NASA aviation safety reporting system

NASA Technical Reports Server (NTRS)

Billings, C. E.; Lauber, J. K.; Funkhouser, H.; Lyman, E. G.; Huff, E. M.

1976-01-01

The origins and development of the NASA Aviation Safety Reporting System (ASRS) are briefly reviewed. The results of the first quarter's activity are summarized and discussed. Examples are given of bulletins describing potential air safety hazards, and the disposition of these bulletins. During the first quarter of operation, the ASRS received 1464 reports; 1407 provided data relevant to air safety. All reports are being processed for entry into the ASRS data base. During the reporting period, 130 alert bulletins describing possible problems in the aviation system were generated and disseminated. Responses were received from FAA and others regarding 108 of the alert bulletins. Action was being taken with respect to 70 of the 108 responses received. Further studies are planned of a number of areas, including human factors problems related to automation of the ground and airborne portions of the national aviation system.

Software Safety Risk in Legacy Safety-Critical Computer Systems

NASA Technical Reports Server (NTRS)

Hill, Janice L.; Baggs, Rhoda

2007-01-01

Safety Standards contain technical and process-oriented safety requirements. Technical requirements are those such as "must work" and "must not work" functions in the system. Process-Oriented requirements are software engineering and safety management process requirements. Address the system perspective and some cover just software in the system > NASA-STD-8719.13B Software Safety Standard is the current standard of interest. NASA programs/projects will have their own set of safety requirements derived from the standard. Safety Cases: a) Documented demonstration that a system complies with the specified safety requirements. b) Evidence is gathered on the integrity of the system and put forward as an argued case. [Gardener (ed.)] c) Problems occur when trying to meet safety standards, and thus make retrospective safety cases, in legacy safety-critical computer systems.

Striving for safety: communicating and deciding in sociotechnical systems

PubMed Central

Flach, John M.; Carroll, John S.; Dainoff, Marvin J.; Hamilton, W. Ian

2015-01-01

How do communications and decisions impact the safety of sociotechnical systems? This paper frames this question in the context of a dynamic system of nested sub-systems. Communications are related to the construct of observability (i.e. how components integrate information to assess the state with respect to local and global constraints). Decisions are related to the construct of controllability (i.e. how component sub-systems act to meet local and global safety goals). The safety dynamics of sociotechnical systems are evaluated as a function of the coupling between observability and controllability across multiple closed-loop components. Two very different domains (nuclear power and the limited service food industry) provide examples to illustrate how this framework might be applied. While the dynamical systems framework does not offer simple prescriptions for achieving safety, it does provide guides for exploring specific systems to consider the potential fit between organisational structures and work demands, and for generalising across different systems regarding how safety can be managed. Practitioner Summary: While offering no simple prescriptions about how to achieve safety in sociotechnical systems, this paper develops a theoretical framework based on dynamical systems theory as a practical guide for generalising from basic research to work domains and for generalising across alternative work domains to better understand how patterns of communication and decision-making impact system safety. PMID:25761155

Software Safety Risk in Legacy Safety-Critical Computer Systems

NASA Technical Reports Server (NTRS)

Hill, Janice; Baggs, Rhoda

2007-01-01

Safety-critical computer systems must be engineered to meet system and software safety requirements. For legacy safety-critical computer systems, software safety requirements may not have been formally specified during development. When process-oriented software safety requirements are levied on a legacy system after the fact, where software development artifacts don't exist or are incomplete, the question becomes 'how can this be done?' The risks associated with only meeting certain software safety requirements in a legacy safety-critical computer system must be addressed should such systems be selected as candidates for reuse. This paper proposes a method for ascertaining formally, a software safety risk assessment, that provides measurements for software safety for legacy systems which may or may not have a suite of software engineering documentation that is now normally required. It relies upon the NASA Software Safety Standard, risk assessment methods based upon the Taxonomy-Based Questionnaire, and the application of reverse engineering CASE tools to produce original design documents for legacy systems.

Nuclear Safety for Space Systems

NASA Astrophysics Data System (ADS)

Offiong, Etim

2010-09-01

It is trite, albeit a truism, to say that nuclear power can provide propulsion thrust needed to launch space vehicles and also, to provide electricity for powering on-board systems, especially for missions to the Moon, Mars and other deep space missions. Nuclear Power Sources(NPSs) are known to provide more capabilities than solar power, fuel cells and conventional chemical means. The worry has always been that of safety. The earliest superpowers(US and former Soviet Union) have designed and launched several nuclear-powered systems, with some failures. Nuclear failures and accidents, however little the number, could be far-reaching geographically, and are catastrophic to humans and the environment. Building on the numerous research works on nuclear power on Earth and in space, this paper seeks to bring to bear, issues relating to safety of space systems - spacecrafts, astronauts, Earth environment and extra terrestrial habitats - in the use and application of nuclear power sources. It also introduces a new formal training course in Space Systems Safety.

NASA System Safety Handbook. Volume 2: System Safety Concepts, Guidelines, and Implementation Examples

NASA Technical Reports Server (NTRS)

Dezfuli, Homayoon; Benjamin, Allan; Everett, Christopher; Feather, Martin; Rutledge, Peter; Sen, Dev; Youngblood, Robert

2015-01-01

This is the second of two volumes that collectively comprise the NASA System Safety Handbook. Volume 1 (NASASP-210-580) was prepared for the purpose of presenting the overall framework for System Safety and for providing the general concepts needed to implement the framework. Volume 2 provides guidance for implementing these concepts as an integral part of systems engineering and risk management. This guidance addresses the following functional areas: 1.The development of objectives that collectively define adequate safety for a system, and the safety requirements derived from these objectives that are levied on the system. 2.The conduct of system safety activities, performed to meet the safety requirements, with specific emphasis on the conduct of integrated safety analysis (ISA) as a fundamental means by which systems engineering and risk management decisions are risk-informed. 3.The development of a risk-informed safety case (RISC) at major milestone reviews to argue that the systems safety objectives are satisfied (and therefore that the system is adequately safe). 4.The evaluation of the RISC (including supporting evidence) using a defined set of evaluation criteria, to assess the veracity of the claims made therein in order to support risk acceptance decisions.

Space engine safety system

NASA Technical Reports Server (NTRS)

Maul, William A.; Meyer, Claudia M.

1991-01-01

A rocket engine safety system was designed to initiate control procedures to minimize damage to the engine or vehicle or test stand in the event of an engine failure. The features and the implementation issues associated with rocket engine safety systems are discussed, as well as the specific concerns of safety systems applied to a space-based engine and long duration space missions. Examples of safety system features and architectures are given, based on recent safety monitoring investigations conducted for the Space Shuttle Main Engine and for future liquid rocket engines. Also, the general design and implementation process for rocket engine safety systems is presented.

Manned space flight nuclear system safety. Voluem 5: Nuclear system safety guidelines. Part 2: Space shuttle/nuclear payloads safety

NASA Technical Reports Server (NTRS)

1972-01-01

The design and operations guidelines and requirements developed in the study of space shuttle nuclear system transportation are presented. Guidelines and requirements are presented for the shuttle, nuclear payloads (reactor, isotope-Brayton and small isotope sources), ground support systems and facilities. Cross indices and references are provided which relate guidelines to each other, and to substantiating data in other volumes. The guidelines are intended for the implementation of nuclear safety related design and operational considerations in future space programs.

System theory and safety models in Swedish, UK, Dutch and Australian road safety strategies.

PubMed

Hughes, B P; Anund, A; Falkmer, T

2015-01-01

Road safety strategies represent interventions on a complex social technical system level. An understanding of a theoretical basis and description is required for strategies to be structured and developed. Road safety strategies are described as systems, but have not been related to the theory, principles and basis by which systems have been developed and analysed. Recently, road safety strategies, which have been employed for many years in different countries, have moved to a 'vision zero', or 'safe system' style. The aim of this study was to analyse the successful Swedish, United Kingdom and Dutch road safety strategies against the older, and newer, Australian road safety strategies, with respect to their foundations in system theory and safety models. Analysis of the strategies against these foundations could indicate potential improvements. The content of four modern cases of road safety strategy was compared against each other, reviewed against scientific systems theory and reviewed against types of safety model. The strategies contained substantial similarities, but were different in terms of fundamental constructs and principles, with limited theoretical basis. The results indicate that the modern strategies do not include essential aspects of systems theory that describe relationships and interdependencies between key components. The description of these strategies as systems is therefore not well founded and deserves further development. Copyright © 2014 Elsevier Ltd. All rights reserved.

The Art World's Concept of Negative Space Applied to System Safety Management

NASA Technical Reports Server (NTRS)

Goodin, James Ronald (Ronnie)

2005-01-01

Tools from several different disciplines can improve system safety management. This paper relates the Art World with our system safety world, showing useful art schools of thought applied to system safety management, developing an art theory-system safety bridge. This bridge is then used to demonstrate relations with risk management, the legal system, personnel management and basic management (establishing priorities). One goal of this presentation/paper is simply to be a fun diversion from the many technical topics presented during the conference.

Critical Characteristics of Radiation Detection System Components to be Dedicated for use in Safety Class and Safety Significant System

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

DAVIS, S.J.

2000-05-25

This document identifies critical characteristics of components to be dedicated for use in Safety Class (SC) or Safety Significant (SS) Systems, Structures, or Components (SSCs). This document identifies the requirements for the components of the common radiation area monitor alarm in the WESF pool cell. These are procured as Commercial Grade Items (CGI), with the qualification testing and formal dedication to be performed at the Waste Encapsulation Storage Facility (WESF), in safety class, safety significant systems. System modifications are to be performed in accordance with the instructions provided on ECN 658230. Components for this change are commercially available and interchangeablemore » with the existing alarm configuration This document focuses on the operational requirements for alarm, declaration of the safety classification, identification of critical characteristics, and interpretation of requirements for procurement. Critical characteristics are identified herein and must be verified, followed by formal dedication, prior to the components being used in safety related applications.« less

NASA aviation safety reporting system

NASA Technical Reports Server (NTRS)

1981-01-01

Aviation safety reports that relate to loss of control in flight, problems that occur as a result of similar sounding alphanumerics, and pilot incapacitation are presented. Problems related to the go around maneuver in air carrier operations, and bulletins (and FAA responses to them) that pertain to air traffic control systems and procedures are included.

Systemic safety project selection tool.

DOT National Transportation Integrated Search

2013-07-01

"The Systemic Safety Project Selection Tool presents a process for incorporating systemic safety planning into traditional safety management processes. The Systemic Tool provides a step-by-step process for conducting systemic safety analysis; conside...

Comparative Safety and Tolerability of Anti-VEGF therapy in Age-Related Macular Degeneration

PubMed Central

Modi, Yasha S.; Tanchon, Carley; Ehlers, Justis P

2015-01-01

Neovascular age-related macular degeneration (NVAMD) is one of the leading causes of blindness. Over the last decade, the treatment of NVAMD has been revolutionized by the development intravitreal anti-vascular endothelial growth factor (VEGF) therapies. Several anti-VEGF medications are used for the treatment of NVAMD. The safety and tolerability of these medications deserve review given the high prevalence of NVAMD and the significant utilization of these medications. Numerous large randomized clinical trials have not shown any definitive differential safety relative to ocular or systemic safety of these medications. Intravitreal anti-VEGF therapy does appear to impact systemic VEGF levels, but the implications of these changes remain unclear. One unique safety concern relates drug compounding and the potential risks of contamination, specifically for bevacizumab. Continued surveillance for systemic safety concerns, particularly for rare events is merited. Overall these medications are well tolerated and effective in the treatment of NVAMD. PMID:25700714

Learning from Taiwan patient-safety reporting system.

PubMed

Lin, Chung-Chih; Shih, Chung-Liang; Liao, Hsun-Hsiang; Wung, Cathy H Y

2012-12-01

The aim of this study is to create a national database to record incidents that endanger patient safety. We try to identify systemic problems in hospitals in order to avoid safety incidents in the future and improve the quality of healthcare. The Taiwan Patient Safety Reporting System employs a voluntary notification model. We define 13 types of patient safety incidents, and the reports of different types of incidents are recorded using common terminology. Statistical analysis is used to identify the incident type, time of occurrence, location, person who reported the incident, and possible reasons for frequently occurring incidents. There were 340 hospitals that joined this program from 2005 to 2010. Over 128,271 incident events were reported and analyzed. The three most common incidents were drug-related incidents, falls, and endo tube related incidents. By analyzing the time of occurrence of incidents, we found that drug-related incidents usually occurred between 8 and 10 am. Falls and endo tube incidents usually occurred between 4 and 6 am. The most common location was wards (57.6%), followed by intensive care areas (13.5%), and pharmacies (9.1%). Among hospital staff, nurses reported the highest number of incidents (68.9%), followed by pharmacists (14.5%) and administrative staff (5.5%). The number of incidents reported by doctors was much lower (1.2%). Most staff members who reported incidents had been working for less than five years (58.1%). The unified reporting system was found to improve the recording and analysis of patient safety incidents. To encourage hospital staff to report incidents, hospitals need to be assisted in establishing an internal report and management system for safety incidents. Hospitals also need a protection mechanism to allow staff members to report incidents without the fear of punishment. By identifying the root causes of safety incidents and sharing the lessons learned across hospitals is the only way such incidents can be

System Safety in an IT Service Organization

NASA Astrophysics Data System (ADS)

Parsons, Mike; Scutt, Simon

Within Logica UK, over 30 IT service projects are considered safetyrelated. These include operational IT services for airports, railway infrastructure asset management, nationwide radiation monitoring and hospital medical records services. A recent internal audit examined the processes and documents used to manage system safety on these services and made a series of recommendations for improvement. This paper looks at the changes and the challenges to introducing them, especially where the service is provided by multiple units supporting both safety and non-safety related services from multiple locations around the world. The recommendations include improvements to service agreements, improved process definitions, routine safety assessment of changes, enhanced call logging, improved staff competency and training, and increased safety awareness. Progress is reported as of today, together with a road map for implementation of the improvements to the service safety management system. A proposal for service assurance levels (SALs) is discussed as a way forward to cover the wide variety of services and associated safety risks.

Exploring safety systems for dispensing in community pharmacies: focusing on how staff relate to organizational components.

PubMed

Harvey, Jasmine; Avery, Anthony J; Ashcroft, Darren; Boyd, Matthew; Phipps, Denham L; Barber, Nicholas

2015-01-01

Identifying risk is an important facet of a safety practice in an organization. To identify risk, all components within a system of operation should be considered. In clinical safety practice, a team of people, technologies, procedures and protocols, management structure and environment have been identified as key components in a system of operation. To explore risks in relation to prescription dispensing in community pharmacies by taking into account relationships between key components that relate to the dispensing process. Fifteen community pharmacies in England with varied characteristics were identified, and data were collected using non-participant observations, shadowing and interviews. Approximately 360 hours of observations and 38 interviews were conducted by the team. Observation field notes from each pharmacy were written into case studies. Overall, 52,500 words from 15 case studies and interview transcripts were analyzed using thematic and line-by-line analyses. Validation techniques included multiple data collectors co-authoring each case study for consensus, review of case studies by members of the wider team including academic and practicing community pharmacists, and patient safety experts and two presentations (internally and externally) to review and discuss findings. Risks identified were related to relationships between people and other key components in dispensing. This included how different levels of staff communicated internally and externally, followed procedures, interacted with technical systems, worked with management, and engaged with the environment. In a dispensing journey, the following categories were identified which show how risks are inextricably linked through relationships between human components and other key components: 1) dispensing with divided attention; 2) dispensing under pressure; 3) dispensing in a restricted space or environment; and, 4) managing external influences. To identify and evaluate risks effectively, an

Consumer product safety: A systems problem

NASA Technical Reports Server (NTRS)

Clark, C. C.

1971-01-01

The manufacturer, tester, retailer, consumer, repairer disposer, trade and professional associations, national and international standards bodies, and governments in several roles are all involved in consumer product safety. A preliminary analysis, drawing on system safety techniques, is utilized to distinguish the inter-relations of these many groups and the responsibilities that they are or could take for product safety, including the slow accident hazards as well as the more commonly discussed fast accident hazards. The importance of interactive computer aided information flow among these groups is particularly stressed.

Traceability of Software Safety Requirements in Legacy Safety Critical Systems

NASA Technical Reports Server (NTRS)

Hill, Janice L.

2007-01-01

How can traceability of software safety requirements be created for legacy safety critical systems? Requirements in safety standards are imposed most times during contract negotiations. On the other hand, there are instances where safety standards are levied on legacy safety critical systems, some of which may be considered for reuse for new applications. Safety standards often specify that software development documentation include process-oriented and technical safety requirements, and also require that system and software safety analyses are performed supporting technical safety requirements implementation. So what can be done if the requisite documents for establishing and maintaining safety requirements traceability are not available?

Safety-related requirements for photovoltaic modules and arrays. Final report

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

Levins, A.

1984-03-01

Underwriters Laboratories has conducted a study to identify and develop safety requirements for photovoltaic module and panel designs and configurations for residential, intermediate, and large scale applications. Concepts for safety systems, where each system is a collection of subsystems which together address the total anticipated hazard situation, are described. Descriptions of hardware, and system usefulness and viability are included. This discussion of safety systems recognizes that there is little history on which to base the expected safety related performance of a photovoltaic system. A comparison of these systems, as against the provisions of the 1984 National Electrical Code covering photovoltaicmore » systems is made. A discussion of the UL investigation of the photovoltaic module evaluated to the provisions of the Proposed UL Standard for Flat-Plate Photovoltaic Modules and Panels is included. Grounding systems, their basis and nature, and the advantages and disadvantages of each are described. The meaning of frame grounding, circuit grounding, and the type of circuit ground are covered. The development of the Standard for Flat-Plate Photovoltaic Modules and Panels has continued, and with both industry comment and a product submittal and listing, the Standard has been refined to a viable document allowing an objective safety review of photovoltaic modules and panels. How this document, and other UL documents would cover investigations of certain other photovoltaic system components is described.« less

The NASA Aviation Safety Reporting System

NASA Technical Reports Server (NTRS)

1983-01-01

This is the fourteenth in a series of reports based on safety-related incidents submitted to the NASA Aviation Safety Reporting System by pilots, controllers, and, occasionally, other participants in the National Aviation System (refs. 1-13). ASRS operates under a memorandum of agreement between the National Aviation and Space Administration and the Federal Aviation Administration. The report contains, first, a special study prepared by the ASRS Office Staff, of pilot- and controller-submitted reports related to the perceived operation of the ATC system since the 1981 walkout of the controllers' labor organization. Next is a research paper analyzing incidents occurring while single-pilot crews were conducting IFR flights. A third section presents a selection of Alert Bulletins issued by ASRS, with the responses they have elicited from FAA and others concerned. Finally, the report contains a list of publications produced by ASRS with instructions for obtaining them.

Overview of Risk Mitigation for Safety-Critical Computer-Based Systems

NASA Technical Reports Server (NTRS)

Torres-Pomales, Wilfredo

2015-01-01

This report presents a high-level overview of a general strategy to mitigate the risks from threats to safety-critical computer-based systems. In this context, a safety threat is a process or phenomenon that can cause operational safety hazards in the form of computational system failures. This report is intended to provide insight into the safety-risk mitigation problem and the characteristics of potential solutions. The limitations of the general risk mitigation strategy are discussed and some options to overcome these limitations are provided. This work is part of an ongoing effort to enable well-founded assurance of safety-related properties of complex safety-critical computer-based aircraft systems by developing an effective capability to model and reason about the safety implications of system requirements and design.

Racial/ethnic differences in obesity and comorbidities between safety-net- and non safety-net integrated health systems

PubMed Central

Balasubramanian, Bijal A.; Garcia, Michael P.; Corley, Douglas A.; Doubeni, Chyke A.; Haas, Jennifer S.; Kamineni, Aruna; Quinn, Virginia P.; Wernli, Karen; Zheng, Yingye; Skinner, Celette Sugg

2017-01-01

Abstract Previous research shows that patients in integrated health systems experience fewer racial disparities compared with more traditional healthcare systems. Little is known about patterns of racial/ethnic disparities between safety-net and non safety-net integrated health systems. We evaluated racial/ethnic differences in body mass index (BMI) and the Charlson comorbidity index from 3 non safety-net- and 1 safety-net integrated health systems in a cross-sectional study. Multinomial logistic regression modeled comorbidity and BMI on race/ethnicity and health care system type adjusting for age, sex, insurance, and zip-code-level income The study included 1.38 million patients. Higher proportions of safety-net versus non safety-net patients had comorbidity score of 3+ (11.1% vs. 5.0%) and BMI ≥35 (27.7% vs. 15.8%). In both types of systems, blacks and Hispanics were more likely than whites to have higher BMIs. Whites were more likely than blacks or Hispanics to have higher comorbidity scores in a safety net system, but less likely to have higher scores in the non safety-nets. The odds of comorbidity score 3+ and BMI 35+ in blacks relative to whites were significantly lower in safety-net than in non safety-net settings. Racial/ethnic differences were present within both safety-net and non safety-net integrated health systems, but patterns differed. Understanding patterns of racial/ethnic differences in health outcomes in safety-net and non safety-net integrated health systems is important to tailor interventions to eliminate racial/ethnic disparities in health and health care. PMID:28296752

Critical Characteristics of Radiation Detection System Components to be Dedicated for use in Safety Class and Safety Significant System

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

DAVIS, S.J.

