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

PubMed

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

2016-01-01

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

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

PubMed

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

2017-11-01

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

A streamlined failure mode and effects analysis

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

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

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

Failure Modes and Effects Analysis (FMEA): A Bibliography

NASA Technical Reports Server (NTRS)

2000-01-01

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

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

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

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

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

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

PubMed

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

2014-12-25

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

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

PubMed Central

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

2015-01-01

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

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

PubMed

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

2014-01-01

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

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

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

Yang, F; Cao, N; Young, L

2014-06-15

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

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

PubMed

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

2017-01-01

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

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

PubMed Central

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

2012-01-01

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

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

PubMed

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

2012-01-01

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

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

PubMed Central

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

2016-01-01

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

Processing Mode Causally Influences Emotional Reactivity

PubMed Central

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

2008-01-01

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

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

NASA Technical Reports Server (NTRS)

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

2001-01-01

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

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

NASA Technical Reports Server (NTRS)

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

2017-01-01

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

Risk analysis of analytical validations by probabilistic modification of FMEA.

PubMed

Barends, D M; Oldenhof, M T; Vredenbregt, M J; Nauta, M J

2012-05-01

Risk analysis is a valuable addition to validation of an analytical chemistry process, enabling not only detecting technical risks, but also risks related to human failures. Failure Mode and Effect Analysis (FMEA) can be applied, using a categorical risk scoring of the occurrence, detection and severity of failure modes, and calculating the Risk Priority Number (RPN) to select failure modes for correction. We propose a probabilistic modification of FMEA, replacing the categorical scoring of occurrence and detection by their estimated relative frequency and maintaining the categorical scoring of severity. In an example, the results of traditional FMEA of a Near Infrared (NIR) analytical procedure used for the screening of suspected counterfeited tablets are re-interpretated by this probabilistic modification of FMEA. Using this probabilistic modification of FMEA, the frequency of occurrence of undetected failure mode(s) can be estimated quantitatively, for each individual failure mode, for a set of failure modes, and the full analytical procedure. Copyright © 2012 Elsevier B.V. All rights reserved.

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

PubMed Central

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

2005-01-01

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

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

PubMed

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

2005-04-01

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

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

PubMed Central

Baik, Jungmi; Kim, Hyunjung; Kim, Rachel

2017-01-01

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

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

PubMed

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

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

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

PubMed

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

2015-08-01

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

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

PubMed

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

2015-10-01

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

Extended Testability Analysis Tool

NASA Technical Reports Server (NTRS)

Melcher, Kevin; Maul, William A.; Fulton, Christopher

2012-01-01

The Extended Testability Analysis (ETA) Tool is a software application that supports fault management (FM) by performing testability analyses on the fault propagation model of a given system. Fault management includes the prevention of faults through robust design margins and quality assurance methods, or the mitigation of system failures. Fault management requires an understanding of the system design and operation, potential failure mechanisms within the system, and the propagation of those potential failures through the system. The purpose of the ETA Tool software is to process the testability analysis results from a commercial software program called TEAMS Designer in order to provide a detailed set of diagnostic assessment reports. The ETA Tool is a command-line process with several user-selectable report output options. The ETA Tool also extends the COTS testability analysis and enables variation studies with sensor sensitivity impacts on system diagnostics and component isolation using a single testability output. The ETA Tool can also provide extended analyses from a single set of testability output files. The following analysis reports are available to the user: (1) the Detectability Report provides a breakdown of how each tested failure mode was detected, (2) the Test Utilization Report identifies all the failure modes that each test detects, (3) the Failure Mode Isolation Report demonstrates the system s ability to discriminate between failure modes, (4) the Component Isolation Report demonstrates the system s ability to discriminate between failure modes relative to the components containing the failure modes, (5) the Sensor Sensor Sensitivity Analysis Report shows the diagnostic impact due to loss of sensor information, and (6) the Effect Mapping Report identifies failure modes that result in specified system-level effects.

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

PubMed

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

2009-09-01

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

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

PubMed

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

2012-07-01

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

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

PubMed Central

Patel, Teresa; Fisher, Stanley P.

2016-01-01

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

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

PubMed

Chen, Ying-Chu; Tsai, Pei-Yi

2017-06-01

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

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

PubMed

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

2015-06-13

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

Medication Safety of Five Oral Chemotherapies: A Proactive Risk Assessment

PubMed Central

Weingart, Saul N.; Spencer, Justin; Buia, Stephanie; Duncombe, Deborah; Singh, Prabhjyot; Gadkari, Mrinalini; Connor, Maureen

2011-01-01

Purpose: Oral chemotherapies represent an emerging risk area in ambulatory oncology practice. To examine the hazards associated with five oral chemotherapies, we performed a proactive risk assessment. Methods: We convened interdisciplinary teams and conducted failure mode and effects analyses (FMEAs) for five oral chemotherapy agents: capecitabine, imatinib, temozolomide, 6-mercaptopurine, and an investigational agent. This involved the creation of process maps for each medication, identification of failure modes, selection of high-risk failure modes, and development of recommendations to mitigate these risks. We analyzed the number of steps and types of failure modes and compared this information across the study drugs. Results: Key vulnerabilities include patient education about drug handling and adverse effects, prescription writing, patient self-administration and medication adherence, and failure to monitor and manage toxicities. Many of these failure modes were common across the five oral chemotherapies, suggesting the presence of common targets for improvement. Streamlining the FMEA itself may promote the dissemination of this method. Conclusion: Each stage of the medication process poses risks to the safe use of oral chemotherapies. FMEAs may identify opportunities to improve medication safety and reduce the risk of patient harm. PMID:21532801

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

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

UAV Swarm Behavior Modeling for Early Exposure of Failure Modes

DTIC Science & Technology

2016-09-01

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

Analysis and design of ion-implanted bubble memory devices

NASA Astrophysics Data System (ADS)

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

1987-04-01

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

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

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

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

PubMed

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

2011-01-01

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

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

PubMed

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

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

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

PubMed Central

2013-01-01

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

Fault detection and diagnosis using neural network approaches

NASA Technical Reports Server (NTRS)

Kramer, Mark A.

1992-01-01

Neural networks can be used to detect and identify abnormalities in real-time process data. Two basic approaches can be used, the first based on training networks using data representing both normal and abnormal modes of process behavior, and the second based on statistical characterization of the normal mode only. Given data representative of process faults, radial basis function networks can effectively identify failures. This approach is often limited by the lack of fault data, but can be facilitated by process simulation. The second approach employs elliptical and radial basis function neural networks and other models to learn the statistical distributions of process observables under normal conditions. Analytical models of failure modes can then be applied in combination with the neural network models to identify faults. Special methods can be applied to compensate for sensor failures, to produce real-time estimation of missing or failed sensors based on the correlations codified in the neural network.

Characterization of delamination and transverse cracking in graphite/epoxy laminates by acoustic emission

NASA Technical Reports Server (NTRS)

Garg, A.; Ishaei, O.

1983-01-01

Efforts to characterize and differentiate between two major failure processes in graphite/epoxy composites - transverse cracking and Mode I delamination are described. Representative laminates were tested in uniaxial tension and flexure. The failure processes were monitored and identified by acoustic emission (AE). The effect of moisture on AE was also investigated. Each damage process was found to have a distinctive AE output that is significantly affected by moisture conditions. It is concluded that AE can serve as a useful tool for detecting and identifying failure modes in composite structures in laboratory and in service environments.

Microstructure-failure mode correlations in braided composites

NASA Technical Reports Server (NTRS)

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

1992-01-01

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

Risk management of key issues of FPSO

NASA Astrophysics Data System (ADS)

Sun, Liping; Sun, Hai

2012-12-01

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

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

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

Xie, J; Wang, J; P, J

2016-06-15

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

High-throughput sequencing: a failure mode analysis.

PubMed

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

2005-01-04

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

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

NASA Astrophysics Data System (ADS)

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

2014-10-01

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

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

Cheong, S-K; Kim, J

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

Experimental Investigation on the Joining of Aluminum Alloy Sheets Using Improved Clinching Process.

PubMed

Chen, Chao; Zhao, Shengdun; Han, Xiaolan; Zhao, Xuzhe; Ishida, Tohru

2017-08-01

Aluminum alloy sheets have been widely used to build the thin-walled structures by mechanical clinching technology in recent years. However, there is an exterior protrusion located on the lower sheet and a pit on the upper sheet, which may restrict the application of the clinching technology in visible areas. In the present study, an improved clinched joint used to join aluminum alloy sheets was investigated by experimental method. The improved clinching process used for joining aluminum alloy evolves through four phases: (a) localized deformation; (b) drawing; (c) backward extrusion; and (d) mechanical interlock forming. A flat surface can be produced using the improved clinching process. Shearing strength, tensile strength, material flow, main geometrical parameters, and failure mode of the improved clinched joint were investigated. The sheet material was compressed to flow radially and upward using a punch, which generated a mechanical interlock by producing severe localized plastic deformation. The neck thickness and interlock of the improved clinched joint were increased by increasing the forming force, which also contributed to increase the strength of the clinched joint. The improved clinched joint can get high shearing strength and tensile strength. Three main failure modes were observed in the failure process, which were neck fracture mode, button separation mode, and mixed failure mode. The improved clinched joint has better joining quality to join aluminum alloy sheets on the thin-walled structures.

Experimental Investigation on the Joining of Aluminum Alloy Sheets Using Improved Clinching Process

PubMed Central

Chen, Chao; Zhao, Shengdun; Han, Xiaolan; Zhao, Xuzhe; Ishida, Tohru

2017-01-01

Aluminum alloy sheets have been widely used to build the thin-walled structures by mechanical clinching technology in recent years. However, there is an exterior protrusion located on the lower sheet and a pit on the upper sheet, which may restrict the application of the clinching technology in visible areas. In the present study, an improved clinched joint used to join aluminum alloy sheets was investigated by experimental method. The improved clinching process used for joining aluminum alloy evolves through four phases: (a) localized deformation; (b) drawing; (c) backward extrusion; and (d) mechanical interlock forming. A flat surface can be produced using the improved clinching process. Shearing strength, tensile strength, material flow, main geometrical parameters, and failure mode of the improved clinched joint were investigated. The sheet material was compressed to flow radially and upward using a punch, which generated a mechanical interlock by producing severe localized plastic deformation. The neck thickness and interlock of the improved clinched joint were increased by increasing the forming force, which also contributed to increase the strength of the clinched joint. The improved clinched joint can get high shearing strength and tensile strength. Three main failure modes were observed in the failure process, which were neck fracture mode, button separation mode, and mixed failure mode. The improved clinched joint has better joining quality to join aluminum alloy sheets on the thin-walled structures. PMID:28763027

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

PubMed

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

2013-12-01

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

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

NASA Technical Reports Server (NTRS)

Robinson, W. W.

1988-01-01

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

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

PubMed

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

2017-12-01

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

Savannah River Site generic data base development

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

Blanton, C.H.; Eide, S.A.

This report describes the results of a project to improve the generic component failure data base for the Savannah River Site (SRS). A representative list of components and failure modes for SRS risk models was generated by reviewing existing safety analyses and component failure data bases and from suggestions from SRS safety analysts. Then sources of data or failure rate estimates were identified and reviewed for applicability. A major source of information was the Nuclear Computerized Library for Assessing Reactor Reliability, or NUCLARR. This source includes an extensive collection of failure data and failure rate estimates for commercial nuclear powermore » plants. A recent Idaho National Engineering Laboratory report on failure data from the Idaho Chemical Processing Plant was also reviewed. From these and other recent sources, failure data and failure rate estimates were collected for the components and failure modes of interest. This information was aggregated to obtain a recommended generic failure rate distribution (mean and error factor) for each component failure mode.« less

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

NASA Astrophysics Data System (ADS)

Rucitra, A. L.

2018-03-01

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

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2010-01-01

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

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

PubMed Central

Magnezi, Racheli; Hemi, Asaf; Hemi, Rina

2016-01-01

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

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

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

Huq, M.

2015-06-15

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

Quality Issues in Propulsion

NASA Technical Reports Server (NTRS)

McCarty, John P.; Lyles, Garry M.

1997-01-01

Propulsion system quality is defined in this paper as having high reliability, that is, quality is a high probability of within-tolerance performance or operation. Since failures are out-of-tolerance performance, the probability of failures and their occurrence is the difference between high and low quality systems. Failures can be described at 3 levels: the system failure (which is the detectable end of a failure), the failure mode (which is the failure process), and the failure cause (which is the start). Failure causes can be evaluated & classified by type. The results of typing flight history failures shows that most failures are in unrecognized modes and result from human error or noise, i.e. failures are when engineers learn how things really work. Although the study based on US launch vehicles, a sampling of failures from other countries indicates the finding has broad application. The parameters of the design of a propulsion system are not single valued, but have dispersions associated with the manufacturing of parts. Many tests are needed to find failures, if the dispersions are large relative to tolerances, which could contribute to the large number of failures in unrecognized modes.

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

PubMed

Ashley, Laura; Armitage, Gerry; Taylor, Julie

2017-03-01

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

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

NASA Astrophysics Data System (ADS)

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

2017-02-01

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

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

PubMed

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

2006-08-15

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

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

PubMed

Jain, Khushboo

2017-03-13

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

MO-G-BRE-05: Clinical Process Improvement and Billing in Radiation Oncology: A Case Study of Applying FMEA for CPT Code 77336 (continuing Medical Physics Consultation)

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

Spirydovich, S; Huq, M

2014-06-15

Purpose: The improvement of quality in healthcare can be assessed by Failure Mode and Effects Analysis (FMEA). In radiation oncology, FMEA, as applied to the billing CPT code 77336, can improve both charge capture and, most importantly, quality of the performed services. Methods: We created an FMEA table for the process performed under CPT code 77336. For a given process step, each member of the assembled team (physicist, dosimetrist, and therapist) independently assigned numerical values for: probability of occurrence (O, 1–10), severity (S, 1–10), and probability of detection (D, 1–10) for every failure mode cause and effect combination. The riskmore » priority number, RPN, was then calculated as a product of O, S and D from which an average RPN was calculated for each combination mentioned above. A fault tree diagram, with each process sorted into 6 categories, was created with linked RPN. For processes with high RPN recommended actions were assigned. 2 separate R and V systems (Lantis and EMR-based ARIA) were considered. Results: We identified 9 potential failure modes and corresponding 19 potential causes of these failure modes all resulting in unjustified 77336 charge and compromised quality of care. In Lantis, the range of RPN was 24.5–110.8, and of S values – 2–10. The highest ranking RPN of 110.8 came from the failure mode described as “end-of-treatment check not done before the completion of treatment”, and the highest S value of 10 (RPN=105) from “overrides not checked”. For the same failure modes, within ARIA electronic environment with its additional controls, RPN values were significantly lower (44.3 for end-of-treatment missing check and 20.0 for overrides not checked). Conclusion: Our work has shown that when charge capture was missed that also resulted in some services not being performed. Absence of such necessary services may result in sub-optimal quality of care rendered to patients.« less

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

PubMed

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

2016-08-01

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

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

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

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

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

Xie, J; Xiao, Y; Wang, J

2014-06-15

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

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

NASA Astrophysics Data System (ADS)

Varzakas, Theodoros H.; Arvanitoyannis, Ioannis S.

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

CONFIG: Qualitative simulation tool for analyzing behavior of engineering devices

NASA Technical Reports Server (NTRS)

Malin, Jane T.; Basham, Bryan D.; Harris, Richard A.

1987-01-01

To design failure management expert systems, engineers mentally analyze the effects of failures and procedures as they propagate through device configurations. CONFIG is a generic device modeling tool for use in discrete event simulation, to support such analyses. CONFIG permits graphical modeling of device configurations and qualitative specification of local operating modes of device components. Computation requirements are reduced by focussing the level of component description on operating modes and failure modes, and specifying qualitative ranges of variables relative to mode transition boundaries. Simulation processing occurs only when modes change or variables cross qualitative boundaries. Device models are built graphically, using components from libraries. Components are connected at ports by graphical relations that define data flow. The core of a component model is its state transition diagram, which specifies modes of operation and transitions among them.

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

PubMed

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

2017-06-30

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

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

PubMed

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

2017-02-01

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

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

PubMed Central

Li, Xixi; He, Mei; Wang, Haiyan

2017-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2008-10-01

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

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

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

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

2012-07-15

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

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

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

Bolted Joints in Three Axially Braided Carbon Fibre/Epoxy Textile Composites with Moulded-in and Drilled Fastener Holes

NASA Astrophysics Data System (ADS)

Ataş, Akın; Gautam, Mayank; Soutis, Constantinos; Potluri, Prasad

2017-04-01

Experimental behaviour of bolted joints in triaxial braided (0°/±45°) carbon fibre/epoxy composite laminates with drilled and moulded-in fastener holes has been investigated in this paper. Braided laminates were manufactured by vacuum infusion process using 12 K T700S carbon fibres (for bias and axial tows) and Araldite LY-564 epoxy resin. Moulded-in fastener holes were formed using guide pins which were inserted in the braided structure prior to the vacuum infusion process. The damage mechanism of the specimens was investigated using ultrasonic C-Scan technique. The specimens were dimensioned to obtain a bearing mode of failure. The bearing strength of the specimens with moulded-in hole was reduced in comparison to the specimens with drilled hole, due to the increased fibre misalignment angle following the pin insertion procedure. An improvement on the bearing strength of moulded-in hole specimens might be developed if the specimen dimensions would be prepared for a net-tension mode of failure where the fibre misalignment would not have an effect as significant as in the case of bearing failure mode, but this mode should be avoided since it leads to sudden catastrophic failures.

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

PubMed Central

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

2010-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2015-11-01

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

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

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

Howe, J

2015-06-15

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

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

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

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

2012-02-01

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

Optimisation of shock absorber process parameters using failure mode and effect analysis and genetic algorithm

NASA Astrophysics Data System (ADS)

Mariajayaprakash, Arokiasamy; Senthilvelan, Thiyagarajan; Vivekananthan, Krishnapillai Ponnambal

2013-07-01

The various process parameters affecting the quality characteristics of the shock absorber during the process were identified using the Ishikawa diagram and by failure mode and effect analysis. The identified process parameters are welding process parameters (squeeze, heat control, wheel speed, and air pressure), damper sealing process parameters (load, hydraulic pressure, air pressure, and fixture height), washing process parameters (total alkalinity, temperature, pH value of rinsing water, and timing), and painting process parameters (flowability, coating thickness, pointage, and temperature). In this paper, the process parameters, namely, painting and washing process parameters, are optimized by Taguchi method. Though the defects are reasonably minimized by Taguchi method, in order to achieve zero defects during the processes, genetic algorithm technique is applied on the optimized parameters obtained by Taguchi method.

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical (PCIs) items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results corresponding to the Orbiter Active Thermal Control Subsystem (ATCS) are documented. The major purpose of the ATCS is to remove the heat, generated during normal Shuttle operations from the Orbiter systems and subsystems. The four major components of the ATCS contributing to the heat removal are: Freon Coolant Loops; Radiator and Flow Control Assembly; Flash Evaporator System; and Ammonia Boiler System. In order to perform the analysis, the IOA process utilized available ATCS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 310 failure modes analyzed, 101 were determined to be PCIs.

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results for the Orbiter Hydraulics/Water Spray Boiler Subsystem. The hydraulic system provides hydraulic power to gimbal the main engines, actuate the main engine propellant control valves, move the aerodynamic flight control surfaces, lower the landing gear, apply wheel brakes, steer the nosewheel, and dampen the external tank (ET) separation. Each hydraulic system has an associated water spray boiler which is used to cool the hydraulic fluid and APU lubricating oil. The IOA analysis process utilized available HYD/WSB hardware drawings, schematics and documents for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 430 failure modes analyzed, 166 were determined to be PCIs.

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbiter Remote Manipulator System (RMS) are documented. The RMS hardware and software are primarily required for deploying and/or retrieving up to five payloads during a single mission, capture and retrieve free-flying payloads, and for performing Manipulator Foot Restraint operations. Specifically, the RMS hardware consists of the following components: end effector; displays and controls; manipulator controller interface unit; arm based electronics; and the arm. The IOA analysis process utilized available RMS hardware drawings, schematics and documents for defining hardware assemblies, components and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 574 failure modes analyzed, 413 were determined to be PCIs.

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

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

Huynh, J; Kim, Y

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

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

PubMed

Li, Xixi; He, Mei; Wang, Haiyan

2017-12-01

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

Failure modes and effects analysis for ocular brachytherapy.

PubMed

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

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

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

PubMed

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

2015-01-01

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

Failure modes and effects analysis automation

NASA Technical Reports Server (NTRS)

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

1988-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis/Critical Items List (FMEA/CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results corresponding to the Orbiter Atmospheric Revitalization and Pressure Control Subsystem (ARPCS) are documented. The ARPCS hardware was categorized into the following subdivisions: (1) Atmospheric Make-up and Control (including the Auxiliary Oxygen Assembly, Oxygen Assembly, and Nitrogen Assembly); and (2) Atmospheric Vent and Control (including the Positive Relief Vent Assembly, Negative Relief Vent Assembly, and Cabin Vent Assembly). The IOA analysis process utilized available ARPCS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Mechanical Actuation System (MAS) hardware. Specifically, the MAS hardware consists of the following components: Air Data Probe (ADP); Elevon Seal Panel (ESP); External Tank Umbilical (ETU); Ku-Band Deploy (KBD); Payload Bay Doors (PBD); Payload Bay Radiators (PBR); Personnel Hatches (PH); Vent Door Mechanism (VDM); and Startracker Door Mechanism (SDM). The IOA analysis process utilized available MAS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.

Independent Orbiter Assessment (IOA): FMEA/CIL assessment

NASA Technical Reports Server (NTRS)

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

1988-01-01

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

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

PubMed Central

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

2013-01-01

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

TU-AB-BRD-01: Process Mapping

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

Palta, J.

2015-06-15

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

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

PubMed

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

2017-04-18

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

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

PubMed

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

2013-09-06

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

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

NASA Technical Reports Server (NTRS)

Robinson, W. W.

1988-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Electrical Power Distribution and Control (EPD and C)/Remote Manipulator System (RMS) hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA analysis of the EPD and C/RMS hardware initially generated 345 failure mode worksheets and identified 117 Potential Critical Items (PCIs) before starting the assessment process. These analysis results were compared to the proposed NASA Post 51-L baseline of 132 FMEAs and 66 CIL items.

TU-AB-BRD-00: Task Group 100

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

NONE

2015-06-15

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

TU-AB-BRD-03: Fault Tree Analysis

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

Dunscombe, P.

2015-06-15

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

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

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

Thomadsen, B.

2015-06-15

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

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) is presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results corresponding to the Orbiter Guidance, Navigation, and Control (GNC) Subsystem hardware are documented. The function of the GNC hardware is to respond to guidance, navigation, and control software commands to effect vehicle control and to provide sensor and controller data to GNC software. Some of the GNC hardware for which failure modes analysis was performed includes: hand controllers; Rudder Pedal Transducer Assembly (RPTA); Speed Brake Thrust Controller (SBTC); Inertial Measurement Unit (IMU); Star Tracker (ST); Crew Optical Alignment Site (COAS); Air Data Transducer Assembly (ADTA); Rate Gyro Assemblies; Accelerometer Assembly (AA); Aerosurface Servo Amplifier (ASA); and Ascent Thrust Vector Control (ATVC). The IOA analysis process utilized available GNC hardware drawings, workbooks, specifications, schematics, and systems briefs for defining hardware assemblies, components, and circuits. Each hardware item was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.

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

PubMed

Varzakas, Theodoros H; Arvanitoyannis, Ioannis S

2007-01-01

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

Characterization of failure processes in tungsten copper composites under fatigue loading conditions

NASA Technical Reports Server (NTRS)

Kim, Yong-Suk; Verrilli, Michael J.; Gabb, Timothy P.

1989-01-01

A fractographic and metallographic investigation was performed on specimens of a tungsten fiber reinforced copper matrix composite (9 vol percent), which had experienced fatigue failures at elevated temperatures. Major failure modes and possible failure mechanisms, with an emphasis placed on characterizing fatigue damage accumulation, were determined. Metallography of specimens fatigued under isothermal cyclic loading suggested that fatigue damage initiates in the matrix. Cracks nucleated within the copper matrix at grain boundaries, and they propagated through cavity coalescence. The growing cracks subsequently interacted with the reinforcing tungsten fibers, producing a localized ductile fiber failure. Examinations of interrupted tests before final failure confirmed the suggested fatigue damage processes.

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

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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

Rusu, I; Thomas, T; Roeske, J

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

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

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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

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

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

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

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

NASA Technical Reports Server (NTRS)

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

1979-01-01

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

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

DOT National Transportation Integrated Search

2011-03-01

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

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

PubMed Central

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

2016-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

Results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Generation (EPG)/Fuel Cell Powerplant (FCP) hardware. The EPG/FCP hardware is required for performing functions of electrical power generation and product water distribution in the Orbiter. Specifically, the EPG/FCP hardware consists of the following divisions: (1) Power Section Assembly (PSA); (2) Reactant Control Subsystem (RCS); (3) Thermal Control Subsystem (TCS); and (4) Water Removal Subsystem (WRS). The IOA analysis process utilized available EPG/FCP hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbital Maneuvering System (OMS) hardware are documented. The OMS provides the thrust to perform orbit insertion, orbit circularization, orbit transfer, rendezvous, and deorbit. The OMS is housed in two independent pods located one on each side of the tail and consists of the following subsystems: Helium Pressurization; Propellant Storage and Distribution; Orbital Maneuvering Engine; and Electrical Power Distribution and Control. The IOA analysis process utilized available OMS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluted and analyzed for possible failure modes and effects. Criticality was asigned based upon the severity of the effect for each failure mode.

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

PubMed Central

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

2013-01-01

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

Investigation of improving MEMS-type VOA reliability

NASA Astrophysics Data System (ADS)

Hong, Seok K.; Lee, Yeong G.; Park, Moo Y.

2003-12-01

MEMS technologies have been applied to a lot of areas, such as optical communications, Gyroscopes and Bio-medical components and so on. In terms of the applications in the optical communication field, MEMS technologies are essential, especially, in multi dimensional optical switches and Variable Optical Attenuators(VOAs). This paper describes the process for the development of MEMS type VOAs with good optical performance and improved reliability. Generally, MEMS VOAs have been fabricated by silicon micro-machining process, precise fibre alignment and sophisticated packaging process. Because, it is composed of many structures with various materials, it is difficult to make devices reliable. We have developed MEMS type VOSs with many failure mode considerations (FMEA: Failure Mode Effect Analysis) in the initial design step, predicted critical failure factors and revised the design, and confirmed the reliability by preliminary test. These predicted failure factors were moisture, bonding strength of the wire, which wired between the MEMS chip and TO-CAN and instability of supplied signals. Statistical quality control tools (ANOVA, T-test and so on) were used to control these potential failure factors and produce optimum manufacturing conditions. To sum up, we have successfully developed reliable MEMS type VOAs with good optical performances by controlling potential failure factors and using statistical quality control tools. As a result, developed VOAs passed international reliability standards (Telcodia GR-1221-CORE).

Investigation of improving MEMS-type VOA reliability

NASA Astrophysics Data System (ADS)

Hong, Seok K.; Lee, Yeong G.; Park, Moo Y.

2004-01-01

MEMS technologies have been applied to a lot of areas, such as optical communications, Gyroscopes and Bio-medical components and so on. In terms of the applications in the optical communication field, MEMS technologies are essential, especially, in multi dimensional optical switches and Variable Optical Attenuators(VOAs). This paper describes the process for the development of MEMS type VOAs with good optical performance and improved reliability. Generally, MEMS VOAs have been fabricated by silicon micro-machining process, precise fibre alignment and sophisticated packaging process. Because, it is composed of many structures with various materials, it is difficult to make devices reliable. We have developed MEMS type VOSs with many failure mode considerations (FMEA: Failure Mode Effect Analysis) in the initial design step, predicted critical failure factors and revised the design, and confirmed the reliability by preliminary test. These predicted failure factors were moisture, bonding strength of the wire, which wired between the MEMS chip and TO-CAN and instability of supplied signals. Statistical quality control tools (ANOVA, T-test and so on) were used to control these potential failure factors and produce optimum manufacturing conditions. To sum up, we have successfully developed reliable MEMS type VOAs with good optical performances by controlling potential failure factors and using statistical quality control tools. As a result, developed VOAs passed international reliability standards (Telcodia GR-1221-CORE).

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbiter Body Flap (BF) subsystem hardware are documented. The BF is a large aerosurface located at the trailing edge of the lower aft fuselage of the Orbiter. The proper function of the BF is essential during the dynamic flight phases of ascent and entry. During the ascent phase of flight, the BF trails in a fixed position. For entry, the BF provides elevon load relief, trim control, and acts as a heat shield for the main engines. Specifically, the BF hardware comprises the following components: Power Drive Unit (PDU), rotary actuators, and torque tubes. The IOA analysis process utilized available BF hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 35 failure modes analyzed, 19 were determined to be PCIs.

Functional Interrupts and Destructive Failures from Single Event Effect Testing of Point-Of-Load Devices

NASA Technical Reports Server (NTRS)

Chen, Dakai; Phan, Anthony; Kim, Hak; Swonger, James; Musil, Paul; LaBel, Kenneth

2013-01-01

We show examples of single event functional interrupt and destructive failure in modern POL devices. The increasing complexity and diversity of the design and process introduce hard SEE modes that are triggered by various mechanisms.

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

PubMed

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

2014-07-15

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

Functional Fault Model Development Process to Support Design Analysis and Operational Assessment

NASA Technical Reports Server (NTRS)

Melcher, Kevin J.; Maul, William A.; Hemminger, Joseph A.

2016-01-01

A functional fault model (FFM) is an abstract representation of the failure space of a given system. As such, it simulates the propagation of failure effects along paths between the origin of the system failure modes and points within the system capable of observing the failure effects. As a result, FFMs may be used to diagnose the presence of failures in the modeled system. FFMs necessarily contain a significant amount of information about the design, operations, and failure modes and effects. One of the important benefits of FFMs is that they may be qualitative, rather than quantitative and, as a result, may be implemented early in the design process when there is more potential to positively impact the system design. FFMs may therefore be developed and matured throughout the monitored system's design process and may subsequently be used to provide real-time diagnostic assessments that support system operations. This paper provides an overview of a generalized NASA process that is being used to develop and apply FFMs. FFM technology has been evolving for more than 25 years. The FFM development process presented in this paper was refined during NASA's Ares I, Space Launch System, and Ground Systems Development and Operations programs (i.e., from about 2007 to the present). Process refinement took place as new modeling, analysis, and verification tools were created to enhance FFM capabilities. In this paper, standard elements of a model development process (i.e., knowledge acquisition, conceptual design, implementation & verification, and application) are described within the context of FFMs. Further, newer tools and analytical capabilities that may benefit the broader systems engineering process are identified and briefly described. The discussion is intended as a high-level guide for future FFM modelers.

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

PubMed

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

2018-02-01

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

Probabilistic framework for product design optimization and risk management

NASA Astrophysics Data System (ADS)

Keski-Rahkonen, J. K.

2018-05-01

Probabilistic methods have gradually gained ground within engineering practices but currently it is still the industry standard to use deterministic safety margin approaches to dimensioning components and qualitative methods to manage product risks. These methods are suitable for baseline design work but quantitative risk management and product reliability optimization require more advanced predictive approaches. Ample research has been published on how to predict failure probabilities for mechanical components and furthermore to optimize reliability through life cycle cost analysis. This paper reviews the literature for existing methods and tries to harness their best features and simplify the process to be applicable in practical engineering work. Recommended process applies Monte Carlo method on top of load-resistance models to estimate failure probabilities. Furthermore, it adds on existing literature by introducing a practical framework to use probabilistic models in quantitative risk management and product life cycle costs optimization. The main focus is on mechanical failure modes due to the well-developed methods used to predict these types of failures. However, the same framework can be applied on any type of failure mode as long as predictive models can be developed.

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

NASA Technical Reports Server (NTRS)

Bailey, P. S.

1986-01-01

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

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

NASA Technical Reports Server (NTRS)

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

2012-01-01

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

User's guide to the Reliability Estimation System Testbed (REST)

NASA Technical Reports Server (NTRS)

Nicol, David M.; Palumbo, Daniel L.; Rifkin, Adam

1992-01-01

The Reliability Estimation System Testbed is an X-window based reliability modeling tool that was created to explore the use of the Reliability Modeling Language (RML). RML was defined to support several reliability analysis techniques including modularization, graphical representation, Failure Mode Effects Simulation (FMES), and parallel processing. These techniques are most useful in modeling large systems. Using modularization, an analyst can create reliability models for individual system components. The modules can be tested separately and then combined to compute the total system reliability. Because a one-to-one relationship can be established between system components and the reliability modules, a graphical user interface may be used to describe the system model. RML was designed to permit message passing between modules. This feature enables reliability modeling based on a run time simulation of the system wide effects of a component's failure modes. The use of failure modes effects simulation enhances the analyst's ability to correctly express system behavior when using the modularization approach to reliability modeling. To alleviate the computation bottleneck often found in large reliability models, REST was designed to take advantage of parallel processing on hypercube processors.

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

PubMed

Zimmermann, Hartmut F; Hentschel, Norbert

2011-01-01

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

Failure mode and effects analysis to reduce risk of anticoagulation levels above the target range during concurrent antimicrobial therapy.

