automation has many strengths and opportunities if weaknesses and threats are respected. On the positive side, standardization, reduction of errors, reduction of cost and increase of throughput are clearly beneficial. Dependence on manufacturers, high initiation cost and somewhat expensive maintenance are less favourable factors. The modern lab and especially the todays lab technicians and academic personnel in the laboratory do not add value for the doctor and his patients by spending lots of time behind the machines. In the future the lab needs to contribute at the bedside suggesting laboratory testing and providing support and interpretation of the obtained results. The human factor will continue to play an important role in testing in haemostasis yet under different circumstances.
78 FR 45052 - Critical Parts for Airplane Propellers; Correction
Federal Register 2010, 2011, 2012, 2013, 2014
2013-07-26
..., early warning devices, maintenance checks, and other similar equipment or procedures. If items of the..., and maintenance processes for propeller critical parts. An unintentional error was introduced in Sec... transportation, Aircraft, Aviation safety, Safety. The Correcting Amendment In consideration of the foregoing...
Yazmir, Boris; Reiner, Miriam
2018-05-15
Any motor action is, by nature, potentially accompanied by human errors. In order to facilitate development of error-tailored Brain-Computer Interface (BCI) correction systems, we focused on internal, human-initiated errors, and investigated EEG correlates of user outcome successes and errors during a continuous 3D virtual tennis game against a computer player. We used a multisensory, 3D, highly immersive environment. Missing and repelling the tennis ball were considered, as 'error' (miss) and 'success' (repel). Unlike most previous studies, where the environment "encouraged" the participant to perform a mistake, here errors happened naturally, resulting from motor-perceptual-cognitive processes of incorrect estimation of the ball kinematics, and can be regarded as user internal, self-initiated errors. Results show distinct and well-defined Event-Related Potentials (ERPs), embedded in the ongoing EEG, that differ across conditions by waveforms, scalp signal distribution maps, source estimation results (sLORETA) and time-frequency patterns, establishing a series of typical features that allow valid discrimination between user internal outcome success and error. The significant delay in latency between positive peaks of error- and success-related ERPs, suggests a cross-talk between top-down and bottom-up processing, represented by an outcome recognition process, in the context of the game world. Success-related ERPs had a central scalp distribution, while error-related ERPs were centro-parietal. The unique characteristics and sharp differences between EEG correlates of error/success provide the crucial components for an improved BCI system. The features of the EEG waveform can be used to detect user action outcome, to be fed into the BCI correction system. Copyright © 2016 IBRO. Published by Elsevier Ltd. All rights reserved.
A particle swarm model for estimating reliability and scheduling system maintenance
NASA Astrophysics Data System (ADS)
Puzis, Rami; Shirtz, Dov; Elovici, Yuval
2016-05-01
Modifying data and information system components may introduce new errors and deteriorate the reliability of the system. Reliability can be efficiently regained with reliability centred maintenance, which requires reliability estimation for maintenance scheduling. A variant of the particle swarm model is used to estimate reliability of systems implemented according to the model view controller paradigm. Simulations based on data collected from an online system of a large financial institute are used to compare three component-level maintenance policies. Results show that appropriately scheduled component-level maintenance greatly reduces the cost of upholding an acceptable level of reliability by reducing the need in system-wide maintenance.
Causal Evidence from Humans for the Role of Mediodorsal Nucleus of the Thalamus in Working Memory.
Peräkylä, Jari; Sun, Lihua; Lehtimäki, Kai; Peltola, Jukka; Öhman, Juha; Möttönen, Timo; Ogawa, Keith H; Hartikainen, Kaisa M
2017-12-01
The mediodorsal nucleus of the thalamus (MD), with its extensive connections to the lateral pFC, has been implicated in human working memory and executive functions. However, this understanding is based solely on indirect evidence from human lesion and imaging studies and animal studies. Direct, causal evidence from humans is missing. To obtain direct evidence for MD's role in humans, we studied patients treated with deep brain stimulation (DBS) for refractory epilepsy. This treatment is thought to prevent the generalization of a seizure by disrupting the functioning of the patient's anterior nuclei of the thalamus (ANT) with high-frequency electric stimulation. This structure is located superior and anterior to MD, and when the DBS lead is implanted in ANT, tip contacts of the lead typically penetrate through ANT into the adjoining MD. To study the role of MD in human executive functions and working memory, we periodically disrupted and recovered MD's function with high-frequency electric stimulation using DBS contacts reaching MD while participants performed a cognitive task engaging several aspects of executive functions. We hypothesized that the efficacy of executive functions, specifically working memory, is impaired when the functioning of MD is perturbed by high-frequency stimulation. Eight participants treated with ANT-DBS for refractory epilepsy performed a computer-based test of executive functions while DBS was repeatedly switched ON and OFF at MD and at the control location (ANT). In comparison to stimulation of the control location, when MD was stimulated, participants committed 2.26 times more errors in general (total errors; OR = 2.26, 95% CI [1.69, 3.01]) and 2.86 times more working memory-related errors specifically (incorrect button presses; OR = 2.88, CI [1.95, 4.24]). Similarly, participants committed 1.81 more errors in general ( OR = 1.81, CI [1.45, 2.24]) and 2.08 times more working memory-related errors ( OR = 2.08, CI [1.57, 2.75]) in comparison to no stimulation condition. "Total errors" is a composite score consisting of basic error types and was mostly driven by working memory-related errors. The facts that MD and a control location, ANT, are only few millimeters away from each other and that their stimulation produces very different results highlight the location-specific effect of DBS rather than regionally unspecific general effect. In conclusion, disrupting and recovering MD's function with high-frequency electric stimulation modulated participants' online working memory performance providing causal, in vivo evidence from humans for the role of MD in human working memory.
45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2010 CFR
2010-10-01
... Funds and State Matching and Maintenance-of-Effort (MOE Funds): (1) Percentage of cases with an error... cases in the sample with an error compared to the total number of cases in the sample; (2) Percentage of cases with an improper payment (both over and under payments), expressed as the total number of cases in...
A Method for the Study of Human Factors in Aircraft Operations
NASA Technical Reports Server (NTRS)
Barnhart, W.; Billings, C.; Cooper, G.; Gilstrap, R.; Lauber, J.; Orlady, H.; Puskas, B.; Stephens, W.
1975-01-01
A method for the study of human factors in the aviation environment is described. A conceptual framework is provided within which pilot and other human errors in aircraft operations may be studied with the intent of finding out how, and why, they occurred. An information processing model of human behavior serves as the basis for the acquisition and interpretation of information relating to occurrences which involve human error. A systematic method of collecting such data is presented and discussed. The classification of the data is outlined.
The Effects of Age, Gender, and Hand on Force Control Capabilities of Healthy Adults.
Lee, Baekhee; Lee, Mina; Yoh, Myeung Sook; You, Heecheon; Park, Hyunji; Jung, Kihyo; Lee, Byung Hwa; Na, Duk L; Kim, Geon Ha
2015-12-01
The present study examined the effects of age (20s to 70s), gender (male and female), and hand (dominant and nondominant) on force control capabilities (FCCs) in four force control phases (initiation, development, maintenance, and termination). Normative data of FCCs by force control phase are needed for various populations in age and gender to identify a type of motor performance reduction and its severity. FCCs of 360 participants (30 for each combination of age group and gender) were measured using a finger dynamometer and quantified in terms of initiation time (IT), development time (DT), maintenance error (ME), and termination time (TT). Although gradual increases (1%~28%) by age were shown in IT, DT, and TT, a dramatic increase in ME was observed among participants in their 50s (26%), 60s (68%), and 70s (160%) compared to those in their 20s~40s. The most distinctive interaction effect of age and gender was found in ME out of the four FCC measures. Lastly, hand and its related interactions were not found significant. Normative FCC data were established for four age groups (20s~40s, 50s, 60s, and 70s) and gender. The normative FCC data can be used for evaluating an individual's motor performance, screening patients with brain disorders, and designing input devices triggered and/or operated by the finger. © 2015, Human Factors and Ergonomics Society.
45 CFR 1355.30 - Other applicable regulations.
Code of Federal Regulations, 2013 CFR
2013-10-01
....30 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL § 1355.30...
Technical Basis for Evaluating Software-Related Common-Cause Failures
DOE Office of Scientific and Technical Information (OSTI.GOV)
Muhlheim, Michael David; Wood, Richard
2016-04-01
The instrumentation and control (I&C) system architecture at a nuclear power plant (NPP) incorporates protections against common-cause failures (CCFs) through the use of diversity and defense-in-depth. Even for well-established analog-based I&C system designs, the potential for CCFs of multiple systems (or redundancies within a system) constitutes a credible threat to defeating the defense-in-depth provisions within the I&C system architectures. The integration of digital technologies into the I&C systems provides many advantages compared to the aging analog systems with respect to reliability, maintenance, operability, and cost effectiveness. However, maintaining the diversity and defense-in-depth for both the hardware and software within themore » digital system is challenging. In fact, the introduction of digital technologies may actually increase the potential for CCF vulnerabilities because of the introduction of undetected systematic faults. These systematic faults are defined as a “design fault located in a software component” and at a high level, are predominately the result of (1) errors in the requirement specification, (2) inadequate provisions to account for design limits (e.g., environmental stress), or (3) technical faults incorporated in the internal system (or architectural) design or implementation. Other technology-neutral CCF concerns include hardware design errors, equipment qualification deficiencies, installation or maintenance errors, instrument loop scaling and setpoint mistakes.« less
Abundance of large old trees in wood-pastures of Transylvania (Romania).
Hartel, Tibor; Hanspach, Jan; Moga, Cosmin I; Holban, Lucian; Szapanyos, Árpád; Tamás, Réka; Hováth, Csaba; Réti, Kinga-Olga
2018-02-01
Wood-pastures are special types of agroforestry systems that integrate trees with livestock grazing. Wood pastures can be hotspots for large old tree abundance and have exceptional natural values; but they are declining all over Europe. While presence of large old trees in wood-pastures can provide arguments for their maintenance, actual data on their distribution and abundance are sparse. Our study is the first to survey large old trees in Eastern Europe over such a large area. We surveyed 97 wood-pastures in Transylvania (Romania) in order to (i) provide a descriptive overview of the large old tree abundance; and (ii) to explore the environmental determinants of the abundance and persistence of large old trees in wood-pastures. We identified 2520 large old trees belonging to 16 taxonomic groups. Oak was present in 66% of the wood-pastures, followed by beech (33%), hornbeam (24%) and pear (22%). For each of these four species we constructed a generalized linear model with quasi-Poisson error distribution to explain individual tree abundance. Oak trees were most abundant in large wood-pastures and in wood-pastures from the Saxon cultural region of Transylvania. Beech abundance related positively to elevation and to proximity of human settlements. Abundance of hornbeam was highest in large wood-pastures, in wood-pastures from the Saxon cultural region, and in places with high cover of adjacent forest and a low human population density. Large old pear trees were most abundant in large wood-pastures that were close to paved roads. The maintenance of large old trees in production landscapes is a challenge for science, policy and local people, but it also can serve as an impetus for integrating economic, ecological and social goals within a landscape. Copyright © 2017 Elsevier B.V. All rights reserved.
Code of Federal Regulations, 2010 CFR
2010-10-01
... 45 Public Welfare 2 2010-10-01 2010-10-01 false Maintenance of a machine readable file; requests for income and eligibility information. 205.57 Section 205.57 Public Welfare Regulations Relating to Public Welfare OFFICE OF FAMILY ASSISTANCE (ASSISTANCE PROGRAMS), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES...
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 4 2011-10-01 2011-10-01 false Scope. 1355.10 Section 1355.10 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE...
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 4 2012-10-01 2012-10-01 false Scope. 1355.10 Section 1355.10 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE...
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 4 2014-10-01 2014-10-01 false Scope. 1355.10 Section 1355.10 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE...
Comprehensive analysis of a medication dosing error related to CPOE.
Horsky, Jan; Kuperman, Gilad J; Patel, Vimla L
2005-01-01
This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.
Applied Operations Research: Augmented Reality in an Industrial Environment
NASA Technical Reports Server (NTRS)
Cole, Stuart K.
2015-01-01
Augmented reality is the application of computer generated data or graphics onto a real world view. Its use provides the operator additional information or a heightened situational awareness. While advancements have been made in automation and diagnostics of high value critical equipment to improve readiness, reliability and maintenance, the need for assisting and support to Operations and Maintenance staff persists. AR can improve the human machine interface where computer capabilities maximize the human experience and analysis capabilities. NASA operates multiple facilities with complex ground based HVCE in support of national aerodynamics and space exploration, and the need exists to improve operational support and close a gap related to capability sustainment where key and experienced staff consistently rotate work assignments and reach their expiration of term of service. The initiation of an AR capability to augment and improve human abilities and training experience in the industrial environment requires planning and establishment of a goal and objectives for the systems and specific applications. This paper explored use of AR in support of Operation staff in real time operation of HVCE and its maintenance. The results identified include identification of specific goal and objectives, challenges related to availability and computer system infrastructure.
Type I Rehearsal and Recognition.
ERIC Educational Resources Information Center
Glenberg, Arthur; Adams, Frederick
1978-01-01
Rote, repetitive Type I Rehearsal is defined as the continuous maintenance of information in memory using the minimum cognitive capacity necessary for maintenance. An analysis of errors made on a forced-choice recognition test supported the hypothesis that acoustic-phonemic components of the memory trace are added or strengthened by this…
Adaptive reduction of constitutive model-form error using a posteriori error estimation techniques
DOE Office of Scientific and Technical Information (OSTI.GOV)
Bishop, Joseph E.; Brown, Judith Alice
In engineering practice, models are typically kept as simple as possible for ease of setup and use, computational efficiency, maintenance, and overall reduced complexity to achieve robustness. In solid mechanics, a simple and efficient constitutive model may be favored over one that is more predictive, but is difficult to parameterize, is computationally expensive, or is simply not available within a simulation tool. In order to quantify the modeling error due to the choice of a relatively simple and less predictive constitutive model, we adopt the use of a posteriori model-form error-estimation techniques. Based on local error indicators in the energymore » norm, an algorithm is developed for reducing the modeling error by spatially adapting the material parameters in the simpler constitutive model. The resulting material parameters are not material properties per se, but depend on the given boundary-value problem. As a first step to the more general nonlinear case, we focus here on linear elasticity in which the “complex” constitutive model is general anisotropic elasticity and the chosen simpler model is isotropic elasticity. As a result, the algorithm for adaptive error reduction is demonstrated using two examples: (1) A transversely-isotropic plate with hole subjected to tension, and (2) a transversely-isotropic tube with two side holes subjected to torsion.« less
Adaptive reduction of constitutive model-form error using a posteriori error estimation techniques
Bishop, Joseph E.; Brown, Judith Alice
2018-06-15
In engineering practice, models are typically kept as simple as possible for ease of setup and use, computational efficiency, maintenance, and overall reduced complexity to achieve robustness. In solid mechanics, a simple and efficient constitutive model may be favored over one that is more predictive, but is difficult to parameterize, is computationally expensive, or is simply not available within a simulation tool. In order to quantify the modeling error due to the choice of a relatively simple and less predictive constitutive model, we adopt the use of a posteriori model-form error-estimation techniques. Based on local error indicators in the energymore » norm, an algorithm is developed for reducing the modeling error by spatially adapting the material parameters in the simpler constitutive model. The resulting material parameters are not material properties per se, but depend on the given boundary-value problem. As a first step to the more general nonlinear case, we focus here on linear elasticity in which the “complex” constitutive model is general anisotropic elasticity and the chosen simpler model is isotropic elasticity. As a result, the algorithm for adaptive error reduction is demonstrated using two examples: (1) A transversely-isotropic plate with hole subjected to tension, and (2) a transversely-isotropic tube with two side holes subjected to torsion.« less
Analyzing temozolomide medication errors: potentially fatal.
Letarte, Nathalie; Gabay, Michael P; Bressler, Linda R; Long, Katie E; Stachnik, Joan M; Villano, J Lee
2014-10-01
The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.
Predictive models of safety based on audit findings: Part 2: Measurement of model validity.
Hsiao, Yu-Lin; Drury, Colin; Wu, Changxu; Paquet, Victor
2013-07-01
Part 1 of this study sequence developed a human factors/ergonomics (HF/E) based classification system (termed HFACS-MA) for safety audit findings and proved its measurement reliability. In Part 2, we used the human error categories of HFACS-MA as predictors of future safety performance. Audit records and monthly safety incident reports from two airlines submitted to their regulatory authority were available for analysis, covering over 6.5 years. Two participants derived consensus results of HF/E errors from the audit reports using HFACS-MA. We adopted Neural Network and Poisson regression methods to establish nonlinear and linear prediction models respectively. These models were tested for the validity of prediction of the safety data, and only Neural Network method resulted in substantially significant predictive ability for each airline. Alternative predictions from counting of audit findings and from time sequence of safety data produced some significant results, but of much smaller magnitude than HFACS-MA. The use of HF/E analysis of audit findings provided proactive predictors of future safety performance in the aviation maintenance field. Copyright © 2013 Elsevier Ltd and The Ergonomics Society. All rights reserved.
45 CFR 1355.32 - Timetable for the reviews.
Code of Federal Regulations, 2013 CFR
2013-10-01
... Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL § 1355.32 Timetable for the...
45 CFR 1355.32 - Timetable for the reviews.
Code of Federal Regulations, 2010 CFR
2010-10-01
... Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL § 1355.32 Timetable for the...
Selecting statistical model and optimum maintenance policy: a case study of hydraulic pump.
Ruhi, S; Karim, M R
2016-01-01
Proper maintenance policy can play a vital role for effective investigation of product reliability. Every engineered object such as product, plant or infrastructure needs preventive and corrective maintenance. In this paper we look at a real case study. It deals with the maintenance of hydraulic pumps used in excavators by a mining company. We obtain the data that the owner had collected and carry out an analysis and building models for pump failures. The data consist of both failure and censored lifetimes of the hydraulic pump. Different competitive mixture models are applied to analyze a set of maintenance data of a hydraulic pump. Various characteristics of the mixture models, such as the cumulative distribution function, reliability function, mean time to failure, etc. are estimated to assess the reliability of the pump. Akaike Information Criterion, adjusted Anderson-Darling test statistic, Kolmogrov-Smirnov test statistic and root mean square error are considered to select the suitable models among a set of competitive models. The maximum likelihood estimation method via the EM algorithm is applied mainly for estimating the parameters of the models and reliability related quantities. In this study, it is found that a threefold mixture model (Weibull-Normal-Exponential) fits well for the hydraulic pump failures data set. This paper also illustrates how a suitable statistical model can be applied to estimate the optimum maintenance period at a minimum cost of a hydraulic pump.
Tailoring a Human Reliability Analysis to Your Industry Needs
NASA Technical Reports Server (NTRS)
DeMott, D. L.
2016-01-01
Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.
The role of predicted solar activity in TOPEX/Poseidon orbit maintenance maneuver design
NASA Technical Reports Server (NTRS)
Frauenholz, Raymond B.; Shapiro, Bruce E.
1992-01-01
Following launch in June 1992, the TOPEX/Poseidon satellite will be placed in a near-circular frozen orbit at an altitude of about 1336 km. Orbit maintenance maneuvers are planned to assure all nodes of the 127-orbit 10-day repeat ground track remain within a 2 km equatorial longitude bandwidth. Orbit determination, maneuver execution, and atmospheric drag prediction errors limit overall targeting performance. This paper focuses on the effects of drag modeling errors, with primary emphasis on the role of SESC solar activity predictions, especially the 27-day outlook of the 10.7 cm solar flux and geomagnetic index used by a simplified version of the Jacchia-Roberts density model developed for this TOPEX/Poseidon application. For data evaluated from 1983-90, the SESC outlook performed better than a simpler persistence strategy, especially during the first 7-10 days. A targeting example illustrates the use of ground track biasing to compensate for expected orbit predictions errors, emphasizing the role of solar activity prediction errors.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Weston, Louise Marie
2007-09-01
A recent report on criticality accidents in nuclear facilities indicates that human error played a major role in a significant number of incidents with serious consequences and that some of these human errors may be related to the emotional state of the individual. A pre-shift test to detect a deleterious emotional state could reduce the occurrence of such errors in critical operations. The effectiveness of pre-shift testing is a challenge because of the need to gather predictive data in a relatively short test period and the potential occurrence of learning effects due to a requirement for frequent testing. This reportmore » reviews the different types of reliability and validity methods and testing and statistical analysis procedures to validate measures of emotional state. The ultimate value of a validation study depends upon the percentage of human errors in critical operations that are due to the emotional state of the individual. A review of the literature to identify the most promising predictors of emotional state for this application is highly recommended.« less
Recent advances in thermoregulation.
Tansey, Etain A; Johnson, Christopher D
2015-09-01
Thermoregulation is the maintenance of a relatively constant core body temperature. Humans normally maintain a body temperature at 37°C, and maintenance of this relatively high temperature is critical to human survival. This concept is so important that control of thermoregulation is often the principal example cited when teaching physiological homeostasis. A basic understanding of the processes underpinning temperature regulation is necessary for all undergraduate students studying biology and biology-related disciplines, and a thorough understanding is necessary for those students in clinical training. Our aim in this review is to broadly present the thermoregulatory process taking into account current advances in this area. First, we summarize the basic concepts of thermoregulation and subsequently assess the physiological responses to heat and cold stress, including vasodilation and vasoconstriction, sweating, nonshivering thermogenesis, piloerection, shivering, and altered behavior. Current research is presented concerning the body's detection of thermal challenge, peripheral and central thermoregulatory control mechanisms, including brown adipose tissue in adult humans and temperature transduction by the relatively recently discovered transient receptor potential channels. Finally, we present an updated understanding of the neuroanatomic circuitry supporting thermoregulation. Copyright © 2015 The American Physiological Society.
Human factors in aviation maintenance, phase four : progress report.
DOT National Transportation Integrated Search
1995-05-01
The fourth phase of research on human factors in aviation maintenance continued to look at the human's role in the aviation maintenance system via investigations, demonstrations, and evaluations of the research program outputs. This report describes ...
Human factors in aviation maintenance, phase 1 : progress report.
DOT National Transportation Integrated Search
1991-11-01
This human factors research in aviation maintenance addresses four tasks including studies of organizational behavior, job and task analysis in maintenance and inspection, advanced technology for training, and the application of job aiding to mainten...
Influence Altitude and Length of Stay in the Mountains of Physical Performance Tourists
ERIC Educational Resources Information Center
Imangulova, Tatiyana; Makogonov, Aleksandr; Zakiryanov, Bauyrzhan; Makogonova, Tatiyana
2016-01-01
Development of adaptation, maintenance of normal human life in extreme environmental conditions is an urgent and a priority for all of humanity, for the recognition of the UN Commission on Sustainable Development "well-being" half of humanity in the XXI century will be directly related to the quality of development and the development of…
Human factors in aviation maintenance, phase five : progress report.
DOT National Transportation Integrated Search
1996-01-01
The fifth phase of research on human factors in aviation maintenance continued to look at the human's role in the aviation maintenance system via investigations, demonstrations, and evaluations of the research program outputs. This report describes t...
Yang, Shu-Hui; Jerng, Jih-Shuin; Chen, Li-Chin; Li, Yu-Tsu; Huang, Hsiao-Fang; Wu, Chao-Ling; Chan, Jing-Yuan; Huang, Szu-Fen; Liang, Huey-Wen; Sun, Jui-Sheng
2017-11-03
Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm. This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Investigation of technology needs for avoiding helicopter pilot error related accidents
NASA Technical Reports Server (NTRS)
Chais, R. I.; Simpson, W. E.
1985-01-01
Pilot error which is cited as a cause or related factor in most rotorcraft accidents was examined. Pilot error related accidents in helicopters to identify areas in which new technology could reduce or eliminate the underlying causes of these human errors were investigated. The aircraft accident data base at the U.S. Army Safety Center was studied as the source of data on helicopter accidents. A randomly selected sample of 110 aircraft records were analyzed on a case-by-case basis to assess the nature of problems which need to be resolved and applicable technology implications. Six technology areas in which there appears to be a need for new or increased emphasis are identified.
Hippocampal interictal epileptiform activity disrupts cognition in humans
Kleen, Jonathan K.; Scott, Rod C.; Holmes, Gregory L.; Roberts, David W.; Rundle, Melissa M.; Testorf, Markus; Lenck-Santini, Pierre-Pascal
2013-01-01
Objective: We investigated whether interictal epileptiform discharges (IED) in the human hippocampus are related to impairment of specific memory processes, and which characteristics of hippocampal IED are most associated with memory dysfunction. Methods: Ten patients had depth electrodes implanted into their hippocampi for preoperative seizure localization. EEG was recorded during 2,070 total trials of a short-term memory task, with memory processing categorized into encoding, maintenance, and retrieval. The influence of hippocampal IED on these processes was analyzed and adjusted to account for individual differences between patients. Results: Hippocampal IED occurring in the memory retrieval period decreased the likelihood of a correct response when they were contralateral to the seizure focus (p < 0.05) or bilateral (p < 0.001). Bilateral IED during the memory maintenance period had a similar effect (p < 0.01), particularly with spike-wave complexes of longer duration (p < 0.01). IED during encoding had no effect, and reaction time was also unaffected by IED. Conclusions: Hippocampal IED in humans may disrupt memory maintenance and retrieval, but not encoding. The particular effects of bilateral IED and those contralateral to the seizure focus may relate to neural compensation in the more functional hemisphere. This study provides biological validity to animal models in the study of IED-related transient cognitive impairment. Moreover, it strengthens the argument that IED may contribute to cognitive impairment in epilepsy depending upon when and where they occur. PMID:23685931
DNA damage and ageing: new-age ideas for an age-old problem
Garinis, George A.; van der Horst, Gijsbertus T. J.; Vijg, Jan; Hoeijmakers, Jan H. J.
2015-01-01
Loss of genome maintenance may causally contribute to ageing, as exemplified by the premature appearance of multiple symptoms of ageing in a growing family of human syndromes and in mice with genetic defects in genome maintenance pathways. Recent evidence revealed a similarity between such prematurely ageing mutants and long-lived mice harbouring mutations in growth signalling pathways. At first sight this seems paradoxical as they represent both extremes of ageing yet show a similar ‘survival’ response that is capable of delaying age-related pathology and extending lifespan. Understanding the mechanistic basis of this response and its connection with genome maintenance would open exciting possibilities for counteracting cancer or age-related diseases, and for promoting longevity. PMID:18978832
Human factors in aviation maintenance, phase three : volume 1 progress report.
DOT National Transportation Integrated Search
1993-08-01
The third phase of research on Human Factors in Aviation Maintenance continued to look at the human's role in the aviation maintenance system via investigations, demonstrations, and evaluations of the research program outputs. This report describes a...
Human factors in aviation maintenance : phase three, volume 2 progress report.
DOT National Transportation Integrated Search
1994-07-01
The third phase of research on human factors in aviation maintenance continued to look at the human's role in the aviation maintenance system via investigations, demonstrations, and evaluations of the research program outputs. This report describes t...
Rong, Hao; Tian, Jin
2015-05-01
The study contributes to human reliability analysis (HRA) by proposing a method that focuses more on human error causality within a sociotechnical system, illustrating its rationality and feasibility by using a case of the Minuteman (MM) III missile accident. Due to the complexity and dynamics within a sociotechnical system, previous analyses of accidents involving human and organizational factors clearly demonstrated that the methods using a sequential accident model are inadequate to analyze human error within a sociotechnical system. System-theoretic accident model and processes (STAMP) was used to develop a universal framework of human error causal analysis. To elaborate the causal relationships and demonstrate the dynamics of human error, system dynamics (SD) modeling was conducted based on the framework. A total of 41 contributing factors, categorized into four types of human error, were identified through the STAMP-based analysis. All factors are related to a broad view of sociotechnical systems, and more comprehensive than the causation presented in the accident investigation report issued officially. Recommendations regarding both technical and managerial improvement for a lower risk of the accident are proposed. The interests of an interdisciplinary approach provide complementary support between system safety and human factors. The integrated method based on STAMP and SD model contributes to HRA effectively. The proposed method will be beneficial to HRA, risk assessment, and control of the MM III operating process, as well as other sociotechnical systems. © 2014, Human Factors and Ergonomics Society.
NASA Technical Reports Server (NTRS)
1972-01-01
The assembly drawings of the receiver unit are presented for the data compression/error correction digital test system. Equipment specifications are given for the various receiver parts, including the TV input buffer register, delta demodulator, TV sync generator, memory devices, and data storage devices.
45 CFR 1356.22 - Implementation requirements for children voluntarily placed in foster care.
Code of Federal Regulations, 2010 CFR
2010-10-01
... voluntary foster care maintenance expenditures made within the first 180 days of the child's placement in... voluntarily placed in foster care. 1356.22 Section 1356.22 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE...
45 CFR 1356.22 - Implementation requirements for children voluntarily placed in foster care.
Code of Federal Regulations, 2012 CFR
2012-10-01
... only for voluntary foster care maintenance expenditures made within the first 180 days of the child's... voluntarily placed in foster care. 1356.22 Section 1356.22 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE...
Code of Federal Regulations, 2010 CFR
2010-10-01
... Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION... rate for FY 1994, FY 1995 and FY 1996, and at the 50 percent level thereafter for expenditures related...
Code of Federal Regulations, 2011 CFR
2011-10-01
... Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION... rate for FY 1994, FY 1995 and FY 1996, and at the 50 percent level thereafter for expenditures related...
45 CFR 1356.22 - Implementation requirements for children voluntarily placed in foster care.
Code of Federal Regulations, 2014 CFR
2014-10-01
... only for voluntary foster care maintenance expenditures made within the first 180 days of the child's... voluntarily placed in foster care. 1356.22 Section 1356.22 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE...
45 CFR 1356.22 - Implementation requirements for children voluntarily placed in foster care.
Code of Federal Regulations, 2013 CFR
2013-10-01
... only for voluntary foster care maintenance expenditures made within the first 180 days of the child's... voluntarily placed in foster care. 1356.22 Section 1356.22 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE...
45 CFR 1356.22 - Implementation requirements for children voluntarily placed in foster care.
Code of Federal Regulations, 2011 CFR
2011-10-01
... voluntary foster care maintenance expenditures made within the first 180 days of the child's placement in... voluntarily placed in foster care. 1356.22 Section 1356.22 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE...
Aged-related Neural Changes during Memory Conjunction Errors
Giovanello, Kelly S.; Kensinger, Elizabeth A.; Wong, Alana T.; Schacter, Daniel L.
2013-01-01
Human behavioral studies demonstrate that healthy aging is often accompanied by increases in memory distortions or errors. Here we used event-related functional MRI to examine the neural basis of age-related memory distortions. We utilized the memory conjunction error paradigm, a laboratory procedure known to elicit high levels of memory errors. For older adults, right parahippocampal gyrus showed significantly greater activity during false than during accurate retrieval. We observed no regions in which activity was greater during false than during accurate retrieval for young adults. Young adults, however, showed significantly greater activity than old adults during accurate retrieval in right hippocampus. By contrast, older adults demonstrated greater activity than young adults during accurate retrieval in right inferior and middle prefrontal cortex. These data are consistent with the notion that age-related memory conjunction errors arise from dysfunction of hippocampal system mechanisms, rather than impairments in frontally-mediated monitoring processes. PMID:19445606
Burkholderia thailandensis: Growth and Laboratory Maintenance.
Garcia, Erin C; Cotter, Peggy A
2016-08-12
Burkholderia thailandensis is a nonpathogenic Gram-negative bacterium found in tropical soils. Closely related to several human pathogens, its ease of genetic manipulation, rapid growth in the laboratory, and low virulence make B. thailandensis a commonly used model organism. This unit describes the fundamental protocols for in vitro growth and maintenance of B. thailandensis in the laboratory. © 2016 by John Wiley & Sons, Inc. Copyright © 2016 John Wiley & Sons, Inc.
A comparison of acoustic montoring methods for common anurans of the northeastern United States
Brauer, Corinne; Donovan, Therese; Mickey, Ruth M.; Katz, Jonathan; Mitchell, Brian R.
2016-01-01
Many anuran monitoring programs now include autonomous recording units (ARUs). These devices collect audio data for extended periods of time with little maintenance and at sites where traditional call surveys might be difficult. Additionally, computer software programs have grown increasingly accurate at automatically identifying the calls of species. However, increased automation may cause increased error. We collected 435 min of audio data with 2 types of ARUs at 10 wetland sites in Vermont and New York, USA, from 1 May to 1 July 2010. For each minute, we determined presence or absence of 4 anuran species (Hyla versicolor, Pseudacris crucifer, Anaxyrus americanus, and Lithobates clamitans) using 1) traditional human identification versus 2) computer-mediated identification with software package, Song Scope® (Wildlife Acoustics, Concord, MA). Detections were compared with a data set consisting of verified calls in order to quantify false positive, false negative, true positive, and true negative rates. Multinomial logistic regression analysis revealed a strong (P < 0.001) 3-way interaction between the ARU recorder type, identification method, and focal species, as well as a trend in the main effect of rain (P = 0.059). Overall, human surveyors had the lowest total error rate (<2%) compared with 18–31% total errors with automated methods. Total error rates varied by species, ranging from 4% for A. americanus to 26% for L. clamitans. The presence of rain may reduce false negative rates. For survey minutes where anurans were known to be calling, the odds of a false negative were increased when fewer individuals of the same species were calling.
Auditing as part of the terminology design life cycle.
Min, Hua; Perl, Yehoshua; Chen, Yan; Halper, Michael; Geller, James; Wang, Yue
2006-01-01
To develop and test an auditing methodology for detecting errors in medical terminologies satisfying systematic inheritance. This methodology is based on various abstraction taxonomies that provide high-level views of a terminology and highlight potentially erroneous concepts. Our auditing methodology is based on dividing concepts of a terminology into smaller, more manageable units. First, we divide the terminology's concepts into areas according to their relationships/roles. Then each multi-rooted area is further divided into partial-areas (p-areas) that are singly-rooted. Each p-area contains a set of structurally and semantically uniform concepts. Two kinds of abstraction networks, called the area taxonomy and p-area taxonomy, are derived. These taxonomies form the basis for the auditing approach. Taxonomies tend to highlight potentially erroneous concepts in areas and p-areas. Human reviewers can focus their auditing efforts on the limited number of problematic concepts following two hypotheses on the probable concentration of errors. A sample of the area taxonomy and p-area taxonomy for the Biological Process (BP) hierarchy of the National Cancer Institute Thesaurus (NCIT) was derived from the application of our methodology to its concepts. These views led to the detection of a number of different kinds of errors that are reported, and to confirmation of the hypotheses on error concentration in this hierarchy. Our auditing methodology based on area and p-area taxonomies is an efficient tool for detecting errors in terminologies satisfying systematic inheritance of roles, and thus facilitates their maintenance. This methodology concentrates a domain expert's manual review on portions of the concepts with a high likelihood of errors.
Simultaneous Control of Error Rates in fMRI Data Analysis
Kang, Hakmook; Blume, Jeffrey; Ombao, Hernando; Badre, David
2015-01-01
The key idea of statistical hypothesis testing is to fix, and thereby control, the Type I error (false positive) rate across samples of any size. Multiple comparisons inflate the global (family-wise) Type I error rate and the traditional solution to maintaining control of the error rate is to increase the local (comparison-wise) Type II error (false negative) rates. However, in the analysis of human brain imaging data, the number of comparisons is so large that this solution breaks down: the local Type II error rate ends up being so large that scientifically meaningful analysis is precluded. Here we propose a novel solution to this problem: allow the Type I error rate to converge to zero along with the Type II error rate. It works because when the Type I error rate per comparison is very small, the accumulation (or global) Type I error rate is also small. This solution is achieved by employing the Likelihood paradigm, which uses likelihood ratios to measure the strength of evidence on a voxel-by-voxel basis. In this paper, we provide theoretical and empirical justification for a likelihood approach to the analysis of human brain imaging data. In addition, we present extensive simulations that show the likelihood approach is viable, leading to ‘cleaner’ looking brain maps and operationally superiority (lower average error rate). Finally, we include a case study on cognitive control related activation in the prefrontal cortex of the human brain. PMID:26272730
Relative navigation for spacecraft formation flying
NASA Technical Reports Server (NTRS)
Hartman, Kate R.; Gramling, Cheryl J.; Lee, Taesul; Kelbel, David A.; Long, Anne C.
1998-01-01
The Goddard Space Flight Center Guidance, Navigation, and Control Center (GNCC) is currently developing and implementing advanced satellite systems to provide autonomous control of formation flyers. The initial formation maintenance capability will be flight-demonstrated on the Earth-Orbiter-1 (EO-1) satellite, which is planned under the National Aeronautics and Space Administration New Millennium Program to be a coflight with the Landsat-7 (L-7) satellite. Formation flying imposes relative navigation accuracy requirements in addition to the orbit accuracy requirements for the individual satellites. In the case of EO-1 and L-7, the two satellites are in nearly coplanar orbits, with a small difference in the longitude of the ascending node to compensate for the Earth's rotation. The GNCC has performed trajectory error analysis for the relative navigation of the EO-1/L-7 formation, as well as for a more advanced tracking configuration using cross-link satellite communications. This paper discusses the orbit determination and prediction accuracy achievable for EO-1 and L-7 under various tracking and orbit determination scenarios and discusses the expected relative separation errors in their formation flying configuration.
Relative Navigation for Spacecraft Formation Flying
NASA Technical Reports Server (NTRS)
Hartman, Kate R.; Gramling, Cheryl J.; Lee, Taesul; Kelbel, David A.; Long, Anne C.
1998-01-01
The Goddard Space Flight Center Guidance, Navigation, and Control Center (GNCC) is currently developing and implementing advanced satellite systems to provide autonomous control of formation flyers. The initial formation maintenance capability will be flight-demonstrated on the Earth-Orbiter-1 (EO-l) satellite, which is planned under the National Aeronautics and Space Administration New Millennium Program to be a coflight with the Landsat-7 (L-7) satellite. Formation flying imposes relative navigation accuracy requirements in addition to the orbit accuracy requirements for the individual satellites. In the case of EO-1 and L-7, the two satellites are in nearly coplanar orbits, with a small difference in the longitude of the ascending node to compensate for the Earth's rotation. The GNCC has performed trajectory error analysis for the relative navigation of the EO-1/L-7 formation, as well as for a more advanced tracking configuration using cross- link satellite communications. This paper discusses the orbit determination and prediction accuracy achievable for EO-1 and L-7 under various tracking and orbit determination scenarios and discusses the expected relative separation errors in their formation flying configuration.
42 CFR 417.484 - Requirement applicable to related entities.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 42 Public Health 3 2012-10-01 2012-10-01 false Requirement applicable to related entities. 417.484 Section 417.484 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL...
42 CFR 417.484 - Requirement applicable to related entities.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 42 Public Health 3 2014-10-01 2014-10-01 false Requirement applicable to related entities. 417.484 Section 417.484 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL...
DOT National Transportation Integrated Search
1998-03-01
Ten years ago the Federal Aviation Administration (FAA) Office of Aviation Medicine embarked on a research and development program dedicated to human factors in aviation maintenance and inspection. Since 1989 FAA has invested over $12M in maintenance...