2000-12-28

This document identifies critical characteristics of components to be dedicated for use in Safety Significant (SS) Systems, Structures, or Components (SSCs). This document identifies the requirements for the components of the common, radiation area, monitor alarm in the WESF pool cell. These are procured as Commercial Grade Items (CGI), with the qualification testing and formal dedication to be performed at the Waste Encapsulation Storage Facility (WESF) for use in safety significant systems. System modifications are to be performed in accordance with the approved design. Components for this change are commercially available and interchangeable with the existing alarm configuration This documentmore » focuses on the operational requirements for alarm, declaration of the safety classification, identification of critical characteristics, and interpretation of requirements for procurement. Critical characteristics are identified herein and must be verified, followed by formal dedication, prior to the components being used in safety related applications.« less

A sensor monitoring system for telemedicine, safety and security applications

NASA Astrophysics Data System (ADS)

Vlissidis, Nikolaos; Leonidas, Filippos; Giovanis, Christos; Marinos, Dimitrios; Aidinis, Konstantinos; Vassilopoulos, Christos; Pagiatakis, Gerasimos; Schmitt, Nikolaus; Pistner, Thomas; Klaue, Jirka

2017-02-01

A sensor system capable of medical, safety and security monitoring in avionic and other environments (e.g. homes) is examined. For application inside an aircraft cabin, the system relies on an optical cellular network that connects each seat to a server and uses a set of database applications to process data related to passengers' health, safety and security status. Health monitoring typically encompasses electrocardiogram, pulse oximetry and blood pressure, body temperature and respiration rate while safety and security monitoring is related to the standard flight attendance duties, such as cabin preparation for take-off, landing, flight in regions of turbulence, etc. In contrast to previous related works, this article focuses on the system's modules (medical and safety sensors and associated hardware), the database applications used for the overall control of the monitoring function and the potential use of the system for security applications. Further tests involving medical, safety and security sensing performed in an real A340 mock-up set-up are also described and reference is made to the possible use of the sensing system in alternative environments and applications, such as health monitoring within other means of transport (e.g. trains or small passenger sea vessels) as well as for remotely located home users, over a wired Ethernet network or the Internet.

Medication Safety Systems and the Important Role of Pharmacists.

PubMed

Mansur, Jeannell M

2016-03-01

Preventable medication-related adverse events continue to occur in the healthcare setting. While the Institute of Medicine's To Err is Human, published in 2000, highlighted the prevalence of medical and medication-related errors in patient morbidity and mortality, there has not been significant documented progress in addressing system contributors to medication errors. The lack of progress may be related to the myriad of pharmaceutical options now available and the nuances of optimizing drug therapy to achieve desired outcomes and prevent undesirable outcomes. However, on a broader scale, there may be opportunities to focus on the design and performance of the many processes that are part of the medication system. Errors may occur in the storage, prescribing, transcription, preparation and dispensing, or administration and monitoring of medications. Each of these nodes of the medication system, with its many components, is prone to failure, resulting in harm to patients. The pharmacist is uniquely trained to be able to impact medication safety at the individual patient level through medication management skills that are part of the clinical pharmacist's role, but also to analyze the performance of medication processes and to lead redesign efforts to mitigate drug-related outcomes that may cause harm. One population that can benefit from a focus on medication safety through clinical pharmacy services and medication safety programs is the elderly, who are at risk for adverse drug events due to their many co-morbidities and the number of medications often used. This article describes the medication safety systems and provides a blueprint for creating a foundation for medication safety programs within healthcare organizations. The specific role of pharmacists and clinical pharmacy services in medication safety is also discussed here and in other articles in this Theme Issue.

49 CFR 191.23 - Reporting safety-related conditions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 3 2011-10-01 2011-10-01 false Reporting safety-related conditions. 191.23... HAZARDOUS MATERIALS SAFETY ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) PIPELINE SAFETY TRANSPORTATION OF NATURAL AND OTHER GAS BY PIPELINE; ANNUAL REPORTS, INCIDENT REPORTS, AND SAFETY-RELATED...

Local Food Systems Food Safety Concerns.

PubMed

Chapman, Benjamin; Gunter, Chris

2018-04-01

Foodborne disease causes an estimated 48 million illnesses and 3,000 deaths annually (Scallan E, et al., Emerg Infect Dis 17:7-15, 2011), with U.S. economic costs estimated at $152 billion to $1.4 trillion annually (Roberts T, Am J Agric Econ 89:1183-1188, 2007; Scharff RL, http://www.pewtrusts.org/en/research-and-analysis/reports/0001/01/01/healthrelated-costs-from-foodborne-illness-in-the-united-states, 2010). An increasing number of these illnesses are associated with fresh fruits and vegetables. An analysis of outbreaks from 1990 to 2003 found that 12% of outbreaks and 20% of outbreak-related illnesses were associated with produce (Klein S, Smith DeWaal CS, Center for Science in the Public Interest, https://cspinet.org/sites/default/files/attachment/ddreport.pdf, June 2008; Lynch M, Tauxe R, Hedberg C, Epidemiol Infect 137:307-315, 2009). These food safety problems have resulted in various stakeholders recommending the shift to a more preventative and risk-based food safety system. A modern risk-based food safety system takes a farm-to-fork preventative approach to food safety and relies on the proactive collection and analysis of data to better understand potential hazards and risk factors, to design and evaluate interventions, and to prioritize prevention efforts. Such a system focuses limited resources at the points in the food system with the likelihood of having greatest benefit to public health. As shared kitchens, food hubs, and local food systems such as community supported agriculture are becoming more prevalent throughout the United States, so are foodborne illness outbreaks at these locations. At these locations, many with limited resources, food safety methods of prevention are rarely the main focus. This lack of focus on food safety knowledge is why a growing number of foodborne illness outbreaks are occurring at these locations.

Integrated therapy safety management system

PubMed Central

Podtschaske, Beatrice; Fuchs, Daniela; Friesdorf, Wolfgang

2013-01-01

Aims The aim is to demonstrate the benefit of the medico-ergonomic approach for the redesign of clinical work systems. Based on the six layer model, a concept for an ‘integrated therapy safety management’ is drafted. This concept could serve as a basis to improve resilience. Methods The concept is developed through a concept-based approach. The state of the art of safety and complexity research in human factors and ergonomics forms the basis. The findings are synthesized to a concept for ‘integrated therapy safety management’. The concept is applied by way of example for the ‘medication process’ to demonstrate its practical implementation. Results The ‘integrated therapy safety management’ is drafted in accordance with the six layer model. This model supports a detailed description of specific work tasks, the corresponding responsibilities and related workflows at different layers by using the concept of ‘bridge managers’. ‘Bridge managers’ anticipate potential errors and monitor the controlled system continuously. If disruptions or disturbances occur, they respond with corrective actions which ensure that no harm results and they initiate preventive measures for future procedures. The concept demonstrates that in a complex work system, the human factor is the key element and final authority to cope with the residual complexity. The expertise of the ‘bridge managers’ and the recursive hierarchical structure results in highly adaptive clinical work systems and increases their resilience. Conclusions The medico-ergonomic approach is a highly promising way of coping with two complexities. It offers a systematic framework for comprehensive analyses of clinical work systems and promotes interdisciplinary collaboration. PMID:24007448

Technical evaluation of the susceptibility of safety-related systems to flooding caused by the failure of non-Category I systems for Turkey Point Nuclear Power Plant, Units 3 and 4

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

Collins, E.K.

1979-08-01

Three separate reviews of the Turkey Point Units 3 and 4 were conducted by the FPLCO between 1972 and 1975. Initially, at the request of NBC in 1972, the FPLCO reviewed several water systems as sources of flooding. Subsequently, as a result of an abnormal occurrence, the drainage system was reviewed. Finally, the facilities were again reviewed at NRC's request and both the potential sources of flooding and safety-related equipment which could be damaged by flooding were identified. The sources of flooding and the appropriate safety equipment are discussed. An evaluation is presented of measures that were taken by FPLCOmore » to minimize the danger of flooding and to protect safety-related equipment.« less

The procedure safety system

NASA Technical Reports Server (NTRS)

Obrien, Maureen E.

1990-01-01

Telerobotic operations, whether under autonomous or teleoperated control, require a much more sophisticated safety system than that needed for most industrial applications. Industrial robots generally perform very repetitive tasks in a controlled, static environment. The safety system in that case can be as simple as shutting down the robot if a human enters the work area, or even simply building a cage around the work space. Telerobotic operations, however, will take place in a dynamic, sometimes unpredictable environment, and will involve complicated and perhaps unrehearsed manipulations. This creates a much greater potential for damage to the robot or objects in its vicinity. The Procedural Safety System (PSS) collects data from external sensors and the robot, then processes it through an expert system shell to determine whether an unsafe condition or potential unsafe condition exists. Unsafe conditions could include exceeding velocity, acceleration, torque, or joint limits, imminent collision, exceeding temperature limits, and robot or sensor component failure. If a threat to safety exists, the operator is warned. If the threat is serious enough, the robot is halted. The PSS, therefore, uses expert system technology to enhance safety thus reducing operator work load, allowing him/her to focus on performing the task at hand without the distraction of worrying about violating safety criteria.

Screening Electronic Health Record-Related Patient Safety Reports Using Machine Learning.

PubMed

Marella, William M; Sparnon, Erin; Finley, Edward

2017-03-01

The objective of this study was to develop a semiautomated approach to screening cases that describe hazards associated with the electronic health record (EHR) from a mandatory, population-based patient safety reporting system. Potentially relevant cases were identified through a query of the Pennsylvania Patient Safety Reporting System. A random sample of cases were manually screened for relevance and divided into training, testing, and validation data sets to develop a machine learning model. This model was used to automate screening of remaining potentially relevant cases. Of the 4 algorithms tested, a naive Bayes kernel performed best, with an area under the receiver operating characteristic curve of 0.927 ± 0.023, accuracy of 0.855 ± 0.033, and F score of 0.877 ± 0.027. The machine learning model and text mining approach described here are useful tools for identifying and analyzing adverse event and near-miss reports. Although reporting systems are beginning to incorporate structured fields on health information technology and the EHR, these methods can identify related events that reporters classify in other ways. These methods can facilitate analysis of legacy safety reports by retrieving health information technology-related and EHR-related events from databases without fields and controlled values focused on this subject and distinguishing them from reports in which the EHR is mentioned only in passing. Machine learning and text mining are useful additions to the patient safety toolkit and can be used to semiautomate screening and analysis of unstructured text in safety reports from frontline staff.

Effect of Occupational Health and Safety Management System on Work-Related Accident Rate and Differences of Occupational Health and Safety Management System Awareness between Managers in South Korea's Construction Industry

PubMed Central

Yoon, Seok J.; Lin, Hsing K.; Chen, Gang; Yi, Shinjea; Choi, Jeawook; Rui, Zhenhua

2013-01-01

Background The study was conducted to investigate the current status of the occupational health and safety management system (OHSMS) in the construction industry and the effect of OHSMS on accident rates. Differences of awareness levels on safety issues among site general managers and occupational health and safety (OHS) managers are identified through surveys. Methods The accident rates for the OHSMS-certified construction companies from 2006 to 2011, when the construction OHSMS became widely available, were analyzed to understand the effect of OHSMS on the work-related injury rates in the construction industry. The Korea Occupational Safety and Health Agency 18001 is the certification to these companies performing OHSMS in South Korea. The questionnaire was created to analyze the differences of OHSMS awareness between site general managers and OHS managers of construction companies. Results The implementation of OHSMS among the top 100 construction companies in South Korea shows that the accident rate decreased by 67% and the fatal accident rate decreased by 10.3% during the period from 2006 to 2011. The survey in this study shows different OHSMS awareness levels between site general managers and OHS managers. The differences were motivation for developing OHSMS, external support needed for implementing OHSMS, problems and effectiveness of implementing OHSMS. Conclusion Both work-related accident and fatal accident rates were found to be significantly reduced by implementing OHSMS in this study. The differences of OHSMS awareness between site general managers and OHS managers were identified through a survey. The effect of these differences on safety and other benefits warrants further research with proper data collection. PMID:24422176

Effect of Occupational Health and Safety Management System on Work-Related Accident Rate and Differences of Occupational Health and Safety Management System Awareness between Managers in South Korea's Construction Industry.

PubMed

Yoon, Seok J; Lin, Hsing K; Chen, Gang; Yi, Shinjea; Choi, Jeawook; Rui, Zhenhua

2013-12-01

The study was conducted to investigate the current status of the occupational health and safety management system (OHSMS) in the construction industry and the effect of OHSMS on accident rates. Differences of awareness levels on safety issues among site general managers and occupational health and safety (OHS) managers are identified through surveys. The accident rates for the OHSMS-certified construction companies from 2006 to 2011, when the construction OHSMS became widely available, were analyzed to understand the effect of OHSMS on the work-related injury rates in the construction industry. The Korea Occupational Safety and Health Agency 18001 is the certification to these companies performing OHSMS in South Korea. The questionnaire was created to analyze the differences of OHSMS awareness between site general managers and OHS managers of construction companies. The implementation of OHSMS among the top 100 construction companies in South Korea shows that the accident rate decreased by 67% and the fatal accident rate decreased by 10.3% during the period from 2006 to 2011. The survey in this study shows different OHSMS awareness levels between site general managers and OHS managers. The differences were motivation for developing OHSMS, external support needed for implementing OHSMS, problems and effectiveness of implementing OHSMS. Both work-related accident and fatal accident rates were found to be significantly reduced by implementing OHSMS in this study. The differences of OHSMS awareness between site general managers and OHS managers were identified through a survey. The effect of these differences on safety and other benefits warrants further research with proper data collection.

A red-flag-based approach to risk management of EHR-related safety concerns.

PubMed

Sittig, Dean F; Singh, Hardeep

2013-01-01

Although electronic health records (EHRs) have a significant potential to improve patient safety, EHR-related safety concerns have begun to emerge. Based on 369 responses to a survey sent to the memberships of the American Society for Healthcare Risk Management and the American Health Lawyers Association and supplemented by our previous work in EHR-related patient safety, we identified the following common EHR-related safety concerns: (1) incorrect patient identification; (2) extended EHR unavailability (either planned or unplanned); (3) failure to heed a computer-generated warning or alert; (4) system-to-system interface errors; (5) failure to identify, find, or use the most recent patient data; (6) misunderstandings about time; (7) incorrect item selected from a list of items; and (8) open or incomplete orders. In this article, we present a "red-flag"-based approach that can be used by risk managers to identify potential EHR safety concerns in their institutions. An organization that routinely conducts EHR-related surveillance activities, such as the ones proposed here, can significantly reduce risks associated with EHR implementation and use. © 2013 American Society for Healthcare Risk Management of the American Hospital Association.

Analyzing Software Errors in Safety-Critical Embedded Systems

NASA Technical Reports Server (NTRS)

Lutz, Robyn R.

1994-01-01

This paper analyzes the root causes of safty-related software faults identified as potentially hazardous to the system are distributed somewhat differently over the set of possible error causes than non-safety-related software faults.

Safety system for child pillion riders of underbone motorcycles in Malaysia.

PubMed

Sivasankar, S; Karmegam, K; Bahri, M T Shamsul; Naeini, H Sadeghi; Kulanthayan, S

2014-01-01

Motorcycles are a common mode of transport for most Malaysians. Underbone motorcycles are one of the most common types of motorcycle used in Malaysia due to their affordable price and ease of use, especially in heavy traffic in the major cities. In Malaysia, it is common to see a young or child pillion rider clinging on to an adult at the front of the motorcycle. One of the main issues facing young pillion riders is that their safety is often not taken into account when they are riding on a motorcycle. This article reviews the legally available systems in child safety for underbone motorcycles in Malaysia while putting forth the need for a safety system for child pillion riders. Various databases were searched for underbone motorcycle safety systems, related legislation, motorcycle accident data, and types of injuries and these were reviewed to put forth the need for a new safety system. In motorcycle-related accidents, children usually sustain lower limb injuries, which could temporarily or permanently inhibit the child's movements. Accident statistics in Malaysia, especially those involving motorcycles, reflect a pressing need for a reduction in the number of accidents. In Malaysia, the legislation does not go beyond the mandatory use of safety helmets for young pillion users. There is a pressing need for another safety system or mechanism(s) for young pillion riders of underbone motorcycles. Enforcement of laws to enforce the usage of passive safety systems such as helmets and protective gear is difficult in underdeveloped and developing countries. The intervention of new technology is inevitable. Therefore, this article highlights the need for a new safety backrest system for child pillion riders to ensure their safety.

Manned space flight nuclear system safety. Volume 6: Space base nuclear system safety plan

NASA Technical Reports Server (NTRS)

1972-01-01

A qualitative identification of the steps required to assure the incorporation of radiological system safety principles and objectives into all phases of a manned space base program are presented. Specific areas of emphasis include: (1) radiological program management, (2) nuclear system safety plan implementation, (3) impact on program, and (4) summary of the key operation and design guidelines and requirements. The plan clearly indicates the necessity of considering and implementing radiological system safety recommendations as early as possible in the development cycle to assure maximum safety and minimize the impact on design and mission plans.

Identification of Crew-Systems Interactions and Decision Related Trends

NASA Technical Reports Server (NTRS)

Jones, Sharon Monica; Evans, Joni K.; Reveley, Mary S.; Withrow, Colleen A.; Ancel, Ersin; Barr, Lawrence

2013-01-01

NASA Vehicle System Safety Technology (VSST) project management uses systems analysis to identify key issues and maintain a portfolio of research leading to potential solutions to its three identified technical challenges. Statistical data and published safety priority lists from academic, industry and other government agencies were reviewed and analyzed by NASA Aviation Safety Program (AvSP) systems analysis personnel to identify issues and future research needs related to one of VSST's technical challenges, Crew Decision Making (CDM). The data examined in the study were obtained from the National Transportation Safety Board (NTSB) Aviation Accident and Incident Data System, Federal Aviation Administration (FAA) Accident/Incident Data System and the NASA Aviation Safety Reporting System (ASRS). In addition, this report contains the results of a review of safety priority lists, information databases and other documented references pertaining to aviation crew systems issues and future research needs. The specific sources examined were: Commercial Aviation Safety Team (CAST) Safety Enhancements Reserved for Future Implementation (SERFIs), Flight Deck Automation Issues (FDAI) and NTSB Most Wanted List and Open Recommendations. Various automation issues taxonomies and priority lists pertaining to human factors, automation and flight design were combined to create a list of automation issues related to CDM.

System for controlling child safety seat environment

NASA Technical Reports Server (NTRS)

Elrod, Susan V. (Inventor); Dabney, Richard W. (Inventor)

2008-01-01

A system is provided to control the environment experienced by a child in a child safety seat. Each of a plurality of thermoelectric elements is individually controllable to be one of heated and cooled relative to an ambient temperature. A first portion of the thermoelectric elements are positioned on the child safety seat such that a child sitting therein is positioned thereover. A ventilator coupled to the child safety seat moves air past a second portion of the thermoelectric elements and filters the air moved therepast. One or more jets coupled to the ventilator receive the filtered air. Each jet is coupled to the child safety seat and can be positioned to direct the heated/cooled filtered air to the vicinity of the head of the child sitting in the child safety seat.

Reporter Concerns in 300 Mode-Related Incident Reports from NASA's Aviation Safety Reporting System

NASA Technical Reports Server (NTRS)

McGreevy, Michael W.

1996-01-01

A model has been developed which represents prominent reporter concerns expressed in the narratives of 300 mode-related incident reports from NASA's Aviation Safety Reporting System (ASRS). The model objectively quantifies the structure of concerns which persist across situations and reporters. These concerns are described and illustrated using verbatim sentences from the original narratives. Report accession numbers are included with each sentence so that concerns can be traced back to the original reports. The results also include an inventory of mode names mentioned in the narratives, and a comparison of individual and joint concerns. The method is based on a proximity-weighted co-occurrence metric and object-oriented complexity reduction.

Effects of organizational safety on employees' proactivity safety behaviors and occupational health and safety management systems in Chinese high-risk small-scale enterprises.

PubMed

Mei, Qiang; Wang, Qiwei; Liu, Suxia; Zhou, Qiaomei; Zhang, Jingjing

2018-06-07

Based on the characteristics of small-scale enterprises, the improvement of occupational health and safety management systems (OHS MS) needs an effective intervention. This study proposed a structural equation model and examined the relationships of perceived organization support for safety (POSS), person-organization safety fit (POSF) and proactivity safety behaviors with safety management, safety procedures and safety hazards identification. Data were collected from 503 employees of 105 Chinese high-risk small-scale enterprises over 6 months. The results showed that both POSS and POSF were positively related to improvement in safety management, safety procedures and safety hazards identification through proactivity safety behaviors. Our findings provide a new perspective on organizational safety for improving OHS MS for small-scale enterprises and extend the application of proactivity safety behaviors.