PubMed

Daniels, Lisa M; Barreto, Jason N; Kuth, John C; Anderson, Jeremy R; Zhang, Beilei; Majka, Andrew J; Morgenthaler, Timothy I; Tosh, Pritish K

2015-07-15

A failure mode and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to above-target International Normalized Ratios (INRs) in warfarin-treated patients receiving concurrent antimicrobial therapy. The INRs of patients on long-term warfarin therapy who received a course of trimethoprim-sulfamethoxazole, metronidazole, fluconazole, miconazole, or voriconazole (highly potentiating antimicrobials, or HPAs) between September 1 and December 31, 2011, were compared with patients on long-term warfarin therapy who did not receive any antimicrobial during the same period. A multidisciplinary team of physicians, pharmacists, and a systems analyst was then formed to complete a step-by-step outline of the processes involved in warfarin management and concomitant HPA therapy, followed by an FMEA. Patients taking trimethoprim-sulfamethoxazole, metronidazole, or fluconazole demonstrated a significantly increased risk of having an INR of >4.5. The FMEA identified 134 failure modes. The most common failure modes were as follows: (1) electronic medical records did not identify all patients receiving warfarin, (2) HPA prescribers were unaware of recommended warfarin therapy when HPAs were prescribed, (3) HPA prescribers were unaware that a patient was taking warfarin and that the drug interaction is significant, and (4) warfarin managers were unaware that an HPA had been prescribed for a patient. An FMEA determined that the risk of adverse events caused by concomitantly administering warfarin and HPAs can be decreased by preemptively identifying patients receiving warfarin, having a care process in place, alerting providers about the patient's risk status, and notifying providers at the anticoagulation clinic. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Risk Based Reliability Centered Maintenance of DOD Fire Protection Systems

DTIC Science & Technology

1999-01-01

2.2.3 Failure Mode and Effect Analysis ( FMEA )............................ 2.2.4 Failure Mode Risk Characterization...Step 2 - System functions and functional failures definition Step 3 - Failure mode and effect analysis ( FMEA ) Step 4 - Failure mode risk...system). The Interface Location column identifies the location where the FMEA of the fire protection system began or stopped. For example, for the fire

Flexural Progressive Failure of Carbon/Glass Interlayer and Intralayer Hybrid Composites.

PubMed

Wang, Qingtao; Wu, Weili; Gong, Zhili; Li, Wei

2018-04-17

The flexural progressive failure modes of carbon fiber and glass fiber (C/G) interlayer and intralayer hybrid composites were investigated in this work. Results showed that the bending failure modes for interlayer hybrid composites are determined by the layup structure. Besides, the bending failure is characterized by the compression failure of the upper layer, when carbon fiber tends to distribute in the upper layer, the interlayer hybrid composite fails early, the failure force is characterized by a multi-stage slightly fluctuating decline and the fracture area exhibits a diamond shape. While carbon fiber distributes in the middle or bottom layer, the failure time starts late, and the failure process exhibits one stage sharp force/stress drop, the fracture zone of glass fiber above the carbon layers presents an inverted trapezoid shape, while the fracture of glass fiber below the carbon layers exhibits an inverted triangular shape. With regards to the intralayer hybrid composites, the C/G hybrid ratio plays a dominating role in the bending failure which could be considered as the mixed failures of four structures. The bending failure of intralayer hybrid composites occurs in advance since carbon fiber are located in each layer; the failure process shows a multi-stage fluctuating decline, and the decline slows down as carbon fiber content increases, and the fracture sound release has the characteristics of a low intensity and high frequency for a long time. By contrast, as glass fiber content increases, the bending failure of intralayer composites is featured with a multi-stage cliff decline with a high amplitude and low frequency for a short-time fracture sound release.

Application of Function-Failure Similarity Method to Rotorcraft Component Design

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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

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

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

2015-06-15

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

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

NASA Technical Reports Server (NTRS)

Patton, Jeff A.

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Distribution and Control (EPD and C)/Electrical Power Generation (EPG) hardware. The EPD and C/EPG hardware is required for performing critical functions of cryogenic reactant storage, electrical power generation and product water distribution in the Orbiter. Specifically, the EPD and C/EPG hardware consists of the following components: Power Section Assembly (PSA); Reactant Control Subsystem (RCS); Thermal Control Subsystem (TCS); Water Removal Subsystem (WRS); and Power Reactant Storage and Distribution System (PRSDS). The IOA analysis process utilized available EPD and C/EPG hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.

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.

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Data Processing System (DPS) hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the NASA FMEA/CIL baseline with proposed Post 51-L updates included. A resolution of each discrepancy from the comparison is provided through additional analysis as required. The results of that comparison is documented for the Orbiter DPS hardware.

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

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

A dynamic integrated fault diagnosis method for power transformers.

PubMed

Gao, Wensheng; Bai, Cuifen; Liu, Tong

2015-01-01

In order to diagnose transformer fault efficiently and accurately, a dynamic integrated fault diagnosis method based on Bayesian network is proposed in this paper. First, an integrated fault diagnosis model is established based on the causal relationship among abnormal working conditions, failure modes, and failure symptoms of transformers, aimed at obtaining the most possible failure mode. And then considering the evidence input into the diagnosis model is gradually acquired and the fault diagnosis process in reality is multistep, a dynamic fault diagnosis mechanism is proposed based on the integrated fault diagnosis model. Different from the existing one-step diagnosis mechanism, it includes a multistep evidence-selection process, which gives the most effective diagnostic test to be performed in next step. Therefore, it can reduce unnecessary diagnostic tests and improve the accuracy and efficiency of diagnosis. Finally, the dynamic integrated fault diagnosis method is applied to actual cases, and the validity of this method is verified.

A Dynamic Integrated Fault Diagnosis Method for Power Transformers

PubMed Central

Gao, Wensheng; Liu, Tong

2015-01-01

In order to diagnose transformer fault efficiently and accurately, a dynamic integrated fault diagnosis method based on Bayesian network is proposed in this paper. First, an integrated fault diagnosis model is established based on the causal relationship among abnormal working conditions, failure modes, and failure symptoms of transformers, aimed at obtaining the most possible failure mode. And then considering the evidence input into the diagnosis model is gradually acquired and the fault diagnosis process in reality is multistep, a dynamic fault diagnosis mechanism is proposed based on the integrated fault diagnosis model. Different from the existing one-step diagnosis mechanism, it includes a multistep evidence-selection process, which gives the most effective diagnostic test to be performed in next step. Therefore, it can reduce unnecessary diagnostic tests and improve the accuracy and efficiency of diagnosis. Finally, the dynamic integrated fault diagnosis method is applied to actual cases, and the validity of this method is verified. PMID:25685841

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

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

Gray, J; Lukose, R; Bronson, J

2015-06-15

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

Real-time diagnostics for a reusable rocket engine

NASA Technical Reports Server (NTRS)

Guo, T. H.; Merrill, W.; Duyar, A.

1992-01-01

A hierarchical, decentralized diagnostic system is proposed for the Real-Time Diagnostic System component of the Intelligent Control System (ICS) for reusable rocket engines. The proposed diagnostic system has three layers of information processing: condition monitoring, fault mode detection, and expert system diagnostics. The condition monitoring layer is the first level of signal processing. Here, important features of the sensor data are extracted. These processed data are then used by the higher level fault mode detection layer to do preliminary diagnosis on potential faults at the component level. Because of the closely coupled nature of the rocket engine propulsion system components, it is expected that a given engine condition may trigger more than one fault mode detector. Expert knowledge is needed to resolve the conflicting reports from the various failure mode detectors. This is the function of the diagnostic expert layer. Here, the heuristic nature of this decision process makes it desirable to use an expert system approach. Implementation of the real-time diagnostic system described above requires a wide spectrum of information processing capability. Generally, in the condition monitoring layer, fast data processing is often needed for feature extraction and signal conditioning. This is usually followed by some detection logic to determine the selected faults on the component level. Three different techniques are used to attack different fault detection problems in the NASA LeRC ICS testbed simulation. The first technique employed is the neural network application for real-time sensor validation which includes failure detection, isolation, and accommodation. The second approach demonstrated is the model-based fault diagnosis system using on-line parameter identification. Besides these model based diagnostic schemes, there are still many failure modes which need to be diagnosed by the heuristic expert knowledge. The heuristic expert knowledge is implemented using a real-time expert system tool called G2 by Gensym Corp. Finally, the distributed diagnostic system requires another level of intelligence to oversee the fault mode reports generated by component fault detectors. The decision making at this level can best be done using a rule-based expert system. This level of expert knowledge is also implemented using G2.

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

PubMed

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

2015-01-01

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

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

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

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

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

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

NASA Astrophysics Data System (ADS)

Li, Xibing; Du, Kun; Li, Diyuan

2015-11-01

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

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

PubMed

Zheng, Yuanshui; Johnson, Randall; Larson, Gary

2016-06-01

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

Dielectric elastomer membranes undergoing inhomogeneous deformation

NASA Astrophysics Data System (ADS)

He, Tianhu; Zhao, Xuanhe; Suo, Zhigang

2009-10-01

Dielectric elastomers are capable of large deformation subject to an electric voltage and are promising for use as actuators, sensors, and generators. Because of large deformation, nonlinear equations of states, and diverse modes of failure, modeling the process of electromechanical transduction has been challenging. This paper studies a membrane of a dielectric elastomer deformed into an out-of-plane axisymmetric shape, a configuration used in a family of commercial devices known as the universal muscle actuators. The kinematics of deformation and charging, together with thermodynamics, leads to equations that govern the state of equilibrium. Numerical results indicate that the field in the membrane can be very inhomogeneous, and that the membrane is susceptible to several modes of failure, including electrical breakdown, loss of tension, and rupture by stretch. Care is needed in the design to balance the requirements of averting various modes of failure while using the material efficiently.

SU-F-T-250: What Does It Take to Correctly Assess the High Failure Modes of an Advanced Radiotherapy Procedure Such as Stereotactic Body Radiation Therapy?

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

Han, D; Vile, D; Rosu, M

Purpose: Assess the correct implementation of risk-based methodology of TG 100 to optimize quality management and patient safety procedures for Stereotactic Body Radiation Therapy. Methods: A detailed process map of SBRT treatment procedure was generated by a team of three physicists with varying clinical experience at our institution to assess the potential high-risk failure modes. The probabilities of occurrence (O), severity (S) and detectability (D) for potential failure mode in each step of the process map were assigned by these individuals independently on the scale from1 to 10. The risk priority numbers (RPN) were computed and analyzed. The highest 30more » potential modes from each physicist’s analysis were then compared. Results: The RPN values assessed by the three physicists ranged from 30 to 300. The magnitudes of the RPN values from each physicist were different, and there was no concordance in the highest RPN values recorded by three physicists independently. The 10 highest RPN values belonged to sub steps of CT simulation, contouring and delivery in the SBRT process map. For these 10 highest RPN values, at least two physicists, irrespective of their length of experience had concordance but no general conclusions emerged. Conclusion: This study clearly shows that the risk-based assessment of a clinical process map requires great deal of preparation, group discussions, and participation by all stakeholders. One group albeit physicists cannot effectively implement risk-based methodology proposed by TG100. It should be a team effort in which the physicists can certainly play the leading role. This also corroborates TG100 recommendation that risk-based assessment of clinical processes is a multidisciplinary team effort.« less

[THE FAILURE MODES AND EFFECTS ANALYSIS FACILITATES A SAFE, TIME AND MONEY SAVING OPEN ACCESS COLONOSCOPY SERVICE].

PubMed

Gingold-Belfer, Rachel; Niv, Yaron; Horev, Nehama; Gross, Shuli; Sahar, Nadav; Dickman, Ram

2017-04-01

Failure modes and effects analysis (FMEA) is used for the identification of potential risks in health care processes. We used a specific FMEA - based form for direct referral for colonoscopy and assessed it for procedurerelated perforations. Ten experts in endoscopy evaluated and computed the entire referral process, modes of preparation for the endoscopic procedure, the endoscopic procedure itself and the discharge process. We used FMEA assessing for likelihood of occurrence, detection and severity and calculated the risk profile number (RPN) for each of the above points. According to the highest RPN results we designed a specific open access referral form and then compared the occurrence of colonic perforations (between 2010 and 2013) in patients who were referred through the open access arm (Group 1) to those who had a prior clinical consultation (non-open access, Group 2). Our experts in endoscopy (5 physicians and 5 nurses) identified 3 categories of failure modes that, on average, reached the highest RPNs. We identified 9,558 colonoscopies in group 1, and 12,567 in group 2. Perforations were identified in three patients from the open access group (1:3186, 0.03%) and in 10 from group 2 (1:1256, 0.07%) (p = 0.024). Direct referral for colonoscopy saved 9,558 pre-procedure consultations and the sum of $850,000. The FMEA tool-based specific referral form facilitates a safe, time and money saving open access colonoscopy service. Our form may be adopted by other gastroenterological clinics in Israel.

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

NASA Astrophysics Data System (ADS)

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

2018-06-01

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

An FMEA evaluation of intensity modulated radiation therapy dose delivery failures at tolerance criteria levels.

PubMed

Faught, Jacqueline Tonigan; Balter, Peter A; Johnson, Jennifer L; Kry, Stephen F; Court, Laurence E; Stingo, Francesco C; Followill, David S

2017-11-01

The objective of this work was to assess both the perception of failure modes in Intensity Modulated Radiation Therapy (IMRT) when the linac is operated at the edge of tolerances given in AAPM TG-40 (Kutcher et al.) and TG-142 (Klein et al.) as well as the application of FMEA to this specific section of the IMRT process. An online survey was distributed to approximately 2000 physicists worldwide that participate in quality services provided by the Imaging and Radiation Oncology Core - Houston (IROC-H). The survey briefly described eleven different failure modes covered by basic quality assurance in step-and-shoot IMRT at or near TG-40 (Kutcher et al.) and TG-142 (Klein et al.) tolerance criteria levels. Respondents were asked to estimate the worst case scenario percent dose error that could be caused by each of these failure modes in a head and neck patient as well as the FMEA scores: Occurrence, Detectability, and Severity. Risk probability number (RPN) scores were calculated as the product of these scores. Demographic data were also collected. A total of 181 individual and three group responses were submitted. 84% were from North America. Most (76%) individual respondents performed at least 80% clinical work and 92% were nationally certified. Respondent medical physics experience ranged from 2.5 to 45 yr (average 18 yr). A total of 52% of individual respondents were at least somewhat familiar with FMEA, while 17% were not familiar. Several IMRT techniques, treatment planning systems, and linear accelerator manufacturers were represented. All failure modes received widely varying scores ranging from 1 to 10 for occurrence, at least 1-9 for detectability, and at least 1-7 for severity. Ranking failure modes by RPN scores also resulted in large variability, with each failure mode being ranked both most risky (1st) and least risky (11th) by different respondents. On average MLC modeling had the highest RPN scores. Individual estimated percent dose errors and severity scores positively correlated (P < 0.01) for each FM as expected. No universal correlations were found between the demographic information collected and scoring, percent dose errors or ranking. Failure modes investigated overall were evaluated as low to medium risk, with average RPNs less than 110. The ranking of 11 failure modes was not agreed upon by the community. Large variability in FMEA scoring may be caused by individual interpretation and/or experience, reflecting the subjective nature of the FMEA tool. © 2017 American Association of Physicists in Medicine.

Failure mode and effects analysis of skin electronic brachytherapy using Esteya® unit

PubMed Central

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

2016-01-01

Purpose Esteya® (Nucletron, an Elekta company, Elekta AB, Stockholm, Sweden) is an electronic brachytherapy device used for skin cancer lesion treatment. In order to establish an adequate level of quality of treatment, a risk analysis of the Esteya treatment process has been done, following the methodology proposed by the TG-100 guidelines of the American Association of Physicists in Medicine (AAPM). Material and methods A multidisciplinary team familiar with the treatment process was formed. This team developed a process map (PM) outlining the stages, through which a patient passed when subjected to the Esteya treatment. They identified potential failure modes (FM) and each individual FM was assessed for the severity (S), frequency of occurrence (O), and lack of detection (D). A list of existing quality management tools was developed and the FMs were consensually reevaluated. Finally, the FMs were ranked according to their risk priority number (RPN) and their S. Results 146 FMs were identified, 106 of which had RPN ≥ 50 and 30 had S ≥ 7. After introducing the quality management tools, only 21 FMs had RPN ≥ 50. The importance of ensuring contact between the applicator and the surface of the patient’s skin was emphasized, so the setup was reviewed by a second individual before each treatment session with periodic quality control to ensure stability of the applicator pressure. Some of the essential quality management tools are already being implemented in the installation are the simple templates for reproducible positioning of skin applicators, that help marking the treatment area and positioning of X-ray tube. Conclusions New quality management tools have been established as a result of the application of the failure modes and effects analysis (FMEA) treatment. However, periodic update of the FMEA process is necessary, since clinical experience has suggested occurring of further new possible potential failure modes. PMID:28115958

Application of ISO 22000 and Failure Mode and Effect Analysis (FMEA) for industrial processing of salmon: a case study.

PubMed

Arvanitoyannis, Ioannis S; Varzakas, Theodoros H

2008-05-01

The Failure Mode and Effect Analysis (FMEA) model was applied for risk assessment of salmon manufacturing. A tentative approach of FMEA application to the salmon industry was attempted in conjunction with ISO 22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (salmon processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points were identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram and fishbone diagram). In this work, a comparison of ISO 22000 analysis with HACCP is carried out over salmon processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the RPN per identified processing hazard. Fish receiving, casing/marking, blood removal, evisceration, filet-making cooling/freezing, and distribution were the processes identified as the ones with the highest RPN (252, 240, 210, 210, 210, 210, 200 respectively) and corrective actions were undertaken. After the application of corrective actions, a second calculation of RPN values was carried out resulting in substantially lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO 22000 system of a salmon processing industry is anticipated to prove advantageous to industrialists, state food inspectors, and consumers.

Application of Failure Mode and Effect Analysis (FMEA) and cause and effect analysis in conjunction with ISO 22000 to a snails (Helix aspersa) processing plant; A case study.

PubMed

Arvanitoyannis, Ioannis S; Varzakas, Theodoros H

2009-08-01

Failure Mode and Effect Analysis (FMEA) has been applied for the risk assessment of snails manufacturing. A tentative approach of FMEA application to the snails industry was attempted in conjunction with ISO 22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (snails processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram, and fishbone diagram). In this work a comparison of ISO22000 analysis with HACCP is carried out over snails processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the RPN per identified processing hazard. Sterilization of tins, bioaccumulation of heavy metals, packaging of shells and poisonous mushrooms, were the processes identified as the ones with the highest RPN (280, 240, 147, 144, respectively) and corrective actions were undertaken. Following the application of corrective actions, a second calculation of RPN values was carried out leading to considerably lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO22000 system of a snails processing industry is considered imperative.

Failure Mode Identification Through Clustering Analysis

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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

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

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

2012-06-25

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

On a common critical state in localized and diffuse failure modes

NASA Astrophysics Data System (ADS)

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

2016-10-01

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

Flexural Progressive Failure of Carbon/Glass Interlayer and Intralayer Hybrid Composites

PubMed Central

Wu, Weili; Gong, Zhili

2018-01-01

The flexural progressive failure modes of carbon fiber and glass fiber (C/G) interlayer and intralayer hybrid composites were investigated in this work. Results showed that the bending failure modes for interlayer hybrid composites are determined by the layup structure. Besides, the bending failure is characterized by the compression failure of the upper layer, when carbon fiber tends to distribute in the upper layer, the interlayer hybrid composite fails early, the failure force is characterized by a multi-stage slightly fluctuating decline and the fracture area exhibits a diamond shape. While carbon fiber distributes in the middle or bottom layer, the failure time starts late, and the failure process exhibits one stage sharp force/stress drop, the fracture zone of glass fiber above the carbon layers presents an inverted trapezoid shape, while the fracture of glass fiber below the carbon layers exhibits an inverted triangular shape. With regards to the intralayer hybrid composites, the C/G hybrid ratio plays a dominating role in the bending failure which could be considered as the mixed failures of four structures. The bending failure of intralayer hybrid composites occurs in advance since carbon fiber are located in each layer; the failure process shows a multi-stage fluctuating decline, and the decline slows down as carbon fiber content increases, and the fracture sound release has the characteristics of a low intensity and high frequency for a long time. By contrast, as glass fiber content increases, the bending failure of intralayer composites is featured with a multi-stage cliff decline with a high amplitude and low frequency for a short-time fracture sound release. PMID:29673236

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

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

Schubert, L; Westerly, D; Vinogradskiy, Y

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

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

NASA Technical Reports Server (NTRS)

Ko, William L.

2004-01-01

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

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

PubMed

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

2017-11-10

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

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

PubMed

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

2016-01-01

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

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

PubMed

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

2010-09-01

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

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

PubMed Central

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

2015-01-01

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

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

PubMed

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

2015-01-01

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

Failure mode and effects analysis: too little for too much?

PubMed

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

2012-07-01

Failure mode and effects analysis (FMEA) is a structured prospective risk assessment method that is widely used within healthcare. FMEA involves a multidisciplinary team mapping out a high-risk process of care, identifying the failures that can occur, and then characterising each of these in terms of probability of occurrence, severity of effects and detectability, to give a risk priority number used to identify failures most in need of attention. One might assume that such a widely used tool would have an established evidence base. This paper considers whether or not this is the case, examining the evidence for the reliability and validity of its outputs, the mathematical principles behind the calculation of a risk prioirty number, and variation in how it is used in practice. We also consider the likely advantages of this approach, together with the disadvantages in terms of the healthcare professionals' time involved. We conclude that although FMEA is popular and many published studies have reported its use within healthcare, there is little evidence to support its use for the quantitative prioritisation of process failures. It lacks both reliability and validity, and is very time consuming. We would not recommend its use as a quantitative technique to prioritise, promote or study patient safety interventions. However, the stage of FMEA involving multidisciplinary mapping process seems valuable and work is now needed to identify the best way of converting this into plans for action.

Academic-Community Hospital Comparison of Vulnerabilities in Door-to-Needle Process for Acute Ischemic Stroke.

PubMed

Prabhakaran, Shyam; Khorzad, Rebeca; Brown, Alexandra; Nannicelli, Anna P; Khare, Rahul; Holl, Jane L

2015-10-01

Although best practices have been developed for achieving door-to-needle (DTN) times ≤60 minutes for stroke thrombolysis, critical DTN process failures persist. We sought to compare these failures in the Emergency Department at an academic medical center and a community hospital. Failure modes effects and criticality analysis was used to identify system and process failures. Multidisciplinary teams involved in DTN care participated in moderated sessions at each site. As a result, DTN process maps were created and potential failures and their causes, frequency, severity, and existing safeguards were identified. For each failure, a risk priority number and criticality score were calculated; failures were then ranked, with the highest scores representing the most critical failures and targets for intervention. We detected a total of 70 failures in 50 process steps and 76 failures in 42 process steps at the community hospital and academic medical center, respectively. At the community hospital, critical failures included (1) delay in registration because of Emergency Department overcrowding, (2) incorrect triage diagnosis among walk-in patients, and (3) delay in obtaining consent for thrombolytic treatment. At the academic medical center, critical failures included (1) incorrect triage diagnosis among walk-in patients, (2) delay in stroke team activation, and (3) delay in obtaining computed tomographic imaging. Although the identification of common critical failures suggests opportunities for a generalizable process redesign, differences in the criticality and nature of failures must be addressed at the individual hospital level, to develop robust and sustainable solutions to reduce DTN time. © 2015 American Heart Association, Inc.

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Landing/Deceleration Subsystem hardware. The Landing/Deceleration Subsystem is utilized to allow the Orbiter to perform a safe landing, allowing for landing-gear deploy activities, steering and braking control throughout the landing rollout to wheel-stop, and to allow for ground-handling capability during the ground-processing phase of the flight cycle. Specifically, the Landing/Deceleration hardware consists of the following components: Nose Landing Gear (NLG); Main Landing Gear (MLG); Brake and Antiskid (B and AS) Electrical Power Distribution and Controls (EPD and C); Nose Wheel Steering (NWS); and Hydraulics Actuators. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Due to the lack of redundancy in the Landing/Deceleration Subsystems there is a high number of critical items.

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

NASA Technical Reports Server (NTRS)

Robinson, W. W.

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the Electrical Power Distribution and Control (EPD and C)/Remote Manipulator System (RMS) hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained in the NASA FMEA/CIL documentation. This report documents the results of the independent analysis of the EPD and C/RMS (both port and starboard) hardware. The EPD and C/RMS subsystem hardware provides the electrical power and power control circuitry required to safely deploy, operate, control, and stow or guillotine and jettison two (one port and one starboard) RMSs. The EPD and C/RMS subsystem is subdivided into the four following functional divisions: Remote Manipulator Arm; Manipulator Deploy Control; Manipulator Latch Control; Manipulator Arm Shoulder Jettison; and Retention Arm Jettison. The IOA analysis process utilized available EPD and C/RMS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based on the severity of the effect for each failure mode.

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

PubMed

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

2010-03-01

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

Failure Mode, Effects, and Criticality Analysis (FMECA)

DTIC Science & Technology

1993-04-01

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

Application of ISO22000, failure mode, and effect analysis (FMEA) cause and effect diagrams and pareto in conjunction with HACCP and risk assessment for processing of pastry products.

PubMed

Varzakas, Theodoros H

2011-09-01

The Failure Mode and Effect Analysis (FMEA) model has been applied for the risk assessment of pastry processing. A tentative approach of FMEA application to the pastry industry was attempted in conjunction with ISO22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (pastry processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram, and fishbone diagram). In this work a comparison of ISO22000 analysis with HACCP is carried out over pastry processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the Risk Priority Number (RPN) per identified processing hazard. Storage of raw materials and storage of final products at -18°C followed by freezing were the processes identified as the ones with the highest RPN (225, 225, and 144 respectively) and corrective actions were undertaken. Following the application of corrective actions, a second calculation of RPN values was carried out leading to considerably lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO22000 system of a pastry processing industry is considered imperative.

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

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

Comprehensive protocol of traceability during IVF: the result of a multicentre failure mode and effect analysis.

PubMed

Rienzi, L; Bariani, F; Dalla Zorza, M; Albani, E; Benini, F; Chamayou, S; Minasi, M G; Parmegiani, L; Restelli, L; Vizziello, G; Costa, A Nanni

2017-08-01

Can traceability of gametes and embryos be ensured during IVF? The use of a simple and comprehensive traceability system that includes the most susceptible phases during the IVF process minimizes the risk of mismatches. Mismatches in IVF are very rare but unfortunately possible with dramatic consequences for both patients and health care professionals. Traceability is thus a fundamental aspect of the treatment. A clear process of patient and cell identification involving witnessing protocols has to be in place in every unit. To identify potential failures in the traceability process and to develop strategies to mitigate the risk of mismatches, previously failure mode and effects analysis (FMEA) has been used effectively. The FMEA approach is however a subjective analysis, strictly related to specific protocols and thus the results are not always widely applicable. To reduce subjectivity and to obtain a widespread comprehensive protocol of traceability, a multicentre centrally coordinated FMEA was performed. Seven representative Italian centres (three public and four private) were selected. The study had a duration of 21 months (from April 2015 to December 2016) and was centrally coordinated by a team of experts: a risk analysis specialist, an expert embryologist and a specialist in human factor. Principal investigators of each centre were first instructed about proactive risk assessment and FMEA methodology. A multidisciplinary team to perform the FMEA analysis was then formed in each centre. After mapping the traceability process, each team identified the possible causes of mistakes in their protocol. A risk priority number (RPN) for each identified potential failure mode was calculated. The results of the FMEA analyses were centrally investigated and consistent corrective measures suggested. The teams performed new FMEA analyses after the recommended implementations. In each centre, this study involved: the laboratory director, the Quality Control & Quality Assurance responsible, Embryologist(s), Gynaecologist(s), Nurse(s) and Administration. The FMEA analyses were performed according to the Joint Commission International. The FMEA teams identified seven main process phases: oocyte collection, sperm collection, gamete processing, insemination, embryo culture, embryo transfer and gamete/embryo cryopreservation. A mean of 19.3 (SD ± 5.8) associated process steps and 41.9 (SD ± 12.4) possible failure modes were recognized per centre. A RPN ≥15 was calculated in a mean of 6.4 steps (range 2-12, SD ± 3.60). A total of 293 failure modes were centrally analysed 45 of which were considered at medium/high risk. After consistent corrective measures implementation and re-evaluation, a significant reduction in the RPNs in all centres (RPN <15 for all steps) was observed. A simple and comprehensive traceability system was designed as the result of the seven FMEA analyses. The validity of FMEA is in general questionable due to the subjectivity of the judgments. The design of this study has however minimized this risk by introducing external experts for the analysis of the FMEA results. Specific situations such as sperm/oocyte donation, import/export and pre-implantation genetic testing were not taken into consideration. Finally, this study is only limited to the analysis of failure modes that may lead to mismatches, other possible procedural mistakes are not accounted for. Every single IVF centre should have a clear and reliable protocol for identification of patients and traceability of cells during manipulation. The results of this study can support IVF groups in better recognizing critical steps in their protocols, understanding identification and witnessing process, and in turn enhancing safety by introducing validated corrective measures. This study was designed by the Italian Society of Embryology Reproduction and Research (SIERR) and funded by the Italian National Transplant Centre (CNT) of the Italian National Institute of Health (ISS). The authors have no conflicts of interest. N/A. © The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com

Critical fault patterns determination in fault-tolerant computer systems

NASA Technical Reports Server (NTRS)

Mccluskey, E. J.; Losq, J.

1978-01-01

The method proposed tries to enumerate all the critical fault-patterns (successive occurrences of failures) without analyzing every single possible fault. The conditions for the system to be operating in a given mode can be expressed in terms of the static states. Thus, one can find all the system states that correspond to a given critical mode of operation. The next step consists in analyzing the fault-detection mechanisms, the diagnosis algorithm and the process of switch control. From them, one can find all the possible system configurations that can result from a failure occurrence. Thus, one can list all the characteristics, with respect to detection, diagnosis, and switch control, that failures must have to constitute critical fault-patterns. Such an enumeration of the critical fault-patterns can be directly used to evaluate the overall system tolerance to failures. Present research is focused on how to efficiently make use of these system-level characteristics to enumerate all the failures that verify these characteristics.

Why Do Medial Unicompartmental Knee Arthroplasties Fail Today?

PubMed

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

2016-05-01

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

A quality risk management model approach for cell therapy manufacturing.

PubMed

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

2010-12-01

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

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

NASA Astrophysics Data System (ADS)

Baccar, D.; Söffker, D.

2017-11-01

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

Mechanics of dual-mode dilative failure in subaqueous sediment deposits

NASA Astrophysics Data System (ADS)

You, Yao; Flemings, Peter; Mohrig, David

2014-07-01

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

Common Cause Failures and Ultra Reliability

NASA Technical Reports Server (NTRS)

Jones, Harry W.

2012-01-01

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

Cascading network failure across the Alzheimer’s disease spectrum

PubMed Central

Knopman, David S.; Gunter, Jeffrey L.; Graff-Radford, Jonathan; Vemuri, Prashanthi; Boeve, Bradley F.; Petersen, Ronald C.; Weiner, Michael W.; Jack, Clifford R.

2016-01-01

Abstract Complex biological systems are organized across various spatiotemporal scales with particular scientific disciplines dedicated to the study of each scale (e.g. genetics, molecular biology and cognitive neuroscience). When considering disease pathophysiology, one must contemplate the scale at which the disease process is being observed and how these processes impact other levels of organization. Historically Alzheimer’s disease has been viewed as a disease of abnormally aggregated proteins by pathologists and molecular biologists and a disease of clinical symptoms by neurologists and psychologists. Bridging the divide between these scales has been elusive, but the study of brain networks appears to be a pivotal inroad to accomplish this task. In this study, we were guided by an emerging systems-based conceptualization of Alzheimer’s disease and investigated changes in brain networks across the disease spectrum. The default mode network has distinct subsystems with unique functional-anatomic connectivity, cognitive associations, and responses to Alzheimer’s pathophysiology. These distinctions provide a window into the systems-level pathophysiology of Alzheimer’s disease. Using clinical phenotyping, metadata, and multimodal neuroimaging data from the Alzheimer’s Disease Neuroimaging Initiative, we characterized the pattern of default mode network subsystem connectivity changes across the entire disease spectrum (n = 128). The two main findings of this paper are (i) the posterior default mode network fails before measurable amyloid plaques and appears to initiate a connectivity cascade that continues throughout the disease spectrum; and (ii) high connectivity between the posterior default mode network and hubs of high connectivity (many located in the frontal lobe) is associated with amyloid accumulation. These findings support a system model best characterized by a cascading network failure—analogous to cascading failures seen in power grids triggered by local overloads proliferating to downstream nodes eventually leading to widespread power outages, or systems failures. The failure begins in the posterior default mode network, which then shifts processing burden to other systems containing prominent connectivity hubs. This model predicts a connectivity ‘overload’ that precedes structural and functional declines and recasts the interpretation of high connectivity from that of a positive compensatory phenomenon to that of a load-shifting process transiently serving a compensatory role. It is unknown whether this systems-level pathophysiology is the inciting event driving downstream molecular events related to synaptic activity embedded in these systems. Possible interpretations include that the molecular-level events drive the network failure, a pathological interaction between the network-level and the molecular-level, or other upstream factors are driving both. PMID:26586695

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

PubMed

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

2013-05-01

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

Numerical Implementation of a Multiple-ISV Thermodynamically-Based Work Potential Theory for Modeling Progressive Damage and Failure in Fiber-Reinforced Laminates

NASA Technical Reports Server (NTRS)

Pineda, Evan J.; Waas, Anthony M.