Goldhaber-Fiebert, Jeremy D; Babiarz, Kimberly S; Garfield, Rachel L; Wulczyn, Fred; Landsverk, John; Horwitz, Sarah M
2014-04-01
U.S. Child Welfare systems are involved in the lives of millions of children, and total spending exceeds $26 billion annually. Out-of-home foster care is a critical and expensive Child Welfare service, a major component of which is the maintenance rate paid to support housing and caring for a foster child. Maintenance rates vary widely across states and over time, but reasons for this variation are not well understood. As evidence-based programs are disseminated to state Child Welfare systems, it is important to understand what may be the important drivers in the uptake of these practices including state spending on core system areas. We assembled a unique, longitudinal, state-level panel dataset (1990-2008) for all 50 states with annual data on foster care maintenance rates and measures of child population in need, poverty, employment, urbanicity, proportion minority, political party control of the state legislature and governorship, federal funding, and lawsuits involving state foster care systems. All monetary values were expressed in per-capita terms and inflation adjusted to 2008 dollars. We used longitudinal panel regressions with robust standard errors and state and year fixed effects to estimate the relationship between state foster care maintenance rates and the other factors in our dataset, lagging all factors by one year to mitigate the possibility that maintenance rates influenced their predictors. Exploratory analyses related maintenance rates to Child Welfare outcomes. State foster care maintenance rates have increased in nominal terms, but in many states, have not kept pace with inflation, leading to lower real rates in 2008 compared to those in 1991 for 54% of states for 2 year-olds, 58% for 9 year-olds, and 65% for 16 year-olds. In multivariate analyses including socioeconomic, demographic, and political factors, monthly foster care maintenance rates declined $15 for each 1% increase in state unemployment and declined $40 if a state's governorship and legislature became Republican, though significance was marginal. In analyses also examining state revenue, federal funding, and legal challenges, maintenance rates increased as the federal share of maximum TANF payments increased. However, >50% of variation in foster care maintenance rates was explained by unobserved state-level factors as measured by state fixed effects. These factors did not appear to be strongly related to 2008 Child Welfare outcomes like foster care placement stability and maltreatment which were also not correlated with foster care maintenance rates. Despite being part of a social safety net, foster care maintenance rates have declined in real terms since 1991 in many states, and there is no strong evidence that they increase in response to harsher economic climates or to federal programs or legal reviews. State variation in maintenance rates was not related to Child Welfare outcomes, though further analysis of this important relationship is needed. Variability in state foster care maintenance rates appears highly idiosyncratic, an important contextual factor to consider when designing and disseminating evidence-based services.
Peripheral refraction and image blur in four meridians in emmetropes and myopes.
Shen, Jie; Spors, Frank; Egan, Donald; Liu, Chunming
2018-01-01
The peripheral refractive error of the human eye has been hypothesized to be a major stimulus for the development of its central refractive error. The purpose of this study was to investigate the changes in the peripheral refractive error across horizontal, vertical and two diagonal meridians in emmetropic and low, moderate and high myopic adults. Thirty-four adult subjects were recruited and aberration was measured using a modified commercial aberrometer. We then computed the refractive error in power vector notation from second-order Zernike terms. Statistical analysis was performed to evaluate the statistical differences in refractive error profiles between the subject groups and across all measured visual field meridians. Small amounts of relative myopic shift were observed in emmetropic and low myopic subjects. However, moderate and high myopic subjects exhibited a relative hyperopic shift in all four meridians. Astigmatism J 0 and J 45 had quadratic or linear changes dependent on the visual field meridians. Peripheral Sphero-Cylindrical Retinal Image Blur increased in emmetropic eyes in most of the measured visual fields. The findings indicate an overall emmetropic or slightly relative myopic periphery (spherical or oblate retinal shape) formed in emmetropes and low myopes, while moderate and high myopes form relative hyperopic periphery (prolate, or less oblate, retinal shape). In general, human emmetropic eyes demonstrate higher amount of peripheral retinal image blur.
Lu, Chi-Yu; Liu, Fei-Tsui; Feng, Chia-Hsien
2011-09-15
The renin-angiotensin-aldosterone system (RAAS) is an essential body fluid maintenance system that controls pressure in the human body. The conversion of angiotensin I to angiotensin II by angiotensin-converting enzyme (ACE) is a key process in the RAAS because angiotensin II causes the vasoconstriction association with hypertension. Because of its effectiveness as an ACE blocker, quinipril is widely used for clinical treatment of hypertension and chronic congestive heart failure(.) Matrix-assisted laser desorption/ionization coupled with time-of-flight analyzer (MALDI-TOF) is a high throughput instrument for biological sample analysis. This study developed a micro-scale approach for using MALDI-TOF to detect quinapril in biological samples. A micro-liquid-liquid-extraction strategy combined with ion-pair interaction successfully extracted quinapril from aqueous layer to organic layer. Quinolones were then used as matrix additives to suppress undesired substances in plasma produce signals. Several factors affecting extraction efficiency were investigated in a biosample with a volume of only 10 μL. This method is successful to monitor quinapril in the clinical therapeutic range. The proposed method proved effective for monitoring the trace amounts of quinapril typically used for clinical therapy. The relative standard deviation (R.S.D.) and relative error (R.E.) used for evaluating within- and between-day assays of quinapril in plasma consistently remained below 15%. Copyright © 2011. Published by Elsevier B.V.
Code of Federal Regulations, 2013 CFR
2013-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... third-party sources. (a) Option to claim in-kind expenditures from third-party sources for non-Federal...
Code of Federal Regulations, 2014 CFR
2014-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... third-party sources. (a) Option to claim in-kind expenditures from third-party sources for non-Federal...
Code of Federal Regulations, 2012 CFR
2012-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... third-party sources. (a) Option to claim in-kind expenditures from third-party sources for non-Federal...
Code of Federal Regulations, 2011 CFR
2011-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... additional Indian Tribes in Fys 1996 through 1998 in the event that there are increased appropriations. (2...
Code of Federal Regulations, 2013 CFR
2013-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... additional Indian Tribes in Fys 1996 through 1998 in the event that there are increased appropriations. (2...
Code of Federal Regulations, 2012 CFR
2012-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... additional Indian Tribes in Fys 1996 through 1998 in the event that there are increased appropriations. (2...
Code of Federal Regulations, 2014 CFR
2014-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... additional Indian Tribes in Fys 1996 through 1998 in the event that there are increased appropriations. (2...
Code of Federal Regulations, 2010 CFR
2010-10-01
... Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE... additional Indian Tribes in Fys 1996 through 1998 in the event that there are increased appropriations. (2...
A framework of medical equipment management system for in-house clinical engineering department.
Chien, Chia-Hung; Huang, Yi-You; Chong, Fok-Ching
2010-01-01
Medical equipment management is an important issue for safety and cost in modern hospital operation. In addition, the use of an efficient information system effectively promotes the managing performance. In this study, we designed a framework of medical equipment management system used for in-house clinical engineering department. The system was web-based, and it integrated clinical engineering and hospital information system components. Through related information application, it efficiently improved the operation management of medical devices immediately and continuously. This system has run in the National Taiwan University Hospital. The results showed only few examples in the error analysis of medical equipment by the maintenance sub-system. The information can be used to improve work quality, to reduce the maintenance cost, and to promote the safety of medical device used in patients and clinical staffs.
[Relations between health information systems and patient safety].
Nøhr, Christian
2012-11-05
Health information systems have the potential to reduce medical errors, and indeed many studies have shown a significant reduction. However, if the systems are not designed and implemented properly, there is evidence that suggest that new types of errors will arise--i.e., technology-induced errors. Health information systems will need to undergo a more rigorous evaluation. Usability evaluation and simulation test with humans in the loop can help to detect and prevent technology-induced errors before they are deployed in real health-care settings.
Model-based VQ for image data archival, retrieval and distribution
NASA Technical Reports Server (NTRS)
Manohar, Mareboyana; Tilton, James C.
1995-01-01
An ideal image compression technique for image data archival, retrieval and distribution would be one with the asymmetrical computational requirements of Vector Quantization (VQ), but without the complications arising from VQ codebooks. Codebook generation and maintenance are stumbling blocks which have limited the use of VQ as a practical image compression algorithm. Model-based VQ (MVQ), a variant of VQ described here, has the computational properties of VQ but does not require explicit codebooks. The codebooks are internally generated using mean removed error and Human Visual System (HVS) models. The error model assumed is the Laplacian distribution with mean, lambda-computed from a sample of the input image. A Laplacian distribution with mean, lambda, is generated with uniform random number generator. These random numbers are grouped into vectors. These vectors are further conditioned to make them perceptually meaningful by filtering the DCT coefficients from each vector. The DCT coefficients are filtered by multiplying by a weight matrix that is found to be optimal for human perception. The inverse DCT is performed to produce the conditioned vectors for the codebook. The only image dependent parameter used in the generation of codebook is the mean, lambda, that is included in the coded file to repeat the codebook generation process for decoding.
2014-04-01
laparoscopic ventral hernia repair. Additional simulation stations were added to the standards and purchases (including a motion tracking system) were...framework for laparoscopic ventral hernia; Incorporation of error-based simulators into an exit assessment of chief surgical residents; Development of...simulating a laparoscopic ventral hernia (LVH) repair. Based on collected data, the lab worked to finalize the incorporation of error-based simulators
Human Error: A Concept Analysis
NASA Technical Reports Server (NTRS)
Hansen, Frederick D.
2007-01-01
Human error is the subject of research in almost every industry and profession of our times. This term is part of our daily language and intuitively understood by most people however, it would be premature to assume that everyone's understanding of human error s the same. For example, human error is used to describe the outcome or consequence of human action, the causal factor of an accident, deliberate violations,a nd the actual action taken by a human being. As a result, researchers rarely agree on the either a specific definition or how to prevent human error. The purpose of this article is to explore the specific concept of human error using Concept Analysis as described by Walker and Avant (1995). The concept of human error is examined as currently used in the literature of a variety of industries and professions. Defining attributes and examples of model, borderline, and contrary cases are described. The antecedents and consequences of human error are also discussed and a definition of human error is offered.
Helle, Samuli
2018-03-01
Revealing causal effects from correlative data is very challenging and a contemporary problem in human life history research owing to the lack of experimental approach. Problems with causal inference arising from measurement error in independent variables, whether related either to inaccurate measurement technique or validity of measurements, seem not well-known in this field. The aim of this study is to show how structural equation modeling (SEM) with latent variables can be applied to account for measurement error in independent variables when the researcher has recorded several indicators of a hypothesized latent construct. As a simple example of this approach, measurement error in lifetime allocation of resources to reproduction in Finnish preindustrial women is modelled in the context of the survival cost of reproduction. In humans, lifetime energetic resources allocated in reproduction are almost impossible to quantify with precision and, thus, typically used measures of lifetime reproductive effort (e.g., lifetime reproductive success and parity) are likely to be plagued by measurement error. These results are contrasted with those obtained from a traditional regression approach where the single best proxy of lifetime reproductive effort available in the data is used for inference. As expected, the inability to account for measurement error in women's lifetime reproductive effort resulted in the underestimation of its underlying effect size on post-reproductive survival. This article emphasizes the advantages that the SEM framework can provide in handling measurement error via multiple-indicator latent variables in human life history studies. © 2017 Wiley Periodicals, Inc.
NASTRAN maintenance and enhancement experiences
NASA Technical Reports Server (NTRS)
Schmitz, R. P.
1975-01-01
The current capability is described which includes isoparametric elements, optimization of grid point sequencing, and eigenvalue routine. Overlay and coding errors were corrected for cyclic symmetry, transient response, and differential stiffness rigid formats. Error corrections and program enhancements are discussed along with developments scheduled for the current year and a brief description of analyses being performed using the program.
NASA Technical Reports Server (NTRS)
1987-01-01
United Scanning Technologies, Inc.'s Infrared thermography is a relatively new noncontact, nondestructive inspection and testing tool which makes temperatures visible to the human eye. Infrared scanning devices produce images that show, by color or black and white shading differences, heat losses through damaged or inadequately insulated walls or roofs. The MISS Aeroscan services are designed to take the guesswork out of industrial roof maintenance and provide companies big savings by identifying the location of moisture damage from roof leaks, effectively targeting maintenance attention.
Spatial Resolution, Grayscale, and Error Diffusion Trade-offs: Impact on Display System Design
NASA Technical Reports Server (NTRS)
Gille, Jennifer L. (Principal Investigator)
1996-01-01
We examine technology trade-offs related to grayscale resolution, spatial resolution, and error diffusion for tessellated display systems. We present new empirical results from our psychophysical study of these trade-offs and compare them to the predictions of a model of human vision.
21 CFR 1040.11 - Specific purpose laser products.
Code of Federal Regulations, 2012 CFR
2012-04-01
... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of...
21 CFR 1040.11 - Specific purpose laser products.
Code of Federal Regulations, 2014 CFR
2014-04-01
... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of...
21 CFR 1040.11 - Specific purpose laser products.
Code of Federal Regulations, 2013 CFR
2013-04-01
... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of...
An error taxonomy system for analysis of haemodialysis incidents.
Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi
2014-12-01
This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.
Auditing as Part of the Terminology Design Life Cycle
Min, Hua; Perl, Yehoshua; Chen, Yan; Halper, Michael; Geller, James; Wang, Yue
2006-01-01
Objective To develop and test an auditing methodology for detecting errors in medical terminologies satisfying systematic inheritance. This methodology is based on various abstraction taxonomies that provide high-level views of a terminology and highlight potentially erroneous concepts. Design Our auditing methodology is based on dividing concepts of a terminology into smaller, more manageable units. First, we divide the terminology’s concepts into areas according to their relationships/roles. Then each multi-rooted area is further divided into partial-areas (p-areas) that are singly-rooted. Each p-area contains a set of structurally and semantically uniform concepts. Two kinds of abstraction networks, called the area taxonomy and p-area taxonomy, are derived. These taxonomies form the basis for the auditing approach. Taxonomies tend to highlight potentially erroneous concepts in areas and p-areas. Human reviewers can focus their auditing efforts on the limited number of problematic concepts following two hypotheses on the probable concentration of errors. Results A sample of the area taxonomy and p-area taxonomy for the Biological Process (BP) hierarchy of the National Cancer Institute Thesaurus (NCIT) was derived from the application of our methodology to its concepts. These views led to the detection of a number of different kinds of errors that are reported, and to confirmation of the hypotheses on error concentration in this hierarchy. Conclusion Our auditing methodology based on area and p-area taxonomies is an efficient tool for detecting errors in terminologies satisfying systematic inheritance of roles, and thus facilitates their maintenance. This methodology concentrates a domain expert’s manual review on portions of the concepts with a high likelihood of errors. PMID:16929044
Accessibility assessment of assistive technology for the hearing impaired.
Áfio, Aline Cruz Esmeraldo; Carvalho, Aline Tomaz de; Caravalho, Luciana Vieira de; Silva, Andréa Soares Rocha da; Pagliuca, Lorita Marlena Freitag
2016-01-01
to assess the automatic accessibility of assistive technology in online courses for the hearing impaired. evaluation study guided by the Assessment and Maintenance step proposed in the Model of Development of Digital Educational Material. The software Assessor and Simulator for the Accessibility of Sites (ASES) was used to analyze the online course "Education on Sexual and Reproductive Health: the use of condoms" according to the accessibility standards of national and international websites. an error report generated by the program identified, in each didactic module, one error and two warnings related to two international principles and six warnings involved with six national recommendations. The warnings relevant to hearing-impaired people were corrected, and the course was considered accessible by automatic assessment. we concluded that the pages of the course were considered, by the software used, appropriate to the standards of web accessibility.
Biobanking human embryonic stem cell lines: policy, ethics and efficiency.
Holm, Søren
2015-12-01
Stem cell banks curating and distributing human embryonic stem cells have been established in a number of countries and by a number of private institutions. This paper identifies and critically discusses a number of arguments that are used to justify the importance of such banks in policy discussions relating to their establishment or maintenance. It is argued (1) that 'ethical arguments' are often more important in the establishment phase and 'efficiency arguments' more important in the maintenance phase, and (2) that arguments relating to the interests of embryo and gamete donors are curiously absent from the particular stem cell banking policy discourse. This to some extent artificially isolates this discourse from the broader discussions about the flows of reproductive materials and tissues in modern society, and such isolation may lead to the interests of important actors being ignored in the policy making process.
Parris, Benjamin A.; Bate, Sarah; Brown, Scott D.; Hodgson, Timothy L.
2012-01-01
A portion of Stroop interference is thought to arise from a failure to maintain goal-oriented behaviour (or goal neglect). The aim of the present study was to investigate whether goal- relevant primes could enhance goal maintenance and reduce the Stroop interference effect. Here it is shown that primes related to the goal of responding quickly in the Stroop task (e.g. fast, quick, hurry) substantially reduced Stroop interference by reducing reaction times to incongruent trials but increasing reaction times to congruent and neutral trials. No effects of the primes were observed on errors. The effects on incongruent, congruent and neutral trials are explained in terms of the influence of the primes on goal maintenance. The results show that goal priming can facilitate goal-oriented behaviour and indicate that automatic processing can modulate executive control. PMID:23056553
Rose, Nathan S
2013-12-01
Individual differences in working memory (WM) are related to performance on secondary memory (SM), and fluid intelligence (gF) tests. However, the source of the relation remains unclear, in part because few studies have controlled for the nature of encoding; therefore, it is unclear whether individual variation is due to encoding, maintenance, or retrieval processes. In the current study, participants performed a WM task (the levels-of-processing span task; Rose, Myerson, Roediger III, & Hale, 2010) and a SM test that tested for both targets and the distracting processing words from the initial WM task. Deeper levels of processing at encoding did not benefit WM, but did benefit subsequent SM, although the amount of benefit was smaller for those with lower WM spans. This result suggests that, despite encoding cues that facilitate retrieval from SM, low spans may have engaged in shallower, maintenance-focused processing to maintain the words in WM. Low spans also recalled fewer targets, more distractors, and more extralist intrusions than high spans, although this was partially due to low spans' poorer recall of targets, which resulted in a greater number of opportunities to commit recall errors. Delayed recall of intrusions and commission of source errors (labeling targets as processing words and vice versa) were significant negative predictors of gF. These results suggest that the ability to use source information to recall relevant information and withhold recall of irrelevant information is a critical source of both individual variation in WM and the relation between WM, SM, and gF. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Goldhaber-Fiebert, Jeremy D.; Babiarz, Kimberly S.; Garfield, Rachel L.; Wulczyn, Fred; Landsverk, John; Horwitz, Sarah M.
2013-01-01
Background U.S. Child Welfare systems are involved in the lives of millions of children, and total spending exceeds $26 billion annually. Out-of-home foster care is a critical and expensive Child Welfare service, a major component of which is the maintenance rate paid to support housing and caring for a foster child. Maintenance rates vary widely across states and over time, but reasons for this variation are not well understood. As evidence-based programs are disseminated to state Child Welfare systems, it is important to understand what may be the important drivers in the uptake of these practices including state spending on core system areas. Data and methods We assembled a unique, longitudinal, state-level panel dataset (1990–2008) for all 50 states with annual data on foster care maintenance rates and measures of child population in need, poverty, employment, urbanicity, proportion minority, political party control of the state legislature and governorship, federal funding, and lawsuits involving state foster care systems. All monetary values were expressed in per-capita terms and inflation adjusted to 2008 dollars. We used longitudinal panel regressions with robust standard errors and state and year fixed effects to estimate the relationship between state foster care maintenance rates and the other factors in our dataset, lagging all factors by one year to mitigate the possibility that maintenance rates influenced their predictors. Exploratory analyses related maintenance rates to Child Welfare outcomes. Findings State foster care maintenance rates have increased in nominal terms, but in many states, have not kept pace with inflation, leading to lower real rates in 2008 compared to those in 1991 for 54% of states for 2 year-olds, 58% for 9 year-olds, and 65% for 16 year-olds. In multivariate analyses including socioeconomic, demographic, and political factors, monthly foster care maintenance rates declined $15 for each 1% increase in state unemployment and declined $40 if a state's governorship and legislature became Republican, though significance was marginal. In analyses also examining state revenue, federal funding, and legal challenges, maintenance rates increased as the federal share of maximum TANF payments increased. However, >50% of variation in foster care maintenance rates was explained by unobserved state-level factors as measured by state fixed effects. These factors did not appear to be strongly related to 2008 Child Welfare outcomes like foster care placement stability and maltreatment which were also not correlated with foster care maintenance rates. Conclusions Despite being part of a social safety net, foster care maintenance rates have declined in real terms since 1991 in many states, and there is no strong evidence that they increase in response to harsher economic climates or to federal programs or legal reviews. State variation in maintenance rates was not related to Child Welfare outcomes, though further analysis of this important relationship is needed. Variability in state foster care maintenance rates appears highly idiosyncratic, an important contextual factor to consider when designing and disseminating evidence-based services. PMID:24659842
ERIC Educational Resources Information Center
Weaver, Sallie J.; Newman-Toker, David E.; Rosen, Michael A.
2012-01-01
Missed, delayed, or wrong diagnoses can have a severe impact on patients, providers, and the entire health care system. One mechanism implicated in such diagnostic errors is the deterioration of cognitive diagnostic skills that are used rarely or not at all over a prolonged period of time. Existing evidence regarding maintenance of effective…
Min, Hua; Zheng, Ling; Perl, Yehoshua; Halper, Michael; De Coronado, Sherri; Ochs, Christopher
2017-05-18
Ontologies are knowledge structures that lend support to many health-information systems. A study is carried out to assess the quality of ontological concepts based on a measure of their complexity. The results show a relation between complexity of concepts and error rates of concepts. A measure of lateral complexity defined as the number of exhibited role types is used to distinguish between more complex and simpler concepts. Using a framework called an area taxonomy, a kind of abstraction network that summarizes the structural organization of an ontology, concepts are divided into two groups along these lines. Various concepts from each group are then subjected to a two-phase QA analysis to uncover and verify errors and inconsistencies in their modeling. A hierarchy of the National Cancer Institute thesaurus (NCIt) is used as our test-bed. A hypothesis pertaining to the expected error rates of the complex and simple concepts is tested. Our study was done on the NCIt's Biological Process hierarchy. Various errors, including missing roles, incorrect role targets, and incorrectly assigned roles, were discovered and verified in the two phases of our QA analysis. The overall findings confirmed our hypothesis by showing a statistically significant difference between the amounts of errors exhibited by more laterally complex concepts vis-à-vis simpler concepts. QA is an essential part of any ontology's maintenance regimen. In this paper, we reported on the results of a QA study targeting two groups of ontology concepts distinguished by their level of complexity, defined in terms of the number of exhibited role types. The study was carried out on a major component of an important ontology, the NCIt. The findings suggest that more complex concepts tend to have a higher error rate than simpler concepts. These findings can be utilized to guide ongoing efforts in ontology QA.
An interactive framework for acquiring vision models of 3-D objects from 2-D images.
Motai, Yuichi; Kak, Avinash
2004-02-01
This paper presents a human-computer interaction (HCI) framework for building vision models of three-dimensional (3-D) objects from their two-dimensional (2-D) images. Our framework is based on two guiding principles of HCI: 1) provide the human with as much visual assistance as possible to help the human make a correct input; and 2) verify each input provided by the human for its consistency with the inputs previously provided. For example, when stereo correspondence information is elicited from a human, his/her job is facilitated by superimposing epipolar lines on the images. Although that reduces the possibility of error in the human marked correspondences, such errors are not entirely eliminated because there can be multiple candidate points close together for complex objects. For another example, when pose-to-pose correspondence is sought from a human, his/her job is made easier by allowing the human to rotate the partial model constructed in the previous pose in relation to the partial model for the current pose. While this facility reduces the incidence of human-supplied pose-to-pose correspondence errors, such errors cannot be eliminated entirely because of confusion created when multiple candidate features exist close together. Each input provided by the human is therefore checked against the previous inputs by invoking situation-specific constraints. Different types of constraints (and different human-computer interaction protocols) are needed for the extraction of polygonal features and for the extraction of curved features. We will show results on both polygonal objects and object containing curved features.
Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study.
Gilbert, Rachel E; Kozak, Melissa C; Dobish, Roxanne B; Bourrier, Venetia C; Koke, Paul M; Kukreti, Vishal; Logan, Heather A; Easty, Anthony C; Trbovich, Patricia L
2018-05-01
Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards. Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent. Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed. We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.
Truck circuits diagnosis for railway lines equipped with an automatic block signalling system
NASA Astrophysics Data System (ADS)
Spunei, E.; Piroi, I.; Muscai, C.; Răduca, E.; Piroi, F.
2018-01-01
This work presents a diagnosis method for detecting track circuits failures on a railway traffic line equipped with an Automatic Block Signalling installation. The diagnosis method uses the installation’s electrical schemas, based on which a series of diagnosis charts have been created. Further, the diagnosis charts were used to develop a software package, CDCBla, which substantially contributes to reducing the diagnosis time and human error during failure remedies. The proposed method can also be used as a training package for the maintenance staff. Since the diagnosis method here does not need signal or measurement inputs, using it does not necessitate additional IT knowledge and can be deployed on a mobile computing device (tablet, smart phone).
Human Factors in Financial Trading: An Analysis of Trading Incidents.
Leaver, Meghan; Reader, Tom W
2016-09-01
This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors-related issues in operational trading incidents. In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors-related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy. © 2016, Human Factors and Ergonomics Society.
Variable habitat conditions drive species covariation in the human microbiota
Mora, Thierry; Walczak, Aleksandra M.
2017-01-01
Two species with similar resource requirements respond in a characteristic way to variations in their habitat—their abundances rise and fall in concert. We use this idea to learn how bacterial populations in the microbiota respond to habitat conditions that vary from person-to-person across the human population. Our mathematical framework shows that habitat fluctuations are sufficient for explaining intra-bodysite correlations in relative species abundances from the Human Microbiome Project. We explicitly show that the relative abundances of closely related species are positively correlated and can be predicted from taxonomic relationships. We identify a small set of functional pathways related to metabolism and maintenance of the cell wall that form the basis of a common resource sharing niche space of the human microbiota. PMID:28448493
Integrating automated structured analysis and design with Ada programming support environments
NASA Technical Reports Server (NTRS)
Hecht, Alan; Simmons, Andy
1986-01-01
Ada Programming Support Environments (APSE) include many powerful tools that address the implementation of Ada code. These tools do not address the entire software development process. Structured analysis is a methodology that addresses the creation of complete and accurate system specifications. Structured design takes a specification and derives a plan to decompose the system subcomponents, and provides heuristics to optimize the software design to minimize errors and maintenance. It can also produce the creation of useable modules. Studies have shown that most software errors result from poor system specifications, and that these errors also become more expensive to fix as the development process continues. Structured analysis and design help to uncover error in the early stages of development. The APSE tools help to insure that the code produced is correct, and aid in finding obscure coding errors. However, they do not have the capability to detect errors in specifications or to detect poor designs. An automated system for structured analysis and design TEAMWORK, which can be integrated with an APSE to support software systems development from specification through implementation is described. These tools completement each other to help developers improve quality and productivity, as well as to reduce development and maintenance costs. Complete system documentation and reusable code also resultss from the use of these tools. Integrating an APSE with automated tools for structured analysis and design provide capabilities and advantages beyond those realized with any of these systems used by themselves.
Human Error In Complex Systems
NASA Technical Reports Server (NTRS)
Morris, Nancy M.; Rouse, William B.
1991-01-01
Report presents results of research aimed at understanding causes of human error in such complex systems as aircraft, nuclear powerplants, and chemical processing plants. Research considered both slips (errors of action) and mistakes (errors of intention), and influence of workload on them. Results indicated that: humans respond to conditions in which errors expected by attempting to reduce incidence of errors; and adaptation to conditions potent influence on human behavior in discretionary situations.
van Schie, Mojca K M; Werth, Esther; Lammers, Gert Jan; Overeem, Sebastiaan; Baumann, Christian R; Fronczek, Rolf
2016-08-01
This two-centre observational study of vigilance measurements assessed the feasibility of vigilance measurements on multiple days using the Sustained Attention to Response Task and the Psychomotor Vigilance Test with portable task equipment, and subsequently assessed the effect of sodium oxybate treatment on vigilance in patients with narcolepsy. Twenty-six patients with narcolepsy and 15 healthy controls were included. The study comprised two in-laboratory days for the Maintenance of Wakefulness Test and the Oxford Sleep Resistance test, followed by 7-day portable vigilance battery measurements. This procedure was repeated for patients with narcolepsy after at least 3 months of stable treatment with sodium oxybate. Patients with narcolepsy had a higher Sustained Attention to Response Task error count, lower Psychomotor Vigilance Test reciprocal reaction time, higher Oxford Sleep Resistance test omission error count adjusted for test duration (Oxford Sleep Resistance testOMIS / MIN ), and lower Oxford Sleep Resistance test and Maintenance of Wakefulness Test sleep latency compared with controls (all P < 0.01). Treatment with sodium oxybate was associated with a longer Maintenance of Wakefulness Test sleep latency (P < 0.01), lower Oxford Sleep Resistance testOMIS / MIN (P = 0.01) and a lower Sustained Attention to Response Task error count (P = 0.01) in patients with narcolepsy, but not with absolute changes in Oxford Sleep Resistance test sleep latency or Psychomotor Vigilance Test reciprocal reaction time. It was concluded that portable measurements of sustained attention as well as in-laboratory Oxford Sleep Resistance test and Maintenance of Wakefulness Test measurements revealed worse performance for narcoleptic patients compared with controls, and that sodium oxybate was associated with an improvement of sustained attention and a better resistance to sleep. © 2016 European Sleep Research Society.
Auditory Signal Processing in Communication: Perception and Performance of Vocal Sounds
Prather, Jonathan F.
2013-01-01
Learning and maintaining the sounds we use in vocal communication require accurate perception of the sounds we hear performed by others and feedback-dependent imitation of those sounds to produce our own vocalizations. Understanding how the central nervous system integrates auditory and vocal-motor information to enable communication is a fundamental goal of systems neuroscience, and insights into the mechanisms of those processes will profoundly enhance clinical therapies for communication disorders. Gaining the high-resolution insight necessary to define the circuits and cellular mechanisms underlying human vocal communication is presently impractical. Songbirds are the best animal model of human speech, and this review highlights recent insights into the neural basis of auditory perception and feedback-dependent imitation in those animals. Neural correlates of song perception are present in auditory areas, and those correlates are preserved in the auditory responses of downstream neurons that are also active when the bird sings. Initial tests indicate that singing-related activity in those downstream neurons is associated with vocal-motor performance as opposed to the bird simply hearing itself sing. Therefore, action potentials related to auditory perception and action potentials related to vocal performance are co-localized in individual neurons. Conceptual models of song learning involve comparison of vocal commands and the associated auditory feedback to compute an error signal that is used to guide refinement of subsequent song performances, yet the sites of that comparison remain unknown. Convergence of sensory and motor activity onto individual neurons points to a possible mechanism through which auditory and vocal-motor signals may be linked to enable learning and maintenance of the sounds used in vocal communication. PMID:23827717
Gong, Yaping; Law, Kenneth S; Chang, Song; Xin, Katherine R
2009-01-01
In this study, the authors developed a dual-concern (i.e., maintenance and performance) model of human resources (HR) management. The authors identified commonly examined HR practices that apply to the middle manager level and classified them into the maintenance- and performance-oriented HR subsystems. The authors found support for the 2-factor model on the basis of responses from 2,148 managers from 463 firms operating in China. Regression results indicate that the performance-oriented HR subsystems had a positive relationship with firm performance and that the relationship was mediated by middle managers' affective commitment to the firm. The maintenance-oriented HR subsystems had a positive relationship with middle managers' continuance commitment but not with their affective commitment and firm performance. This study contributes to the understanding of how HR practices relate to firm performance and offers an improved test of the argument that valuable and firm-specific HR provide a source of competitive advantage. (PsycINFO Database Record (c) 2009 APA, all rights reserved).
‘Why should I care?’ Challenging free will attenuates neural reaction to errors
Pourtois, Gilles; Brass, Marcel
2015-01-01
Whether human beings have free will has been a philosophical question for centuries. The debate about free will has recently entered the public arena through mass media and newspaper articles commenting on scientific findings that leave little to no room for free will. Previous research has shown that encouraging such a deterministic perspective influences behavior, namely by promoting cursory and antisocial behavior. Here we propose that such behavioral changes may, at least partly, stem from a more basic neurocognitive process related to response monitoring, namely a reduced error detection mechanism. Our results show that the error-related negativity, a neural marker of error detection, was reduced in individuals led to disbelieve in free will. This finding shows that reducing the belief in free will has a specific impact on error detection mechanisms. More generally, it suggests that abstract beliefs about intentional control can influence basic and automatic processes related to action control. PMID:24795441
Automated Comparative Auditing of NCIT Genomic Roles Using NCBI
Cohen, Barry; Oren, Marc; Min, Hua; Perl, Yehoshua; Halper, Michael
2008-01-01
Biomedical research has identified many human genes and various knowledge about them. The National Cancer Institute Thesaurus (NCIT) represents such knowledge as concepts and roles (relationships). Due to the rapid advances in this field, it is to be expected that the NCIT’s Gene hierarchy will contain role errors. A comparative methodology to audit the Gene hierarchy with the use of the National Center for Biotechnology Information’s (NCBI’s) Entrez Gene database is presented. The two knowledge sources are accessed via a pair of Web crawlers to ensure up-to-date data. Our algorithms then compare the knowledge gathered from each, identify discrepancies that represent probable errors, and suggest corrective actions. The primary focus is on two kinds of gene-roles: (1) the chromosomal locations of genes, and (2) the biological processes in which genes plays a role. Regarding chromosomal locations, the discrepancies revealed are striking and systematic, suggesting a structurally common origin. In regard to the biological processes, difficulties arise because genes frequently play roles in multiple processes, and processes may have many designations (such as synonymous terms). Our algorithms make use of the roles defined in the NCIT Biological Process hierarchy to uncover many probable gene-role errors in the NCIT. These results show that automated comparative auditing is a promising technique that can identify a large number of probable errors and corrections for them in a terminological genomic knowledge repository, thus facilitating its overall maintenance. PMID:18486558
PrimPol prevents APOBEC/AID family mediated DNA mutagenesis
Pilzecker, Bas; Buoninfante, Olimpia Alessandra; Pritchard, Colin; Blomberg, Olga S.; Huijbers, Ivo J.; van den Berk, Paul C.M.; Jacobs, Heinz
2016-01-01
Abstract PrimPol is a DNA damage tolerant polymerase displaying both translesion synthesis (TLS) and (re)-priming properties. This led us to study the consequences of a PrimPol deficiency in tolerating mutagenic lesions induced by members of the APOBEC/AID family of cytosine deaminases. Interestingly, during somatic hypermutation, PrimPol counteracts the generation of C>G transversions on the leading strand. Independently, mutation analyses in human invasive breast cancer confirmed a pro-mutagenic activity of APOBEC3B and revealed a genome-wide anti-mutagenic activity of PRIMPOL as well as most Y-family TLS polymerases. PRIMPOL especially prevents APOBEC3B targeted cytosine mutations within TpC dinucleotides. As C transversions induced by APOBEC/AID family members depend on the formation of AP-sites, we propose that PrimPol reprimes preferentially downstream of AP-sites on the leading strand, to prohibit error-prone TLS and simultaneously stimulate error-free homology directed repair. These in vivo studies are the first demonstrating a critical anti-mutagenic activity of PrimPol in genome maintenance. PMID:26926109
Error rates in forensic DNA analysis: definition, numbers, impact and communication.
Kloosterman, Ate; Sjerps, Marjan; Quak, Astrid
2014-09-01
Forensic DNA casework is currently regarded as one of the most important types of forensic evidence, and important decisions in intelligence and justice are based on it. However, errors occasionally occur and may have very serious consequences. In other domains, error rates have been defined and published. The forensic domain is lagging behind concerning this transparency for various reasons. In this paper we provide definitions and observed frequencies for different types of errors at the Human Biological Traces Department of the Netherlands Forensic Institute (NFI) over the years 2008-2012. Furthermore, we assess their actual and potential impact and describe how the NFI deals with the communication of these numbers to the legal justice system. We conclude that the observed relative frequency of quality failures is comparable to studies from clinical laboratories and genetic testing centres. Furthermore, this frequency is constant over the five-year study period. The most common causes of failures related to the laboratory process were contamination and human error. Most human errors could be corrected, whereas gross contamination in crime samples often resulted in irreversible consequences. Hence this type of contamination is identified as the most significant source of error. Of the known contamination incidents, most were detected by the NFI quality control system before the report was issued to the authorities, and thus did not lead to flawed decisions like false convictions. However in a very limited number of cases crucial errors were detected after the report was issued, sometimes with severe consequences. Many of these errors were made in the post-analytical phase. The error rates reported in this paper are useful for quality improvement and benchmarking, and contribute to an open research culture that promotes public trust. However, they are irrelevant in the context of a particular case. Here case-specific probabilities of undetected errors are needed. These should be reported, separately from the match probability, when requested by the court or when there are internal or external indications for error. It should also be made clear that there are various other issues to consider, like DNA transfer. Forensic statistical models, in particular Bayesian networks, may be useful to take the various uncertainties into account and demonstrate their effects on the evidential value of the forensic DNA results. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Understanding human management of automation errors
McBride, Sara E.; Rogers, Wendy A.; Fisk, Arthur D.
2013-01-01
Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance. PMID:25383042
Understanding human management of automation errors.
McBride, Sara E; Rogers, Wendy A; Fisk, Arthur D
2014-01-01
Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance.
Kim, Su Kyoung; Kirchner, Elsa Andrea; Stefes, Arne; Kirchner, Frank
2017-12-14
Reinforcement learning (RL) enables robots to learn its optimal behavioral strategy in dynamic environments based on feedback. Explicit human feedback during robot RL is advantageous, since an explicit reward function can be easily adapted. However, it is very demanding and tiresome for a human to continuously and explicitly generate feedback. Therefore, the development of implicit approaches is of high relevance. In this paper, we used an error-related potential (ErrP), an event-related activity in the human electroencephalogram (EEG), as an intrinsically generated implicit feedback (rewards) for RL. Initially we validated our approach with seven subjects in a simulated robot learning scenario. ErrPs were detected online in single trial with a balanced accuracy (bACC) of 91%, which was sufficient to learn to recognize gestures and the correct mapping between human gestures and robot actions in parallel. Finally, we validated our approach in a real robot scenario, in which seven subjects freely chose gestures and the real robot correctly learned the mapping between gestures and actions (ErrP detection (90% bACC)). In this paper, we demonstrated that intrinsically generated EEG-based human feedback in RL can successfully be used to implicitly improve gesture-based robot control during human-robot interaction. We call our approach intrinsic interactive RL.
Milekovic, Tomislav; Ball, Tonio; Schulze-Bonhage, Andreas; Aertsen, Ad; Mehring, Carsten
2013-01-01
Background Brain-machine interfaces (BMIs) can translate the neuronal activity underlying a user’s movement intention into movements of an artificial effector. In spite of continuous improvements, errors in movement decoding are still a major problem of current BMI systems. If the difference between the decoded and intended movements becomes noticeable, it may lead to an execution error. Outcome errors, where subjects fail to reach a certain movement goal, are also present during online BMI operation. Detecting such errors can be beneficial for BMI operation: (i) errors can be corrected online after being detected and (ii) adaptive BMI decoding algorithm can be updated to make fewer errors in the future. Methodology/Principal Findings Here, we show that error events can be detected from human electrocorticography (ECoG) during a continuous task with high precision, given a temporal tolerance of 300–400 milliseconds. We quantified the error detection accuracy and showed that, using only a small subset of 2×2 ECoG electrodes, 82% of detection information for outcome error and 74% of detection information for execution error available from all ECoG electrodes could be retained. Conclusions/Significance The error detection method presented here could be used to correct errors made during BMI operation or to adapt a BMI algorithm to make fewer errors in the future. Furthermore, our results indicate that smaller ECoG implant could be used for error detection. Reducing the size of an ECoG electrode implant used for BMI decoding and error detection could significantly reduce the medical risk of implantation. PMID:23383315
NASA Astrophysics Data System (ADS)
Zhang, Yunju; Chen, Zhongyi; Guo, Ming; Lin, Shunsheng; Yan, Yinyang
2018-01-01
With the large capacity of the power system, the development trend of the large unit and the high voltage, the scheduling operation is becoming more frequent and complicated, and the probability of operation error increases. This paper aims at the problem of the lack of anti-error function, single scheduling function and low working efficiency for technical support system in regional regulation and integration, the integrated construction of the error prevention of the integrated architecture of the system of dispatching anti - error of dispatching anti - error of power network based on cloud computing has been proposed. Integrated system of error prevention of Energy Management System, EMS, and Operation Management System, OMS have been constructed either. The system architecture has good scalability and adaptability, which can improve the computational efficiency, reduce the cost of system operation and maintenance, enhance the ability of regional regulation and anti-error checking with broad development prospects.