NASA Safety Manual. Volume 3: System Safety

NASA Technical Reports Server (NTRS)

1970-01-01

This Volume 3 of the NASA Safety Manual sets forth the basic elements and techniques for managing a system safety program and the technical methods recommended for use in developing a risk evaluation program that is oriented to the identification of hazards in aerospace hardware systems and the development of residual risk management information for the program manager that is based on the hazards identified. The methods and techniques described in this volume are in consonance with the requirements set forth in NHB 1700.1 (VI), Chapter 3. This volume and future volumes of the NASA Safety Manual shall not be rewritten, reprinted, or reproduced in any manner. Installation implementing procedures, if necessary, shall be inserted as page supplements in accordance with the provisions of Appendix A. No portion of this volume or future volumes of the NASA Safety Manual shall be invoked in contracts.

Safety concerns related to modular/prefabricated building construction.

PubMed

Fard, Maryam Mirhadi; Terouhid, Seyyed Amin; Kibert, Charles J; Hakim, Hamed

2017-03-01

The US construction industry annually experiences a relatively high rate of fatalities and injuries; therefore, improving safety practices should be considered a top priority for this industry. Modular/prefabricated building construction is a construction strategy that involves manufacturing of the whole building or some of its components off-site. This research focuses on the safety performance of the modular/prefabricated building construction sector during both manufacturing and on-site processes. This safety evaluation can serve as the starting point for improving the safety performance of this sector. Research was conducted based on Occupational Safety and Health Administration investigated accidents. The study found 125 accidents related to modular/prefabricated building construction. The details of each accident were closely examined to identify the types of injury and underlying causes. Out of 125 accidents, there were 48 fatalities (38.4%), 63 hospitalized injuries (50.4%), and 14 non-hospitalized injuries (11.2%). It was found that, the most common type of injury in modular/prefabricated construction was 'fracture', and the most common cause of accidents was 'fall'. The most frequent cause of cause (underlying and root cause) was 'unstable structure'. In this research, the accidents were also examined in terms of corresponding location, occupation, equipment as well as activities during which the accidents occurred. For improving safety records of the modular/prefabricated construction sector, this study recommends that future research be conducted on stabilizing structures during their lifting, storing, and permanent installation, securing fall protection systems during on-site assembly of components while working from heights, and developing training programmes and standards focused on modular/prefabricated construction.

Comprehensive Lifecycle for Assuring System Safety

NASA Technical Reports Server (NTRS)

Knight, John C.; Rowanhill, Jonathan C.

2017-01-01

CLASS is a novel approach to the enhancement of system safety in which the system safety case becomes the focus of safety engineering throughout the system lifecycle. CLASS also expands the role of the safety case across all phases of the system's lifetime, from concept formation to decommissioning. As CLASS has been developed, the concept has been generalized to a more comprehensive notion of assurance becoming the driving goal, where safety is an important special case. This report summarizes major aspects of CLASS and contains a bibliography of papers that provide additional details.

77 FR 70409 - System Safety Program

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-26

...-0060, Notice No. 2] 2130-AC31 System Safety Program AGENCY: Federal Railroad Administration (FRA... passenger railroads to develop and implement a system safety program (SSP) to improve the safety of their... Division, U.S. Department of Transportation, Federal Railroad Administration, Office of Railroad Safety...

The complexity of patient safety reporting systems in UK dentistry.

PubMed

Renton, T; Master, S

2016-10-21

Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.

Creating an Oversight Infrastructure for Electronic Health Record-Related Patient Safety Hazards

PubMed Central

Singh, Hardeep; Classen, David C.; Sittig, Dean F.

2013-01-01

Electronic health records (EHRs) have potential quality and safety benefits. However, reports of EHR-related safety hazards are now emerging. The Office of the National Coordinator (ONC) for Health Information Technology (HIT) recently sponsored an Institute of Medicine committee to evaluate how HIT use affects patient safety. In this paper, we propose the creation of a national EHR oversight program to provide dedicated surveillance of EHR-related safety hazards and to promote learning from identified errors, close calls, and adverse events. The program calls for data gathering, investigation/analysis and regulatory components. The first two functions will depend on institution-level EHR safety committees that will investigate all known EHR-related adverse events and near-misses and report them nationally using standardized methods. These committees should also perform routine safety self-assessments to proactively identify new risks. Nationally, we propose the long-term creation of a centralized, non-partisan board with an appropriate legal and regulatory infrastructure to ensure the safety of EHRs. We discuss the rationale of the proposed oversight program and its potential organizational components and functions. These include mechanisms for robust data collection and analyses of all safety concerns using multiple methods that extend beyond reporting; multidisciplinary investigation of selected high-risk safety events; and enhanced coordination with other national agencies in order to facilitate broad dissemination of hazards information. Implementation of this proposed infrastructure can facilitate identification of EHR-related adverse events and errors and potentially create a safer and more effective EHR-based health care delivery system. PMID:22080284

Safety Metrics for Human-Computer Controlled Systems

NASA Technical Reports Server (NTRS)

Leveson, Nancy G; Hatanaka, Iwao

2000-01-01

The rapid growth of computer technology and innovation has played a significant role in the rise of computer automation of human tasks in modem production systems across all industries. Although the rationale for automation has been to eliminate "human error" or to relieve humans from manual repetitive tasks, various computer-related hazards and accidents have emerged as a direct result of increased system complexity attributed to computer automation. The risk assessment techniques utilized for electromechanical systems are not suitable for today's software-intensive systems or complex human-computer controlled systems.This thesis will propose a new systemic model-based framework for analyzing risk in safety-critical systems where both computers and humans are controlling safety-critical functions. A new systems accident model will be developed based upon modem systems theory and human cognitive processes to better characterize system accidents, the role of human operators, and the influence of software in its direct control of significant system functions Better risk assessments will then be achievable through the application of this new framework to complex human-computer controlled systems.

Impact of Passive Safety on FHR Instrumentation Systems Design and Classification

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

Holcomb, David Eugene

2015-01-01

Fluoride salt-cooled high-temperature reactors (FHRs) will rely more extensively on passive safety than earlier reactor classes. 10CFR50 Appendix A, General Design Criteria for Nuclear Power Plants, establishes minimum design requirements to provide reasonable assurance of adequate safety. 10CFR50.69, Risk-Informed Categorization and Treatment of Structures, Systems and Components for Nuclear Power Reactors, provides guidance on how the safety significance of systems, structures, and components (SSCs) should be reflected in their regulatory treatment. The Nuclear Energy Institute (NEI) has provided 10 CFR 50.69 SSC Categorization Guideline (NEI-00-04) that factors in probabilistic risk assessment (PRA) model insights, as well as deterministic insights, throughmore » an integrated decision-making panel. Employing the PRA to inform deterministic requirements enables an appropriately balanced, technically sound categorization to be established. No FHR currently has an adequate PRA or set of design basis accidents to enable establishing the safety classification of its SSCs. While all SSCs used to comply with the general design criteria (GDCs) will be safety related, the intent is to limit the instrumentation risk significance through effective design and reliance on inherent passive safety characteristics. For example, FHRs have no safety-significant temperature threshold phenomena, thus enabling the primary and reserve reactivity control systems required by GDC 26 to be passively, thermally triggered at temperatures well below those for which core or primary coolant boundary damage would occur. Moreover, the passive thermal triggering of the primary and reserve shutdown systems may relegate the control rod drive motors to the control system, substantially decreasing the amount of safety-significant wiring needed. Similarly, FHR decay heat removal systems are intended to be running continuously to minimize the amount of safety-significant instrumentation needed to

Why system safety programs can fail

NASA Technical Reports Server (NTRS)

Hammer, W.

1971-01-01

Factors that cause system safety programs to fail are discussed from the viewpoint that in general these programs have not achieved their intended aims. The one item which is considered to contribute most to failure of a system safety program is a poor statement of work which consists of ambiguity, lack of clear definition, use of obsolete requirements, and pure typographical errors. It is pointed out that unless safety requirements are stated clearly, and where they are readily apparent as firm requirements, some of them will be overlooked by designers and contractors. The lack of clarity is stated as being a major contributing factor in system safety program failure and usually evidenced in: (1) lack of clear requirements by the procuring activity, (2) lack of clear understanding of system safety by other managers, and (3) lack of clear methodology to be employed by system safety engineers.

Does the concept of safety culture help or hinder systems thinking in safety?

PubMed

Reiman, Teemu; Rollenhagen, Carl

2014-07-01

The concept of safety culture has become established in safety management applications in all major safety-critical domains. The idea that safety culture somehow represents a "systemic view" on safety is seldom explicitly spoken out, but nevertheless seem to linger behind many safety culture discourses. However, in this paper we argue that the "new" contribution to safety management from safety culture never really became integrated with classical engineering principles and concepts. This integration would have been necessary for the development of a more genuine systems-oriented view on safety; e.g. a conception of safety in which human, technological, organisational and cultural factors are understood as mutually interacting elements. Without of this integration, researchers and the users of the various tools and methods associated with safety culture have sometimes fostered a belief that "safety culture" in fact represents such a systemic view about safety. This belief is, however, not backed up by theoretical or empirical evidence. It is true that safety culture, at least in some sense, represents a holistic term-a totality of factors that include human, organisational and technological aspects. However, the departure for such safety culture models is still human and organisational factors rather than technology (or safety) itself. The aim of this paper is to critically review the various uses of the concept of safety culture as representing a systemic view on safety. The article will take a look at the concepts of culture and safety culture based on previous studies, and outlines in more detail the theoretical challenges in safety culture as a systems concept. The paper also presents recommendations on how to make safety culture more systemic. Copyright © 2013 Elsevier Ltd. All rights reserved.

The aviation safety reporting system

NASA Technical Reports Server (NTRS)

Reynard, W. D.

1984-01-01

The aviation safety reporting system, an accident reporting system, is presented. The system identifies deficiencies and discrepancies and the data it provides are used for long term identification of problems. Data for planning and policy making are provided. The system offers training in safety education to pilots. Data and information are drawn from the available data bases.

NASA Aviation Safety Reporting System (ASRS)

NASA Technical Reports Server (NTRS)

Connell, Linda

2011-01-01

The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 900,000 reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 5,500 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides de-identified report information through the online ASRS Database at http://asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation \\vill discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

NASA Aviation Safety Reporting System (ASRS)

NASA Technical Reports Server (NTRS)

Connell, Linda J.

2017-01-01

The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 1.4 million reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 6,000 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides selected de-identified report information through the online ASRS Database at http:asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation will discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

Integrating system safety into the basic systems engineering process

NASA Technical Reports Server (NTRS)

Griswold, J. W.

1971-01-01

The basic elements of a systems engineering process are given along with a detailed description of what the safety system requires from the systems engineering process. Also discussed is the safety that the system provides to other subfunctions of systems engineering.

49 CFR 385.103 - Safety monitoring system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 5 2010-10-01 2010-10-01 false Safety monitoring system. 385.103 Section 385.103... Safety Monitoring System for Mexico-Domiciled Carriers § 385.103 Safety monitoring system. (a) General... Vehicle Safety Standards (FMVSSs), and Hazardous Materials Regulations (HMRs). (b) Roadside monitoring...

49 CFR 385.103 - Safety monitoring system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Safety monitoring system. 385.103 Section 385.103... Safety Monitoring System for Mexico-Domiciled Carriers § 385.103 Safety monitoring system. (a) General... Vehicle Safety Standards (FMVSSs), and Hazardous Materials Regulations (HMRs). (b) Roadside monitoring...

[Expert investigation on food safety standard system framework construction in China].

PubMed

He, Xiang; Yan, Weixing; Fan, Yongxiang; Zeng, Biao; Peng, Zhen; Sun, Zhenqiu

2013-09-01

Through investigating food safety standard framework among food safety experts, to summarize the basic elements and principles of food safety standard system, and provide policy advices for food safety standards framework. A survey was carried out among 415 experts from government, professional institutions and the food industry/enterprises using the National Food Safety Standard System Construction Consultation Questionnaire designed in the name of the Secretariat of National Food Safety Standard Committee. Experts have different advices in each group about the principles of food product standards, food additive product standards, food related product standards, hygienic practice, test methods. According to the results, the best solution not only may reflect experts awareness of the work of food safety standards situation, but also provide advices for setting and revision of food safety standards for the next. Through experts investigation, the framework and guiding principles of food safety standard had been built.

49 CFR 385.703 - Safety monitoring system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 5 2010-10-01 2010-10-01 false Safety monitoring system. 385.703 Section 385.703... Safety Monitoring System for Non-North American Carriers § 385.703 Safety monitoring system. (a) General... Vehicle Safety Standards (FMVSSs), and Hazardous Materials Regulations (HMRs). (b) Roadside monitoring...

49 CFR 385.703 - Safety monitoring system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Safety monitoring system. 385.703 Section 385.703... Safety Monitoring System for Non-North American Carriers § 385.703 Safety monitoring system. (a) General... Vehicle Safety Standards (FMVSSs), and Hazardous Materials Regulations (HMRs). (b) Roadside monitoring...

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems.

PubMed

Pham, Julius Cuong; Williams, Tamara L; Sparnon, Erin M; Cillie, Tam K; Scharen, Hilda F; Marella, William M

2016-05-01

In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of events reported in each database were related

ASRDI oxygen technology survey, Volume 7: Characteristics of metals that influence system safety

NASA Technical Reports Server (NTRS)

Pelouch, J. J., Jr.

1974-01-01

A literature survey and analysis of the material and process factors affecting the safety of metals in oxygen systems is presented. In addition, the practices of those who specify, build, or use oxygen systems relative to the previous is summarized. Alloys based on iron, copper, nickel, and aluminum were investigated representing the bulk of metals found in oxygen systems. Safety-related characteristics of other miscellaneous metals are summarized. It was found that factors affecting the safety of metals in oxygen systems exit in all phases of the evolutionary process, from smelting and mill techniques through end-production fabrication. The safety of a given metal in an oxygen system was determined to be influenced by the particular service requirement. The metal characteristics should favorably influence fulfillment of these requirements. Thus, no singular metal or alloy could be classified as safest for all types of oxygen service.

System safety engineering analysis handbook

NASA Technical Reports Server (NTRS)

Ijams, T. E.

1972-01-01

The basic requirements and guidelines for the preparation of System Safety Engineering Analysis are presented. The philosophy of System Safety and the various analytic methods available to the engineering profession are discussed. A text-book description of each of the methods is included.

Modelling safety of multistate systems with ageing components

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

Kołowrocki, Krzysztof; Soszyńska-Budny, Joanna

An innovative approach to safety analysis of multistate ageing systems is presented. Basic notions of the ageing multistate systems safety analysis are introduced. The system components and the system multistate safety functions are defined. The mean values and variances of the multistate systems lifetimes in the safety state subsets and the mean values of their lifetimes in the particular safety states are defined. The multi-state system risk function and the moment of exceeding by the system the critical safety state are introduced. Applications of the proposed multistate system safety models to the evaluation and prediction of the safty characteristics ofmore » the consecutive “m out of n: F” is presented as well.« less

Safety policy and requirements for payloads using the space transportation system

NASA Technical Reports Server (NTRS)

1989-01-01

The safety policy and requirements are established applicable to the Space Transportation System (STS) payloads and their ground support equipment (GSE). The requirements are intended to protect flight and ground personnel, the STS, other payloads, GSE, the general public, public-private property, and the environment from payload-related hazards. The technical and system safety requirements applicable to STS payloads (including payload-provided ground and flight supports systems) during ground and flight operations are contained.

System safety education focused on industrial engineering

NASA Technical Reports Server (NTRS)

Johnston, W. L.; Morris, R. S.

1971-01-01

An educational program, designed to train students with the specific skills needed to become safety specialists, is described. The discussion concentrates on application, selection, and utilization of various system safety analytical approaches. Emphasis is also placed on the management of a system safety program, its relationship with other disciplines, and new developments and applications of system safety techniques.

Systems Thinking and Patient Safety

DTIC Science & Technology

2005-01-01

1 Prologue Systems Thinking and Patient Safety Paul M. Schyve Patient safety is a prominent theme in health care delivery today. This should... patient safety and a willingness to invest in patient safety research. This volume—published by the Agency for Healthcare Research and Quality (AHRQ...The recent advent of the health care field’s emphasis on patient safety came at a favorable time. One or two decades earlier, our response would have

Patterns in Safety-Related Projects

NASA Astrophysics Data System (ADS)

Parsons, Mike; Hunter, Charles

Within Logica UK, safety-related projects are run in a variety of ways depending on the constraints imposed and how the risks and mitigations are owned and handled. A total of eight different types of project development patterns have been identified and this paper discusses each type. A simple decision tool has been developed based on the patterns which is used as an aid in deciding how to bid a safety project, allowing tradeoffs between risk ownership, development methods and cost to be assessed.

Product Engineering Class in the Software Safety Risk Taxonomy for Building Safety-Critical Systems

NASA Technical Reports Server (NTRS)

Hill, Janice; Victor, Daniel

2008-01-01

When software safety requirements are imposed on legacy safety-critical systems, retrospective safety cases need to be formulated as part of recertifying the systems for further use and risks must be documented and managed to give confidence for reusing the systems. The SEJ Software Development Risk Taxonomy [4] focuses on general software development issues. It does not, however, cover all the safety risks. The Software Safety Risk Taxonomy [8] was developed which provides a construct for eliciting and categorizing software safety risks in a straightforward manner. In this paper, we present extended work on the taxonomy for safety that incorporates the additional issues inherent in the development and maintenance of safety-critical systems with software. An instrument called a Software Safety Risk Taxonomy Based Questionnaire (TBQ) is generated containing questions addressing each safety attribute in the Software Safety Risk Taxonomy. Software safety risks are surfaced using the new TBQ and then analyzed. In this paper we give the definitions for the specialized Product Engineering Class within the Software Safety Risk Taxonomy. At the end of the paper, we present the tool known as the 'Legacy Systems Risk Database Tool' that is used to collect and analyze the data required to show traceability to a particular safety standard

In-space propellant systems safety. Volume 3: System safety analysis

NASA Technical Reports Server (NTRS)

1972-01-01

The primary objective was to examine from a system safety viewpoint in-space propellant logistic elements and operations to define the potential hazards and to recommend means to reduce, eliminate or control them. A secondary objective was to conduct trade studies of specific systems or operations to determine the safest of alternate approaches.

A Smartphone-Based Driver Safety Monitoring System Using Data Fusion

PubMed Central

Lee, Boon-Giin; Chung, Wan-Young

2012-01-01

This paper proposes a method for monitoring driver safety levels using a data fusion approach based on several discrete data types: eye features, bio-signal variation, in-vehicle temperature, and vehicle speed. The driver safety monitoring system was developed in practice in the form of an application for an Android-based smartphone device, where measuring safety-related data requires no extra monetary expenditure or equipment. Moreover, the system provides high resolution and flexibility. The safety monitoring process involves the fusion of attributes gathered from different sensors, including video, electrocardiography, photoplethysmography, temperature, and a three-axis accelerometer, that are assigned as input variables to an inference analysis framework. A Fuzzy Bayesian framework is designed to indicate the driver’s capability level and is updated continuously in real-time. The sensory data are transmitted via Bluetooth communication to the smartphone device. A fake incoming call warning service alerts the driver if his or her safety level is suspiciously compromised. Realistic testing of the system demonstrates the practical benefits of multiple features and their fusion in providing a more authentic and effective driver safety monitoring. PMID:23247416

Software system safety

NASA Technical Reports Server (NTRS)

Uber, James G.

1988-01-01

Software itself is not hazardous, but since software and hardware share common interfaces there is an opportunity for software to create hazards. Further, these software systems are complex, and proven methods for the design, analysis, and measurement of software safety are not yet available. Some past software failures, future NASA software trends, software engineering methods, and tools and techniques for various software safety analyses are reviewed. Recommendations to NASA are made based on this review.

A Study of the System Safety Concept as it Relates to the New Walter Reed Army Medical Center, Washington, DC.

DTIC Science & Technology

1978-03-31

established the safety level of the% * originally designed facility and the extent of current safety * modifications. The objectives evaluated the...Program could identify many safety hazards thus leading to design improvements. The study provided several recommendations to formalize the Systems Safety... design , construction, and proposed systems management of the new Walter Reed Army Medical Center (WRAMC), Washington, D.C., was conducted during the

Evaluation Of The Vehicle Radar Safety Systems Rashid Radar Safety Brake Collision Warning System, Final Report

DOT National Transportation Integrated Search

1988-02-01

THIS EVALUATION OF THE VEHICLE RADAR SAFETY SYSTEMS? ANTI-COLLISION DEVICE (HEREAFTER VRSS) WAS UNDERTAKEN BY THE OPERATOR PERFORMANCE AND SAFETY ANALYSIS DIVISION OF THE TRANSPORTATION SYSTEMS CENTER AT THE REQUEST OF THE NATIONAL HIGHWAY TRAFFIC SA...

[New international initiatives to create systems of effective risk prediction and food safety].