2011-01-01

A thermodynamically-based work potential theory for modeling progressive damage and failure in fiber-reinforced laminates is presented. The current, multiple-internal state variable (ISV) formulation, enhanced Schapery theory (EST), utilizes separate ISVs for modeling the effects of damage and failure. Damage is considered to be the effect of any structural changes in a material that manifest as pre-peak non-linearity in the stress versus strain response. Conversely, failure is taken to be the effect of the evolution of any mechanisms that results in post-peak strain softening. It is assumed that matrix microdamage is the dominant damage mechanism in continuous fiber-reinforced polymer matrix laminates, and its evolution is controlled with a single ISV. Three additional ISVs are introduced to account for failure due to mode I transverse cracking, mode II transverse cracking, and mode I axial failure. Typically, failure evolution (i.e., post-peak strain softening) results in pathologically mesh dependent solutions within a finite element method (FEM) setting. Therefore, consistent character element lengths are introduced into the formulation of the evolution of the three failure ISVs. Using the stationarity of the total work potential with respect to each ISV, a set of thermodynamically consistent evolution equations for the ISVs is derived. The theory is implemented into commercial FEM software. Objectivity of total energy dissipated during the failure process, with regards to refinements in the FEM mesh, is demonstrated. The model is also verified against experimental results from two laminated, T800/3900-2 panels containing a central notch and different fiber-orientation stacking sequences. Global load versus displacement, global load versus local strain gage data, and macroscopic failure paths obtained from the models are compared to the experiments.

A Thermodynamically-Based Mesh Objective Work Potential Theory for Predicting Intralaminar Progressive Damage and Failure in Fiber-Reinforced Laminates

NASA Technical Reports Server (NTRS)

Pineda, Evan J.; Waas, Anthony M.

2012-01-01

A thermodynamically-based work potential theory for modeling progressive damage and failure in fiber-reinforced laminates is presented. The current, multiple-internal state variable (ISV) formulation, enhanced Schapery theory (EST), utilizes separate ISVs for modeling the effects of damage and failure. Damage is considered to be the effect of any structural changes in a material that manifest as pre-peak non-linearity in the stress versus strain response. Conversely, failure is taken to be the effect of the evolution of any mechanisms that results in post-peak strain softening. It is assumed that matrix microdamage is the dominant damage mechanism in continuous fiber-reinforced polymer matrix laminates, and its evolution is controlled with a single ISV. Three additional ISVs are introduced to account for failure due to mode I transverse cracking, mode II transverse cracking, and mode I axial failure. Typically, failure evolution (i.e., post-peak strain softening) results in pathologically mesh dependent solutions within a finite element method (FEM) setting. Therefore, consistent character element lengths are introduced into the formulation of the evolution of the three failure ISVs. Using the stationarity of the total work potential with respect to each ISV, a set of thermodynamically consistent evolution equations for the ISVs is derived. The theory is implemented into commercial FEM software. Objectivity of total energy dissipated during the failure process, with regards to refinements in the FEM mesh, is demonstrated. The model is also verified against experimental results from two laminated, T800/3900-2 panels containing a central notch and different fiber-orientation stacking sequences. Global load versus displacement, global load versus local strain gage data, and macroscopic failure paths obtained from the models are compared to the experiments.

Failure-Modes-And-Effects Analysis Of Software Logic

NASA Technical Reports Server (NTRS)

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

1996-01-01

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

Failure Mode and Effects Analysis (FMEA) Introductory Overview

DTIC Science & Technology

2012-06-14

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

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

NASA Astrophysics Data System (ADS)

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

2014-06-01

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

Experimental Study On The Effect Of Micro-Cracks On Brazilian Tensile Strength

NASA Astrophysics Data System (ADS)

Wang, Xiangyu

2015-12-01

For coal mine ground control issues, it is necessary to propose a failure criteria accounting for the transversely isotropic behaviors of rocks. Hence, it is very helpful to provide experimental data for the validation of the failure criteria. In this paper, the method for preparing transversely isotropic specimens and the scheme of the Brazilian tensile strength test are presented. Results obtained from Brazilian split tests under dry and water-saturated conditions reflect the effect of the development direction β of the structural plane, such as the bedding fissure, on the tensile strength, ultimate displacement, failure mode, and the whole splitting process. The results show that the tensile strength decreases linearly with increasing β. The softening coefficient of the tensile strength shows a sinusoidal function. The values of the slope and inflection point for the curve vary at the different stages of the Brazilian test. The failure mode of the rock specimen presented in this paper generally coincides with the standard Brazilian splitting failure mode. Based on the test results, the major influencing factors for the Brazilian splitting strength are analyzed and a mathematical model for solving the Brazilian splitting strength is proposed. The findings in this paper would greatly benefit the coal mine ground control studies when the surrounding rocks of interest show severe transversely isotropic behaviors.

A novel methodology for in-process monitoring of flow forming

NASA Astrophysics Data System (ADS)

Appleby, Andrew; Conway, Alastair; Ion, William

2017-10-01

Flow forming (FF) is an incremental cold working process with near-net-shape forming capability. Failures by fracture due to high deformation can be unexpected and sometimes catastrophic, causing tool damage. If process failures can be identified in real time, an automatic cut-out could prevent costly tool damage. Sound and vibration monitoring is well established and commercially viable in the machining sector to detect current and incipient process failures, but not for FF. A broad-frequency microphone was used to record the sound signature of the manufacturing cycle for a series of FF parts. Parts were flow formed using single and multiple passes, and flaws were introduced into some of the parts to simulate the presence of spontaneously initiated cracks. The results show that this methodology is capable of identifying both introduced defects and spontaneous failures during flow forming. Further investigation is needed to categorise and identify different modes of failure and identify further potential applications in rotary forming.

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

PubMed

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

2015-02-01

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

Static and fatigue testing of full-scale fuselage panels fabricated using a Therm-X(R) process

NASA Technical Reports Server (NTRS)

Dinicola, Albert J.; Kassapoglou, Christos; Chou, Jack C.

1992-01-01

Large, curved, integrally stiffened composite panels representative of an aircraft fuselage structure were fabricated using a Therm-X process, an alternative concept to conventional two-sided hard tooling and contour vacuum bagging. Panels subsequently were tested under pure shear loading in both static and fatigue regimes to assess the adequacy of the manufacturing process, the effectiveness of damage tolerant design features co-cured with the structure, and the accuracy of finite element and closed-form predictions of postbuckling capability and failure load. Test results indicated the process yielded panels of high quality and increased damage tolerance through suppression of common failure modes such as skin-stiffener separation and frame-stiffener corner failure. Finite element analyses generally produced good predictions of postbuckled shape, and a global-local modelling technique yielded failure load predictions that were within 7% of the experimental mean.

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

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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

NASA Astrophysics Data System (ADS)

Mirzaei Rafsanjani, H.; Rezaei Nasab, A.

2012-05-01

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

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

NASA Astrophysics Data System (ADS)

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

2008-12-01

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

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

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

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

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

40 CFR Appendix D to Subpart B of... - SAE J2810 Standard for Recovery Only Equipment for HFC-134a Refrigerant

Code of Federal Regulations, 2011 CFR

2011-07-01

...) refrigerant to be returned to a refrigerant reclamation facility that will process it to the appropriate ARI... and Assembly Processes (Process FMEA) and Effects Analysis for Machinery (Machinery FMEA). SAE... Manufacturing and Assembly Processes (Process FMEA), and Potential Failure Mode and Effects Analysis for...

40 CFR Appendix D to Subpart B of... - SAE J2810 Standard for Recovery Only Equipment for HFC-134a Refrigerant

Code of Federal Regulations, 2013 CFR

2013-07-01

...) refrigerant to be returned to a refrigerant reclamation facility that will process it to the appropriate ARI... and Assembly Processes (Process FMEA) and Effects Analysis for Machinery (Machinery FMEA). SAE... Manufacturing and Assembly Processes (Process FMEA), and Potential Failure Mode and Effects Analysis for...

40 CFR Appendix D to Subpart B of... - SAE J2810 Standard for Recovery Only Equipment for HFC-134a Refrigerant

Code of Federal Regulations, 2012 CFR

2012-07-01

...) refrigerant to be returned to a refrigerant reclamation facility that will process it to the appropriate ARI... and Assembly Processes (Process FMEA) and Effects Analysis for Machinery (Machinery FMEA). SAE... Manufacturing and Assembly Processes (Process FMEA), and Potential Failure Mode and Effects Analysis for...

40 CFR Appendix D to Subpart B of... - SAE J2810 Standard for Recovery Only Equipment for HFC-134a Refrigerant

Code of Federal Regulations, 2010 CFR

2010-07-01

...) refrigerant to be returned to a refrigerant reclamation facility that will process it to the appropriate ARI... and Assembly Processes (Process FMEA) and Effects Analysis for Machinery (Machinery FMEA). SAE... Manufacturing and Assembly Processes (Process FMEA), and Potential Failure Mode and Effects Analysis for...

40 CFR Appendix D to Subpart B of... - SAE J2810 Standard for Recovery Only Equipment for HFC-134a Refrigerant

Code of Federal Regulations, 2014 CFR

2014-07-01

...) refrigerant to be returned to a refrigerant reclamation facility that will process it to the appropriate ARI... and Assembly Processes (Process FMEA) and Effects Analysis for Machinery (Machinery FMEA). SAE... Manufacturing and Assembly Processes (Process FMEA), and Potential Failure Mode and Effects Analysis for...

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

NASA Astrophysics Data System (ADS)

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

2014-06-01

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

Failure mode analysis to predict product reliability.

NASA Technical Reports Server (NTRS)

Zemanick, P. P.

1972-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2011-08-01

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

Meso-Scale Progressive Damage Behavior Characterization of Triaxial Braided Composites under Quasi-Static Tensile Load

NASA Astrophysics Data System (ADS)

Ren, Yiru; Zhang, Songjun; Jiang, Hongyong; Xiang, Jinwu

2018-04-01

Based on continuum damage mechanics (CDM), a sophisticated 3D meso-scale finite element (FE) model is proposed to characterize the progressive damage behavior of 2D Triaxial Braided Composites (2DTBC) with 60° braiding angle under quasi-static tensile load. The modified Von Mises strength criterion and 3D Hashin failure criterion are used to predict the damage initiation of the pure matrix and fiber tows. A combining interface damage and friction constitutive model is applied to predict the interface damage behavior. Murakami-Ohno stiffness degradation scheme is employed to predict the damage evolution process of each constituent. Coupling with the ordinary and translational symmetry boundary conditions, the tensile elastic response including tensile strength and failure strain of 2DTBC are in good agreement with the available experiment data. The numerical results show that the main failure modes of the composites under axial tensile load are pure matrix cracking, fiber and matrix tension failure in bias fiber tows, matrix tension failure in axial fiber tows and interface debonding; the main failure modes of the composites subjected to transverse tensile load are free-edge effect, matrix tension failure in bias fiber tows and interface debonding.

Capturing a failure of an ASIC in-situ, using infrared radiometry and image processing software

NASA Technical Reports Server (NTRS)

Ruiz, Ronald P.

2003-01-01

Failures in electronic devices can sometimes be tricky to locate-especially if they are buried inside radiation-shielded containers designed to work in outer space. Such was the case with a malfunctioning ASIC (Application Specific Integrated Circuit) that was drawing excessive power at a specific temperature during temperature cycle testing. To analyze the failure, infrared radiometry (thermography) was used in combination with image processing software to locate precisely where the power was being dissipated at the moment the failure took place. The IR imaging software was used to make the image of the target and background, appear as unity. As testing proceeded and the failure mode was reached, temperature changes revealed the precise location of the fault. The results gave the design engineers the information they needed to fix the problem. This paper describes the techniques and equipment used to accomplish this failure analysis.

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

PubMed Central

Ye, Qing; Pan, Hao; Liu, Changhua

2015-01-01

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

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

PubMed

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

2018-04-01

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

Mod 1 wind turbine generator failure modes and effects analysis

NASA Technical Reports Server (NTRS)

1979-01-01

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

Quality control of inkjet technology for DNA microarray fabrication.

PubMed

Pierik, Anke; Dijksman, Frits; Raaijmakers, Adrie; Wismans, Ton; Stapert, Henk

2008-12-01

A robust manufacturing process is essential to make high-quality DNA microarrays, especially for use in diagnostic tests. We investigated different failure modes of the inkjet printing process used to manufacture low-density microarrays. A single nozzle inkjet spotter was provided with two optical imaging systems, monitoring in real time the flight path of every droplet. If a droplet emission failure is detected, the printing process is automatically stopped. We analyzed over 1.3 million droplets. This information was used to investigate the performance of the inkjet system and to obtain detailed insight into the frequency and causes of jetting failures. Of all the substrates investigated, 96.2% were produced without any system or jetting failures. In 1.6% of the substrates, droplet emission failed and was correctly identified. Appropriate measures could then be taken to get the process back on track. In 2.2%, the imaging systems failed while droplet emission occurred correctly. In 0.1% of the substrates, droplet emission failure that was not timely detected occurred. Thus, the overall yield of the microarray manufacturing process was 99.9%, which is highly acceptable for prototyping.

Monitoring of waste disposal in deep geological formations

NASA Astrophysics Data System (ADS)

German, V.; Mansurov, V.

2003-04-01

In the paper application of kinetic approach for description of rock failure process and waste disposal microseismic monitoring is advanced. On base of two-stage model of failure process the capability of rock fracture is proved. The requests to monitoring system such as real time mode of data registration and processing and its precision range are formulated. The method of failure nuclei delineation in a rock masses is presented. This method is implemented in a software program for strong seismic events forecasting. It is based on direct use of the fracture concentration criterion. The method is applied to the database of microseismic events of the North Ural Bauxite Mine. The results of this application, such as: efficiency, stability, possibility of forecasting rockburst are discussed.

Mechanical Behavior of Brittle Rock-Like Specimens with Pre-existing Fissures Under Uniaxial Loading: Experimental Studies and Particle Mechanics Approach

NASA Astrophysics Data System (ADS)

Cao, Ri-hong; Cao, Ping; Lin, Hang; Pu, Cheng-zhi; Ou, Ke

2016-03-01

Joints and fissures with similar orientation or characteristics are common in natural rocks; the inclination and density of the fissures affect the mechanical properties and failure mechanism of the rock mass. However, the strength, crack coalescence pattern, and failure mode of rock specimens containing multi-fissures have not been studied comprehensively. In this paper, combining similar material testing and discrete element numerical method (PFC2D), the peak strength and failure characteristics of rock-like materials with multi-fissures are explored. Rock-like specimens were made of cement and sand and pre-existing fissures created by inserting steel shims into cement mortar paste and removing them during curing. The peak strength of multi-fissure specimens depends on the fissure angle α (which is measured counterclockwise from horizontal) and fissure number ( N f). Under uniaxial compressional loading, the peak strength increased with increasing α. The material strength was lowest for α = 25°, and highest for α = 90°. The influence of N f on the peak strength depended on α. For α = 25° and 45°, N f had a strong effect on the peak strength, while for higher α values, especially for the 90° sample, there were no obvious changes in peak strength with different N f. Under uniaxial compression, the coalescence modes between the fissures can be classified into three categories: S-mode, T-mode, and M-mode. Moreover, the failure mode can be classified into four categories: mixed failure, shear failure, stepped path failure, and intact failure. The failure mode of the specimen depends on α and N f. The peak strength and failure modes in the numerically simulated and experimental results are in good agreement.

Analysis and Test Correlation of Proof of Concept Box for Blended Wing Body-Low Speed Vehicle

NASA Technical Reports Server (NTRS)

Spellman, Regina L.

2003-01-01

The Low Speed Vehicle (LSV) is a 14.2% scale remotely piloted vehicle of the revolutionary Blended Wing Body concept. The design of the LSV includes an all composite airframe. Due to internal manufacturing capability restrictions, room temperature layups were necessary. An extensive materials testing and manufacturing process development effort was underwent to establish a process that would achieve the high modulus/low weight properties required to meet the design requirements. The analysis process involved a loads development effort that incorporated aero loads to determine internal forces that could be applied to a traditional FEM of the vehicle and to conduct detailed component analyses. A new tool, Hypersizer, was added to the design process to address various composite failure modes and to optimize the skin panel thickness of the upper and lower skins for the vehicle. The analysis required an iterative approach as material properties were continually changing. As a part of the material characterization effort, test articles, including a proof of concept wing box and a full-scale wing, were fabricated. The proof of concept box was fabricated based on very preliminary material studies and tested in bending, torsion, and shear. The box was then tested to failure under shear. The proof of concept box was also analyzed using Nastran and Hypersizer. The results of both analyses were scaled to determine the predicted failure load. The test results were compared to both the Nastran and Hypersizer analytical predictions. The actual failure occurred at 899 lbs. The failure was predicted at 1167 lbs based on the Nastran analysis. The Hypersizer analysis predicted a lower failure load of 960 lbs. The Nastran analysis alone was not sufficient to predict the failure load because it does not identify local composite failure modes. This analysis has traditionally been done using closed form solutions. Although Hypersizer is typically used as an optimizer for the design process, the failure prediction was used to help gain acceptance and confidence in this new tool. The correlated models and process were to be used to analyze the full BWB-LSV airframe design. The analysis and correlation with test results of the proof of concept box is presented here, including the comparison of the Nastran and Hypersizer results.

Rupture Dynamics and Scaling Behavior of Hydraulically Stimulated Micro-Earthquakes in a Shale Reservoir

NASA Astrophysics Data System (ADS)

Viegas, G. F.; Urbancic, T.; Baig, A. M.

2014-12-01

In hydraulic fracturing completion programs fluids are injected under pressure into fractured rock formations to open escape pathways for trapped hydrocarbons along pre-existing and newly generated fractures. To characterize the failure process, we estimate static and dynamic source and rupture parameters, such as dynamic and static stress drop, radiated energy, seismic efficiency, failure modes, failure plane orientations and dimensions, and rupture velocity to investigate the rupture dynamics and scaling relations of micro-earthquakes induced during a hydraulic fracturing shale completion program in NE British Columbia, Canada. The relationships between the different parameters combined with the in-situ stress field and rock properties provide valuable information on the rupture process giving insights into the generation and development of the fracture network. Approximately 30,000 micro-earthquakes were recorded using three multi-sensor arrays of high frequency geophones temporarily placed close to the treatment area at reservoir depth (~2km). On average the events have low radiated energy, low dynamic stress and low seismic efficiency, consistent with the obtained slow rupture velocities. Events fail in overshoot mode (slip weakening failure model), with fluids lubricating faults and decreasing friction resistance. Events occurring in deeper formations tend to have faster rupture velocities and are more efficient in radiating energy. Variations in rupture velocity tend to correlate with variation in depth, fault azimuth and elapsed time, reflecting a dominance of the local stress field over other factors. Several regions with different characteristic failure modes are identifiable based on coherent stress drop, seismic efficiency, rupture velocities and fracture orientations. Variations of source parameters with rock rheology and hydro-fracture fluids are also observed. Our results suggest that the spatial and temporal distribution of events with similar characteristic rupture behaviors can be used to determine reservoir geophysical properties, constrain reservoir geo-mechanical models, classify dynamic rupture processes for fracture models and improve fracture treatment designs.

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

NASA Technical Reports Server (NTRS)

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

1980-01-01

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

Tensile failure criteria for fiber composite materials

NASA Technical Reports Server (NTRS)

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

1972-01-01

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

Health management system for rocket engines

NASA Technical Reports Server (NTRS)

Nemeth, Edward

1990-01-01

The functional framework of a failure detection algorithm for the Space Shuttle Main Engine (SSME) is developed. The basic algorithm is based only on existing SSME measurements. Supplemental measurements, expected to enhance failure detection effectiveness, are identified. To support the algorithm development, a figure of merit is defined to estimate the likelihood of SSME criticality 1 failure modes and the failure modes are ranked in order of likelihood of occurrence. Nine classes of failure detection strategies are evaluated and promising features are extracted as the basis for the failure detection algorithm. The failure detection algorithm provides early warning capabilities for a wide variety of SSME failure modes. Preliminary algorithm evaluation, using data from three SSME failures representing three different failure types, demonstrated indications of imminent catastrophic failure well in advance of redline cutoff in all three cases.

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

NASA Technical Reports Server (NTRS)

Ephrath, A. R.

1975-01-01

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

Damage Instability and Transition From Quasi-Static to Dynamic Fracture

NASA Technical Reports Server (NTRS)

Davila, Carlos G.

2015-01-01

In a typical mechanical test, the loading phase is intended to be a quasi-static process, while the failure and collapse is usually a dynamic event. The structural strength and modes of damage can seldom be predicted without accounting for these two aspects of the response. For a proper prediction, it is therefore essential to use tools and methodologies that are capable of addressing both aspects of responses. In some cases, implicit quasi-static models have been shown to be able to predict the entire response of a structure, including the unstable path that leads to fracture. However, is it acceptable to ignore the effect of inertial forces in the formation of damage? In this presentation we examine aspects of the damage processes that must be simulated for an accurate prediction of structural strength and modes of failure.

Deep geothermal: The ‘Moon Landing’ mission in the unconventional energy and minerals space

DOE PAGES

Regenauer-Lieb, Klaus; Bunger, Andrew; Chua, Hui Tong; ...

2015-01-30

Deep geothermal from the hot crystalline basement has remained an unsolved frontier for the geothermal industry for the past 30 years. This poses the challenge for developing a new unconventional geomechanics approach to stimulate such reservoirs. While a number of new unconventional brittle techniques are still available to improve stimulation on short time scales, the astonishing richness of failure modes of longer time scales in hot rocks has so far been overlooked. These failure modes represent a series of microscopic processes: brittle microfracturing prevails at low temperatures and fairly high deviatoric stresses, while upon increasing temperature and decreasing applied stressmore » or longer time scales, the failure modes switch to transgranular and intergranular creep fractures. Accordingly, fluids play an active role and create their own pathways through facilitating shear localization by a process of time-dependent dissolution and precipitation creep, rather than being a passive constituent by simply following brittle fractures that are generated inside a shear zone caused by other localization mechanisms. We lay out a new paradigm for reservoir stimulation by reactivating pre-existing faults at reservoir scale in a reservoir scale aseismic, ductile manner. A side effect of the new “soft” stimulation method is that owing to the design specification of a macroscopic ductile response, the proposed method offers the potential of a safer control over the stimulation process compared to conventional stimulation protocols such as currently employed in shale gas reservoirs.« less

Fracture and Failure in Micro- and Nano-Scale

NASA Astrophysics Data System (ADS)

Charitidis, Costas A.

Indentation and scratch in micro- and nano-scale are the most commonly used techniques for quantifying thin film and systems properties. Among them are different failure modes such as deformation, friction, fracture toughness, fatigue. Failure modes can be activated either by a cycle of indentation or by scratching of the samples to provide an estimation of the fracture toughness and interfacial fracture energies. In the present study, we report on the failure and fracture modes in two cases of engineering materials; that is transparent SiOx thin films onto poly(ethylene terephthalate) (PET) membranes and glass-ceramic materials. The SiOx/PET system meets the demands regarding scratch-resistance, wettability, biocompatibility, gas transmission, or friction, while maintaining the bulk characteristics of PET (such as easy processing, good mechanical properties, reasonably low permeability to oxygen and carbon dioxide gases (barrier properties), and good chemical coupling with antibacterial coatings). Glass-ceramic materials, since their first accidental production in the mid fifties by S.D. Stookey, have been used in a vast area of applications, from household cooktops and stoves, to missile nose cones and mirror mounts of orbital telescopes and from decorative wall coverings to medical applications. The fracture modes, namely transgranular and intergranular modes in glass-ceramic materials have paid less attention in literature comparing with ceramic materials. In the former case the crack paves its way irrespectively of the direction of the grain boundaries, i.e., the interfaces between the different phases. In the latter case the crack preferentially follows them, i.e., debonds the interfaces.

Development of GENOA Progressive Failure Parallel Processing Software Systems

NASA Technical Reports Server (NTRS)

Abdi, Frank; Minnetyan, Levon

1999-01-01

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

Modes of failure in disordered solids

NASA Astrophysics Data System (ADS)

Roy, Subhadeep; Biswas, Soumyajyoti; Ray, Purusattam

2017-12-01

The two principal ingredients determining the failure modes of disordered solids are the strength of heterogeneity and the length scale of the region affected in the solid following a local failure. While the latter facilitates damage nucleation, the former leads to diffused damage—the two extreme natures of the failure modes. In this study, using the random fiber bundle model as a prototype for disordered solids, we classify all failure modes that are the results of interplay between these two effects. We obtain scaling criteria for the different modes and propose a general phase diagram that provides a framework for understanding previous theoretical and experimental attempts of interpolation between these modes. As the fiber bundle model is a long-standing model for interpreting various features of stressed disordered solids, the general phase diagram can serve as a guiding principle in anticipating the responses of disordered solids in general.

Real-time diagnostics of the reusable rocket engine using on-line system identification

NASA Technical Reports Server (NTRS)

Guo, T.-H.; Merrill, W.; Duyar, A.

1990-01-01

A model-based failure diagnosis system has been proposed for real-time diagnosis of SSME failures. Actuation, sensor, and system degradation failure modes are all considered by the proposed system. In the case of SSME actuation failures, it was shown that real-time identification can effectively be used for failure diagnosis purposes. It is a direct approach since it reduces the detection, isolation, and the estimation of the extent of the failures to the comparison of parameter values before and after the failure. As with any model-based failure detection system, the proposed approach requires a fault model that embodies the essential characteristics of the failure process. The proposed diagnosis approach has the added advantage that it can be used as part of an intelligent control system for failure accommodation purposes.

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

PubMed Central

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

2013-01-01

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

An Experimental Investigation of Silicone-to-Metal Bond Strength in Composite Space Docking System Seals

NASA Technical Reports Server (NTRS)

Gaier, James R.; Siamidis, John; Larkin, Elizabeth M. G.

2010-01-01

The National Aeronautics and Space Administration (NASA) is currently developing a new universal docking mechanism for future space exploration missions called the Low Impact Docking System (LIDS). A candidate LIDS main interface seal design is a composite assembly of silicone elastomer seals vacuum molded into grooves in an electroless nickel plated aluminum retainer. The strength of the silicone-tometal bond is a critical consideration for the new system, especially due to the presence of small areas of disbond created during the molding process. In the work presented herein, seal-to-retainer bonds of subscale seal specimens with different sizes of intentional disbond were destructively tensile tested. Nominal specimens without intentional disbonds were also tested. Tension was applied either uniformly on the entire seal circumference or locally in one short circumferential length. Bond failure due to uniform tension produced a wide scatter of observable failure modes and measured load-displacement behaviors. Although the preferable failure mode for the seal-to-retainer bond is cohesive failure of the elastomer material, the dominant observed failure mode under the uniform loading condition was found to be the less desirable adhesive failure of the bond in question. The uniform tension case results did not show a correlation between disbond size and bond strength. Localized tension was found to produce failure either as immediate tearing of the elastomer material outside the bond region or as complete peel-out of the seal in one piece. The obtained results represent a valuable benchmark for comparison in the future between adhesion loads under various separation conditions and composite seal bond strength.

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

PubMed

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

2014-01-01

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

Inter-computer communication architecture for a mixed redundancy distributed system

NASA Technical Reports Server (NTRS)

Lala, Jaynarayan H.; Adams, Stuart J.

1987-01-01

The triply redundant intercomputer network for the Advanced Information Processing System (AIPS), an architecture developed to serve as the core avionics system for a broad range of aerospace vehicles, is discussed. The AIPS intercomputer network provides a high-speed, Byzantine-fault-resilient communication service between processing sites, even in the presence of arbitrary failures of simplex and duplex processing sites on the IC network. The IC network contention poll has evolved from the Laning Poll. An analysis of the failure modes and effects and a simulation of the AIPS contention poll, demonstrate the robustness of the system.

Mechanism of electromigration failure in Damascene processed copper interconnects

NASA Astrophysics Data System (ADS)

Michael, Nancy Lyn

2002-11-01

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

Development of Second Generation Intact Stability Criteria

DTIC Science & Technology

2011-12-01

the intact stability performance of ships, have motivated the development of the second generation intact stability criteria by the IMO Subcommittee on...primary modes of stability failures which are being addressed. The second generation intact stability criteria are planned to have a multitiered structure...and 2 vulnerability criteria that are used as a preliminary design process check of dynamic stability failure risk. This report describes the U.S

Nanowire failure: long = brittle and short = ductile.

PubMed

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

2012-02-08

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

Failure mode and effects analysis outputs: are they valid?

PubMed

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

2012-06-10

Failure Mode and Effects Analysis (FMEA) is a prospective risk assessment tool that has been widely used within the aerospace and automotive industries and has been utilised within healthcare since the early 1990s. The aim of this study was to explore the validity of FMEA outputs within a hospital setting in the United Kingdom. Two multidisciplinary teams each conducted an FMEA for the use of vancomycin and gentamicin. Four different validity tests were conducted: Face validity: by comparing the FMEA participants' mapped processes with observational work. Content validity: by presenting the FMEA findings to other healthcare professionals. Criterion validity: by comparing the FMEA findings with data reported on the trust's incident report database. Construct validity: by exploring the relevant mathematical theories involved in calculating the FMEA risk priority number. Face validity was positive as the researcher documented the same processes of care as mapped by the FMEA participants. However, other healthcare professionals identified potential failures missed by the FMEA teams. Furthermore, the FMEA groups failed to include failures related to omitted doses; yet these were the failures most commonly reported in the trust's incident database. Calculating the RPN by multiplying severity, probability and detectability scores was deemed invalid because it is based on calculations that breach the mathematical properties of the scales used. There are significant methodological challenges in validating FMEA. It is a useful tool to aid multidisciplinary groups in mapping and understanding a process of care; however, the results of our study cast doubt on its validity. FMEA teams are likely to need different sources of information, besides their personal experience and knowledge, to identify potential failures. As for FMEA's methodology for scoring failures, there were discrepancies between the teams' estimates and similar incidents reported on the trust's incident database. Furthermore, the concept of multiplying ordinal scales to prioritise failures is mathematically flawed. Until FMEA's validity is further explored, healthcare organisations should not solely depend on their FMEA results to prioritise patient safety issues.

Cyclic Load Effects on Long Term Behavior of Polymer Matrix Composites

NASA Technical Reports Server (NTRS)

Shah, A. R.; Chamis, C. C.

1996-01-01

A methodology to compute the fatigue life for different ratios, r, of applied stress to the laminate strength based on first ply failure criteria combined with thermal cyclic loads has been developed and demonstrated. Degradation effects resulting from long term environmental exposure and thermo-mechanical cyclic loads are considered in the simulation process. A unified time-stress dependent multi-factor interaction equation model developed at NASA Lewis Research Center has been used to account for the degradation of material properties caused by cyclic and aging loads. Effect of variation in the thermal cyclic load amplitude on a quasi-symmetric graphite/epoxy laminate has been studied with respect to the impending failure modes. The results show that, for the laminate under consideration, the fatigue life under combined mechanical and low thermal amplitude cyclic loads is higher than that due to mechanical loads only. However, as the thermal amplitude increases, the life also decreases. The failure mode changes from tensile under mechanical loads only to the compressive and shear at high mechanical and thermal loads. Also, implementation of the developed methodology in the design process has been discussed.

Failure mode and effects analysis: A community practice perspective.

PubMed

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

2017-11-01

To report our early experiences with failure mode and effects analysis (FMEA) in a community practice setting. The FMEA facilitator received extensive training at the AAPM Summer School. Early efforts focused on department education and emphasized the need for process evaluation in the context of high profile radiation therapy accidents. A multidisciplinary team was assembled with representation from each of the major department disciplines. Stereotactic radiosurgery (SRS) was identified as the most appropriate treatment technique for the first FMEA evaluation, as it is largely self-contained and has the potential to produce high impact failure modes. Process mapping was completed using breakout sessions, and then compiled into a simple electronic format. Weekly sessions were used to complete the FMEA evaluation. Risk priority number (RPN) values > 100 or severity scores of 9 or 10 were considered high risk. The overall time commitment was also tracked. The final SRS process map contained 15 major process steps and 183 subprocess steps. Splitting the process map into individual assignments was a successful strategy for our group. The process map was designed to contain enough detail such that another radiation oncology team would be able to perform our procedures. Continuous facilitator involvement helped maintain consistent scoring during FMEA. Practice changes were made responding to the highest RPN scores, and new resulting RPN scores were below our high-risk threshold. The estimated person-hour equivalent for project completion was 258 hr. This report provides important details on the initial steps we took to complete our first FMEA, providing guidance for community practices seeking to incorporate this process into their quality assurance (QA) program. Determining the feasibility of implementing complex QA processes into different practice settings will take on increasing significance as the field of radiation oncology transitions into the new TG-100 QA paradigm. © 2017 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.

Consistency of FMEA used in the validation of analytical procedures.

PubMed

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

2011-02-20

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

Development of STS/Centaur failure probabilities liftoff to Centaur separation

NASA Technical Reports Server (NTRS)

Hudson, J. M.

1982-01-01

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

Application of ICH Q9 Quality Risk Management Tools for Advanced Development of Hot Melt Coated Multiparticulate Systems.

PubMed

Stocker, Elena; Becker, Karin; Hate, Siddhi; Hohl, Roland; Schiemenz, Wolfgang; Sacher, Stephan; Zimmer, Andreas; Salar-Behzadi, Sharareh

2017-01-01

This study aimed to apply quality risk management based on the The International Conference on Harmonisation guideline Q9 for the early development stage of hot melt coated multiparticulate systems for oral administration. N-acetylcysteine crystals were coated with a formulation composing tripalmitin and polysorbate 65. The critical quality attributes (CQAs) were initially prioritized using failure mode and effects analysis. The CQAs of the coated material were defined as particle size, taste-masking efficiency, and immediate release profile. The hot melt coated process was characterized via a flowchart, based on the identified potential critical process parameters (CPPs) and their impact on the CQAs. These CPPs were prioritized using a process failure mode, effects, and criticality analysis and their critical impact on the CQAs was experimentally confirmed using a statistical design of experiments. Spray rate, atomization air pressure, and air flow rate were identified as CPPs. Coating amount and content of polysorbate 65 in the coating formulation were identified as critical material attributes. A hazard and critical control points analysis was applied to define control strategies at the critical process points. A fault tree analysis evaluated causes for potential process failures. We successfully demonstrated that a standardized quality risk management approach optimizes the product development sustainability and supports the regulatory aspects. Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

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

PubMed

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

2014-04-01

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

40 CFR Appendix B to Subpart G of... - Substitutes Subject to Use Restrictions and Unacceptable Substitutes

Code of Federal Regulations, 2013 CFR

2013-07-01

... inches) and right-hand thread direction for CO2 refrigerant service containers.3 Manufacturers should... Failure Mode and Effect Analysis in Manufacturing and Assembly Process [Process FMEA] on the MVAC as... submitted to demonstrate it can be used safely in this end-use. CFC-11, CFC-12, R-502 Industrial Process...