Yoshikawa, Munemitsu; Yamashiro, Kenji; Miyake, Masahiro; Oishi, Maho; Akagi-Kurashige, Yumiko; Kumagai, Kyoko; Nakata, Isao; Nakanishi, Hideo; Oishi, Akio; Gotoh, Norimoto; Yamada, Ryo; Matsuda, Fumihiko; Yoshimura, Nagahisa
2014-10-21
We investigated the association between refractive error in a Japanese population and myopia-related genes identified in two recent large-scale genome-wide association studies. Single-nucleotide polymorphisms (SNPs) in 51 genes that were reported by the Consortium for Refractive Error and Myopia and/or the 23andMe database were genotyped in 3712 healthy Japanese volunteers from the Nagahama Study using HumanHap610K Quad, HumanOmni2.5M, and/or HumanExome Arrays. To evaluate the association between refractive error and recently identified myopia-related genes, we used three approaches to perform quantitative trait locus analyses of mean refractive error in both eyes of the participants: per-SNP, gene-based top-SNP, and gene-based all-SNP analyses. Association plots of successfully replicated genes also were investigated. In our per-SNP analysis, eight myopia gene associations were replicated successfully: GJD2, RASGRF1, BICC1, KCNQ5, CD55, CYP26A1, LRRC4C, and B4GALNT2.Seven additional gene associations were replicated in our gene-based analyses: GRIA4, BMP2, QKI, BMP4, SFRP1, SH3GL2, and EHBP1L1. The signal strength of the reported SNPs and their tagging SNPs increased after considering different linkage disequilibrium patterns across ethnicities. Although two previous studies suggested strong associations between PRSS56, LAMA2, TOX, and RDH5 and myopia, we could not replicate these results. Our results confirmed the significance of the myopia-related genes reported previously and suggested that gene-based replication analyses are more effective than per-SNP analyses. Our comparison with two previous studies suggested that BMP3 SNPs cause myopia primarily in Caucasian populations, while they may exhibit protective effects in Asian populations. Copyright 2014 The Association for Research in Vision and Ophthalmology, Inc.
21 CFR 1040.11 - Specific purpose laser products.
Code of Federal Regulations, 2011 CFR
2011-04-01
... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of... 1040.11 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...
21 CFR 1040.11 - Specific purpose laser products.
Code of Federal Regulations, 2010 CFR
2010-04-01
... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of... 1040.11 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...
The SACADA database for human reliability and human performance
DOE Office of Scientific and Technical Information (OSTI.GOV)
Y. James Chang; Dennis Bley; Lawrence Criscione
2014-05-01
Lack of appropriate and sufficient human performance data has been identified as a key factor affecting human reliability analysis (HRA) quality especially in the estimation of human error probability (HEP). The Scenario Authoring, Characterization, and Debriefing Application (SACADA) database was developed by the U.S. Nuclear Regulatory Commission (NRC) to address this data need. An agreement between NRC and the South Texas Project Nuclear Operating Company (STPNOC) was established to support the SACADA development with aims to make the SACADA tool suitable for implementation in the nuclear power plants' operator training program to collect operator performance information. The collected data wouldmore » support the STPNOC's operator training program and be shared with the NRC for improving HRA quality. This paper discusses the SACADA data taxonomy, the theoretical foundation, the prospective data to be generated from the SACADA raw data to inform human reliability and human performance, and the considerations on the use of simulator data for HRA. Each SACADA data point consists of two information segments: context and performance results. Context is a characterization of the performance challenges to task success. The performance results are the results of performing the task. The data taxonomy uses a macrocognitive functions model for the framework. At a high level, information is classified according to the macrocognitive functions of detecting the plant abnormality, understanding the abnormality, deciding the response plan, executing the response plan, and team related aspects (i.e., communication, teamwork, and supervision). The data are expected to be useful for analyzing the relations between context, error modes and error causes in human performance.« less
Relative peripheral hyperopic defocus alters central refractive development in infant monkeys
Smith, Earl L.; Hung, Li-Fang; Huang, Juan
2009-01-01
Understanding the role of peripheral defocus on central refractive development is critical because refractive errors can vary significantly with eccentricity and peripheral refractions have been implicated in the genesis of central refractive errors in humans. Two rearing strategies were used to determine whether peripheral hyperopia alters central refractive development in rhesus monkeys. In intact eyes, lens-induced relative peripheral hyperopia produced central axial myopia. Moreover, eliminating the fovea by laser photoablation did not prevent compensating myopic changes in response to optically imposed hyperopia. These results show that peripheral refractive errors can have a substantial impact on central refractive development in primates. PMID:19632261
Human operator response to error-likely situations in complex engineering systems
NASA Technical Reports Server (NTRS)
Morris, Nancy M.; Rouse, William B.
1988-01-01
The causes of human error in complex systems are examined. First, a conceptual framework is provided in which two broad categories of error are discussed: errors of action, or slips, and errors of intention, or mistakes. Conditions in which slips and mistakes might be expected to occur are identified, based on existing theories of human error. Regarding the role of workload, it is hypothesized that workload may act as a catalyst for error. Two experiments are presented in which humans' response to error-likely situations were examined. Subjects controlled PLANT under a variety of conditions and periodically provided subjective ratings of mental effort. A complex pattern of results was obtained, which was not consistent with predictions. Generally, the results of this research indicate that: (1) humans respond to conditions in which errors might be expected by attempting to reduce the possibility of error, and (2) adaptation to conditions is a potent influence on human behavior in discretionary situations. Subjects' explanations for changes in effort ratings are also explored.
Human error mitigation initiative (HEMI) : summary report.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Stevens, Susan M.; Ramos, M. Victoria; Wenner, Caren A.
2004-11-01
Despite continuing efforts to apply existing hazard analysis methods and comply with requirements, human errors persist across the nuclear weapons complex. Due to a number of factors, current retroactive and proactive methods to understand and minimize human error are highly subjective, inconsistent in numerous dimensions, and are cumbersome to characterize as thorough. An alternative and proposed method begins with leveraging historical data to understand what the systemic issues are and where resources need to be brought to bear proactively to minimize the risk of future occurrences. An illustrative analysis was performed using existing incident databases specific to Pantex weapons operationsmore » indicating systemic issues associated with operating procedures that undergo notably less development rigor relative to other task elements such as tooling and process flow. Future recommended steps to improve the objectivity, consistency, and thoroughness of hazard analysis and mitigation were delineated.« less
Defining health information technology-related errors: new developments since to err is human.
Sittig, Dean F; Singh, Hardeep
2011-07-25
Despite the promise of health information technology (HIT), recent literature has revealed possible safety hazards associated with its use. The Office of the National Coordinator for HIT recently sponsored an Institute of Medicine committee to synthesize evidence and experience from the field on how HIT affects patient safety. To lay the groundwork for defining, measuring, and analyzing HIT-related safety hazards, we propose that HIT-related error occurs anytime HIT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted. These errors, or the decisions that result from them, significantly increase the risk of adverse events and patient harm. We describe how a sociotechnical approach can be used to understand the complex origins of HIT errors, which may have roots in rapidly evolving technological, professional, organizational, and policy initiatives.
Human error and human factors engineering in health care.
Welch, D L
1997-01-01
Human error is inevitable. It happens in health care systems as it does in all other complex systems, and no measure of attention, training, dedication, or punishment is going to stop it. The discipline of human factors engineering (HFE) has been dealing with the causes and effects of human error since the 1940's. Originally applied to the design of increasingly complex military aircraft cockpits, HFE has since been effectively applied to the problem of human error in such diverse systems as nuclear power plants, NASA spacecraft, the process control industry, and computer software. Today the health care industry is becoming aware of the costs of human error and is turning to HFE for answers. Just as early experimental psychologists went beyond the label of "pilot error" to explain how the design of cockpits led to air crashes, today's HFE specialists are assisting the health care industry in identifying the causes of significant human errors in medicine and developing ways to eliminate or ameliorate them. This series of articles will explore the nature of human error and how HFE can be applied to reduce the likelihood of errors and mitigate their effects.
Errare machinale est: the use of error-related potentials in brain-machine interfaces
Chavarriaga, Ricardo; Sobolewski, Aleksander; Millán, José del R.
2014-01-01
The ability to recognize errors is crucial for efficient behavior. Numerous studies have identified electrophysiological correlates of error recognition in the human brain (error-related potentials, ErrPs). Consequently, it has been proposed to use these signals to improve human-computer interaction (HCI) or brain-machine interfacing (BMI). Here, we present a review of over a decade of developments toward this goal. This body of work provides consistent evidence that ErrPs can be successfully detected on a single-trial basis, and that they can be effectively used in both HCI and BMI applications. We first describe the ErrP phenomenon and follow up with an analysis of different strategies to increase the robustness of a system by incorporating single-trial ErrP recognition, either by correcting the machine's actions or by providing means for its error-based adaptation. These approaches can be applied both when the user employs traditional HCI input devices or in combination with another BMI channel. Finally, we discuss the current challenges that have to be overcome in order to fully integrate ErrPs into practical applications. This includes, in particular, the characterization of such signals during real(istic) applications, as well as the possibility of extracting richer information from them, going beyond the time-locked decoding that dominates current approaches. PMID:25100937
Barnette, Daniel W.
2002-01-01
The present invention provides a method of grid generation that uses the geometry of the problem space and the governing relations to generate a grid. The method can generate a grid with minimized discretization errors, and with minimal user interaction. The method of the present invention comprises assigning grid cell locations so that, when the governing relations are discretized using the grid, at least some of the discretization errors are substantially zero. Conventional grid generation is driven by the problem space geometry; grid generation according to the present invention is driven by problem space geometry and by governing relations. The present invention accordingly can provide two significant benefits: more efficient and accurate modeling since discretization errors are minimized, and reduced cost grid generation since less human interaction is required.
The control of translational accuracy is a determinant of healthy ageing in yeast
Leadsham, Jane E.; Sauvadet, Aimie; Tarrant, Daniel; Adam, Ilectra S.; Saromi, Kofo; Laun, Peter; Rinnerthaler, Mark; Breitenbach-Koller, Hannelore; Breitenbach, Michael; Tuite, Mick F.; Gourlay, Campbell W.
2017-01-01
Life requires the maintenance of molecular function in the face of stochastic processes that tend to adversely affect macromolecular integrity. This is particularly relevant during ageing, as many cellular functions decline with age, including growth, mitochondrial function and energy metabolism. Protein synthesis must deliver functional proteins at all times, implying that the effects of protein synthesis errors like amino acid misincorporation and stop-codon read-through must be minimized during ageing. Here we show that loss of translational accuracy accelerates the loss of viability in stationary phase yeast. Since reduced translational accuracy also reduces the folding competence of at least some proteins, we hypothesize that negative interactions between translational errors and age-related protein damage together overwhelm the cellular chaperone network. We further show that multiple cellular signalling networks control basal error rates in yeast cells, including a ROS signal controlled by mitochondrial activity, and the Ras pathway. Together, our findings indicate that signalling pathways regulating growth, protein homeostasis and energy metabolism may jointly safeguard accurate protein synthesis during healthy ageing. PMID:28100667
The control of translational accuracy is a determinant of healthy ageing in yeast.
von der Haar, Tobias; Leadsham, Jane E; Sauvadet, Aimie; Tarrant, Daniel; Adam, Ilectra S; Saromi, Kofo; Laun, Peter; Rinnerthaler, Mark; Breitenbach-Koller, Hannelore; Breitenbach, Michael; Tuite, Mick F; Gourlay, Campbell W
2017-01-01
Life requires the maintenance of molecular function in the face of stochastic processes that tend to adversely affect macromolecular integrity. This is particularly relevant during ageing, as many cellular functions decline with age, including growth, mitochondrial function and energy metabolism. Protein synthesis must deliver functional proteins at all times, implying that the effects of protein synthesis errors like amino acid misincorporation and stop-codon read-through must be minimized during ageing. Here we show that loss of translational accuracy accelerates the loss of viability in stationary phase yeast. Since reduced translational accuracy also reduces the folding competence of at least some proteins, we hypothesize that negative interactions between translational errors and age-related protein damage together overwhelm the cellular chaperone network. We further show that multiple cellular signalling networks control basal error rates in yeast cells, including a ROS signal controlled by mitochondrial activity, and the Ras pathway. Together, our findings indicate that signalling pathways regulating growth, protein homeostasis and energy metabolism may jointly safeguard accurate protein synthesis during healthy ageing. © 2017 The Authors.
Cheng, Ching-Min; Hwang, Sheue-Ling
2015-03-01
This paper outlines the human error identification (HEI) techniques that currently exist to assess latent human errors. Many formal error identification techniques have existed for years, but few have been validated to cover latent human error analysis in different domains. This study considers many possible error modes and influential factors, including external error modes, internal error modes, psychological error mechanisms, and performance shaping factors, and integrates several execution procedures and frameworks of HEI techniques. The case study in this research was the operational process of changing chemical cylinders in a factory. In addition, the integrated HEI method was used to assess the operational processes and the system's reliability. It was concluded that the integrated method is a valuable aid to develop much safer operational processes and can be used to predict human error rates on critical tasks in the plant. Copyright © 2014 Elsevier Ltd and The Ergonomics Society. All rights reserved.
Russ, Alissa L; Zillich, Alan J; Melton, Brittany L; Russell, Scott A; Chen, Siying; Spina, Jeffrey R; Weiner, Michael; Johnson, Elizabette G; Daggy, Joanne K; McManus, M Sue; Hawsey, Jason M; Puleo, Anthony G; Doebbeling, Bradley N; Saleem, Jason J
2014-01-01
Objective To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. Materials and methods We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug–allergy, drug–drug interaction, and drug–disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Results Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1–5) compared to original alerts: 4 (1–7); p=0.024). Discussion Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. Conclusions This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes. PMID:24668841
Russ, Alissa L; Zillich, Alan J; Melton, Brittany L; Russell, Scott A; Chen, Siying; Spina, Jeffrey R; Weiner, Michael; Johnson, Elizabette G; Daggy, Joanne K; McManus, M Sue; Hawsey, Jason M; Puleo, Anthony G; Doebbeling, Bradley N; Saleem, Jason J
2014-10-01
To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Human Factors in Financial Trading
Leaver, Meghan; Reader, Tom W.
2016-01-01
Objective This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. Background Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors–related issues in operational trading incidents. Method In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. Results Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors–related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. Conclusion We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. Application This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy. PMID:27142394
Probabilistic confidence for decisions based on uncertain reliability estimates
NASA Astrophysics Data System (ADS)
Reid, Stuart G.
2013-05-01
Reliability assessments are commonly carried out to provide a rational basis for risk-informed decisions concerning the design or maintenance of engineering systems and structures. However, calculated reliabilities and associated probabilities of failure often have significant uncertainties associated with the possible estimation errors relative to the 'true' failure probabilities. For uncertain probabilities of failure, a measure of 'probabilistic confidence' has been proposed to reflect the concern that uncertainty about the true probability of failure could result in a system or structure that is unsafe and could subsequently fail. The paper describes how the concept of probabilistic confidence can be applied to evaluate and appropriately limit the probabilities of failure attributable to particular uncertainties such as design errors that may critically affect the dependability of risk-acceptance decisions. This approach is illustrated with regard to the dependability of structural design processes based on prototype testing with uncertainties attributable to sampling variability.
TOPEX/POSEIDON orbit maintenance maneuver design
NASA Technical Reports Server (NTRS)
Bhat, R. S.; Frauenholz, R. B.; Cannell, Patrick E.
1990-01-01
The Ocean Topography Experiment (TOPEX/POSEIDON) mission orbit requirements are outlined, as well as its control and maneuver spacing requirements including longitude and time targeting. A ground-track prediction model dealing with geopotential, luni-solar gravity, and atmospheric-drag perturbations is considered. Targeting with all modeled perturbations is discussed, and such ground-track prediction errors as initial semimajor axis, orbit-determination, maneuver-execution, and atmospheric-density modeling errors are assessed. A longitude targeting strategy for two extreme situations is investigated employing all modeled perturbations and prediction errors. It is concluded that atmospheric-drag modeling errors are the prevailing ground-track prediction error source early in the mission during high solar flux, and that low solar-flux levels expected late in the experiment stipulate smaller maneuver magnitudes.
Integrated Blade Inspection System (IBIS) Upgrade Study
1992-12-01
the maintenance contract for the IBIS is equally divided among its 4-1 three major components, then the FPIM’s maintenance costs account for 33% of...network to the blade inspection problem, the output of the network must be interpreted in a slightly different manner to account for the cost of the...missed detections, respectively. The costs associated with the two types of error are drastically different and should be accounted for in the
Maintenance-free operation of WDM quantum key distribution system through a field fiber over 30 days
NASA Astrophysics Data System (ADS)
Yoshino, Ken-ichiro; Ochi, Takao; Fujiwara, Mikio; Sasaki, Masahide; Tajima, Akio
2013-12-01
Maintenance-free wavelength-division-multiplexing quantum key distribution for 30 days was achieved through a 22-km field fiber. Using polarization-independent interferometers and stabilization techniques, we attained a quantum bit error rate as low as 1.70% and a key rate as high as 229.8 kbps, making the record of total secure key of 595.6 Gbits accumulated over an uninterrupted operation period.
Verifying and Postprocesing the Ensemble Spread-Error Relationship
NASA Astrophysics Data System (ADS)
Hopson, Tom; Knievel, Jason; Liu, Yubao; Roux, Gregory; Wu, Wanli
2013-04-01
With the increased utilization of ensemble forecasts in weather and hydrologic applications, there is a need to verify their benefit over less expensive deterministic forecasts. One such potential benefit of ensemble systems is their capacity to forecast their own forecast error through the ensemble spread-error relationship. The paper begins by revisiting the limitations of the Pearson correlation alone in assessing this relationship. Next, we introduce two new metrics to consider in assessing the utility an ensemble's varying dispersion. We argue there are two aspects of an ensemble's dispersion that should be assessed. First, and perhaps more fundamentally: is there enough variability in the ensembles dispersion to justify the maintenance of an expensive ensemble prediction system (EPS), irrespective of whether the EPS is well-calibrated or not? To diagnose this, the factor that controls the theoretical upper limit of the spread-error correlation can be useful. Secondly, does the variable dispersion of an ensemble relate to variable expectation of forecast error? Representing the spread-error correlation in relation to its theoretical limit can provide a simple diagnostic of this attribute. A context for these concepts is provided by assessing two operational ensembles: 30-member Western US temperature forecasts for the U.S. Army Test and Evaluation Command and 51-member Brahmaputra River flow forecasts of the Climate Forecast and Applications Project for Bangladesh. Both of these systems utilize a postprocessing technique based on quantile regression (QR) under a step-wise forward selection framework leading to ensemble forecasts with both good reliability and sharpness. In addition, the methodology utilizes the ensemble's ability to self-diagnose forecast instability to produce calibrated forecasts with informative skill-spread relationships. We will describe both ensemble systems briefly, review the steps used to calibrate the ensemble forecast, and present verification statistics using error-spread metrics, along with figures from operational ensemble forecasts before and after calibration.
Stereoscopic distance perception
NASA Technical Reports Server (NTRS)
Foley, John M.
1989-01-01
Limited cue, open-loop tasks in which a human observer indicates distances or relations among distances are discussed. By open-loop tasks, it is meant tasks in which the observer gets no feedback as to the accuracy of the responses. What happens when cues are added and when the loop is closed are considered. The implications of this research for the effectiveness of visual displays is discussed. Errors in visual distance tasks do not necessarily mean that the percept is in error. The error could arise in transformations that intervene between the percept and the response. It is argued that the percept is in error. It is also argued that there exist post-perceptual transformations that may contribute to the error or be modified by feedback to correct for the error.
Human error in airway facilities.
DOT National Transportation Integrated Search
2001-01-01
This report examines human errors in Airway Facilities (AF) with the intent of preventing these errors from being : passed on to the new Operations Control Centers. To effectively manage errors, they first have to be identified. : Human factors engin...
Human Factors Directions for Civil Aviation
NASA Technical Reports Server (NTRS)
Hart, Sandra G.
2002-01-01
Despite considerable progress in understanding human capabilities and limitations, incorporating human factors into aircraft design, operation, and certification, and the emergence of new technologies designed to reduce workload and enhance human performance in the system, most aviation accidents still involve human errors. Such errors occur as a direct or indirect result of untimely, inappropriate, or erroneous actions (or inactions) by apparently well-trained and experienced pilots, controllers, and maintainers. The field of human factors has solved many of the more tractable problems related to simple ergonomics, cockpit layout, symbology, and so on. We have learned much about the relationships between people and machines, but know less about how to form successful partnerships between humans and the information technologies that are beginning to play a central role in aviation. Significant changes envisioned in the structure of the airspace, pilots and controllers' roles and responsibilities, and air/ground technologies will require a similarly significant investment in human factors during the next few decades to ensure the effective integration of pilots, controllers, dispatchers, and maintainers into the new system. Many of the topics that will be addressed are not new because progress in crucial areas, such as eliminating human error, has been slow. A multidisciplinary approach that capitalizes upon human studies and new classes of information, computational models, intelligent analytical tools, and close collaborations with organizations that build, operate, and regulate aviation technology will ensure that the field of human factors meets the challenge.
Issues Related to Effects of New Maintenance Concept on AF Specialists Working in the Field
DOT National Transportation Integrated Search
1990-03-07
This working paper was prepared by the Transportation Systems Center, Operator : performance and Safety Analysis Division (DTS-45) for the Federal Aviation Ad : ministration. The paper provides initial thinking on groups of human resource issues : re...
Performance of an online translation tool when applied to patient educational material.
Khanna, Raman R; Karliner, Leah S; Eck, Matthias; Vittinghoff, Eric; Koenig, Christopher J; Fang, Margaret C
2011-11-01
Language barriers may prevent clinicians from tailoring patient educational material to the needs of individuals with limited English proficiency. Online translation tools could fill this gap, but their accuracy is unknown. We evaluated the accuracy of an online translation tool for patient educational material. We selected 45 sentences from a pamphlet available in both English and Spanish, and translated it into Spanish using GoogleTranslate™ (GT). Three bilingual Spanish speakers then performed a blinded evaluation on these 45 sentences, comparing GT-translated sentences to those translated professionally, along four domains: fluency (grammatical correctness), adequacy (information preservation), meaning (connotation maintenance), and severity (perceived dangerousness of an error if present). In addition, evaluators indicated whether they had a preference for either the GT-translated or professionally translated sentences. The GT-translated sentences had significantly lower fluency scores compared to the professional translation (3.4 vs. 4.7, P < 0.001), but similar adequacy (4.2 vs. 4.5, P = 0.19) and meaning (4.5 vs. 4.8, P = 0.29) scores. The GT-translated sentences were more likely to have any error (39% vs. 22%, P = 0.05), but not statistically more likely to have a severe error (4% vs. 2%, P = 0.61). Evaluators preferred the professional translation for complex sentences, but not for simple ones. When applied to patient educational material, GT performed comparably to professional human translation in terms of preserving information and meaning, though it was slightly worse in preserving grammar. In situations where professional human translations are unavailable or impractical, online translation may someday fill an important niche. Copyright © 2011 Society of Hospital Medicine.
Roberts, Rachel M; Davis, Melissa C
2015-01-01
There is a need for an evidence-based approach to training professional psychologists in the administration and scoring of standardized tests such as the Wechsler Adult Intelligence Scale (WAIS) due to substantial evidence that these tasks are associated with numerous errors that have the potential to significantly impact clients' lives. Twenty three post-graduate psychology students underwent training in using the WAIS-IV according to a best-practice teaching model that involved didactic teaching, independent study of the test manual, and in-class practice with teacher supervision and feedback. Video recordings and test protocols from a role-played test administration were analyzed for errors according to a comprehensive checklist with self, peer, and faculty member reviews. 91.3% of students were rated as having demonstrated competency in administration and scoring. All students were found to make errors, with substantially more errors being detected by the faculty member than by self or peers. Across all subtests, the most frequent errors related to failure to deliver standardized instructions verbatim from the manual. The failure of peer and self-reviews to detect the majority of the errors suggests that novice feedback (self or peers) may be ineffective to eliminate errors and the use of more senior peers may be preferable. It is suggested that involving senior trainees, recent graduates and/or experienced practitioners in the training of post-graduate students may have benefits for both parties, promoting a peer-learning and continuous professional development approach to the development and maintenance of skills in psychological assessment.
Brain activity related to working memory for temporal order and object information.
Roberts, Brooke M; Libby, Laura A; Inhoff, Marika C; Ranganath, Charan
2017-06-08
Maintaining items in an appropriate sequence is important for many daily activities; however, remarkably little is known about the neural basis of human temporal working memory. Prior work suggests that the prefrontal cortex (PFC) and medial temporal lobe (MTL), including the hippocampus, play a role in representing information about temporal order. The involvement of these areas in successful temporal working memory, however, is less clear. Additionally, it is unknown whether regions in the PFC and MTL support temporal working memory across different timescales, or at coarse or fine levels of temporal detail. To address these questions, participants were scanned while completing 3 working memory task conditions (Group, Position and Item) that were matched in terms of difficulty and the number of items to be actively maintained. Group and Position trials probed temporal working memory processes, requiring the maintenance of hierarchically organized coarse and fine temporal information, respectively. To isolate activation related to temporal working memory, Group and Position trials were contrasted against Item trials, which required detailed working memory maintenance of visual objects. Results revealed that working memory encoding and maintenance of temporal information relative to visual information was associated with increased activation in dorsolateral PFC (DLPFC), and perirhinal cortex (PRC). In contrast, maintenance of visual details relative to temporal information was characterized by greater activation of parahippocampal cortex (PHC), medial and anterior PFC, and retrosplenial cortex. In the hippocampus, a dissociation along the longitudinal axis was observed such that the anterior hippocampus was more active for working memory encoding and maintenance of visual detail information relative to temporal information, whereas the posterior hippocampus displayed the opposite effect. Posterior parietal cortex was the only region to show sensitivity to temporal working memory across timescales, and was particularly involved in the encoding and maintenance of fine temporal information relative to maintenance of temporal information at more coarse timescales. Collectively, these results highlight the involvement of PFC and MTL in temporal working memory processes, and suggest a dissociation in the type of working memory information represented along the longitudinal axis of the hippocampus. Copyright © 2017 Elsevier B.V. All rights reserved.
Jian, Bo-Lin; Peng, Chao-Chung
2017-06-15
Due to the direct influence of night vision equipment availability on the safety of night-time aerial reconnaissance, maintenance needs to be carried out regularly. Unfortunately, some defects are not easy to observe or are not even detectable by human eyes. As a consequence, this study proposed a novel automatic defect detection system for aviator's night vision imaging systems AN/AVS-6(V)1 and AN/AVS-6(V)2. An auto-focusing process consisting of a sharpness calculation and a gradient-based variable step search method is applied to achieve an automatic detection system for honeycomb defects. This work also developed a test platform for sharpness measurement. It demonstrates that the honeycomb defects can be precisely recognized and the number of the defects can also be determined automatically during the inspection. Most importantly, the proposed approach significantly reduces the time consumption, as well as human assessment error during the night vision goggle inspection procedures.
Breaks in the 45S rDNA Lead to Recombination-Mediated Loss of Repeats.
Warmerdam, Daniël O; van den Berg, Jeroen; Medema, René H
2016-03-22
rDNA repeats constitute the most heavily transcribed region in the human genome. Tumors frequently display elevated levels of recombination in rDNA, indicating that the repeats are a liability to the genomic integrity of a cell. However, little is known about how cells deal with DNA double-stranded breaks in rDNA. Using selective endonucleases, we show that human cells are highly sensitive to breaks in 45S but not the 5S rDNA repeats. We find that homologous recombination inhibits repair of breaks in 45S rDNA, and this results in repeat loss. We identify the structural maintenance of chromosomes protein 5 (SMC5) as contributing to recombination-mediated repair of rDNA breaks. Together, our data demonstrate that SMC5-mediated recombination can lead to error-prone repair of 45S rDNA repeats, resulting in their loss and thereby reducing cellular viability. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.
Cost effectiveness of the U.S. Geological Survey's stream-gaging program in Wisconsin
Walker, J.F.; Osen, L.L.; Hughes, P.E.
1987-01-01
A minimum budget of $510,000 is required to operate the program; a budget less than this does not permit proper service and maintenance of the gaging stations. At this minimum budget, the theoretical average standard error of instantaneous discharge is 14.4%. The maximum budget analyzed was $650,000 and resulted in an average standard of error of instantaneous discharge of 7.2%.
Advanced automated glass cockpit certification: Being wary of human factors
NASA Technical Reports Server (NTRS)
Amalberti, Rene; Wilbaux, Florence
1994-01-01
This paper presents some facets of the French experience with human factors in the process of certification of advanced automated cockpits. Three types of difficulties are described: first, the difficulties concerning the hotly debated concept of human error and its non-linear relationship to risk of accident; a typology of errors to be taken into account in the certification process is put forward to respond to this issue. Next, the difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. The last difficulties to be considered are those related to the goals of certification itself on these new aircraft and the status of findings from human factor analyses (in particular, what should be done with disappointing results, how much can the changes induced by human factors investigation economically affect aircraft design, how many errors do we need to accumulate before we revise the system, what should be remedied when human factor problems are discovered at the certification stage: the machine? pilot training? the rules? or everything?). The growth of advanced-automated glass cockpits has forced the international aeronautical community to pay more attention to human factors during the design phase, the certification phase and pilot training. The recent creation of a human factor desk at the DGAC-SFACT (Official French services) is a direct consequence of this. The paper is divided into three parts. Part one debates human error and its relationship with system design and accident risk. Part two describes difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. Part three focuses on concrete outcomes of human factors for certification purposes.
Ciullo, Dana L.
2015-01-01
Introduction Decades of research have suggested that nutritional intake contributes to the development of human disease, mainly by influencing the development of obesity and obesity-related conditions. A relatively large body of research indicates that functional variation in human taste perception can influence nutritional intake as well as body mass accumulation. However, there are a considerable number of studies that suggest that no link between these variables actually exists. These discrepancies in the literature likely result from the confounding influence of a variety of other, uncontrolled, factors that can influence ingestive behavior. Strategy In this review, the use of controlled animal experimentation to alleviate at least some of these issues related to the lack of control of experimental variables is discussed. Specific examples of the use of some of these techniques are examined. Discussion and conclusions The review will close with some specific suggestions aimed at strengthening the link between gustatory neural input and its putative influence on ingestive behaviors and the maintenance of body weight. PMID:26557212
Human factors and the FDA's goals: improved medical device design.
Burlington, D B
1996-01-01
The Food and Drug Administration's new human factors design requirements for medical devices were previewed by the director of the FDA's Center for Devices and Radiological Health (CDRH) at AAMI/FDA's Human Factors in Medical Devices Conference held in September 1995. Director Bruce Burlington, MD, said the FDA plans to take a closer look at how new medical devices are designed to ensure proper attention has been paid to human error prevention. As a medical practitioner who has witnessed use-related deaths and injuries, Burlington stressed the importance of the medical community's reporting use errors as they occur and manufacturers' creating easy-to-use labeling and packaging. He also called for simplicity and quality of design in medical products, and asked for a consolidated effort of all professionals involved in human factors issues to help implement and further the FDA's new human factors program. An edited version of his presentation appears here.
NASA Technical Reports Server (NTRS)
Mallasch, Paul G.; Babic, Slavoljub
1994-01-01
The United States Air Force (USAF) provides NASA Lewis Research Center with monthly reports containing the Synchronous Satellite Catalog and the associated Two Line Mean Element Sets. The USAF Synchronous Satellite Catalog supplies satellite orbital parameters collected by an automated monitoring system and provided to Lewis Research Center as text files on magnetic tape. Software was developed to facilitate automated formatting, data normalization, cross-referencing, and error correction of Synchronous Satellite Catalog files before loading into the NASA Geosynchronous Satellite Orbital Statistics Database System (GSOSTATS). This document contains the User's Guide and Software Maintenance Manual with information necessary for installation, initialization, start-up, operation, error recovery, and termination of the software application. It also contains implementation details, modification aids, and software source code adaptations for use in future revisions.
Modular Organization of Exploratory Force Development Under Isometric Conditions in the Human Arm.
Roh, Jinsook; Lee, Sang Wook; Wilger, Kevin D
2018-01-31
Muscle coordination of isometric force production can be explained by a smaller number of modules. Variability in force output, however, is higher during exploratory/transient force development phases than force maintenance phase, and it is not clear whether the same modular structure underlies both phases. In this study, eight neurologically-intact adults isometrically performed target force matches in 54 directions at hands, and electromyographic (EMG) data from eight muscles were parsed into four sequential phases. Despite the varying degree of motor complexity across phases (significant between-phase differences in EMG-force correlation, angular errors, and between-force correlations), the number/composition of motor modules were found equivalent across phases, suggesting that the CNS systematically modulated activation of the same set of motor modules throughout sequential force development.
45 CFR 1355.39 - Administrative and judicial review.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 4 2014-10-01 2014-10-01 false Administrative and judicial review. 1355.39 Section 1355.39 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR 1355.39 - Administrative and judicial review.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 4 2012-10-01 2012-10-01 false Administrative and judicial review. 1355.39 Section 1355.39 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR 1355.39 - Administrative and judicial review.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 4 2011-10-01 2011-10-01 false Administrative and judicial review. 1355.39 Section 1355.39 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
21 CFR 520.1468 - Naproxen granules.
Code of Federal Regulations, 2010 CFR
2010-04-01
... and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) ANIMAL DRUGS, FEEDS, AND RELATED PRODUCTS ORAL DOSAGE FORM NEW ANIMAL DRUGS § 520.1468 Naproxen granules. (a... musculoskeletal system of the horse. (2)(i) For oral maintenance therapy following initial intravenous dosage...
21 CFR 522.1468 - Naproxen for injection.
Code of Federal Regulations, 2010 CFR
2010-04-01
... Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) ANIMAL DRUGS, FEEDS, AND RELATED PRODUCTS IMPLANTATION OR INJECTABLE DOSAGE FORM NEW ANIMAL DRUGS § 522.1468.... Five milligrams per kilogram of body weight intravenously followed by maintenance oral therapy of 10...
Package Design Affects Accuracy Recognition for Medications.
Endestad, Tor; Wortinger, Laura A; Madsen, Steinar; Hortemo, Sigurd
2016-12-01
Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors. An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors. In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated. The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications. Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications. A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose. © 2016, Human Factors and Ergonomics Society.
ERIC Educational Resources Information Center
Ozolinš, Janis Talivaldis
2017-01-01
A recurring theme in many places concerns the nurturing and maintenance of a civil society that is committed to justice, to human fulfilment and a community that actively pursues the good of all its members. The creation of a civil society where there is respect for persons and a concern for the good of others is an important social aim and though…
Prospect theory does not describe the feedback-related negativity value function.
Sambrook, Thomas D; Roser, Matthew; Goslin, Jeremy
2012-12-01
Humans handle uncertainty poorly. Prospect theory accounts for this with a value function in which possible losses are overweighted compared to possible gains, and the marginal utility of rewards decreases with size. fMRI studies have explored the neural basis of this value function. A separate body of research claims that prediction errors are calculated by midbrain dopamine neurons. We investigated whether the prospect theoretic effects shown in behavioral and fMRI studies were present in midbrain prediction error coding by using the feedback-related negativity, an ERP component believed to reflect midbrain prediction errors. Participants' stated satisfaction with outcomes followed prospect theory but their feedback-related negativity did not, instead showing no effect of marginal utility and greater sensitivity to potential gains than losses. Copyright © 2012 Society for Psychophysiological Research.
Stochastic Models of Human Errors
NASA Technical Reports Server (NTRS)
Elshamy, Maged; Elliott, Dawn M. (Technical Monitor)
2002-01-01
Humans play an important role in the overall reliability of engineering systems. More often accidents and systems failure are traced to human errors. Therefore, in order to have meaningful system risk analysis, the reliability of the human element must be taken into consideration. Describing the human error process by mathematical models is a key to analyzing contributing factors. Therefore, the objective of this research effort is to establish stochastic models substantiated by sound theoretic foundation to address the occurrence of human errors in the processing of the space shuttle.
Yeast hnRNP-related proteins contribute to the maintenance of telomeres
DOE Office of Scientific and Technical Information (OSTI.GOV)
Lee-Soety, Julia Y., E-mail: jlee04@sju.edu; Jones, Jennifer; MacGibeny, Margaret A.
Highlights: Black-Right-Pointing-Pointer Yeast hnRNP-related proteins are able to prevent faster senescence in telomerase-null cells. Black-Right-Pointing-Pointer The conserved RRMs in Npl3 are important for telomere maintenance. Black-Right-Pointing-Pointer Human hnRNP A1 is unable to complement the lack of NPL3 in yeast. Black-Right-Pointing-Pointer Npl3 and Cbc2 may work as telomere capping proteins. -- Abstract: Telomeres protect the ends of linear chromosomes, which if eroded to a critical length can become uncapped and lead to replicative senescence. Telomerase maintains telomere length in some cells, but inappropriate expression facilitates the immortality of cancer cells. Recently, proteins involved in RNA processing and ribosome assembly, such asmore » hnRNP (heterogeneous nuclear ribonucleoprotein) A1, have been found to participate in telomere maintenance in mammals. The Saccharomyces cerevisiae protein Npl3 shares significant amino acid sequence similarities with hnRNP A1. We found that deleting NPL3 accelerated the senescence of telomerase null cells. The highly conserved RNA recognition motifs (RRM) in Npl3 appear to be important for preventing faster senescence. Npl3 preferentially binds telomere sequences in vitro, suggesting that Npl3 may affect telomeres directly. Despite similarities between the two proteins, human hnRNP A1 is unable to complement the lack of Npl3 to rescue accelerated senescence in tlc1 npl3 cells. Deletion of CBC2, which encodes another hnRNP-related protein that associates with Npl3, also accelerates senescence. Potential mechanisms by which hnRNP-related proteins maintain telomeres are discussed.« less
Space Station Human Factors Research Review. Volume 4: Inhouse Advanced Development and Research
NASA Technical Reports Server (NTRS)
Tanner, Trieve (Editor); Clearwater, Yvonne A. (Editor); Cohen, Marc M. (Editor)
1988-01-01
A variety of human factors studies related to space station design are presented. Subjects include proximity operations and window design, spatial perceptual issues regarding displays, image management, workload research, spatial cognition, virtual interface, fault diagnosis in orbital refueling, and error tolerance and procedure aids.