PubMed

Efimochkinal, N R; Bagryantseva, E C; Dupouy, E C; Khotimchenko, S A; Permyakov, E V; Sheveleva, S A; Arnautov, O V

2016-01-01

Ensuring food safety is one of the most important problems that is directly related to health protection of the population. The problem is particularly relevant on aglobalscale because ofincreasingnumberoffood-borne diseases andimportance of the health consequence early detection. In accordance with the position of the Codex Alimentarius Commission, food safety concept also includes quality. In this case, creation of the national, supranational and international early warning systems related to the food safety, designed with the purpose to prevent or minimize risks on different stages of the food value chain in various countries, regions and climate zones specific to national nutrition and lifestyle in different groups of population, gains particular importance. The article describes the principles and working examples of international, supranational and national food safety early warning systems. Great importance is given to the hazards of microbial origin - emergent pathogens. Example of the rapid reaction to the appearance of cases, related to the melanin presence in infant formula, are presented. Analysis of the current food safety and quality control system in Russian Federation shows that main improvements are mostly related to the development of the efficient monitoring, diagnostics and rapid alert procedures forfood safety on interregional and international levels that will allow to estimate real contamination of food with the most dangerous pathogens, chemical and biological contaminants, and the development of the electronic database and scientifically proved algorithms for food safety and quality management for targeted prevention activities against existing and emerging microbiological and other etiology risks, and public health protection.

49 CFR 659.25 - Annual review of system safety program plan and system security plan.

Code of Federal Regulations, 2010 CFR

2010-10-01

... system security plan. 659.25 Section 659.25 Transportation Other Regulations Relating to Transportation... and system security plan. (a) The oversight agency shall require the rail transit agency to conduct an annual review of its system safety program plan and system security plan. (b) In the event the rail...

Manned space flight nuclear system safety. Volume 4: Space shuttle nuclear system transportation. Part 1: Space shuttle nuclear safety

NASA Technical Reports Server (NTRS)

1972-01-01

An analysis of the nuclear safety aspects (design and operational considerations) in the transport of nuclear payloads to and from earth orbit by the space shuttle is presented. Three representative nuclear payloads used in the study were: (1) the zirconium hydride reactor Brayton power module, (2) the large isotope Brayton power system and (3) small isotopic heat sources which can be a part of an upper stage or part of a logistics module. Reference data on the space shuttle and nuclear payloads are presented in an appendix. Safety oriented design and operational requirements were identified to integrate the nuclear payloads in the shuttle mission. Contingency situations were discussed and operations and design features were recommended to minimize the nuclear hazards. The study indicates the safety, design and operational advantages in the use of a nuclear payload transfer module. The transfer module can provide many of the safety related support functions (blast and fragmentation protection, environmental control, payload ejection) minimizing the direct impact on the shuttle.

Patient Safety and the Malpractice System.

PubMed

Swift, James Q

2017-05-01

The cost of health care in the United States and malpractice insurance has escalated greatly over the past 30 years. In an ideal world, the goals of the tort system would be aligned with efforts at improving safety. In fact, there is little evidence that the tort system and the processes of risk management and informed consent have improved patient safety. This article explores the disunion between patient safety and the malpractice system. Copyright © 2016 Elsevier Inc. All rights reserved.

Hospital nurses' working conditions in relation to motivation and patient safety.

PubMed

Toode, Kristi; Routasalo, Pirkko; Helminen, Mika; Suominen, Tarja

2015-03-01

There is a lack of empirical knowledge about nurses' perceptions of their workplace characteristics and conditions, such as level of autonomy and decision authority, work climate, teamwork, skill exploitation and learning opportunities, and their work motivation in relation to practice outputs such as patient safety. Such knowledge is needed particularly in countries, such as Estonia, where hospital systems for preventing errors and improving patient safety are in the early stages of development. This article reports the findings from a cross-sectional survey of hospital nurses in Estonia that was aimed at determining their perceptions of workplace characteristics, working conditions, work motivation and patient safety, and at exploring the relationship between these. Results suggest that perceptions of personal control over their work can affect nurses' motivation, and that perceptions of work satisfaction might be relevant to patient safety improvement work.

Commonalities and Differences in Functional Safety Systems Between ISS Payloads and Industrial Applications

NASA Astrophysics Data System (ADS)

Malyshev, Mikhail; Kreimer, Johannes

2013-09-01

Safety analyses for electrical, electronic and/or programmable electronic (E/E/EP) safety-related systems used in payload applications on-board the International Space Station (ISS) are often based on failure modes, effects and criticality analysis (FMECA). For industrial applications of E/E/EP safety-related systems, comparable strategies exist and are defined in the IEC-61508 standard. This standard defines some quantitative criteria based on potential failure modes (for example, Safe Failure Fraction). These criteria can be calculated for an E/E/EP system or components to assess their compliance to requirements of a particular Safety Integrity Level (SIL). The standard defines several SILs depending on how much risk has to be mitigated by a safety-critical system. When a FMECA is available for an ISS payload or its subsystem, it may be possible to calculate the same or similar parameters as defined in the 61508 standard. One example of a payload that has a dedicated functional safety subsystem is the Electromagnetic Levitator (EML). This payload for the ISS is planned to be operated on-board starting 2014. The EML is a high-temperature materials processing facility. The dedicated subsystem "Hazard Control Electronics" (HCE) is implemented to ensure compliance to failure tolerance in limiting samples processing parameters to maintain generation of the potentially toxic by-products to safe limits in line with the requirements applied to the payloads by the ISS Program. The objective of this paper is to assess the implementation of the HCE in the EML against criteria for functional safety systems in the IEC-61508 standard and to evaluate commonalities and differences with respect to safety requirements levied on ISS Payloads. An attempt is made to assess a possibility of using commercially available components and systems certified for compliance to industrial functional safety standards in ISS payloads.

Safer Systems: A NextGen Aviation Safety Strategic Goal

NASA Technical Reports Server (NTRS)

Darr, Stephen T.; Ricks, Wendell R.; Lemos, Katherine A.

2008-01-01

The Joint Planning and Development Office (JPDO), is charged by Congress with developing the concepts and plans for the Next Generation Air Transportation System (NextGen). The National Aviation Safety Strategic Plan (NASSP), developed by the Safety Working Group of the JPDO, focuses on establishing the goals, objectives, and strategies needed to realize the safety objectives of the NextGen Integrated Plan. The three goal areas of the NASSP are Safer Practices, Safer Systems, and Safer Worldwide. Safer Practices emphasizes an integrated, systematic approach to safety risk management through implementation of formalized Safety Management Systems (SMS) that incorporate safety data analysis processes, and the enhancement of methods for ensuring safety is an inherent characteristic of NextGen. Safer Systems emphasizes implementation of safety-enhancing technologies, which will improve safety for human-centered interfaces and enhance the safety of airborne and ground-based systems. Safer Worldwide encourages coordinating the adoption of the safer practices and safer systems technologies, policies and procedures worldwide, such that the maximum level of safety is achieved across air transportation system boundaries. This paper introduces the NASSP and its development, and focuses on the Safer Systems elements of the NASSP, which incorporates three objectives for NextGen systems: 1) provide risk reducing system interfaces, 2) provide safety enhancements for airborne systems, and 3) provide safety enhancements for ground-based systems. The goal of this paper is to expose avionics and air traffic management system developers to NASSP objectives and Safer Systems strategies.

Transportation systems safety hazard analysis tool (SafetyHAT) user guide (version 1.0)

DOT National Transportation Integrated Search

2014-03-24

This is a user guide for the transportation system Safety Hazard Analysis Tool (SafetyHAT) Version 1.0. SafetyHAT is a software tool that facilitates System Theoretic Process Analysis (STPA.) This user guide provides instructions on how to download, ...

Performance of food safety management systems in poultry meat preparation processing plants in relation to Campylobacter spp. contamination.

PubMed

Sampers, Imca; Jacxsens, Liesbeth; Luning, Pieternel A; Marcelis, Willem J; Dumoulin, Ann; Uyttendaele, Mieke

2010-08-01

A diagnostic instrument comprising a combined assessment of core control and assurance activities and a microbial assessment instrument were used to measure the performance of current food safety management systems (FSMSs) of two poultry meat preparation companies. The high risk status of the company's contextual factors, i.e., starting from raw materials (poultry carcasses) with possible high numbers and prevalence of pathogens such as Campylobacter spp., requires advanced core control and assurance activities in the FSMS to guarantee food safety. The level of the core FSMS activities differed between the companies, and this difference was reflected in overall microbial quality (mesophilic aerobic count), presence of hygiene indicators (Enterobacteriaceae, Staphylococcus aureus, and Escherichia coli), and contamination with pathogens such as Salmonella, Listeria monocytogenes, and Campylobacter spp. The food safety output expressed as a microbial safety profile was related to the variability in the prevalence and contamination levels of Campylobacter spp. in poultry meat preparations found in a Belgian nationwide study. Although a poultry meat processing company could have an advanced FSMS in place and a good microbial profile (i.e., lower prevalence of pathogens, lower microbial numbers, and less variability in microbial contamination), these positive factors might not guarantee pathogen-free products. Contamination could be attributed to the inability to apply effective interventions to reduce or eliminate pathogens in the production chain of (raw) poultry meat preparations.

Safety features of subcritical fluid fueled systems

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

Bell, C.R.

1995-10-01

Accelerator-driven transmutation technology has been under study at Los Alamos for several years for application to nuclear waste treatment, tritium production, energy generation, and recently, to the disposition of excess weapons plutonium. Studies and evaluations performed to date at Los Alamos have led to a current focus on a fluid-fuel, fission system operating in a neutron source-supported subcritical mode, using molten salt reactor technology and accelerator-driven proton-neutron spallation. In this paper, the safety features and characteristics of such systems are explored from the perspective of the fundamental nuclear safety objectives that any reactor-type system should address. This exploration is qualitativemore » in nature and uses current vintage solid-fueled reactors as a baseline for comparison. Based on the safety perspectives presented, such systems should be capable of meeting the fundamental nuclear safety objectives. In addition, they should be able to provide the safety robustness desired for advanced reactors. However, the manner in which safety objectives and robustness are achieved is very different from that associated with conventional reactors. Also, there are a number of safety design and operational challenges that will have to be addressed for the safety potential of such systems to be credible.« less

49 CFR Appendix C to Part 238 - Suspension System Safety Performance Standards

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 4 2010-10-01 2010-10-01 false Suspension System Safety Performance Standards C Appendix C to Part 238 Transportation Other Regulations Relating to Transportation (Continued) FEDERAL RAILROAD ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PASSENGER EQUIPMENT SAFETY STANDARDS Pt. 238, App. C...

Vaccine safety monitoring systems in developing countries: an example of the Vietnam model.

PubMed

Ali, Mohammad; Rath, Barbara; Thiem, Vu Dinh

2015-01-01

Only few health intervention programs have been as successful as vaccination programs with respect to preventing morbidity and mortality in developing countries. However, the success of a vaccination program is threatened by rumors and misunderstanding about the risks of vaccines. It is short-sighted to plan the introduction of vaccines into developing countries unless effective vaccine safety monitoring systems are in place. Such systems that track adverse events following immunization (AEFI) is currently lacking in most developing countries. Therefore, any rumor may affect the entire vaccination program. Public health authorities should implement the safety monitoring system of vaccines, and disseminate safety issues in a proactive mode. Effective safety surveillance systems should allow for the conduct of both traditional and alternative epidemiologic studies through the use of prospective data sets. The vaccine safety data link implemented in Vietnam in mid-2002 indicates that it is feasible to establish a vaccine safety monitoring system for the communication of vaccine safety in developing countries. The data link provided the investigators an opportunity to evaluate AEFI related to measles vaccine. Implementing such vaccine safety monitoring system is useful in all developing countries. The system should be able to make objective and clear communication regarding safety issues of vaccines, and the data should be reported to the public on a regular basis for maintaining their confidence in vaccination programs.

46 CFR 62.25-15 - Safety control systems.

Code of Federal Regulations, 2011 CFR

2011-10-01

....35-50. Note: Safety control systems include automatic and manual safety trip controls and automatic... engines. (e) Automatic safety trip control systems must— (1) Be provided where there is an immediate... 46 Shipping 2 2011-10-01 2011-10-01 false Safety control systems. 62.25-15 Section 62.25-15...

Certification Strategies using Run-Time Safety Assurance for Part 23 Autopilot Systems

NASA Technical Reports Server (NTRS)

Hook, Loyd R.; Clark, Matthew; Sizoo, David; Skoog, Mark A.; Brady, James

2016-01-01

Part 23 aircraft operation, and in particular general aviation, is relatively unsafe when compared to other common forms of vehicle travel. Currently, there exists technologies that could increase safety statistics for these aircraft; however, the high burden and cost of performing the requisite safety critical certification processes for these systems limits their proliferation. For this reason, many entities, including the Federal Aviation Administration, NASA, and the US Air Force, are considering new options for certification for technologies that will improve aircraft safety. Of particular interest, are low cost autopilot systems for general aviation aircraft, as these systems have the potential to positively and significantly affect safety statistics. This paper proposes new systems and techniques, leveraging run-time verification, for the assurance of general aviation autopilot systems, which would be used to supplement the current certification process and provide a viable path for near-term low-cost implementation. In addition, discussions on preliminary experimentation and building the assurance case for a system, based on these principles, is provided.

Effects and Satisfaction of Medical Device Safety Information Reporting System Using Electronic Medical Record.

PubMed

Jang, Hye Jung; Choi, Young Deuk; Kim, Nam Hyun

2017-04-01

This paper describes an evaluation study on the effectiveness of developing an in-hospital medical device safety information reporting system for managing safety information, including adverse incident data related to medical devices, following the enactment of the Medical Device Act in Korea. Medical device safety information reports were analyzed for 190 cases that took place prior to the application of a medical device safety information reporting system and during a period when the reporting system was used. Also, questionnaires were used to measure the effectiveness of the medical device safety information reporting system. The analysis was based on the questionnaire responses of 15 reporters who submitted reports in both the pre- and post-reporting system periods. Sixty-two reports were submitted in paper form, but after the system was set up, this number more than doubled to 128 reports in electronic form. In terms of itemized reporting, a total of 45 items were reported. Before the system was used, 23 items had been reported, but this increased to 32 items after the system was put to use. All survey variables of satisfaction received a mean of over 3 points, while positive attitude , potential benefits , and positive benefits all exceeded 4 points, each receiving 4.20, 4.20, and 4.13, respectively. Among the variables, time-consuming and decision-making had the lowest mean values, each receiving 3.53. Satisfaction was found to be high for system quality and user satisfaction , but relatively low for time-consuming and decision-making . We were able to verify that effective reporting and monitoring of adverse incidents and the safety of medical devices can be implemented through the establishment of an in-hospital medical device safety information reporting system that can enhance patient safety and medical device risk management.

Occupational Safety and Health System for Workers Engaged in Emergency Response Operations in the USA.

PubMed

Toyoda, Hiroyuki; Kubo, Tatsuhiko; Mori, Koji

2016-12-03

To study the occupational safety and health systems used for emergency response workers in the USA, we performed interviews with related federal agencies and conducted research on related studies. We visited the Federal Emergency Management Agency (FEMA) and National Institute for Occupational Safety and Health (NIOSH) in the USA and performed interviews with their managers on the agencies' roles in the national emergency response system. We also obtained information prepared for our visit from the USA's Occupational Safety and Health Administration (OSHA). In addition, we conducted research on related studies and information on the website of the agencies. We found that the USA had an established emergency response system based on their National Incident Management System (NIMS). This enabled several organizations to respond to emergencies cooperatively using a National Response Framework (NRF) that clarifies the roles and cooperative functions of each federal agency. The core system in NIMS was the Incident Command System (ICS), within which a Safety Officer was positioned as one of the command staff supporting the commander. All ICS staff were required to complete a training program specific to their position; in addition, the Safety Officer was required to have experience. The All-Hazards model was commonly used in the emergency response system. We found that FEMA coordinated support functions, and OSHA and NIOSH, which had specific functions to protect workers, worked cooperatively under NRF. These agencies employed certified industrial hygienists that play a professional role in safety and health. NIOSH recently executed support activities during disasters and other emergencies. The USA's emergency response system is characterized by functions that protect the lives and health of emergency response workers. Trained and experienced human resources support system effectiveness. The findings provided valuable information that could be used to improve the

Are health professionals' perceptions of patient safety related to figures on safety incidents?

PubMed

Martijn, Lucie; Harmsen, Mirjam; Gaal, Sander; Mettes, Dirk; van Dulmen, Simone; Wensing, Michel

2013-10-01

The study aims to explore whether health care professionals' perceptions of patient safety in their practice were associated with the number of patient safety incidents identified in patient records. Seventy primary care practices of general practice, general dental practice, midwifery practices and allied health care practices were used in the study. A retrospective audit of 50 patient records was performed to identify patient safety incidents in each of the practices and a survey among health professionals to identify their perceptions of patient safety. All health professions felt that 'communication breakdowns inside the practice' as well as 'communication breakdowns outside the practice' and 'reporting of patient safety concerns' were a threat to patient safety in their work setting. We found little association between the perceptions of health professionals and the number of safety incidents. The only item with a significant relation to a higher number of safety incidents referred to the perception of 'communication problems outside the practice' as a threat to patient safety. This study indicates that the assessment of professionals' perceptions may be complementary to observed safety incidents, but not linked to an objective measure of patient safety. © 2012 John Wiley & Sons Ltd.

Design an optimum safety policy for personnel safety management - A system dynamic approach

NASA Astrophysics Data System (ADS)

Balaji, P.

2014-10-01

Personnel safety management (PSM) ensures that employee's work conditions are healthy and safe by various proactive and reactive approaches. Nowadays it is a complex phenomenon because of increasing dynamic nature of organisations which results in an increase of accidents. An important part of accident prevention is to understand the existing system properly and make safety strategies for that system. System dynamics modelling appears to be an appropriate methodology to explore and make strategy for PSM. Many system dynamics models of industrial systems have been built entirely for specific host firms. This thesis illustrates an alternative approach. The generic system dynamics model of Personnel safety management was developed and tested in a host firm. The model was undergone various structural, behavioural and policy tests. The utility and effectiveness of model was further explored through modelling a safety scenario. In order to create effective safety policy under resource constraint, DOE (Design of experiment) was used. DOE uses classic designs, namely, fractional factorials and central composite designs. It used to make second order regression equation which serve as an objective function. That function was optimized under budget constraint and optimum value used for safety policy which shown greatest improvement in overall PSM. The outcome of this research indicates that personnel safety management model has the capability for acting as instruction tool to improve understanding of safety management and also as an aid to policy making.

Design an optimum safety policy for personnel safety management - A system dynamic approach

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

Balaji, P.

2014-10-06

Personnel safety management (PSM) ensures that employee's work conditions are healthy and safe by various proactive and reactive approaches. Nowadays it is a complex phenomenon because of increasing dynamic nature of organisations which results in an increase of accidents. An important part of accident prevention is to understand the existing system properly and make safety strategies for that system. System dynamics modelling appears to be an appropriate methodology to explore and make strategy for PSM. Many system dynamics models of industrial systems have been built entirely for specific host firms. This thesis illustrates an alternative approach. The generic system dynamicsmore » model of Personnel safety management was developed and tested in a host firm. The model was undergone various structural, behavioural and policy tests. The utility and effectiveness of model was further explored through modelling a safety scenario. In order to create effective safety policy under resource constraint, DOE (Design of experiment) was used. DOE uses classic designs, namely, fractional factorials and central composite designs. It used to make second order regression equation which serve as an objective function. That function was optimized under budget constraint and optimum value used for safety policy which shown greatest improvement in overall PSM. The outcome of this research indicates that personnel safety management model has the capability for acting as instruction tool to improve understanding of safety management and also as an aid to policy making.« less

Autonomous Flight Safety System

NASA Technical Reports Server (NTRS)

Simpson, James

2010-01-01

The Autonomous Flight Safety System (AFSS) is an independent self-contained subsystem mounted onboard a launch vehicle. AFSS has been developed by and is owned by the US Government. Autonomously makes flight termination/destruct decisions using configurable software-based rules implemented on redundant flight processors using data from redundant GPS/IMU navigation sensors. AFSS implements rules determined by the appropriate Range Safety officials.

Electronic clinical safety reporting system: a benefits evaluation.

PubMed

Elliott, Pamela; Martin, Desmond; Neville, Doreen

2014-06-11

, accessibility, and consistency. The implementation process encountered challenges related to customizing the software and the development of the classification system for coding occurrences. This impacted on the ability of the managers to close-out files in a timely fashion. The issues that were identified, and suggestions for improvements to the form itself, were shared with the Project Team as soon as they were noted. Changes were made to the system before the rollout. There were many benefits realized from the new system that can contribute to improved clinical safety. The participants preferred the electronic system over the paper-based system. The lessons learned during the implementation process resulted in recommendations that informed the rollout of the system in Eastern Health, and in other health care organizations in the province of Newfoundland and Labrador. This study also informed the evaluation of other health organizations in the province, which was completed in 2013.