40 CFR Appendix B to Subpart G of... - Substitutes Subject to Use Restrictions and Unacceptable Substitutes

Code of Federal Regulations, 2014 CFR

2014-07-01

... inches) and right-hand thread direction for CO2 refrigerant service containers.3 Manufacturers should... Failure Mode and Effect Analysis in Manufacturing and Assembly Process [Process FMEA] on the MVAC as... submitted to demonstrate it can be used safely in this end-use. CFC-11, CFC-12, R-502 Industrial Process...

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

NASA Astrophysics Data System (ADS)

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

2017-12-01

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

Fatigue failure of osteocyte cellular processes: implications for the repair of bone.

PubMed

Dooley, C; Cafferky, D; Lee, T C; Taylor, D

2014-01-25

The physical effects of fatigue failure caused by cyclic strain are important and for most materials well understood. However, nothing is known about this mode of failure in living cells. We developed a novel method that allowed us to apply controlled levels of cyclic displacement to networks of osteocytes in bone. We showed that under cyclic loading, fatigue failure takes place in the dendritic processes of osteocytes at cyclic strain levels as low as one tenth of the strain needed for instantaneous rupture. The number of cycles to failure was inversely correlated with the strain level. Further experiments demonstrated that these failures were not artefacts of our methods of sample preparation and testing, and that fatigue failure of cell processes also occurs in vivo. This work is significant as it is the first time it has been possible to conduct fatigue testing on cellular material of any kind. Many types of cells experience repetitive loading which may cause failure or damage requiring repair. It is clinically important to determine how cyclic strain affects cells and how they respond in order to gain a deeper understanding of the physiological processes stimulated in this manner. The more we understand about the natural repair process in bone the more targeted the intervention methods may become if disruption of the repair process occurred. Our results will help to understand how the osteocyte cell network is disrupted in the vicinity of matrix damage, a crucial step in bone remodelling.

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

NASA Technical Reports Server (NTRS)

Bynum, M. C., III

1987-01-01

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

A systems engineering approach to automated failure cause diagnosis in space power systems

NASA Technical Reports Server (NTRS)

Dolce, James L.; Faymon, Karl A.

1987-01-01

Automatic failure-cause diagnosis is a key element in autonomous operation of space power systems such as Space Station's. A rule-based diagnostic system has been developed for determining the cause of degraded performance. The knowledge required for such diagnosis is elicited from the system engineering process by using traditional failure analysis techniques. Symptoms, failures, causes, and detector information are represented with structured data; and diagnostic procedural knowledge is represented with rules. Detected symptoms instantiate failure modes and possible causes consistent with currently held beliefs about the likelihood of the cause. A diagnosis concludes with an explanation of the observed symptoms in terms of a chain of possible causes and subcauses.

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

NASA Technical Reports Server (NTRS)

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

1988-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Backup Flight System (BFS) hardware, generating draft failure modes and Potential Critical Items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the proposed NASA Post 51-L FMEA/CIL baseline. A resolution of each discrepancy from the comparison is provided through additional analysis as required. This report documents the results of that comparison for the Orbiter BFS hardware. The IOA product for the BFS analysis consisted of 29 failure mode worksheets that resulted in 21 Potential Critical Items (PCI) being identified. This product was originally compared with the proposed NASA BFS baseline and subsequently compared with the applicable Data Processing System (DPS), Electrical Power Distribution and Control (EPD and C), and Displays and Controls NASA CIL items. The comparisons determined if there were any results which had been found by the IOA but were not in the NASA baseline. The original assessment determined there were numerous failure modes and potential critical items in the IOA analysis that were not contained in the NASA BFS baseline. Conversely, the NASA baseline contained three FMEAs (IMU, ADTA, and Air Data Probe) for CIL items that were not identified in the IOA product.

Independent Orbiter Assessment (IOA): FMEA/CIL assessment

NASA Technical Reports Server (NTRS)

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

1988-01-01

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

Evaluating the Effect of Minimizing Screws on Stabilization of Symphysis Mandibular Fracture by 3D Finite Element Analysis.

PubMed

Kharmanda, Ghias; Kharma, Mohamed-Yaser

2017-06-01

The objective of this work is to integrate structural optimization and reliability concepts into mini-plate fixation strategy used in symphysis mandibular fractures. The structural reliability levels are next estimated when considering a single failure mode and multiple failure modes. A 3-dimensional finite element model is developed in order to evaluate the ability of reducing the negative effect due to the stabilization of the fracture. Topology optimization process is considered in the conceptual design stage to predict possible fixation layouts. In the detailed design stage, suitable mini-plates are selected taking into account the resulting topology and different anatomical considerations. Several muscle forces are considered in order to obtain realistic predictions. Since some muscles can be cut or harmed during the surgery and cannot operate at its maximum capacity, there is a strong motivation to introduce the loading uncertainties in order to obtain reliable designs. The structural reliability is carried out for a single failure mode and multiple failure modes. The different results are validated with a clinical case of a male patient with symphysis fracture. In this case while use of the upper plate fixation with four holes, only two screws were applied to protect adjacent vital structure. This behavior does not affect the stability of the fracture. The proposed strategy to optimize bone plates leads to fewer complications and second surgeries, less patient discomfort, and shorter time of healing.

Compendium of Mechanical Limit-States

NASA Technical Reports Server (NTRS)

Kowal, Michael

1996-01-01

A compendium was compiled and is described to provide a diverse set of limit-state relationships for use in demonstrating the application of probabilistic reliability methods to mechanical systems. The different limit-state relationships can be used to analyze the reliability of a candidate mechanical system. In determining the limit-states to be included in the compendium, a comprehensive listing of the possible failure modes that could affect mechanical systems reliability was generated. Previous literature defining mechanical modes of failure was studied, and cited failure modes were included. From this, classifications for failure modes were derived and are described in some detail.

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

PubMed

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

2004-01-01

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

Composite Interlaminar Shear Fracture Toughness, G(sub 2c): Shear Measurement of Sheer Myth?

NASA Technical Reports Server (NTRS)

OBrien, T. Kevin

1997-01-01

The concept of G2c as a measure of the interlaminar shear fracture toughness of a composite material is critically examined. In particular, it is argued that the apparent G2c as typically measured is inconsistent with the original definition of shear fracture. It is shown that interlaminar shear failure actually consists of tension failures in the resin rich layers between plies followed by the coalescence of ligaments created by these failures and not the sliding of two planes relative to one another that is assumed in fracture mechanics theory. Several strain energy release rate solutions are reviewed for delamination in composite laminates and structural components where failures have been experimentally documented. Failures typically occur at a location where the mode 1 component accounts for at least one half of the total G at failure. Hence, it is the mode I and mixed-mode interlaminar fracture toughness data that will be most useful in predicting delamination failure in composite components in service. Although apparent G2c measurements may prove useful for completeness of generating mixed-mode criteria, the accuracy of these measurements may have very little influence on the prediction of mixed-mode failures in most structural components.

Basic failure mechanisms in advanced composites

NASA Technical Reports Server (NTRS)

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

1972-01-01

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

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

PubMed

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

2017-06-01

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

Reusable rocket engine turbopump condition monitoring

NASA Technical Reports Server (NTRS)

Hampson, M. E.

1984-01-01

Significant improvements in engine readiness with reductions in maintenance costs and turn-around times can be achieved with an engine condition monitoring systems (CMS). The CMS provides health status of critical engine components, without disassembly, through monitoring with advanced sensors. Engine failure reports over 35 years were categorized into 20 different modes of failure. Rotor bearings and turbine blades were determined to be the most critical in limiting turbopump life. Measurement technologies were matched to each of the failure modes identified. Three were selected to monitor the rotor bearings and turbine blades: the isotope wear detector and fiberoptic deflectometer (bearings), and the fiberoptic pyrometer (blades). Signal processing algorithms were evaluated for their ability to provide useful health data to maintenance personnel. Design modifications to the Space Shuttle Main Engine (SSME) high pressure turbopumps were developed to incorporate the sensors. Laboratory test fixtures have been designed for monitoring the rotor bearings and turbine blades in simulated turbopump operating conditions.

Accelerated stress testing of terrestrial solar cells

NASA Technical Reports Server (NTRS)

Lathrop, J. W.; Hawkins, D. C.; Prince, J. L.; Walker, H. A.

1982-01-01

The development of an accelerated test schedule for terrestrial solar cells is described. This schedule, based on anticipated failure modes deduced from a consideration of IC failure mechanisms, involves bias-temperature testing, humidity testing (including both 85-85 and pressure cooker stress), and thermal-cycle thermal-shock testing. Results are described for 12 different unencapsulated cell types. Both gradual electrical degradation and sudden catastrophic mechanical change were observed. These effects can be used to discriminate between cell types and technologies relative to their reliability attributes. Consideration is given to identifying laboratory failure modes which might lead to severe degradation in the field through second quadrant operation. Test results indicate that the ability of most cell types to withstand accelerated stress testing depends more on the manufacturer's design, processing, and worksmanship than on the particular metallization system. Preliminary tests comparing accelerated test results on encapsulated and unencapsulated cells are described.

Failure Atlas for Rolling Bearings in Wind Turbines

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

Tallian, T. E.

2006-01-01

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

75 FR 51931 - Airworthiness Directives; Dassault-Aviation Model FALCON 7X Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-24

... root cause: A leakage failure mode of Transient Voltage Suppressor (TVS) diodes used on Power... condition is a leakage failure mode of TVS diodes used on PDCU cards or GCU cards in the PPDB, which in... discovery of a common root cause: A leakage failure mode of Transient Voltage Suppressor (TVS) diodes used...

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

NASA Astrophysics Data System (ADS)

Sawant, M.; Christou, A.

2012-12-01

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

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

NASA Astrophysics Data System (ADS)

Gunawan, Insan; Taufik, Ahmad

2007-10-01

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

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

PubMed

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

2016-12-01

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

Resistance spot welding of ultra-fine grained steel sheets produced by constrained groove pressing: Optimization and characterization

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

Khodabakhshi, F.; Kazeminezhad, M., E-mail: mkazemi@sharif.edu; Kokabi, A.H.

2012-07-15

Constrained groove pressing as a severe plastic deformation method is utilized to produce ultra-fine grained low carbon steel sheets. The ultra-fine grained sheets are joined via resistance spot welding process and the characteristics of spot welds are investigated. Resistance spot welding process is optimized for welding of the sheets with different severe deformations and their results are compared with those of as-received samples. The effects of failure mode and expulsion on the performance of ultra-fine grained sheet spot welds have been investigated in the present paper and the welding current and time of resistance spot welding process according to thesemore » subjects are optimized. Failure mode and failure load obtained in tensile-shear test, microhardness, X-ray diffraction, transmission electron microscope and scanning electron microscope images have been used to describe the performance of spot welds. The region between interfacial to pullout mode transition and expulsion limit is defined as the optimum welding condition. The results show that optimum welding parameters (welding current and welding time) for ultra-fine grained sheets are shifted to lower values with respect to those for as-received specimens. In ultra-fine grained sheets, one new region is formed named recrystallized zone in addition to fusion zone, heat affected zone and base metal. It is shown that microstructures of different zones in ultra-fine grained sheets are finer than those of as-received sheets. - Highlights: Black-Right-Pointing-Pointer Resistance spot welding process is optimized for joining of UFG steel sheets. Black-Right-Pointing-Pointer Optimum welding current and time are decreased with increasing the CGP pass number. Black-Right-Pointing-Pointer Microhardness at BM, HAZ, FZ and recrystallized zone is enhanced due to CGP.« less

Safety Strategies in an Academic Radiation Oncology Department and Recommendations for Action

PubMed Central

Terezakis, Stephanie A.; Pronovost, Peter; Harris, Kendra; DeWeese, Theodore; Ford, Eric

2013-01-01

Background Safety initiatives in the United States continue to work on providing guidance as to how the average practitioner might make patients safer in the face of the complex process by which radiation therapy (RT), an essential treatment used in the management of many patients with cancer, is prepared and delivered. Quality control measures can uncover certain specific errors such as machine dose mis-calibration or misalignments of the patient in the radiation treatment beam. However, they are less effective at uncovering less common errors that can occur anywhere along the treatment planning and delivery process, and even when the process is functioning as intended, errors still occur. Prioritizing Risks and Implementing Risk-Reduction Strategies Activities undertaken at the radiation oncology department at the Johns Hopkins Hospital (Baltimore) include Failure Mode and Effects Analysis (FMEA), risk-reduction interventions, and voluntary error and near-miss reporting systems. A visual process map portrayed 269 RT steps occurring among four subprocesses—including consult, simulation, treatment planning, and treatment delivery. Two FMEAs revealed 127 and 159 possible failure modes, respectively. Risk-reduction interventions for 15 “top-ranked” failure modes were implemented. Since the error and near-miss reporting system’s implementation in the department in 2007, 253 events have been logged. However, the system may be insufficient for radiation oncology, for which a greater level of practice-specific information is required to fully understand each event. Conclusions The “basic science” of radiation treatment has received considerable support and attention in developing novel therapies to benefit patients. The time has come to apply the same focus and resources to ensuring that patients safely receive the maximal benefits possible. PMID:21819027

Practical, transparent prospective risk analysis for the clinical laboratory.

PubMed

Janssens, Pim Mw

2014-11-01

Prospective risk analysis (PRA) is an essential element in quality assurance for clinical laboratories. Practical approaches to conducting PRA in laboratories, however, are scarce. On the basis of the classical Failure Mode and Effect Analysis method, an approach to PRA was developed for application to key laboratory processes. First, the separate, major steps of the process under investigation are identified. Scores are then given for the Probability (P) and Consequence (C) of predefined types of failures and the chances of Detecting (D) these failures. Based on the P and C scores (on a 10-point scale), an overall Risk score (R) is calculated. The scores for each process were recorded in a matrix table. Based on predetermined criteria for R and D, it was determined whether a more detailed analysis was required for potential failures and, ultimately, where risk-reducing measures were necessary, if any. As an illustration, this paper presents the results of the application of PRA to our pre-analytical and analytical activities. The highest R scores were obtained in the stat processes, the most common failure type in the collective process steps was 'delayed processing or analysis', the failure type with the highest mean R score was 'inappropriate analysis' and the failure type most frequently rated as suboptimal was 'identification error'. The PRA designed is a useful semi-objective tool to identify process steps with potential failures rated as risky. Its systematic design and convenient output in matrix tables makes it easy to perform, practical and transparent. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

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

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

Dennis, L.B.

1994-12-01

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

Failure Characteristics of Granite Influenced by Sample Height-to-Width Ratios and Intermediate Principal Stress Under True-Triaxial Unloading Conditions

NASA Astrophysics Data System (ADS)

Li, Xibing; Feng, Fan; Li, Diyuan; Du, Kun; Ranjith, P. G.; Rostami, Jamal

2018-05-01

The failure modes and peak unloading strength of a typical hard rock, Miluo granite, with particular attention to the sample height-to-width ratio (between 2 and 0.5), and the intermediate principal stress was investigated using a true-triaxial test system. The experimental results indicate that both sample height-to-width ratios and intermediate principal stress have an impact on the failure modes, peak strength and severity of rockburst in hard rock under true-triaxial unloading conditions. For longer rectangular specimens, the transition of failure mode from shear to slabbing requires higher intermediate principal stress. With the decrease in sample height-to-width ratios, slabbing failure is more likely to occur under the condition of lower intermediate principal stress. For same intermediate principal stress, the peak unloading strength monotonically increases with the decrease in sample height-to-width. However, the peak unloading strength as functions of intermediate principal stress for different types of rock samples (with sample height-to-width ratio of 2, 1 and 0.5) all present the pattern of initial increase, followed by a subsequent decrease. The curves fitted to octahedral shear stress as a function of mean effective stress also validate the applicability of the Mogi-Coulomb failure criterion for all considered rock sizes under true-triaxial unloading conditions, and the corresponding cohesion C and internal friction angle φ are calculated. The severity of strainburst of granite depends on the sample height-to-width ratios and intermediate principal stress. Therefore, different supporting strategies are recommended in deep tunneling projects and mining activities. Moreover, the comparison of test results of different σ 2/ σ 3 also reveals the little influence of minimum principal stress on failure characteristics of granite during the true-triaxial unloading process.

Processing, Structural Characterization and Comparative Studies on Uniaxial Tensile Properties of a New Type of Porous Twisted Wire Material

PubMed Central

Wu, Fei; Zhou, Zhaoyao; Duan, Liuyang; Xiao, Zhiyu

2015-01-01

A self-developed rotary multi-cutter device cuts stainless steel wire ropes into segments to fabricate twisted wires. Stainless steel porous twisted wire materials (PTWMs) with a spatial composite intertexture structure are produced by the compaction and subsequent vacuum solid-phase sintering of twisted wires. The stainless steel PTWMs show two types of typical uniaxial tensile failure modes, i.e., a 45° angle fracture mode and an auxetic failure mode (the PTWMs expand along the direction perpendicular to the tension). The effects of the sintering parameters, porosities, wire diameters, and sampling direction on the tensile properties of the PTWMs are carefully investigated. By increasing the sintering temperature from 1130 °C to 1330 °C, the tensile strength of the PTWMs with 70% target porosity increased from 7.7 MPa to 28.6 MPa and the total failure goes down to 50%. When increasing the sintering time from 90 min to 150 min, the tensile strength increases from 12.4 MPa to 19.1 MPa and the total failure elongation drops to 78.6%. The tensile strength of the PTWMs increases from 28.9 MPa to 112.7 MPa with decreasing porosity from 69.5% to 46.0%, and the total failure elongation also increases from 14.8% to 40.7%. The tensile strength and the failure strain of the PTWMs with fine wires are higher than those of the PTWMs with coarse wires under the same porosity. Sampling direction has a small influence on the tensile properties of the PTWMs. PMID:28793526

Processing, Structural Characterization and Comparative Studies on Uniaxial Tensile Properties of a New Type of Porous Twisted Wire Material.

PubMed

Wu, Fei; Zhou, Zhaoyao; Duan, Liuyang; Xiao, Zhiyu

2015-08-27

A self-developed rotary multi-cutter device cuts stainless steel wire ropes into segments to fabricate twisted wires. Stainless steel porous twisted wire materials (PTWMs) with a spatial composite intertexture structure are produced by the compaction and subsequent vacuum solid-phase sintering of twisted wires. The stainless steel PTWMs show two types of typical uniaxial tensile failure modes, i.e. , a 45° angle fracture mode and an auxetic failure mode (the PTWMs expand along the direction perpendicular to the tension). The effects of the sintering parameters, porosities, wire diameters, and sampling direction on the tensile properties of the PTWMs are carefully investigated. By increasing the sintering temperature from 1130 °C to 1330 °C, the tensile strength of the PTWMs with 70% target porosity increased from 7.7 MPa to 28.6 MPa and the total failure goes down to 50%. When increasing the sintering time from 90 min to 150 min, the tensile strength increases from 12.4 MPa to 19.1 MPa and the total failure elongation drops to 78.6%. The tensile strength of the PTWMs increases from 28.9 MPa to 112.7 MPa with decreasing porosity from 69.5% to 46.0%, and the total failure elongation also increases from 14.8% to 40.7%. The tensile strength and the failure strain of the PTWMs with fine wires are higher than those of the PTWMs with coarse wires under the same porosity. Sampling direction has a small influence on the tensile properties of the PTWMs.

Innovative fabrication processing of advanced composite materials concepts for primary aircraft structures

NASA Technical Reports Server (NTRS)

Kassapoglou, Christos; Dinicola, Al J.; Chou, Jack C.

1992-01-01

The autoclave based THERM-X(sub R) process was evaluated by cocuring complex curved panels with frames and stiffeners. The process was shown to result in composite parts of high quality with good compaction at sharp radius regions and corners of intersecting parts. The structural properties of the postbuckled panels fabricated were found to be equivalent to those of conventionally tooled hand laid-up parts. Significant savings in bagging time over conventional tooling were documented. Structural details such as cocured shear ties and embedded stiffener flanges in the skin were found to suppress failure modes such as failure at corners of intersecting members and skin stiffeners separation.

Geophysical Signatures of Shear-Induced Damage and Frictional Processes on Rock Joints

NASA Astrophysics Data System (ADS)

Hedayat, Ahmadreza; Haeri, Hadi; Hinton, John; Masoumi, Hossein; Spagnoli, Giovanni

2018-02-01

In this study, ultrasonic waves recorded during direct shear experiments on rock joints were employed to investigate the shear failure processes. Three types of wave attributes were systematically observed prior to the shear failure of the rock joints: (a) maximum in the amplitude of the transmitted wave, (b) maximum in the dominant frequency of the transmitted wave, and (c) maximum in the velocity of the wave. Different processes occurring during both frictional sliding and stick-slip oscillations were identified in this study: (a) interseismic phase and (b) preseismic phase. The interseismic phase is associated with elastic loading, very small local slip rate, and increasing ultrasonic transmission along the contact surfaces. The rock joint is considered locked, and the increase in ultrasonic transmission represents an increase in the real (true) area of contact because of interlocking and contact aging. The start of the preseismic phase is marked by the onset of precursors for different regions of the rock joint. Following the interseismic and preseismic phases, coseismic phase occurs. The coseismic phase begins with the reduction in the applied shear stress and is associated with an abrupt increase in the local slip rate. The reductions in transmitted amplitude, wave velocity, and dominant frequency all indicate the preseismic phase when the asperity contacts begin to fail before macroscopic frictional sliding. The observation of the preseismic phase in both the loading phase leading to stable sliding and stick-slip failure modes suggests that microphysical processes of fault weakening may share key features for these two failure modes.

Biomarkers of Myocardial Stress and Fibrosis as Predictors of Mode of Death in Patients with Chronic Heart Failure

PubMed Central

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

2014-01-01

Objective To determine whether biomarkers of myocardial stress and fibrosis improve prediction of mode of death in patients with chronic heart failure. Background The two most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of mode of death may facilitate treatment decisions. The relationship between NT-proBNP, galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown. Methods HF-ACTION was a randomized controlled trial of exercise training vs. usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (LVEF<35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox-proportional hazards modeling, and interaction testing was used to measure differential association between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP. Results After a median follow up of 2.5 years, there were 155 deaths: 49 from pump failure 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk of both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death but this relationship was attenuated after adjustment for clinical risk factors. Clinical variables along with NT-proBNP levels were stronger predictors of pump failure (C statistic: 0.87) than sudden cardiac death (C statistic: 0.73). Addition of ST2 and galectin-3 led to improved net risk classification of 11% for sudden cardiac death, but not pump failure. Conclusions Clinical predictors along with NT-proBNP levels were strong predictors of pump failure risk, with insignificant incremental contributions of ST2 and galectin-3. Predictability of sudden cardiac death risk was less robust and enhanced by information provided by novel biomarkers. PMID:24952693

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

NASA Technical Reports Server (NTRS)

Flores, Melissa; Malin, Jane T.

2013-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2013-09-01

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

Nondestructive SEM for surface and subsurface wafer imaging

NASA Technical Reports Server (NTRS)

Propst, Roy H.; Bagnell, C. Robert; Cole, Edward I., Jr.; Davies, Brian G.; Dibianca, Frank A.; Johnson, Darryl G.; Oxford, William V.; Smith, Craig A.

1987-01-01

The scanning electron microscope (SEM) is considered as a tool for both failure analysis as well as device characterization. A survey is made of various operational SEM modes and their applicability to image processing methods on semiconductor devices.

Failure strengths of denture teeth fabricated on injection molded or compression molded denture base resins.

PubMed

Robison, Nathan E; Tantbirojn, Daranee; Versluis, Antheunis; Cagna, David R

2016-08-01

Denture tooth fracture or debonding remains a common problem in removable prosthodontics. The purpose of this in vitro study was to explore factors determining failure strengths for combinations of different denture tooth designs (shape, materials) and injection or compression molded denture base resins. Three central incisor denture tooth designs were tested: nanohybrid composite (NHC; Ivoclar Phonares II), interpenetrating network (IPN; Dentsply Portrait), and microfiller reinforced polyacrylic (MRP; VITA Physiodens). Denture teeth of each type were processed on an injection molded resin (IvoBase HI; Ivoclar Vivadent AG) or a compression molded resin (Lucitone 199; Dentsply Intl) (n=11 or 12). The denture teeth were loaded at 45 degrees on the incisal edge. The failure load was recorded and analyzed with 2-way ANOVA (α=.05), and the fracture mode was categorized from observed fracture surfaces as cohesive, adhesive, or mixed failure. The following failure loads (mean ±SD) were recorded: NHC/injection molded 280 ±52 N; IPN/injection molded 331 ±41 N; MRP/injection molded 247 ±23 N; NHC/compression molded 204 ±31 N; IPN/compression molded 184 ±17 N; MRP/compression molded 201 ±16 N. Injection molded resin yielded significantly higher failure strength for all denture teeth (P<.001), among which IPN had the highest strength. Failure was predominantly cohesive in the teeth, with the exception of mixed mode for the IPN/compression group. When good bonding was achieved, the strength of the structure (denture tooth/base resin combination) was determined by the strength of the denture teeth, which may be affected by the processing technique. Copyright © 2016 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.

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

NASA Astrophysics Data System (ADS)

Buscarnera, G.

2013-12-01

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

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

PubMed

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

2008-07-01

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

A multidimensional anisotropic strength criterion based on Kelvin modes

NASA Astrophysics Data System (ADS)

Arramon, Yves Pierre

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

Low-thrust mission risk analysis, with application to a 1980 rendezvous with the comet Encke

NASA Technical Reports Server (NTRS)

Yen, C. L.; Smith, D. B.

1973-01-01

A computerized failure process simulation procedure is used to evaluate the risk in a solar electric space mission. The procedure uses currently available thrust-subsystem reliability data and performs approximate simulations of the thrust sybsystem burn operation, the system failure processes, and the retargeting operations. The method is applied to assess the risks in carrying out a 1980 rendezvous mission to the comet Encke. Analysis of the results and evaluation of the effects of various risk factors on the mission show that system component failure rates are the limiting factors in attaining a high mission relability. It is also shown that a well-designed trajectory and system operation mode can be used effectively to partially compensate for unreliable thruster performance.

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

PubMed

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

2016-05-01

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

Manufacturing and shear response characterization of carbon nanofiber modified CFRP using the out-of-autoclave-vacuum-bag-only cure process.

PubMed

McDonald, Erin E; Wallace, Landon F; Hickman, Gregory J S; Hsiao, Kuang-Ting

2014-01-01

The interlaminar shear response is studied for carbon nanofiber (CNF) modified out-of-autoclave-vacuum-bag-only (OOA-VBO) carbon fiber reinforced plastic (CFRP). Commercial OOA-VBO prepregs were coated with a CNF modified epoxy solution and a control epoxy solution without CNF to make CNF modified samples and control samples, respectively. Tensile testing was used to study the in-plane shear performance of [± 45°]4s composite laminates. Significant difference in failure modes between the control and CNF modified CFRPs was identified. The control samples experienced half-plane interlaminar delamination, whereas the CNF modified samples experienced a localized failure in the intralaminar region. Digital image correlation (DIC) surface strain results of the control sample showed no further surface strain increase along the delaminated section when the sample was further elongated prior to sample failure. On the other hand, the DIC results of the CNF modified sample showed that the surface strain increased relatively and uniformly across the CFRP as the sample was further elongated until sample failure. The failure mode evidence along with microscope pictures indicated that the CNF modification acted as a beneficial reinforcement inhibiting interlaminar delamination.

Manufacturing and Shear Response Characterization of Carbon Nanofiber Modified CFRP Using the Out-of-Autoclave-Vacuum-Bag-Only Cure Process

PubMed Central

McDonald, Erin E.; Wallace, Landon F.; Hickman, Gregory J. S.; Hsiao, Kuang-Ting

2014-01-01

The interlaminar shear response is studied for carbon nanofiber (CNF) modified out-of-autoclave-vacuum-bag-only (OOA-VBO) carbon fiber reinforced plastic (CFRP). Commercial OOA-VBO prepregs were coated with a CNF modified epoxy solution and a control epoxy solution without CNF to make CNF modified samples and control samples, respectively. Tensile testingwas used to study the in-plane shear performance of [±45°]4s composite laminates. Significant difference in failure modes between the control and CNF modified CFRPs was identified. The control samples experienced half-plane interlaminar delamination, whereas the CNF modified samples experienced a localized failure in the intralaminar region. Digital image correlation (DIC) surface strain results of the control sample showed no further surface strain increase along the delaminated section when the sample was further elongated prior to sample failure. On the other hand, the DIC results of the CNF modified sample showed that the surface strain increased relatively and uniformly across the CFRP as the sample was further elongated until sample failure. The failure mode evidence along with microscope pictures indicated that the CNF modification acted as a beneficial reinforcement inhibiting interlaminar delamination. PMID:24688435

Experimental Tests on the Composite Foam Sandwich Pipes Subjected to Axial Load

NASA Astrophysics Data System (ADS)

Li, Feng; Zhao, QiLin; Xu, Kang; Zhang, DongDong

2015-12-01

Compared to the composite thin-walled tube, the composite foam sandwich pipe has better local flexural rigidity, which can take full advantage of the high strength of composite materials. In this paper, a series of composite foam sandwich pipes with different parameters were designed and manufactured using the prefabricated polyurethane foam core-skin co-curing molding technique with E-glass fabric prepreg. The corresponding axial-load compressive tests were conducted to investigate the influence factors that experimentally determine the axial compressive performances of the tubes. In the tests, the detailed failure process and the corresponding load-displacement characteristics were obtained; the influence rules of the foam core density, surface layer thickness, fiber ply combination and end restraint on the failure modes and ultimate bearing capacity were studied. Results indicated that: (1) the fiber ply combination, surface layer thickness and end restraint have a great influence on the ultimate load bearing capacity; (2) a reasonable fiber ply combination and reliable interfacial adhesion not only optimize the strength but also transform the failure mode from brittle failure to ductile failure, which is vital to the fully utilization of the composite strength of these composite foam sandwich pipes.

Stress redistribution and damage in interconnects caused by electromigration

NASA Astrophysics Data System (ADS)

Chiras, Stefanie Ruth

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

Global resilience analysis of water distribution systems.

PubMed

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

2016-12-01

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

Investigation of advanced fault insertion and simulator methods

NASA Technical Reports Server (NTRS)

Dunn, W. R.; Cottrell, D.

1986-01-01

The cooperative agreement partly supported research leading to the open-literature publication cited. Additional efforts under the agreement included research into fault modeling of semiconductor devices. Results of this research are presented in this report which is summarized in the following paragraphs. As a result of the cited research, it appears that semiconductor failure mechanism data is abundant but of little use in developing pin-level device models. Failure mode data on the other hand does exist but is too sparse to be of any statistical use in developing fault models. What is significant in the failure mode data is that, unlike classical logic, MSI and LSI devices do exhibit more than 'stuck-at' and open/short failure modes. Specifically they are dominated by parametric failures and functional anomalies that can include intermittent faults and multiple-pin failures. The report discusses methods of developing composite pin-level models based on extrapolation of semiconductor device failure mechanisms, failure modes, results of temperature stress testing and functional modeling. Limitations of this model particularly with regard to determination of fault detection coverage and latency time measurement are discussed. Indicated research directions are presented.

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

NASA Astrophysics Data System (ADS)

Zhu, Qi-Zhi

2017-02-01

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

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

PubMed

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

2014-06-01

The aim of this study was to determine whether biomarkers of myocardial stress and fibrosis improve prediction of the mode of death in patients with chronic heart failure. The 2 most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of the mode of death may facilitate treatment decisions. The relationship between amino-terminal pro-brain natriuretic peptide (NT-proBNP), galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown. HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) was a randomized controlled trial of exercise training versus usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox proportional hazards modeling, and interaction testing was used to measure differential associations between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP. After a median follow-up period of 2.5 years, there were 155 deaths: 49 from pump failure, 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk for both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death, but this relationship was attenuated after adjustment for clinical risk factors. Clinical variables along with NT-proBNP levels were stronger predictors of pump failure (C statistic: 0.87) than sudden cardiac death (C statistic: 0.73). Addition of ST2 and galectin-3 led to improved net risk classification of 11% for sudden cardiac death, but not pump failure. Clinical predictors along with NT-proBNP levels were strong predictors of pump failure risk, with insignificant incremental contributions of ST2 and galectin-3. Predictability of sudden cardiac death risk was less robust and enhanced by information provided by novel biomarkers. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Numerical model of thermo-mechanical coupling for the tensile failure process of brittle materials

NASA Astrophysics Data System (ADS)

Fu, Yu; Wang, Zhe; Ren, Fengyu; Wang, Daguo

2017-10-01

A numerical model of thermal cracking with a thermo-mechanical coupling effect was established. The theory of tensile failure and heat conduction is used to study the tensile failure process of brittle materials, such as rock and concrete under high temperature environment. The validity of the model is verified by thick-wall cylinders with analytical solutions. The failure modes of brittle materials under thermal stresses caused by temperature gradient and different thermal expansion coefficient were studied by using a thick-wall cylinder model and an embedded particle model, respectively. In the thick-wall cylinder model, different forms of cracks induced by temperature gradient were obtained under different temperature boundary conditions. In the embedded particle model, radial cracks were produced in the medium part with lower tensile strength when temperature increased because of the different thermal expansion coefficient. Model results are in good agreement with the experimental results, thereby providing a new finite element method for analyzing the thermal damage process and mechanism of brittle materials.