NASA Astrophysics Data System (ADS)
Young, Kenneth C.; Cook, James J. H.; Oduko, Jennifer M.; Bosmans, Hilde
2006-03-01
European Guidelines for quality control in digital mammography specify minimum and achievable standards of image quality in terms of threshold contrast, based on readings of images of the CDMAM test object by human observers. However this is time-consuming and has large inter-observer error. To overcome these problems a software program (CDCOM) is available to automatically read CDMAM images, but the optimal method of interpreting the output is not defined. This study evaluates methods of determining threshold contrast from the program, and compares these to human readings for a variety of mammography systems. The methods considered are (A) simple thresholding (B) psychometric curve fitting (C) smoothing and interpolation and (D) smoothing and psychometric curve fitting. Each method leads to similar threshold contrasts but with different reproducibility. Method (A) had relatively poor reproducibility with a standard error in threshold contrast of 18.1 +/- 0.7%. This was reduced to 8.4% by using a contrast-detail curve fitting procedure. Method (D) had the best reproducibility with an error of 6.7%, reducing to 5.1% with curve fitting. A panel of 3 human observers had an error of 4.4% reduced to 2.9 % by curve fitting. All automatic methods led to threshold contrasts that were lower than for humans. The ratio of human to program threshold contrasts varied with detail diameter and was 1.50 +/- .04 (sem) at 0.1mm and 1.82 +/- .06 at 0.25mm for method (D). There were good correlations between the threshold contrast determined by humans and the automated methods.
Screwworm Eradication Data System (SEDS) operational manual, part 3
NASA Technical Reports Server (NTRS)
1976-01-01
All phases of SEDS operation as well as utility routines, error messages, and system disk maintenance procedures are described. Display layouts and examples of runs are included as additional explanation to SEDS program procedures.
NASA Technical Reports Server (NTRS)
Diorio, Kimberly A.; Voska, Ned (Technical Monitor)
2002-01-01
This viewgraph presentation provides information on Human Factors Process Failure Modes and Effects Analysis (HF PFMEA). HF PFMEA includes the following 10 steps: Describe mission; Define System; Identify human-machine; List human actions; Identify potential errors; Identify factors that effect error; Determine likelihood of error; Determine potential effects of errors; Evaluate risk; Generate solutions (manage error). The presentation also describes how this analysis was applied to a liquid oxygen pump acceptance test.
NASA Technical Reports Server (NTRS)
Mcruer, D. T.; Clement, W. F.; Allen, R. W.
1981-01-01
Human errors tend to be treated in terms of clinical and anecdotal descriptions, from which remedial measures are difficult to derive. Correction of the sources of human error requires an attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A comprehensive analytical theory of the cause-effect relationships governing propagation of human error is indispensable to a reconstruction of the underlying and contributing causes. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation, maritime, automotive, and process control operations is highlighted. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.
Error in the Honeybee Waggle Dance Improves Foraging Flexibility
Okada, Ryuichi; Ikeno, Hidetoshi; Kimura, Toshifumi; Ohashi, Mizue; Aonuma, Hitoshi; Ito, Etsuro
2014-01-01
The honeybee waggle dance communicates the location of profitable food sources, usually with a certain degree of error in the directional information ranging from 10–15° at the lower margin. We simulated one-day colonial foraging to address the biological significance of information error in the waggle dance. When the error was 30° or larger, the waggle dance was not beneficial. If the error was 15°, the waggle dance was beneficial when the food sources were scarce. When the error was 10° or smaller, the waggle dance was beneficial under all the conditions tested. Our simulation also showed that precise information (0–5° error) yielded great success in finding feeders, but also caused failures at finding new feeders, i.e., a high-risk high-return strategy. The observation that actual bees perform the waggle dance with an error of 10–15° might reflect, at least in part, the maintenance of a successful yet risky foraging trade-off. PMID:24569525
Single-Session Attention Bias Modification and Error-Related Brain Activity
Nelson, Brady D.; Jackson, Felicia; Amir, Nader; Hajcak, Greg
2015-01-01
An attentional bias to threat has been implicated in the etiology and maintenance of anxiety disorders. Recently, attention bias modification (ABM) has been shown to reduce threat biases and decrease anxiety. However, it is unclear whether ABM modifies neural activity linked to anxiety and risk. The current study examined the relationship between ABM and the error-related negativity (ERN), a putative biomarker of risk for anxiety disorders, and the relationship between the ERN and ABM-based changes in attention to threat. Fifty-nine participants completed a single-session of ABM and a flanker task to elicit the ERN—in counterbalanced order (i.e., ABM-before vs. ABM-after the ERN was measured). Results indicated that the ERN was smaller (i.e., less negative) among individuals who completed ABM-before relative to those who completed ABM-after. Furthermore, greater attentional disengagement from negative stimuli during ABM was associated with a smaller ERN among ABM-before and ABM-after participants. The present study suggests a direct relationship between the malleability of negative attention bias and the ERN. Explanations are provided for how ABM may contribute to reductions in the ERN. Overall, the present study indicates that a single-session of ABM may be related to a decrease in neural activity linked to anxiety and risk. PMID:26063611
Predicted outcomes of vaccinating wildlife to reduce human risk of Lyme disease.
Tsao, Kimberly; Fish, Durland; Galvani, Alison P
2012-07-01
Vaccination efforts for Lyme disease prevention in humans have focused on wildlife reservoirs to target the causative agent, Borrelia burgdorferi, for elimination in vector ticks. Multiple host species are involved in the transmission and maintenance of the bacterium, but not all host species can be vaccinated effectively. To evaluate vaccinating a subset of hosts in the context of host-tick interactions, we constructed and evaluated a dynamic model of B. burgdorferi transmission in mice. Our analyses indicate that on average, a mouse-targeted vaccine is expected to proportionally reduce infection prevalence among ticks by 56%. However, relative to mouse vaccination, human risk of exposure is dominated by the number of tick bites received per person, the proportion of tick blood meals taken from the highly reservoir-competent white-footed mouse relative to other hosts, and the average number of tick bites per mouse. Variation in these factors reduces the predictability of vaccination outcomes. Additionally, contributions of nonmouse hosts to pathogen maintenance preclude elimination of B. burgdorferi through mouse vaccination alone. Our findings indicate that to increase the impact of wildlife vaccination, reducing tick populations by acaricide application, in addition to targeting additional reservoir-competent host species, should be employed.
45 CFR 1355.54 - Submittal of advance planning documents.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 4 2014-10-01 2014-10-01 false Submittal of advance planning documents. 1355.54 Section 1355.54 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR 1355.54 - Submittal of advance planning documents.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 4 2011-10-01 2011-10-01 false Submittal of advance planning documents. 1355.54 Section 1355.54 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR 1355.53 - Conditions for approval of funding.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 4 2014-10-01 2014-10-01 false Conditions for approval of funding. 1355.53 Section 1355.53 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR 1355.53 - Conditions for approval of funding.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 4 2012-10-01 2012-10-01 false Conditions for approval of funding. 1355.53 Section 1355.53 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR 1355.54 - Submittal of advance planning documents.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 4 2012-10-01 2012-10-01 false Submittal of advance planning documents. 1355.54 Section 1355.54 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR 1355.53 - Conditions for approval of funding.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 4 2011-10-01 2011-10-01 false Conditions for approval of funding. 1355.53 Section 1355.53 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
Effect of contrast on human speed perception
NASA Technical Reports Server (NTRS)
Stone, Leland S.; Thompson, Peter
1992-01-01
This study is part of an ongoing collaborative research effort between the Life Science and Human Factors Divisions at NASA ARC to measure the accuracy of human motion perception in order to predict potential errors in human perception/performance and to facilitate the design of display systems that minimize the effects of such deficits. The study describes how contrast manipulations can produce significant errors in human speed perception. Specifically, when two simultaneously presented parallel gratings are moving at the same speed within stationary windows, the lower-contrast grating appears to move more slowly. This contrast-induced misperception of relative speed is evident across a wide range of contrasts (2.5-50 percent) and does not appear to saturate (e.g., a 50 percent contrast grating appears slower than a 70 percent contrast grating moving at the same speed). The misperception is large: a 70 percent contrast grating must, on average, be slowed by 35 percent to match a 10 percent contrast grating moving at 2 deg/sec (N = 6). Furthermore, it is largely independent of the absolute contrast level and is a quasilinear function of log contrast ratio. A preliminary parametric study shows that, although spatial frequency has little effect, the relative orientation of the two gratings is important. Finally, the effect depends on the temporal presentation of the stimuli: the effects of contrast on perceived speed appears lessened when the stimuli to be matched are presented sequentially. These data constrain both physiological models of visual cortex and models of human performance. We conclude that viewing conditions that effect contrast, such as fog, may cause significant errors in speed judgments.
NASA Technical Reports Server (NTRS)
Mcruer, D. T.; Clement, W. F.; Allen, R. W.
1980-01-01
Human error, a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents is investigated. Correction of the sources of human error requires that one attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations is presented. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.
Wiegmann, D A; Shappell, S A
1999-12-01
The present study examined the role of human error and crew-resource management (CRM) failures in U.S. Naval aviation mishaps. All tactical jet (TACAIR) and rotary wing Class A flight mishaps between fiscal years 1990-1996 were reviewed. Results indicated that over 75% of both TACAIR and rotary wing mishaps were attributable, at least in part, to some form of human error of which 70% were associated with aircrew human factors. Of these aircrew-related mishaps, approximately 56% involved at least one CRM failure. These percentages are very similar to those observed prior to the implementation of aircrew coordination training (ACT) in the fleet, suggesting that the initial benefits of the program have not persisted and that CRM failures continue to plague Naval aviation. Closer examination of these CRM-related mishaps suggest that the type of flight operations (preflight, routine, emergency) do play a role in the etiology of CRM failures. A larger percentage of CRM failures occurred during non-routine or extremis flight situations when TACAIR mishaps were considered. In contrast, a larger percentage of rotary wing CRM mishaps involved failures that occurred during routine flight operations. These findings illustrate the complex etiology of CRM failures within Naval aviation and support the need for ACT programs tailored to the unique problems faced by specific communities in the fleet.
Computational dissection of human episodic memory reveals mental process-specific genetic profiles
Luksys, Gediminas; Fastenrath, Matthias; Coynel, David; Freytag, Virginie; Gschwind, Leo; Heck, Angela; Jessen, Frank; Maier, Wolfgang; Milnik, Annette; Riedel-Heller, Steffi G.; Scherer, Martin; Spalek, Klara; Vogler, Christian; Wagner, Michael; Wolfsgruber, Steffen; Papassotiropoulos, Andreas; de Quervain, Dominique J.-F.
2015-01-01
Episodic memory performance is the result of distinct mental processes, such as learning, memory maintenance, and emotional modulation of memory strength. Such processes can be effectively dissociated using computational models. Here we performed gene set enrichment analyses of model parameters estimated from the episodic memory performance of 1,765 healthy young adults. We report robust and replicated associations of the amine compound SLC (solute-carrier) transporters gene set with the learning rate, of the collagen formation and transmembrane receptor protein tyrosine kinase activity gene sets with the modulation of memory strength by negative emotional arousal, and of the L1 cell adhesion molecule (L1CAM) interactions gene set with the repetition-based memory improvement. Furthermore, in a large functional MRI sample of 795 subjects we found that the association between L1CAM interactions and memory maintenance revealed large clusters of differences in brain activity in frontal cortical areas. Our findings provide converging evidence that distinct genetic profiles underlie specific mental processes of human episodic memory. They also provide empirical support to previous theoretical and neurobiological studies linking specific neuromodulators to the learning rate and linking neural cell adhesion molecules to memory maintenance. Furthermore, our study suggests additional memory-related genetic pathways, which may contribute to a better understanding of the neurobiology of human memory. PMID:26261317
Computational dissection of human episodic memory reveals mental process-specific genetic profiles.
Luksys, Gediminas; Fastenrath, Matthias; Coynel, David; Freytag, Virginie; Gschwind, Leo; Heck, Angela; Jessen, Frank; Maier, Wolfgang; Milnik, Annette; Riedel-Heller, Steffi G; Scherer, Martin; Spalek, Klara; Vogler, Christian; Wagner, Michael; Wolfsgruber, Steffen; Papassotiropoulos, Andreas; de Quervain, Dominique J-F
2015-09-01
Episodic memory performance is the result of distinct mental processes, such as learning, memory maintenance, and emotional modulation of memory strength. Such processes can be effectively dissociated using computational models. Here we performed gene set enrichment analyses of model parameters estimated from the episodic memory performance of 1,765 healthy young adults. We report robust and replicated associations of the amine compound SLC (solute-carrier) transporters gene set with the learning rate, of the collagen formation and transmembrane receptor protein tyrosine kinase activity gene sets with the modulation of memory strength by negative emotional arousal, and of the L1 cell adhesion molecule (L1CAM) interactions gene set with the repetition-based memory improvement. Furthermore, in a large functional MRI sample of 795 subjects we found that the association between L1CAM interactions and memory maintenance revealed large clusters of differences in brain activity in frontal cortical areas. Our findings provide converging evidence that distinct genetic profiles underlie specific mental processes of human episodic memory. They also provide empirical support to previous theoretical and neurobiological studies linking specific neuromodulators to the learning rate and linking neural cell adhesion molecules to memory maintenance. Furthermore, our study suggests additional memory-related genetic pathways, which may contribute to a better understanding of the neurobiology of human memory.
Human Reliability and the Cost of Doing Business
NASA Technical Reports Server (NTRS)
DeMott, Diana
2014-01-01
Most businesses recognize that people will make mistakes and assume errors are just part of the cost of doing business, but does it need to be? Companies with high risk, or major consequences, should consider the effect of human error. In a variety of industries, Human Errors have caused costly failures and workplace injuries. These have included: airline mishaps, medical malpractice, administration of medication and major oil spills have all been blamed on human error. A technique to mitigate or even eliminate some of these costly human errors is the use of Human Reliability Analysis (HRA). Various methodologies are available to perform Human Reliability Assessments that range from identifying the most likely areas for concern to detailed assessments with human error failure probabilities calculated. Which methodology to use would be based on a variety of factors that would include: 1) how people react and act in different industries, and differing expectations based on industries standards, 2) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 3) type and availability of data and 4) how the industry views risk & reliability influences ( types of emergencies, contingencies and routine tasks versus cost based concerns). The Human Reliability Assessments should be the first step to reduce, mitigate or eliminate the costly mistakes or catastrophic failures. Using Human Reliability techniques to identify and classify human error risks allows a company more opportunities to mitigate or eliminate these risks and prevent costly failures.
Riddell, Nina; Faou, Pierre; Murphy, Melanie; Giummarra, Loretta; Downs, Rachael A.; Rajapaksha, Harinda
2017-01-01
Purpose Microarray and RNA sequencing studies in the chick model of early optically induced refractive error have implicated thousands of genes, many of which have also been linked to ocular pathologies in humans, including age-related macular degeneration (AMD), choroidal neovascularization, glaucoma, and cataract. These findings highlight the potential relevance of the chick model to understanding both refractive error development and the progression to secondary pathological complications. The present study aimed to determine whether proteomic responses to early optical defocus in the chick share similarities with these transcriptome-level changes, particularly in terms of dysregulation of pathology-related molecular processes. Methods Chicks were assigned to a lens condition (monocular +10 D [diopters] to induce hyperopia, −10 D to induce myopia, or no lens) on post-hatch day 5. Biometric measures were collected following a further 6 h and 48 h of rearing. The retina/RPE was then removed and prepared for liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS) on an LTQ-Orbitrap Elite. Raw data were processed using MaxQuant, and differentially abundant proteins were identified using moderated t tests (fold change ≥1.5, Benjamini-Hochberg adjusted p<0.05). These differentially abundant proteins were compared with the genes and proteins implicated in previous exploratory transcriptome and proteomic studies of refractive error, as well as the genes and proteins linked to the ocular pathologies listed above for which myopia or hyperopia are risk factors. Finally, gene set enrichment analysis (GSEA) was used to assess whether gene sets from the Human Phenotype Ontology database were enriched in the lens groups relative to the no lens groups, and at the top or bottom of the protein data ranked by Spearman’s correlation with refraction at 6 and 48 h. Results Refractive errors of −2.63 D ± 0.31 D (mean ± standard error, SE) and 3.90 D ± 0.37 D were evident in the negative and positive lens groups, respectively, at 6 h. By 48 h, refractive compensation to both lens types was almost complete (negative lens −9.70 D ± 0.41 D, positive lens 7.70 D ± 0.44 D). More than 140 differentially abundant proteins were identified in each lens group relative to the no lens controls at both time points. No proteins were differentially abundant between the negative and positive lens groups at 6 h, and 13 were differentially abundant at 48 h. As there was substantial overlap in the proteins implicated across the six comparisons, a total of 390 differentially abundant proteins were identified. Sixty-five of these 390 proteins had previously been implicated in transcriptome studies of refractive error animal models, and 42 had previously been associated with AMD, choroidal neovascularization, glaucoma, and/or cataract in humans. The overlap of differentially abundant proteins with AMD-associated genes and proteins was statistically significant for all conditions (Benjamini-Hochberg adjusted p<0.05), with over-representation analysis implicating ontologies related to oxidative stress, cholesterol homeostasis, and melanin biosynthesis. GSEA identified significant enrichment of genes associated with abnormal electroretinogram, photophobia, and nyctalopia phenotypes in the proteins negatively correlated with ocular refraction across the lens groups at 6 h. The implicated proteins were primarily linked to photoreceptor dystrophies and mitochondrial disorders in humans. Conclusions Optical defocus in the chicks induces rapid changes in the abundance of many proteins in the retina/RPE that have previously been linked to inherited and age-related ocular pathologies in humans. Similar changes have been identified in a meta-analysis of chick refractive error transcriptome studies, highlighting the chick as a model for the study of optically induced stress with possible relevance to understanding the development of a range of pathological states in humans. PMID:29259393
Henneman, Elizabeth A
2017-07-01
The Institute of Medicine (now National Academy of Medicine) reports "To Err is Human" and "Crossing the Chasm" made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the "near miss" process and as the final safety net for the patient is of paramount importance. The nurse's role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies. ©2017 American Association of Critical-Care Nurses.
NASA Technical Reports Server (NTRS)
Fields, J. M.
1980-01-01
The data from seven surveys of community response to environmental noise are reanalyzed to assess the relative influence of peak noise levels and the numbers of noise events on human response. The surveys do not agree on the value of the tradeoff between the effects of noise level and numbers of events. The value of the tradeoff cannot be confidently specified in any survey because the tradeoff estimate may have a large standard error of estimate and because the tradeoff estimate may be seriously biased by unknown noise measurement errors. Some evidence suggests a decrease in annoyance with very high numbers of noise events but this evidence is not strong enough to lead to the rejection of the conventionally accepted assumption that annoyance is related to a log transformation of the number of noise events.
Hazardous chemical incidents in schools--United States, 2002-2007.
2008-11-07
Chemicals that can cause adverse health effects are used in many elementary and secondary schools (e.g., in chemistry laboratories, art classrooms, automotive repair areas, printing and other vocational shops, and facility maintenance areas). Every year, unintentional and intentional releases of these chemicals, or related fires or explosions, occur in schools, causing injuries, costly cleanups, and lost school days. The federal Agency for Toxic Substances and Disease Registry (ATSDR) conducts national public health surveillance of chemical incidents through its Hazardous Substances Emergency Events Surveillance (HSEES) system. To identify school-related incidents and elucidate their causes and consequences to highlight the need for intervention, ATSDR conducted an analysis of HSEES data for 2002-2007. During that period, 423 chemical incidents in elementary and secondary schools were reported by 15 participating states. Mercury was the most common chemical released. The analysis found that 62% of reported chemical incidents at elementary and secondary schools resulted from human error (i.e., mistakes in the use or handling of a substance), and 30% of incidents resulted in at least one acute injury. Proper chemical use and management (e.g., keeping an inventory and properly storing, labeling, and disposing of chemicals) is essential to protect school building occupants. Additional education directed at raising awareness of the problem and providing resources to reduce the risk is needed to ensure that schools are safe from unnecessary dangers posed by hazardous chemicals.
Human Reliability and the Cost of Doing Business
NASA Technical Reports Server (NTRS)
DeMott, D. L.
2014-01-01
Human error cannot be defined unambiguously in advance of it happening, it often becomes an error after the fact. The same action can result in a tragic accident for one situation or a heroic action given a more favorable outcome. People often forget that we employ humans in business and industry for the flexibility and capability to change when needed. In complex systems, operations are driven by their specifications of the system and the system structure. People provide the flexibility to make it work. Human error has been reported as being responsible for 60%-80% of failures, accidents and incidents in high-risk industries. We don't have to accept that all human errors are inevitable. Through the use of some basic techniques, many potential human error events can be addressed. There are actions that can be taken to reduce the risk of human error.
NASA Technical Reports Server (NTRS)
Clement, W. F.; Allen, R. W.; Heffley, R. K.; Jewell, W. F.; Jex, H. R.; Mcruer, D. T.; Schulman, T. M.; Stapleford, R. L.
1980-01-01
The NASA Ames Research Center proposed a man-vehicle systems research facility to support flight simulation studies which are needed for identifying and correcting the sources of human error associated with current and future air carrier operations. The organization of research facility is reviewed and functional requirements and related priorities for the facility are recommended based on a review of potentially critical operational scenarios. Requirements are included for the experimenter's simulation control and data acquisition functions, as well as for the visual field, motion, sound, computation, crew station, and intercommunications subsystems. The related issues of functional fidelity and level of simulation are addressed, and specific criteria for quantitative assessment of various aspects of fidelity are offered. Recommendations for facility integration, checkout, and staffing are included.
2014-10-01
accountability of individual load con- sumption, forewarning of maintenance problems, and aware- ness of human activity based on electrical activity...accountability and maintenance examples were identified from our desks at MIT. Tech support can be anywhere and do the same. Human Activity DepNILM...provides awareness of human activity within a net- work. Each device has an electrical fingerprint, and specific de- vices imply associated human actions
Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris; Bjørn, Brian; Lilja, Beth; Mogensen, Torben
2011-03-01
Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.
The Importance of HRA in Human Space Flight: Understanding the Risks
NASA Technical Reports Server (NTRS)
Hamlin, Teri
2010-01-01
Human performance is critical to crew safety during space missions. Humans interact with hardware and software during ground processing, normal flight, and in response to events. Human interactions with hardware and software can cause Loss of Crew and/or Vehicle (LOCV) through improper actions, or may prevent LOCV through recovery and control actions. Humans have the ability to deal with complex situations and system interactions beyond the capability of machines. Human Reliability Analysis (HRA) is a method used to qualitatively and quantitatively assess the occurrence of human failures that affect availability and reliability of complex systems. Modeling human actions with their corresponding failure probabilities in a Probabilistic Risk Assessment (PRA) provides a more complete picture of system risks and risk contributions. A high-quality HRA can provide valuable information on potential areas for improvement, including training, procedures, human interfaces design, and the need for automation. Modeling human error has always been a challenge in part because performance data is not always readily available. For spaceflight, the challenge is amplified not only because of the small number of participants and limited amount of performance data available, but also due to the lack of definition of the unique factors influencing human performance in space. These factors, called performance shaping factors in HRA terminology, are used in HRA techniques to modify basic human error probabilities in order to capture the context of an analyzed task. Many of the human error modeling techniques were developed within the context of nuclear power plants and therefore the methodologies do not address spaceflight factors such as the effects of microgravity and longer duration missions. This presentation will describe the types of human error risks which have shown up as risk drivers in the Shuttle PRA which may be applicable to commercial space flight. As with other large PRAs of complex machines, human error in the Shuttle PRA proved to be an important contributor (12 percent) to LOCV. An existing HRA technique was adapted for use in the Shuttle PRA, but additional guidance and improvements are needed to make the HRA task in space-related PRAs easier and more accurate. Therefore, this presentation will also outline plans for expanding current HRA methodology to more explicitly cover spaceflight performance shaping factors.
Remote maintenance monitoring system
NASA Technical Reports Server (NTRS)
Simpkins, Lorenz G. (Inventor); Owens, Richard C. (Inventor); Rochette, Donn A. (Inventor)
1992-01-01
A remote maintenance monitoring system retrofits to a given hardware device with a sensor implant which gathers and captures failure data from the hardware device, without interfering with its operation. Failure data is continuously obtained from predetermined critical points within the hardware device, and is analyzed with a diagnostic expert system, which isolates failure origin to a particular component within the hardware device. For example, monitoring of a computer-based device may include monitoring of parity error data therefrom, as well as monitoring power supply fluctuations therein, so that parity error and power supply anomaly data may be used to trace the failure origin to a particular plane or power supply within the computer-based device. A plurality of sensor implants may be rerofit to corresponding plural devices comprising a distributed large-scale system. Transparent interface of the sensors to the devices precludes operative interference with the distributed network. Retrofit capability of the sensors permits monitoring of even older devices having no built-in testing technology. Continuous real time monitoring of a distributed network of such devices, coupled with diagnostic expert system analysis thereof, permits capture and analysis of even intermittent failures, thereby facilitating maintenance of the monitored large-scale system.
Understanding Risk Tolerance and Building an Effective Safety Culture
NASA Technical Reports Server (NTRS)
Loyd, David
2018-01-01
Estimates range from 65-90 percent of catastrophic mishaps are due to human error. NASA's human factors-related mishaps causes are estimated at approximately 75 percent. As much as we'd like to error-proof our work environment, even the most automated and complex technical endeavors require human interaction... and are vulnerable to human frailty. Industry and government are focusing not only on human factors integration into hazardous work environments, but also looking for practical approaches to cultivating a strong Safety Culture that diminishes risk. Industry and government organizations have recognized the value of monitoring leading indicators to identify potential risk vulnerabilities. NASA has adapted this approach to assess risk controls associated with hazardous, critical, and complex facilities. NASA's facility risk assessments integrate commercial loss control, OSHA (Occupational Safety and Health Administration) Process Safety, API (American Petroleum Institute) Performance Indicator Standard, and NASA Operational Readiness Inspection concepts to identify risk control vulnerabilities.
Computer integrated documentation
NASA Technical Reports Server (NTRS)
Boy, Guy
1991-01-01
The main technical issues of the Computer Integrated Documentation (CID) project are presented. The problem of automation of documents management and maintenance is analyzed both from an artificial intelligence viewpoint and from a human factors viewpoint. Possible technologies for CID are reviewed: conventional approaches to indexing and information retrieval; hypertext; and knowledge based systems. A particular effort was made to provide an appropriate representation for contextual knowledge. This representation is used to generate context on hypertext links. Thus, indexing in CID is context sensitive. The implementation of the current version of CID is described. It includes a hypertext data base, a knowledge based management and maintenance system, and a user interface. A series is also presented of theoretical considerations as navigation in hyperspace, acquisition of indexing knowledge, generation and maintenance of a large documentation, and relation to other work.
Myths and realities of electronics maintenance.
Harris, Douglas H
2008-06-01
The author presents and discusses discoveries and developments contributing to enhanced electronics maintenance performance. This body of research is viewed from the vantage point of Nick Bond's 1970 Ely Award-winning article in Human Factors, "Some Persistent Myths About Military Electronics Maintenance." Bond identified a set of myths and summarized research that not only produced information and techniques leading to demonstrably improved maintenance performance but also exploded many unfounded beliefs that were commonly held before the research had been conducted and the findings disseminated. The period from 1964 through 1986, as reflected by publications in the journal, was a productive period of research that led to greater understanding of human factors in electronics maintenance and to numerous advances that contributed, ultimately, to more effective maintenance performance. Technological advances, combined with what we learned about maintenance performance, have substantially reduced the maintenance burden and enhanced the maintenance of electronic systems. Some of the principal lessons learned from this research on electronics maintenance apply to understanding the effects of equipment complexity, providing an optimal role for automation, designing more appropriate on-the-job training, and enhancing troubleshooting skills.
Functional conservation of Gsdma cluster genes specifically duplicated in the mouse genome.
Tanaka, Shigekazu; Mizushina, Youichi; Kato, Yoriko; Tamura, Masaru; Shiroishi, Toshihiko
2013-10-03
Mouse Gasdermin A3 (Gsdma3) is the causative gene for dominant skin mutations exhibiting alopecia. Mouse has two other Gsdma3-related genes, Gsdma and Gsdma2, whereas human and rat have only one related gene. To date, no skin mutation has been reported for human GSDMA and rat Gsdma as well as mouse Gsdma and Gsdma2. Therefore, it is possible that only Gsdma3 has gain-of-function type mutations to cause dominant skin phenotype. To elucidate functional divergence among the Gsdma-related genes in mice, and to infer the function of the human and rat orthologs, we examined in vivo function of mouse Gsdma by generating Gsdma knockout mice and transgenic mice that overexpress wild-type Gsdma or Gsdma harboring a point mutation (Alanine339Threonine). The Gsdma knockout mice shows no visible phenotype, indicating that Gsdma is not essential for differentiation of epidermal cells and maintenance of the hair cycle, and that Gsdma is expressed specifically both in the inner root sheath of hair follicles and in suprabasal cell layers, whereas Gsdma3 is expressed only in suprabasal layers. By contrast, both types of the transgenic mice exhibited epidermal hyperplasia resembling the Gsdma3 mutations, although the phenotype depended on the genetic background. These results indicate that the mouse Gsdma and Gsdma3 genes share common function to regulate epithelial maintenance and/or homeostasis, and suggest that the function of human GSDMA and rat Gsdma, which are orthologs of mouse Gsdma, is conserved as well.
Theoretical investigation of aberrations upon ametropic human eyes
NASA Astrophysics Data System (ADS)
Tan, Bo; Chen, Ying-Ling; Lewis, J. W. L.; Baker, Kevin
2003-11-01
The human eye aberrations are important for visual acuity and ophthalmic diagnostics and surgical procedures. Reported monochromatic aberration data of the normal 20/20 human eyes are scarce. There exist even fewer reports of the relation between ametropic conditions and aberrations. We theoretically investigate the monochromatic and chromatic aberrations of human eyes for refractive errors of -10 to +10 diopters. Schematic human eye models are employed using optical design software for axial, index, and refractive types of ametropia.
Managing human fallibility in critical aerospace situations
NASA Astrophysics Data System (ADS)
Tew, Larry
2014-11-01
Human fallibility is pervasive in the aerospace industry with over 50% of errors attributed to human error. Consider the benefits to any organization if those errors were significantly reduced. Aerospace manufacturing involves high value, high profile systems with significant complexity and often repetitive build, assembly, and test operations. In spite of extensive analysis, planning, training, and detailed procedures, human factors can cause unexpected errors. Handling such errors involves extensive cause and corrective action analysis and invariably schedule slips and cost growth. We will discuss success stories, including those associated with electro-optical systems, where very significant reductions in human fallibility errors were achieved after receiving adapted and specialized training. In the eyes of company and customer leadership, the steps used to achieve these results lead to in a major culture change in both the workforce and the supporting management organization. This approach has proven effective in other industries like medicine, firefighting, law enforcement, and aviation. The roadmap to success and the steps to minimize human error are known. They can be used by any organization willing to accept human fallibility and take a proactive approach to incorporate the steps needed to manage and minimize error.
GTARG - The TOPEX/Poseidon ground track maintenance maneuver targeting program
NASA Technical Reports Server (NTRS)
Shapiro, Bruce E.; Bhat, Ramachandra S.
1993-01-01
GTARG is a computer program used to design orbit maintenance maneuvers for the TOPEX/Poseidon satellite. These maneuvers ensure that the ground track is kept within +/-1 km with of an = 9.9 day exact repeat pattern. Maneuver parameters are determined using either of two targeting strategies: longitude targeting, which maximizes the time between maneuvers, and time targeting, in which maneuvers are targeted to occur at specific intervals. The GTARG algorithm propagates nonsingular mean elements, taking into account anticipated error sigma's in orbit determination, Delta v execution, drag prediction and Delta v quantization. A satellite unique drag model is used which incorporates an approximate mean orbital Jacchia-Roberts atmosphere and a variable mean area model. Maneuver Delta v magnitudes are targeted to precisely maintain either the unbiased ground track itself, or a comfortable (3 sigma) error envelope about the unbiased ground track.
Defining the Relationship Between Human Error Classes and Technology Intervention Strategies
NASA Technical Reports Server (NTRS)
Wiegmann, Douglas A.; Rantanen, Eas M.
2003-01-01
The modus operandi in addressing human error in aviation systems is predominantly that of technological interventions or fixes. Such interventions exhibit considerable variability both in terms of sophistication and application. Some technological interventions address human error directly while others do so only indirectly. Some attempt to eliminate the occurrence of errors altogether whereas others look to reduce the negative consequences of these errors. In any case, technological interventions add to the complexity of the systems and may interact with other system components in unforeseeable ways and often create opportunities for novel human errors. Consequently, there is a need to develop standards for evaluating the potential safety benefit of each of these intervention products so that resources can be effectively invested to produce the biggest benefit to flight safety as well as to mitigate any adverse ramifications. The purpose of this project was to help define the relationship between human error and technological interventions, with the ultimate goal of developing a set of standards for evaluating or measuring the potential benefits of new human error fixes.
Human homosexuality: a paradigmatic arena for sexually antagonistic selection?
Camperio Ciani, Andrea; Battaglia, Umberto; Zanzotto, Giovanni
2015-01-29
Sexual conflict likely plays a crucial role in the origin and maintenance of homosexuality in our species. Although environmental factors are known to affect human homosexual (HS) preference, sibling concordances and population patterns related to HS indicate that genetic components are also influencing this trait in humans. We argue that multilocus, partially X-linked genetic factors undergoing sexually antagonistic selection that promote maternal female fecundity at the cost of occasional male offspring homosexuality are the best candidates capable of explaining the frequency, familial clustering, and pedigree asymmetries observed in HS male proband families. This establishes male HS as a paradigmatic example of sexual conflict in human biology. HS in females, on the other hand, is currently a more elusive phenomenon from both the empirical and theoretical standpoints because of its fluidity and marked environmental influence. Genetic and epigenetic mechanisms, the latter involving sexually antagonistic components, have been hypothesized for the propagation and maintenance of female HS in the population. However, further data are needed to truly clarify the evolutionary dynamics of this trait. Copyright © 2015 Cold Spring Harbor Laboratory Press; all rights reserved.
Human Homosexuality: A Paradigmatic Arena for Sexually Antagonistic Selection?
Ciani, Andrea Camperio; Battaglia, Umberto; Zanzotto, Giovanni
2015-01-01
Sexual conflict likely plays a crucial role in the origin and maintenance of homosexuality in our species. Although environmental factors are known to affect human homosexual (HS) preference, sibling concordances and population patterns related to HS indicate that genetic components are also influencing this trait in humans. We argue that multilocus, partially X-linked genetic factors undergoing sexually antagonistic selection that promote maternal female fecundity at the cost of occasional male offspring homosexuality are the best candidates capable of explaining the frequency, familial clustering, and pedigree asymmetries observed in HS male proband families. This establishes male HS as a paradigmatic example of sexual conflict in human biology. HS in females, on the other hand, is currently a more elusive phenomenon from both the empirical and theoretical standpoints because of its fluidity and marked environmental influence. Genetic and epigenetic mechanisms, the latter involving sexually antagonistic components, have been hypothesized for the propagation and maintenance of female HS in the population. However, further data are needed to truly clarify the evolutionary dynamics of this trait. PMID:25635045
Gerstein, Aleeza C; Nielsen, Kirsten
2017-04-01
Cryptococcus is predominantly an AIDS-related pathogen that causes significant morbidity and mortality in immunocompromised patients. Research studies have historically focused on understanding how the organism causes human disease through the use of in vivo and in vitro model systems to identify virulence factors. Cryptococcus is not an obligate pathogen, however, as human-human transmission is either absent or rare. Selection in the environment must thus be invoked to shape the evolution of this taxa, and directly influences genotypic and trait diversity. Importantly, the evolution and maintenance of pathogenicity must also stem directly from environmental selection. To that end, here we examine abiotic and biotic stresses in the environment, and discuss how they could shape the factors that are commonly identified as important virulence traits. We identify a number of important unanswered questions about Cryptococcus diversity and evolution that are critical for understanding this deadly pathogen, and discuss how implementation of modern sampling and genomic tools could be utilized to answer these questions. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.
Standardized Curriculum for Commercial Garment and Apparel Construction.
ERIC Educational Resources Information Center
Mississippi State Dept. of Education, Jackson. Office of Vocational, Technical and Adult Education.
Standardized curricula are provided for two courses for the secondary vocational education program in Mississippi: commercial garment and apparel construction I and II. The seven units in commercial garment and apparel construction I are as follows: orientation; securing a job; human relations; safety; maintenance; needle trade techniques; and…
45 CFR 1355.25 - Principles of child and family services.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 4 2014-10-01 2014-10-01 false Principles of child and family services. 1355.25 Section 1355.25 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR Appendix C to Part 1355 - Electronic Data Transmission Format
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 4 2014-10-01 2014-10-01 false Electronic Data Transmission Format C Appendix C to Part 1355 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL Pt...
45 CFR 1355.25 - Principles of child and family services.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 4 2012-10-01 2012-10-01 false Principles of child and family services. 1355.25 Section 1355.25 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
45 CFR Appendix C to Part 1355 - Electronic Data Transmission Format
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 4 2012-10-01 2012-10-01 false Electronic Data Transmission Format C Appendix C to Part 1355 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL Pt...
A Hypermedia Information System for Aviation.
ERIC Educational Resources Information Center
Hartzell, Karin M.
The Hypermedia Information System (HIS) is being developed under the auspices of the Federal Aviation Administration (FAA) Office of Aviation Medicine's (AAM) Human Factors in Aviation Maintenance (HFAM) research program. The goal of the hypermedia project is to create new tools and methods for aviation-related information storage and retrieval.…
Human factors in aviation maintenance, phase two : progress report.
DOT National Transportation Integrated Search
1993-04-01
In this second phase of research on Human Factors in Aviation Maintenance, the emphasis has evolved from problem definition to development of demonstrations and prototypes. These demonstrations include a computer-based training simulation for trouble...
Applying lessons learned to enhance human performance and reduce human error for ISS operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1999-01-01
A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy{close_quote}s Idaho National Engineering and Environmental Laboratory (INEEL) is developing a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper will describe previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS. {copyright} {ital 1999 American Institute of Physics.}« less
Applying lessons learned to enhance human performance and reduce human error for ISS operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1998-09-01
A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy`s Idaho National Engineering and Environmental Laboratory (INEEL) is developed a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper describes previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS.« less
Persistently active neurons in human medial frontal and medial temporal lobe support working memory
Kamiński, J; Sullivan, S; Chung, JM; Ross, IB; Mamelak, AN; Rutishauser, U
2017-01-01
Persistent neural activity is a putative mechanism for the maintenance of working memories. Persistent activity relies on the activity of a distributed network of areas, but the differential contribution of each area remains unclear. We recorded single neurons in the human medial frontal cortex and the medial temporal lobe while subjects held up to three items in memory. We found persistently active neurons in both areas. Persistent activity of hippocampal and amygdala neurons was stimulus-specific, formed stable attractors, and was predictive of memory content. Medial frontal cortex persistent activity, on the other hand, was modulated by memory load and task set but was not stimulus-specific. Trial-by-trial variability in persistent activity in both areas was related to memory strength, because it predicted the speed and accuracy by which stimuli were remembered. This work reveals, in humans, direct evidence for a distributed network of persistently active neurons supporting working memory maintenance. PMID:28218914
Structured methods for identifying and correcting potential human errors in aviation operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1997-10-01
Human errors have been identified as the source of approximately 60% of the incidents and accidents that occur in commercial aviation. It can be assumed that a very large number of human errors occur in aviation operations, even though in most cases the redundancies and diversities built into the design of aircraft systems prevent the errors from leading to serious consequences. In addition, when it is acknowledged that many system failures have their roots in human errors that occur in the design phase, it becomes apparent that the identification and elimination of potential human errors could significantly decrease the risksmore » of aviation operations. This will become even more critical during the design of advanced automation-based aircraft systems as well as next-generation systems for air traffic management. Structured methods to identify and correct potential human errors in aviation operations have been developed and are currently undergoing testing at the Idaho National Engineering and Environmental Laboratory (INEEL).« less
Patient safety in otolaryngology: a descriptive review.