System Safety in Aircraft Acquisition

DTIC Science & Technology

1984-01-01

Relationship Between JSSC and SOHP ..... .......... 6- 1 Some Similarities in the Departments’ Approaches to System Safety... RELATIONSHIP BETWEEN JSSC AND SOHP The annual JSSC sponsored by the safety centers coordinates safety activities. It was described recently as "an unchartered...developed an excellent working relationship . Re- presentatives from SOHP can and do influence tasks undertaken by JSSC. Con- versely, SOUP is the one

System safety education focused on system management

NASA Technical Reports Server (NTRS)

Grose, V. L.

1971-01-01

System safety is defined and characteristics of the system are outlined. Some of the principle characteristics include role of humans in hazard analysis, clear language for input and output, system interdependence, self containment, and parallel analysis of elements.

76 FR 14592 - Safety Management System; Withdrawal

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-17

...-06A] RIN 2120-AJ15 Safety Management System; Withdrawal AGENCY: Federal Aviation Administration (FAA... (``product/ service providers'') to develop a Safety Management System (SMS). The FAA is withdrawing the... management with a set of robust decision-making tools to use to improve safety. The FAA received 89 comments...

Database management systems for process safety.

PubMed

Early, William F

2006-03-17

Several elements of the process safety management regulation (PSM) require tracking and documentation of actions; process hazard analyses, management of change, process safety information, operating procedures, training, contractor safety programs, pre-startup safety reviews, incident investigations, emergency planning, and compliance audits. These elements can result in hundreds of actions annually that require actions. This tracking and documentation commonly is a failing identified in compliance audits, and is difficult to manage through action lists, spreadsheets, or other tools that are comfortably manipulated by plant personnel. This paper discusses the recent implementation of a database management system at a chemical plant and chronicles the improvements accomplished through the introduction of a customized system. The system as implemented modeled the normal plant workflows, and provided simple, recognizable user interfaces for ease of use.

System safety management lessons learned from the US Army acquisition process

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

Piatt, J.A.

1989-05-01

The Assistant Secretary of the Army for Research, Development and Acquisition directed the Army Safety Center to provide an audit of the causes of accidents and safety of use restrictions on recently fielded systems by tracking residual hazards back through the acquisition process. The objective was to develop lessons learned'' that could be applied to the acquisition process to minimize mishaps in fielded systems. System safety management lessons learned are defined as Army practices or policies, derived from past successes and failures, that are expected to be effective in eliminating or reducing specific systemic causes of residual hazards. They aremore » broadly applicable and supportive of the Army structure and acquisition objectives. Pacific Northwest Laboratory (PNL) was given the task of conducting an independent, objective appraisal of the Army's system safety program in the context of the Army materiel acquisition process by focusing on four fielded systems which are products of that process. These systems included the Apache helicopter, the Bradley Fighting Vehicle (BFV), the Tube Launched, Optically Tracked, Wire Guided (TOW) Missile and the High Mobility Multipurpose Wheeled Vehicle (HMMWV). The objective of this study was to develop system safety management lessons learned associated with the acquisition process. The first step was to identify residual hazards associated with the selected systems. Since it was impossible to track all residual hazards through the acquisition process, certain well-known, high visibility hazards were selected for detailed tracking. These residual hazards illustrate a variety of systemic problems. Systemic or process causes were identified for each residual hazard and analyzed to determine why they exist. System safety management lessons learned were developed to address related systemic causal factors. 29 refs., 5 figs.« less

Commercial grade item (CGI) dedication of MDR relays for nuclear safety related applications

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

Das, R.K.; Julka, A.; Modi, G.

1994-08-01

MDR relays manufactured by Potter and Brumfield (P and B) have been used in various safety related applications in commercial nuclear power plants. These include emergency safety features (ESF) actuation systems, emergency core cooling systems (ECCS) actuation, and reactor protection systems. The MDR relays manufactured prior to May 1990 showed signs of generic failure due to corrosion and outgassing of coil varnish. P and B has made design changes to correct these problems in relays manufactured after May 1990. However, P and B does not manufacture the relays under any 10CFR50 Appendix B quality assurance (QA) program. They manufacture themore » relays under their commercial QA program and supply these as commercial grade items. This necessitates CGI Dedication of these relays for use in nuclear-safety-related applications. This paper presents a CGI dedication program that has been used to dedicate the MDR relays manufactured after May 1990. The program is in compliance with current Nuclear Regulatory Commission (NRC) and Electric Power Research Institute (EPRI) guidelines and applicable industry standards; it specifies the critical characteristics of the relays, provides the tests and analysis required to verify the critical characteristics, the acceptance criteria for the test results, performs source verification to qualify P and B for its control of the critical characteristics, and provides documentation. The program provides reasonable assurance that the new MDR relays will perform their intended safety functions.« less

Safety analysis and review system (SARS) assessment report

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

Browne, E.T.

1981-03-01

Under DOE Order 5481.1, Safety Analysis and Review System for DOE Operations, safety analyses are required for DOE projects in order to ensure that: (1) potential hazards are systematically identified; (2) potential impacts are analyzed; (3) reasonable measures have been taken to eliminate, control, or mitigate the hazards; and (4) there is documented management authorization of the DOE operation based on an objective assessment of the adequacy of the safety analysis. This report is intended to provide the DOE Office of Plans and Technology Assessment (OPTA) with an independent evaluation of the adequacy of the ongoing safety analysis effort. Asmore » part of this effort, a number of site visits and interviews were conducted, and FE SARS documents were reviewed. The latter included SARS Implementation Plans for a number of FE field offices, as well as safety analysis reports completed for certain FE operations. This report summarizes SARS related efforts at the DOE field offices visited and evaluates the extent to which they fulfill the requirements of DOE 5481.1.« less

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 7 2012-10-01 2012-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 7 2011-10-01 2011-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 7 2013-10-01 2013-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 7 2014-10-01 2014-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 7 2010-10-01 2010-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

Safety climate and culture: Integrating psychological and systems perspectives.

PubMed

Casey, Tristan; Griffin, Mark A; Flatau Harrison, Huw; Neal, Andrew

2017-07-01

Safety climate research has reached a mature stage of development, with a number of meta-analyses demonstrating the link between safety climate and safety outcomes. More recently, there has been interest from systems theorists in integrating the concept of safety culture and to a lesser extent, safety climate into systems-based models of organizational safety. Such models represent a theoretical and practical development of the safety climate concept by positioning climate as part of a dynamic work system in which perceptions of safety act to constrain and shape employee behavior. We propose safety climate and safety culture constitute part of the enabling capitals through which organizations build safety capability. We discuss how organizations can deploy different configurations of enabling capital to exert control over work systems and maintain safe and productive performance. We outline 4 key strategies through which organizations to reconcile the system control problems of promotion versus prevention, and stability versus flexibility. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Health and safety management systems: liability or asset?

PubMed

Bennett, David

2002-01-01

Health and safety management systems have a background in theory and in various interests among employers and workplace health and safety professionals. These have resulted in a number of national systems emanating from national standard-writing centres and from employers' organizations. In some cases these systems have been recognized as national standards. The contenders for an international standard have been the International Organization of Standardization (ISO) and the International Labour Organization (ILO). The quality and environmental management systems of ISO indicate what an ISO health and safety management standard would look like. The ILO Guidelines on Safety and Health Management Systems, by contrast, are stringent, specific and potentially effective in improving health and safety performance in the workplace.

Defining and classifying medical error: lessons for patient safety reporting systems.

PubMed

Tamuz, M; Thomas, E J; Franchois, K E

2004-02-01

It is important for healthcare providers to report safety related events, but little attention has been paid to how the definition and classification of events affects a hospital's ability to learn from its experience. To examine how the definition and classification of safety related events influences key organizational routines for gathering information, allocating incentives, and analyzing event reporting data. In semi-structured interviews, professional staff and administrators in a tertiary care teaching hospital and its pharmacy were asked to describe the existing programs designed to monitor medication safety, including the reporting systems. With a focus primarily on the pharmacy staff, interviews were audio recorded, transcribed, and analyzed using qualitative research methods. Eighty six interviews were conducted, including 36 in the hospital pharmacy. Examples are presented which show that: (1) the definition of an event could lead to under-reporting; (2) the classification of a medication error into alternative categories can influence the perceived incentives and disincentives for incident reporting; (3) event classification can enhance or impede organizational routines for data analysis and learning; and (4) routines that promote organizational learning within the pharmacy can reduce the flow of medication error data to the hospital. These findings from one hospital raise important practical and research questions about how reporting systems are influenced by the definition and classification of safety related events. By understanding more clearly how hospitals define and classify their experience, we may improve our capacity to learn and ultimately improve patient safety.

Quantitative safety assessment of air traffic control systems through system control capacity

NASA Astrophysics Data System (ADS)

Guo, Jingjing

Quantitative Safety Assessments (QSA) are essential to safety benefit verification and regulations of developmental changes in safety critical systems like the Air Traffic Control (ATC) systems. Effectiveness of the assessments is particularly desirable today in the safe implementations of revolutionary ATC overhauls like NextGen and SESAR. QSA of ATC systems are however challenged by system complexity and lack of accident data. Extending from the idea "safety is a control problem" in the literature, this research proposes to assess system safety from the control perspective, through quantifying a system's "control capacity". A system's safety performance correlates to this "control capacity" in the control of "safety critical processes". To examine this idea in QSA of the ATC systems, a Control-capacity Based Safety Assessment Framework (CBSAF) is developed which includes two control capacity metrics and a procedural method. The two metrics are Probabilistic System Control-capacity (PSC) and Temporal System Control-capacity (TSC); each addresses an aspect of a system's control capacity. And the procedural method consists three general stages: I) identification of safety critical processes, II) development of system control models and III) evaluation of system control capacity. The CBSAF was tested in two case studies. The first one assesses an en-route collision avoidance scenario and compares three hypothetical configurations. The CBSAF was able to capture the uncoordinated behavior between two means of control, as was observed in a historic midair collision accident. The second case study compares CBSAF with an existing risk based QSA method in assessing the safety benefits of introducing a runway incursion alert system. Similar conclusions are reached between the two methods, while the CBSAF has the advantage of simplicity and provides a new control-based perspective and interpretation to the assessments. The case studies are intended to investigate the

49 CFR 659.15 - System safety program standard.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 7 2010-10-01 2010-10-01 false System safety program standard. 659.15 Section 659... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.15 System safety program standard. (a) General requirement. Each state...

Clinical Evaluation of a Safety-device to Prevent Urinary Catheter Inflation Related Injuries.

PubMed

Davis, Niall F; Cunnane, Eoghan M; Mooney, Rory O'C; Forde, James C; Walsh, Michael T

2018-05-01

To evaluate the feasibility of a novel "safety-valve" device for preventing catheter related urethral trauma during urethral catheterization (UC). To assess the opinions of clinicians on the performance of the safety-valve device. A validated prototype "safety-valve" device for preventing catheter balloon inflation related urethral injuries was prospectively piloted in male patients requiring UC in a tertiary referral teaching hospital (n = 100). The device allows fluid in the catheter system to decant through an activated safety threshold pressure valve if the catheter anchoring balloon is misplaced. Users evaluated the "safety-valve" with an anonymous questionnaire. The primary outcome measurement was prevention of anchoring balloon inflation in the urethra. Secondary outcome measurement was successful inflation of urinary catheter anchoring balloon in the bladder. Patient age was 76 ± 12 years and American Society of Anaesthesiologists grade was 3 ± 1.4. The "safety-valve" was utilized by 34 clinicians and activated in 7% (n = 7/100) patients during attempted UC, indicating that the catheter anchoring balloon was incorrectly positioned in the patient's urethra. In these 7 cases, the catheter was successfully manipulated into the urinary bladder and inflated. 31 of 34 (91%) clinicians completed the questionnaire. Ten percent (n = 3/31) of respondents had previously inflated a urinary catheter anchoring balloon in the urethra and 100% (n = 31) felt that a safety mechanism for preventing balloon inflation in the urethra should be compulsory for all UCs. The safety-valve device piloted in this clinical study offers an effective solution for preventing catheter balloon inflation related urethral injuries. Copyright © 2018 Elsevier Inc. All rights reserved.

Cabin Safety Issues Related to Pre-Departure and Inflight Issues

NASA Technical Reports Server (NTRS)

Connell, Linda

2014-01-01

The Aviation Safety Reporting System (ASRS) in a partnership between the National Aeronautics and Space Administration (NASA), the Federal Aviation Administration (FAA), participating carriers, and labor organizations. It is designed to improve the National Airspace System by collecting and studying reports detailing unsafe conditions and events in the aviation industry. Employees are able to report safety issues or concerns with confidentiality and without fear of discipline. Safety reports highlighting the human element in cabin safety issues and concerns.

Assessing the safety effects of cooperative intelligent transport systems: A bowtie analysis approach.

PubMed

Ehlers, Ute Christine; Ryeng, Eirin Olaussen; McCormack, Edward; Khan, Faisal; Ehlers, Sören

2017-02-01

The safety effects of cooperative intelligent transport systems (C-ITS) are mostly unknown and associated with uncertainties, because these systems represent emerging technology. This study proposes a bowtie analysis as a conceptual framework for evaluating the safety effect of cooperative intelligent transport systems. These seek to prevent road traffic accidents or mitigate their consequences. Under the assumption of the potential occurrence of a particular single vehicle accident, three case studies demonstrate the application of the bowtie analysis approach in road traffic safety. The approach utilizes exemplary expert estimates and knowledge from literature on the probability of the occurrence of accident risk factors and of the success of safety measures. Fuzzy set theory is applied to handle uncertainty in expert knowledge. Based on this approach, a useful tool is developed to estimate the effects of safety-related cooperative intelligent transport systems in terms of the expected change in accident occurrence and consequence probability. Copyright © 2016 Elsevier Ltd. All rights reserved.

46 CFR 62.25-15 - Safety control systems.

Code of Federal Regulations, 2012 CFR

2012-10-01

... manual safety trip controls must be provided for all main boilers, turbines, and internal combustion... 46 Shipping 2 2012-10-01 2012-10-01 false Safety control systems. 62.25-15 Section 62.25-15... AUTOMATION General Requirements for All Automated Vital Systems § 62.25-15 Safety control systems. (a...

46 CFR 62.25-15 - Safety control systems.

Code of Federal Regulations, 2013 CFR

2013-10-01

... manual safety trip controls must be provided for all main boilers, turbines, and internal combustion... 46 Shipping 2 2013-10-01 2013-10-01 false Safety control systems. 62.25-15 Section 62.25-15... AUTOMATION General Requirements for All Automated Vital Systems § 62.25-15 Safety control systems. (a...

46 CFR 62.25-15 - Safety control systems.

Code of Federal Regulations, 2014 CFR

2014-10-01

... manual safety trip controls must be provided for all main boilers, turbines, and internal combustion... 46 Shipping 2 2014-10-01 2014-10-01 false Safety control systems. 62.25-15 Section 62.25-15... AUTOMATION General Requirements for All Automated Vital Systems § 62.25-15 Safety control systems. (a...

An assessment of traffic safety culture related to engagement efforts to improve traffic safety : research programs.

DOT National Transportation Integrated Search

2016-12-01

The Center for Health and Safety Culture at Montana State University developed a survey to investigate the traffic safety culture related to engagement in traffic safety citizenship behaviors. The development of the survey was based on an augmented f...

Mine safety assessment using gray relational analysis and bow tie model

PubMed Central

2018-01-01

Mine safety assessment is a precondition for ensuring orderly and safety in production. The main purpose of this study was to prevent mine accidents more effectively by proposing a composite risk analysis model. First, the weights of the assessment indicators were determined by the revised integrated weight method, in which the objective weights were determined by a variation coefficient method and the subjective weights determined by the Delphi method. A new formula was then adopted to calculate the integrated weights based on the subjective and objective weights. Second, after the assessment indicator weights were determined, gray relational analysis was used to evaluate the safety of mine enterprises. Mine enterprise safety was ranked according to the gray relational degree, and weak links of mine safety practices identified based on gray relational analysis. Third, to validate the revised integrated weight method adopted in the process of gray relational analysis, the fuzzy evaluation method was used to the safety assessment of mine enterprises. Fourth, for first time, bow tie model was adopted to identify the causes and consequences of weak links and allow corresponding safety measures to be taken to guarantee the mine’s safe production. A case study of mine safety assessment was presented to demonstrate the effectiveness and rationality of the proposed composite risk analysis model, which can be applied to other related industries for safety evaluation. PMID:29561875

Systems pharmacology augments drug safety surveillance

PubMed Central

Lorberbaum, Tal; Nasir, Mavra; Keiser, Michael J.; Vilar, Santiago; Hripcsak, George; Tatonetti, Nicholas P.

2014-01-01

Small molecule drugs are the foundation of modern medical practice yet their use is limited by the onset of unexpected and severe adverse events (AEs). Regulatory agencies rely on post-marketing surveillance to monitor safety once drugs are approved for clinical use. Despite advances in pharmacovigilance methods that address issues of confounding bias, clinical data of AEs are inherently noisy. Systems pharmacology– the integration of systems biology and chemical genomics – can illuminate drug mechanisms of action. We hypothesize that these data can improve drug safety surveillance by highlighting drugs with a mechanistic connection to the target phenotype (enriching true positives) and filtering those that do not (depleting false positives). We present an algorithm, the modular assembly of drug safety subnetworks (MADSS), to combine systems pharmacology and pharmacovigilance data and significantly improve drug safety monitoring for four clinically relevant adverse drug reactions. PMID:25670520

Food safety systems in a small dairy factory: implementation, major challenges, and assessment of systems' performances.

PubMed

Cusato, Sueli; Gameiro, Augusto H; Corassin, Carlos H; Sant'ana, Anderson S; Cruz, Adriano G; Faria, José de Assis F; de Oliveira, Carlos Augusto F

2013-01-01

The present study describes the implementation of a food safety system in a dairy processing plant located in the State of São Paulo, Brazil, and the challenges found during the process. In addition, microbiological indicators have been used to assess system's implementation performance. The steps involved in the implementation of a food safety system included a diagnosis of the prerequisites, implementation of the good manufacturing practices (GMPs), sanitation standard operating procedures (SSOPs), training of the food handlers, and hazard analysis and critical control point (HACCP). In the initial diagnosis, conformity with 70.7% (n=106) of the items analyzed was observed. A total of 12 critical control points (CCPs) were identified: (1) reception of the raw milk, (2) storage of the raw milk, (3 and 4) reception of the ingredients and packaging, (5) milk pasteurization, (6 and 7) fermentation and cooling, (8) addition of ingredients, (9) filling, (10) storage of the finished product, (11) dispatching of the product, and (12) sanitization of the equipment. After implementation of the food safety system, a significant reduction in the yeast and mold count was observed (p<0.05). The main difficulties encountered for the implementation of food safety system were related to the implementation of actions established in the flow chart and to the need for constant training/adherence of the workers to the system. Despite this, the implementation of the food safety system was shown to be challenging, but feasible to be reached by small-scale food industries.

Trinity cable safety system.

DOT National Transportation Integrated Search

2007-01-31

Cab1eSafety System (CASS).is being tested by the Oklahoma Department of Transportation (ODOT) along I-35 in McClain County. CASS will be compare with two other system approve by ODOT. Using C-shaped post tensioned cables, CASS is designed to...

49 CFR 385.715 - Duration of safety monitoring system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Duration of safety monitoring system. 385.715... SAFETY FITNESS PROCEDURES Safety Monitoring System for Non-North American Carriers § 385.715 Duration of safety monitoring system. (a) Each non-North America-domiciled carrier subject to this subpart will...

49 CFR 385.117 - Duration of safety monitoring system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 5 2010-10-01 2010-10-01 false Duration of safety monitoring system. 385.117... SAFETY FITNESS PROCEDURES Safety Monitoring System for Mexico-Domiciled Carriers § 385.117 Duration of safety monitoring system. (a) Each Mexico-domiciled carrier subject to this subpart will remain in the...

49 CFR 385.117 - Duration of safety monitoring system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Duration of safety monitoring system. 385.117... SAFETY FITNESS PROCEDURES Safety Monitoring System for Mexico-Domiciled Carriers § 385.117 Duration of safety monitoring system. (a) Each Mexico-domiciled carrier subject to this subpart will remain in the...

49 CFR 385.715 - Duration of safety monitoring system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 5 2010-10-01 2010-10-01 false Duration of safety monitoring system. 385.715... SAFETY FITNESS PROCEDURES Safety Monitoring System for Non-North American Carriers § 385.715 Duration of safety monitoring system. (a) Each non-North America-domiciled carrier subject to this subpart will...

Quality and Safety Implications of Emergency Department Information Systems

PubMed Central

Farley, Heather L.; Baumlin, Kevin M.; Hamedani, Azita G.; Cheung, Dickson S.; Edwards, Michael R.; Fuller, Drew C.; Genes, Nicholas; Griffey, Richard T.; Kelly, John J.; McClay, James C.; Nielson, Jeff; Phelan, Michael P.; Shapiro, Jason S.; Stone-Griffith, Suzanne; Pines, Jesse M.