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

PubMed

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

2016-09-01

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

NASA's Evolutionary Xenon Thruster (NEXT) Power Processing Unit (PPU) Capacitor Failure Root Cause Analysis

NASA Technical Reports Server (NTRS)

Soeder, James F.; Pinero, Luis; Schneidegger, Robert; Dunning, John; Birchenough, Art

2012-01-01

The NASA's Evolutionary Xenon Thruster (NEXT) project is developing an advanced ion propulsion system for future NASA missions for solar system exploration. A critical element of the propulsion system is the Power Processing Unit (PPU) which supplies regulated power to the key components of the thruster. The PPU contains six different power supplies including the beam, discharge, discharge heater, neutralizer, neutralizer heater, and accelerator supplies. The beam supply is the largest and processes up to 93+% of the power. The NEXT PPU had been operated for approximately 200+ hours and has experienced a series of three capacitor failures in the beam supply. The capacitors are in the same, nominally non-critical location the input filter capacitor to a full wave switching inverter. The three failures occurred after about 20, 30, and 135 hours of operation. This paper provides background on the NEXT PPU and the capacitor failures. It discusses the failure investigation approach, the beam supply power switching topology and its operating modes, capacitor characteristics and circuit testing. Finally, it identifies root cause of the failures to be the unusual confluence of circuit switching frequency, the physical layout of the power circuits, and the characteristics of the capacitor.

NASA's Evolutionary Xenon Thruster (NEXT) Power Processing Unit (PPU) Capacitor Failure Root Cause Analysis

NASA Technical Reports Server (NTRS)

Soeder, James F.; Scheidegger, Robert J.; Pinero, Luis R.; Birchenough, Arthur J.; Dunning, John W.

2012-01-01

The NASA s Evolutionary Xenon Thruster (NEXT) project is developing an advanced ion propulsion system for future NASA missions for solar system exploration. A critical element of the propulsion system is the Power Processing Unit (PPU) which supplies regulated power to the key components of the thruster. The PPU contains six different power supplies including the beam, discharge, discharge heater, neutralizer, neutralizer heater, and accelerator supplies. The beam supply is the largest and processes up to 93+% of the power. The NEXT PPU had been operated for approximately 200+ hr and has experienced a series of three capacitor failures in the beam supply. The capacitors are in the same, nominally non-critical location-the input filter capacitor to a full wave switching inverter. The three failures occurred after about 20, 30, and 135 hr of operation. This paper provides background on the NEXT PPU and the capacitor failures. It discusses the failure investigation approach, the beam supply power switching topology and its operating modes, capacitor characteristics and circuit testing. Finally, it identifies root cause of the failures to be the unusual confluence of circuit switching frequency, the physical layout of the power circuits, and the characteristics of the capacitor.

Product Quality Improvement Using FMEA for Electric Parking Brake (EPB)

NASA Astrophysics Data System (ADS)

Dumitrescu, C. D.; Gruber, G. C.; Tişcă, I. A.

2016-08-01

One of the most frequently used methods to improve product quality is complex FMEA. (Failure Modes and Effects Analyses). In the literature various FMEA is known, depending on the mode and depending on the targets; we mention here some of these names: Failure Modes and Effects Analysis Process, or analysis Failure Mode and Effects Reported (FMECA). Whatever option is supported by the work team, the goal of the method is the same: optimize product design activities in research, design processes, implementation of manufacturing processes, optimization of mining product to beneficiaries. According to a market survey conducted on parts suppliers to vehicle manufacturers FMEA method is used in 75%. One purpose of the application is that after the research and product development is considered resolved, any errors which may be detected; another purpose of applying the method is initiating appropriate measures to avoid mistakes. Achieving these two goals leads to a high level distribution in applying, to avoid errors already in the design phase of the product, thereby avoiding the emergence and development of additional costs in later stages of product manufacturing. During application of FMEA method using standardized forms; with their help will establish the initial assemblies of product structure, in which all components will be viewed without error. The work is an application of the method FMEA quality components to optimize the structure of the electrical parking brake (Electric Parching Brake - E.P.B). This is a component attached to the roller system which ensures automotive replacement of conventional mechanical parking brake while ensuring its comfort, functionality, durability and saves space in the passenger compartment. The paper describes the levels at which they appealed in applying FMEA, working arrangements in the 4 distinct levels of analysis, and how to determine the number of risk (Risk Priority Number); the analysis of risk factors and established authors who have imposed measures to reduce / eliminate risk completely exploiting this complex product.

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

NASA Technical Reports Server (NTRS)

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

1980-01-01

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

Transverse Isotropy of Phyllite Under Brazilian Tests: Laboratory Testing and Numerical Simulations

NASA Astrophysics Data System (ADS)

Xu, Guowen; He, Chuan; Chen, Ziquan; Su, Ang

2018-04-01

Phyllite is a low-grade, metamorphic rock with well-developed foliation. We characterized the fracture pattern and failure strength of phyllite specimens under Brazilian tests. The specimens were obtained from the Zhegu mountain tunnel in China and had different foliation-loading angles, namely 0°, 15°, 30°, 45°, 60°, 75° and 90°. The processes for the initiation and propagation of macro-cracks were recorded using high-speed photography. The evolution of micro-cracks was analyzed based on the results of acoustic emission (AE) tests. The failure process of the specimens during the Brazilian tests was simulated with a new numerical approach based on the particle discrete element method. The influence of foliation strength and the microstructure of the rock matrix were also studied numerically. The experimental results showed that the failure strength of the specimens was related to their fracture patterns and the areas of their fracture surfaces. The initial cracking point of the specimens appeared at the upper or lower loading position, and the cracks propagated to the boundaries of the specimens along or across foliation. The temporal distributions of the AE counts and AE energy of the specimens were affected predominantly by the fracture pattern, and we divided these distributions into two modes: the peak mode and the uniformly distributed mode. The numerical results indicated that the fracture surface was roughly parallel to the loading direction and that the surface was located in the central part of the disk specimens for rocks with loose structure (low coordination number or large crack density) or with strong foliation, i.e., foliation with high shear strength. The failure pattern and trends of variation in failure strength as a function of foliation-loading angles varied with the ratio of cohesion to the tensile strength of foliation, the crack density, and the coordination number.

Microstructure and Mechanical Performance of Friction Stir Spot-Welded Aluminum-5754 Sheets

NASA Astrophysics Data System (ADS)

Pathak, N.; Bandyopadhyay, K.; Sarangi, M.; Panda, Sushanta Kumar

2013-01-01

Friction stir spot welding (FSSW) is a recent trend of joining light-weight sheet metals while fabricating automotive and aerospace body components. For the successful application of this solid-state welding process, it is imperative to have a thorough understanding of the weld microstructure, mechanical performance, and failure mechanism. In the present study, FSSW of aluminum-5754 sheet metal was tried using tools with circular and tapered pin considering different tool rotational speeds, plunge depths, and dwell times. The effects of tool design and process parameters on temperature distribution near the sheet-tool interface, weld microstructure, weld strength, and failure modes were studied. It was found that the peak temperature was higher while welding with a tool having circular pin compared to tapered pin, leading to a bigger dynamic recrystallized stir zone (SZ) with a hook tip bending towards the upper sheet and away from the keyhole. Hence, higher lap shear separation load was observed in the welds made from circular pin compared to those made from tapered pin. Due to influence of size and hardness of SZ on crack propagation, three different failure modes of weld nugget were observed through optical cross-sectional micrograph and SEM fractographs.

The Impact of Thermocycling Process on the Dislodgement Force of Different Endodontic Cements

PubMed Central

Saghiri, Mohammad Ali; Asatourian, Armen; Garcia-Godoy, Franklin; Gutmann, James L.; Sheibani, Nader

2013-01-01

To evaluate the effects of thermocycling (500 cycles, 5°C/55°C) on the push-out bond strength of calcium silicate based cements including WMTA, Nano-WMTA, and Bioaggregate to root dentin. Forty-eight dentin slices were prepared and divided into 3 groups (n = 16) and filled with Angelus WMTA, Nano-WMTA, or Bioaggregate. After incubation, half of the samples were thermocycled while the other half remained untreated. Push-out bond strength was calculated, and the modes of the bond failures were determined by SEM. The highest bond strength was seen in nonthermocycled Nano-WMTA samples and the lowest in thermocycled Bioaggregate samples. The significant differences between nonthermocycled and thermocycled samples were only noticed in WMTA and Nano-WMTA groups (P < 0.001). The mode of failure for thermocycled samples of all three cements was mostly cohesive. Thermocycling process can drastically affect the push-out bond strength of calcium silicate based cements. The intrastructural damages occurred due to the thermal stresses, causing cohesive failures in set materials. Sealing property of endodontic cements which have experienced the thermal stresses can be jeopardized due to occlusal forces happening in furcation cites. PMID:24063004

Researchers at NREL Find Fewer Failures of PV Panels and Different

Science.gov Websites

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

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

NASA Technical Reports Server (NTRS)

Becker, D. D.

1980-01-01

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

Failure mode and effects analysis outputs: are they valid?

PubMed Central

2012-01-01

Background Failure Mode and Effects Analysis (FMEA) is a prospective risk assessment tool that has been widely used within the aerospace and automotive industries and has been utilised within healthcare since the early 1990s. The aim of this study was to explore the validity of FMEA outputs within a hospital setting in the United Kingdom. Methods Two multidisciplinary teams each conducted an FMEA for the use of vancomycin and gentamicin. Four different validity tests were conducted: · Face validity: by comparing the FMEA participants’ mapped processes with observational work. · Content validity: by presenting the FMEA findings to other healthcare professionals. · Criterion validity: by comparing the FMEA findings with data reported on the trust’s incident report database. · Construct validity: by exploring the relevant mathematical theories involved in calculating the FMEA risk priority number. Results Face validity was positive as the researcher documented the same processes of care as mapped by the FMEA participants. However, other healthcare professionals identified potential failures missed by the FMEA teams. Furthermore, the FMEA groups failed to include failures related to omitted doses; yet these were the failures most commonly reported in the trust’s incident database. Calculating the RPN by multiplying severity, probability and detectability scores was deemed invalid because it is based on calculations that breach the mathematical properties of the scales used. Conclusion There are significant methodological challenges in validating FMEA. It is a useful tool to aid multidisciplinary groups in mapping and understanding a process of care; however, the results of our study cast doubt on its validity. FMEA teams are likely to need different sources of information, besides their personal experience and knowledge, to identify potential failures. As for FMEA’s methodology for scoring failures, there were discrepancies between the teams’ estimates and similar incidents reported on the trust’s incident database. Furthermore, the concept of multiplying ordinal scales to prioritise failures is mathematically flawed. Until FMEA’s validity is further explored, healthcare organisations should not solely depend on their FMEA results to prioritise patient safety issues. PMID:22682433

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

NASA Technical Reports Server (NTRS)

Monaghan, Mark W.; Gillespie, Amanda M.

2013-01-01

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

Determination of Turbine Blade Life from Engine Field Data

NASA Technical Reports Server (NTRS)

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

2013-01-01

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

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

DTIC Science & Technology

2016-06-01

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

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

NASA Technical Reports Server (NTRS)

Dempsey, Paula J.

2014-01-01

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

Scanning electron microscope fractography of induced fatigue-damaged saline breast implants.

PubMed

Brandon, H J; Jerina, K L; Savoy, T L; Wolf, C J

2006-01-01

Breast implant strength and durability is presently an important topic in biomaterials science. Research studies are being conducted to determine the mechanisms and rates of failure in order to assess the in vivo performance of breast implants. Fatigue life is a measure of breast implant durability since fatigue failure is a potential in vivo failure mechanism. This study describes the characterization of the fracture surface morphology of breast implant shell regions that have failed due to cyclic fatigue. Saline breast implants were fatigue tested to failure using a laboratory apparatus in which flat plates cyclically compressed the implants. The implants were unimplanted control devices of both textured and smooth saline implants. The failure surfaces of the fatigued shells were examined using scanning electron microscopy (SEM). The morphological features of the failure surfaces are described for implants with short and long fatigue lifetimes. The details of both the inside and outside surfaces of the shell at the failure location are described. Two different modes of failure were observed in both the textured and smooth shells. These modes depend on the magnitude of the cyclic load and corresponding number of fatigue cycles at failure. The first mode is a tear in the shell of about 18 mm in length, and the second mode is a pinhole approximately 1 mm in diameter. Details of the surface morphology for these two types of failure modes and shell thickness data are presented herein. There was no significant change in the crosslink density of the shell as a result of fatigue.

Accuracy of binding mode prediction with a cascadic stochastic tunneling method.

PubMed

Fischer, Bernhard; Basili, Serena; Merlitz, Holger; Wenzel, Wolfgang

2007-07-01

We investigate the accuracy of the binding modes predicted for 83 complexes of the high-resolution subset of the ASTEX/CCDC receptor-ligand database using the atomistic FlexScreen approach with a simple forcefield-based scoring function. The median RMS deviation between experimental and predicted binding mode was just 0.83 A. Over 80% of the ligands dock within 2 A of the experimental binding mode, for 60 complexes the docking protocol locates the correct binding mode in all of ten independent simulations. Most docking failures arise because (a) the experimental structure clashed in our forcefield and is thus unattainable in the docking process or (b) because the ligand is stabilized by crystal water. 2007 Wiley-Liss, Inc.

Simulation Assisted Risk Assessment: Blast Overpressure Modeling

NASA Technical Reports Server (NTRS)

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

2006-01-01

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

A bivariate model for analyzing recurrent multi-type automobile failures

NASA Astrophysics Data System (ADS)

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

2017-09-01

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

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

NASA Technical Reports Server (NTRS)

Packard, Michael H.

2002-01-01

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

Surface-wave potential for triggering tectonic (nonvolcanic) tremor

USGS Publications Warehouse

Hill, D.P.

2010-01-01

Source processes commonly posed to explain instances of remote dynamic triggering of tectonic (nonvolcanic) tremor by surface waves include frictional failure and various modes of fluid activation. The relative potential for Love- and Rayleigh-wave dynamic stresses to trigger tectonic tremor through failure on critically stressed thrust and vertical strike-slip faults under the Coulomb-Griffith failure criteria as a function of incidence angle is anticorrelated over the 15- to 30-km-depth range that hosts tectonic tremor. Love-wave potential is high for strike-parallel incidence on low-angle reverse faults and null for strike-normal incidence; the opposite holds for Rayleigh waves. Love-wave potential is high for both strike-parallel and strike-normal incidence on vertical, strike-slip faults and minimal for ~45?? incidence angles. The opposite holds for Rayleigh waves. This pattern is consistent with documented instances of tremor triggered by Love waves incident on the Cascadia mega-thrust and the San Andreas fault (SAF) in central California resulting from shear failure on weak faults (apparent friction, ????? 0.2). However, documented instances of tremor triggered by surface waves with strike-parallel incidence along the Nankai megathrust beneath Shikoku, Japan, is associated primarily with Rayleigh waves. This is consistent with the tremor bursts resulting from mixed-mode failure (crack opening and shear failure) facilitated by near-lithostatic ambient pore pressure, low differential stress, with a moderate friction coefficient (?? ~ 0.6) on the Nankai subduction interface. Rayleigh-wave dilatational stress is relatively weak at tectonic tremor source depths and seems unlikely to contribute significantly to the triggering process, except perhaps for an indirect role on the SAF in sustaining tremor into the Rayleigh-wave coda that was initially triggered by Love waves.

Surface-wave potential for triggering tectonic (nonvolcanic) tremor-corrected

USGS Publications Warehouse

Hill, David P.

2012-01-01

Source processes commonly posed to explain instances of remote dynamic triggering of tectonic (nonvolcanic) tremor by surface waves include frictional failure and various modes of fluid activation. The relative potential for Love- and Rayleigh-wave dynamic stresses to trigger tectonic tremor through failure on critically stressed thrust and vertical strike-slip faults under the Coulomb-Griffith failure criteria as a function of incidence angle are anticorrelated over the 15- to 30-km-depth range that hosts tectonic tremor. Love-wave potential is high for strike-parallel incidence on low-angle reverse faults and null for strike-normal incidence; the opposite holds for Rayleigh waves. Love-wave potential is high for both strike-parallel and strike-normal incidence on vertical, strike-slip faults and minimal for ~45° incidence angles. The opposite holds for Rayleigh waves. This pattern is consistent with documented instances of tremor triggered by Love waves incident on the Cascadia megathrust and the San Andreas fault (SAF) in central California resulting from shear failure on weak faults (apparent friction is μ* ≤ 0:2). Documented instances of tremor triggered by surface waves with strike-parallel incidence along the Nankai megathrust beneath Shikoku, Japan, however, are associated primarily with Rayleigh waves. This is consistent with the tremor bursts resulting from mixed-mode failure (crack opening and shear failure) facilitated by near-lithostatic ambient pore pressure, low differential stress, with a moderate friction coefficient (μ ~ 0:6) on the Nankai subduction interface. Rayleigh-wave dilatational stress is relatively weak at tectonic tremor source depths and seems unlikely to contribute significantly to the triggering process, except perhaps for an indirect role on the SAF in sustaining tremor into the Rayleigh-wave coda that was initially triggered by Love waves.

Sensor failure detection system. [for the F100 turbofan engine

NASA Technical Reports Server (NTRS)

Beattie, E. C.; Laprad, R. F.; Mcglone, M. E.; Rock, S. M.; Akhter, M. M.

1981-01-01

Advanced concepts for detecting, isolating, and accommodating sensor failures were studied to determine their applicability to the gas turbine control problem. Five concepts were formulated based upon such techniques as Kalman filters and a screening process led to the selection of one advanced concept for further evaluation. The selected advanced concept uses a Kalman filter to generate residuals, a weighted sum square residuals technique to detect soft failures, likelihood ratio testing of a bank of Kalman filters for isolation, and reconfiguring of the normal mode Kalman filter by eliminating the failed input to accommodate the failure. The advanced concept was compared to a baseline parameter synthesis technique. The advanced concept was shown to be a viable concept for detecting, isolating, and accommodating sensor failures for the gas turbine applications.

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

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

Williams, M. W.

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

Ground Vehicle Condition Based Maintenance

DTIC Science & Technology

2010-10-04

Diagnostic Process Map 32 FMEAs Developed : • Diesel Engine • Transmission • Alternators Analysis : • Identify failure modes • Derive design factors and...S&T Initiatives  TARDEC P&D Process Map  Component Testing  ARL CBM Research  AMSAA SDC & Terrain Modeling UNCLASSIFIED 3 CBM+ Overview...UNCLASSIFIED 4 RCM and CBM are core processes for CBM+ System Development • Army Regulation 750-1, 20 Sep 2007, p. 79 - Reliability Centered Maintenance (RCM

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

PubMed

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

2005-09-01

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

Use of mechanistic simulations as a quantitative risk-ranking tool within the quality by design framework.

PubMed

Stocker, Elena; Toschkoff, Gregor; Sacher, Stephan; Khinast, Johannes G

2014-11-20

The purpose of this study is to evaluate the use of computer simulations for generating quantitative knowledge as a basis for risk ranking and mechanistic process understanding, as required by ICH Q9 on quality risk management systems. In this specific publication, the main focus is the demonstration of a risk assessment workflow, including a computer simulation for the generation of mechanistic understanding of active tablet coating in a pan coater. Process parameter screening studies are statistically planned under consideration of impacts on a potentially critical quality attribute, i.e., coating mass uniformity. Based on computer simulation data the process failure mode and effects analysis of the risk factors is performed. This results in a quantitative criticality assessment of process parameters and the risk priority evaluation of failure modes. The factor for a quantitative reassessment of the criticality and risk priority is the coefficient of variation, which represents the coating mass uniformity. The major conclusion drawn from this work is a successful demonstration of the integration of computer simulation in the risk management workflow leading to an objective and quantitative risk assessment. Copyright © 2014. Published by Elsevier B.V.

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

PubMed

Rath, Frank

2008-01-01

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

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

NASA Astrophysics Data System (ADS)

Wessiani, N. A.; Yoshio, F.

2018-04-01

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

A Reliability Model for Ni-BaTiO3-Based (BME) Ceramic Capacitors

NASA Technical Reports Server (NTRS)

Liu, Donhang

2014-01-01

The evaluation of multilayer ceramic capacitors (MLCCs) with base-metal electrodes (BMEs) for potential NASA space project applications requires an in-depth understanding of their reliability. The reliability of an MLCC is defined as the ability of the dielectric material to retain its insulating properties under stated environmental and operational conditions for a specified period of time t. In this presentation, a general mathematic expression of a reliability model for a BME MLCC is developed and discussed. The reliability model consists of three parts: (1) a statistical distribution that describes the individual variation of properties in a test group of samples (Weibull, log normal, normal, etc.), (2) an acceleration function that describes how a capacitors reliability responds to external stresses such as applied voltage and temperature (All units in the test group should follow the same acceleration function if they share the same failure mode, independent of individual units), and (3) the effect and contribution of the structural and constructional characteristics of a multilayer capacitor device, such as the number of dielectric layers N, dielectric thickness d, average grain size r, and capacitor chip size S. In general, a two-parameter Weibull statistical distribution model is used in the description of a BME capacitors reliability as a function of time. The acceleration function that relates a capacitors reliability to external stresses is dependent on the failure mode. Two failure modes have been identified in BME MLCCs: catastrophic and slow degradation. A catastrophic failure is characterized by a time-accelerating increase in leakage current that is mainly due to existing processing defects (voids, cracks, delamination, etc.), or the extrinsic defects. A slow degradation failure is characterized by a near-linear increase in leakage current against the stress time; this is caused by the electromigration of oxygen vacancies (intrinsic defects). The two identified failure modes follow different acceleration functions. Catastrophic failures follow the traditional power-law relationship to the applied voltage. Slow degradation failures fit well to an exponential law relationship to the applied electrical field. Finally, the impact of capacitor structure on the reliability of BME capacitors is discussed with respect to the number of dielectric layers in an MLCC unit, the number of BaTiO3 grains per dielectric layer, and the chip size of the capacitor device.

Compression failure of composite laminates

NASA Technical Reports Server (NTRS)

Pipes, R. B.

1983-01-01

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

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

NASA Technical Reports Server (NTRS)

1974-01-01

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

Determination of Turbine Blade Life from Engine Field Data

NASA Technical Reports Server (NTRS)

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

2012-01-01

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

WE-G-BRC-02: Risk Assessment for HDR Brachytherapy

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

Mayadev, J.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

WE-G-BRC-01: Risk Assessment for Radiosurgery

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

Kim, G.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

WE-G-BRC-03: Risk Assessment for Physics Plan Review

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

Parker, S.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

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

NONE

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

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

NASA Technical Reports Server (NTRS)

Schmeckpeper, K. R.

1987-01-01

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

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

NASA Technical Reports Server (NTRS)

1996-01-01

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

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

Puskar, Joseph David; Quintana, Michael A.; Sorensen, Neil Robert

A program is underway at Sandia National Laboratories to predict long-term reliability of photovoltaic (PV) systems. The vehicle for the reliability predictions is a Reliability Block Diagram (RBD), which models system behavior. Because this model is based mainly on field failure and repair times, it can be used to predict current reliability, but it cannot currently be used to accurately predict lifetime. In order to be truly predictive, physics-informed degradation processes and failure mechanisms need to be included in the model. This paper describes accelerated life testing of metal foil tapes used in thin-film PV modules, and how tape jointmore » degradation, a possible failure mode, can be incorporated into the model.« less

Compression failure of angle-ply laminates

NASA Technical Reports Server (NTRS)

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

1991-01-01

The present work deals with modes and mechanisms of failure in compression of angle-ply laminates. Experimental results were obtained from 42 angle-ply IM7/8551-7a specimens with a lay-up of ((plus or minus theta)/(plus or minus theta)) sub 6s where theta, the off-axis angle, ranged from 0 degrees to 90 degrees. The results showed four failure modes, these modes being a function of off-axis angle. Failure modes include fiber compression, inplane transverse tension, inplane shear, and inplane transverse compression. Excessive interlaminar shear strain was also considered as an important mode of failure. At low off-axis angles, experimentally observed values were considerably lower than published strengths. It was determined that laminate imperfections in the form of layer waviness could be a major factor in reducing compression strength. Previously developed linear buckling and geometrically nonlinear theories were used, with modifications and enhancements, to examine the influence of layer waviness on compression response. The wavy layer is described by a wave amplitude and a wave length. Linear elastic stress-strain response is assumed. The geometrically nonlinear theory, in conjunction with the maximum stress failure criterion, was used to predict compression failure and failure modes for the angle-ply laminates. A range of wave length and amplitudes were used. It was found that for 0 less than or equal to theta less than or equal to 15 degrees failure was most likely due to fiber compression. For 15 degrees less than theta less than or equal to 35 degrees, failure was most likely due to inplane transverse tension. For 35 degrees less than theta less than or equal to 70 degrees, failure was most likely due to inplane shear. For theta less than 70 degrees, failure was most likely due to inplane transverse compression. The fiber compression and transverse tension failure modes depended more heavily on wave length than on wave amplitude. Thus using a single parameter, such as a ratio of wave amplitude to wave length, to describe waviness in a laminate would be inaccurate. Throughout, results for AS4/3502, studied previously, are included for comparison. At low off-axis angles, the AS4/3502 material system was found to be less sensitive to layer waviness than IM7/8551-7a. Analytical predictions were also obtained for laminates with waviness in only some of the layers. For this type of waviness, laminate compression strength could also be considered a function of which layers in the laminate were wavy, and where those wavy layers were. Overall, the geometrically nonlinear model correlates well with experimental results.

Chapter 3: Photovoltaic Module Stability and Reliability

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

Jordan, Dirk; Kurtz, Sarah

2017-01-01

Profits realized from investment in photovoltaic will benefit from decades of reliable operation. Service life prediction through accelerated tests is only possible if indoor tests duplicate power loss and failure modes observed in fielded systems. Therefore, detailing and quantifying power loss and failure modes is imperative. In the first section, we examine recent trends in degradation rates, the gradual power loss observed for different technologies, climates and other significant factors. In the second section, we provide a summary of the most commonly observed failure modes in fielded systems.

Failure analysis of aluminum alloy components

NASA Technical Reports Server (NTRS)

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

1973-01-01

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

Processes of coastal bluff erosion in weakly lithified sands, Pacifica, California, USA

USGS Publications Warehouse

Collins, B.D.; Sitar, N.

2008-01-01

Coastal bluff erosion and landsliding are currently the major geomorphic processes sculpting much of the marine terrace dominated coastline of northern California. In this study, we identify the spatial and temporal processes responsible for erosion and landsliding in an area of weakly lithified sand coastal bluffs located south of San Francisco, California. Using the results of a five year observational study consisting of site visits, terrestrial lidar scanning, and development of empirical failure indices, we identify the lithologic and process controls that determine the failure mechanism and mode for coastal bluff retreat in this region and present concise descriptions of each process. Bluffs composed of weakly cemented sands (unconfined compressive strength - UCS between 5 and 30??kPa) fail principally due to oversteepening by wave action with maximum slope inclinations on the order of 65 at incipient failure. Periods of significant wave action were identified on the basis of an empirical wave run-up equation, predicting failure when wave run-up exceeds the seasonal average value and the bluff toe elevation. The empirical relationship was verified through recorded observations of failures. Bluffs composed of moderately cemented sands (UCS up to 400??kPa) fail due to precipitation-induced groundwater seepage, which leads to tensile strength reduction and fracture. An empirical rainfall threshold was also developed to predict failure on the basis of a 48-hour cumulative precipitation index but was found to be dependent on a time delay in groundwater seepage in some cases.

Availability Estimate of a Conceptual ESM System.

DTIC Science & Technology

1979-06-01

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

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

NASA Astrophysics Data System (ADS)

Colavito, Kyle

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

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

NASA Technical Reports Server (NTRS)

Barnes, J. E.

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Auxiliary Power Unit (APU). The APUs are required to provide power to the Orbiter hydraulics systems during ascent and entry flight phases for aerosurface actuation, main engine gimballing, landing gear extension, and other vital functions. For analysis purposes, the APU system was broken down into ten functional subsystems. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. A preponderance of 1/1 criticality items were related to failures that allowed the hydrazine fuel to escape into the Orbiter aft compartment, creating a severe fire hazard, and failures that caused loss of the gas generator injector cooling system.

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

NASA Technical Reports Server (NTRS)

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

1988-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1990-01-01

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

Accelerated fatigue durability of a high performance composite

NASA Technical Reports Server (NTRS)

Rotem, A.

1982-01-01

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

Lightning Pin Injection Testing on MOSFETS

NASA Technical Reports Server (NTRS)

Ely, Jay J.; Nguyen, Truong X.; Szatkowski, George N.; Koppen, Sandra V.; Mielnik, John J.; Vaughan, Roger K.; Wysocki, Philip F.; Celaya, Jose R.; Saha, Sankalita

2009-01-01

Lightning transients were pin-injected into metal-oxide-semiconductor field-effect transistors (MOSFETs) to induce fault modes. This report documents the test process and results, and provides a basis for subsequent lightning tests. MOSFETs may be present in DC-DC power supplies and electromechanical actuator circuits that may be used on board aircraft. Results show that unprotected MOSFET Gates are susceptible to failure, even when installed in systems in well-shielded and partial-shielded locations. MOSFET Drains and Sources are significantly less susceptible. Device impedance decreased (current increased) after every failure. Such a failure mode may lead to cascading failures, as the damaged MOSFET may allow excessive current to flow through other circuitry. Preliminary assessments on a MOSFET subjected to 20-stroke pin-injection testing demonstrate that Breakdown Voltage, Leakage Current and Threshold Voltage characteristics show damage, while the device continues to meet manufacturer performance specifications. The purpose of this research is to develop validated tools, technologies, and techniques for automated detection, diagnosis and prognosis that enable mitigation of adverse events during flight, such as from lightning transients; and to understand the interplay between lightning-induced surges and aging (i.e. humidity, vibration thermal stress, etc.) on component degradation.

Laser Indirect Shock Welding of Fine Wire to Metal Sheet.

PubMed

Wang, Xiao; Huang, Tao; Luo, Yapeng; Liu, Huixia

2017-09-12

The purpose of this paper is to present an advanced method for welding fine wire to metal sheet, namely laser indirect shock welding (LISW). This process uses silica gel as driver sheet to accelerate the metal sheet toward the wire to obtain metallurgical bonding. A series of experiments were implemented to validate the welding ability of Al sheet/Cu wire and Al sheet/Ag wire. It was found that the use of a driver sheet can maintain high surface quality of the metal sheet. With the increase of laser pulse energy, the bonding area of the sheet/wire increased and the welding interfaces were nearly flat. Energy dispersive spectroscopy (EDS) results show that the intermetallic phases were absent and a short element diffusion layer which would limit the formation of the intermetallic phases emerging at the welding interface. A tensile shear test was used to measure the mechanical strength of the welding joints. The influence of laser pulse energy on the tensile failure modes was investigated, and two failure modes, including interfacial failure and failure through the wire, were observed. The nanoindentation test results indicate that as the distance to the welding interface decreased, the microhardness increased due to the plastic deformation becoming more violent.

A Automated Tool for Supporting FMEAs of Digital Systems

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

Yue,M.; Chu, T.-L.; Martinez-Guridi, G.