Danino, Julian; Muzaffar, Jameel; Metcalfe, Chris; Coulson, Chris
2017-03-01
Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within Otolaryngology, although patient safety has evolved along similar themes as other surgical specialties; there are several specific high-risk areas. Medical error is a common problem and its human cost is of immense importance. Steps to reduce such errors require the identification of high-risk practice within a complex healthcare system. The commitment to patient safety and quality improvement in medicine depend on personal responsibility and professional accountability.
Kraemer, Sara; Carayon, Pascale
2007-03-01
This paper describes human errors and violations of end users and network administration in computer and information security. This information is summarized in a conceptual framework for examining the human and organizational factors contributing to computer and information security. This framework includes human error taxonomies to describe the work conditions that contribute adversely to computer and information security, i.e. to security vulnerabilities and breaches. The issue of human error and violation in computer and information security was explored through a series of 16 interviews with network administrators and security specialists. The interviews were audio taped, transcribed, and analyzed by coding specific themes in a node structure. The result is an expanded framework that classifies types of human error and identifies specific human and organizational factors that contribute to computer and information security. Network administrators tended to view errors created by end users as more intentional than unintentional, while errors created by network administrators as more unintentional than intentional. Organizational factors, such as communication, security culture, policy, and organizational structure, were the most frequently cited factors associated with computer and information security.
Intervention strategies for the management of human error
NASA Technical Reports Server (NTRS)
Wiener, Earl L.
1993-01-01
This report examines the management of human error in the cockpit. The principles probably apply as well to other applications in the aviation realm (e.g. air traffic control, dispatch, weather, etc.) as well as other high-risk systems outside of aviation (e.g. shipping, high-technology medical procedures, military operations, nuclear power production). Management of human error is distinguished from error prevention. It is a more encompassing term, which includes not only the prevention of error, but also a means of disallowing an error, once made, from adversely affecting system output. Such techniques include: traditional human factors engineering, improvement of feedback and feedforward of information from system to crew, 'error-evident' displays which make erroneous input more obvious to the crew, trapping of errors within a system, goal-sharing between humans and machines (also called 'intent-driven' systems), paperwork management, and behaviorally based approaches, including procedures, standardization, checklist design, training, cockpit resource management, etc. Fifteen guidelines for the design and implementation of intervention strategies are included.
NASA Technical Reports Server (NTRS)
Landon, Lauren Blackwell; Vessey, William B.; Barrett, Jamie D.
2015-01-01
A team is defined as: "two or more individuals who interact socially and adaptively, have shared or common goals, and hold meaningful task interdependences; it is hierarchically structured and has a limited life span; in it expertise and roles are distributed; and it is embedded within an organization/environmental context that influences and is influenced by ongoing processes and performance outcomes" (Salas, Stagl, Burke, & Goodwin, 2007, p. 189). From the NASA perspective, a team is commonly understood to be a collection of individuals that is assigned to support and achieve a particular mission. Thus, depending on context, this definition can encompass both the spaceflight crew and the individuals and teams in the larger multi-team system who are assigned to support that crew during a mission. The Team Risk outcomes of interest are predominantly performance related, with a secondary emphasis on long-term health; this is somewhat unique in the NASA HRP in that most Risk areas are medically related and primarily focused on long-term health consequences. In many operational environments (e.g., aviation), performance is assessed as the avoidance of errors. However, the research on performance errors is ambiguous. It implies that actions may be dichotomized into "correct" or "incorrect" responses, where incorrect responses or errors are always undesirable. Researchers have argued that this dichotomy is a harmful oversimplification, and it would be more productive to focus on the variability of human performance and how organizations can manage that variability (Hollnagel, Woods, & Leveson, 2006) (Category III1). Two problems occur when focusing on performance errors: 1) the errors are infrequent and, therefore, difficult to observe and record; and 2) the errors do not directly correspond to failure. Research reveals that humans are fairly adept at correcting or compensating for performance errors before such errors result in recognizable or recordable failures. Astronauts are notably adept high performers. Most failures are recorded only when multiple, small errors occur and humans are unable to recognize and correct or compensate for these errors in time to prevent a failure (Dismukes, Berman, Loukopoulos, 2007) (Category III). More commonly, observers record variability in levels of performance. Some teams commit no observable errors but fail to achieve performance objectives or perform only adequately, while other teams commit some errors but perform spectacularly. Successful performance, therefore, cannot be viewed as simply the absence of errors or the avoidance of failure Johnson Space Center (JSC) Joint Leadership Team, 2008). While failure is commonly attributed to making a major error, focusing solely on the elimination of error(s) does not significantly reduce the risk of failure. Failure may also occur when performance is simply insufficient or an effort is incapable of adjusting sufficiently to a contextual change (e.g., changing levels of autonomy).
Advanced Outage and Control Center: Strategies for Nuclear Plant Outage Work Status Capabilities
DOE Office of Scientific and Technical Information (OSTI.GOV)
Gregory Weatherby
The research effort is a part of the Light Water Reactor Sustainability (LWRS) Program. LWRS is a research and development program sponsored by the Department of Energy, performed in close collaboration with industry to provide the technical foundations for licensing and managing the long-term, safe and economical operation of current nuclear power plants. The LWRS Program serves to help the US nuclear industry adopt new technologies and engineering solutions that facilitate the continued safe operation of the plants and extension of the current operating licenses. The Outage Control Center (OCC) Pilot Project was directed at carrying out the applied researchmore » for development and pilot of technology designed to enhance safe outage and maintenance operations, improve human performance and reliability, increase overall operational efficiency, and improve plant status control. Plant outage management is a high priority concern for the nuclear industry from cost and safety perspectives. Unfortunately, many of the underlying technologies supporting outage control are the same as those used in the 1980’s. They depend heavily upon large teams of staff, multiple work and coordination locations, and manual administrative actions that require large amounts of paper. Previous work in human reliability analysis suggests that many repetitive tasks, including paper work tasks, may have a failure rate of 1.0E-3 or higher (Gertman, 1996). With between 10,000 and 45,000 subtasks being performed during an outage (Gomes, 1996), the opportunity for human error of some consequence is a realistic concern. Although a number of factors exist that can make these errors recoverable, reducing and effectively coordinating the sheer number of tasks to be performed, particularly those that are error prone, has the potential to enhance outage efficiency and safety. Additionally, outage management requires precise coordination of work groups that do not always share similar objectives. Outage managers are concerned with schedule and cost, union workers are concerned with performing work that is commensurate with their trade, and support functions (safety, quality assurance, and radiological controls, etc.) are concerned with performing the work within the plants controls and procedures. Approaches to outage management should be designed to increase the active participation of work groups and managers in making decisions that closed the gap between competing objectives and the potential for error and process inefficiency.« less
Using Intelligent Simulation to Enhance Human Performance in Aircraft Maintenance
NASA Technical Reports Server (NTRS)
Johnson, William B.; Norton, Jeffrey E.
1992-01-01
Human factors research and development investigates the capabilities and limitations of the human within a system. Of the many variables affecting human performance in the aviation maintenance system, training is among the most important. The advent of advanced technology hardware and software has created intelligent training simulations. This paper describes one advanced technology training system under development for the Federal Aviation Administration.
Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities
Raju, Tonse N. K.; Suresh, Gautham; Higgins, Rosemary D.
2012-01-01
Case reports and observational studies continue to report adverse events from medical errors. However, despite considerable attention to patient safety in the popular media, this topic is not a regular component of medical education, and much research needs to be carried out to understand the causes, consequences, and prevention of healthcare-related adverse events during neonatal intensive care. To address the knowledge gaps and to formulate a research and educational agenda in neonatology, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) invited a panel of experts to a workshop in August 2010. Patient safety issues discussed were: the reasons for errors, including systems design, working conditions, and worker fatigue; a need to develop a “culture” of patient safety; the role of electronic medical records, information technology, and simulators in reducing errors; error disclosure practices; medico-legal concerns; and educational needs. Specific neonatology-related topics discussed were: errors during resuscitation, mechanical ventilation, and performance of invasive procedures; medication errors including those associated with milk feedings; diagnostic errors; and misidentification of patients. This article provides an executive summary of the workshop. PMID:21386749
Daboul, Amro; Ivanovska, Tatyana; Bülow, Robin; Biffar, Reiner; Cardini, Andrea
2018-01-01
Using 3D anatomical landmarks from adult human head MRIs, we assessed the magnitude of inter-operator differences in Procrustes-based geometric morphometric analyses. An in depth analysis of both absolute and relative error was performed in a subsample of individuals with replicated digitization by three different operators. The effect of inter-operator differences was also explored in a large sample of more than 900 individuals. Although absolute error was not unusual for MRI measurements, including bone landmarks, shape was particularly affected by differences among operators, with up to more than 30% of sample variation accounted for by this type of error. The magnitude of the bias was such that it dominated the main pattern of bone and total (all landmarks included) shape variation, largely surpassing the effect of sex differences between hundreds of men and women. In contrast, however, we found higher reproducibility in soft-tissue nasal landmarks, despite relatively larger errors in estimates of nasal size. Our study exemplifies the assessment of measurement error using geometric morphometrics on landmarks from MRIs and stresses the importance of relating it to total sample variance within the specific methodological framework being used. In summary, precise landmarks may not necessarily imply negligible errors, especially in shape data; indeed, size and shape may be differentially impacted by measurement error and different types of landmarks may have relatively larger or smaller errors. Importantly, and consistently with other recent studies using geometric morphometrics on digital images (which, however, were not specific to MRI data), this study showed that inter-operator biases can be a major source of error in the analysis of large samples, as those that are becoming increasingly common in the 'era of big data'.
Ivanovska, Tatyana; Bülow, Robin; Biffar, Reiner; Cardini, Andrea
2018-01-01
Using 3D anatomical landmarks from adult human head MRIs, we assessed the magnitude of inter-operator differences in Procrustes-based geometric morphometric analyses. An in depth analysis of both absolute and relative error was performed in a subsample of individuals with replicated digitization by three different operators. The effect of inter-operator differences was also explored in a large sample of more than 900 individuals. Although absolute error was not unusual for MRI measurements, including bone landmarks, shape was particularly affected by differences among operators, with up to more than 30% of sample variation accounted for by this type of error. The magnitude of the bias was such that it dominated the main pattern of bone and total (all landmarks included) shape variation, largely surpassing the effect of sex differences between hundreds of men and women. In contrast, however, we found higher reproducibility in soft-tissue nasal landmarks, despite relatively larger errors in estimates of nasal size. Our study exemplifies the assessment of measurement error using geometric morphometrics on landmarks from MRIs and stresses the importance of relating it to total sample variance within the specific methodological framework being used. In summary, precise landmarks may not necessarily imply negligible errors, especially in shape data; indeed, size and shape may be differentially impacted by measurement error and different types of landmarks may have relatively larger or smaller errors. Importantly, and consistently with other recent studies using geometric morphometrics on digital images (which, however, were not specific to MRI data), this study showed that inter-operator biases can be a major source of error in the analysis of large samples, as those that are becoming increasingly common in the 'era of big data'. PMID:29787586
ERIC Educational Resources Information Center
Boedigheimer, Dan
2010-01-01
Approximately 70% of aviation accidents are attributable to human error. The greatest opportunity for further improving aviation safety is found in reducing human errors in the cockpit. The purpose of this quasi-experimental, mixed-method research was to evaluate whether there was a difference in pilot attitudes toward reducing human error in the…
Evaluating a medical error taxonomy.
Brixey, Juliana; Johnson, Todd R; Zhang, Jiajie
2002-01-01
Healthcare has been slow in using human factors principles to reduce medical errors. The Center for Devices and Radiological Health (CDRH) recognizes that a lack of attention to human factors during product development may lead to errors that have the potential for patient injury, or even death. In response to the need for reducing medication errors, the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) released the NCC MERP taxonomy that provides a standard language for reporting medication errors. This project maps the NCC MERP taxonomy of medication error to MedWatch medical errors involving infusion pumps. Of particular interest are human factors associated with medical device errors. The NCC MERP taxonomy of medication errors is limited in mapping information from MEDWATCH because of the focus on the medical device and the format of reporting.
A method for automatic feature points extraction of human vertebrae three-dimensional model
NASA Astrophysics Data System (ADS)
Wu, Zhen; Wu, Junsheng
2017-05-01
A method for automatic extraction of the feature points of the human vertebrae three-dimensional model is presented. Firstly, the statistical model of vertebrae feature points is established based on the results of manual vertebrae feature points extraction. Then anatomical axial analysis of the vertebrae model is performed according to the physiological and morphological characteristics of the vertebrae. Using the axial information obtained from the analysis, a projection relationship between the statistical model and the vertebrae model to be extracted is established. According to the projection relationship, the statistical model is matched with the vertebrae model to get the estimated position of the feature point. Finally, by analyzing the curvature in the spherical neighborhood with the estimated position of feature points, the final position of the feature points is obtained. According to the benchmark result on multiple test models, the mean relative errors of feature point positions are less than 5.98%. At more than half of the positions, the error rate is less than 3% and the minimum mean relative error is 0.19%, which verifies the effectiveness of the method.
This style guide is for use by developers of new methods for SW-846 and editors of existing SW-846 methods. Its use will help assure consistent method format and minimize editorial errors during the development and maintenance of SW-846.
Jeon, Hong Jin; Kim, Ji-Hae; Kim, Bin-Na; Park, Seung Jin; Fava, Maurizio; Mischoulon, David; Kang, Eun-Ho; Roh, Sungwon; Lee, Dongsoo
2014-12-01
Human error is defined as an unintended error that is attributable to humans rather than machines, and that is important to avoid to prevent accidents. We aimed to investigate the association between sleep quality and human errors among train drivers. Cross-sectional. Population-based. A sample of 5,480 subjects who were actively working as train drivers were recruited in South Korea. The participants were 4,634 drivers who completed all questionnaires (response rate 84.6%). None. The Pittsburgh Sleep Quality Index (PSQI), the Center for Epidemiologic Studies Depression Scale (CES-D), the Impact of Event Scale-Revised (IES-R), the State-Trait Anxiety Inventory (STAI), and the Korean Occupational Stress Scale (KOSS). Of 4,634 train drivers, 349 (7.5%) showed more than one human error per 5 y. Human errors were associated with poor sleep quality, higher PSQI total scores, short sleep duration at night, and longer sleep latency. Among train drivers with poor sleep quality, those who experienced severe posttraumatic stress showed a significantly higher number of human errors than those without. Multiple logistic regression analysis showed that human errors were significantly associated with poor sleep quality and posttraumatic stress, whereas there were no significant associations with depression, trait and state anxiety, and work stress after adjusting for age, sex, education years, marital status, and career duration. Poor sleep quality was found to be associated with more human errors in train drivers, especially in those who experienced severe posttraumatic stress. © 2014 Associated Professional Sleep Societies, LLC.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Taylor, Paul A.; Cooper, Candice Frances; Burnett, Damon J.
Light body armor development for the warfighter is based on trial-and-error testing of prototype designs against ballistic projectiles. Torso armor testing against blast is virtually nonexistent but necessary to ensure adequate protection against injury to the heart and lungs. In this report, we discuss the development of a high-fidelity human torso model, it's merging with the existing Sandia Human Head-Neck Model, and development of the modeling & simulation (M&S) capabilities necessary to simulate wound injury scenarios. Using the new Sandia Human Torso Model, we demonstrate the advantage of virtual simulation in the investigation of wound injury as it relates tomore » the warfighter experience. We present the results of virtual simulations of blast loading and ballistic projectile impact to the tors o with and without notional protective armor. In this manner, we demonstrate the ad vantages of applying a modeling and simulation approach to the investigation of wound injury and relative merit assessments of protective body armor without the need for trial-and-error testing.« less
Lombardo, Franco; Berellini, Giuliano; Labonte, Laura R; Liang, Guiqing; Kim, Sean
2016-03-01
We present a systematic evaluation of the Wajima superpositioning method to estimate the human intravenous (i.v.) pharmacokinetic (PK) profile based on a set of 54 marketed drugs with diverse structure and range of physicochemical properties. We illustrate the use of average of "best methods" for the prediction of clearance (CL) and volume of distribution at steady state (VDss) as described in our earlier work (Lombardo F, Waters NJ, Argikar UA, et al. J Clin Pharmacol. 2013;53(2):178-191; Lombardo F, Waters NJ, Argikar UA, et al. J Clin Pharmacol. 2013;53(2):167-177). These methods provided much more accurate prediction of human PK parameters, yielding 88% and 70% of the prediction within 2-fold error for VDss and CL, respectively. The prediction of human i.v. profile using Wajima superpositioning of rat, dog, and monkey time-concentration profiles was tested against the observed human i.v. PK using fold error statistics. The results showed that 63% of the compounds yielded a geometric mean of fold error below 2-fold, and an additional 19% yielded a geometric mean of fold error between 2- and 3-fold, leaving only 18% of the compounds with a relatively poor prediction. Our results showed that good superposition was observed in any case, demonstrating the predictive value of the Wajima approach, and that the cause of poor prediction of human i.v. profile was mainly due to the poorly predicted CL value, while VDss prediction had a minor impact on the accuracy of human i.v. profile prediction. Copyright © 2016. Published by Elsevier Inc.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Sanfilippo, Antonio P.; Riensche, Roderick M.; Haack, Jereme N.
“Gamification”, the application of gameplay to real-world problems, enables the development of human computation systems that support decision-making through the integration of social and machine intelligence. One of gamification’s major benefits includes the creation of a problem solving environment where the influence of cognitive and cultural biases on human judgment can be curtailed through collaborative and competitive reasoning. By reducing biases on human judgment, gamification allows human computation systems to exploit human creativity relatively unhindered by human error. Operationally, gamification uses simulation to harvest human behavioral data that provide valuable insights for the solution of real-world problems.
Care 3 phase 2 report, maintenance manual
NASA Technical Reports Server (NTRS)
Bryant, L. A.; Stiffler, J. J.
1982-01-01
CARE 3 (Computer-Aided Reliability Estimation, version three) is a computer program designed to help estimate the reliability of complex, redundant systems. Although the program can model a wide variety of redundant structures, it was developed specifically for fault-tolerant avionics systems--systems distinguished by the need for extremely reliable performance since a system failure could well result in the loss of human life. It substantially generalizes the class of redundant configurations that could be accommodated, and includes a coverage model to determine the various coverage probabilities as a function of the applicable fault recovery mechanisms (detection delay, diagnostic scheduling interval, isolation and recovery delay, etc.). CARE 3 further generalizes the class of system structures that can be modeled and greatly expands the coverage model to take into account such effects as intermittent and transient faults, latent faults, error propagation, etc.
Building an experience factory for maintenance
NASA Technical Reports Server (NTRS)
Valett, Jon D.; Condon, Steven E.; Briand, Lionel; Kim, Yong-Mi; Basili, Victor R.
1994-01-01
This paper reports the preliminary results of a study of the software maintenance process in the Flight Dynamics Division (FDD) of the National Aeronautics and Space Administration/Goddard Space Flight Center (NASA/GSFC). This study is being conducted by the Software Engineering Laboratory (SEL), a research organization sponsored by the Software Engineering Branch of the FDD, which investigates the effectiveness of software engineering technologies when applied to the development of applications software. This software maintenance study began in October 1993 and is being conducted using the Quality Improvement Paradigm (QIP), a process improvement strategy based on three iterative steps: understanding, assessing, and packaging. The preliminary results represent the outcome of the understanding phase, during which SEL researchers characterized the maintenance environment, product, and process. Findings indicate that a combination of quantitative and qualitative analysis is effective for studying the software maintenance process, that additional measures should be collected for maintenance (as opposed to new development), and that characteristics such as effort, error rate, and productivity are best considered on a 'release' basis rather than on a project basis. The research thus far has documented some basic differences between new development and software maintenance. It lays the foundation for further application of the QIP to investigate means of improving the maintenance process and product in the FDD.
Analyzing human errors in flight mission operations
NASA Technical Reports Server (NTRS)
Bruno, Kristin J.; Welz, Linda L.; Barnes, G. Michael; Sherif, Josef
1993-01-01
A long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.
Development and validation of Aviation Causal Contributors for Error Reporting Systems (ACCERS).
Baker, David P; Krokos, Kelley J
2007-04-01
This investigation sought to develop a reliable and valid classification system for identifying and classifying the underlying causes of pilot errors reported under the Aviation Safety Action Program (ASAP). ASAP is a voluntary safety program that air carriers may establish to study pilot and crew performance on the line. In ASAP programs, similar to the Aviation Safety Reporting System, pilots self-report incidents by filing a short text description of the event. The identification of contributors to errors is critical if organizations are to improve human performance, yet it is difficult for analysts to extract this information from text narratives. A taxonomy was needed that could be used by pilots to classify the causes of errors. After completing a thorough literature review, pilot interviews and a card-sorting task were conducted in Studies 1 and 2 to develop the initial structure of the Aviation Causal Contributors for Event Reporting Systems (ACCERS) taxonomy. The reliability and utility of ACCERS was then tested in studies 3a and 3b by having pilots independently classify the primary and secondary causes of ASAP reports. The results provided initial evidence for the internal and external validity of ACCERS. Pilots were found to demonstrate adequate levels of agreement with respect to their category classifications. ACCERS appears to be a useful system for studying human error captured under pilot ASAP reports. Future work should focus on how ACCERS is organized and whether it can be used or modified to classify human error in ASAP programs for other aviation-related job categories such as dispatchers. Potential applications of this research include systems in which individuals self-report errors and that attempt to extract and classify the causes of those events.
Differences among Job Positions Related to Communication Errors at Construction Sites
NASA Astrophysics Data System (ADS)
Takahashi, Akiko; Ishida, Toshiro
In a previous study, we classified the communicatio n errors at construction sites as faulty intention and message pattern, inadequate channel pattern, and faulty comprehension pattern. This study seeks to evaluate the degree of risk of communication errors and to investigate differences among people in various job positions in perception of communication error risk . Questionnaires based on the previous study were a dministered to construction workers (n=811; 149 adminis trators, 208 foremen and 454 workers). Administrators evaluated all patterns of communication error risk equally. However, foremen and workers evaluated communication error risk differently in each pattern. The common contributing factors to all patterns wer e inadequate arrangements before work and inadequate confirmation. Some factors were common among patterns but other factors were particular to a specific pattern. To help prevent future accidents at construction sites, administrators should understand how people in various job positions perceive communication errors and propose human factors measures to prevent such errors.
Review of Residential Comfort Control Products and Opportunities
DOE Office of Scientific and Technical Information (OSTI.GOV)
Metzger, Cheryn E.; Goyal, Siddharth; Baechler, Michael C.
This paper begins by discussing the interaction of each major component in advanced sensor and control applications related to HVAC equipment. The paper also looks at the applications of these components to commissioning, maintenance and operations of the HVAC equipment in residential buildings. A summary of state-of-the-art product features is also provided. These products are categorized through their primary application type (commissioning/maintenance or operation) and the features are categorized by component type (sensors, data storage, human-in-the-loop, communication, and controls). A common theme that emerges from this study is the importance of the ability for various product categories to be connectedmore » to each other. There are many manufacturers of sensors and many manufacturers of controls, but the power to automate any commissioning, maintenance or operation application, requires connectivity.« less
Human Error and the International Space Station: Challenges and Triumphs in Science Operations
NASA Technical Reports Server (NTRS)
Harris, Samantha S.; Simpson, Beau C.
2016-01-01
Any system with a human component is inherently risky. Studies in human factors and psychology have repeatedly shown that human operators will inevitably make errors, regardless of how well they are trained. Onboard the International Space Station (ISS) where crew time is arguably the most valuable resource, errors by the crew or ground operators can be costly to critical science objectives. Operations experts at the ISS Payload Operations Integration Center (POIC), located at NASA's Marshall Space Flight Center in Huntsville, Alabama, have learned that from payload concept development through execution, there are countless opportunities to introduce errors that can potentially result in costly losses of crew time and science. To effectively address this challenge, we must approach the design, testing, and operation processes with two specific goals in mind. First, a systematic approach to error and human centered design methodology should be implemented to minimize opportunities for user error. Second, we must assume that human errors will be made and enable rapid identification and recoverability when they occur. While a systematic approach and human centered development process can go a long way toward eliminating error, the complete exclusion of operator error is not a reasonable expectation. The ISS environment in particular poses challenging conditions, especially for flight controllers and astronauts. Operating a scientific laboratory 250 miles above the Earth is a complicated and dangerous task with high stakes and a steep learning curve. While human error is a reality that may never be fully eliminated, smart implementation of carefully chosen tools and techniques can go a long way toward minimizing risk and increasing the efficiency of NASA's space science operations.
Blood transfusion sampling and a greater role for error recovery.
Oldham, Jane
Patient identification errors in pre-transfusion blood sampling ('wrong blood in tube') are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue. PROJECT PURPOSE: This narrative review of the literature is part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error as a prerequisite to examining current and potential approaches to error reduction. A broad search of the literature was undertaken to identify themes relating to this phenomenon. KEY DISCOVERIES: Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery. Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.
DOT National Transportation Integrated Search
1990-11-01
The Federal Aviation Administration sponsored a 2-day meeting in December 1989 as part of a continuing program to address issues of human factors and personnel performance in aviation maintenance and inspection. This meeting focused on issues of "inf...
Modeling human response errors in synthetic flight simulator domain
NASA Technical Reports Server (NTRS)
Ntuen, Celestine A.
1992-01-01
This paper presents a control theoretic approach to modeling human response errors (HRE) in the flight simulation domain. The human pilot is modeled as a supervisor of a highly automated system. The synthesis uses the theory of optimal control pilot modeling for integrating the pilot's observation error and the error due to the simulation model (experimental error). Methods for solving the HRE problem are suggested. Experimental verification of the models will be tested in a flight quality handling simulation.
Space station needs, attributes, and architectural options: Technology development
NASA Technical Reports Server (NTRS)
Robert, A. C.
1983-01-01
The technology development of the space station is examined as it relates to space station growth and equipment requirements for future missions. Future mission topics are refined and used to establish a systems data base. Technology for human factors engineering, space maintenance, satellite design, and laser communications and tracking is discussed.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 4 2011-10-01 2011-10-01 false Withholding Federal funds due to failure to... Section 1355.36 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 4 2012-10-01 2012-10-01 false Withholding Federal funds due to failure to... Section 1355.36 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 4 2014-10-01 2014-10-01 false Withholding Federal funds due to failure to... Section 1355.36 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES GENERAL...
Kansas Vocational Agriculture Education. Basic Core Curriculum Project, Horticulture III.
ERIC Educational Resources Information Center
Albracht, James, Ed.
This secondary horticulture curriculum guide is one of a set of three designated as the basic core of instruction for horticulture programs in Kansas. Units of instruction are presented in eight sections: (1) Human Relations, (2) Business Operations, (3) Greenhouse, (4) Retail Flowershop Operation, (5) Landscape Nursery, (6) Lawn Maintenance, (7)…
Modeling the Dynamic Transmission of Dengue Fever: Investigating Disease Persistence
Medeiros, Líliam César de Castro; Castilho, César Augusto Rodrigues; Braga, Cynthia; de Souza, Wayner Vieira; Regis, Leda; Monteiro, Antonio Miguel Vieira
2011-01-01
Background Dengue is a disease of great complexity, due to interactions between humans, mosquitoes and various virus serotypes as well as efficient vector survival strategies. Thus, understanding the factors influencing the persistence of the disease has been a challenge for scientists and policy makers. The aim of this study is to investigate the influence of various factors related to humans and vectors in the maintenance of viral transmission during extended periods. Methodology/Principal Findings We developed a stochastic cellular automata model to simulate the spread of dengue fever in a dense community. Each cell can correspond to a built area, and human and mosquito populations are individually monitored during the simulations. Human mobility and renewal, as well as vector infestation, are taken into consideration. To investigate the factors influencing the maintenance of viral circulation, two sets of simulations were performed: (1st) varying human renewal rates and human population sizes and (2nd) varying the house index (fraction of infested buildings) and vector per human ratio. We found that viral transmission is inhibited with the combination of small human populations with low renewal rates. It is also shown that maintenance of viral circulation for extended periods is possible at low values of house index. Based on the results of the model and on a study conducted in the city of Recife, Brazil, which associates vector infestation with Aedes aegytpi egg counts, we question the current methodology used in calculating the house index, based on larval survey. Conclusions/Significance This study contributed to a better understanding of the dynamics of dengue subsistence. Using basic concepts of metapopulations, we concluded that low infestation rates in a few neighborhoods ensure the persistence of dengue in large cities and suggested that better strategies should be implemented to obtain measures of house index values, in order to improve the dengue monitoring and control system. PMID:21264356
Defining the Relationship Between Human Error Classes and Technology Intervention Strategies
NASA Technical Reports Server (NTRS)
Wiegmann, Douglas A.; Rantanen, Esa; Crisp, Vicki K. (Technical Monitor)
2002-01-01
One of the main factors in all aviation accidents is human error. The NASA Aviation Safety Program (AvSP), therefore, has identified several human-factors safety technologies to address this issue. Some technologies directly address human error either by attempting to reduce the occurrence of errors or by mitigating the negative consequences of errors. However, new technologies and system changes may also introduce new error opportunities or even induce different types of errors. Consequently, a thorough understanding of the relationship between error classes and technology "fixes" is crucial for the evaluation of intervention strategies outlined in the AvSP, so that resources can be effectively directed to maximize the benefit to flight safety. The purpose of the present project, therefore, was to examine the repositories of human factors data to identify the possible relationship between different error class and technology intervention strategies. The first phase of the project, which is summarized here, involved the development of prototype data structures or matrices that map errors onto "fixes" (and vice versa), with the hope of facilitating the development of standards for evaluating safety products. Possible follow-on phases of this project are also discussed. These additional efforts include a thorough and detailed review of the literature to fill in the data matrix and the construction of a complete database and standards checklists.
NASA Astrophysics Data System (ADS)
Kwintarini, Widiyanti; Wibowo, Agung; Arthaya, Bagus M.; Yuwana Martawirya, Yatna
2018-03-01
The purpose of this study was to improve the accuracy of three-axis CNC Milling Vertical engines with a general approach by using mathematical modeling methods of machine tool geometric errors. The inaccuracy of CNC machines can be caused by geometric errors that are an important factor during the manufacturing process and during the assembly phase, and are factors for being able to build machines with high-accuracy. To improve the accuracy of the three-axis vertical milling machine, by knowing geometric errors and identifying the error position parameters in the machine tool by arranging the mathematical modeling. The geometric error in the machine tool consists of twenty-one error parameters consisting of nine linear error parameters, nine angle error parameters and three perpendicular error parameters. The mathematical modeling approach of geometric error with the calculated alignment error and angle error in the supporting components of the machine motion is linear guide way and linear motion. The purpose of using this mathematical modeling approach is the identification of geometric errors that can be helpful as reference during the design, assembly and maintenance stages to improve the accuracy of CNC machines. Mathematically modeling geometric errors in CNC machine tools can illustrate the relationship between alignment error, position and angle on a linear guide way of three-axis vertical milling machines.
2011-09-01
Transport Association ( ATA ) Maintenance & Ramp Human Factors Task Force committee members—we are deeply grateful for their contributions in the...6 Air Transport Association ( ATA ) Human Factors Task Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Form Development...garnered many valuable les- sons, safety improvements, and significant returns on their investment. 1The FAA ATA Human Factors Taskforce has
Dong, Yufeng; Long, Teng; Wang, Cuicui; Mirando, Anthony J.; Chen, Jianquan; O’Keefe, Regis J.
2014-01-01
Human bone marrow-derived stromal/stem cells (BMSCs) have great therapeutic potential for treating skeletal disease and facilitating skeletal repair, although maintaining their multipotency and expanding these cells ex vivo have proven difficult. Because most stem cell-based applications to skeletal regeneration and repair in the clinic would require large numbers of functional BMSCs, recent research has focused on methods for the appropriate selection, expansion, and maintenance of BMSC populations during long-term culture. We describe here a novel biological method that entails selection of human BMSCs based on NOTCH2 expression and activation of the NOTCH signaling pathway in cultured BMSCs via a tissue culture plate coated with recombinant human JAGGED1 (JAG1) ligand. We demonstrate that transient JAG1-mediated NOTCH signaling promotes human BMSC maintenance and expansion while increasing their skeletogenic differentiation capacity, both ex vivo and in vivo. This study is the first of its kind to describe a NOTCH-mediated methodology for the maintenance and expansion of human BMSCs and will serve as a platform for future clinical or translational studies aimed at skeletal regeneration and repair. PMID:25368376
LACIE performance predictor FOC users manual
NASA Technical Reports Server (NTRS)
1976-01-01
The LACIE Performance Predictor (LPP) is a computer simulation of the LACIE process for predicting worldwide wheat production. The simulation provides for the introduction of various errors into the system and provides estimates based on these errors, thus allowing the user to determine the impact of selected error sources. The FOC LPP simulates the acquisition of the sample segment data by the LANDSAT Satellite (DAPTS), the classification of the agricultural area within the sample segment (CAMS), the estimation of the wheat yield (YES), and the production estimation and aggregation (CAS). These elements include data acquisition characteristics, environmental conditions, classification algorithms, the LACIE aggregation and data adjustment procedures. The operational structure for simulating these elements consists of the following key programs: (1) LACIE Utility Maintenance Process, (2) System Error Executive, (3) Ephemeris Generator, (4) Access Generator, (5) Acquisition Selector, (6) LACIE Error Model (LEM), and (7) Post Processor.
Long-Term Surveillance and Maintenance Plan for the U.S. Department of Energy Amchitka, Alaska, Site
DOE Office of Scientific and Technical Information (OSTI.GOV)
None
2008-09-01
This Long-Term Surveillance and Maintenance Plan describes how the U.S. Department of Energy (DOE) intends to fulfill its mission to maintain protection of human health and the environment at the Amchitka, Alaska, Site1. Three underground nuclear tests were conducted on Amchitka Island. The U.S. Department of Defense, in conjunction with the U.S. Atomic Energy Commission (AEC), conducted the first nuclear test (Long Shot) to provide data that would improve the United States' capability of detecting underground nuclear explosions. The second nuclear test (Milrow) was a weapons-related test conducted by AEC as a means to study the feasibility of detonating amore » much larger device. The final nuclear test (Cannikin), the largest United States underground test, was a weapons-related test. Surface disturbances associated with these tests have been remediated. However, radioactivity remains deep below the surface, contained in and around the test cavities, for which no feasible remediation technology has been identified. In 2006, the groundwater model (Hassan et al. 2002) was updated using 2005 data collected by the Consortium for Risk Evaluation with Stakeholder Participation. Model simulation results indicate there is no breakthrough or seepage of radionuclides into the marine environment within 2,000 years. The Amchitka conceptual model is reasonable; the flow and transport simulation is based on the best available information and data. The simulation results are a quantitative prediction supported by the best available science and technology. This Long-Term Surveillance and Maintenance Plan is an additional step intended for the protection of human health and the environment. This plan may be modified from time to time in the future consistent with the mission to protect human health« less
An analysis of pilot error-related aircraft accidents
NASA Technical Reports Server (NTRS)
Kowalsky, N. B.; Masters, R. L.; Stone, R. B.; Babcock, G. L.; Rypka, E. W.
1974-01-01
A multidisciplinary team approach to pilot error-related U.S. air carrier jet aircraft accident investigation records successfully reclaimed hidden human error information not shown in statistical studies. New analytic techniques were developed and applied to the data to discover and identify multiple elements of commonality and shared characteristics within this group of accidents. Three techniques of analysis were used: Critical element analysis, which demonstrated the importance of a subjective qualitative approach to raw accident data and surfaced information heretofore unavailable. Cluster analysis, which was an exploratory research tool that will lead to increased understanding and improved organization of facts, the discovery of new meaning in large data sets, and the generation of explanatory hypotheses. Pattern recognition, by which accidents can be categorized by pattern conformity after critical element identification by cluster analysis.
NASA Astrophysics Data System (ADS)
Roohi, S.; Ardalan, A. A.; Khodakarami, M.
2009-04-01
Dams as one of the engineering structures play very important role in human life. Because, from primary human needs such as providing drinking water to professional needs such as water powerhouse creation in order to provide power for industrial centers, hospitals, manufactures and agriculture, have considerable dependent on dams. In addition destruction of a dam can be as dangerous as earthquake. Therefore maintenance, stability control and monitoring deformation of them is indispensable. In order to control stability of dams and their around lands and monitoring deformation a network is created by surveyor, geologist and dam experts on crest and body of dam or on land near the dam. Geodetic observations are done in this network by precise surveying instrument in deferent time then by using linear least square parametric adjustment method, adjusted coordinates with their variance- covariance matrix and error ellipses, redundancy numbers for observation, blunders and … are estimated in each epoch. Then displacement vectors are computed in each point of network, After that by use of Lagrangeian deformation idea and constitution of deformation equations movement, displacement model is determined and strain tensor is computed. we can induce deformation information from strain tensor in different ways such as strain ellipse then interpret deformation that happen in each point of network. Also we can compute rigid rotation from anti-symmetric part of displacement gradient tensor. After processing tow consequence epochs observations of horzontal geodetic network of Hnna dam in southwest of Esfahan, the most semi-major axis of error ellipse is estimated about 0.9mm for point D10, largest displacement is 1.4mm for point C3 that it's semimajor axis of displacement error ellipse is 1.3mm and there is different shear in all of network points exceptional points D2,C3 and C2. There is different dilatation in most of points. These amount of maximum shear and dilatation are justified because of horizontal displacement and subsidence of dam due to pressure of water that conserve behind it. Key word: strain tensor, monitoring deformation, Geodetic network, deformation equation movement, error ellipse, strain ellipse, shear, dilatation
Development and implementation of a human accuracy program in patient foodservice.
Eden, S H; Wood, S M; Ptak, K M
1987-04-01
For many years, industry has utilized the concept of human error rates to monitor and minimize human errors in the production process. A consistent quality-controlled product increases consumer satisfaction and repeat purchase of product. Administrative dietitians have applied the concepts of using human error rates (the number of errors divided by the number of opportunities for error) at four hospitals, with a total bed capacity of 788, within a tertiary-care medical center. Human error rate was used to monitor and evaluate trayline employee performance and to evaluate layout and tasks of trayline stations, in addition to evaluating employees in patient service areas. Long-term employees initially opposed the error rate system with some hostility and resentment, while newer employees accepted the system. All employees now believe that the constant feedback given by supervisors enhances their self-esteem and productivity. Employee error rates are monitored daily and are used to counsel employees when necessary; they are also utilized during annual performance evaluation. Average daily error rates for a facility staffed by new employees decreased from 7% to an acceptable 3%. In a facility staffed by long-term employees, the error rate increased, reflecting improper error documentation. Patient satisfaction surveys reveal satisfaction, for tray accuracy increased from 88% to 92% in the facility staffed by long-term employees and has remained above the 90% standard in the facility staffed by new employees.
Stem cell exhaustion due to Runx1 deficiency is prevented by Evi5 activation in leukemogenesis
Jacob, Bindya; Yamashita, Namiko; Wang, Chelsia Qiuxia; Taniuchi, Ichiro; Littman, Dan R.; Asou, Norio
2010-01-01
The RUNX1/AML1 gene is the most frequently mutated gene in human leukemia. Conditional deletion of Runx1 in adult mice results in an increase of hematopoietic stem cells (HSCs), which serve as target cells for leukemia; however, Runx1−/− mice do not develop spontaneous leukemia. Here we show that maintenance of Runx1−/− HSCs is compromised, progressively resulting in HSC exhaustion. In leukemia development, the stem cell exhaustion was rescued by additional genetic changes. Retroviral insertional mutagenesis revealed Evi5 activation as a cooperating genetic alteration and EVI5 overexpression indeed prevented Runx1−/− HSC exhaustion in mice. Moreover, EVI5 was frequently overexpressed in human RUNX1-related leukemias. These results provide insights into the mechanism for maintenance of pre-leukemic stem cells and may provide a novel direction for therapeutic applications. PMID:20008790
Systematic characterization of deubiquitylating enzymes for roles in maintaining genome integrity.