2013-01-01

The Health Information Technology for Economic and Clinical Health Act of 2009 and the Centers for Medicare & Medicaid Services “meaningful use” incentive programs, in tandem with the boundless additional requirements for detailed reporting of quality metrics, have galvanized hospital efforts to implement hospital-based electronic health records. As such, emergency department information systems (EDISs) are an important and unique component of most hospitals’ electronic health records. System functionality varies greatly and affects physician decisionmaking, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety. This article is a joint effort by members of the Quality Improvement and Patient Safety Section and the Informatics Section of the American College of Emergency Physicians. The aim of this effort is to examine the benefits and potential threats to quality and patient safety that could result from the choice of a particular EDIS, its implementation and optimization, and the hospital’s or physician group’s approach to continuous improvement of the EDIS. Specifically, we explored the following areas of potential EDIS safety concerns: communication failure, wrong order–wrong patient errors, poor data display, and alert fatigue. Case studies are presented that illustrate the potential harm that could befall patients from an inferior EDIS product or suboptimal execution of such a product in the clinical environment. The authors have developed 7 recommendations to improve patient safety with respect to the deployment of EDISs. These include ensuring that emergency providers actively participate in selection of the EDIS product, in the design of processes related to EDIS implementation and optimization, and in the monitoring of the system’s ongoing success or failure. Our recommendations apply to emergency departments using any type of EDIS: custom-developed systems, best-of-breed vendor systems, or

Unintentional and undetermined firearm related deaths: a preventable death analysis for three safety devices.

PubMed

Vernick, J S; O'Brien, M; Hepburn, L M; Johnson, S B; Webster, D W; Hargarten, S W

2003-12-01

To determine the proportion of unintentional and undetermined firearm related deaths preventable by three safety devices: personalization devices, loaded chamber indicators (LCIs), and magazine safeties. A personalized gun will operate only for an authorized user, a LCI indicates when the gun contains ammunition, and a magazine safety prevents the gun from firing when the ammunition magazine is removed. Information about all unintentional and undetermined firearm deaths from 1991-98 was obtained from the Office of the Chief Medical Examiner for Maryland, and from the Wisconsin Firearm Injury Reporting System for Milwaukee. Data regarding the victim, shooter, weapon, and circumstances were abstracted. Coding rules to classify each death as preventable, possibly preventable, or not preventable by each of the three safety devices were also applied. There were a total of 117 firearm related deaths in our sample, 95 (81%) involving handguns. Forty three deaths (37%) were classified as preventable by a personalized gun, 23 (20%) by a LCI, and five (4%) by a magazine safety. Overall, 52 deaths (44%) were preventable by at least one safety device. Deaths involving children 0-17 (relative risk (RR) 3.3, 95% confidence interval (CI) 2.1 to 5.1) and handguns (RR 8.1, 95% CI 1.2 to 53.5) were more likely to be preventable. Projecting the findings to the entire United States, an estimated 442 deaths might have been prevented in 2000 had all guns been equipped with these safety devices. Incorporating safety devices into firearms is an important injury intervention, with the potential to save hundreds of lives each year.

Overview of Energy Systems` safety analysis report programs. Safety Analysis Report Update Program

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

Not Available

1992-03-01

The primary purpose of an Safety Analysis Report (SAR) is to provide a basis for judging the adequacy of a facility`s safety. The SAR documents the safety analyses that systematically identify the hazards posed by the facility, analyze the consequences and risk of potential accidents, and describe hazard control measures that protect the health and safety of the public and employees. In addition, some SARs document, as Technical Safety Requirements (TSRs, which include Technical Specifications and Operational Safety Requirements), technical and administrative requirements that ensure the facility is operated within prescribed safety limits. SARs also provide conveniently summarized information thatmore » may be used to support procedure development, training, inspections, and other activities necessary to facility operation. This ``Overview of Energy Systems Safety Analysis Report Programs`` Provides an introduction to the programs and processes used in the development and maintenance of the SARs. It also summarizes some of the uses of the SARs within Energy Systems and DOE.« less

Safety System Design for Technology Education. A Safety Guide for Technology Education Courses K-12.

ERIC Educational Resources Information Center

North Carolina State Dept. of Public Instruction, Raleigh. Div. of Vocational Education.

This manual is designed to involve both teachers and students in planning and controlling a safety system for technology education classrooms. The safety program involves students in the design and maintenance of the system by including them in the analysis of the classroom environment, job safety analysis, safety inspection, and machine safety…

Implementation Procedure for STS Payloads, System Safety Requirements

NASA Technical Reports Server (NTRS)

1979-01-01

Guidelines and instructions for the implementation of the SP&R system safety requirements applicable to STS payloads are provided. The initial contact meeting with the payload organization and the subsequent safety reviews necessary to comply with the system safety requirements of the SP&R document are described. Waiver instructions are included for the cases in which a safety requirement cannot be met.

NASA aviation safety reporting system

NASA Technical Reports Server (NTRS)

1979-01-01

The human factors frequency considered a cause of or contributor to hazardous events onboard air carriers are examined with emphasis on distractions. Safety reports that have been analyzed, processed, and entered into the aviation safety reporting system data base are discussed. A sampling of alert bulletins and responses to them is also presented.

14 CFR 415.131 - Flight safety system crew data.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 4 2014-01-01 2014-01-01 false Flight safety system crew data. 415.131... Launch Vehicle From a Non-Federal Launch Site § 415.131 Flight safety system crew data. (a) An applicant's safety review document must identify each flight safety system crew position and the role of that...

Cushion System for Multi-Use Child Safety Seat

NASA Technical Reports Server (NTRS)

Dabney, Richard W. (Inventor); Elrod, Susan V. (Inventor)

2007-01-01

A cushion system for use with a child safety seat has a plurality of bladders assembled to form a seat cushion that cooperates with the seat's safety harness. One or more sensors coupled to the safety harness sense tension therein and generate a signal indicative of the tension. Each of the bladders is individually pressurized by a pressurization system to define a support configuration of the seat cushion. The pressurization system is disabled when tension in the safety harness has attained a threshold level.

Cushion system for multi-use child safety seat

NASA Technical Reports Server (NTRS)

Elrod, Susan V. (Inventor); Dabney, Richard W. (Inventor)

2007-01-01

A cushion system for use with a child safety seat has a plurality of bladders assembled to form a seat cushion that cooperates with the seat's safety harness. One or more sensors coupled to the safety harness sense tension therein and generate a signal indicative of the tension. Each of the bladders is individually pressurized by a pressurization system to define a support configuration of the seat cushion. The pressurization system is disabled when tension in the safety harness has attained a threshold level.

Safety-related requirements for photovoltaic modules and arrays

NASA Technical Reports Server (NTRS)

Levins, A.; Smoot, A.; Wagner, R.

1984-01-01

Safety requirements for photovoltaic module and panel designs and configurations for residential, intermediate, and large scale applications are investigated. Concepts for safety systems, where each system is a collection of subsystems which together address the total anticipated hazard situation, are described. Descriptions of hardware, and system usefulness and viability are included. A comparison of these systems, as against the provisions of the 1984 National Electrical Code covering photovoltaic systems is made. A discussion of the Underwriters Laboratory UL investigation of the photovoltaic module evaluated to the provisions of the proposed UL standard for plat plate photovoltaic modules and panels is included. Grounding systems, their basis and nature, and the advantages and disadvantages of each are described. The meaning of frame grounding, circuit groundings, and the type of circuit ground are covered.

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

PubMed

McNab, Duncan; Bowie, Paul; Morrison, Jill; Ross, Alastair

2016-11-01

Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners' curriculum. Current methods that are taught and employed to improve safety often use a 'find-and-fix' approach to identify components of a system (including humans) where performance could be improved. However, the complex interactions and inter-dependence between components in healthcare systems mean that cause and effect are not always linked in a predictable manner. The Safety-II approach has been proposed as a new way to understand how safety is achieved in complex systems that may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and various ways to achieve success, dependent on work conditions, may be possible. Traditional approaches to improve the quality and safety of care often aim to constrain variability but understanding and managing variability may be a more beneficial approach. The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with 'traditional' methods to enhance patient safety training, outcomes and curriculum coverage.

EMS helicopter incidents reported to the NASA Aviation Safety Reporting System

NASA Technical Reports Server (NTRS)

Connell, Linda J.; Reynard, William D.

1993-01-01

The objectives of this evaluation were to: Identify the types of safety-related incidents reported to the Aviation Safety Reporting System (ASRS) in Emergency Medical Service (EMS) helicopter operations; Describe the operational conditions surrounding these incidents, such as weather, airspace, flight phase, time of day; and Assess the contribution to these incidents of selected human factors considerations, such as communication, distraction, time pressure, workload, and flight/duty impact.

Systems safety monitoring using the National Full-Scale Aerodynamic Complex Bar Chart Monitor

NASA Technical Reports Server (NTRS)

Jung, Oscar

1990-01-01

Attention is given to the Bar Chart Monitor system designed for safety monitoring of all model and facility test-related articles in wind tunnels. The system's salient features and its integration into the data acquisition system are discussed.

NASA aviation safety reporting system

NASA Technical Reports Server (NTRS)

1977-01-01

During the third quarter of operation of the Aviation Safety Reporting System (ASRS), 1429 reports concerning aviation safety were received from pilots, air traffic controllers, and others in the national aviation system. Details of the administration and results of the program are discussed. The design and construction of the ASRS data base are briefly presented. Altitude deviations and potential aircraft conflicts associated with misunderstood clearances were studied and the results are discussed. Summary data regarding alert bulletins, examples of alert bulletins and responses to them, and a sample of deidentified ASRS reports are provided.

Aviation Safety Reporting System: Process and Procedures

NASA Technical Reports Server (NTRS)

Connell, Linda J.

1997-01-01

The Aviation Safety Reporting System (ASRS) was established in 1976 under an agreement between the Federal Aviation Administration (FAA) and the National Aeronautics and Space Administration (NASA). This cooperative safety program invites pilots, air traffic controllers, flight attendants, maintenance personnel, and others to voluntarily report to NASA any aviation incident or safety hazard. The FAA provides most of the program funding. NASA administers the program, sets its policies in consultation with the FAA and aviation community, and receives the reports submitted to the program. The FAA offers those who use the ASRS program two important reporting guarantees: confidentiality and limited immunity. Reports sent to ASRS are held in strict confidence. More than 350,000 reports have been submitted since the program's beginning without a single reporter's identity being revealed. ASRS removes all personal names and other potentially identifying information before entering reports into its database. This system is a very successful, proof-of-concept for gathering safety data in order to provide timely information about safety issues. The ASRS information is crucial to aviation safety efforts both nationally and internationally. It can be utilized as the first step in safety by providing the direction and content to informed policies, procedures, and research, especially human factors. The ASRS process and procedures will be presented as one model of safety reporting feedback systems.

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

PubMed

Hatcher, Irene; Sullivan, Mark; Hutchinson, James; Thurman, Susan; Gaffney, F Andrew

2004-10-01

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

Unintentional and undetermined firearm related deaths: a preventable death analysis for three safety devices

PubMed Central

Vernick, J; O'Brien, M; Hepburn, L; Johnson, S; Webster, D; Hargarten, S

2003-01-01

Objective: To determine the proportion of unintentional and undetermined firearm related deaths preventable by three safety devices: personalization devices, loaded chamber indicators (LCIs), and magazine safeties. A personalized gun will operate only for an authorized user, a LCI indicates when the gun contains ammunition, and a magazine safety prevents the gun from firing when the ammunition magazine is removed. Design: Information about all unintentional and undetermined firearm deaths from 1991–98 was obtained from the Office of the Chief Medical Examiner for Maryland, and from the Wisconsin Firearm Injury Reporting System for Milwaukee. Data regarding the victim, shooter, weapon, and circumstances were abstracted. Coding rules to classify each death as preventable, possibly preventable, or not preventable by each of the three safety devices were also applied. Results: There were a total of 117 firearm related deaths in our sample, 95 (81%) involving handguns. Forty three deaths (37%) were classified as preventable by a personalized gun, 23 (20%) by a LCI, and five (4%) by a magazine safety. Overall, 52 deaths (44%) were preventable by at least one safety device. Deaths involving children 0–17 (relative risk (RR) 3.3, 95% confidence interval (CI) 2.1 to 5.1) and handguns (RR 8.1, 95% CI 1.2 to 53.5) were more likely to be preventable. Projecting the findings to the entire United States, an estimated 442 deaths might have been prevented in 2000 had all guns been equipped with these safety devices. Conclusion: Incorporating safety devices into firearms is an important injury intervention, with the potential to save hundreds of lives each year. PMID:14693889

The Parable of the Boiled System Safety Professional: Drift to Failure

NASA Technical Reports Server (NTRS)

Shivers, C. Herbert

2011-01-01

Recall from the Parable of the Boiled Frog, that tossing a frog into boiling water causes the frog to jump out and hop away while placing a frog in suitable temperature water and slowly bringing the water to a boil results in the frog boiling due to not being aware of the slowly increasing danger, theoretically, of course. System safety professionals must guard against allowing dangers to creep unnoticed into their projects and be ever alert to notice signs of impending problems. People have used various phrases related to the idea, most notably, latent conditions, James Reason in Managing the Risks of Organizational Accidents (1, pp 10-11), Drift to Failure, Sydney Dekker (2, pp 82-86) in Resilience Engineering: Chronicling the Emergence of Confused Consensus in Resilience Engineering: Concepts and Precepts, Hollnagel, Woods and Leveson, and normalization of deviance, Diane Vaughan in The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA (3). Reason also said, If eternal vigilance is the price of liberty, then chronic unease is the price of safety (1, p 37). Our challenge as system safety professionals is to be aware of the emergence of signals that warn us of slowly eroding safety margins. This paper will discuss how system safety professionals might better perform in that regard.

Revised fire safety system cuts emergency response time.

PubMed

Keir, D C

1979-03-01

As Margaret R. Pardee Memorial Hospital, Hendersonville, NC. expanded, fire safety plans had to be reevaluated. With each new addition, fire safety responsibilities for hospital personnel multiplied and overlapped. Confusion resulted, and a revised, simplified, and coordinated fire safety system was devised. Seventeen false alarms within one year, caused by a faulty sprinkler system, gave hospital personnel ample opportunity to test the system and iron out unexpected problems.

Neighborhood Crime-Related Safety and Its Relation to Children's Physical Activity.

PubMed

Kneeshaw-Price, Stephanie H; Saelens, Brian E; Sallis, James F; Frank, Lawrence D; Grembowski, David E; Hannon, Peggy A; Smith, Nicholas L; Chan, K C Gary

2015-06-01

Crime is both a societal safety and public health issue. Examining different measures and aspects of crime-related safety and their correlations may provide insight into the unclear relationship between crime and children's physical activity. We evaluated five neighborhood crime-related safety measures to determine how they were interrelated. We then explored which crime-related safety measures were associated with children's total moderate-to-vigorous physical activity (MVPA) and MVPA in their neighborhoods. Significant positive correlations between observed neighborhood incivilities and parents' perceptions of general crime and disorder were found (r = 0.30, p = 0.0002), as were associations between parents' perceptions of general crime and disorder and perceptions of stranger danger (r = 0.30, p = 0.0002). Parent report of prior crime victimization in their neighborhood was associated with observed neighborhood incivilities (r = 0.22, p = 0.007) and their perceptions of both stranger danger (r = 0.24, p = 0.003) and general crime and disorder (r = 0.37, p < 0.0001). After accounting for covariates, police-reported crime within the census block group in which children lived was associated with less physical activity, both total and in their neighborhood (beta = -0.09, p = 0.005, beta = -0.01, p = 0.02, respectively). Neighborhood-active children living in the lowest crime-quartile neighborhoods based on police reports had 40 min more of total MVPA on average compared to neighborhood-active children living in the highest crime-quartile neighborhoods. Findings suggest that police reports of neighborhood crime may be contributing to lower children's physical activity.

Telemedicine to promote patient safety: Use of phone-based interactive voice response system (IVRS) to reduce adverse safety events in predialysis CKD

PubMed Central

Weiner, Shoshana; Fink, Jeffery C.

2017-01-01

Chronic kidney disease (CKD) patients have several features conferring upon them a high risk of adverse safety events, which are defined as incidents with unintended harm related to processes of care or medications. These characteristics include impaired renal function, polypharmacy, and frequent health system encounters. The consequences of such events in CKD can include new or prolonged hospitalization, accelerated renal function loss, acute kidney injury, end-stage renal disease and death. Health information technology administered via telemedicine presents opportunities for CKD patients to remotely communicate safety-related findings to providers for the purpose of improving their care. However, many CKD patients have limitations which hinder their use of telemedicine and access to the broad capabilities of health information technology. In this review we summarize previous assessments of the pre-dialysis CKD populations’ proficiency in using telemedicine modalities and describe the use of interactive voice-response system (IVRS) to gauge the safety phenotype of the CKD patient. We discuss the potential for expanded IVRS use in CKD to address the safety threats inherent to this population. PMID:28224940

Comparing Occupational Health and Safety Management System Programming with Injury Rates in Poultry Production.

PubMed

Autenrieth, Daniel A; Brazile, William J; Douphrate, David I; Román-Muñiz, Ivette N; Reynolds, Stephen J

2016-01-01

Effective methods to reduce work-related injuries and illnesses in animal production agriculture are sorely needed. One approach that may be helpful for agriculture producers is the adoption of occupational health and safety management systems. In this replication study, the authors compared the injury rates on 32 poultry growing operations with the level of occupational health and safety management system programming at each farm. Overall correlations between injury rates and programming level were determined, as were correlations between individual management system subcomponents to ascertain which parts might be the most useful for poultry producers. It was found that, in general, higher levels of occupational health and safety management system programming were associated with lower rates of workplace injuries and illnesses, and that Management Leadership was the system subcomponent with the strongest correlation. The strength and significance of the observed associations were greater on poultry farms with more complete management system assessments. These findings are similar to those from a previous study of the dairy production industry, suggesting that occupational health and safety management systems may hold promise as a comprehensive way for producers to improve occupational health and safety performance. Further research is needed to determine the effectiveness of such systems to reduce farm work injuries and illnesses. These results are timely given the increasing focus on occupational safety and health management systems.

Could changes in the wheelchair delivery system improve safety?

PubMed Central

Kirby, R L; Coughlan, S G; Christie, M

1995-01-01

Despite emerging evidence about the high incidence and severity of wheelchair-related injuries, regulations governing wheelchair safety are almost nonexistent in Canada. The authors believe that, to improve wheelchair safety, a concerted effort by government, manufacturers, purchasing groups, users and clinicians is needed. Health Canada's Health Protection Branch should treat wheelchairs as medical devices (as defined in the Food and Drugs Act 1985) and improve its injury-reporting network. Manufacturers should give a higher priority to safety in wheelchair design, improve their educational materials and formalize postmarketing surveillance. Purchasing groups should try to ensure that they do not stifle innovation in wheelchair design by setting unrealistic reimbursement ceilings and should use their market power more effectively. Users should obtain their wheelchairs in specialized settings, heed safety warnings and make more effective use of litigation when such action is warranted. Clinicians should ensure that patients are equipped with the most appropriate wheelchair for their needs, that they are given adequate training in safe wheelchair use and that they understand the dangers involved. Rapid changes in wheelchair technology and emerging evidence about the high incidence and severity of injuries related to wheelchair use suggest that such changes are needed in the wheelchair delivery system. PMID:7489551

Identifying behaviour patterns of construction safety using system archetypes.

PubMed

Guo, Brian H W; Yiu, Tak Wing; González, Vicente A

2015-07-01

Construction safety management involves complex issues (e.g., different trades, multi-organizational project structure, constantly changing work environment, and transient workforce). Systems thinking is widely considered as an effective approach to understanding and managing the complexity. This paper aims to better understand dynamic complexity of construction safety management by exploring archetypes of construction safety. To achieve this, this paper adopted the ground theory method (GTM) and 22 interviews were conducted with participants in various positions (government safety inspector, client, health and safety manager, safety consultant, safety auditor, and safety researcher). Eight archetypes were emerged from the collected data: (1) safety regulations, (2) incentive programs, (3) procurement and safety, (4) safety management in small businesses (5) production and safety, (6) workers' conflicting goals, (7) blame on workers, and (8) reactive and proactive learning. These archetypes capture the interactions between a wide range of factors within various hierarchical levels and subsystems. As a free-standing tool, they advance the understanding of dynamic complexity of construction safety management and provide systemic insights into dealing with the complexity. They also can facilitate system dynamics modelling of construction safety process. Copyright © 2015 Elsevier Ltd. All rights reserved.

An analysis of electronic health record-related patient safety incidents.

PubMed

Palojoki, Sari; Mäkelä, Matti; Lehtonen, Lasse; Saranto, Kaija

2017-06-01

The aim of this study was to analyse electronic health record-related patient safety incidents in the patient safety incident reporting database in fully digital hospitals in Finland. We compare Finnish data to similar international data and discuss their content with regard to the literature. We analysed the types of electronic health record-related patient safety incidents that occurred at 23 hospitals during a 2-year period. A procedure of taxonomy mapping served to allow comparisons. This study represents a rare examination of patient safety risks in a fully digital environment. The proportion of electronic health record-related incidents was markedly higher in our study than in previous studies with similar data. Human-computer interaction problems were the most frequently reported. The results show the possibility of error arising from the complex interaction between clinicians and computers.