2008-09-07

Although designs of digital systems can be very different from each other, they typically use many of the same types of generic digital components. Determining the impacts of the failure modes of these generic components on a digital system can be used to support development of a reliability model of the system. A novel approach was proposed for such a purpose by decomposing the system into a level of the generic digital components and propagating failure modes to the system level, which generally is time-consuming and difficult to implement. To overcome the associated issues of implementing the proposed FMEA approach,more » an automated tool for a digital feedwater control system (DFWCS) has been developed in this study. The automated FMEA tool is in nature a simulation platform developed by using or recreating the original source code of the different module software interfaced by input and output variables that represent physical signals exchanged between modules, the system, and the controlled process. For any given failure mode, its impacts on associated signals are determined first and the variables that correspond to these signals are modified accordingly by the simulation. Criteria are also developed, as part of the simulation platform, to determine whether the system has lost its automatic control function, which is defined as a system failure in this study. The conceptual development of the automated FMEA support tool can be generalized and applied to support FMEAs for reliability assessment of complex digital systems.« less

Development of wheelchair caster testing equipment and preliminary testing of caster models

PubMed Central

Mhatre, Anand; Ott, Joseph

2017-01-01

Background Because of the adverse environmental conditions present in less-resourced environments (LREs), the World Health Organization (WHO) has recommended that specialised wheelchair test methods may need to be developed to support product quality standards in these environments. A group of experts identified caster test methods as a high priority because of their common failure in LREs, and the insufficiency of existing test methods described in the International Organization for Standardization (ISO) Wheelchair Testing Standards (ISO 7176). Objectives To develop and demonstrate the feasibility of a caster system test method. Method Background literature and expert opinions were collected to identify existing caster test methods, caster failures common in LREs and environmental conditions present in LREs. Several conceptual designs for the caster testing method were developed, and through an iterative process using expert feedback, a final concept and a design were developed and a prototype was fabricated. Feasibility tests were conducted by testing a series of caster systems from wheelchairs used in LREs, and failure modes were recorded and compared to anecdotal reports about field failures. Results The new caster testing system was developed and it provides the flexibility to expose caster systems to typical conditions in LREs. Caster failures such as stem bolt fractures, fork fractures, bearing failures and tire cracking occurred during testing trials and are consistent with field failures. Conclusion The new caster test system has the capability to incorporate necessary test factors that degrade caster quality in LREs. Future work includes developing and validating a testing protocol that results in failure modes common during wheelchair use in LRE. PMID:29062762

Clinical Risk Assessment in Intensive Care Unit

PubMed Central

Asefzadeh, Saeed; Yarmohammadian, Mohammad H.; Nikpey, Ahmad; Atighechian, Golrokh

2013-01-01

Background: Clinical risk management focuses on improving the quality and safety of health care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks. The goal of this study is to identify and assess the failure modes in the ICU of Qazvin's Social Security Hospital (Razi Hospital) through Failure Mode and Effect Analysis (FMEA). Methods: This was a qualitative-quantitative research by Focus Discussion Group (FDG) performed in Qazvin Province, Iran during 2011. The study population included all individuals and owners who are familiar with the process in ICU. Sampling method was purposeful and the FDG group members were selected by the researcher. The research instrument was standard worksheet that has been used by several researchers. Data was analyzed by FMEA technique. Results: Forty eight clinical errors and failure modes identified, results showed that the highest risk probability number (RPN) was in respiratory care “Ventilator's alarm malfunction (no alarm)” with the score 288, and the lowest was in gastrointestinal “not washing the NG-Tube” with the score 8. Conclusions: Many of the identified errors can be prevented by group members. Clinical risk assessment and management is the key to delivery of effective health care. PMID:23930171

PV Degradation Curves: Non-Linearities and Failure Modes

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

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

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

Modelling Coastal Cliff Recession Based on the GIM-DDD Method

NASA Astrophysics Data System (ADS)

Gong, Bin; Wang, Shanyong; Sloan, Scott William; Sheng, Daichao; Tang, Chun'an

2018-04-01

The unpredictable and instantaneous collapse behaviour of coastal rocky cliffs may cause damage that extends significantly beyond the area of failure. Gravitational movements that occur during coastal cliff recession involve two major stages: the small deformation stage and the large displacement stage. In this paper, a method of simulating the entire progressive failure process of coastal rocky cliffs is developed based on the gravity increase method (GIM), the rock failure process analysis method and the discontinuous deformation analysis method, and it is referred to as the GIM-DDD method. The small deformation stage, which includes crack initiation, propagation and coalescence processes, and the large displacement stage, which includes block translation and rotation processes during the rocky cliff collapse, are modelled using the GIM-DDD method. In addition, acoustic emissions, stress field variations, crack propagation and failure mode characteristics are further analysed to provide insights that can be used to predict, prevent and minimize potential economic losses and casualties. The calculation and analytical results are consistent with previous studies, which indicate that the developed method provides an effective and reliable approach for performing rocky cliff stability evaluations and coastal cliff recession analyses and has considerable potential for improving the safety and protection of seaside cliff areas.

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

NASA Astrophysics Data System (ADS)

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

2017-10-01

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

Sounds of Failure: Passive Acoustic Measurements of Excited Vibrational Modes

NASA Astrophysics Data System (ADS)

Brzinski, Theodore A.; Daniels, Karen E.

2018-05-01

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

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

PubMed

Brzinski, Theodore A; Daniels, Karen E

2018-05-25

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

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

PubMed Central

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

2017-01-01

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

Foresight begins with FMEA. Delivering accurate risk assessments.

PubMed

Passey, R D

1999-03-01

If sufficient factors are taken into account and two- or three-stage analysis is employed, failure mode and effect analysis represents an excellent technique for delivering accurate risk assessments for products and processes, and for relating them to legal liability. This article describes a format that facilitates easy interpretation.

Comparison of hand laid-up tape and filament wound composite cylinders and panels with and without impact damage

NASA Technical Reports Server (NTRS)

Jegley, Dawn C.; Lopez, Osvaldo F.

1991-01-01

Experimentally determined axial compressive failure loads, strains and failure modes of composite flat panels and cylinders are presented. A comparison of two types of filament wound flat graphite-epoxy panels indicates that the winding pattern can influence structural response. A comparison of hand laid-up tape and filament wound composite cylinders indicates that fabrication method may not significantly influence the failure mode or average failure strain of thick-walled (radius-to-thickness ratio less than 15) graphite-epoxy cylinders. The interaction of manufacturing-induced features (fiber cross-overs) and low-speed impact damage for graphite-epoxy specimens is also presented. Filament would flat panels with many fiber cross-overs exhibited lower failure strains than filament wound panels without fiber cross-overs for all impact speeds examined. Graphite-thermoplastic cylinders exhibited a significantly different failure mode from the graphite-epoxy cylinders.

Ultrasonic nonlinear guided wave inspection of microscopic damage in a composite structure

NASA Astrophysics Data System (ADS)

Zhang, Li; Borigo, Cody; Owens, Steven; Lissenden, Clifford; Rose, Joseph; Hakoda, Chris

2017-02-01

Sudden structural failure is a severe safety threat to many types of military and industrial composite structures. Because sudden structural failure may occur in a composite structure shortly after macroscale damage initiates, reliable early diagnosis of microdamage formation in the composite structure is critical to ensure safe operation and to reduce maintenance costs. Ultrasonic guided waves have been widely used for long-range defect detection in various structures. When guided waves are generated under certain excitation conditions, in addition to the traditional linear wave mode (known as the fundamental harmonic wave mode), a number of nonlinear higher-order harmonic wave modes are also be generated. Research shows that the nonlinear parameters of a higher-order harmonic wave mode could have excellent sensitivity to microstructural changes in a material. In this work, we successfully employed a nonlinear guided wave structural health monitoring (SHM) method to detect microscopic impact damage in a 32-layer carbon/epoxy fiber-reinforced composite plate. Our effort has demonstrated that, utilizing appropriate transducer design, equipment, excitation signals, and signal processing techniques, nonlinear guided wave parameter measurements can be reliably used to monitor microdamage initiation and growth in composite structures.

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

NASA Astrophysics Data System (ADS)

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

2018-05-01

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

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

PubMed

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

2013-01-01

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

Microstructural characterization of ultra thin copper interconnects

NASA Astrophysics Data System (ADS)

Yang, Hee-Dong

The present study investigates the defects related to reliability issues, such as physical failures developed during processing and end use. In the first part of this study, kinetic analysis using the Johnson-Mehl-Avrami (JMA) model demonstrates that a self-annealing mechanism in electroplated Cu films depends on the film properties, such as thickness and the amount of crystal defects in an as-deposited state. In order to obtain the evidence of such defects, the microstructural characterization of defects in ultra thin copper interconnects using transmission electron microscopy (TEM) is presented. Examination of the defects using TEM reveals that voids filled with gas form as a lens shape along the {110} habit planes of the copper matrix. In the second part of this study, methodology and results of an electro-thermal-fatigue (ETF) testing, designed for early detection of process defects, are presented. Such ETF testing combines high-density current electrical stressing and thermal cycling to accelerate the evolution of defects in Cu interconnects. In ETF testing, the evolution of defects provides the nucleation sites for voids which open or close during thermal cycling. Then, the accumulation of voids creates the change in resistance when they reach a critical size. As a result of voids evolution, the high current density and high joule heating create a transient resistance increase. ETF testing reveals two failure modes, and the mode-I failure has the importance in detecting defects. The number of cycles to failure in ETF testing decreases with higher current density, but the rate of thermal cycling has no effect. Results from this investigation suggest that impurities in the copper electrodeposition process must be carefully controlled to achieve reliable ultra thin copper interconnects.

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

PubMed

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

2007-07-24

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

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

NASA Astrophysics Data System (ADS)

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

2017-04-01

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

Experimental strength of restorations with fibre posts at different stages, with and without using a simulated ligament.

PubMed

Pérez-González, A; González-Lluch, C; Sancho-Bru, J L; Rodríguez-Cervantes, P J; Barjau-Escribano, A; Forner-Navarro, L

2012-03-01

The aim of this study was to analyse the strength and failure mode of teeth restored with fibre posts under retention and flexural-compressive loads at different stages of the restoration and to analyse whether including a simulated ligament in the experimental setup has any effect on the strength or the failure mode. Thirty human maxillary central incisors were distributed in three different groups to be restored with simulation of different restoration stages (1: only post, 2: post and core, 3: post-core and crown), using Rebilda fibre posts. The specimens were inserted in resin blocks and loaded by means of a universal testing machine until failure under tension (stage 1) and 50º flexion (stages 2-3). Half the specimens in each group were restored using a simulated ligament between root dentine and resin block and the other half did not use this element. Failure in stage 1 always occurred at the post-dentine interface, with a mean failure load of 191·2 N. Failure in stage 2 was located mainly in the core or coronal dentine (mean failure load of 505·9 N). Failure in stage 3 was observed in the coronal dentine (mean failure load 397·4 N). Failure loads registered were greater than expected masticatory loads. Fracture modes were mostly reparable, thus indicating that this post is clinically valid at the different stages of restoration studied. The inclusion of the simulated ligament in the experimental system did not show a statistically significant effect on the failure load or the failure mode. © 2011 Blackwell Publishing Ltd.

Li-ion Battery Separators, Mechanical Integrity and Failure Mechanisms Leading to Soft and Hard Internal Shorts

PubMed Central

Zhang, Xiaowei; Sahraei, Elham; Wang, Kai

2016-01-01

Separator integrity is an important factor in preventing internal short circuit in lithium-ion batteries. Local penetration tests (nail or conical punch) often produce presumably sporadic results, where in exactly similar cell and test set-ups one cell goes to thermal runaway while the other shows minimal reactions. We conducted an experimental study of the separators under mechanical loading, and discovered two distinct deformation and failure mechanisms, which could explain the difference in short circuit characteristics of otherwise similar tests. Additionally, by investigation of failure modes, we provided a hypothesis about the process of formation of local “soft short circuits” in cells with undetectable failure. Finally, we proposed a criterion for predicting onset of soft short from experimental data. PMID:27581185

Optoelectronic Devices with Complex Failure Modes

NASA Technical Reports Server (NTRS)

Johnston, A.

2000-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Life Support System (LSS) and Airlock Support System (ALSS). Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. The LSS provides for the management of the supply water, collection of metabolic waste, management of waste water, smoke detection, and fire suppression. The ALSS provides water, oxygen, and electricity to support an extravehicular activity in the airlock.

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

PubMed

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

2001-01-01

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

Automated Mixed Traffic Vehicle (AMTV) technology and safety study

NASA Technical Reports Server (NTRS)

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

1978-01-01

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

Space Shuttle Hot Cabin Emergency Responses

NASA Technical Reports Server (NTRS)

Stepaniak, P.; Effenhauser, R. K.; McCluskey, R.; Gillis, D. B.; Hamilton, D.; Kuznetz, L. H.

2005-01-01

Methods: Human thermal tolerance, countermeasures, and thermal model data were reviewed and compared to existing shuttle ECS failure temperature and humidity profiles for each failure mode. Increases in core temperature associated with cognitive impairment was identified, as was metabolic heat generation of crewmembers, temperature monitoring, and communication capabilities after partial power-down and other limiting factors. Orbiter landing strategies and a hydration and salt replacement protocol were developed to put wheels on deck in each failure mode prior to development of significant cognitive impairment or collapse of crewmembers. Thermal tradeoffs for use of the Advanced Crew Escape Suit (ACES), Liquid Cooling Garment, integrated G-suit and Quick Don Mask were examined. candidate solutions involved trade-offs or conflicts with cabin oxygen partial pressure limits, system power-downs to limit heat generation, risks of alternate and emergency landing sites or compromise of Mode V-VIII scenarios. Results: Rehydration and minimized cabin workloads are required in all failure modes. Temperature/humidity profiles increase rapidly in two failure modes, and deorbit is recommended without the ACES, ICU and g-suit. This latter configuration limits several shuttle approach and landing escape modes and requires communication modifications. Additional data requirements were identified and engineering simulations were recommended to develop more current shuttle temperature and humidity profiles. Discussion: After failure of the shuttle ECS, there is insufficient cooling capacity of the ACES to protect crewmembers from rising cabin temperature and humidity. The LCG is inadequate for cabin temperatures above 76 F. Current shuttle future life policy makes it unlikely that major engineering upgrades necessary to address this problem will occur.

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

NASA Technical Reports Server (NTRS)

Howard, Philip M.

2015-01-01

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

FMEA team performance in health care: A qualitative analysis of team member perceptions.

PubMed

Wetterneck, Tosha B; Hundt, Ann Schoofs; Carayon, Pascale

2009-06-01

: Failure mode and effects analysis (FMEA) is a commonly used prospective risk assessment approach in health care. Failure mode and effects analyses are time consuming and resource intensive, and team performance is crucial for FMEA success. We evaluate FMEA team members' perceptions of FMEA team performance to provide recommendations to improve the FMEA process in health care organizations. : Structured interviews and survey questionnaires were administered to team members of 2 FMEA teams at a Midwest Hospital to evaluate team member perceptions of FMEA team performance and factors influencing team performance. Interview transcripts underwent content analysis, and descriptive statistics were performed on questionnaire results to identify and quantify FMEA team performance. Theme-based nodes were categorized using the input-process-outcome model for team performance. : Twenty-eight interviews and questionnaires were completed by 24 team members. Four persons participated on both teams. There were significant differences between the 2 teams regarding perceptions of team functioning and overall team effectiveness that are explained by difference in team inputs and process (e.g., leadership/facilitation, team objectives, attendance of process owners). : Evaluation of team members' perceptions of team functioning produced useful insights that can be used to model future team functioning. Guidelines for FMEA team success are provided.

Degradation mechanisms in high-power multi-mode InGaAs-AlGaAs strained quantum well lasers for high-reliability applications

NASA Astrophysics Data System (ADS)

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

2015-03-01

Laser diode manufacturers perform accelerated multi-cell lifetests to estimate lifetimes of lasers using an empirical model. Since state-of-the-art laser diodes typically require a long period of latency before they degrade, significant amount of stress is applied to the lasers to generate failures in relatively short test durations. A drawback of this approach is the lack of mean-time-to-failure data under intermediate and low stress conditions, leading to uncertainty in model parameters (especially optical power and current exponent) and potential overestimation of lifetimes at usage conditions. This approach is a concern especially for satellite communication systems where high reliability is required of lasers for long-term duration in the space environment. A number of groups have studied reliability and degradation processes in GaAs-based lasers, but none of these studies have yielded a reliability model based on the physics of failure. The lack of such a model is also a concern for space applications where complete understanding of degradation mechanisms is necessary. Our present study addresses the aforementioned issues by performing long-term lifetests under low stress conditions followed by failure mode analysis (FMA) and physics of failure investigation. We performed low-stress lifetests on both MBE- and MOCVD-grown broad-area InGaAs- AlGaAs strained QW lasers under ACC (automatic current control) mode to study low-stress degradation mechanisms. Our lifetests have accumulated over 36,000 test hours and FMA is performed on failures using our angle polishing technique followed by EL. This technique allows us to identify failure types by observing dark line defects through a window introduced in backside metal contacts. We also investigated degradation mechanisms in MOCVD-grown broad-area InGaAs-AlGaAs strained QW lasers using various FMA techniques. Since it is a challenge to control defect densities during the growth of laser structures, we chose to control defect densities by introducing extrinsic point defects to the laser via proton irradiation with different energies and fluences. These lasers were subsequently lifetested to study degradation processes in the lasers with different defect densities and also to study precursor signatures of failures - traps and non-radiative recombination centers (NRCs) in pre- and post-stressed lasers. Lastly, we employed focused ion beam (FIB), electron beam induced current (EBIC), and highresolution TEM (HR-TEM) techniques to further study dark line defects and dislocations in both post-aged and postproton irradiated lasers. We report on our long-term low-stress lifetest results and physics of failure investigation results.

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

NASA Astrophysics Data System (ADS)

Mastio, Michael Joseph, Jr.

2005-11-01

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

Plastic Pipe Failure, Risk, and Threat Analysis

DOT National Transportation Integrated Search

2009-04-29

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

Reusable Rocket Engine Maintenance Study

NASA Technical Reports Server (NTRS)

Macgregor, C. A.

1982-01-01

Approximately 85,000 liquid rocket engine failure reports, obtained from 30 years of developing and delivering major pump feed engines, were reviewed and screened and reduced to 1771. These were categorized into 16 different failure modes. Failure propagation diagrams were established. The state of the art of engine condition monitoring for in-flight sensors and between flight inspection technology was determined. For the 16 failure modes, the potential measurands and diagnostic requirements were identified, assessed and ranked. Eight areas are identified requiring advanced technology development.

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

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

Lee C. Cadwallader

2010-06-01

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

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

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

Lee C. Cadwallader

2007-08-01

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

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

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

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

2009-01-23

Failure occurs when one or more of the intended functions of a product are no longer fulfilled to the customer's satisfaction. The most critical product failures are those that escape design reviews and in-house quality inspection and are found by the customer. The product may work for a while until its performance degrades to an unacceptable level or it may have not worked even before customer took possession of the product. The end results of failures which may lead to unsafe conditions or major losses of the main function are rated high in severity. Failure Modes and Effects Analysis (FMEA)more » is a tool widely used in the automotive, aerospace, and electronics industries to identify, prioritize, and eliminate known potential failures, problems, and errors from systems under design, before the product is released (Stamatis, 1997). Several industrial FMEA standards such as those published by the Society of Automotive Engineers, US Department of Defense, and the Automotive Industry Action Group employ the Risk Priority Number (RPN) to measure risk and severity of failures. The Risk Priority Number (RPN) is a product of 3 indices: Occurrence (O), Severity (S), and Detection (D). In a traditional FMEA process design engineers typically analyze the 'root cause' and 'end-effects' of potential failures in a sub-system or component and assign penalty points through the O, S, D values to each failure. The analysis is organized around categories called failure modes, which link the causes and effects of failures. A few actions are taken upon completing the FMEA worksheet. The RPN column generally will identify the high-risk areas. The idea of performing FMEA is to eliminate or reduce known and potential failures before they reach the customers. Thus, a plan of action must be in place for the next task. Not all failures can be resolved during the product development cycle, thus prioritization of actions must be made within the design group. One definition of detection difficulty (D) is how well the organization controls the development process. Another definition relates to the detectability of a particular failure in the product when it is in the hands of the customer. The former asks 'What is the chance of catching the problem before we give it to the customer'? The latter asks 'What is the chance of the customer catching the problem before the problem results in a catastrophic failure?' (Palady, 1995) These differing definitions confuse the FMEA users when one tries to determine detection difficulty. Are we trying to measure how easy it is to detect where a failure has occurred or when it has occurred? Or are we trying to measure how easy or difficult it is to prevent failures? Ordinal scale variables are used to rank-order industries such as, hotels, restaurants, and movies (Note that a 4 star hotel is not necessarily twice as good as a 2 star hotel). Ordinal values preserve rank in a group of items, but the distance between the values cannot be measured since a distance function does not exist. Thus, the product or sum of ordinal variables loses its rank since each parameter has different scales. The RPN is a product of 3 independent ordinal variables, it can indicate that some failure types are 'worse' than others, but give no quantitative indication of their relative effects. To resolve the ambiguity of measuring detection difficulty and the irrational logic of multiplying 3 ordinal indices, a new methodology was created to overcome these shortcomings, Life Cost-Based FMEA. Life Cost-Based FMEA measures failure/risk in terms of monetary cost. Cost is a universal parameter that can be easily related to severity by engineers and others. Thus, failure cost can be estimated using the following simplest form: Expected Failure Cost = {sup n}{Sigma}{sub i=1}p{sub i}c{sub i}, p: Probability of a particular failure occurring; c: Monetary cost associated with that particular failure; and n: Total number of failure scenarios. FMEA is most effective when there are inputs into it from all concerned disciplines of the product development team. However, FMEA is a long process and can become tedious and won't be effective if too many people participate. An ideal team should have 3 to 4 people from: design, manufacturing, and service departments if possible. Depending on how complex the system is, the entire process can take anywhere from one to four weeks working full time. Thus, it is important to agree to the time commitment before starting the analysis else, anxious managers might stop the procedure before it is completed.« less

49 CFR Appendix C to Part 236 - Safety Assurance Criteria and Processes

Code of Federal Regulations, 2010 CFR

2010-10-01

... system (all its elements including hardware and software) must be designed to assure safe operation with... unsafe errors in the software due to human error in the software specification, design, or coding phases... (hardware or software, or both) are used in combination to ensure safety. If a common mode failure exists...

A study of laser surface treatment in bonded repair of composite aircraft structures.

PubMed

Li, Shaolong; Sun, Ting; Liu, Chang; Yang, Wenfeng; Tang, Qingru

2018-03-01

Surface pre-treatment is one of the key processes in bonded repair of aircraft carbon fibre reinforced polymer composites. This paper investigates the surface modification of physical and chemical properties by laser ablation and conventional polish treatment techniques. Surface morphology analysed by laser scanning confocal microscopy and scanning electron microscopy showed that a laser-treated surface displayed higher roughness than that of a polish-treated specimen. The laser-treated laminate exhibited more functional groups in the form of O 1 s/C 1 s atomic ratio of 30.89% for laser-treated and 20.14% for polish-treated as evidenced by X-ray photoelectron spectroscopy observation. Contact angle goniometry demonstrated that laser treatment can provide increased surface free energy and wettability. In the light of mechanical interlocking, molecular bonding and thermodynamics theories on adhesion, laser etching process displayed enhanced bonding performance relative to the polishing surface treatment. These properties resulted in an increased single lap shear strength and a cohesive failure mode for laser etching while an adhesive failure mode occurred in polish-treated specimen.

A study of laser surface treatment in bonded repair of composite aircraft structures

NASA Astrophysics Data System (ADS)

Li, Shaolong; Sun, Ting; Liu, Chang; Yang, Wenfeng; Tang, Qingru

2018-03-01

Surface pre-treatment is one of the key processes in bonded repair of aircraft carbon fibre reinforced polymer composites. This paper investigates the surface modification of physical and chemical properties by laser ablation and conventional polish treatment techniques. Surface morphology analysed by laser scanning confocal microscopy and scanning electron microscopy showed that a laser-treated surface displayed higher roughness than that of a polish-treated specimen. The laser-treated laminate exhibited more functional groups in the form of O 1 s/C 1 s atomic ratio of 30.89% for laser-treated and 20.14% for polish-treated as evidenced by X-ray photoelectron spectroscopy observation. Contact angle goniometry demonstrated that laser treatment can provide increased surface free energy and wettability. In the light of mechanical interlocking, molecular bonding and thermodynamics theories on adhesion, laser etching process displayed enhanced bonding performance relative to the polishing surface treatment. These properties resulted in an increased single lap shear strength and a cohesive failure mode for laser etching while an adhesive failure mode occurred in polish-treated specimen.

A study of laser surface treatment in bonded repair of composite aircraft structures

PubMed Central

Sun, Ting; Liu, Chang; Yang, Wenfeng; Tang, Qingru

2018-01-01

Surface pre-treatment is one of the key processes in bonded repair of aircraft carbon fibre reinforced polymer composites. This paper investigates the surface modification of physical and chemical properties by laser ablation and conventional polish treatment techniques. Surface morphology analysed by laser scanning confocal microscopy and scanning electron microscopy showed that a laser-treated surface displayed higher roughness than that of a polish-treated specimen. The laser-treated laminate exhibited more functional groups in the form of O 1 s/C 1 s atomic ratio of 30.89% for laser-treated and 20.14% for polish-treated as evidenced by X-ray photoelectron spectroscopy observation. Contact angle goniometry demonstrated that laser treatment can provide increased surface free energy and wettability. In the light of mechanical interlocking, molecular bonding and thermodynamics theories on adhesion, laser etching process displayed enhanced bonding performance relative to the polishing surface treatment. These properties resulted in an increased single lap shear strength and a cohesive failure mode for laser etching while an adhesive failure mode occurred in polish-treated specimen. PMID:29657748

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

PubMed

Deng, Xinyang; Jiang, Wen

2017-09-12

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

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

PubMed Central

Deng, Xinyang

2017-01-01

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

The Processing and Mechanical Properties of High Temperature/High Performance Composites. Book 3, Section 2: Strength and Fracture Resistance. Part 2

DTIC Science & Technology

1989-10-15

reinfied with c doinAwatfhe exhibit imptant fallure./ amle behavior" in mode I. me II and mixed mode /fl. as well as In ompresslon. The failure xqunce...In addition, when KO/Kc-2.5, the linear perturbation results overestimate KI/Kc along CFt . Both the previous observations would imply that crack growth...Viscoelastic Regions with Application to 3-D Crack Analysis.", Ph.D. thesis , Massachusseus Institute of Technology, 1987. Fares N. and Li V.C., (1988

Failure of a laminated composite under tension-compression fatigue loading

NASA Technical Reports Server (NTRS)

Rotem, A.; Nelson, H. G.

1989-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2018-02-01

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

Thermal barrier coating life prediction model

NASA Technical Reports Server (NTRS)

Pilsner, B. H.; Hillery, R. V.; Mcknight, R. L.; Cook, T. S.; Kim, K. S.; Duderstadt, E. C.

1986-01-01

The objectives of this program are to determine the predominant modes of degradation of a plasma sprayed thermal barrier coating system, and then to develop and verify life prediction models accounting for these degradation modes. The program is divided into two phases, each consisting of several tasks. The work in Phase 1 is aimed at identifying the relative importance of the various failure modes, and developing and verifying life prediction model(s) for the predominant model for a thermal barrier coating system. Two possible predominant failure mechanisms being evaluated are bond coat oxidation and bond coat creep. The work in Phase 2 will develop design-capable, causal, life prediction models for thermomechanical and thermochemical failure modes, and for the exceptional conditions of foreign object damage and erosion.

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

NASA Technical Reports Server (NTRS)

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

2010-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results for the Orbiter Elevon system hardware. The elevon actuators are located at the trailing edge of the wing surface. The proper function of the elevons is essential during the dynamic flight phases of ascent and entry. In the ascent phase of flight, the elevons are used for relieving high wing loads. For entry, the elevons are used to pitch and roll the vehicle. Specifically, the elevon system hardware comprises the following components: flow cutoff valve; switching valve; electro-hydraulic (EH) servoactuator; secondary delta pressure transducer; bypass valve; power valve; power valve check valve; primary actuator; primary delta pressure transducer; and primary actuator position transducer. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 25 failure modes analyzed, 18 were determined to be PCIs.

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

NASA Technical Reports Server (NTRS)

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

1988-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Life Support and Airlock Support Systems (LSS and ALSS) hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the NASA FMEA/CIL baseline with proposed Post 51-L updates included. The discrepancies were flagged for potential future resolution. This report documents the results of that comparison for the Orbiter LSS and ALSS hardware. The IOA product for the LSS and ALSS analysis consisted of 511 failure mode worksheets that resulted in 140 potential critical items. Comparison was made to the NASA baseline which consisted of 456 FMEAs and 101 CIL items. The IOA analysis identified 39 failure modes, 6 of which were classified as CIL items, for components not covered by the NASA FMEAs. It was recommended that these failure modes be added to the NASA FMEA baseline. The overall assessment produced agreement on all but 301 FMEAs which caused differences in 111 CIL items.

Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards.

PubMed

Ofek, Fanny; Magnezi, Racheli; Kurzweil, Yaffa; Gazit, Inbal; Berkovitch, Sofia; Tal, Orna

2016-01-01

Intravenous potassium chloride (IV KCl) solutions are widely used in hospitals for treatment of hypokalemia. As ampoules of concentrated KCL must be diluted before use, critical incidents have been associated with its preparation and administration. Currently, we have introduced ready-to-use diluted KCl infusion solutions to minimize the use of high-alert concentrated KCl. Since this process may be associated with considerable risks, we embraced a proactive hazard analysis as a tool to implement a change in high-alert drug usage in a hospital setting. Failure mode and effect analysis (FMEA) is a systematic tool to analyze and identify risks in system operations. We used FMEA to examine the hazards associated with the implementation of the ready-to-use solutions. A multidisciplinary team analyzed the risks by identifying failure modes, conducting a hazard analysis and calculating the criticality index (CI) for each failure mode. A 1-day survey was performed as an evaluation step after a trial run period of approximately 4 months. Six major possible risks were identified. The most severe risks were prioritized and specific recommendations were formulated. Out of 28 patients receiving IV KCl on the day of the survey, 22 received the ready-to-use solutions and 6 received the concentrated solutions as instructed. Only 1 patient received inappropriate ready-to-use KCl. Using the FMEA tool in our study has proven once again that by creating a gradient of severity of potential vulnerable elements, we are able to proactively promote safer and more efficient processes in health care systems. This article presents a utilization of this method for implementing a change in hospital policy regarding the routine use of IV KCl.

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

NASA Technical Reports Server (NTRS)

Rotem, Assa

1990-01-01

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

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

PubMed

Giardina, M; Castiglia, F; Tomarchio, E

2014-12-01

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

Behaviors of 40Cr steel treated by laser quenching on impact abrasive wear

NASA Astrophysics Data System (ADS)

Chen, Zhikai; Zhu, Qinghai; Wang, Jing; Yun, Xiao; He, Bing; Luo, Jingshuai

2018-07-01

In present work, laser quenching had been carried out to improve the impact abrasive wear resistance of 40Cr steel. The distinct microstructure between original and quenched region was demonstrated after laser quenching. Since the effect of temperature and cooling rate, the phase combinations were apparently different for quenched layer in depth. The impact abrasive wear resistance of sample was experimentally investigated and the improved level was assessed in light of the average mass loss of three repetitive tests. Worn surface was detected by means of SEM, OM and EDS, and results showed that three typical failure modes were performed during the processing of impact abrasive wear, including abrasive wear, impact effect and rolling contact fatigue. Basing on the different worn surface profile, the mainly failure mode was respectively pointed out for matrix and quenched sample, which was significantly in accordance with the result of impact abrasive wear.

Autonomous diagnostics and prognostics of signal and data distribution systems

NASA Astrophysics Data System (ADS)

Blemel, Kenneth G.

2001-07-01

Wiring is the nervous system of any complex system and is attached to or services nearly every subsystem. Damage to optical wiring systems can cause serious interruptions in communication, command and control systems. Electrical wiring faults and failures due to opens, shorts, and arcing probably result in adverse effects to the systems serviced by the wiring. Abnormalities in a system usually can be detected by monitoring some wiring parameter such as vibration, data activity or power consumption. This paper introduces the mapping of wiring to critical functions during system engineering to automatically define the Failure Modes Effects and Criticality Analysis. This mapping can be used to define the sensory processes needed to perform diagnostics during system engineering. This paper also explains the use of Operational Modes and Criticality Effects Analysis in the development of Sentient Wiring Systems as a means for diagnostic, prognostics and health management of wiring in aerospace and transportation systems.

Laser Indirect Shock Welding of Fine Wire to Metal Sheet

PubMed Central

Wang, Xiao; Huang, Tao; Luo, Yapeng; Liu, Huixia

2017-01-01

The purpose of this paper is to present an advanced method for welding fine wire to metal sheet, namely laser indirect shock welding (LISW). This process uses silica gel as driver sheet to accelerate the metal sheet toward the wire to obtain metallurgical bonding. A series of experiments were implemented to validate the welding ability of Al sheet/Cu wire and Al sheet/Ag wire. It was found that the use of a driver sheet can maintain high surface quality of the metal sheet. With the increase of laser pulse energy, the bonding area of the sheet/wire increased and the welding interfaces were nearly flat. Energy dispersive spectroscopy (EDS) results show that the intermetallic phases were absent and a short element diffusion layer which would limit the formation of the intermetallic phases emerging at the welding interface. A tensile shear test was used to measure the mechanical strength of the welding joints. The influence of laser pulse energy on the tensile failure modes was investigated, and two failure modes, including interfacial failure and failure through the wire, were observed. The nanoindentation test results indicate that as the distance to the welding interface decreased, the microhardness increased due to the plastic deformation becoming more violent. PMID:28895900

Orthogonal series generalized likelihood ratio test for failure detection and isolation. [for aircraft control

NASA Technical Reports Server (NTRS)

Hall, Steven R.; Walker, Bruce K.

1990-01-01

A new failure detection and isolation algorithm for linear dynamic systems is presented. This algorithm, the Orthogonal Series Generalized Likelihood Ratio (OSGLR) test, is based on the assumption that the failure modes of interest can be represented by truncated series expansions. This assumption leads to a failure detection algorithm with several desirable properties. Computer simulation results are presented for the detection of the failures of actuators and sensors of a C-130 aircraft. The results show that the OSGLR test generally performs as well as the GLR test in terms of time to detect a failure and is more robust to failure mode uncertainty. However, the OSGLR test is also somewhat more sensitive to modeling errors than the GLR test.

Porosity evolution at the brittle-ductile transition in the continental crust: Implications for deep hydro-geothermal circulation.

PubMed

Violay, M; Heap, M J; Acosta, M; Madonna, C

2017-08-09

Recently, projects have been proposed to engineer deep geothermal reservoirs in the ductile crust. To examine their feasibility, we performed high-temperature (up to 1000 °C), high-pressure (130 MPa) triaxial experiments on granite (initially-intact and shock-cooled samples) in which we measured the evolution of porosity during deformation. Mechanical data and post-mortem microstuctural characterisation (X-ray computed tomography and scanning electron microscopy) indicate that (1) the failure mode was brittle up to 900 °C (shear fracture formation) but ductile at 1000 °C (no strain localisation); (2) only deformation up to 800 °C was dilatant; (3) deformation at 900 °C was brittle but associated with net compaction due to an increase in the efficiency of crystal plastic processes; (4) ductile deformation at 1000 °C was compactant; (5) thermally-shocking the granite did not influence strength or failure mode. Our data show that, while brittle behaviour increases porosity, porosity loss is associated with both ductile behaviour and transitional behaviour as the failure mode evolves from brittle to ductile. Extrapolating our data to geological strain rates suggests that the brittle-ductile transition occurs at a temperature of 400 ± 100 °C, and is associated with the limit of fluid circulation in the deep continental crust.