Nishi, Ryotaro; Wijnhoven, Paul; le Sage, Carlos; Tjeertes, Jorrit; Galanty, Yaron; Forment, Josep V; Clague, Michael J; Urbé, Sylvie; Jackson, Stephen P
2014-10-01
DNA double-strand breaks (DSBs) are perhaps the most toxic of all DNA lesions, with defects in the DNA-damage response to DSBs being associated with various human diseases. Although it is known that DSB repair pathways are tightly regulated by ubiquitylation, we do not yet have a comprehensive understanding of how deubiquitylating enzymes (DUBs) function in DSB responses. Here, by carrying out a multidimensional screening strategy for human DUBs, we identify several with hitherto unknown links to DSB repair, the G2/M DNA-damage checkpoint and genome-integrity maintenance. Phylogenetic analyses reveal functional clustering within certain DUB subgroups, suggesting evolutionally conserved functions and/or related modes of action. Furthermore, we establish that the DUB UCHL5 regulates DSB resection and repair by homologous recombination through protecting its interactor, NFRKB, from degradation. Collectively, our findings extend the list of DUBs promoting the maintenance of genome integrity, and highlight their potential as therapeutic targets for cancer.
Grimault, Stephan; Nolden, Sophie; Lefebvre, Christine; Vachon, François; Hyde, Krista; Peretz, Isabelle; Zatorre, Robert; Robitaille, Nicolas; Jolicoeur, Pierre
2014-07-01
We used magnetoencephalography (MEG) to examine brain activity related to the maintenance of non-verbal pitch information in auditory short-term memory (ASTM). We focused on brain activity that increased with the number of items effectively held in memory by the participants during the retention interval of an auditory memory task. We used very simple acoustic materials (i.e., pure tones that varied in pitch) that minimized activation from non-ASTM related systems. MEG revealed neural activity in frontal, temporal, and parietal cortices that increased with a greater number of items effectively held in memory by the participants during the maintenance of pitch representations in ASTM. The present results reinforce the functional role of frontal and temporal cortices in the retention of pitch information in ASTM. This is the first MEG study to provide both fine spatial localization and temporal resolution on the neural mechanisms of non-verbal ASTM for pitch in relation to individual differences in the capacity of ASTM. This research contributes to a comprehensive understanding of the mechanisms mediating the representation and maintenance of basic non-verbal auditory features in the human brain. Copyright © 2014 Elsevier Inc. All rights reserved.
Reflections on human error - Matters of life and death
NASA Technical Reports Server (NTRS)
Wiener, Earl L.
1989-01-01
The last two decades have witnessed a rapid growth in the introduction of automatic devices into aircraft cockpits, and eleswhere in human-machine systems. This was motivated in part by the assumption that when human functioning is replaced by machine functioning, human error is eliminated. Experience to date shows that this is far from true, and that automation does not replace humans, but changes their role in the system, as well as the types and severity of the errors they make. This altered role may lead to fewer, but more critical errors. Intervention strategies to prevent these errors, or ameliorate their consequences include basic human factors engineering of the interface, enhanced warning and alerting systems, and more intelligent interfaces that understand the strategic intent of the crew and can detect and trap inconsistent or erroneous input before it affects the system.
Wind speed time series reconstruction using a hybrid neural genetic approach
NASA Astrophysics Data System (ADS)
Rodriguez, H.; Flores, J. J.; Puig, V.; Morales, L.; Guerra, A.; Calderon, F.
2017-11-01
Currently, electric energy is used in practically all modern human activities. Most of the energy produced came from fossil fuels, making irreversible damage to the environment. Lately, there has been an effort by nations to produce energy using clean methods, such as solar and wind energy, among others. Wind energy is one of the cleanest alternatives. However, the wind speed is not constant, making the planning and operation at electric power systems a difficult activity. Knowing in advance the amount of raw material (wind speed) used for energy production allows us to estimate the energy to be generated by the power plant, helping the maintenance planning, the operational management, optimal operational cost. For these reasons, the forecast of wind speed becomes a necessary task. The forecast process involves the use of past observations from the variable to forecast (wind speed). To measure wind speed, weather stations use devices called anemometers, but due to poor maintenance, connection error, or natural wear, they may present false or missing data. In this work, a hybrid methodology is proposed, and it uses a compact genetic algorithm with an artificial neural network to reconstruct wind speed time series. The proposed methodology reconstructs the time series using a ANN defined by a Compact Genetic Algorithm.
10 CFR 50.73 - Licensee event report system.
Code of Federal Regulations, 2010 CFR
2010-01-01
... plant design; or (2) Normal and expected wear or degradation. (x) Any event that posed an actual threat... discovery of each component or system failure or procedural error. (J) For each human performance related...
This project summary highlights recent findings from research undertaken to develop improved methods to assess potential human health risks related to drinking water disinfection byproduct (DBP) exposures.
A Simple Model Predicting Individual Weight Change in Humans
Thomas, Diana M.; Martin, Corby K.; Heymsfield, Steven; Redman, Leanne M.; Schoeller, Dale A.; Levine, James A.
2010-01-01
Excessive weight in adults is a national concern with over 2/3 of the US population deemed overweight. Because being overweight has been correlated to numerous diseases such as heart disease and type 2 diabetes, there is a need to understand mechanisms and predict outcomes of weight change and weight maintenance. A simple mathematical model that accurately predicts individual weight change offers opportunities to understand how individuals lose and gain weight and can be used to foster patient adherence to diets in clinical settings. For this purpose, we developed a one dimensional differential equation model of weight change based on the energy balance equation is paired to an algebraic relationship between fat free mass and fat mass derived from a large nationally representative sample of recently released data collected by the Centers for Disease Control. We validate the model's ability to predict individual participants’ weight change by comparing model estimates of final weight data from two recent underfeeding studies and one overfeeding study. Mean absolute error and standard deviation between model predictions and observed measurements of final weights are less than 1.8 ± 1.3 kg for the underfeeding studies and 2.5 ± 1.6 kg for the overfeeding study. Comparison of the model predictions to other one dimensional models of weight change shows improvement in mean absolute error, standard deviation of mean absolute error, and group mean predictions. The maximum absolute individual error decreased by approximately 60% substantiating reliability in individual weight change predictions. The model provides a viable method for estimating individual weight change as a result of changes in intake and determining individual dietary adherence during weight change studies. PMID:24707319
Human Factors in Aviation Maintenance. Phase 1
1991-11-01
Aircraft Maintenance Information SystemSupyyse AMP ......... Aircraft Maintenance Personnel CRM ....... Cockpit Resource Management AMT... developments were sponsored by the Department of interchange of relevant information between system par- Defense (DoD). Fewer than twenty systems are...ofindividuals without complicating lines ofcommand andothers in the maintenance system is repeated for row "I." orthe allocation ofresponsibility
Functional Conservation of Gsdma Cluster Genes Specifically Duplicated in the Mouse Genome
Tanaka, Shigekazu; Mizushina, Youichi; Kato, Yoriko; Tamura, Masaru; Shiroishi, Toshihiko
2013-01-01
Mouse Gasdermin A3 (Gsdma3) is the causative gene for dominant skin mutations exhibiting alopecia. Mouse has two other Gsdma3-related genes, Gsdma and Gsdma2, whereas human and rat have only one related gene. To date, no skin mutation has been reported for human GSDMA and rat Gsdma as well as mouse Gsdma and Gsdma2. Therefore, it is possible that only Gsdma3 has gain-of-function type mutations to cause dominant skin phenotype. To elucidate functional divergence among the Gsdma-related genes in mice, and to infer the function of the human and rat orthologs, we examined in vivo function of mouse Gsdma by generating Gsdma knockout mice and transgenic mice that overexpress wild-type Gsdma or Gsdma harboring a point mutation (Alanine339Threonine). The Gsdma knockout mice shows no visible phenotype, indicating that Gsdma is not essential for differentiation of epidermal cells and maintenance of the hair cycle, and that Gsdma is expressed specifically both in the inner root sheath of hair follicles and in suprabasal cell layers, whereas Gsdma3 is expressed only in suprabasal layers. By contrast, both types of the transgenic mice exhibited epidermal hyperplasia resembling the Gsdma3 mutations, although the phenotype depended on the genetic background. These results indicate that the mouse Gsdma and Gsdma3 genes share common function to regulate epithelial maintenance and/or homeostasis, and suggest that the function of human GSDMA and rat Gsdma, which are orthologs of mouse Gsdma, is conserved as well. PMID:23979942
A stochastic dynamic model for human error analysis in nuclear power plants
NASA Astrophysics Data System (ADS)
Delgado-Loperena, Dharma
Nuclear disasters like Three Mile Island and Chernobyl indicate that human performance is a critical safety issue, sending a clear message about the need to include environmental press and competence aspects in research. This investigation was undertaken to serve as a roadmap for studying human behavior through the formulation of a general solution equation. The theoretical model integrates models from two heretofore-disassociated disciplines (behavior specialists and technical specialists), that historically have independently studied the nature of error and human behavior; including concepts derived from fractal and chaos theory; and suggests re-evaluation of base theory regarding human error. The results of this research were based on comprehensive analysis of patterns of error, with the omnipresent underlying structure of chaotic systems. The study of patterns lead to a dynamic formulation, serving for any other formula used to study human error consequences. The search for literature regarding error yielded insight for the need to include concepts rooted in chaos theory and strange attractors---heretofore unconsidered by mainstream researchers who investigated human error in nuclear power plants or those who employed the ecological model in their work. The study of patterns obtained from the rupture of a steam generator tube (SGTR) event simulation, provided a direct application to aspects of control room operations in nuclear power plant operations. In doing so, the conceptual foundation based in the understanding of the patterns of human error analysis can be gleaned, resulting in reduced and prevent undesirable events.
Paglieri, Fabio; Focaroli, Valentina; Bramlett, Jessica; Tierno, Valeria; McIntyre, Joseph M.; Addessi, Elsa; Evans, Theodore A.; Beran, Michael J.
2013-01-01
Choosing to wait for a better outcome (delay choice) and sustaining the delay prior to that outcome (delay maintenance) are both prerequisites for successful self control in intertemporal choices. However, most existing experimental methods test these skills in isolation from each other, and no significant correlation has been observed in performance across these tasks. In this study we introduce a new paradigm, the hybrid delay task, which combines an initial delay choice with a subsequent delay maintenance stage. This allows testing how often choosing to wait is paired with the actual ability to do so. We tested 18 capuchin monkeys (Cebus apella) from two laboratories in various conditions, and we found that subjects frequently chose the delayed reward but then failed to wait for it, due to poor delay maintenance. However, performance improved with experience and different behavioral responses for error correction were evident. These findings have far reaching implications: if such a high error rate was observed also in other species (possibly including Homo sapiens), this may indicate that delay choice tasks that make use of salient, prepotent stimuli do not reliably assess generalized self control, insofar as choosing to wait does not entail always being able to do so. PMID:23274585
Cost-effectiveness of the Federal stream-gaging program in Virginia
Carpenter, D.H.
1985-01-01
Data uses and funding sources were identified for the 77 continuous stream gages currently being operated in Virginia by the U.S. Geological Survey with a budget of $446,000. Two stream gages were identified as not being used sufficiently to warrant continuing their operation. Operation of these stations should be considered for discontinuation. Data collected at two other stations were identified as having uses primarily related to short-term studies; these stations should also be considered for discontinuation at the end of the data collection phases of the studies. The remaining 73 stations should be kept in the program for the foreseeable future. The current policy for operation of the 77-station program requires a budget of $446,000/yr. The average standard error of estimation of streamflow records is 10.1%. It was shown that this overall level of accuracy at the 77 sites could be maintained with a budget of $430,500 if resources were redistributed among the gages. A minimum budget of $428,500 is required to operate the 77-gage program; a smaller budget would not permit proper service and maintenance of the gages and recorders. At the minimum budget, with optimized operation, the average standard error would be 10.4%. The maximum budget analyzed was $650,000, which resulted in an average standard error of 5.5%. The study indicates that a major component of error is caused by lost or missing data. If perfect equipment were available, the standard error for the current program and budget could be reduced to 7.6%. This also can be interpreted to mean that the streamflow data have a standard error of this magnitude during times when the equipment is operating properly. (Author 's abstract)
Multiparametric methane sensor for environmental monitoring
NASA Astrophysics Data System (ADS)
Borecki, M.; Duk, M.; Kociubiński, A.; Korwin-Pawlowski, M. L.
2016-12-01
Today, methane sensors find applications mostly in safety alarm installations, gas parameters detection and air pollution classification. Such sensors and sensors elements exists for industry and home use. Under development area of methane sensors application is dedicated to ground gases monitoring. Proper monitoring of soil gases requires reliable and maintenance-free semi-constant and longtime examination at relatively low cost of equipment. The sensors for soil monitoring have to work on soil probe. Therefore, sensor is exposed to environment conditions, as a wide range of temperatures and a full scale of humidity changes, as well as rain, snow and wind, that are not specified for classical methane sensors. Development of such sensor is presented in this paper. The presented sensor construction consists of five commercial non dispersive infra-red (NDIR) methane sensing units, a set of temperature and humidity sensing units, a gas chamber equipped with a micro-fan, automated gas valves and also a microcontroller that controls the measuring procedure. The electronics part of sensor was installed into customized 3D printed housing equipped with self-developed gas valves. The main development of proposed sensor is on the side of experimental evaluation of construction reliability and results of data processing included safety procedures and function for hardware error correction. Redundant methane sensor units are used providing measurement error correction as well as improved measurement accuracy. The humidity and temperature sensors are used for internal compensation of methane measurements as well as for cutting-off the sensor from the environment when the conditions exceed allowable parameters. Results obtained during environment sensing prove that the gas concentration readings are not sensitive to gas chamber vertical or horizontal position. It is important as vertical sensor installation on soil probe is simpler that horizontal one. Data acquired during six month of environment monitoring prove that error correction of methane sensing units was essential for maintenance free sensor operation, despite used safety procedures.
Mattos, Diego; Mateus, José Roberto; Merino, Eugenio
2012-01-01
The use of mind maps as a method of building knowledge, planning, organizing activities and ideas can be seen in the literature related to ergonomics. The results of such use are relevant and its use in academic area found. However, regarding to its use in industrial environments, studies can't not be found. With this scenario, and based on the perception of the ergonomist about the importance of using methods such as mind maps in support of human cognition, it seems pertinent to its use in industry sectors whose cognitive demand requires. Given these assumptions, this study aimed to apply the method of Mind Maps in Productive Maintenance sector of a Brazilian paper. The Productive Maintenance sector in the Paper Industry has an important contribution to operational performance. With practical Predictive Maintenance, Preventive Maintenance and Corrective Maintenance, the industry advocates to make the machines to produce paper is not to stop producing when they are programmed to do so. Among the practices cited, the Preventive Maintenance is one that leads to pre-determined intervals in order to reduce the possibility of placing the equipment in a condition below the required level of acceptance. Therefore, this article aims to propose using the tool "mental maps" in order to collaborate in planning and implementation of preventive maintenance activities in the sector of mechanical maintenance of a pulp and paper industry in southern Brazil. The study investigated the maintenance sector through its employees, who went through training about the tool and then use it and ergonomists company.
Airline Maintenance Manpower Optimization from the De Novo Perspective
NASA Astrophysics Data System (ADS)
Liou, James J. H.; Tzeng, Gwo-Hshiung
Human resource management (HRM) is an important issue for today’s competitive airline marketing. In this paper, we discuss a multi-objective model designed from the De Novo perspective to help airlines optimize their maintenance manpower portfolio. The effectiveness of the model and solution algorithm is demonstrated in an empirical study of the optimization of the human resources needed for airline line maintenance. Both De Novo and traditional multiple objective programming (MOP) methods are analyzed. A comparison of the results with those of traditional MOP indicates that the proposed model and solution algorithm does provide better performance and an improved human resource portfolio.
Chaplain Corps Cadet Chapel Community Center Chapel Institutional Review Board Not Human Subjects Research Requirements 7 Not Human Subjects Research Form 8 Researcher Instructions - Activities Submitted to DoD IRB 9 Review 18 Not Human Subjects Errors 19 Exempt Research Most Frequent Errors 20 Most Frequent Errors for
Development of an FAA-EUROCONTROL technique for the analysis of human error in ATM : final report.
DOT National Transportation Integrated Search
2002-07-01
Human error has been identified as a dominant risk factor in safety-oriented industries such as air traffic control (ATC). However, little is known about the factors leading to human errors in current air traffic management (ATM) systems. The first s...
Dialysis Facility Safety: Processes and Opportunities.
Garrick, Renee; Morey, Rishikesh
2015-01-01
Unintentional human errors are the source of most safety breaches in complex, high-risk environments. The environment of dialysis care is extremely complex. Dialysis patients have unique and changing physiology, and the processes required for their routine care involve numerous open-ended interfaces between providers and an assortment of technologically advanced equipment. Communication errors, both within the dialysis facility and during care transitions, and lapses in compliance with policies and procedures are frequent areas of safety risk. Some events, such as air emboli and needle dislodgments occur infrequently, but are serious risks. Other adverse events include medication errors, patient falls, catheter and access-related infections, access infiltrations and prolonged bleeding. A robust safety system should evaluate how multiple, sequential errors might align to cause harm. Systems of care can be improved by sharing the results of root cause analyses, and "good catches." Failure mode effects and analyses can be used to proactively identify and mitigate areas of highest risk, and methods drawn from cognitive psychology, simulation training, and human factor engineering can be used to advance facility safety. © 2015 Wiley Periodicals, Inc.
Neural dynamics of reward probability coding: a Magnetoencephalographic study in humans
Thomas, Julie; Vanni-Mercier, Giovanna; Dreher, Jean-Claude
2013-01-01
Prediction of future rewards and discrepancy between actual and expected outcomes (prediction error) are crucial signals for adaptive behavior. In humans, a number of fMRI studies demonstrated that reward probability modulates these two signals in a large brain network. Yet, the spatio-temporal dynamics underlying the neural coding of reward probability remains unknown. Here, using magnetoencephalography, we investigated the neural dynamics of prediction and reward prediction error computations while subjects learned to associate cues of slot machines with monetary rewards with different probabilities. We showed that event-related magnetic fields (ERFs) arising from the visual cortex coded the expected reward value 155 ms after the cue, demonstrating that reward value signals emerge early in the visual stream. Moreover, a prediction error was reflected in ERF peaking 300 ms after the rewarded outcome and showing decreasing amplitude with higher reward probability. This prediction error signal was generated in a network including the anterior and posterior cingulate cortex. These findings pinpoint the spatio-temporal characteristics underlying reward probability coding. Together, our results provide insights into the neural dynamics underlying the ability to learn probabilistic stimuli-reward contingencies. PMID:24302894
Borescope Inspection Management for Engine
NASA Astrophysics Data System (ADS)
Zhongda, Yuan
2018-03-01
In this paper, we try to explain the problems need to be improved from the two perspectives of maintenance program management and maintenance human risk control. On the basis of optimization analysis of borescope inspection maintenance scheme, the defect characteristics and expansion rules of engine heat terminal components are summarized, and some optimization measures are introduced. This paper analyses human risk problem of engine hole from the aspects of qualification management, training requirements and perfection of system, and puts forward some suggestions on management.
Latent error detection: A golden two hours for detection.
Saward, Justin R E; Stanton, Neville A
2017-03-01
Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.
Avoiding Human Error in Mission Operations: Cassini Flight Experience
NASA Technical Reports Server (NTRS)
Burk, Thomas A.
2012-01-01
Operating spacecraft is a never-ending challenge and the risk of human error is ever- present. Many missions have been significantly affected by human error on the part of ground controllers. The Cassini mission at Saturn has not been immune to human error, but Cassini operations engineers use tools and follow processes that find and correct most human errors before they reach the spacecraft. What is needed are skilled engineers with good technical knowledge, good interpersonal communications, quality ground software, regular peer reviews, up-to-date procedures, as well as careful attention to detail and the discipline to test and verify all commands that will be sent to the spacecraft. Two areas of special concern are changes to flight software and response to in-flight anomalies. The Cassini team has a lot of practical experience in all these areas and they have found that well-trained engineers with good tools who follow clear procedures can catch most errors before they get into command sequences to be sent to the spacecraft. Finally, having a robust and fault-tolerant spacecraft that allows ground controllers excellent visibility of its condition is the most important way to ensure human error does not compromise the mission.
Using a Delphi Method to Identify Human Factors Contributing to Nursing Errors.
Roth, Cheryl; Brewer, Melanie; Wieck, K Lynn
2017-07-01
The purpose of this study was to identify human factors associated with nursing errors. Using a Delphi technique, this study used feedback from a panel of nurse experts (n = 25) on an initial qualitative survey questionnaire followed by summarizing the results with feedback and confirmation. Synthesized factors regarding causes of errors were incorporated into a quantitative Likert-type scale, and the original expert panel participants were queried a second time to validate responses. The list identified 24 items as most common causes of nursing errors, including swamping and errors made by others that nurses are expected to recognize and fix. The responses provided a consensus top 10 errors list based on means with heavy workload and fatigue at the top of the list. The use of the Delphi survey established consensus and developed a platform upon which future study of nursing errors can evolve as a link to future solutions. This list of human factors in nursing errors should serve to stimulate dialogue among nurses about how to prevent errors and improve outcomes. Human and system failures have been the subject of an abundance of research, yet nursing errors continue to occur. © 2016 Wiley Periodicals, Inc.
45 CFR 1356.21 - Foster care maintenance payments program implementation requirements.
Code of Federal Regulations, 2013 CFR
2013-10-01
... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND... maintain the family unit and prevent the unnecessary removal of a child from his/her home, as long as the...
45 CFR 1356.21 - Foster care maintenance payments program implementation requirements.
Code of Federal Regulations, 2010 CFR
2010-10-01
... be filed within 60 days of the judicial determination that the child is an abandoned infant; or, (iii... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND...
45 CFR 1356.21 - Foster care maintenance payments program implementation requirements.
Code of Federal Regulations, 2014 CFR
2014-10-01
... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND... maintain the family unit and prevent the unnecessary removal of a child from his/her home, as long as the...
45 CFR 1356.21 - Foster care maintenance payments program implementation requirements.
Code of Federal Regulations, 2011 CFR
2011-10-01
... be filed within 60 days of the judicial determination that the child is an abandoned infant; or, (iii... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND...
45 CFR 1356.21 - Foster care maintenance payments program implementation requirements.
Code of Federal Regulations, 2012 CFR
2012-10-01
... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND... maintain the family unit and prevent the unnecessary removal of a child from his/her home, as long as the...
NASA Astrophysics Data System (ADS)
Ighravwe, D. E.; Oke, S. A.; Adebiyi, K. A.
2018-03-01
This paper draws on the "human reliability" concept as a structure for gaining insight into the maintenance workforce assessment in a process industry. Human reliability hinges on developing the reliability of humans to a threshold that guides the maintenance workforce to execute accurate decisions within the limits of resources and time allocations. This concept offers a worthwhile point of deviation to encompass three elegant adjustments to literature model in terms of maintenance time, workforce performance and return-on-workforce investments. These fully explain the results of our influence. The presented structure breaks new grounds in maintenance workforce theory and practice from a number of perspectives. First, we have successfully implemented fuzzy goal programming (FGP) and differential evolution (DE) techniques for the solution of optimisation problem in maintenance of a process plant for the first time. The results obtained in this work showed better quality of solution from the DE algorithm compared with those of genetic algorithm and particle swarm optimisation algorithm, thus expressing superiority of the proposed procedure over them. Second, the analytical discourse, which was framed on stochastic theory, focusing on specific application to a process plant in Nigeria is a novelty. The work provides more insights into maintenance workforce planning during overhaul rework and overtime maintenance activities in manufacturing systems and demonstrated capacity in generating substantially helpful information for practice.
ERIC Educational Resources Information Center
Burton, Rob J. F.; Peoples, Sue; Cooper, Mark H.
2012-01-01
Improving animal welfare is an important part of the development of the agricultural industry, particularly at a time when intensification and the encroachment of factory-style production systems is making the maintenance of human-animal relations increasingly difficult. Animal science deals with the issue of improving stockmanship by focusing on…
Developmental Differences in Error-Related ERPs in Middle- to Late-Adolescent Males
ERIC Educational Resources Information Center
Santesso, Diane L.; Segalowitz, Sidney J.
2008-01-01
Although there are some studies documenting structural brain changes during late adolescence, there are few showing functional brain changes over this period in humans. Of special interest would be functional changes in the medial frontal cortex that reflect response monitoring. In order to examine such age-related differences, the authors…
Analysis of F-16 radar discrepancies
NASA Astrophysics Data System (ADS)
Riche, K. A.
1982-12-01
One hundred and eight aircraft were randomly selected from three USAF F-16 bases and examined. These aircraft included 63 single-seat F-16As and 45 two-seat F-16Bs and encompassed 8,525 sorties and 748 radar system write-ups. Programs supported by the Statistical Package for the Social Sciences (SPSS) were run on the data. Of the 748 discrepancies, over one-third of them occurred within three sorties of each other and half within six sorties. Sixteen percent of all aircraft which had a discrepancy within three sorties had another write-up within the next three sorties. Designated repeat/recurring write-ups represented one-third of all the instances in which the write-up separation interval was three sorties or less. This is an indication that maintenance is unable to correct equipment failures as they occur, most likely because the false alarm rate is too high and maintenance is unable to duplicate the error conditions on the ground for correct error diagnosis.
Analysis of measured data of human body based on error correcting frequency
NASA Astrophysics Data System (ADS)
Jin, Aiyan; Peipei, Gao; Shang, Xiaomei
2014-04-01
Anthropometry is to measure all parts of human body surface, and the measured data is the basis of analysis and study of the human body, establishment and modification of garment size and formulation and implementation of online clothing store. In this paper, several groups of the measured data are gained, and analysis of data error is gotten by analyzing the error frequency and using analysis of variance method in mathematical statistics method. Determination of the measured data accuracy and the difficulty of measured parts of human body, further studies of the causes of data errors, and summarization of the key points to minimize errors possibly are also mentioned in the paper. This paper analyses the measured data based on error frequency, and in a way , it provides certain reference elements to promote the garment industry development.
Dual S and Ku-band tracking feed for a TDRS reflector antenna
NASA Technical Reports Server (NTRS)
Pullara, J. C.; Bales, C. W.; Kefalas, G. P.; Uyehara, M.
1974-01-01
The results are presented of a trade study designed to identify a synchronous satellite antenna system suitable for receiving and transmitting data from lower orbiting satellites at both S- and K sub u-bands simultaneously as part of the Tracking and Data Relay Satellite System. All related problems associated with maintaining a data link between two satellites with a K sub u-band half-power beamwidth of 0.4 db are considered including data link maintenance techniques, beam pointing accuracies, gimbal and servo errors, solar heating, angle tracking schemes, acquisition problems and aids, tracking accuracies versus SNR, antenna feed designs, equipment designs, weight and power budgets, and detailed candidate antenna system designs.
Wei, Duo; Bodenreider, Olivier
2015-01-01
Objectives To investigate errors identified in SNOMED CT by human reviewers with help from the Abstraction Network methodology and examine why they had escaped detection by the Description Logic (DL) classifier. Case study; Two examples of errors are presented in detail (one missing IS-A relation and one duplicate concept). After correction, SNOMED CT is reclassified to ensure that no new inconsistency was introduced. Conclusions DL-based auditing techniques built in terminology development environments ensure the logical consistency of the terminology. However, complementary approaches are needed for identifying and addressing other types of errors. PMID:20841848
Wei, Duo; Bodenreider, Olivier
2010-01-01
To investigate errors identified in SNOMED CT by human reviewers with help from the Abstraction Network methodology and examine why they had escaped detection by the Description Logic (DL) classifier. Case study; Two examples of errors are presented in detail (one missing IS-A relation and one duplicate concept). After correction, SNOMED CT is reclassified to ensure that no new inconsistency was introduced. DL-based auditing techniques built in terminology development environments ensure the logical consistency of the terminology. However, complementary approaches are needed for identifying and addressing other types of errors.
An MEG signature corresponding to an axiomatic model of reward prediction error.
Talmi, Deborah; Fuentemilla, Lluis; Litvak, Vladimir; Duzel, Emrah; Dolan, Raymond J
2012-01-02
Optimal decision-making is guided by evaluating the outcomes of previous decisions. Prediction errors are theoretical teaching signals which integrate two features of an outcome: its inherent value and prior expectation of its occurrence. To uncover the magnetic signature of prediction errors in the human brain we acquired magnetoencephalographic (MEG) data while participants performed a gambling task. Our primary objective was to use formal criteria, based upon an axiomatic model (Caplin and Dean, 2008a), to determine the presence and timing profile of MEG signals that express prediction errors. We report analyses at the sensor level, implemented in SPM8, time locked to outcome onset. We identified, for the first time, a MEG signature of prediction error, which emerged approximately 320 ms after an outcome and expressed as an interaction between outcome valence and probability. This signal followed earlier, separate signals for outcome valence and probability, which emerged approximately 200 ms after an outcome. Strikingly, the time course of the prediction error signal, as well as the early valence signal, resembled the Feedback-Related Negativity (FRN). In simultaneously acquired EEG data we obtained a robust FRN, but the win and loss signals that comprised this difference wave did not comply with the axiomatic model. Our findings motivate an explicit examination of the critical issue of timing embodied in computational models of prediction errors as seen in human electrophysiological data. Copyright © 2011 Elsevier Inc. All rights reserved.
Accessibility limits recall from visual working memory.
Rajsic, Jason; Swan, Garrett; Wilson, Daryl E; Pratt, Jay
2017-09-01
In this article, we demonstrate limitations of accessibility of information in visual working memory (VWM). Recently, cued-recall has been used to estimate the fidelity of information in VWM, where the feature of a cued object is reproduced from memory (Bays, Catalao, & Husain, 2009; Wilken & Ma, 2004; Zhang & Luck, 2008). Response error in these tasks has been largely studied with respect to failures of encoding and maintenance; however, the retrieval operations used in these tasks remain poorly understood. By varying the number and type of object features provided as a cue in a visual delayed-estimation paradigm, we directly assess the nature of retrieval errors in delayed estimation from VWM. Our results demonstrate that providing additional object features in a single cue reliably improves recall, largely by reducing swap, or misbinding, responses. In addition, performance simulations using the binding pool model (Swan & Wyble, 2014) were able to mimic this pattern of performance across a large span of parameter combinations, demonstrating that the binding pool provides a possible mechanism underlying this pattern of results that is not merely a symptom of one particular parametrization. We conclude that accessing visual working memory is a noisy process, and can lead to errors over and above those of encoding and maintenance limitations. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
Oudman, Erik; Nijboer, Tanja C W; Postma, Albert; Wijnia, Jan W; Kerklaan, Sandra; Lindsen, Karen; Van der Stigchel, Stefan
2013-01-01
Patients with Korsakoff's syndrome show devastating amnesia and executive deficits. Consequently, the ability to perform instrumental activities such as making coffee is frequently diminished. It is currently unknown whether patients with Korsakoff's syndrome are able to (re)learn instrumental activities. A good candidate for an effective teaching technique in Korsakoff's syndrome is errorless learning as it is based on intact implicit memory functioning. Therefore, the aim of the current study was two-fold: to investigate whether patients with Korsakoff's syndrome are able to (re)learn instrumental activities, and to compare the effectiveness of errorless learning with trial and error learning in the acquisition and maintenance of an instrumental activity, namely using a washing machine to do the laundry. Whereas initial learning performance in the errorless learning condition was superior, both intervention techniques resulted in similar improvement over eight learning sessions. Moreover, performance in a different spatial layout showed a comparable improvement. Notably, in follow-up sessions starting after four weeks without practice, performance was still elevated in the errorless learning condition, but not in the trial and error condition. The current study demonstrates that (re)learning and maintenance of an instrumental activity is possible in patients with Korsakoff's syndrome.
Automation design and crew coordination
NASA Technical Reports Server (NTRS)
Segal, Leon D.
1993-01-01
Advances in technology have greatly impacted the appearance of the modern aircraft cockpit. Where once one would see rows upon rows. The introduction of automation has greatly altered the demands on the pilots and the dynamics of aircrew task performance. While engineers and designers continue to implement the latest technological innovations in the cockpit - claiming higher reliability and decreased workload - a large percentage of aircraft accidents are still attributed to human error. Rather than being the main instigators of accidents, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. This paper looks at some of the variables that need to be considered if we are to eliminate at least one of these inheritances - poor design. Specifically, this paper describes the first part of a comprehensive study aimed at identifying the effects of automation on crew coordination.
Dietary enrichment counteracts age-associated cognitive dysfunction in canines.
Milgram, N W; Zicker, S C; Head, E; Muggenburg, B A; Murphey, H; Ikeda-Douglas, C J; Cotman, C W
2002-01-01
Advanced age is accompanied by cognitive decline indicative of central nervous system dysfunction. One possibly critical causal factor is oxidative stress. Accordingly, we studied the effects of dietary antioxidants and age in a canine model of aging that parallels the key features of cognitive decline and neuropathology in humans. Old and young animals were placed on either a standard control food, or a food enriched with a broad spectrum of antioxidants and mitochondrial enzymatic cofactors. After 6 months of treatment, the animals were tested on four increasingly difficult oddity discrimination learning problems. The old animals learned more slowly than the young, making significantly more errors. However, this age-associated decline was reduced in the animals fed the enriched food, particularly on the more difficult tasks. These results indicate that maintenance on foods fortified with complex mixtures of antioxidants can partially counteract the deleterious effects of aging on cognition. Copyright 2002 Elsevier Science Inc.
The role of the insula in intuitive expert bug detection in computer code: an fMRI study.
Castelhano, Joao; Duarte, Isabel C; Ferreira, Carlos; Duraes, Joao; Madeira, Henrique; Castelo-Branco, Miguel
2018-05-09
Software programming is a complex and relatively recent human activity, involving the integration of mathematical, recursive thinking and language processing. The neural correlates of this recent human activity are still poorly understood. Error monitoring during this type of task, requiring the integration of language, logical symbol manipulation and other mathematical skills, is particularly challenging. We therefore aimed to investigate the neural correlates of decision-making during source code understanding and mental manipulation in professional participants with high expertise. The present fMRI study directly addressed error monitoring during source code comprehension, expert bug detection and decision-making. We used C code, which triggers the same sort of processing irrespective of the native language of the programmer. We discovered a distinct role for the insula in bug monitoring and detection and a novel connectivity pattern that goes beyond the expected activation pattern evoked by source code understanding in semantic language and mathematical processing regions. Importantly, insula activity levels were critically related to the quality of error detection, involving intuition, as signalled by reported initial bug suspicion, prior to final decision and bug detection. Activity in this salience network (SN) region evoked by bug suspicion was predictive of bug detection precision, suggesting that it encodes the quality of the behavioral evidence. Connectivity analysis provided evidence for top-down circuit "reutilization" stemming from anterior cingulate cortex (BA32), a core region in the SN that evolved for complex error monitoring such as required for this type of recent human activity. Cingulate (BA32) and anterolateral (BA10) frontal regions causally modulated decision processes in the insula, which in turn was related to activity of math processing regions in early parietal cortex. In other words, earlier brain regions used during evolution for other functions seem to be reutilized in a top-down manner for a new complex function, in an analogous manner as described for other cultural creations such as reading and literacy.
Daud-Gallotti, Renata Mahfuz; Morinaga, Christian Valle; Arlindo-Rodrigues, Marcelo; Velasco, Irineu Tadeu; Arruda Martins, Milton; Tiberio, Iolanda Calvo
2011-01-01
INTRODUCTION: Patient safety is seldom assessed using objective evaluations during undergraduate medical education. OBJECTIVE: To evaluate the performance of fifth-year medical students using an objective structured clinical examination focused on patient safety after implementation of an interactive program based on adverse events recognition and disclosure. METHODS: In 2007, a patient safety program was implemented in the internal medicine clerkship of our hospital. The program focused on human error theory, epidemiology of incidents, adverse events, and disclosure. Upon completion of the program, students completed an objective structured clinical examination with five stations and standardized patients. One station focused on patient safety issues, including medical error recognition/disclosure, the patient-physician relationship and humanism issues. A standardized checklist was completed by each standardized patient to assess the performance of each student. The student's global performance at each station and performance in the domains of medical error, the patient-physician relationship and humanism were determined. The correlations between the student performances in these three domains were calculated. RESULTS: A total of 95 students participated in the objective structured clinical examination. The mean global score at the patient safety station was 87.59±1.24 points. Students' performance in the medical error domain was significantly lower than their performance on patient-physician relationship and humanistic issues. Less than 60% of students (n = 54) offered the simulated patient an apology after a medical error occurred. A significant correlation was found between scores obtained in the medical error domains and scores related to both the patient-physician relationship and humanistic domains. CONCLUSIONS: An objective structured clinical examination is a useful tool to evaluate patient safety competencies during the medical student clerkship. PMID:21876976
Exponential error reduction in pretransfusion testing with automation.
South, Susan F; Casina, Tony S; Li, Lily
2012-08-01
Protecting the safety of blood transfusion is the top priority of transfusion service laboratories. Pretransfusion testing is a critical element of the entire transfusion process to enhance vein-to-vein safety. Human error associated with manual pretransfusion testing is a cause of transfusion-related mortality and morbidity and most human errors can be eliminated by automated systems. However, the uptake of automation in transfusion services has been slow and many transfusion service laboratories around the world still use manual blood group and antibody screen (G&S) methods. The goal of this study was to compare error potentials of commonly used manual (e.g., tiles and tubes) versus automated (e.g., ID-GelStation and AutoVue Innova) G&S methods. Routine G&S processes in seven transfusion service laboratories (four with manual and three with automated G&S methods) were analyzed using failure modes and effects analysis to evaluate the corresponding error potentials of each method. Manual methods contained a higher number of process steps ranging from 22 to 39, while automated G&S methods only contained six to eight steps. Corresponding to the number of the process steps that required human interactions, the risk priority number (RPN) of the manual methods ranged from 5304 to 10,976. In contrast, the RPN of the automated methods was between 129 and 436 and also demonstrated a 90% to 98% reduction of the defect opportunities in routine G&S testing. This study provided quantitative evidence on how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thus would improve the safety of blood transfusion. © 2012 American Association of Blood Banks.
NASA Technical Reports Server (NTRS)
Woodbury, Sarah K.
2008-01-01
The introduction of United Space Alliance's Human Engineering Modeling and Performance Laboratory began in early 2007 in an attempt to address the problematic workspace design issues that the Space Shuttle has imposed on technicians performing maintenance and inspection operations. The Space Shuttle was not expected to require the extensive maintenance it undergoes between flights. As a result, extensive, costly resources have been expended on workarounds and modifications to accommodate ground processing personnel. Consideration of basic human factors principles for design of maintenance is essential during the design phase of future space vehicles, facilities, and equipment. Simulation will be needed to test and validate designs before implementation.
Human factors in aviation crashes involving older pilots.