System safety checklist Skylab program report

NASA Technical Reports Server (NTRS)

Mcnail, E. M.

1974-01-01

Design criteria statement applicable to a wide variety of flight systems, experiments and other payloads, associated ground support equipment and facility support systems are presented. The document reflects a composite of experience gained throughout the aerospace industry prior to Skylab and additional experience gained during the Skylab Program. It has been prepared to provide current and future program organizations with a broad source of safety-related design criteria and to suggest methods for systematic and progressive application of the criteria beginning with preliminary development of design requirements and specifications. Recognizing the users obligation to shape the checklist to his particular needs, a summary of the historical background, rationale, objectives, development and implementation approach, and benefits based on Skylab experience has been included.

Safety Management Systems.

ERIC Educational Resources Information Center

Fido, A. T.; Wood, D. O.

This document discusses the issues that need to be considered by the education and training system as it responds to the changing needs of industry in Great Britain. Following a general introduction, the development of quality management ideas is traced. The underlying principles of safety and risk management are clarified and the implications of…

46 CFR 62.25-15 - Safety control systems.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 2 2010-10-01 2010-10-01 false Safety control systems. 62.25-15 Section 62.25-15 Shipping COAST GUARD, DEPARTMENT OF HOMELAND SECURITY (CONTINUED) MARINE ENGINEERING VITAL SYSTEM AUTOMATION General Requirements for All Automated Vital Systems § 62.25-15 Safety control systems. (a...

EHR Safety: The Way Forward to Safe and Effective Systems

PubMed Central

Walker, James M.; Carayon, Pascale; Leveson, Nancy; Paulus, Ronald A.; Tooker, John; Chin, Homer; Bothe, Albert; Stewart, Walter F.

2008-01-01

Diverse stakeholders—clinicians, researchers, business leaders, policy makers, and the public—have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents. PMID:18308981

Four Pillars for Improving the Quality of Safety-Critical Software-Reliant Systems

DTIC Science & Technology

2013-04-01

Studies of safety-critical software-reliant systems developed using the current practices of build-then-test show that requirements and architecture ... design defects make up approximately 70% of all defects, many system level related to operational quality attributes, and 80% of these defects are

Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.

PubMed

Keohane, Carol A; Hayes, Judy; Saniuk, Catherine; Rothschild, Jeffrey M; Bates, David W

2005-01-01

The Institute of Medicine report To Err Is Human: Building a Safe Health System greatly increased national awareness of the need to improve patient safety in general and medication safety in particular. Infusion-related errors are associated with the greatest risk of harm, and "smart" (computerized) infusion systems are currently available that can avert high-risk errors and provide previously unavailable data for continuous quality improvement (CQI) efforts. As healthcare organizations consider how to invest scarce dollars, infusion nurses have a key role to play in assessing need, evaluating technology, and selecting and implementing specific products. This article reviews the need to improve intravenous medication safety. It describes smart infusion systems and the results they have achieved. Finally, it details the lessons learned and the opportunities identified through the use of smart infusion technology at Brigham and Women's Hospital in Boston, Massachusetts.

33 CFR 96.220 - What makes up a safety management system?

Code of Federal Regulations, 2011 CFR

2011-07-01

... SECURITY VESSEL OPERATING REGULATIONS RULES FOR THE SAFE OPERATION OF VESSELS AND SAFETY MANAGEMENT SYSTEMS Company and Vessel Safety Management Systems § 96.220 What makes up a safety management system? (a) The safety management system must document the responsible person's— (1) Safety and pollution prevention...

Commercial-off-the-shelf (COTS) hardware and software for train control applications : system safety considerations.

DOT National Transportation Integrated Search

2003-04-01

The objective of this study was to assess the feasibility of using commercial off-the-shelf(COTS)processor-based systems for safety- related railroad applications. From the safety perspective,the fundamental challenges of using COTS products are most...

Are automatic systems the future of motorcycle safety? A novel methodology to prioritize potential safety solutions based on their projected effectiveness.

PubMed

Gil, Gustavo; Savino, Giovanni; Piantini, Simone; Baldanzini, Niccolò; Happee, Riender; Pierini, Marco

2017-11-17

Motorcycle riders are involved in significantly more crashes per kilometer driven than passenger car drivers. Nonetheless, the development and implementation of motorcycle safety systems lags far behind that of passenger cars. This research addresses the identification of the most effective motorcycle safety solutions in the context of different countries. A knowledge-based system of motorcycle safety (KBMS) was developed to assess the potential for various safety solutions to mitigate or avoid motorcycle crashes. First, a set of 26 common crash scenarios was identified from the analysis of multiple crash databases. Second, the relative effectiveness of 10 safety solutions was assessed for the 26 crash scenarios by a panel of experts. Third, relevant information about crashes was used to weigh the importance of each crash scenario in the region studied. The KBMS method was applied with an Italian database, with a total of more than 1 million motorcycle crashes in the period 2000-2012. When applied to the Italian context, the KBMS suggested that automatic systems designed to compensate for riders' or drivers' errors of commission or omission are the potentially most effective safety solution. The KBMS method showed an effective way to compare the potential of various safety solutions, through a scored list with the expected effectiveness of each safety solution for the region to which the crash data belong. A comparison of our results with a previous study that attempted a systematic prioritization of safety systems for motorcycles (PISa project) showed an encouraging agreement. Current results revealed that automatic systems have the greatest potential to improve motorcycle safety. Accumulating and encoding expertise in crash analysis from a range of disciplines into a scalable and reusable analytical tool, as proposed with the use of KBMS, has the potential to guide research and development of effective safety systems. As the expert assessment of the crash

Work-related injury factors and safety climate perception in truck drivers.

PubMed

Anderson, Naomi J; Smith, Caroline K; Byrd, Jesse L

2017-08-01

The trucking industry has a high burden of work-related injuries. This study examined factors, such as safety climate perceptions, that may impact injury risk. A random sample of 9800 commercial driver's license holders (CDL) were sent surveys, only 4360 were eligible truck drivers. Descriptive statistics and logistic regression models were developed to describe the population and identify variables associated with work-related injury. 2189 drivers completed the pertinent interview questions. Driving less-than-truckload, daytime sleepiness, pressure to work faster, and having a poor composite score for safety perceptions were all associated with increased likelihood of work-related injury. Positive safety perception score was protective for odds of work-related injury, and increased claim filing when injured. Positive psychological safety climate is associated with decreased likelihood of work-related injury and increased likelihood that a driver injured on the job files a workers' compensation claim. © 2017 Wiley Periodicals, Inc.

A review and discussion of flight management system incidents reported to the Aviation Safety Reporting System

DOT National Transportation Integrated Search

1992-02-01

This report covers the activities related to the description, classification and : analysis of the types and kinds of flight crew errors, incidents and actions, as : reported to the Aviation Safety Reporting System (ASRS) database, that can occur as ...

Autonomous Flight Safety System - Phase III

NASA Technical Reports Server (NTRS)

2008-01-01

The Autonomous Flight Safety System (AFSS) is a joint KSC and Wallops Flight Facility project that uses tracking and attitude data from onboard Global Positioning System (GPS) and inertial measurement unit (IMU) sensors and configurable rule-based algorithms to make flight termination decisions. AFSS objectives are to increase launch capabilities by permitting launches from locations without range safety infrastructure, reduce costs by eliminating some downrange tracking and communication assets, and reduce the reaction time for flight termination decisions.

Scan tour of safety-related intelligent transportation systems across the United States.

DOT National Transportation Integrated Search

2015-09-01

The Utah Department of Transportation (UDOT) has long been on the forefront of nationwide efforts to improve : roadway safety. Their safety focus encompasses infrastructure improvements as well as non-infrastructure elements : such as education and e...

Comparative health and safety assessment of the SPS and alternative electrical generation systems

NASA Astrophysics Data System (ADS)

Habegger, L. J.; Gasper, J. R.; Brown, C. D.

1980-07-01

A comparative analysis of health and safety risks is presented for the Satellite Power System and five alternative baseload electrical generation systems: a low-Btu coal gasification system with an open-cycle gas turbine combined with a steam topping cycle; a light water fission reactor system without fuel reprocessing; a liquid metal fast breeder fission reactor system; a central station terrestrial photovoltaic system; and a first generation fusion system with magnetic confinement. For comparison, risk from a decentralized roof-top photovoltaic system with battery storage is also evaluated. Quantified estimates of public and occupational risks within ranges of uncertainty were developed for each phase of the energy system. The potential significance of related major health and safety issues that remain unquantitied are also discussed.

Comparative health and safety assessment of the SPS and alternative electrical generation systems

NASA Technical Reports Server (NTRS)

Habegger, L. J.; Gasper, J. R.; Brown, C. D.

1980-01-01

A comparative analysis of health and safety risks is presented for the Satellite Power System and five alternative baseload electrical generation systems: a low-Btu coal gasification system with an open-cycle gas turbine combined with a steam topping cycle; a light water fission reactor system without fuel reprocessing; a liquid metal fast breeder fission reactor system; a central station terrestrial photovoltaic system; and a first generation fusion system with magnetic confinement. For comparison, risk from a decentralized roof-top photovoltaic system with battery storage is also evaluated. Quantified estimates of public and occupational risks within ranges of uncertainty were developed for each phase of the energy system. The potential significance of related major health and safety issues that remain unquantitied are also discussed.

Clinical Relation Extraction Toward Drug Safety Surveillance Using Electronic Health Record Narratives: Classical Learning Versus Deep Learning

PubMed Central

Munkhdalai, Tsendsuren; Liu, Feifan

2018-01-01

Background Medication and adverse drug event (ADE) information extracted from electronic health record (EHR) notes can be a rich resource for drug safety surveillance. Existing observational studies have mainly relied on structured EHR data to obtain ADE information; however, ADEs are often buried in the EHR narratives and not recorded in structured data. Objective To unlock ADE-related information from EHR narratives, there is a need to extract relevant entities and identify relations among them. In this study, we focus on relation identification. This study aimed to evaluate natural language processing and machine learning approaches using the expert-annotated medical entities and relations in the context of drug safety surveillance, and investigate how different learning approaches perform under different configurations. Methods We have manually annotated 791 EHR notes with 9 named entities (eg, medication, indication, severity, and ADEs) and 7 different types of relations (eg, medication-dosage, medication-ADE, and severity-ADE). Then, we explored 3 supervised machine learning systems for relation identification: (1) a support vector machines (SVM) system, (2) an end-to-end deep neural network system, and (3) a supervised descriptive rule induction baseline system. For the neural network system, we exploited the state-of-the-art recurrent neural network (RNN) and attention models. We report the performance by macro-averaged precision, recall, and F1-score across the relation types. Results Our results show that the SVM model achieved the best average F1-score of 89.1% on test data, outperforming the long short-term memory (LSTM) model with attention (F1-score of 65.72%) as well as the rule induction baseline system (F1-score of 7.47%) by a large margin. The bidirectional LSTM model with attention achieved the best performance among different RNN models. With the inclusion of additional features in the LSTM model, its performance can be boosted to an average F1

System safety in Stirling engine development

NASA Technical Reports Server (NTRS)

Bankaitis, H.

1981-01-01

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

Fire safety evaluation system for NASA office/laboratory buildings

NASA Astrophysics Data System (ADS)

Nelson, H. E.

1986-11-01

A fire safety evaluation system for office/laboratory buildings is developed. The system is a life safety grading system. The system scores building construction, hazardous areas, vertical openings, sprinklers, detectors, alarms, interior finish, smoke control, exit systems, compartmentation, and emergency preparedness.

Overview of Energy Systems' safety analysis report programs

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

Not Available

1992-03-01

The primary purpose of an Safety Analysis Report (SAR) is to provide a basis for judging the adequacy of a facility's safety. The SAR documents the safety analyses that systematically identify the hazards posed by the facility, analyze the consequences and risk of potential accidents, and describe hazard control measures that protect the health and safety of the public and employees. In addition, some SARs document, as Technical Safety Requirements (TSRs, which include Technical Specifications and Operational Safety Requirements), technical and administrative requirements that ensure the facility is operated within prescribed safety limits. SARs also provide conveniently summarized information thatmore » may be used to support procedure development, training, inspections, and other activities necessary to facility operation. This Overview of Energy Systems Safety Analysis Report Programs'' Provides an introduction to the programs and processes used in the development and maintenance of the SARs. It also summarizes some of the uses of the SARs within Energy Systems and DOE.« less

Analysis of Aviation Safety Reporting System Incident Data Associated with the Technical Challenges of the Atmospheric Environment Safety Technology Project

NASA Technical Reports Server (NTRS)

Withrow, Colleen A.; Reveley, Mary S.

2014-01-01

This study analyzed aircraft incidents in the NASA Aviation Safety Reporting System (ASRS) that apply to two of the three technical challenges (TCs) in NASA's Aviation Safety Program's Atmospheric Environment Safety Technology Project. The aircraft incidents are related to airframe icing and atmospheric hazards TCs. The study reviewed incidents that listed their primary problem as weather or environment-nonweather between 1994 and 2011 for aircraft defined by Federal Aviation Regulations (FAR) Parts 121, 135, and 91. The study investigated the phases of flight, a variety of anomalies, flight conditions, and incidents by FAR part, along with other categories. The first part of the analysis focused on airframe-icing-related incidents and found 275 incidents out of 3526 weather-related incidents over the 18-yr period. The second portion of the study focused on atmospheric hazards and found 4647 incidents over the same time period. Atmospheric hazards-related incidents included a range of conditions from clear air turbulence and wake vortex, to controlled flight toward terrain, ground encounters, and incursions.

Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety.

PubMed

Brand, C; Ibrahim, J; Bain, C; Jones, C; King, B

2007-05-01

Several event studies, including the Australian Safety and Quality in Healthcare Study, emphasize gaps in safety for hospitalized patients. It is now recognized that system-based factors contribute significantly to risk of adverse events and this has led to a shift in focus of patient safety from the autonomous responsibility of medical clinicians to a systems-based approach. The aim of this study was to determine medical practitioner awareness of, level of engagement in and barriers to engagement in a systems approach to patient safety and quality. Information from acute and subacute care medical practitioners at a metropolitan public hospital was collected within an anonymous structured electronic survey, a discussion group and key informant interviews. There were 73 survey respondents (response rate 7.6%). Fifty-one (69.9%) were unaware of the Institute of Medicine report 'To Err is human'. Thirty-six (49.3%) were unaware of the Australian Quality in Healthcare Study and 12 (16.4%) had read the article. There was a positive relation identified between awareness and seniority. There was a low level of participation in systems-focused quality and safety activities and limited understanding of the role of systems in medical error causation. There was uncertainty about the changing role of medical practitioners in patient safety and perceived lack of skills to effectively engage with hospital management about safety and quality issues. Several factors are limiting engagement of medical practitioners in a systems approach to patient safety. Increased educational support is needed and may be best focused within clinical effectiveness activities pertinent to practitioner interest and expertise.

Radiation safety issues related to radiolabeled antibodies. [Contains glossary

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

Barber, D.E.; Baum, J.W.; Meinhold, C. B.

1991-03-01

Techniques related to the use of radiolabeled antibodies in humans are reviewed and evaluated in this report. It is intended as an informational resource for the US Nuclear Regulatory Commission (NRC) and NRC licensees. Descriptions of techniques and health and safety issues are provided. Principal methods for labeling antibodies are summarized to help identify related radiation safety problems in the preparation of dosages for administration to patients. The descriptions are derived from an extensive literature review and consultations with experts in the field. A glossary of terms and acronyms is also included. An assessment was made of the extent ofmore » the involvement of organizations (other than the NRC) with safety issues related to radiolabeled antibodies, in order to identify regulatory issues which require attention. Federal regulations and guides were also reviewed for their relevance. A few (but significant) differences between the use of common radiopharmaceuticals and radiolabeled antibodies were observed. The clearance rate of whole, radiolabeled immunoglobulin is somewhat slower than common radiopharmaceuticals, and new methods of administration are being used. New nuclides are being used or considered (e.g., Re-186 and At-211) for labeling antibodies. Some of these nuclides present new dosimetry, instrument calibration, and patient management problems. Subjects related to radiation safety that require additional research are identified. 149 refs., 3 figs., 20 tabs.« less

Using Active Learning to Identify Health Information Technology Related Patient Safety Events.

PubMed

Fong, Allan; Howe, Jessica L; Adams, Katharine T; Ratwani, Raj M

2017-01-18

The widespread adoption of health information technology (HIT) has led to new patient safety hazards that are often difficult to identify. Patient safety event reports, which are self-reported descriptions of safety hazards, provide one view of potential HIT-related safety events. However, identifying HIT-related reports can be challenging as they are often categorized under other more predominate clinical categories. This challenge of identifying HIT-related reports is exacerbated by the increasing number and complexity of reports which pose challenges to human annotators that must manually review reports. In this paper, we apply active learning techniques to support classification of patient safety event reports as HIT-related. We evaluated different strategies and demonstrated a 30% increase in average precision of a confirmatory sampling strategy over a baseline no active learning approach after 10 learning iterations.

Ecological Issues Related to Children's Health and Safety

ERIC Educational Resources Information Center

Aldridge, Jerry; Kohler, Maxie

2009-01-01

Issues concerning the health and safety of children and youth occur at multiple levels. Bronfenbrenner (1995) proposed an ecological systems approach in which multiple systems interact to enhance or diminish children's development. The same systems are at work in health promotion. The authors present and review articles that reflect the multiple…

Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system.

PubMed

Yang, Shu-Hui; Jerng, Jih-Shuin; Chen, Li-Chin; Li, Yu-Tsu; Huang, Hsiao-Fang; Wu, Chao-Ling; Chan, Jing-Yuan; Huang, Szu-Fen; Liang, Huey-Wen; Sun, Jui-Sheng

2017-11-03

Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm. This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © Article author(s) (or their employer(s) unless otherwise stated in the

Autonomous system for launch vehicle range safety

NASA Astrophysics Data System (ADS)

Ferrell, Bob; Haley, Sam

2001-02-01

The Autonomous Flight Safety System (AFSS) is a launch vehicle subsystem whose ultimate goal is an autonomous capability to assure range safety (people and valuable resources), flight personnel safety, flight assets safety (recovery of valuable vehicles and cargo), and global coverage with a dramatic simplification of range infrastructure. The AFSS is capable of determining current vehicle position and predicting the impact point with respect to flight restriction zones. Additionally, it is able to discern whether or not the launch vehicle is an immediate threat to public safety, and initiate the appropriate range safety response. These features provide for a dramatic cost reduction in range operations and improved reliability of mission success. .

33 CFR 147.847 - Safety Zone; BW PIONEER Floating Production, Storage, and Offloading System Safety Zone.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 33 Navigation and Navigable Waters 2 2010-07-01 2010-07-01 false Safety Zone; BW PIONEER Floating... ZONES § 147.847 Safety Zone; BW PIONEER Floating Production, Storage, and Offloading System Safety Zone. (a) Description. The BW PIONEER, a Floating Production, Storage and Offloading (FPSO) system, is in...

Demonstration of a Safety Analysis on a Complex System

NASA Technical Reports Server (NTRS)

Leveson, Nancy; Alfaro, Liliana; Alvarado, Christine; Brown, Molly; Hunt, Earl B.; Jaffe, Matt; Joslyn, Susan; Pinnell, Denise; Reese, Jon; Samarziya, Jeffrey;

A safety-based decision making architecture for autonomous systems

NASA Technical Reports Server (NTRS)

Musto, Joseph C.; Lauderbaugh, L. K.

1991-01-01

Engineering systems designed specifically for space applications often exhibit a high level of autonomy in the control and decision-making architecture. As the level of autonomy increases, more emphasis must be placed on assimilating the safety functions normally executed at the hardware level or by human supervisors into the control architecture of the system. The development of a decision-making structure which utilizes information on system safety is detailed. A quantitative measure of system safety, called the safety self-information, is defined. This measure is analogous to the reliability self-information defined by McInroy and Saridis, but includes weighting of task constraints to provide a measure of both reliability and cost. An example is presented in which the safety self-information is used as a decision criterion in a mobile robot controller. The safety self-information is shown to be consistent with the entropy-based Theory of Intelligent Machines defined by Saridis.

Patient safety goals for the proposed Federal Health Information Technology Safety Center.

PubMed

Sittig, Dean F; Classen, David C; Singh, Hardeep

2015-03-01

The Office of the National Coordinator for Health Information Technology is expected to oversee creation of a Health Information Technology (HIT) Safety Center. While its functions are still being defined, the center is envisioned as a public-private entity focusing on promotion of HIT related patient safety. We propose that the HIT Safety Center leverages its unique position to work with key administrative and policy stakeholders, healthcare organizations (HCOs), and HIT vendors to achieve four goals: (1) facilitate creation of a nationwide 'post-marketing' surveillance system to monitor HIT related safety events; (2) develop methods and governance structures to support investigation of major HIT related safety events; (3) create the infrastructure and methods needed to carry out random assessments of HIT related safety in complex HCOs; and (4) advocate for HIT safety with government and private entities. The convening ability of a federally supported HIT Safety Center could be critically important to our transformation to a safe and effective HIT enabled healthcare system. © The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Total Quality Management and the System Safety Secretary

NASA Technical Reports Server (NTRS)

Elliott, Suzan E.