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

PubMed Central

Rosen, M. A.; Sampson, J. B.; Jackson, E. V.; Koka, R.; Chima, A. M.; Ogbuagu, O. U.; Marx, M. K.; Koroma, M.; Lee, B. H.

2014-01-01

Background Anaesthesia care in developed countries involves sophisticated technology and experienced providers. However, advanced machines may be inoperable or fail frequently when placed into the austere medical environment of a developing country. Failure mode and effects analysis (FMEA) is a method for engaging local staff in identifying real or potential breakdowns in processes or work systems and to develop strategies to mitigate risks. Methods Nurse anaesthetists from the two tertiary care hospitals in Freetown, Sierra Leone, participated in three sessions moderated by a human factors specialist and an anaesthesiologist. Sessions were audio recorded, and group discussion graphically mapped by the session facilitator for analysis and commentary. These sessions sought to identify potential barriers to implementing an anaesthesia machine designed for austere medical environments—the universal anaesthesia machine (UAM)—and also engaging local nurse anaesthetists in identifying potential solutions to these barriers. Results Participating Sierra Leonean clinicians identified five main categories of failure modes (resource availability, environmental issues, staff knowledge and attitudes, and workload and staffing issues) and four categories of mitigation strategies (resource management plans, engaging and educating stakeholders, peer support for new machine use, and collectively advocating for needed resources). Conclusions We identified factors that may limit the impact of a UAM and devised likely effective strategies for mitigating those risks. PMID:24833727

Spontaneous attentional fluctuations in impaired states and pathological conditions: a neurobiological hypothesis.

PubMed

Sonuga-Barke, Edmund J S; Castellanos, F Xavier

2007-01-01

In traditional accounts, fluctuations in sustained and focused attention and associated attentional lapses during task performance are regarded as the result of failures of top-down and effortful higher order processes. The current paper reviews an alternative hypothesis: that spontaneous patterns of very low frequency (<0.1 Hz) coherence within a specific brain network ('default-mode network') thought to support a pattern of generalized task-non-specific cognition during rest, can persist or intrude into periods of active task-specific processing, producing periodic fluctuations in attention that compete with goal-directed activity. We review recent studies supporting the existence of the resting state default network, examine the mechanism underpinning it, describe the consequent temporally distinctive effects on cognition and behaviour of default-mode interference into active processing periods, and suggest some factors that might predispose to it. Finally, we explore the putative role of default-mode interference as a cause of performance variability in attention deficit/hyperactivity disorder.

The unifying role of dissipative action in the dynamic failure of solids

DOE PAGES

Grady, Dennis

2015-05-19

Dissipative action, the product of dissipation energy and transport time, is fundamental to the dynamic failure of solids. Invariance of the dissipative action underlies the fourth-power nature of structured shock waves observed in selected solid metals and compounds. Dynamic failure through shock compaction, tensile spall and adiabatic shear are also governed by a constancy of the dissipative action. This commonality underlying the various modes of dynamic failure is described and leads to deeper insights into failure of solids in the intense shock wave event. These insights are in turn leading to a better understanding of the shock deformation processes underlyingmore » the fourth-power law. Experimental result and material models encompassing the dynamic failure of solids are explored for the purpose of demonstrating commonalities leading to invariance of the dissipation action. As a result, calculations are extended to aluminum and uranium metals with the intent of predicting micro-scale energetics and spatial scales in the structured shock wave.« less

Influence of Weathering Depth and Fracture Intensity to Cut-slope Movements

NASA Astrophysics Data System (ADS)

Yoon, W. S.; Choi, J. W.; Jeong, U.; Kim, J. H.

2003-04-01

Generally, Failure modes in cut slopes are triggered by combination of various failure factors which have different effects on failure modes according to ground condition. It is, therefore, important to identify the behavioural characteristic of cut slope in that they reflect the failure mechanism. From the careful field investigation for 373 road cuts along the national highway in Korea, we analysed various types of failure modes for different ground conditions. The ground conditions which control failure modes of cut slopes and their related failure factors are dependent on weathering (or soil) depth and intensity of discontinuities in cut slopes. Firstly, the ratio of the soil depth and slope height (soil depth ratio; SR) is important parameter to classify ground conditions into soil-like masses and rock masses. When a SR value is greater than 0.4, sliding failures on discontinuities do not occur. In this case, weathering condition, slope gradient and external rainfall play a key role on failure factors of cut-slope. The proposed 0.4, therefore, is the critical SR value to identify the soil-like masses and rock masses. Secondly, Intensity of discontinuities is expressed by block size ratio (BR), which is defined by the ratio of block size index (Ib; ISRM (1978)) and slope height. For a rock slope (SR<0.4), when BR is greater than 0.01, key failure modes in a cut slope are wedge sliding, fall and topple. In this case, attitudes and shear strength of discontinuities play an important role on behaviour of cut-slope. When BR is less than 0.01, however, behaviour of cut slope shows circular sliding and surface failure like soil-like mass. To sum up, we could divide the ground conditions in cut-slope into 3 classes on the basis of SR (soil depth ratio) and BR (block size ratio); JRM (joint rock mass), HRM (highly fractured rock mass) and SLM (soil-like mass). Moreover, to evaluate the stability of cut-slope reasonably, it needs new evaluating categories having different weighting factors for each ground condition.

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

NASA Technical Reports Server (NTRS)

1966-01-01

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

A Generic Modeling Process to Support Functional Fault Model Development

NASA Technical Reports Server (NTRS)

Maul, William A.; Hemminger, Joseph A.; Oostdyk, Rebecca; Bis, Rachael A.

2016-01-01

Functional fault models (FFMs) are qualitative representations of a system's failure space that are used to provide a diagnostic of the modeled system. An FFM simulates the failure effect propagation paths within a system between failure modes and observation points. These models contain a significant amount of information about the system including the design, operation and off nominal behavior. The development and verification of the models can be costly in both time and resources. In addition, models depicting similar components can be distinct, both in appearance and function, when created individually, because there are numerous ways of representing the failure space within each component. Generic application of FFMs has the advantages of software code reuse: reduction of time and resources in both development and verification, and a standard set of component models from which future system models can be generated with common appearance and diagnostic performance. This paper outlines the motivation to develop a generic modeling process for FFMs at the component level and the effort to implement that process through modeling conventions and a software tool. The implementation of this generic modeling process within a fault isolation demonstration for NASA's Advanced Ground System Maintenance (AGSM) Integrated Health Management (IHM) project is presented and the impact discussed.

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

NASA Astrophysics Data System (ADS)

Takahashi, Masakazu; Nanba, Reiji; Fukue, Yoshinori

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

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

NASA Astrophysics Data System (ADS)

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

2017-10-01

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

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

PubMed

Sghaireen, Mohd G

2015-06-01

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

Unitized Stiffened Composite Textile Panels: Manufacturing, Characterization, Experiments, and Analysis

NASA Astrophysics Data System (ADS)

Kosztowny, Cyrus Joseph Robert

Use of carbon fiber textiles in complex manufacturing methods creates new implementations of structural components by increasing performance, lowering manufacturing costs, and making composites overall more attractive across industry. Advantages of textile composites include high area output, ease of handling during the manufacturing process, lower production costs per material used resulting from automation, and provide post-manufacturing assembly mainstreaming because significantly more complex geometries such as stiffened shell structures can be manufactured with fewer pieces. One significant challenge with using stiffened composite structures is stiffener separation under compression. Axial compression loading conditions have frequently observed catastrophic structural failure due to stiffeners separating from the shell skin. Characterizing stiffener separation behavior is often costly computationally and experimentally. The objectives of this research are to demonstrate unitized stiffened textile composite panels can be manufactured to produce quality test specimens, that existing characterization techniques applied to state-of-the-art high-performance composites provide valuable information in modeling such structures, that the unitized structure concept successfully removes stiffener separation as a primary structural failure mode, and that modeling textile material failure modes are sufficient to accurately capture postbuckling and final failure responses of the stiffened structures. The stiffened panels in this study have taken the integrally stiffened concept to an extent such that the stiffeners and skin are manufactured at the same time, as one single piece, and from the same composite textile layers. Stiffener separation is shown to be removed as a primary structural failure mode for unitized stiffened composite textile panels loaded under axial compression well into the postbuckling regime. Instead of stiffener separation, a material damaging and failure model effectively captures local post-peak material response via incorporating a mesoscale model using a multiscaling framework with a smeared crack element-based failure model in the macroscale stiffened panel. Material damage behavior is characterized by simple experimental tests and incorporated into the post-peak stiffness degradation law in the smeared crack implementation. Computational modeling results are in overall excellent agreement compared to the experimental responses.

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

NASA Technical Reports Server (NTRS)

Smart, Christian

1998-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Ascent Thrust Vector Control (ATVC) Actuator hardware are documented. The function of the Ascent Thrust Vector Control Actuators (ATVC) is to gimbal the main engines to provide for attitude and flight path control during ascent. During first stage flight, the SRB nozzles provide nearly all the steering. After SRB separation, the Orbiter is steered by gimbaling of its main engines. There are six electrohydraulic servoactuators, one pitch and one yaw for each of the three main engines. Each servoactuator is composed of four electrohydraulic servovalve assemblies, one second stage power spool valve assembly, one primary piston assembly and a switching valve. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Critical failures resulting in loss of ATVC were mainly due to loss of hydraulic fluid, fluid contamination and mechanical failures.

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

NASA Technical Reports Server (NTRS)

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

2007-01-01

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

Fatigue damage accumulation in various metal matrix composites

NASA Technical Reports Server (NTRS)

Johnson, W. S.

1987-01-01

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

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

PubMed Central

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

2017-01-01

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

TU-FG-201-11: Evaluating the Validity of Prospective Risk Analysis Methods: A Comparison of Traditional FMEA and Modified Healthcare FMEA

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

Lah, J; Manger, R; Kim, G

Purpose: To examine the ability of traditional Failure mode and effects analysis (FMEA) and a light version of Healthcare FMEA (HFMEA), called Scenario analysis of FMEA (SAFER) by comparing their outputs in terms of the risks identified and their severity rankings. Methods: We applied two prospective methods of the quality management to surface image guided, linac-based radiosurgery (SIG-RS). For the traditional FMEA, decisions on how to improve an operation are based on risk priority number (RPN). RPN is a product of three indices: occurrence, severity and detectability. The SAFER approach; utilized two indices-frequency and severity-which were defined by a multidisciplinarymore » team. A criticality matrix was divided into 4 categories; very low, low, high and very high. For high risk events, an additional evaluation was performed. Based upon the criticality of the process, it was decided if additional safety measures were needed and what they comprise. Results: Two methods were independently compared to determine if the results and rated risks were matching or not. Our results showed an agreement of 67% between FMEA and SAFER approaches for the 15 riskiest SIG-specific failure modes. The main differences between the two approaches were the distribution of the values and the failure modes (No.52, 54, 154) that have high SAFER scores do not necessarily have high FMEA RPN scores. In our results, there were additional risks identified by both methods with little correspondence. In the SAFER, when the risk score is determined, the basis of the established decision tree or the failure mode should be more investigated. Conclusion: The FMEA method takes into account the probability that an error passes without being detected. SAFER is inductive because it requires the identification of the consequences from causes, and semi-quantitative since it allow the prioritization of risks and mitigation measures, and thus is perfectly applicable to clinical parts of radiotherapy.« less

A dual-mode generalized likelihood ratio approach to self-reorganizing digital flight control system design

NASA Technical Reports Server (NTRS)

Bueno, R.; Chow, E.; Gershwin, S. B.; Willsky, A. S.

1975-01-01

The research is reported on the problems of failure detection and reliable system design for digital aircraft control systems. Failure modes, cross detection probability, wrong time detection, application of performance tools, and the GLR computer package are discussed.

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

NASA Astrophysics Data System (ADS)

Li, Hui; Ou, Jinping

2008-07-01

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

Failure Maps for Rectangular 17-4PH Stainless Steel Sandwiched Foam Panels

NASA Technical Reports Server (NTRS)

Raj, S. V.; Ghosn, L. J.

2007-01-01

A new and innovative concept is proposed for designing lightweight fan blades for aircraft engines using commercially available 17-4PH precipitation hardened stainless steel. Rotating fan blades in aircraft engines experience a complex loading state consisting of combinations of centrifugal, distributed pressure and torsional loads. Theoretical failure plastic collapse maps, showing plots of the foam relative density versus face sheet thickness, t, normalized by the fan blade span length, L, have been generated for rectangular 17-4PH sandwiched foam panels under these three loading modes assuming three failure plastic collapse modes. These maps show that the 17-4PH sandwiched foam panels can fail by either the yielding of the face sheets, yielding of the foam core or wrinkling of the face sheets depending on foam relative density, the magnitude of t/L and the loading mode. The design envelop of a generic fan blade is superimposed on the maps to provide valuable insights on the probable failure modes in a sandwiched foam fan blade.

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

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

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

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

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

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

1996-12-31

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

Elevation maps of the San Francisco Bay region, California, a digital database

USGS Publications Warehouse

Graham, Scott E.; Pike, Richard J.

1998-01-01

PREFACE: Topography, the configuration of the land surface, plays a major role in various natural processes that have helped shape the ten-county San Francisco Bay region and continue to affect its development. Such processes include a dangerous type of landslide, the debris flow (Ellen and others, 1997) as well as other modes of slope failure that damage property but rarely threaten life directly?slumping, translational sliding, and earthflow (Wentworth and others, 1997). Different types of topographic information at both local and regional scales are helpful in assessing the likelihood of slope failure and the mapping the extent of its past activity, as well as addressing other issues in hazard mitigation and land-use policy. The most useful information is quantitative.

Carbon Fiber Strand Tensile Failure Dynamic Event Characterization

NASA Technical Reports Server (NTRS)

Johnson, Kenneth L.; Reeder, James

2016-01-01

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

Neural Correlates of Success and Failure Signals During Neurofeedback Learning.

PubMed

Radua, Joaquim; Stoica, Teodora; Scheinost, Dustin; Pittenger, Christopher; Hampson, Michelle

2018-05-15

Feedback-driven learning, observed across phylogeny and of clear adaptive value, is frequently operationalized in simple operant conditioning paradigms, but it can be much more complex, driven by abstract representations of success and failure. This study investigates the neural processes involved in processing success and failure during feedback learning, which are not well understood. Data analyzed were acquired during a multisession neurofeedback experiment in which ten participants were presented with, and instructed to modulate, the activity of their orbitofrontal cortex with the aim of decreasing their anxiety. We assessed the regional blood-oxygenation-level-dependent response to the individualized neurofeedback signals of success and failure across twelve functional runs acquired in two different magnetic resonance sessions in each of ten individuals. Neurofeedback signals of failure correlated early during learning with deactivation in the precuneus/posterior cingulate and neurofeedback signals of success correlated later during learning with deactivation in the medial prefrontal/anterior cingulate cortex. The intensity of the latter deactivations predicted the efficacy of the neurofeedback intervention in the reduction of anxiety. These findings indicate a role for regulation of the default mode network during feedback learning, and suggest a higher sensitivity to signals of failure during the early feedback learning and to signals of success subsequently. Copyright © 2016 IBRO. Published by Elsevier Ltd. All rights reserved.

Through thickness mechanical properties of chemical vapor infiltration and nano-infiltration and transient eutectic-phase processed SiC/SiC composites

DOE PAGES

Shih, Chunghao Phillip; Katoh, Yutai; Ozawa, Kazumi; ...

2014-04-08

The through thickness (interlaminar) shear strength and trans-thickness tensile strength of three different nuclear-grade SiC/SiC composites were evaluated at room temperature by the double-notched shear and diametral compression tests, respectively. With increasing densification of the interlaminar matrix region, a transition in failure locations from interlayer to intrafiber bundle was observed, along with significant increases in the value of the interlaminar shear strength. Under trans-thickness tensile loading, cracks were found to propagate easily in the unidirectional composite. Furthermore, the 2D woven composite had a higher trans-thickness tensile strength (38 MPa) because the failure mode involved debonding, fiber pull-out and fiber failure.

Through thickness mechanical properties of chemical vapor infiltration and nano-infiltration and transient eutectic-phase processed SiC/SiC composites

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

Shih, Chunghao Phillip; Katoh, Yutai; Ozawa, Kazumi

The through thickness (interlaminar) shear strength and trans-thickness tensile strength of three different nuclear-grade SiC/SiC composites were evaluated at room temperature by the double-notched shear and diametral compression tests, respectively. With increasing densification of the interlaminar matrix region, a transition in failure locations from interlayer to intrafiber bundle was observed, along with significant increases in the value of the interlaminar shear strength. Under trans-thickness tensile loading, cracks were found to propagate easily in the unidirectional composite. Furthermore, the 2D woven composite had a higher trans-thickness tensile strength (38 MPa) because the failure mode involved debonding, fiber pull-out and fiber failure.

Microcircuit failure analysis using the SEM. [Scanning Electron Microscopes

NASA Technical Reports Server (NTRS)

Nicolas, D. P.

1974-01-01

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

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

NASA Technical Reports Server (NTRS)

Ratcliffe, James G.

2004-01-01

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

Fault Tree Analysis: Its Implications for Use in Education.

ERIC Educational Resources Information Center

Barker, Bruce O.

This study introduces the concept of Fault Tree Analysis as a systems tool and examines the implications of Fault Tree Analysis (FTA) as a technique for isolating failure modes in educational systems. A definition of FTA and discussion of its history, as it relates to education, are provided. The step by step process for implementation and use of…

Operational excellence (six sigma) philosophy: Application to software quality assurance

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

Lackner, M.

1997-11-01

This report contains viewgraphs on operational excellence philosophy of six sigma applied to software quality assurance. This report outlines the following: goal of six sigma; six sigma tools; manufacturing vs administrative processes; Software quality assurance document inspections; map software quality assurance requirements document; failure mode effects analysis for requirements document; measuring the right response variables; and questions.

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

NASA Technical Reports Server (NTRS)

Klein, William E.; Lali, Vincent R.

1990-01-01

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

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

USGS Publications Warehouse

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

2012-01-01

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

Effects of Gas Pressure on the Failure Characteristics of Coal

NASA Astrophysics Data System (ADS)

Xie, Guangxiang; Yin, Zhiqiang; Wang, Lei; Hu, Zuxiang; Zhu, Chuanqi

2017-07-01

Several experiments were conducted using self-developed equipment for visual gas-solid coupling mechanics. The raw coal specimens were stored in a container filled with gas (99% CH4) under different initial gas pressure conditions (0.0, 0.5, 1.0, and 1.5 MPa) for 24 h prior to testing. Then, the specimens were tested in a rock-testing machine, and the mechanical properties, surface deformation and failure modes were recorded using strain gauges, an acoustic emission (AE) system and a camera. An analysis of the fractals of fragments and dissipated energy was performed to understand the changes observed in the stress-strain and crack propagation behaviour of the gas-containing coal specimens. The results demonstrate that increased gas pressure leads to a reduction in the uniaxial compression strength (UCS) of gas-containing coal and the critical dilatancy stress. The AE, surface deformation and fractal analysis results show that the failure mode changes during the gas state. Interestingly, a higher initial gas pressure will cause the damaged cracks and failure of the gas-containing coal samples to become severe. The dissipated energy characteristic in the failure process of a gas-containing coal sample is analysed using a combination of fractal theory and energy principles. Using the theory of fracture mechanics, based on theoretical analyses and calculations, the stress intensity factor of crack tips increases as the gas pressure increases, which is the main cause of the reduction in the UCS and critical dilatancy stress and explains the influence of gas in coal failure. More serious failure is created in gas-containing coal under a high gas pressure and low exterior load.

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

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

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

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

Microcracking, microcrack-induced delamination, and longitudinal splitting of advanced composite structures

NASA Technical Reports Server (NTRS)

Nairn, John A.

1992-01-01

A combined analytical and experimental study was conducted to analyze microcracking, microcrack-induced delamination, and longitudinal splitting in polymer matrix composites. Strain energy release rates, calculated by a variational analysis, were used in a failure criterion to predict microcracking. Predictions and test results were compared for static, fatigue, and cyclic thermal loading. The longitudinal splitting analysis accounted for the effects of fiber bridging. Test data are analyzed and compared for longitudinal splitting and delamination under mixed-mode loading. This study emphasizes the importance of using fracture mechanics analyses to understand the complex failure processes that govern composite strength and life.

Fracture Reactivation in Chemically Reactive Rock Systems

NASA Astrophysics Data System (ADS)

Eichhubl, P.; Hooker, J. N.

2013-12-01

Reactivation of existing fractures is a fundamental process of brittle failure that controls the nucleation of earthquake ruptures, propagation and linkage of hydraulic fractures in oil and gas production, and the evolution of fault and fracture networks and thus of fluid and heat transport in the upper crust. At depths below 2-3 km, and frequently shallower, brittle processes of fracture growth, linkage, and reactivation compete with chemical processes of fracture sealing by mineral precipitation, with precipitation rates similar to fracture opening rates. We recently found rates of fracture opening in tectonically quiescent settings of 10-20 μm/m.y., rates similar to euhedral quartz precipitation under these conditions. The tendency of existing partially or completely cemented fractures to reactivate will vary depending on strain rate, mineral precipitation kinetics, strength contrast between host rock and fracture cement, stress conditions, degree of fracture infill, and fracture network geometry. Natural fractures in quartzite of the Cambrian Eriboll Formation, NW Scotland, exhibit a complex history of fracture formation and reactivation, with reactivation involving both repeated crack-seal opening-mode failure and shear failure of fractures that formed in opening mode. Fractures are partially to completely sealed with crack-seal or euhedral quartz cement or quartz cement fragmented by shear reactivation. Degree of cementation controls the tendency of fractures for later shear reactivation, to interact elastically with adjacent open fractures, and their intersection behavior. Using kinematic, dynamic, and diagenetic criteria, we determine the sequence of opening-mode fracture formation and later shear reactivation. We find that sheared fracture systems of similar orientation display spatially varying sense of slip We attribute these inconsistent directions of shear reactivation to 1) a heterogeneous stress field in this highly fractured rock unit and 2) variations in the degree of fracture cement infill in fractures of same orientation, allowing fractures to reactivate at times when adjacent, more cemented fractures remain dormant. The observed interaction of chemical and mechanical fracture growth and sealing processes in this chemically reactive and heavily deformed rock unit results in a complex fracture network geometry not generally observed in less chemically reactive, shallower crustal environments.

Weighting and Bayes Nets for Rollup of Surveillance Metrics

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

Henson, Kriste; Sentz, Kari; Hamada, Michael

2012-04-30

The LANL IKE team proposes that the surveillance metrics for several data stream that are used to detect the same failure mode be weighted. Similarly, the failure mode metrics are weighted to obtain a subsystem metric. E.g., if there n data streams (nodes 1-n), the failure mode (node 0) metric is obtained as M{sub 0} = w{sub 1}M{sub 1} + {hor_ellipsis} + w{sub n}M{sub n}, where {Sigma}{sub i=1}{sup n} w{sub i} = 1. This proposal has been implemented with Bayes Nets using the Netica/IKE software by specifying an appropriate conditional probability table (CPT). This CPT is calculated using the samemore » form as (1), where the data stream metrics for the true (T) and false (F) states are replaced by 1 and 0, respectively. Then using this CPT, the failure mode metric calculated by Netica/IKE equals (1). This result has two nice features. First, the rollup Bayes nets is doing can be easily explained. Second, because Bayes Nets can implement this rollup using Netica/IKE, then data marshalling (allocating next year's budget) can be studied. A proof that the claim 'failure mode metric calculated by Netica/IKE equals (1)' for n = 2 and n = 3 follows as well as the sketch of a proof by induction for general n.« less

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

NASA Technical Reports Server (NTRS)

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

1987-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbiter Main Propulsion System (MPS) hardware are documented. The Orbiter MPS consists of two subsystems: the Propellant Management Subsystem (PMS) and the Helium Subsystem. The PMS is a system of manifolds, distribution lines and valves by which the liquid propellants pass from the External Tank (ET) to the Space Shuttle Main Engines (SSMEs) and gaseous propellants pass from the SSMEs to the ET. The Helium Subsystem consists of a series of helium supply tanks and their associated regulators, check valves, distribution lines, and control valves. The Helium Subsystem supplies helium that is used within the SSMEs for inflight purges and provides pressure for actuation of SSME valves during emergency pneumatic shutdowns. The balance of the helium is used to provide pressure to operate the pneumatically actuated valves within the PMS. Each component was evaluated and analyzed for possible failure modes and effects. Criticalities were assigned based on the worst possible effect of each failure mode. Of the 690 failure modes analyzed, 349 were determined to be PCIs.

Computational hydraulics of a cascade of experimental-scale landside dam failures

NASA Astrophysics Data System (ADS)

Wright, N.; Guan, M.

2015-12-01

Abstract: Landslide dams typically comprise unconsolidated and poorly sorted material, and are vulnerable to rapid failure and breaching, particularly in mountainous areas during high intense rainfalls. A large flash flood with high-concentrated sediment can be formed in a short period, and the magnitude is likely to be amplified along the flow direction due to the inclusion of a large amount of sediment. This can result in significant and sudden flood risk downstream for human life and property. Numerous field evidence has indicated the various risks of landslide dam failures. In general, cascading landslide dams can be formed along the sloping channel due to the randomness and unpredictability of landslides, which complexes the hydraulics of landslide dam failures. The failure process of a single dam and subsequent floods has attracted attention in multidisciplinary studies. However, the dynamic failure process of cascading landslide dams has been poorly understood. From a viewpoint of simulation, this study evaluates the formation and development of rapid sediment-charged floods due to cascading failure of landslide dams through detailed hydro-morphodynamic modelling. The model used is based on shallow water theory and it has been successful in predicting the flow and morphological process during sudden dam-break, as well as full and partial dyke-breach. Various experimental-scale scenarios are modelled, including: (1) failure of a single full dam in a sloping channel, (2) failure of two dams in a sloping channel, (3) failure of multiple landslide dams (four) in a sloping channel. For each scenario, different failure modes (sudden/gradual) and bed boundary (fixed /mobile) are assumed and simulated. The study systematically explores the tempo-spatial evolution of landslide-induced floods (discharge, flow velocity, and flow concentration) and geomorphic properties along the sloping channel. The effects of in-channel erosion and flow-driven sediment from dams on the development of flood process are investigated. The results improve the understanding of the formation and development mechanism of flash floods due to cascading landslide dam failures. The findings are beneficial for downstream flood risk assessment and developing control strategies for landslide-induced floods.

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

NASA Technical Reports Server (NTRS)

Mediavilla, Anthony Scott

1986-01-01

The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbiter Nose Wheel Steering (NWS) hardware are documented. The NWS hardware provides primary directional control for the Orbiter vehicle during landing rollout. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. The original NWS design was envisioned as a backup system to differential braking for directional control of the Orbiter during landing rollout. No real effort was made to design the NWS system as fail operational. The brakes have much redundancy built into their design but the poor brake/tire performance has forced the NSTS to upgrade NWS to the primary mode of directional control during rollout. As a result, a large percentage of the NWS system components have become Potential Critical Items (PCI).

Fatigue crack growth in an aluminum alloy-fractographic study

NASA Astrophysics Data System (ADS)

Salam, I.; Muhammad, W.; Ejaz, N.

2016-08-01

A two-fold approach was adopted to understand the fatigue crack growth process in an Aluminum alloy; fatigue crack growth test of samples and analysis of fractured surfaces. Fatigue crack growth tests were conducted on middle tension M(T) samples prepared from an Aluminum alloy cylinder. The tests were conducted under constant amplitude loading at R ratio 0.1. The stress applied was from 20,30 and 40 per cent of the yield stress of the material. The fatigue crack growth data was recorded. After fatigue testing, the samples were subjected to detailed scanning electron microscopic (SEM) analysis. The resulting fracture surfaces were subjected to qualitative and quantitative fractographic examinations. Quantitative fracture analysis included an estimation of crack growth rate (CGR) in different regions. The effect of the microstructural features on fatigue crack growth was examined. It was observed that in stage II (crack growth region), the failure mode changes from intergranular to transgranular as the stress level increases. In the region of intergranular failure the localized brittle failure was observed and fatigue striations are difficult to reveal. However, in the region of transgranular failure the crack path is independent of the microstructural features. In this region, localized ductile failure mode was observed and well defined fatigue striations were present in the wake of fatigue crack. The effect of interaction of growing fatigue crack with microstructural features was not substantial. The final fracture (stage III) was ductile in all the cases.

Investigation of a ceramic matrix composite under strain controlled fatigue condition

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

Gudaitis, J.J.; Mall, S.

The fatigue behavior along with damage mechanisms and failure modes of a fiber reinforced ceramic matrix composite with a cross-ply lay-up was investigated under strain controlled mode. Two fatigue conditions involving tension-tension and tension-compression cycling were employed. The strain range versus fatigue life curves for both fatigue conditions were in agreement with each other. However, damage mechanisms and failure modes were different for both cases.

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

PubMed

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

2016-01-01

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

Oblique impacts into low impedance layers

NASA Astrophysics Data System (ADS)

Stickle, A. M.; Schultz, P. H.

2009-12-01

Planetary impacts occur indiscriminately, in all locations and materials. Varied geologic settings can have significant effects on the impact process, including the coupling between the projectile and target, the final damage patterns and modes of deformation that occur. For example, marine impact craters are not identical to impacts directly into bedrock or into sedimentary materials, though many of the same fundamental processes occur. It is therefore important, especially when considering terrestrial impacts, to understand how a low impedance sedimentary layer over bedrock affects the deformation process during and after a hypervelocity impact. As a first step, detailed comparisons between impacts and hydrocode models were performed. Experiments performed at the NASA Ames Vertical Gun Range of oblique impacts into polymethylmethacrylate (PMMA) targets with low impedance layers were performed and compared to experiments of targets without low impedance layers, as well as to hydrocode models under identical conditions. Impact velocities ranged from 5 km/s to 5.6 km/s, with trajectories from 30 degrees to 90 degrees above the horizontal. High-speed imaging provided documentation of the sequence and location of failure due to impact, which was compared to theoretical models. Plasticine and ice were used to construct the low impedance layers. The combination of experiments and models reveals the modes of failure due to a hypervelocity impact. How such failure is manifested at large scales can present a challenge for hydrocodes. CTH models tend to overestimate the amount of damage occurring within the targets and have difficulties perfectly reproducing morphologies; nevertheless, they provide significant and useful information about the failure modes and style within the material. CTH models corresponding to the experiments allow interpretation of the underlying processes involved as well as provide a benchmark for the experimental analysis. The transparency of PMMA allows a clear view of failure patterns within the target, providing a 3D picture of the final damage, as well as damage formation and propagation. Secondly, PMMA has mechanical properties similar to those of brittle rocks in the upper crust, making it an appropriate material for comparison to geologic materials. An impact into a PMMA target with a one-projectile-diameter thick plasticine layer causes damage distinct from an impact into a PMMA target without a low impedance layer. The extent of the final damage is much less in the target with the low impedance layer and begins to form at later times, there is little to no crater visible on the surface, and the formation and propagation of the damage is completely different, creating distinct subsurface damage patterns. Three-dimensional CTH hydrocode models show that the pressure history of material around and underneath the impact point is also different when a low impedance layer is present, leading to the variations in damage forming within the targets.

Space tug propulsion system failure mode, effects and criticality analysis

NASA Technical Reports Server (NTRS)

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

1972-01-01

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

Sleeve Expansion of Bolt Holes in Railroad Rail : Volume I, Description and Planning

DOT National Transportation Integrated Search

1980-02-01

The most predominant failure mode of rails with bolt joints is a web crack initiating at the rail bolt hole. This failure mode is of a classical fatigue nature induced by web stress concentration around the bolt hole. This program was conducted to ap...

Uniaxial experimental study of the acoustic emission and deformation behavior of composite rock based on 3D digital image correlation (DIC)

NASA Astrophysics Data System (ADS)

Cheng, Jian-Long; Yang, Sheng-Qi; Chen, Kui; Ma, Dan; Li, Feng-Yuan; Wang, Li-Ming

2017-12-01

In this paper, uniaxial compression tests were carried out on a series of composite rock specimens with different dip angles, which were made from two types of rock-like material with different strength. The acoustic emission technique was used to monitor the acoustic signal characteristics of composite rock specimens during the entire loading process. At the same time, an optical non-contact 3D digital image correlation technique was used to study the evolution of axial strain field and the maximal strain field before and after the peak strength at different stress levels during the loading process. The effect of bedding plane inclination on the deformation and strength during uniaxial loading was analyzed. The methods of solving the elastic constants of hard and weak rock were described. The damage evolution process, deformation and failure mechanism, and failure mode during uniaxial loading were fully determined. The experimental results show that the θ = 0{°}-45{°} specimens had obvious plastic deformation during loading, and the brittleness of the θ = 60{°}-90{°} specimens gradually increased during the loading process. When the anisotropic angle θ increased from 0{°} to 90{°}, the peak strength, peak strain, and apparent elastic modulus all decreased initially and then increased. The failure mode of the composite rock specimen during uniaxial loading can be divided into three categories: tensile fracture across the discontinuities (θ = 0{°}-30{°}), sliding failure along the discontinuities (θ = 45{°}-75{°}), and tensile-split along the discontinuities (θ = 90{°}). The axial strain of the weak and hard rock layers in the composite rock specimen during the loading process was significantly different from that of the θ = 0{°}-45{°} specimens and was almost the same as that of the θ = 60{°}-90{°} specimens. As for the strain localization highlighted in the maximum principal strain field, the θ = 0{°}-30{°} specimens appeared in the rock matrix approximately parallel to the loading direction, while in the θ = 45{°}-90{°} specimens it appeared at the hard and weak rock layer interface.