Li, Guohua; Baker, Susan P; Lamb, Margaret W; Grabowski, Jurek G; Rebok, George W
2002-02-01
Pilot errors are recognized as a contributing factor in as many as 80% of aviation crashes. Experimental studies using flight simulators indicate that due to decreased working memory capacity, older pilots are outperformed by their younger counterparts in communication tasks and flight summary scores. This study examines age-related differences in crash circumstances and pilot errors in a sample of pilots who flew commuter aircraft or air taxis and who were involved in airplane or helicopter crashes. A historical cohort of 3306 pilots who in 1987 flew commuter aircraft or air taxis and were 45-54 yr of age was constructed using the Federal Aviation Administration's airmen information system. Crash records of the study subjects for the years 1983-1997 were obtained from the National Transportation Safety Board (NTSB) by matching name and date of birth. NTSB's investigation reports were reviewed to identify pilot errors and other contributing factors. Comparisons of crash circumstances and human factors were made between pilots aged 40-49 yr and pilots aged 50-63 yr. A total of 165 crash records were studied, with 52% of these crashes involving pilots aged 50-63 yr. Crash circumstances, such as time and location of crash, type and phase of flight, and weather conditions, were similar between the two age groups. Pilot error was a contributing factor in 73% of the crashes involving younger pilots and in 69% of the crashes involving older pilots (p = 0.50). Age-related differences in the pattern of pilot errors were statistically insignificant. Overall, 23% of pilot errors were attributable to inattentiveness, 20% to flawed decisions, 18% to mishandled aircraft kinetics, and 18% to mishandled wind/runway conditions. Neither crash circumstances nor the prevalence and patterns of pilot errors appear to change significantly as age increases from the 40s to the 50s and early 60s.
Using APEX to Model Anticipated Human Error: Analysis of a GPS Navigational Aid
NASA Technical Reports Server (NTRS)
VanSelst, Mark; Freed, Michael; Shefto, Michael (Technical Monitor)
1997-01-01
The interface development process can be dramatically improved by predicting design facilitated human error at an early stage in the design process. The approach we advocate is to SIMULATE the behavior of a human agent carrying out tasks with a well-specified user interface, ANALYZE the simulation for instances of human error, and then REFINE the interface or protocol to minimize predicted error. This approach, incorporated into the APEX modeling architecture, differs from past approaches to human simulation in Its emphasis on error rather than e.g. learning rate or speed of response. The APEX model consists of two major components: (1) a powerful action selection component capable of simulating behavior in complex, multiple-task environments; and (2) a resource architecture which constrains cognitive, perceptual, and motor capabilities to within empirically demonstrated limits. The model mimics human errors arising from interactions between limited human resources and elements of the computer interface whose design falls to anticipate those limits. We analyze the design of a hand-held Global Positioning System (GPS) device used for radical and navigational decisions in small yacht recalls. The analysis demonstrates how human system modeling can be an effective design aid, helping to accelerate the process of refining a product (or procedure).
Accurate typing of short tandem repeats from genome-wide sequencing data and its applications.
Fungtammasan, Arkarachai; Ananda, Guruprasad; Hile, Suzanne E; Su, Marcia Shu-Wei; Sun, Chen; Harris, Robert; Medvedev, Paul; Eckert, Kristin; Makova, Kateryna D
2015-05-01
Short tandem repeats (STRs) are implicated in dozens of human genetic diseases and contribute significantly to genome variation and instability. Yet profiling STRs from short-read sequencing data is challenging because of their high sequencing error rates. Here, we developed STR-FM, short tandem repeat profiling using flank-based mapping, a computational pipeline that can detect the full spectrum of STR alleles from short-read data, can adapt to emerging read-mapping algorithms, and can be applied to heterogeneous genetic samples (e.g., tumors, viruses, and genomes of organelles). We used STR-FM to study STR error rates and patterns in publicly available human and in-house generated ultradeep plasmid sequencing data sets. We discovered that STRs sequenced with a PCR-free protocol have up to ninefold fewer errors than those sequenced with a PCR-containing protocol. We constructed an error correction model for genotyping STRs that can distinguish heterozygous alleles containing STRs with consecutive repeat numbers. Applying our model and pipeline to Illumina sequencing data with 100-bp reads, we could confidently genotype several disease-related long trinucleotide STRs. Utilizing this pipeline, for the first time we determined the genome-wide STR germline mutation rate from a deeply sequenced human pedigree. Additionally, we built a tool that recommends minimal sequencing depth for accurate STR genotyping, depending on repeat length and sequencing read length. The required read depth increases with STR length and is lower for a PCR-free protocol. This suite of tools addresses the pressing challenges surrounding STR genotyping, and thus is of wide interest to researchers investigating disease-related STRs and STR evolution. © 2015 Fungtammasan et al.; Published by Cold Spring Harbor Laboratory Press.
Li, Yuanyuan; Tollefsbol, Trygve O
2016-01-01
Aging is considered as one of the most important developmental processes in organisms and is closely associated with global deteriorations of epigenetic markers such as aberrant methylomic patterns. This altered epigenomic state, referred to ‘epigenetic drift’, reflects deficient maintenance of epigenetic marks and contributes to impaired cellular and molecular functions in aged cells. Epigenetic drift-induced abnormal changes during aging are scantily repaired by epigenetic modulators. This inflexibility in the aged epigenome may lead to an age-related decline in phenotypic plasticity at the cellular and molecular levels due to epigenetic drift. This perspective aims to provide novel concepts for understanding epigenetic effects on the aging process and to provide insights into epigenetic prevention and therapeutic strategies for age-related human disease. PMID:27882781
2012-08-01
additional threats and errors in the corresponding form. Make sure your handwriting is legible. Keep a n ope n mind, eve n if you feel pe ople are doing...observation form. Write on additional threats and errors. Make sure your handwriting is legible. On a piece of bla nk pa per, you m ay want to m...to see a briefing report on this round of LOSA in a month. The report does not contain any identifiable information. In fact, it does not say
Sensitivity to prediction error in reach adaptation
Haith, Adrian M.; Harran, Michelle D.; Shadmehr, Reza
2012-01-01
It has been proposed that the brain predicts the sensory consequences of a movement and compares it to the actual sensory feedback. When the two differ, an error signal is formed, driving adaptation. How does an error in one trial alter performance in the subsequent trial? Here we show that the sensitivity to error is not constant but declines as a function of error magnitude. That is, one learns relatively less from large errors compared with small errors. We performed an experiment in which humans made reaching movements and randomly experienced an error in both their visual and proprioceptive feedback. Proprioceptive errors were created with force fields, and visual errors were formed by perturbing the cursor trajectory to create a visual error that was smaller, the same size, or larger than the proprioceptive error. We measured single-trial adaptation and calculated sensitivity to error, i.e., the ratio of the trial-to-trial change in motor commands to error size. We found that for both sensory modalities sensitivity decreased with increasing error size. A reanalysis of a number of previously published psychophysical results also exhibited this feature. Finally, we asked how the brain might encode sensitivity to error. We reanalyzed previously published probabilities of cerebellar complex spikes (CSs) and found that this probability declined with increasing error size. From this we posit that a CS may be representative of the sensitivity to error, and not error itself, a hypothesis that may explain conflicting reports about CSs and their relationship to error. PMID:22773782
Implementation of a critical incident reporting system in a neurosurgical department.
Kantelhardt, P; Müller, M; Giese, A; Rohde, V; Kantelhardt, S R
2011-02-01
Critical incident monitoring is an important tool for quality improvement and the maintenance of high safety standards. It was developed for aviation safety and is now widely accepted as a useful tool to reduce medical care-related morbidity and mortality. Despite this widespread acceptance, the literature has no reports on any neurosurgical applications of critical incident monitoring. We describe the introduction of a mono-institutional critical incident reporting system in a neurosurgical department. Furthermore, we have developed a formula to assess possible counterstrategies. All staff members of a neurosurgical department were advised to report critical incidents. The anonymous reporting form contained a box for the description of the incident, several multiple-choice questions on specific risk factors, place and reason for occurrence of the incident, severity of the consequences and suggested counterstrategies. The incident data was entered into an online documentation system (ADKA DokuPik) and evaluated by an external specialist. For data analysis we applied a modified assessment scheme initially designed for flight safety. Data collection was started in September 2008. The average number of reported incidents was 18 per month (currently 216 in total). Most incidents occurred on the neurosurgical ward (64%). Human error was involved in 86% of the reported incidents. The largest group of incidents consisted of medication-related problems. Accordingly, counterstrategies were developed, resulting in a decrease in the relative number of reported medication-related incidents from 42% (March 09) to 30% (September 09). Implementation of the critical incident reporting system presented no technical problems. The reporting rate was high compared to that reported in the current literature. The formulation, evaluation and introduction of specific counterstrategies to guard against selected groups of incidents may improve patient safety in neurosurgical departments. © Georg Thieme Verlag KG Stuttgart · New York.
25 CFR 170.804 - How is BIA's Road Maintenance Program related to the IRR Program?
Code of Federal Regulations, 2010 CFR
2010-04-01
... 25 Indians 1 2010-04-01 2010-04-01 false How is BIA's Road Maintenance Program related to the IRR... WATER INDIAN RESERVATION ROADS PROGRAM BIA Road Maintenance § 170.804 How is BIA's Road Maintenance Program related to the IRR Program? The following chart illustrates how BIA's Road Maintenance Program is...
45 CFR 1357.30 - State fiscal requirements (title IV-B, subpart 1, child welfare services).
Code of Federal Regulations, 2013 CFR
2013-10-01
... match the title IV-B, subpart 1 allotment may include foster care maintenance expenditures in any amount... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND...
45 CFR 1357.30 - State fiscal requirements (title IV-B, subpart 1, child welfare services).
Code of Federal Regulations, 2012 CFR
2012-10-01
... match the title IV-B, subpart 1 allotment may include foster care maintenance expenditures in any amount... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND...
45 CFR 1357.30 - State fiscal requirements (title IV-B, subpart 1, child welfare services).
Code of Federal Regulations, 2010 CFR
2010-10-01
... match the title IV-B, subpart 1 allotment may include foster care maintenance expenditures in any amount... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND...
45 CFR 1357.30 - State fiscal requirements (title IV-B, subpart 1, child welfare services).
Code of Federal Regulations, 2011 CFR
2011-10-01
... match the title IV-B, subpart 1 allotment may include foster care maintenance expenditures in any amount... (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND...
Effects of noise on the performance of a memory decision response task
NASA Technical Reports Server (NTRS)
Lawton, B. W.
1972-01-01
An investigation has been made to determine the effects of noise on human performance. Fourteen subjects performed a memory-decision-response task in relative quiet and while listening to tape recorded noises. Analysis of the data obtained indicates that performance was degraded in the presence of noise. Significant increases in problem solution times were found for impulsive noise conditions as compared with times found for the no-noise condition. Performance accuracy was also degraded. Significantly more error responses occurred at higher noise levels; a direct or positive relation was found between error responses and noise level experienced by the subjects.
An Analysis of the Waste Water Treatment Operator Occupation.
ERIC Educational Resources Information Center
Clark, Anthony B.; And Others
The occupational analysis contains a brief job description for the waste water treatment occupations of operator and maintenance mechanic and 13 detailed task statements which specify job duties (tools, equipment, materials, objects acted upon, performance knowledge, safety considerations/hazards, decisions, cues, and errors) and learning skills…
EOS Aqua Mission Status at Earth Science Constellation MOWG Meeting @ LASP April 13, 2016
NASA Technical Reports Server (NTRS)
Guit, William J.
2016-01-01
This presentation reflects the EOS Aqua mission status, spacecraft subsystem summary, recent and planned activities, inclination adjust maneuvers, propellant usage and lifetime estimate, orbital maintenance maneuvers, conjunction assessment high interest events, ground track error, spacecraft orbital parameters trends and predictions.
Cognition in Space Workshop. 1; Metrics and Models
NASA Technical Reports Server (NTRS)
Woolford, Barbara; Fielder, Edna
2005-01-01
"Cognition in Space Workshop I: Metrics and Models" was the first in a series of workshops sponsored by NASA to develop an integrated research and development plan supporting human cognition in space exploration. The workshop was held in Chandler, Arizona, October 25-27, 2004. The participants represented academia, government agencies, and medical centers. This workshop addressed the following goal of the NASA Human System Integration Program for Exploration: to develop a program to manage risks due to human performance and human error, specifically ones tied to cognition. Risks range from catastrophic error to degradation of efficiency and failure to accomplish mission goals. Cognition itself includes memory, decision making, initiation of motor responses, sensation, and perception. Four subgoals were also defined at the workshop as follows: (1) NASA needs to develop a human-centered design process that incorporates standards for human cognition, human performance, and assessment of human interfaces; (2) NASA needs to identify and assess factors that increase risks associated with cognition; (3) NASA needs to predict risks associated with cognition; and (4) NASA needs to mitigate risk, both prior to actual missions and in real time. This report develops the material relating to these four subgoals.
Online Deviation Detection for Medical Processes
Christov, Stefan C.; Avrunin, George S.; Clarke, Lori A.
2014-01-01
Human errors are a major concern in many medical processes. To help address this problem, we are investigating an approach for automatically detecting when performers of a medical process deviate from the acceptable ways of performing that process as specified by a detailed process model. Such deviations could represent errors and, thus, detecting and reporting deviations as they occur could help catch errors before harm is done. In this paper, we identify important issues related to the feasibility of the proposed approach and empirically evaluate the approach for two medical procedures, chemotherapy and blood transfusion. For the evaluation, we use the process models to generate sample process executions that we then seed with synthetic errors. The process models describe the coordination of activities of different process performers in normal, as well as in exceptional situations. The evaluation results suggest that the proposed approach could be applied in clinical settings to help catch errors before harm is done. PMID:25954343
Hughes, Charmayne M L; Baber, Chris; Bienkiewicz, Marta; Worthington, Andrew; Hazell, Alexa; Hermsdörfer, Joachim
2015-01-01
Approximately 33% of stroke patients have difficulty performing activities of daily living, often committing errors during the planning and execution of such activities. The objective of this study was to evaluate the ability of the human error identification (HEI) technique SHERPA (Systematic Human Error Reduction and Prediction Approach) to predict errors during the performance of daily activities in stroke patients with left and right hemisphere lesions. Using SHERPA we successfully predicted 36 of the 38 observed errors, with analysis indicating that the proportion of predicted and observed errors was similar for all sub-tasks and severity levels. HEI results were used to develop compensatory cognitive strategies that clinicians could employ to reduce or prevent errors from occurring. This study provides evidence for the reliability and validity of SHERPA in the design of cognitive rehabilitation strategies in stroke populations.
2010-03-15
Swiss cheese model of human error causation. ................................................................... 3 2. Results for the classification of...based on Reason’s “ Swiss cheese ” model of human error (1990). Figure 1 describes how an accident is likely to occur when all of the errors, or “holes...align. A detailed description of HFACS can be found in Wiegmann and Shappell (2003). Figure 1. The Swiss cheese model of human error
Social deviance activates the brain's error-monitoring system.
Kim, Bo-Rin; Liss, Alison; Rao, Monica; Singer, Zachary; Compton, Rebecca J
2012-03-01
Social psychologists have long noted the tendency for human behavior to conform to social group norms. This study examined whether feedback indicating that participants had deviated from group norms would elicit a neural signal previously shown to be elicited by errors and monetary losses. While electroencephalograms were recorded, participants (N = 30) rated the attractiveness of 120 faces and received feedback giving the purported average rating made by a group of peers. The feedback was manipulated so that group ratings either were the same as a participant's rating or deviated by 1, 2, or 3 points. Feedback indicating deviance from the group norm elicited a feedback-related negativity, a brainwave signal known to be elicited by objective performance errors and losses. The results imply that the brain treats deviance from social norms as an error.
Human-simulation-based learning to prevent medication error: A systematic review.
Sarfati, Laura; Ranchon, Florence; Vantard, Nicolas; Schwiertz, Vérane; Larbre, Virginie; Parat, Stéphanie; Faudel, Amélie; Rioufol, Catherine
2018-01-31
In the past 2 decades, there has been an increasing interest in simulation-based learning programs to prevent medication error (ME). To improve knowledge, skills, and attitudes in prescribers, nurses, and pharmaceutical staff, these methods enable training without directly involving patients. However, best practices for simulation for healthcare providers are as yet undefined. By analysing the current state of experience in the field, the present review aims to assess whether human simulation in healthcare helps to reduce ME. A systematic review was conducted on Medline from 2000 to June 2015, associating the terms "Patient Simulation," "Medication Errors," and "Simulation Healthcare." Reports of technology-based simulation were excluded, to focus exclusively on human simulation in nontechnical skills learning. Twenty-one studies assessing simulation-based learning programs were selected, focusing on pharmacy, medicine or nursing students, or concerning programs aimed at reducing administration or preparation errors, managing crises, or learning communication skills for healthcare professionals. The studies varied in design, methodology, and assessment criteria. Few demonstrated that simulation was more effective than didactic learning in reducing ME. This review highlights a lack of long-term assessment and real-life extrapolation, with limited scenarios and participant samples. These various experiences, however, help in identifying the key elements required for an effective human simulation-based learning program for ME prevention: ie, scenario design, debriefing, and perception assessment. The performance of these programs depends on their ability to reflect reality and on professional guidance. Properly regulated simulation is a good way to train staff in events that happen only exceptionally, as well as in standard daily activities. By integrating human factors, simulation seems to be effective in preventing iatrogenic risk related to ME, if the program is well designed. © 2018 John Wiley & Sons, Ltd.
Lee, Michael; Hills, Mark; Conomos, Dimitri; Stutz, Michael D.; Dagg, Rebecca A.; Lau, Loretta M.S.; Reddel, Roger R.; Pickett, Hilda A.
2014-01-01
Telomeres are terminal repetitive DNA sequences on chromosomes, and are considered to comprise almost exclusively hexameric TTAGGG repeats. We have evaluated telomere sequence content in human cells using whole-genome sequencing followed by telomere read extraction in a panel of mortal cell strains and immortal cell lines. We identified a wide range of telomere variant repeats in human cells, and found evidence that variant repeats are generated by mechanistically distinct processes during telomerase- and ALT-mediated telomere lengthening. Telomerase-mediated telomere extension resulted in biased repeat synthesis of variant repeats that differed from the canonical sequence at positions 1 and 3, but not at positions 2, 4, 5 or 6. This indicates that telomerase is most likely an error-prone reverse transcriptase that misincorporates nucleotides at specific positions on the telomerase RNA template. In contrast, cell lines that use the ALT pathway contained a large range of variant repeats that varied greatly between lines. This is consistent with variant repeats spreading from proximal telomeric regions throughout telomeres in a stochastic manner by recombination-mediated templating of DNA synthesis. The presence of unexpectedly large numbers of variant repeats in cells utilizing either telomere maintenance mechanism suggests a conserved role for variant sequences at human telomeres. PMID:24225324
A Quality Improvement Project to Decrease Human Milk Errors in the NICU.
Oza-Frank, Reena; Kachoria, Rashmi; Dail, James; Green, Jasmine; Walls, Krista; McClead, Richard E
2017-02-01
Ensuring safe human milk in the NICU is a complex process with many potential points for error, of which one of the most serious is administration of the wrong milk to the wrong infant. Our objective was to describe a quality improvement initiative that was associated with a reduction in human milk administration errors identified over a 6-year period in a typical, large NICU setting. We employed a quasi-experimental time series quality improvement initiative by using tools from the model for improvement, Six Sigma methodology, and evidence-based interventions. Scanned errors were identified from the human milk barcode medication administration system. Scanned errors of interest were wrong-milk-to-wrong-infant, expired-milk, or preparation errors. The scanned error rate and the impact of additional improvement interventions from 2009 to 2015 were monitored by using statistical process control charts. From 2009 to 2015, the total number of errors scanned declined from 97.1 per 1000 bottles to 10.8. Specifically, the number of expired milk error scans declined from 84.0 per 1000 bottles to 8.9. The number of preparation errors (4.8 per 1000 bottles to 2.2) and wrong-milk-to-wrong-infant errors scanned (8.3 per 1000 bottles to 2.0) also declined. By reducing the number of errors scanned, the number of opportunities for errors also decreased. Interventions that likely had the greatest impact on reducing the number of scanned errors included installation of bedside (versus centralized) scanners and dedicated staff to handle milk. Copyright © 2017 by the American Academy of Pediatrics.
Diver Relative UUV Navigation for Joint Human-Robot Operations
2013-09-01
loop response: (10) where Kej is the gain that scales the position error to force . Substituting the measured values for ζ and ων as well as the...Underwater Vehicle; Tethered ; Hovering; Autonomous Underwater Vehicle; Joint human-robot operations; dynamic, uncertain environments 15. NUMBER OF PAGES...4 Figure 3. The SeaBotix vLBV300 tethered AUV platform (left), and the planar vectored thruster
The AMPK-related kinase SNARK regulates muscle mass and myocyte survival
Lessard, Sarah J.; Rivas, Donato A.; So, Kawai; Koh, Ho-Jin; Queiroz, André Lima; Hirshman, Michael F.; Fielding, Roger A.; Goodyear, Laurie J.
2015-01-01
The maintenance of skeletal muscle mass is critical for sustaining health; however, the mechanisms responsible for muscle loss with aging and chronic diseases, such as diabetes and obesity, are poorly understood. We found that expression of a member of the AMPK-related kinase family, the SNF1-AMPK-related kinase (SNARK, also known as NUAK2), increased with muscle cell differentiation. SNARK expression increased in skeletal muscles from young mice exposed to metabolic stress and in muscles from healthy older human subjects. The regulation of SNARK expression in muscle with differentiation and physiological stress suggests that SNARK may function in the maintenance of muscle mass. Consistent with this hypothesis, decreased endogenous SNARK expression (using siRNA) in cultured muscle cells resulted in increased apoptosis and decreased cell survival under conditions of metabolic stress. Likewise, muscle-specific transgenic animals expressing a SNARK dominant-negative inactive mutant (SDN) had increased myonuclear apoptosis and activation of apoptotic mediators in muscle. Moreover, animals expressing SDN had severe, age-accelerated muscle atrophy and increased adiposity, consistent with sarcopenic obesity. Reduced SNARK activity, in vivo and in vitro, caused downregulation of the Rho kinase signaling pathway, a key mediator of cell survival. These findings reveal a critical role for SNARK in myocyte survival and the maintenance of muscle mass with age. PMID:26690705
Reinhart, Robert M G; Zhu, Julia; Park, Sohee; Woodman, Geoffrey F
2015-09-02
Posterror learning, associated with medial-frontal cortical recruitment in healthy subjects, is compromised in neuropsychiatric disorders. Here we report novel evidence for the mechanisms underlying learning dysfunctions in schizophrenia. We show that, by noninvasively passing direct current through human medial-frontal cortex, we could enhance the event-related potential related to learning from mistakes (i.e., the error-related negativity), a putative index of prediction error signaling in the brain. Following this causal manipulation of brain activity, the patients learned a new task at a rate that was indistinguishable from healthy individuals. Moreover, the severity of delusions interacted with the efficacy of the stimulation to improve learning. Our results demonstrate a causal link between disrupted prediction error signaling and inefficient learning in schizophrenia. These findings also demonstrate the feasibility of nonpharmacological interventions to address cognitive deficits in neuropsychiatric disorders. When there is a difference between what we expect to happen and what we actually experience, our brains generate a prediction error signal, so that we can map stimuli to responses and predict outcomes accurately. Theories of schizophrenia implicate abnormal prediction error signaling in the cognitive deficits of the disorder. Here, we combine noninvasive brain stimulation with large-scale electrophysiological recordings to establish a causal link between faulty prediction error signaling and learning deficits in schizophrenia. We show that it is possible to improve learning rate, as well as the neural signature of prediction error signaling, in patients to a level quantitatively indistinguishable from that of healthy subjects. The results provide mechanistic insight into schizophrenia pathophysiology and suggest a future therapy for this condition. Copyright © 2015 the authors 0270-6474/15/3512232-09$15.00/0.
NASA Astrophysics Data System (ADS)
Belkhode, Pramod Namdeorao
2017-06-01
Field data based model is proposed to reduce the overhauling time and human energy consumed in liner piston maintenance activity so as to increase the productivity of liner piston maintenance activity. The independent variables affecting the phenomenon such as anthropometric parameters of workers (Eastman Kodak Co. Ltd in Section VIA Appendix-A: Anthropometric Data. Ergonomic Design for People at Work, Van Nostrans Reinhold, New York, 1), workers parameters, specification of liner piston data, specification of tools used in liner piston maintenance activity, specification of solvents, axial clearance of big end bearing and bolt elongation, workstation data (Eastman Kodak Co. Ltd in Work Place Ergonomic Design for People at Work, Van Nostrans Reinhold, New York, 2) and extraneous variables, namely, temperature, humidity at workplace, illumination at workplace and noise at workplace (Eastman Kodak Co. Ltd in Chapter V Environment Ergonomic Design for People at Work, Van Nostrans Reinhold, New York, 3) are taken into account. The model is formulated for dependent variables of liner piston maintenance activity to minimize the overhauling time and human energy consumption so as to improve the productivity of liner piston maintenance activity. The developed model can predict the performance of liner piston maintenance activity which involves man and machine system (Schenck in Theories of Engineering Experimentation, Mc-Graw Hill, New York 4). The model is then optimized by optimization technique and the sensitivity analysis of the model has also been estimated.
Human errors and measurement uncertainty
NASA Astrophysics Data System (ADS)
Kuselman, Ilya; Pennecchi, Francesca
2015-04-01
Evaluating the residual risk of human errors in a measurement and testing laboratory, remaining after the error reduction by the laboratory quality system, and quantifying the consequences of this risk for the quality of the measurement/test results are discussed based on expert judgments and Monte Carlo simulations. A procedure for evaluation of the contribution of the residual risk to the measurement uncertainty budget is proposed. Examples are provided using earlier published sets of expert judgments on human errors in pH measurement of groundwater, elemental analysis of geological samples by inductively coupled plasma mass spectrometry, and multi-residue analysis of pesticides in fruits and vegetables. The human error contribution to the measurement uncertainty budget in the examples was not negligible, yet also not dominant. This was assessed as a good risk management result.
Lisa J. Bate; Michael J. Wisdom; Barbara C. Wales
2007-01-01
A key element of forest management is the maintenance of sufficient densities of snags (standing dead trees) to support associated wildlife. Management factors that influence snag densities, however, are numerous and complex. Consequently, accurate methods to estimate and model snag densities are needed. Using data collected in 2002 and Current Vegetation Survey (CVS)...
Do Cows Belong in Nature? The Cultural Basis of Agriculture in Sweden and Australia
ERIC Educational Resources Information Center
Saltzman, Katarina; Head, Lesley; Stenseke, Marie
2011-01-01
Within the now extensive recent literature on cultures of nature, agriculture has received less attention than might have been expected given its threshold role in transforming human relations with the earth and with plants and animals. The concept and practice of agriculture can be understood as central to the emergence and maintenance of the…
DOT National Transportation Integrated Search
2001-02-01
The Human Factors Analysis and Classification System (HFACS) is a general human error framework : originally developed and tested within the U.S. military as a tool for investigating and analyzing the human : causes of aviation accidents. Based upon ...
Space station proximity operations windows: Human factors design guidelines
NASA Technical Reports Server (NTRS)
Haines, Richard F.
1987-01-01
Proximity operations refers to all activities outside the Space Station which take place within a 1-km radius. Since there will be a large number of different operations involving manned and unmanned vehicles, single- and multiperson crews, automated and manually controlled flight, a wide variety of cargo, and construction/repair activities, accurate and continuous human monitoring of these operations from a specially designed control station on Space Station will be required. Total situational awareness will be required. This paper presents numerous human factors design guidelines and related background information for control windows which will support proximity operations. Separate sections deal with natural and artificial illumination geometry; all basic rendezvous vector approaches; window field-of-view requirements; window size; shape and placement criteria; window optical characteristics as they relate to human perception; maintenance and protection issues; and a comprehensive review of windows installed on U.S. and U.S.S.R. manned vehicles.
Using model order tests to determine sensory inputs in a motion study
NASA Technical Reports Server (NTRS)
Repperger, D. W.; Junker, A. M.
1977-01-01
In the study of motion effects on tracking performance, a problem of interest is the determination of what sensory inputs a human uses in controlling his tracking task. In the approach presented here a simple canonical model (FID or a proportional, integral, derivative structure) is used to model the human's input-output time series. A study of significant changes in reduction of the output error loss functional is conducted as different permutations of parameters are considered. Since this canonical model includes parameters which are related to inputs to the human (such as the error signal, its derivatives and integration), the study of model order is equivalent to the study of which sensory inputs are being used by the tracker. The parameters are obtained which have the greatest effect on reducing the loss function significantly. In this manner the identification procedure converts the problem of testing for model order into the problem of determining sensory inputs.
40 CFR 1066.235 - Speed verification procedure.
Code of Federal Regulations, 2012 CFR
2012-07-01
... before testing, and after major maintenance. (c) Procedure. Use one of the following procedures to verify... dynamometer control circuits. Determine the speed error as follows: (i) Set the dynamometer to speed-control mode. Set the dynamometer speed to a value between 4.2 m/s and the maximum speed expected during...
Code of Federal Regulations, 2013 CFR
2013-01-01
...) Credit means the right granted by a creditor to an applicant to defer payment of a debt, incur debt and defer its payment, or purchase property or services and defer payment therefor. (k) Credit card means... notwithstanding the maintenance of procedures reasonably adapted to avoid such errors. (t) Judgmental system of...
Code of Federal Regulations, 2011 CFR
2011-01-01
...) Credit means the right granted by a creditor to an applicant to defer payment of a debt, incur debt and defer its payment, or purchase property or services and defer payment therefor. (k) Credit card means... notwithstanding the maintenance of procedures reasonably adapted to avoid such errors. (t) Judgmental system of...
Code of Federal Regulations, 2014 CFR
2014-01-01
...) Credit means the right granted by a creditor to an applicant to defer payment of a debt, incur debt and defer its payment, or purchase property or services and defer payment therefor. (k) Credit card means... notwithstanding the maintenance of procedures reasonably adapted to avoid such errors. (t) Judgmental system of...
Van de Vreede, Melita; McGrath, Anne; de Clifford, Jan
2018-05-14
Objective. The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods. Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results. There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Conclusions. Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.
Ultra Reliable Closed Loop Life Support for Long Space Missions
NASA Technical Reports Server (NTRS)
Jones, Harry W.; Ewert, Michael K.
2010-01-01
Spacecraft human life support systems can achieve ultra reliability by providing sufficient spares to replace all failed components. The additional mass of spares for ultra reliability is approximately equal to the original system mass, provided that the original system reliability is not too low. Acceptable reliability can be achieved for the Space Shuttle and Space Station by preventive maintenance and by replacing failed units. However, on-demand maintenance and repair requires a logistics supply chain in place to provide the needed spares. In contrast, a Mars or other long space mission must take along all the needed spares, since resupply is not possible. Long missions must achieve ultra reliability, a very low failure rate per hour, since they will take years rather than weeks and cannot be cut short if a failure occurs. Also, distant missions have a much higher mass launch cost per kilogram than near-Earth missions. Achieving ultra reliable spacecraft life support systems with acceptable mass will require a well-planned and extensive development effort. Analysis must determine the reliability requirement and allocate it to subsystems and components. Ultra reliability requires reducing the intrinsic failure causes, providing spares to replace failed components and having "graceful" failure modes. Technologies, components, and materials must be selected and designed for high reliability. Long duration testing is needed to confirm very low failure rates. Systems design should segregate the failure causes in the smallest, most easily replaceable parts. The system must be designed, developed, integrated, and tested with system reliability in mind. Maintenance and reparability of failed units must not add to the probability of failure. The overall system must be tested sufficiently to identify any design errors. A program to develop ultra reliable space life support systems with acceptable mass should start soon since it must be a long term effort.
2018-01-01
Reports an error in "Facing Humanness: Facial Width-to-Height Ratio Predicts Ascriptions of Humanity" by Jason C. Deska, E. Paige Lloyd and Kurt Hugenberg ( Journal of Personality and Social Psychology , Advanced Online Publication, Aug 28, 2017, np). In the article, there is a data error in the Results section of Study 1c. The fourth sentence of the fourth paragraph should read as follows: High fWHR targets (M= 74.39, SD=18.25) were rated as equivalently evolved as their low fWHR counterparts (M=79.39, SD=15.91). (The following abstract of the original article appeared in record 2017-36694-001.) The ascription of mind to others is central to social cognition. Most research on the ascription of mind has focused on motivated, top-down processes. The current work provides novel evidence that facial width-to-height ratio (fWHR) serves as a bottom-up perceptual signal of humanness. Using a range of well-validated operational definitions of humanness, we provide evidence across 5 studies that target faces with relatively greater fWHR are seen as less than fully human compared with their relatively lower fWHR counterparts. We then present 2 ancillary studies exploring whether the fWHR-to-humanness link is mediated by previously established fWHR-trait links in the literature. Finally, 3 additional studies extend this fWHR-humanness link beyond measurements of humanness, demonstrating that the fWHR-humanness link has consequences for downstream social judgments including the sorts of crimes people are perceived to be guilty of and the social tasks for which they seem helpful. In short, we provide evidence for the hypothesis that individuals with relatively greater facial width-to-height ratio are routinely denied sophisticated, humanlike minds. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
22 CFR 120.38 - Maintenance levels.
Code of Federal Regulations, 2014 CFR
2014-04-01
... 22 Foreign Relations 1 2014-04-01 2014-04-01 false Maintenance levels. 120.38 Section 120.38 Foreign Relations DEPARTMENT OF STATE INTERNATIONAL TRAFFIC IN ARMS REGULATIONS PURPOSE AND DEFINITIONS § 120.38 Maintenance levels. (a) Organizational-level maintenance (or basic-level maintenance) is the...
Moissl-Eichinger, Christine; Auerbach, Anna K.; Probst, Alexander J.; ...
2015-03-17
Space agencies maintain highly controlled cleanrooms to ensure the demands of planetary protection. To study potential effects of microbiome control, we analyzed microbial communities in two particulate-controlled cleanrooms (ISO 5 and ISO 8) and two vicinal uncontrolled areas (office, changing room) by cultivation and 16S rRNA gene amplicon analysis (cloning, pyrotagsequencing, and PhyloChip G3 analysis). Maintenance procedures affected the microbiome on total abundance and microbial community structure concerning richness, diversity and relative abundance of certain taxa. Cleanroom areas were found to be mainly predominated by potentially human-associated bacteria; archaeal signatures were detected in every area. Results indicate that microorganisms weremore » mainly spread from the changing room (68%) into the cleanrooms, potentially carried along with human activity. The numbers of colony forming units were reduced by up to ~400 fold from the uncontrolled areas towards the ISO 5 cleanroom, accompanied with a reduction of the living portion of microorganisms from 45% (changing area) to 1% of total 16S rRNA gene signatures as revealed via propidium monoazide treatment of the samples. Our results demonstrate the strong effects of cleanroom maintenance on microbial communities in indoor environments and can be used to improve the design and operation of biologically controlled cleanrooms.« less
Moissl-Eichinger, Christine; Auerbach, Anna K.; Probst, Alexander J.; Mahnert, Alexander; Tom, Lauren; Piceno, Yvette; Andersen, Gary L.; Venkateswaran, Kasthuri; Rettberg, Petra; Barczyk, Simon; Pukall, Rüdiger; Berg, Gabriele
2015-01-01
Space agencies maintain highly controlled cleanrooms to ensure the demands of planetary protection. To study potential effects of microbiome control, we analyzed microbial communities in two particulate-controlled cleanrooms (ISO 5 and ISO 8) and two vicinal uncontrolled areas (office, changing room) by cultivation and 16S rRNA gene amplicon analysis (cloning, pyrotagsequencing, and PhyloChip G3 analysis). Maintenance procedures affected the microbiome on total abundance and microbial community structure concerning richness, diversity and relative abundance of certain taxa. Cleanroom areas were found to be mainly predominated by potentially human-associated bacteria; archaeal signatures were detected in every area. Results indicate that microorganisms were mainly spread from the changing room (68%) into the cleanrooms, potentially carried along with human activity. The numbers of colony forming units were reduced by up to ~400 fold from the uncontrolled areas towards the ISO 5 cleanroom, accompanied with a reduction of the living portion of microorganisms from 45% (changing area) to 1% of total 16S rRNA gene signatures as revealed via propidium monoazide treatment of the samples. Our results demonstrate the strong effects of cleanroom maintenance on microbial communities in indoor environments and can be used to improve the design and operation of biologically controlled cleanrooms. PMID:25778463
NASA Astrophysics Data System (ADS)
Moissl-Eichinger, Christine; Auerbach, Anna K.; Probst, Alexander J.; Mahnert, Alexander; Tom, Lauren; Piceno, Yvette; Andersen, Gary L.; Venkateswaran, Kasthuri; Rettberg, Petra; Barczyk, Simon; Pukall, Rüdiger; Berg, Gabriele
2015-03-01
Space agencies maintain highly controlled cleanrooms to ensure the demands of planetary protection. To study potential effects of microbiome control, we analyzed microbial communities in two particulate-controlled cleanrooms (ISO 5 and ISO 8) and two vicinal uncontrolled areas (office, changing room) by cultivation and 16S rRNA gene amplicon analysis (cloning, pyrotagsequencing, and PhyloChip G3 analysis). Maintenance procedures affected the microbiome on total abundance and microbial community structure concerning richness, diversity and relative abundance of certain taxa. Cleanroom areas were found to be mainly predominated by potentially human-associated bacteria; archaeal signatures were detected in every area. Results indicate that microorganisms were mainly spread from the changing room (68%) into the cleanrooms, potentially carried along with human activity. The numbers of colony forming units were reduced by up to ~400 fold from the uncontrolled areas towards the ISO 5 cleanroom, accompanied with a reduction of the living portion of microorganisms from 45% (changing area) to 1% of total 16S rRNA gene signatures as revealed via propidium monoazide treatment of the samples. Our results demonstrate the strong effects of cleanroom maintenance on microbial communities in indoor environments and can be used to improve the design and operation of biologically controlled cleanrooms.
Axelrod, David E; Vedula, Sudeepti; Obaniyi, James
2017-05-01
The effectiveness of cancer chemotherapy is limited by intra-tumor heterogeneity, the emergence of spontaneous and induced drug-resistant mutant subclones, and the maximum dose to which normal tissues can be exposed without adverse side effects. The goal of this project was to determine if intermittent schedules of the maximum dose that allows colon crypt maintenance could overcome these limitations, specifically by eliminating mixtures of drug-resistant mutants from heterogeneous early colon adenomas while maintaining colon crypt function. A computer model of cell dynamics in human colon crypts was calibrated with measurements of human biopsy specimens. The model allowed simulation of continuous and intermittent dose schedules of a cytotoxic chemotherapeutic drug, as well as the drug's effect on the elimination of mutant cells and the maintenance of crypt function. Colon crypts can tolerate a tenfold greater intermittent dose than constant dose. This allows elimination of a mixture of relatively drug-sensitive and drug-resistant mutant subclones from heterogeneous colon crypts. Mutants can be eliminated whether they arise spontaneously or are induced by the cytotoxic drug. An intermittent dose, at the maximum that allows colon crypt maintenance, can be effective in eliminating a heterogeneous mixture of mutant subclones before they fill the crypt and form an adenoma.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Moissl-Eichinger, Christine; Auerbach, Anna K.; Probst, Alexander J.