Algorithm for Determination of Orion Ascent Abort Mode Achievability

NASA Technical Reports Server (NTRS)

Tedesco, Mark B.

2011-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2015-02-01

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

Qualification and issues with space flight laser systems and components

NASA Astrophysics Data System (ADS)

Ott, Melanie N.; Coyle, D. B.; Canham, John S.; Leidecker, Henning W., Jr.

2006-02-01

The art of flight quality solid-state laser development is still relatively young, and much is still unknown regarding the best procedures, components, and packaging required for achieving the maximum possible lifetime and reliability when deployed in the harsh space environment. One of the most important issues is the limited and unstable supply of quality, high power diode arrays with significant technological heritage and market lifetime. Since Spectra Diode Labs Inc. ended their involvement in the pulsed array business in the late 1990's, there has been a flurry of activity from other manufacturers, but little effort focused on flight quality production. This forces NASA, inevitably, to examine the use of commercial parts to enable space flight laser designs. System-level issues such as power cycling, operational derating, duty cycle, and contamination risks to other laser components are some of the more significant unknown, if unquantifiable, parameters that directly effect transmitter reliability. Designs and processes can be formulated for the system and the components (including thorough modeling) to mitigate risk based on the known failures modes as well as lessons learned that GSFC has collected over the past ten years of space flight operation of lasers. In addition, knowledge of the potential failure modes related to the system and the components themselves can allow the qualification testing to be done in an efficient yet, effective manner. Careful test plan development coupled with physics of failure knowledge will enable cost effect qualification of commercial technology. Presented here will be lessons learned from space flight experience, brief synopsis of known potential failure modes, mitigation techniques, and options for testing from the system level to the component level.

Qualification and Issues with Space Flight Laser Systems and Components

NASA Technical Reports Server (NTRS)

Ott, Melanie N.; Coyle, D. Barry; Canham, John S.; Leidecker, Henning W.

2006-01-01

The art of flight quality solid-state laser development is still relatively young, and much is still unknown regarding the best procedures, components, and packaging required for achieving the maximum possible lifetime and reliability when deployed in the harsh space environment. One of the most important issues is the limited and unstable supply of quality, high power diode arrays with significant technological heritage and market lifetime. Since Spectra Diode Labs Inc. ended their involvement in the pulsed array business in the late 1990's, there has been a flurry of activity from other manufacturers, but little effort focused on flight quality production. This forces NASA, inevitably, to examine the use of commercial parts to enable space flight laser designs. System-level issues such as power cycling, operational derating, duty cycle, and contamination risks to other laser components are some of the more significant unknown, if unquantifiable, parameters that directly effect transmitter reliability. Designs and processes can be formulated for the system and the components (including thorough modeling) to mitigate risk based on the known failures modes as well as lessons learned that GSFC has collected over the past ten years of space flight operation of lasers. In addition, knowledge of the potential failure modes related to the system and the components themselves can allow the qualification testing to be done in an efficient yet, effective manner. Careful test plan development coupled with physics of failure knowledge will enable cost effect qualification of commercial technology. Presented here will be lessons learned from space flight experience, brief synopsis of known potential failure modes, mitigation techniques, and options for testing from the system level to the component level.

Qualification and Issues with Space Flight Laser Systems and Components

NASA Technical Reports Server (NTRS)

Ott, Melanie N.; Coyle, D. Barry; Canham, John S.; Leidecker, Henning W.

2006-01-01

The art of flight quality solid-state laser development is still relatively young, and much is still unknown regarding the best procedures, components, and packaging required for achieving the maximum possible lifetime and reliability when deployed in the harsh space environment. One of the most important issues is the limited and unstable supply of quality, high power diode arrays with significant technological heritage and market lifetime. Since Spectra Diode Labs Inc. ended their involvement in the pulsed array business in the late 199O's, there has been a flurry of activity from other manufacturers, but little effort focused on flight quality production. This forces NASA, inevitably, to examine the use of commercial parts to enable space flight laser designs. System-level issues such as power cycling, operational derating, duty cycle, and contamination risks to other laser components are some of the more significant unknown, if unquantifiable, parameters that directly effect transmitter reliability. Designs and processes can be formulated for the system and the components (including thorough modeling) to mitigate risk based on the known failures modes as well as lessons learned that GSFC has collected over the past ten years of space flight operation of lasers. In addition, knowledge of the potential failure modes related to the system and the components themselves can allow the qualification testing to be done in an efficient yet, effective manner. Careful test plan development coupled with physics of failure knowledge will enable cost effect qualification of commercial technology. Presented here will be lessons learned from space flight experience, brief synopsis of known potential failure modes, mitigation techniques, and options for testing from the system level to the component level.

Thermostructural responses of carbon phenolics in a restrained thermal growth test

NASA Technical Reports Server (NTRS)

Wang, C. Jeff

1992-01-01

The thermostructural response of carbon phenolic components in a solid rocket motor (SRM) is a complex process. It involves simultaneous heat and mass transfer along with chemical reactions in a multiphase system with time-dependent material properties and boundary conditions. In contrast to metals, the fracture of fiber-reinforced composites is characterized by the initiation and progression of multiple failures of different modes such as matrix cracks, interfacial debonding, fiber breaks, and delamination. The investigation of thermostructural responses of SRM carbon phenolics is further complicated by different failure modes under static and dynamic load applications. Historically, there have been several types of post-firing anomalies found in the carbon phenolic composites of the Space Shuttle SRM nozzle. Three major failure modes which have been observed on SRM nozzles are pocketing (spallation), ply-lift, and wedge-out. In order to efficiently control these anomalous phenomena, an investigation of fracture mechanisms under NASA/MSFC RSRM (Redesigned Solid Rocket Motor) and SPIP (Solid Propulsion Integrity Program) programs have been conducted following each anomaly. This report reviews the current progress in understanding the effects of the thermostructural behavior of carbon phenolics on the failure mechanisms of the SRM nozzle. A literature search was conducted and a technical bibliography was developed to support consolidation and assimilation of learning from the RSRM and SPIP investigation efforts. Another important objective of this report is to present a knowledge-based design basis for carbon phenolics that combines the analyses of thermochemical decomposition, pore pressure stresses, and thermostructural properties. Possible areas of application of the knowledge-based design include critical material properties development, nozzle component design, and SRM materials control.

Acoustic emission measurements of aerospace materials and structures

NASA Technical Reports Server (NTRS)

Sachse, Wolfgang; Gorman, Michael R.

1993-01-01

A development status evaluation is given for aerospace applications of AE location, detection, and source characterization. Attention is given to the neural-like processing of AE signals for graphite/epoxy. It is recommended that development efforts for AE make connections between the material failure process and source dynamics, and study the effects of composite material anisotropy and inhomogeneity on the propagation of AE waves. Broadband, as well as frequency- and wave-mode selective sensors, need to be developed.

Matrix Dominated Failure of Fiber-Reinforced Composite Laminates Under Static and Dynamic Loading

NASA Astrophysics Data System (ADS)

Schaefer, Joseph Daniel

Hierarchical material systems provide the unique opportunity to connect material knowledge to solving specific design challenges. Representing the quickest growing class of hierarchical materials in use, fiber-reinforced polymer composites (FRPCs) offer superior strength and stiffness-to-weight ratios, damage tolerance, and decreasing production costs compared to metals and alloys. However, the implementation of FRPCs has historically been fraught with inadequate knowledge of the material failure behavior due to incomplete verification of recent computational constitutive models and improper (or non-existent) experimental validation, which has severely slowed creation and development. Noted by the recent Materials Genome Initiative and the Worldwide Failure Exercise, current state of the art qualification programs endure a 20 year gap between material conceptualization and implementation due to the lack of effective partnership between computational coding (simulation) and experimental characterization. Qualification processes are primarily experiment driven; the anisotropic nature of composites predisposes matrix-dominant properties to be sensitive to strain rate, which necessitates extensive testing. To decrease the qualification time, a framework that practically combines theoretical prediction of material failure with limited experimental validation is required. In this work, the Northwestern Failure Theory (NU Theory) for composite lamina is presented as the theoretical basis from which the failure of unidirectional and multidirectional composite laminates is investigated. From an initial experimental characterization of basic lamina properties, the NU Theory is employed to predict the matrix-dependent failure of composites under any state of biaxial stress from quasi-static to 1000 s-1 strain rates. It was found that the number of experiments required to characterize the strain-rate-dependent failure of a new composite material was reduced by an order of magnitude, and the resulting strain-rate-dependence was applicable for a large class of materials. The presented framework provides engineers with the capability to quickly identify fiber and matrix combinations for a given application and determine the failure behavior over the range of practical loadings cases. The failure-mode-based NU Theory may be especially useful when partnered with computational approaches (which often employ micromechanics to determine constituent and constitutive response) to provide accurate validation of the matrix-dominated failure modes experienced by laminates during progressive failure.

Combined investigation of Eddy current and ultrasonic techniques for composite materials NDE

NASA Technical Reports Server (NTRS)

Davis, C. W.; Nath, S.; Fulton, J. P.; Namkung, M.

1993-01-01

Advanced composites are not without trade-offs. Their increased designability brings an increase in the complexity of their internal geometry and, as a result, an increase in the number of failure modes associated with a defect. When two or more isotropic materials are combined in a composite, the isotropic material failure modes may also combine. In a laminate, matrix delamination, cracking and crazing, and voids and porosity, will often combine with fiber breakage, shattering, waviness, and separation to bring about ultimate structural failure. This combining of failure modes can result in defect boundaries of different sizes, corresponding to the failure of each structural component. This paper discusses a dual-technology NDE (Non Destructive Evaluation) (eddy current (EC) and ultrasonics (UT)) study of graphite/epoxy (gr/ep) laminate samples. Eddy current and ultrasonic raster (Cscan) imaging were used together to characterize the effects of mechanical impact damage, high temperature thermal damage and various types of inserts in gr/ep laminate samples of various stacking sequences.

On the strength of random fiber networks

NASA Astrophysics Data System (ADS)

Deogekar, S.; Picu, R. C.

2018-07-01

Damage accumulation and failure in random fiber networks is of importance in a variety of applications, from design of synthetic materials, such as paper and non-wovens, to accidental tearing of biological tissues. In this work we study these processes using three-dimensional models of athermal fiber networks, focusing attention on the modes of failure and on the relationship between network strength and network structural parameters. We consider network failure at small and large strains associated with the rupture of inter-fiber bonds. It is observed that the strength increases linearly with the network volume fraction and with the bond strength, while the stretch at peak stress is inversely related to these two parameters. A small fraction of the bonds rupture before peak stress and this fraction increases with increasing failure stretch. Rendering the bond strength stochastic causes a reduction of the network strength. However, heterogeneity retards damage localization and increases the stretch at peak stress, therefore promoting ductility.

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

PubMed

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

2006-03-28

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

Accretion mode of oceanic ridges governed by axial mechanical strength

NASA Astrophysics Data System (ADS)

Sibrant, A. L. R.; Mittelstaedt, E.; Davaille, A.; Pauchard, L.; Aubertin, A.; Auffray, L.; Pidoux, R.

2018-04-01

Oceanic spreading ridges exhibit structural changes as a function of spreading rate, mantle temperature and the balance of tectonic and magmatic accretion. The role that these or other processes have in governing the overall shape of oceanic ridges is unclear. Here, we use laboratory experiments to simulate ridge spreading in colloidal aqueous dispersions whose rheology evolves from purely viscous to elastic and brittle when placed in contact with a saline water solution. We find that ridge shape becomes increasingly linear with spreading rate until reaching a minimum tortuosity. This behaviour is predicted by the axial failure parameter ΠF, a dimensionless number describing the balance of brittle and plastic failure of axial lithosphere. Slow-spreading, fault-dominated and fast-spreading, fluid intrusion-dominated ridges on Earth and in the laboratory are separated by the same critical ΠF value, suggesting that the axial failure mode governs ridge geometry. Values of ΠF can also be calculated for different mantle temperatures and applied to other planets or the early Earth. For higher mantle temperatures during the Archaean, our results preclude the predicted formation of large tectonic plates at high spreading velocity.

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

NASA Technical Reports Server (NTRS)

Howard, Philip M.

2007-01-01

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

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

NASA Astrophysics Data System (ADS)

Propes, Nicholas C.; Vachtsevanos, George

2003-08-01

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

Design and Demonstration of Emergency Control Modes for Enhanced Engine Performance

NASA Technical Reports Server (NTRS)

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

2013-01-01

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

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

NASA Technical Reports Server (NTRS)

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

2008-01-01

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

Fatigue Characterization of Fire Resistant Syntactic Foam Core Material

NASA Astrophysics Data System (ADS)

Hossain, Mohammad Mynul

Eco-Core is a fire resistant material for sandwich structural application; it was developed at NC A&T State University. The Eco-Core is made of very small amount of phenolic resin and large volume of flyash by a syntactic process. The process development, static mechanical and fracture, fire and toxicity safety and water absorption properties and the design of sandwich structural panels with Eco-Core material was established and published in the literature. One of the important properties that is needed for application in transportation vehicles is the fatigue performance under different stress states. Fatigue data are not available even for general syntactic foams. The objective of this research is to investigate the fatigue performance of Eco-Core under three types of stress states, namely, cyclic compression, shear and flexure, then document failure modes, and develop empherical equations for predicting fatigue life of Eco-Core under three stress states. Compression-Compression fatigue was performed directly on Eco-Core cylindrical specimen, whereas shear and flexure fatigue tests were performed using sandwich beam made of E glass-Vinyl Ester face sheet and Eco-Core material. Compression-compression fatigue test study was conducted at two values of stress ratios (R=10 and 5), for the maximum compression stress (sigmamin) range of 60% to 90% of compression strength (sigmac = 19.6 +/- 0.25 MPa) for R=10 and 95% to 80% of compression strength for R=5. The failure modes were characterized by the material compliance change: On-set (2% compliance change), propagation (5%) and ultimate failure (7%). The number of load cycles correspond to each of these three damages were characterized as on-set, propagation and total lives. A similar approach was used in shear and flexure fatigue tests with stress ratio of R=0.1. The fatigue stress-number of load cycles data followed the standard power law equation for all three stress states. The constant of the equation were established for the three stress states and three types of the failure modes. This equation was used to estimate endurance limit (106 cycles) of the material. Like metallic materials, the compression fatigue life of Eco-Core was found to be dependent on the stress range instead of maximum or mean cyclic stress. Furthermore shear and flexural ultimate failure of the core material was found to be due to a combination of shear and tensile stress.

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

NASA Technical Reports Server (NTRS)

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

2005-01-01

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

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

NASA Technical Reports Server (NTRS)

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

2006-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2018-01-01

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

Dynamic Response and Failure Mechanism of Brittle Rocks Under Combined Compression-Shear Loading Experiments

NASA Astrophysics Data System (ADS)

Xu, Yuan; Dai, Feng

2018-03-01

A novel method is developed for characterizing the mechanical response and failure mechanism of brittle rocks under dynamic compression-shear loading: an inclined cylinder specimen using a modified split Hopkinson pressure bar (SHPB) system. With the specimen axis inclining to the loading direction of SHPB, a shear component can be introduced into the specimen. Both static and dynamic experiments are conducted on sandstone specimens. Given carefully pulse shaping, the dynamic equilibrium of the inclined specimens can be satisfied, and thus the quasi-static data reduction is employed. The normal and shear stress-strain relationships of specimens are subsequently established. The progressive failure process of the specimen illustrated via high-speed photographs manifests a mixed failure mode accommodating both the shear-dominated failure and the localized tensile damage. The elastic and shear moduli exhibit certain loading-path dependence under quasi-static loading but loading-path insensitivity under high loading rates. Loading rate dependence is evidently demonstrated through the failure characteristics involving fragmentation, compression and shear strength and failure surfaces based on Drucker-Prager criterion. Our proposed method is convenient and reliable to study the dynamic response and failure mechanism of rocks under combined compression-shear loading.

THE EFFECT OF LASER SHOCK PEENING ON THE LIFE AND FAILURE MODE OF A COLD PILGER DIE

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

Lavender, Curt A.; Hong, Sung-tae; Smith, Mark T.

2008-08-11

The laser shock peening process was used to increase fatigue life of pilger dies made of A2 tool steel by imparting compressive residual stresses to fatigue prone areas of the dies. The result of X-Ray diffraction analysis indicated that deep, high- magnitude compressive residual stresses were generated by the laser shock peening process, and the peened dies exhibited a significant increase of in-service life. Fractography of the failed dies indicates that the fracture mechanism was altered by the peening process.

MEMS Reliability Assurance Activities at JPL

NASA Technical Reports Server (NTRS)

Kayali, S.; Lawton, R.; Stark, B.

2000-01-01

An overview of Microelectromechanical Systems (MEMS) reliability assurance and qualification activities at JPL is presented along with the a discussion of characterization of MEMS structures implemented on single crystal silicon, polycrystalline silicon, CMOS, and LIGA processes. Additionally, common failure modes and mechanisms affecting MEMS structures, including radiation effects, are discussed. Common reliability and qualification practices contained in the MEMS Reliability Assurance Guideline are also presented.

In Vitro Evaluation and Mechanism Analysis of the Fiber Shedding Property of Textile Pile Debridement Materials

PubMed Central

Fu, Yijun; Xie, Qixue; Lao, Jihong; Wang, Lu

2016-01-01

Fiber shedding is a critical problem in biomedical textile debridement materials, which leads to infection and impairs wound healing. In this work, single fiber pull-out test was proposed as an in vitro evaluation for the fiber shedding property of a textile pile debridement material. Samples with different structural design (pile densities, numbers of ground yarns and coating times) were prepared and estimated under this testing method. Results show that single fiber pull-out test offers an appropriate in vitro evaluation for the fiber shedding property of textile pile debridement materials. Pull-out force for samples without back-coating exhibited a slight escalating trend with the supplement in pile density and number of ground yarn plies, while back-coating process significantly raised the single fiber pull-out force. For fiber shedding mechanism analysis, typical pull-out behavior and failure modes of the single fiber pull-out test were analyzed in detail. Three failure modes were found in this study, i.e., fiber slippage, coating point rupture and fiber breakage. In summary, to obtain samples with desirable fiber shedding property, fabric structural design, preparation process and raw materials selection should be taken into full consideration. PMID:28773428

TH-EF-BRC-04: Quality Management Program

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

Yorke, E.

2016-06-15

This Hands-on Workshop will be focused on providing participants with experience with the principal tools of TG 100 and hence start to build both competence and confidence in the use of risk-based quality management techniques. The three principal tools forming the basis of TG 100’s risk analysis: Process mapping, Failure-Modes and Effects Analysis and fault-tree analysis will be introduced with a 5 minute refresher presentation and each presentation will be followed by a 30 minute small group exercise. An exercise on developing QM from the risk analysis follows. During the exercise periods, participants will apply the principles in 2 differentmore » clinical scenarios. At the conclusion of each exercise there will be ample time for participants to discuss with each other and the faculty their experience and any challenges encountered. Learning Objectives: To review the principles of Process Mapping, Failure Modes and Effects Analysis and Fault Tree Analysis. To gain familiarity with these three techniques in a small group setting. To share and discuss experiences with the three techniques with faculty and participants. Director, TreatSafely, LLC. Director, Center for the Assessment of Radiological Sciences. Occasional Consultant to the IAEA and Varian.« less

TH-EF-BRC-03: Fault Tree Analysis

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

Thomadsen, B.

2016-06-15

This Hands-on Workshop will be focused on providing participants with experience with the principal tools of TG 100 and hence start to build both competence and confidence in the use of risk-based quality management techniques. The three principal tools forming the basis of TG 100’s risk analysis: Process mapping, Failure-Modes and Effects Analysis and fault-tree analysis will be introduced with a 5 minute refresher presentation and each presentation will be followed by a 30 minute small group exercise. An exercise on developing QM from the risk analysis follows. During the exercise periods, participants will apply the principles in 2 differentmore » clinical scenarios. At the conclusion of each exercise there will be ample time for participants to discuss with each other and the faculty their experience and any challenges encountered. Learning Objectives: To review the principles of Process Mapping, Failure Modes and Effects Analysis and Fault Tree Analysis. To gain familiarity with these three techniques in a small group setting. To share and discuss experiences with the three techniques with faculty and participants. Director, TreatSafely, LLC. Director, Center for the Assessment of Radiological Sciences. Occasional Consultant to the IAEA and Varian.« less

TH-EF-BRC-00: TG-100 Workshop

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

NONE

2016-06-15

This Hands-on Workshop will be focused on providing participants with experience with the principal tools of TG 100 and hence start to build both competence and confidence in the use of risk-based quality management techniques. The three principal tools forming the basis of TG 100’s risk analysis: Process mapping, Failure-Modes and Effects Analysis and fault-tree analysis will be introduced with a 5 minute refresher presentation and each presentation will be followed by a 30 minute small group exercise. An exercise on developing QM from the risk analysis follows. During the exercise periods, participants will apply the principles in 2 differentmore » clinical scenarios. At the conclusion of each exercise there will be ample time for participants to discuss with each other and the faculty their experience and any challenges encountered. Learning Objectives: To review the principles of Process Mapping, Failure Modes and Effects Analysis and Fault Tree Analysis. To gain familiarity with these three techniques in a small group setting. To share and discuss experiences with the three techniques with faculty and participants. Director, TreatSafely, LLC. Director, Center for the Assessment of Radiological Sciences. Occasional Consultant to the IAEA and Varian.« less

TH-EF-BRC-02: FMEA

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

Huq, M.

2016-06-15

This Hands-on Workshop will be focused on providing participants with experience with the principal tools of TG 100 and hence start to build both competence and confidence in the use of risk-based quality management techniques. The three principal tools forming the basis of TG 100’s risk analysis: Process mapping, Failure-Modes and Effects Analysis and fault-tree analysis will be introduced with a 5 minute refresher presentation and each presentation will be followed by a 30 minute small group exercise. An exercise on developing QM from the risk analysis follows. During the exercise periods, participants will apply the principles in 2 differentmore » clinical scenarios. At the conclusion of each exercise there will be ample time for participants to discuss with each other and the faculty their experience and any challenges encountered. Learning Objectives: To review the principles of Process Mapping, Failure Modes and Effects Analysis and Fault Tree Analysis. To gain familiarity with these three techniques in a small group setting. To share and discuss experiences with the three techniques with faculty and participants. Director, TreatSafely, LLC. Director, Center for the Assessment of Radiological Sciences. Occasional Consultant to the IAEA and Varian.« less

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

Dunscombe, P.

This Hands-on Workshop will be focused on providing participants with experience with the principal tools of TG 100 and hence start to build both competence and confidence in the use of risk-based quality management techniques. The three principal tools forming the basis of TG 100’s risk analysis: Process mapping, Failure-Modes and Effects Analysis and fault-tree analysis will be introduced with a 5 minute refresher presentation and each presentation will be followed by a 30 minute small group exercise. An exercise on developing QM from the risk analysis follows. During the exercise periods, participants will apply the principles in 2 differentmore » clinical scenarios. At the conclusion of each exercise there will be ample time for participants to discuss with each other and the faculty their experience and any challenges encountered. Learning Objectives: To review the principles of Process Mapping, Failure Modes and Effects Analysis and Fault Tree Analysis. To gain familiarity with these three techniques in a small group setting. To share and discuss experiences with the three techniques with faculty and participants. Director, TreatSafely, LLC. Director, Center for the Assessment of Radiological Sciences. Occasional Consultant to the IAEA and Varian.« less

Effects of process parameters on friction self-piercing riveting of dissimilar materials

DOE PAGES

Liu, Xun; Lim, Yong Chae; Li, Yongbing; ...

2016-05-24

In the present work, a recently developed solid state joining technique, Friction self-piercing riveting (F-SPR), has been applied for joining high strength aluminum alloy AA7075-T6 to magnesium alloy AZ31B. The process was performed on a specially designed machine where the spindle can achieve the motion of sudden stop. Effects of rivet rotating rate and punch speed on axial plunge force, torque, joint microstructure and quality have been analyzed systematically. During F-SPR, higher rotating rate and slower punch speed can reduce axial force and torque, which correspondingly results in a slightly smaller interlock between rivet leg and joined materials. Improved localmore » flowability of both aluminum and magnesium alloys under a higher rotating speed results in a thicker aluminum layer surrounding the rivet leg, where formation of Al-Mg intermetallics was observed. Equivalent joint strength obtained in this study are higher than the yield strength of the AZ31 Mg alloy. One of the tensile failure modes is the rivet fracture, which is due to local softening of rivet leg from frictional heat. Lastly, other two failure modes include rivet pullout and shear through of bottom sheet.« less

An immune-inspired swarm aggregation algorithm for self-healing swarm robotic systems.

PubMed

Timmis, J; Ismail, A R; Bjerknes, J D; Winfield, A F T

2016-08-01

Swarm robotics is concerned with the decentralised coordination of multiple robots having only limited communication and interaction abilities. Although fault tolerance and robustness to individual robot failures have often been used to justify the use of swarm robotic systems, recent studies have shown that swarm robotic systems are susceptible to certain types of failure. In this paper we propose an approach to self-healing swarm robotic systems and take inspiration from the process of granuloma formation, a process of containment and repair found in the immune system. We use a case study of a swarm performing team work where previous works have demonstrated that partially failed robots have the most detrimental effect on overall swarm behaviour. We have developed an immune inspired approach that permits the recovery from certain failure modes during operation of the swarm, overcoming issues that effect swarm behaviour associated with partially failed robots. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Numerical investigation of contact stresses for fretting fatigue damage initiation

NASA Astrophysics Data System (ADS)

Bhatti, N. A.; Abdel Wahab, M.

2017-05-01

Fretting fatigue phenomena occurs due to interaction between contacting bodies under application of cyclic and normal loads. In addition to environmental conditions and material properties, the response at the contact interface highly depends on the combination of applied loads. High stress concentration is present at the contact interface, which can start the damage nucleation process. At the culmination of nucleation process several micro cracks are initiated, ultimately leading to the structural failure. In this study, effect of ratio of tangential to normal load on contact stresses, slip amplitude and damage initiation is studied using finite element analysis. The results are evaluated for Ruiz parameter as it involves the slip amplitude which in an important factor in fretting fatigue conditions. It is observed that tangential to normal load ratio influences the stick zone size and damage initiation life. Furthermore, it is observed that tensile stress is the most important factor that drives the damage initiation to failure for the cases where failure occurs predominantly in mode I manner.

Product Support Manager Guidebook

DTIC Science & Technology

2011-04-01

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

Comparison of micro push-out bond strengths of two fiber posts luted using simplified adhesive approaches.

PubMed

Mumcu, Emre; Erdemir, Ugur; Topcu, Fulya Toksoy

2010-05-01

By means of a micro push-out test, this study compared the bond strengths of two types of fiber-reinforced posts cemented with luting cements based on two currently available adhesive approaches as well as evaluated their failure modes. Sixty extracted single-rooted human maxillary central incisor and canine teeth were sectioned below the cementoenamel junction, and the roots were endodontically treated. Following standardized post space preparation, the roots were divided into two fiber post groups and then further into three subgroups of 10 specimens each according to the luting cements. A push-out test was performed to measure regional bond strengths, and the fracture modes were evaluated using a stereomicroscope. At the root section, there were no statistically significant differences (p>0.05) in push-out bond strength among the tested luting cements. Nevertheless, the push-out bond strength values of glass fiber-reinforced posts were higher than those of carbon fiber-reinforced posts, irrespective of the adhesive approach used. On failure mode, the predominant failure mode was adhesive failure between dentin and the luting cement.

Identification of priorities for medication safety in neonatal intensive care.

PubMed

Kunac, Desireé L; Reith, David M

2005-01-01

Although neonates are reported to be at greater risk of medication error than infants and older children, little is known about the causes and characteristics of error in this patient group. Failure mode and effects analysis (FMEA) is a technique used in industry to evaluate system safety and identify potential hazards in advance. The aim of this study was to identify and prioritize potential failures in the neonatal intensive care unit (NICU) medication use process through application of FMEA. Using the FMEA framework and a systems-based approach, an eight-member multidisciplinary panel worked as a team to create a flow diagram of the neonatal unit medication use process. Then by brainstorming, the panel identified all potential failures, their causes and their effects at each step in the process. Each panel member independently rated failures based on occurrence, severity and likelihood of detection to allow calculation of a risk priority score (RPS). The panel identified 72 failures, with 193 associated causes and effects. Vulnerabilities were found to be distributed across the entire process, but multiple failures and associated causes were possible when prescribing the medication and when preparing the drug for administration. The top ranking issue was a perceived lack of awareness of medication safety issues (RPS score 273), due to a lack of medication safety training. The next highest ranking issues were found to occur at the administration stage. Common potential failures related to errors in the dose, timing of administration, infusion pump settings and route of administration. Perceived causes were multiple, but were largely associated with unsafe systems for medication preparation and storage in the unit, variable staff skill level and lack of computerised technology. Interventions to decrease medication-related adverse events in the NICU should aim to increase staff awareness of medication safety issues and focus on medication administration processes.

The integration methods of fuzzy fault mode and effect analysis and fault tree analysis for risk analysis of yogurt production

NASA Astrophysics Data System (ADS)

Aprilia, Ayu Rizky; Santoso, Imam; Ekasari, Dhita Murita

2017-05-01

Yogurt is a product based on milk, which has beneficial effects for health. The process for the production of yogurt is very susceptible to failure because it involves bacteria and fermentation. For an industry, the risks may cause harm and have a negative impact. In order for a product to be successful and profitable, it requires the analysis of risks that may occur during the production process. Risk analysis can identify the risks in detail and prevent as well as determine its handling, so that the risks can be minimized. Therefore, this study will analyze the risks of the production process with a case study in CV.XYZ. The method used in this research is the Fuzzy Failure Mode and Effect Analysis (fuzzy FMEA) and Fault Tree Analysis (FTA). The results showed that there are 6 risks from equipment variables, raw material variables, and process variables. Those risks include the critical risk, which is the risk of a lack of an aseptic process, more specifically if starter yogurt is damaged due to contamination by fungus or other bacteria and a lack of sanitation equipment. The results of quantitative analysis of FTA showed that the highest probability is the probability of the lack of an aseptic process, with a risk of 3.902%. The recommendations for improvement include establishing SOPs (Standard Operating Procedures), which include the process, workers, and environment, controlling the starter of yogurt and improving the production planning and sanitation equipment using hot water immersion.

Multi-mode reliability-based design of horizontal curves.

PubMed

Essa, Mohamed; Sayed, Tarek; Hussein, Mohamed

2016-08-01

Recently, reliability analysis has been advocated as an effective approach to account for uncertainty in the geometric design process and to evaluate the risk associated with a particular design. In this approach, a risk measure (e.g. probability of noncompliance) is calculated to represent the probability that a specific design would not meet standard requirements. The majority of previous applications of reliability analysis in geometric design focused on evaluating the probability of noncompliance for only one mode of noncompliance such as insufficient sight distance. However, in many design situations, more than one mode of noncompliance may be present (e.g. insufficient sight distance and vehicle skidding at horizontal curves). In these situations, utilizing a multi-mode reliability approach that considers more than one failure (noncompliance) mode is required. The main objective of this paper is to demonstrate the application of multi-mode (system) reliability analysis to the design of horizontal curves. The process is demonstrated by a case study of Sea-to-Sky Highway located between Vancouver and Whistler, in southern British Columbia, Canada. Two noncompliance modes were considered: insufficient sight distance and vehicle skidding. The results show the importance of accounting for several noncompliance modes in the reliability model. The system reliability concept could be used in future studies to calibrate the design of various design elements in order to achieve consistent safety levels based on all possible modes of noncompliance. Copyright © 2016 Elsevier Ltd. All rights reserved.

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

PubMed

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

2014-10-01

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

Introduction to Concurrent Engineering: Electronic Circuit Design and Production Applications

DTIC Science & Technology

1992-09-01

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

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

NASA Technical Reports Server (NTRS)

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

1991-01-01

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

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

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

Manger, R; Pawlicki, T; Kim, G

2015-06-15

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

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

NASA Technical Reports Server (NTRS)

Mall, S.; Johnson, W. S.

1985-01-01

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

Code development for ships -- A demonstration

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

Ayyub, B.; Mansour, A.E.; White, G.

1996-12-31

A demonstration summary of a reliability-based structural design code for ships is presented for two ship types, a cruiser and a tanker. For both ship types, code requirements cover four failure modes: hull girder bulking, unstiffened plate yielding and buckling, stiffened plate buckling, and fatigue of critical detail. Both serviceability and ultimate limit states are considered. Because of limitation on the length, only hull girder modes are presented in this paper. Code requirements for other modes will be presented in future publication. A specific provision of the code will be a safety check expression. The design variables are to bemore » taken at their nominal values, typically values in the safe side of the respective distributions. Other safety check expressions for hull girder failure that include load combination factors, as well as consequence of failure factors, are considered. This paper provides a summary of safety check expressions for the hull girder modes.« less

The development of control and monitoring system on marine current renewable energy Case study: strait of Toyapakeh - Nusa Penida, Bali

NASA Astrophysics Data System (ADS)

Arief, I. S.; Suherman, I. H.; Wardani, A. Y.; Baidowi, A.

2017-05-01

Control and monitoring system is a continuous process of securing the asset in the Marine Current Renewable Energy. A control and monitoring system is existed each critical components which is embedded in Failure Mode Effect Analysis (FMEA) method. As the result, the process in this paper developed through a matrix sensor. The matrix correlated to critical components and monitoring system which supported by sensors to conduct decision-making.

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

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

Delamination modeling of laminate plate made of sublaminates

NASA Astrophysics Data System (ADS)

Kormaníková, Eva; Kotrasová, Kamila

2017-07-01

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