Space agencies maintain highly controlled cleanrooms to ensure the demands of planetary protection. To study potential effects of microbiome control, we analyzed microbial communities in two particulate-controlled cleanrooms (ISO 5 and ISO 8) and two vicinal uncontrolled areas (office, changing room) by cultivation and 16S rRNA gene amplicon analysis (cloning, pyrotagsequencing, and PhyloChip G3 analysis). Maintenance procedures affected the microbiome on total abundance and microbial community structure concerning richness, diversity and relative abundance of certain taxa. Cleanroom areas were found to be mainly predominated by potentially human-associated bacteria; archaeal signatures were detected in every area. Results indicate that microorganisms weremore » mainly spread from the changing room (68%) into the cleanrooms, potentially carried along with human activity. The numbers of colony forming units were reduced by up to ~400 fold from the uncontrolled areas towards the ISO 5 cleanroom, accompanied with a reduction of the living portion of microorganisms from 45% (changing area) to 1% of total 16S rRNA gene signatures as revealed via propidium monoazide treatment of the samples. Our results demonstrate the strong effects of cleanroom maintenance on microbial communities in indoor environments and can be used to improve the design and operation of biologically controlled cleanrooms.« less
10 CFR 712.38 - Maintenance of medical records.
Code of Federal Regulations, 2010 CFR
2010-01-01
... 10 Energy 4 2010-01-01 2010-01-01 false Maintenance of medical records. 712.38 Section 712.38 Energy DEPARTMENT OF ENERGY HUMAN RELIABILITY PROGRAM Medical Standards § 712.38 Maintenance of medical... medical record. The psychological record must: (1) Contain any clinical reports, test protocols and data...
Code of Federal Regulations, 2012 CFR
2012-04-01
... 21 Food and Drugs 4 2012-04-01 2012-04-01 false Maintenance. 211.58 Section 211.58 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS: GENERAL... Maintenance. Any building used in the manufacture, processing, packing, or holding of a drug product shall be...
Code of Federal Regulations, 2013 CFR
2013-04-01
... 21 Food and Drugs 4 2013-04-01 2013-04-01 false Maintenance. 211.58 Section 211.58 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS: GENERAL... Maintenance. Any building used in the manufacture, processing, packing, or holding of a drug product shall be...
Code of Federal Regulations, 2010 CFR
2010-04-01
... 21 Food and Drugs 4 2010-04-01 2010-04-01 false Maintenance. 211.58 Section 211.58 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS: GENERAL... Maintenance. Any building used in the manufacture, processing, packing, or holding of a drug product shall be...
Code of Federal Regulations, 2014 CFR
2014-04-01
... 21 Food and Drugs 4 2014-04-01 2014-04-01 false Maintenance. 211.58 Section 211.58 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS: GENERAL... Maintenance. Any building used in the manufacture, processing, packing, or holding of a drug product shall be...
Code of Federal Regulations, 2011 CFR
2011-04-01
... 21 Food and Drugs 4 2011-04-01 2011-04-01 false Maintenance. 211.58 Section 211.58 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS: GENERAL... Maintenance. Any building used in the manufacture, processing, packing, or holding of a drug product shall be...
45 CFR 96.134 - Maintenance of effort regarding State expenditures.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 1 2011-10-01 2011-10-01 false Maintenance of effort regarding State expenditures. 96.134 Section 96.134 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION BLOCK GRANTS Substance Abuse Prevention and Treatment Block Grant § 96.134 Maintenance of effort...
45 CFR 96.134 - Maintenance of effort regarding State expenditures.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 1 2014-10-01 2014-10-01 false Maintenance of effort regarding State expenditures. 96.134 Section 96.134 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION BLOCK GRANTS Substance Abuse Prevention and Treatment Block Grant § 96.134 Maintenance of effort...
45 CFR 96.134 - Maintenance of effort regarding State expenditures.
Code of Federal Regulations, 2013 CFR
2013-10-01
... 45 Public Welfare 1 2013-10-01 2013-10-01 false Maintenance of effort regarding State expenditures. 96.134 Section 96.134 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION BLOCK GRANTS Substance Abuse Prevention and Treatment Block Grant § 96.134 Maintenance of effort...
45 CFR 96.134 - Maintenance of effort regarding State expenditures.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 1 2012-10-01 2012-10-01 false Maintenance of effort regarding State expenditures. 96.134 Section 96.134 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION BLOCK GRANTS Substance Abuse Prevention and Treatment Block Grant § 96.134 Maintenance of effort...
10 CFR 712.38 - Maintenance of medical records.
Code of Federal Regulations, 2014 CFR
2014-01-01
... 10 Energy 4 2014-01-01 2014-01-01 false Maintenance of medical records. 712.38 Section 712.38 Energy DEPARTMENT OF ENERGY HUMAN RELIABILITY PROGRAM Medical Standards § 712.38 Maintenance of medical records. (a) The medical records of HRP candidates and HRP-certified individuals must be maintained in...
10 CFR 712.38 - Maintenance of medical records.
Code of Federal Regulations, 2012 CFR
2012-01-01
... 10 Energy 4 2012-01-01 2012-01-01 false Maintenance of medical records. 712.38 Section 712.38 Energy DEPARTMENT OF ENERGY HUMAN RELIABILITY PROGRAM Medical Standards § 712.38 Maintenance of medical records. (a) The medical records of HRP candidates and HRP-certified individuals must be maintained in...
42 CFR 124.510 - Record maintenance requirements.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 42 Public Health 1 2011-10-01 2011-10-01 false Record maintenance requirements. 124.510 Section 124.510 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH RESOURCES... Persons Unable To Pay § 124.510 Record maintenance requirements. (a) Facilities not certified under § 124...
42 CFR 124.510 - Record maintenance requirements.
Code of Federal Regulations, 2010 CFR
2010-10-01
... 42 Public Health 1 2010-10-01 2010-10-01 false Record maintenance requirements. 124.510 Section 124.510 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH RESOURCES... Persons Unable To Pay § 124.510 Record maintenance requirements. (a) Facilities not certified under § 124...
Software platform for managing the classification of error- related potentials of observers
NASA Astrophysics Data System (ADS)
Asvestas, P.; Ventouras, E.-C.; Kostopoulos, S.; Sidiropoulos, K.; Korfiatis, V.; Korda, A.; Uzunolglu, A.; Karanasiou, I.; Kalatzis, I.; Matsopoulos, G.
2015-09-01
Human learning is partly based on observation. Electroencephalographic recordings of subjects who perform acts (actors) or observe actors (observers), contain a negative waveform in the Evoked Potentials (EPs) of the actors that commit errors and of observers who observe the error-committing actors. This waveform is called the Error-Related Negativity (ERN). Its detection has applications in the context of Brain-Computer Interfaces. The present work describes a software system developed for managing EPs of observers, with the aim of classifying them into observations of either correct or incorrect actions. It consists of an integrated platform for the storage, management, processing and classification of EPs recorded during error-observation experiments. The system was developed using C# and the following development tools and frameworks: MySQL, .NET Framework, Entity Framework and Emgu CV, for interfacing with the machine learning library of OpenCV. Up to six features can be computed per EP recording per electrode. The user can select among various feature selection algorithms and then proceed to train one of three types of classifiers: Artificial Neural Networks, Support Vector Machines, k-nearest neighbour. Next the classifier can be used for classifying any EP curve that has been inputted to the database.
Certification for civil flight decks and the human-computer interface
NASA Technical Reports Server (NTRS)
Mcclumpha, Andrew J.; Rudisill, Marianne
1994-01-01
This paper will address the issue of human factor aspects of civil flight deck certification, with emphasis on the pilot's interface with automation. In particular, three questions will be asked that relate to this certification process: (1) are the methods, data, and guidelines available from human factors to adequately address the problems of certifying as safe and error tolerant the complex automated systems of modern civil transport aircraft; (2) do aircraft manufacturers effectively apply human factors information during the aircraft flight deck design process; and (3) do regulatory authorities effectively apply human factors information during the aircraft certification process?
Marathe, A R; Taylor, D M
2015-08-01
Decoding algorithms for brain-machine interfacing (BMI) are typically only optimized to reduce the magnitude of decoding errors. Our goal was to systematically quantify how four characteristics of BMI command signals impact closed-loop performance: (1) error magnitude, (2) distribution of different frequency components in the decoding errors, (3) processing delays, and (4) command gain. To systematically evaluate these different command features and their interactions, we used a closed-loop BMI simulator where human subjects used their own wrist movements to command the motion of a cursor to targets on a computer screen. Random noise with three different power distributions and four different relative magnitudes was added to the ongoing cursor motion in real time to simulate imperfect decoding. These error characteristics were tested with four different visual feedback delays and two velocity gains. Participants had significantly more trouble correcting for errors with a larger proportion of low-frequency, slow-time-varying components than they did with jittery, higher-frequency errors, even when the error magnitudes were equivalent. When errors were present, a movement delay often increased the time needed to complete the movement by an order of magnitude more than the delay itself. Scaling down the overall speed of the velocity command can actually speed up target acquisition time when low-frequency errors and delays are present. This study is the first to systematically evaluate how the combination of these four key command signal features (including the relatively-unexplored error power distribution) and their interactions impact closed-loop performance independent of any specific decoding method. The equations we derive relating closed-loop movement performance to these command characteristics can provide guidance on how best to balance these different factors when designing BMI systems. The equations reported here also provide an efficient way to compare a diverse range of decoding options offline.
NASA Astrophysics Data System (ADS)
Marathe, A. R.; Taylor, D. M.
2015-08-01
Objective. Decoding algorithms for brain-machine interfacing (BMI) are typically only optimized to reduce the magnitude of decoding errors. Our goal was to systematically quantify how four characteristics of BMI command signals impact closed-loop performance: (1) error magnitude, (2) distribution of different frequency components in the decoding errors, (3) processing delays, and (4) command gain. Approach. To systematically evaluate these different command features and their interactions, we used a closed-loop BMI simulator where human subjects used their own wrist movements to command the motion of a cursor to targets on a computer screen. Random noise with three different power distributions and four different relative magnitudes was added to the ongoing cursor motion in real time to simulate imperfect decoding. These error characteristics were tested with four different visual feedback delays and two velocity gains. Main results. Participants had significantly more trouble correcting for errors with a larger proportion of low-frequency, slow-time-varying components than they did with jittery, higher-frequency errors, even when the error magnitudes were equivalent. When errors were present, a movement delay often increased the time needed to complete the movement by an order of magnitude more than the delay itself. Scaling down the overall speed of the velocity command can actually speed up target acquisition time when low-frequency errors and delays are present. Significance. This study is the first to systematically evaluate how the combination of these four key command signal features (including the relatively-unexplored error power distribution) and their interactions impact closed-loop performance independent of any specific decoding method. The equations we derive relating closed-loop movement performance to these command characteristics can provide guidance on how best to balance these different factors when designing BMI systems. The equations reported here also provide an efficient way to compare a diverse range of decoding options offline.
Health-risk behaviors in agriculture and related factors, southeastern Anatolian region of Turkey.
Yavuz, Hasret; Simsek, Zeynep; Akbaba, Muhsin
2014-01-01
Human behavior plays a central role in the maintenance of health and the prevention of diseases. This study aimed to determine the risky behaviors of farm operators selected from a province of Turkey's southeastern Anatolian region, as well as the factors related to risky behaviors. In this cross-sectional analysis, 380 farm operators were enrolled through simple random selection method, and the response rate was 85%. Health-risk behavior was measured using the Control List of Occupational Risks in Agriculture. Of 323 farm operators, 85.4% were male. The prevalence of risky behaviors related to measures of environmental risks were higher in animal husbandry, transportation, transportation and maintenance of machinery, pesticide application, child protection, thermal stress, and psychosocial factors in the work place. Education, age, duration of work, and size of agricultural area were associated with risky behaviors in a multiple linear regression (P < .05). Findings showed that a certified training program and a behavior surveillance system for agriculture should be developed.
Meier, Matt E.; Kane, Michael J.
2015-01-01
Three experiments examined the relation between working memory capacity (WMC) and two different forms of cognitive conflict: stimulus-stimulus (S-S) and stimulus-response (SR) interference. Our goal was to test whether WMC’s relation to conflict-task performance is mediated by stimulus-identification processes (captured by S-S conflict), response-selection processes (captured by S-R conflict), or both. In Experiment 1, subjects completed a single task presenting both S-S and S-R conflict trials, plus trials that combined the two conflict types. We limited ostensible goal-maintenance contributions to performance by requiring the same goal for all trial types and by presenting frequent conflict trials that reinforced the goal. WMC predicted resolution of S-S conflict as expected: Higher-WMC subjects showed reduced response time interference. Although WMC also predicted S-R interference, here, higher-WMC subjects showed increased error interference. Experiment 2A replicated these results in a version of the conflict task without combined S-S/S-R trials. Experiment 2B increased the proportion of congruent (non-conflict) trials to promote reliance on goal-maintenance processes. Here, higher-WMC subjects resolved both S-S and S-R conflict more successfully than did lower-WMC subjects. The results were consistent with Kane and Engle’s (2003) two-factor theory of cognitive control, according to which WMC predicts executive-task performance through goal-maintenance and conflict-resolution processes. However, the present results add specificity to the account by suggesting that higher-WMC subjects better resolve cognitive conflict because they more efficiently select relevant stimulus features against irrelevant, distracting ones. PMID:26120774
Meier, Matt E; Kane, Michael J
2015-11-01
Three experiments examined the relation between working memory capacity (WMC) and 2 different forms of cognitive conflict: stimulus-stimulus (S-S) and stimulus-response (S-R) interference. Our goal was to test whether WMC's relation to conflict-task performance is mediated by stimulus-identification processes (captured by S-S conflict), response-selection processes (captured by S-R conflict), or both. In Experiment 1, subjects completed a single task presenting both S-S and S-R conflict trials, plus trials that combined the 2 conflict types. We limited ostensible goal-maintenance contributions to performance by requiring the same goal for all trial types and by presenting frequent conflict trials that reinforced the goal. WMC predicted resolution of S-S conflict as expected: Higher WMC subjects showed reduced response time interference. Although WMC also predicted S-R interference, here, higher WMC subjects showed increased error interference. Experiment 2A replicated these results in a version of the conflict task without combined S-S/S-R trials. Experiment 2B increased the proportion of congruent (nonconflict) trials to promote reliance on goal-maintenance processes. Here, higher WMC subjects resolved both S-S and S-R conflict more successfully than did lower WMC subjects. The results were consistent with Kane and Engle's (2003) 2-factor theory of cognitive control, according to which WMC predicts executive-task performance through goal-maintenance and conflict-resolution processes. However, the present results add specificity to the account by suggesting that higher WMC subjects better resolve cognitive conflict because they more efficiently select relevant stimulus features against irrelevant, distracting ones. (c) 2015 APA, all rights reserved).
Anthropometric data error detecting and correction with a computer
NASA Technical Reports Server (NTRS)
Chesak, D. D.
1981-01-01
Data obtained with automated anthropometric data aquisition equipment was examined for short term errors. The least squares curve fitting technique was used to ascertain which data values were erroneous and to replace them, if possible, with corrected values. Errors were due to random reflections of light, masking of the light rays, and other types of optical and electrical interference. It was found that the signals were impossible to eliminate from the initial data produced by the television cameras, and that this was primarily a software problem requiring a digital computer to refine the data off line. The specific data of interest was related to the arm reach envelope of a human being.
Lerner, Matthew D; Mikami, Amori Yee; Levine, Karen
2011-01-01
This study examined the effectiveness of a novel intervention called 'socio-dramatic affective-relational intervention' (SDARI), intended to improve social skills among adolescents with Asperger syndrome and high functioning autism diagnoses. SDARI adapts dramatic training activities to focus on in vivo practice of areas of social skill deficit among this population. SDARI was administered as a six-week summer program in a community human service agency. Nine SDARI participants and eight age- and diagnosis-group matched adolescents not receiving SDARI were compared on child- and parent-report of social functioning at three week intervals beginning six weeks prior to intervention and ending six weeks post-intervention. Hierarchical Linear Modeling (HLM) was used to estimate growth trends between groups to assess treatment outcomes and post-treatment maintenance. Results indicated significant improvement and post-treatment maintenance among SDARI participants on several measures of child social functioning. Implications for practice and research are discussed.
Evidence Accumulation and Choice Maintenance Are Dissociated in Human Perceptual Decision Making
Pedersen, Mads Lund; Endestad, Tor; Biele, Guido
2015-01-01
Perceptual decision making in monkeys relies on decision neurons, which accumulate evidence and maintain choices until a response is given. In humans, several brain regions have been proposed to accumulate evidence, but it is unknown if these regions also maintain choices. To test if accumulator regions in humans also maintain decisions we compared delayed and self-paced responses during a face/house discrimination decision making task. Computational modeling and fMRI results revealed dissociated processes of evidence accumulation and decision maintenance, with potential accumulator activations found in the dorsomedial prefrontal cortex, right inferior frontal gyrus and bilateral insula. Potential maintenance activation spanned the frontal pole, temporal gyri, precuneus and the lateral occipital and frontal orbital cortices. Results of a quantitative reverse inference meta-analysis performed to differentiate the functions associated with the identified regions did not narrow down potential accumulation regions, but suggested that response-maintenance might rely on a verbalization of the response. PMID:26510176
Automated Identification of Abnormal Adult EEGs
López, S.; Suarez, G.; Jungreis, D.; Obeid, I.; Picone, J.
2016-01-01
The interpretation of electroencephalograms (EEGs) is a process that is still dependent on the subjective analysis of the examiners. Though interrater agreement on critical events such as seizures is high, it is much lower on subtler events (e.g., when there are benign variants). The process used by an expert to interpret an EEG is quite subjective and hard to replicate by machine. The performance of machine learning technology is far from human performance. We have been developing an interpretation system, AutoEEG, with a goal of exceeding human performance on this task. In this work, we are focusing on one of the early decisions made in this process – whether an EEG is normal or abnormal. We explore two baseline classification algorithms: k-Nearest Neighbor (kNN) and Random Forest Ensemble Learning (RF). A subset of the TUH EEG Corpus was used to evaluate performance. Principal Components Analysis (PCA) was used to reduce the dimensionality of the data. kNN achieved a 41.8% detection error rate while RF achieved an error rate of 31.7%. These error rates are significantly lower than those obtained by random guessing based on priors (49.5%). The majority of the errors were related to misclassification of normal EEGs. PMID:27195311
Kan, Hirohito; Arai, Nobuyuki; Takizawa, Masahiro; Omori, Kazuyoshi; Kasai, Harumasa; Kunitomo, Hiroshi; Hirose, Yasujiro; Shibamoto, Yuta
2018-06-11
We developed a non-regularized, variable kernel, sophisticated harmonic artifact reduction for phase data (NR-VSHARP) method to accurately estimate local tissue fields without regularization for quantitative susceptibility mapping (QSM). We then used a digital brain phantom to evaluate the accuracy of the NR-VSHARP method, and compared it with the VSHARP and iterative spherical mean value (iSMV) methods through in vivo human brain experiments. Our proposed NR-VSHARP method, which uses variable spherical mean value (SMV) kernels, minimizes L2 norms only within the volume of interest to reduce phase errors and save cortical information without regularization. In a numerical phantom study, relative local field and susceptibility map errors were determined using NR-VSHARP, VSHARP, and iSMV. Additionally, various background field elimination methods were used to image the human brain. In a numerical phantom study, the use of NR-VSHARP considerably reduced the relative local field and susceptibility map errors throughout a digital whole brain phantom, compared with VSHARP and iSMV. In the in vivo experiment, the NR-VSHARP-estimated local field could sufficiently achieve minimal boundary losses and phase error suppression throughout the brain. Moreover, the susceptibility map generated using NR-VSHARP minimized the occurrence of streaking artifacts caused by insufficient background field removal. Our proposed NR-VSHARP method yields minimal boundary losses and highly precise phase data. Our results suggest that this technique may facilitate high-quality QSM. Copyright © 2017. Published by Elsevier Inc.
Overview of medical errors and adverse events
2012-01-01
Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures. PMID:22339769
NASA Astrophysics Data System (ADS)
Szeląg, Bartosz; Barbusiński, Krzysztof; Studziński, Jan; Bartkiewicz, Lidia
2017-11-01
In the study, models developed using data mining methods are proposed for predicting wastewater quality indicators: biochemical and chemical oxygen demand, total suspended solids, total nitrogen and total phosphorus at the inflow to wastewater treatment plant (WWTP). The models are based on values measured in previous time steps and daily wastewater inflows. Also, independent prediction systems that can be used in case of monitoring devices malfunction are provided. Models of wastewater quality indicators were developed using MARS (multivariate adaptive regression spline) method, artificial neural networks (ANN) of the multilayer perceptron type combined with the classification model (SOM) and cascade neural networks (CNN). The lowest values of absolute and relative errors were obtained using ANN+SOM, whereas the MARS method produced the highest error values. It was shown that for the analysed WWTP it is possible to obtain continuous prediction of selected wastewater quality indicators using the two developed independent prediction systems. Such models can ensure reliable WWTP work when wastewater quality monitoring systems become inoperable, or are under maintenance.
Characteristics of hyperthermia-induced hyperventilation in humans
Tsuji, Bun; Hayashi, Keiji; Kondo, Narihiko; Nishiyasu, Takeshi
2016-01-01
ABSTRACT In humans, hyperthermia leads to activation of a set of thermoregulatory responses that includes cutaneous vasodilation and sweating. Hyperthermia also increases ventilation in humans, as is observed in panting dogs, but the physiological significance and characteristics of the hyperventilatory response in humans remain unclear. The relative contribution of respiratory heat loss to total heat loss in a hot environment in humans is small, and this hyperventilation causes a concomitant reduction in arterial CO2 pressure (hypocapnia), which can cause cerebral hypoperfusion. Consequently, hyperventilation in humans may not contribute to the maintenance of physiological homeostasis (i.e., thermoregulation). To gain some insight into the physiological significance of hyperthermia-induced hyperventilation in humans, in this review, we discuss 1) the mechanisms underlying hyperthermia-induced hyperventilation, 2) the factors modulating this response, and 3) the physiological consequences of the response. PMID:27227102
Behavioral Health Program Element
NASA Technical Reports Server (NTRS)
Leveton, Lauren B.
2006-01-01
The project goal is to develop behavioral health prevention and maintenance system for continued crew health, safety, and performance for exploration missions. The basic scope includes a) Operationally-relevant research related to clinical cognitive and behavioral health of crewmembers; b) Ground-based studies using analog environments (Antarctic, NEEMO, simulations, and other testbeds; c) ISS studies (ISSMP) focusing on operational issues related to behavioral health outcomes and standards; d) Technology development activities for monitoring and diagnostic tools; and e) Cross-disciplinary research (e.g., human factors and habitability research, skeletal muscle, radiation).
The effect of low light intensity on the maintenance of circadian synchrony in human subjects
NASA Technical Reports Server (NTRS)
Winget, C. M.; Lyman, J.; Beljan, J. R.
1976-01-01
Experiments were conducted on six healthy male subjects aged 20-23 yr and exposed for 21 days in a confined regulated environment to 16L:8D light:dark cycle with a view toward determining whether the light environment of 16L:8D at the relatively low light intensity of 15 ft.c. is adequate for the maintenance of circadian synchrony in man. The light intensity was 100 ft.c. during the first seven days, reduced to 15 ft.c. during the next seven days, and increased again to 100 ft.c. during the last seven days. Rectal temperature (RT) and heart rate (HR) were recorded throughout the three phases. In the 100 ft.c. regime, the RT and HR rhythms remained stable and circadian throughout. It is shown that 15 ft.c. light intensity is at or below threshold for maintaining circadian synchrony of human physiologic rhythms marked by instability and internal desynchronization with degradation of performance and well-being.
Cui, Le; Jia, Yan; Cheng, Zhi-Wei; Gao, Ying; Zhang, Gao-Lei; Li, Jing-Yi; He, Cong-Fen
2016-12-01
The human skin barrier has an important role in protection and defense, reflected not only in the ability to resist entry of harmful substances into the human body, but also in the ability to prevent loss of water and nutrients. Once the skin barrier is damaged, the skin may become dry, scaly, and wrinkled, and a series of skin problems may occur. In this article, we review the composition of lipids, such as ceramides, cholesterol, and free fatty acids, in the skin and examine the expression of enzymes related to lipid metabolism, such as kallikreins, elongase of elongation of very long-chain fatty acids, hydrolases, and lipid synthases. Additionally, we discuss the involvement of these proteins in skin barrier function and structure. The information presented in this review is expected to provide a theoretical basis for the development of skin care products facilitating the maintenance and repair of skin barrier function. © 2016 Wiley Periodicals, Inc.
Animal Proteins as Important Contributors to a Healthy Human Diet.
Elmadfa, Ibrahim; Meyer, Alexa L
2017-02-08
Adequate protein intake is critical for health and development. Generally, protein of animal origin is of higher quality for humans owing to its amino acid pattern and good digestibility. When administered in mixtures it can enhance the quality of plant proteins, but its availability is often low in low-income communities, especially in young children, the elderly, and pregnant and lactating women, who have increased requirements and in whom high-quality protein also stimulates (bone) growth and maintenance. Although high protein intake was associated with increased type 2 diabetes mellitus risk, milk and seafood are good sources of branched chain amino acids and taurine, which act beneficially on glucose metabolism and blood pressure. However, high consumption of protein-rich animal food is also associated with adverse health effects and higher risk for noncommunicable diseases, partly related to other components of these foods, like saturated fatty acids and potential carcinogens in processed meat but also the atherogenic methionine metabolite homocysteine. In moderation, however, animal proteins are especially important for health maintenance in vulnerable persons.
Selective updating of working memory content modulates meso-cortico-striatal activity.
Murty, Vishnu P; Sambataro, Fabio; Radulescu, Eugenia; Altamura, Mario; Iudicello, Jennifer; Zoltick, Bradley; Weinberger, Daniel R; Goldberg, Terry E; Mattay, Venkata S
2011-08-01
Accumulating evidence from non-human primates and computational modeling suggests that dopaminergic signals arising from the midbrain (substantia nigra/ventral tegmental area) mediate striatal gating of the prefrontal cortex during the selective updating of working memory. Using event-related functional magnetic resonance imaging, we explored the neural mechanisms underlying the selective updating of information stored in working memory. Participants were scanned during a novel working memory task that parses the neurophysiology underlying working memory maintenance, overwriting, and selective updating. Analyses revealed a functionally coupled network consisting of a midbrain region encompassing the substantia nigra/ventral tegmental area, caudate, and dorsolateral prefrontal cortex that was selectively engaged during working memory updating compared to the overwriting and maintenance of working memory content. Further analysis revealed differential midbrain-dorsolateral prefrontal interactions during selective updating between low-performing and high-performing individuals. These findings highlight the role of this meso-cortico-striatal circuitry during the selective updating of working memory in humans, which complements previous research in behavioral neuroscience and computational modeling. Published by Elsevier Inc.
Compound Stimulus Presentation Does Not Deepen Extinction in Human Causal Learning
Griffiths, Oren; Holmes, Nathan; Westbrook, R. Fred
2017-01-01
Models of associative learning have proposed that cue-outcome learning critically depends on the degree of prediction error encountered during training. Two experiments examined the role of error-driven extinction learning in a human causal learning task. Target cues underwent extinction in the presence of additional cues, which differed in the degree to which they predicted the outcome, thereby manipulating outcome expectancy and, in the absence of any change in reinforcement, prediction error. These prediction error manipulations have each been shown to modulate extinction learning in aversive conditioning studies. While both manipulations resulted in increased prediction error during training, neither enhanced extinction in the present human learning task (one manipulation resulted in less extinction at test). The results are discussed with reference to the types of associations that are regulated by prediction error, the types of error terms involved in their regulation, and how these interact with parameters involved in training. PMID:28232809
Uetera, Yushi; Kishii, Kozue; Yasuhara, Hiroshi; Kumada, Naohito; Moriya, Kyoji; Saito, Ryoichi; Okazaki, Mitsuhiro; Misawa, Yoshiki; Kawamura, Kunio
2013-01-01
This report deals with the construction and management of the reverse osmosis (RO) water system for final rinsing of surgical instruments in the washer-disinfector. Numerous operational challenges were encountered in our RO water system and these were analyzed utilizing the Ishikawa Fishbone diagram. The aim was to find potential problems and promote preventive system management for RO water. It was found that the measures that existed were inappropriate for preventing contamination in the heat-labile RO water system. The storage tank was found to be significantly contaminated and had to be replaced with a new one equipped with a sampling port and water drainage system. Additional filters and an UV treatment lamp were installed. The whole system disinfection started 1.5 years later using a peracetic acid-based compound after confirming the material compatibility. Operator errors were found when a new water engineer took over the duty from his predecessor. It was also found that there were some deficiencies in the standard operating procedures (SOPs), and that on-the-job training was not enough. The water engineer failed to disinfect the sampling port and water drainage system. The RO membrane had been used for 4 years, even though the SOP standard specified changing it as every 3 years. Various bacteria, such as Rothia mucilaginosa, were cultured from the RO water sampled from the equipment. Because Rothia mucilaginosa is a resident in the oral cavity and upper respiratory tract, it is believed that the bacteria were introduced into the system by the maintenance personnel or working environment. Therefore, the presence of R. mucilaginosa implied the failure of sanitary maintenance procedures. This study suggests that water systems should be designed based on the plans for profound system maintenance. It also suggests that SOP and on-the job training are essential to avoid any operator errors. These results must be carefully considered when either constructing new RO systems or performing maintenance and periodical examination of the equipment. Reverse osmosis (RO) water is used for final rinsing in our washer-disinfector. The authors used the Ishikawa Fishbone diagram to clarify the critical points for optimizing RO water quality. There existed no measures to prevent contamination in the heat-labile RO water system. The storage tank was significantly contaminated and had to be replaced with a new one equipped with a sampling port and water drainage system. Additional filters and an UV treatment lamp were installed. The whole system disinfection started 1.5 years later using a peracetic acid-based compound after confirming the material compatibility. Operator errors occurred when a new water engineer took over the duty from his predecessor. There were neither standard operating procedures (SOPs) nor on-the-job training. The new water engineer had failed to disinfect the sampling port and water drainage system. Rothia mucilaginosa was cultured from the RO water. It is a resident in the oral cavity and upper respiratory tract. This implied the possible failure of sanitary procedures in the system maintenance. The Ishikawa Fishbone diagram was useful for this study. It suggests that water systems should be designed with plans for system maintenance taken into account. It also suggests that SOP and on-the job training are essential in order to avoid operator errors.
Kim, Jun Sik; Jeong, Byung Yong
2018-05-03
The study aimed to describe the characteristics of occupational injuries of female workers in the residential healthcare facilities for the elderly, and analyze human errors as causes of accidents. From the national industrial accident compensation data, 506 female injuries were analyzed by age and occupation. The results showed that medical service worker was the most prevalent (54.1%), followed by social welfare worker (20.4%). Among injuries, 55.7% were <1 year of work experience, and 37.9% were ≥60 years old. Slips/falls were the most common type of accident (42.7%), and proportion of injured by slips/falls increases with age. Among human errors, action errors were the primary reasons, followed by perception errors, and cognition errors. Besides, the ratios of injuries by perception errors and action errors increase with age, respectively. The findings of this study suggest that there is a need to design workplaces that accommodate the characteristics of older female workers.
The human factors of quality and QA in R D environments
DOE Office of Scientific and Technical Information (OSTI.GOV)
Hill, S.G.
1990-01-01
Achieving quality is a human activity. It is therefore important to consider the human in the design, development and evaluation of work processes and environments in an effort to enhance human performance and minimize error. It is also important to allow for individual differences when considering human factors issues. Human Factors is the field of study which can provide information on integrating the human into the system. Human factors and quality are related for the customer of R D work, R D personnel who perform the work, and the quality professional who overviews the process of quality in the work.more » 18 refs., 1 fig.« less
Multi-Unit Considerations for Human Reliability Analysis
DOE Office of Scientific and Technical Information (OSTI.GOV)
St. Germain, S.; Boring, R.; Banaseanu, G.
This paper uses the insights from the Standardized Plant Analysis Risk-Human Reliability Analysis (SPAR-H) methodology to help identify human actions currently modeled in the single unit PSA that may need to be modified to account for additional challenges imposed by a multi-unit accident as well as identify possible new human actions that might be modeled to more accurately characterize multi-unit risk. In identifying these potential human action impacts, the use of the SPAR-H strategy to include both errors in diagnosis and errors in action is considered as well as identifying characteristics of a multi-unit accident scenario that may impact themore » selection of the performance shaping factors (PSFs) used in SPAR-H. The lessons learned from the Fukushima Daiichi reactor accident will be addressed to further help identify areas where improved modeling may be required. While these multi-unit impacts may require modifications to a Level 1 PSA model, it is expected to have much more importance for Level 2 modeling. There is little currently written specifically about multi-unit HRA issues. A review of related published research will be presented. While this paper cannot answer all issues related to multi-unit HRA, it will hopefully serve as a starting point to generate discussion and spark additional ideas towards the proper treatment of HRA in a multi-unit PSA.« less
Contextual specificity in perception and action
NASA Technical Reports Server (NTRS)
Proffitt, Dennis R.
1991-01-01
The visually guided control of helicopter flight is a human achievement, and, thus, understanding this skill is, in part, a psychological problem. The abilities of skilled pilots are impressive, and yet it is of concern that pilots' performance is less than ideal: they suffer from workload constraints, make occasional errors, and are subject to such debilities as simulator sickness. Remedying such deficiencies is both an engineering and a psychological problem. When studying the psychological aspects of this problem, it is desirable to simplify the problem as much as possible, and thereby, sidestep as many intractable psychological issues as possible. Simply stated, we do not want to have to resolve such polemics as the mind-body problem in order to contribute to the design of more effective helicopter systems. On the other hand, the study of human behavior is a psychological endeavor and certain problems cannot be evaded. Four related issues that are of psychological significance in understanding the visually guided control of helicopter flight are discussed. First, a selected discussion of the nature of descriptive levels in analyzing human perception and performance is presented. It is argued that the appropriate level of description for perception is kinematical, and for performance, it is procedural. Second, it is argued that investigations into pilot performance cannot ignore the nature of pilots' phenomenal experience. The conscious control of actions is not based upon environmental states of affairs, nor upon the optical information that specifies them. Actions are coupled to perceptions. Third, the acquisition of skilled actions in the context of inherent misperceptions is discussed. Such skills may be error prone in some situations, but not in others. Finally, I discuss the contextual relativity of human errors. Each of these four issues relates to a common theme: the control of action is mediated by phenomenal experience, the veracity of which is context specific.
[Risk and risk management in aviation].
Müller, Manfred
2004-10-01
RISK MANAGEMENT: The large proportion of human errors in aviation accidents suggested the solution--at first sight brilliant--to replace the fallible human being by an "infallible" digitally-operating computer. However, even after the introduction of the so-called HITEC-airplanes, the factor human error still accounts for 75% of all accidents. Thus, if the computer is ruled out as the ultimate safety system, how else can complex operations involving quick and difficult decisions be controlled? OPTIMIZED TEAM INTERACTION/PARALLEL CONNECTION OF THOUGHT MACHINES: Since a single person is always "highly error-prone", support and control have to be guaranteed by a second person. The independent work of mind results in a safety network that more efficiently cushions human errors. NON-PUNITIVE ERROR MANAGEMENT: To be able to tackle the actual problems, the open discussion of intervened errors must not be endangered by the threat of punishment. It has been shown in the past that progress is primarily achieved by investigating and following up mistakes, failures and catastrophes shortly after they happened. HUMAN FACTOR RESEARCH PROJECT: A comprehensive survey showed the following result: By far the most frequent safety-critical situation (37.8% of all events) consists of the following combination of risk factors: 1. A complication develops. 2. In this situation of increased stress a human error occurs. 3. The negative effects of the error cannot be corrected or eased because there are deficiencies in team interaction on the flight deck. This means, for example, that a negative social climate has the effect of a "turbocharger" when a human error occurs. It needs to be pointed out that a negative social climate is not identical with a dispute. In many cases the working climate is burdened without the responsible person even noticing it: A first negative impression, too much or too little respect, contempt, misunderstandings, not expressing unclear concern, etc. can considerably reduce the efficiency of a team.
Cognitive factors in the close visual and magnetic particle inspection of welds underwater.
Leach, J; Morris, P E
1998-06-01
Underwater close visual inspection (CVI) and magnetic particle inspection (MPI) are major components of the commercial diver's job of nondestructive testing and the maintenance of subsea structures. We explored the accuracy of CVI in Experiment 1 and that of MPI in Experiment 2 and observed high error rates (47% and 24%, respectively). Performance was strongly correlated with embedded figures and visual search tests and was unrelated to length of professional diving experience, formal inspection qualification, or age. Cognitive tests of memory for designs, spatial relations, dotted outlines, and block design failed to correlate with performance. Actual or potential applications of this research include more reliable inspection reporting, increased effectiveness from current inspection techniques, and directions for the refinement of subsea inspection equipment.
Competition between learned reward and error outcome predictions in anterior cingulate cortex.
Alexander, William H; Brown, Joshua W
2010-02-15
The anterior cingulate cortex (ACC) is implicated in performance monitoring and cognitive control. Non-human primate studies of ACC show prominent reward signals, but these are elusive in human studies, which instead show mainly conflict and error effects. Here we demonstrate distinct appetitive and aversive activity in human ACC. The error likelihood hypothesis suggests that ACC activity increases in proportion to the likelihood of an error, and ACC is also sensitive to the consequence magnitude of the predicted error. Previous work further showed that error likelihood effects reach a ceiling as the potential consequences of an error increase, possibly due to reductions in the average reward. We explored this issue by independently manipulating reward magnitude of task responses and error likelihood while controlling for potential error consequences in an Incentive Change Signal Task. The fMRI results ruled out a modulatory effect of expected reward on error likelihood effects in favor of a competition effect between expected reward and error likelihood. Dynamic causal modeling showed that error likelihood and expected reward signals are intrinsic to the ACC rather than received from elsewhere. These findings agree with interpretations of ACC activity as signaling both perceptions of risk and predicted reward. Copyright 2009 Elsevier Inc. All rights reserved.
Using machine learning to emulate human hearing for predictive maintenance of equipment
NASA Astrophysics Data System (ADS)
Verma, Dinesh; Bent, Graham
2017-05-01
At the current time, interfaces between humans and machines use only a limited subset of senses that humans are capable of. The interaction among humans and computers can become much more intuitive and effective if we are able to use more senses, and create other modes of communicating between them. New machine learning technologies can make this type of interaction become a reality. In this paper, we present a framework for a holistic communication between humans and machines that uses all of the senses, and discuss how a subset of this capability can allow machines to talk to humans to indicate their health for various tasks such as predictive maintenance.
Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred
2015-01-01
Human-robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human-robot interaction experiments. For that, we analyzed 201 videos of five human-robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human-robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies.
Cytokines in Male Fertility and Reproductive Pathologies: Immunoregulation and Beyond
Loveland, Kate L.; Klein, Britta; Pueschl, Dana; Indumathy, Sivanjah; Bergmann, Martin; Loveland, Bruce E.; Hedger, Mark P.; Schuppe, Hans-Christian
2017-01-01
Germline development in vivo is dependent on the environment formed by somatic cells and the differentiation cues they provide; hence, the impact of local factors is highly relevant to the production of sperm. Knowledge of how somatic and germline cells interact is central to achieving biomedical goals relating to restoring, preserving or restricting fertility in humans. This review discusses the growing understanding of how cytokines contribute to testicular function and maintenance of male reproductive health, and to the pathologies associated with their abnormal activity in this organ. Here we consider both cytokines that signal through JAKs and are regulated by SOCS, and those utilizing other pathways, such as the MAP kinases and SMADs. The importance of cytokines in the establishment and maintenance of the testis as an immune-privilege site are described. Current research relating to the involvement of immune cells in testis development and disease is highlighted. This includes new data relating to testicular cancer which reinforce the understanding that tumorigenic cells shape their microenvironment through cytokine actions. Clinical implications in pathologies relating to local inflammation and to immunotherapies are discussed. PMID:29250030
Patient identification in blood sampling.
Davidson, Anne; Bolton-Maggs, Paula
The majority of adverse reports relating to blood transfusions result from human error, including misidentification of patients and incorrect labelling of samples. This article outlines best practice in blood sampling for transfusion (but is recommended for all pathology samples) and the role of patient empowerment in improving safety.