1993-01-01

The system safety secretary is a valuable member of the system safety team. As downsizing occurs to meet economic constraints, the Total Quality Management (TQM) approach is frequently adopted as a formula for success and, in some cases, for survival.

Summary and evaluation of responses received on the alcohol safety interlock system

DOT National Transportation Integrated Search

1971-05-01

This report summarizes and evaluates devices and suggestions provided by respondents to the DOT Prospectus entitled "Some Considerations Related to the Development of an Alcohol Safety Interlock System (ASIS)". The responses are categorized into: (1)...

Implementation and evaluation of a prototype consumer reporting system for patient safety events.

PubMed

Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C; Quigley, Denise D; Hunter, Lauren E; Ridgely, M Susan; Schneider, Eric C

2017-08-01

No methodologically robust system exists for capturing consumer-generated patient safety reports. To address this challenge, we developed and pilot-tested a prototype consumer reporting system for patient safety, the Health Care Safety Hotline. Mixed methods evaluation. The Hotline was implemented in two US healthcare systems from 1 February 2014 through 30 June 2015. Patients, family members and caregivers associated with two US healthcare systems. A consumer-oriented incident reporting system for telephone or web-based administration was developed to elicit medical mistakes and care-related injuries. Key informant interviews, measurement of website traffic and analysis of completed reports. Key informants indicated that Hotline participation was motivated by senior leaders' support and alignment with existing quality and safety initiatives. During the measurement period from 1 October 2014 through 30 June 2015, the home page had 1530 visitors with a unique IP address. During its 17 months of operation, the Hotline received 37 completed reports including 20 mistakes without harm and 15 mistakes with injury. The largest category of mistake concerned problems with diagnosis or advice from a health practitioner. Hotline reports prompted quality reviews, an education intervention, and patient follow-ups. While generating fewer reports than its capacity to manage, the Health Care Safety Hotline demonstrated the feasibility of consumer-oriented patient safety reporting. Further research is needed to understand how to increase consumers' use of these systems. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Influence Map Methodology for Evaluating Systemic Safety Issues

NASA Technical Reports Server (NTRS)

2008-01-01

"Raising the bar" in safety performance is a critical challenge for many organizations, including Kennedy Space Center. Contributing-factor taxonomies organize information about the reasons accidents occur and therefore are essential elements of accident investigations and safety reporting systems. Organizations must balance efforts to identify causes of specific accidents with efforts to evaluate systemic safety issues in order to become more proactive about improving safety. This project successfully addressed the following two problems: (1) methods and metrics to support the design of effective taxonomies are limited and (2) influence relationships among contributing factors are not explicitly modeled within a taxonomy.

Advanced Test Reactor Safety Basis Upgrade Lessons Learned Relative to Design Basis Verification and Safety Basis Management

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

G. L. Sharp; R. T. McCracken

The Advanced Test Reactor (ATR) is a pressurized light-water reactor with a design thermal power of 250 MW. The principal function of the ATR is to provide a high neutron flux for testing reactor fuels and other materials. The reactor also provides other irradiation services such as radioisotope production. The ATR and its support facilities are located at the Test Reactor Area of the Idaho National Engineering and Environmental Laboratory (INEEL). An audit conducted by the Department of Energy's Office of Independent Oversight and Performance Assurance (DOE OA) raised concerns that design conditions at the ATR were not adequately analyzedmore » in the safety analysis and that legacy design basis management practices had the potential to further impact safe operation of the facility.1 The concerns identified by the audit team, and issues raised during additional reviews performed by ATR safety analysts, were evaluated through the unreviewed safety question process resulting in shutdown of the ATR for more than three months while these concerns were resolved. Past management of the ATR safety basis, relative to facility design basis management and change control, led to concerns that discrepancies in the safety basis may have developed. Although not required by DOE orders or regulations, not performing design basis verification in conjunction with development of the 10 CFR 830 Subpart B upgraded safety basis allowed these potential weaknesses to be carried forward. Configuration management and a clear definition of the existing facility design basis have a direct relation to developing and maintaining a high quality safety basis which properly identifies and mitigates all hazards and postulated accident conditions. These relations and the impact of past safety basis management practices have been reviewed in order to identify lessons learned from the safety basis upgrade process and appropriate actions to resolve possible concerns with respect to the current ATR

The Design of a Practical Enterprise Safety Management System

NASA Astrophysics Data System (ADS)

Gabbar, Hossam A.; Suzuki, Kazuhiko

This book presents design guidelines and implementation approaches for enterprise safety management system as integrated within enterprise integrated systems. It shows new model-based safety management where process design automation is integrated with enterprise business functions and components. It proposes new system engineering approach addressed to new generation chemical industry. It will help both the undergraduate and professional readers to build basic knowledge about issues and problems of designing practical enterprise safety management system, while presenting in clear way, the system and information engineering practices to design enterprise integrated solution.

Human factors systems approach to healthcare quality and patient safety

PubMed Central

Carayon, Pascale; Wetterneck, Tosha B.; Rivera-Rodriguez, A. Joy; Hundt, Ann Schoofs; Hoonakker, Peter; Holden, Richard; Gurses, Ayse P.

2013-01-01

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety. PMID:23845724

Security warning method and system for worker safety during live-line working

NASA Astrophysics Data System (ADS)

Jiang, Chilong; Zou, Dehua; Long, Chenhai; Yang, Miao; Zhang, Zhanlong; Mei, Daojun

2017-09-01

Live-line working is an essential part in the operations in an electric power system. Live-line workers are required to wear shielding clothing. Shielding clothing, however, acts as a closed environment for the human body. Working in a closed environment for a long time can change the physiological responses of the body and even endanger personal safety. According to the typical conditions of live-line working, this study synthesizes environmental factors related to shielding clothing and the physiological factors of the body to establish the heart rate variability index RMSSD and the comprehensive security warning index SWI. On the basis of both indices, this paper proposes a security warning method and system for the safety live-line workers. The system can monitor the real-time status of workers during live-line working to provide security warning and facilitate the effective safety supervision by the live operation center during actual live-line working.

Safety systems in gamma irradiation facilities.

PubMed

Drndarevic, V

1997-08-01

A new electronic device has been developed to guard against individuals gaining entry through the product entry and exit ports into our irradiation facility for industrial sterilization. This device uses the output from electronic sensors and pressure mats to assure that only the transport cabins may pass through these ports. Any intention of personnel trespassing is detected, the process is stopped by the safety system, and the source is placed in safe position. Owing to a simple construction, the new device enables reliable operation, is inexpensive, easy to implement, and improves the existing safety systems.

Models Extracted from Text for System-Software Safety Analyses

NASA Technical Reports Server (NTRS)

Malin, Jane T.

2010-01-01

This presentation describes extraction and integration of requirements information and safety information in visualizations to support early review of completeness, correctness, and consistency of lengthy and diverse system safety analyses. Software tools have been developed and extended to perform the following tasks: 1) extract model parts and safety information from text in interface requirements documents, failure modes and effects analyses and hazard reports; 2) map and integrate the information to develop system architecture models and visualizations for safety analysts; and 3) provide model output to support virtual system integration testing. This presentation illustrates the methods and products with a rocket motor initiation case.

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety.

PubMed

Heget, Jeffrey R; Bagian, James P; Lee, Caryl Z; Gosbee, John W

2002-12-01

In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities. To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond. NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.

Factors Implicated in Safety-related Firefighter Fatalities.

PubMed

Kahn, Steven A; Palmieri, Tina L; Sen, Soman; Woods, Jason; Gunter, Oliver L

Firefighting is wrought with risk, as 80-100 firefighters (FFs) die on the job each year in the United States. Many of the fatalities have been analyzed by the National Institute for Occupational Safety and Health (NIOSH) to determine contributing factors. The purpose of this study is to determine variables that put FFs at risk for potentially preventable workplace mortality such as use of personal protective equipment (PPE), seat belts, and appropriate training/fitness/clearance for duty. The NIOSH FF Fatality Database reports from 2009 to 2014 were analyzed. Data including age, gender, years on the job, weather, other calls on the same shift, and department type were compared between FFs who employed PPE, seat belts, or wellness/fitness and those who did not. A second group of FFs was determined by NIOSH to have inexperience, lack of training, or inappropriate clearance for duty implicated in their fatalities. Comparisons for the second group were between those whose department used training and safety-related standard operating protocols and those who did not. In 84/176 deaths, PPE/seat belts/fitness was implicated in the fatality. Lack of PPE was more likely on clear days (P = .03) but less likely on cloudy and windy days (P < .001). These FFs dying with lack of PPE had more time on the job in a single department, 18 vs 13 years (P = .03), and more time in a volunteer department, 17 vs 8 years (P < .01). Being deployed on another call during the same shift was associated with lack of PPE-34 vs 16% of those who had not been on another call (P = .005). Lack of training, experience, or medical clearance was implicated in fatalities for 100/176 FFs. FFs who worked in departments that lacked standard operating protocols for respirator fit testing, PPE, fitness testing, rapid intervention, medical clearance, safety/distress alarms, vehicle maintenance, or incident command were statistically more likely to have lack of experience/training/clearance implicated in the

Avation Safety Reporting System (ASRS) 40th Anniversary

NASA Image and Video Library

2016-09-28

Avation Safety Reporting System (ASRS) 40th Anniversary lunch and open house at the Sunnyvale office. Thomas A Edwards, Deputy Center Director NASA Ames (Left), presents a plaque On the anniversary of the aviation safety reporting system, this award is in recognition of 18 years of outstanding leadership as Program Director, resulting in strong program growth, expanded partnership and a widely recognized impact on National and Global transportation safety. Presented to Linda J. Connell, ASRS Program Director (Right)

System interface for an integrated intelligent safety system (ISS) for vehicle applications.

PubMed

Hannan, Mahammad A; Hussain, Aini; Samad, Salina A

2010-01-01

This paper deals with the interface-relevant activity of a vehicle integrated intelligent safety system (ISS) that includes an airbag deployment decision system (ADDS) and a tire pressure monitoring system (TPMS). A program is developed in LabWindows/CVI, using C for prototype implementation. The prototype is primarily concerned with the interconnection between hardware objects such as a load cell, web camera, accelerometer, TPM tire module and receiver module, DAQ card, CPU card and a touch screen. Several safety subsystems, including image processing, weight sensing and crash detection systems, are integrated, and their outputs are combined to yield intelligent decisions regarding airbag deployment. The integrated safety system also monitors tire pressure and temperature. Testing and experimentation with this ISS suggests that the system is unique, robust, intelligent, and appropriate for in-vehicle applications.

System Interface for an Integrated Intelligent Safety System (ISS) for Vehicle Applications

PubMed Central

Hannan, Mahammad A.; Hussain, Aini; Samad, Salina A.

2010-01-01

This paper deals with the interface-relevant activity of a vehicle integrated intelligent safety system (ISS) that includes an airbag deployment decision system (ADDS) and a tire pressure monitoring system (TPMS). A program is developed in LabWindows/CVI, using C for prototype implementation. The prototype is primarily concerned with the interconnection between hardware objects such as a load cell, web camera, accelerometer, TPM tire module and receiver module, DAQ card, CPU card and a touch screen. Several safety subsystems, including image processing, weight sensing and crash detection systems, are integrated, and their outputs are combined to yield intelligent decisions regarding airbag deployment. The integrated safety system also monitors tire pressure and temperature. Testing and experimentation with this ISS suggests that the system is unique, robust, intelligent, and appropriate for in-vehicle applications. PMID:22205861

30 CFR 250.804 - Production safety-system testing and records.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 30 Mineral Resources 2 2013-07-01 2013-07-01 false Production safety-system testing and records... Gas Production Safety Systems § 250.804 Production safety-system testing and records. (a) Inspection... devices operating at temperatures which could ignite a methane-air mixture shall not be used. All...

30 CFR 250.804 - Production safety-system testing and records.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 2 2012-07-01 2012-07-01 false Production safety-system testing and records... Gas Production Safety Systems § 250.804 Production safety-system testing and records. (a) Inspection... devices operating at temperatures which could ignite a methane-air mixture shall not be used. All...

30 CFR 250.804 - Production safety-system testing and records.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 2 2014-07-01 2014-07-01 false Production safety-system testing and records... Gas Production Safety Systems § 250.804 Production safety-system testing and records. (a) Inspection... devices operating at temperatures which could ignite a methane-air mixture shall not be used. All...

Comprehensive Safety Analysis 2010 Safety Measurement System (SMS) Methodology, Version 2.1 Revised December 2010

DOT National Transportation Integrated Search

2010-12-01

This report documents the Safety Measurement System (SMS) methodology developed to support the Comprehensive Safety Analysis 2010 (CSA 2010) Initiative for the Federal Motor Carrier Safety Administration (FMCSA). The SMS is one of the major tools for...

Safety Characteristics in System Application Software for Human Rated Exploration

NASA Technical Reports Server (NTRS)

Mango, E. J.

2016-01-01

NASA and its industry and international partners are embarking on a bold and inspiring development effort to design and build an exploration class space system. The space system is made up of the Orion system, the Space Launch System (SLS) and the Ground Systems Development and Operations (GSDO) system. All are highly coupled together and dependent on each other for the combined safety of the space system. A key area of system safety focus needs to be in the ground and flight application software system (GFAS). In the development, certification and operations of GFAS, there are a series of safety characteristics that define the approach to ensure mission success. This paper will explore and examine the safety characteristics of the GFAS development.

Analyzing system safety in lithium-ion grid energy storage

DOE PAGES

Rosewater, David; Williams, Adam

2015-10-08

As grid energy storage systems become more complex, it grows more di cult to design them for safe operation. This paper first reviews the properties of lithium-ion batteries that can produce hazards in grid scale systems. Then the conventional safety engineering technique Probabilistic Risk Assessment (PRA) is reviewed to identify its limitations in complex systems. To address this gap, new research is presented on the application of Systems-Theoretic Process Analysis (STPA) to a lithium-ion battery based grid energy storage system. STPA is anticipated to ll the gaps recognized in PRA for designing complex systems and hence be more e ectivemore » or less costly to use during safety engineering. It was observed that STPA is able to capture causal scenarios for accidents not identified using PRA. Additionally, STPA enabled a more rational assessment of uncertainty (all that is not known) thereby promoting a healthy skepticism of design assumptions. Lastly, we conclude that STPA may indeed be more cost effective than PRA for safety engineering in lithium-ion battery systems. However, further research is needed to determine if this approach actually reduces safety engineering costs in development, or improves industry safety standards.« less

Analyzing system safety in lithium-ion grid energy storage

NASA Astrophysics Data System (ADS)

Rosewater, David; Williams, Adam

2015-12-01

As grid energy storage systems become more complex, it grows more difficult to design them for safe operation. This paper first reviews the properties of lithium-ion batteries that can produce hazards in grid scale systems. Then the conventional safety engineering technique Probabilistic Risk Assessment (PRA) is reviewed to identify its limitations in complex systems. To address this gap, new research is presented on the application of Systems-Theoretic Process Analysis (STPA) to a lithium-ion battery based grid energy storage system. STPA is anticipated to fill the gaps recognized in PRA for designing complex systems and hence be more effective or less costly to use during safety engineering. It was observed that STPA is able to capture causal scenarios for accidents not identified using PRA. Additionally, STPA enabled a more rational assessment of uncertainty (all that is not known) thereby promoting a healthy skepticism of design assumptions. We conclude that STPA may indeed be more cost effective than PRA for safety engineering in lithium-ion battery systems. However, further research is needed to determine if this approach actually reduces safety engineering costs in development, or improves industry safety standards.

An Autonomous Flight Safety System

NASA Technical Reports Server (NTRS)

Bull, James B.; Lanzi, Raymond J.

2007-01-01

The Autonomous Flight Safety System (AFSS) being developed by NASA s Goddard Space Flight Center s Wallops Flight Facility and Kennedy Space Center has completed two successful developmental flights and is preparing for a third. AFSS has been demonstrated to be a viable architecture for implementation of a completely vehicle based system capable of protecting life and property in event of an errant vehicle by terminating the flight or initiating other actions. It is capable of replacing current human-in-the-loop systems or acting in parallel with them. AFSS is configured prior to flight in accordance with a specific rule set agreed upon by the range safety authority and the user to protect the public and assure mission success. This paper discusses the motivation for the project, describes the method of development, and presents an overview of the evolving architecture and the current status.

Development of a methodology for assessing the safety of embedded software systems

NASA Technical Reports Server (NTRS)

Garrett, C. J.; Guarro, S. B.; Apostolakis, G. E.

1993-01-01

A Dynamic Flowgraph Methodology (DFM) based on an integrated approach to modeling and analyzing the behavior of software-driven embedded systems for assessing and verifying reliability and safety is discussed. DFM is based on an extension of the Logic Flowgraph Methodology to incorporate state transition models. System models which express the logic of the system in terms of causal relationships between physical variables and temporal characteristics of software modules are analyzed to determine how a certain state can be reached. This is done by developing timed fault trees which take the form of logical combinations of static trees relating the system parameters at different point in time. The resulting information concerning the hardware and software states can be used to eliminate unsafe execution paths and identify testing criteria for safety critical software functions.

Clinical Relation Extraction Toward Drug Safety Surveillance Using Electronic Health Record Narratives: Classical Learning Versus Deep Learning.

PubMed

Munkhdalai, Tsendsuren; Liu, Feifan; Yu, Hong

2018-04-25

Medication and adverse drug event (ADE) information extracted from electronic health record (EHR) notes can be a rich resource for drug safety surveillance. Existing observational studies have mainly relied on structured EHR data to obtain ADE information; however, ADEs are often buried in the EHR narratives and not recorded in structured data. To unlock ADE-related information from EHR narratives, there is a need to extract relevant entities and identify relations among them. In this study, we focus on relation identification. This study aimed to evaluate natural language processing and machine learning approaches using the expert-annotated medical entities and relations in the context of drug safety surveillance, and investigate how different learning approaches perform under different configurations. We have manually annotated 791 EHR notes with 9 named entities (eg, medication, indication, severity, and ADEs) and 7 different types of relations (eg, medication-dosage, medication-ADE, and severity-ADE). Then, we explored 3 supervised machine learning systems for relation identification: (1) a support vector machines (SVM) system, (2) an end-to-end deep neural network system, and (3) a supervised descriptive rule induction baseline system. For the neural network system, we exploited the state-of-the-art recurrent neural network (RNN) and attention models. We report the performance by macro-averaged precision, recall, and F1-score across the relation types. Our results show that the SVM model achieved the best average F1-score of 89.1% on test data, outperforming the long short-term memory (LSTM) model with attention (F1-score of 65.72%) as well as the rule induction baseline system (F1-score of 7.47%) by a large margin. The bidirectional LSTM model with attention achieved the best performance among different RNN models. With the inclusion of additional features in the LSTM model, its performance can be boosted to an average F1-score of 77.35%. It shows that

Functional Safety of Hybrid Laser Safety Systems - How can a Combination between Passive and Active Components Prevent Accidents?

NASA Astrophysics Data System (ADS)

Lugauer, F. P.; Stiehl, T. H.; Zaeh, M. F.

Modern laser systems are widely used in industry due to their excellent flexibility and high beam intensities. This leads to an increased hazard potential, because conventional laser safety barriers only offer a short protection time when illuminated with high laser powers. For that reason active systems are used more and more to prevent accidents with laser machines. These systems must fulfil the requirements of functional safety, e.g. according to IEC 61508, which causes high costs. The safety provided by common passive barriers is usually unconsidered in this context. In the presented approach, active and passive systems are evaluated from a holistic perspective. To assess the functional safety of hybrid safety systems, the failure probability of passive barriers is analysed and added to the failure probability of the active system.

Assessment of the State-of-the-Art of System-Wide Safety and Assurance Technologies

NASA Technical Reports Server (NTRS)

Roychoudhury, Indranil; Reveley, Mary S.; Phojanamongkolkij, Nipa; Leone, Karen M.

2017-01-01

Since its initiation, the System-wide Safety Assurance Technologies (SSAT) Project has been focused on developing multidisciplinary tools and techniques that are verified and validated to ensure prevention of loss of property and life in NextGen and enable proactive risk management through predictive methods. To this end, four technical challenges have been listed to help realize the goals of SSAT, namely (i) assurance of flight critical systems, (ii) discovery of precursors to safety incidents, (iii) assuring safe human-systems integration, and (iv) prognostic algorithm design for safety assurance. The objective of this report is to provide an extensive survey of SSAT-related research accomplishments by researchers within and outside NASA to get an understanding of what the state-of-the-art is for technologies enabling each of the four technical challenges. We hope that this report will serve as a good resource for anyone interested in gaining an understanding of the SSAT technical challenges, and also be useful in the future for project planning and resource allocation for related research.

Safety evaluation of intersection conflict warning system.

DOT National Transportation Integrated Search

2016-06-01

FHWA organized a pooled fund study of 40 States to evaluate low-cost safety strategies as part of its strategic highway safety effort. One of the strategies selected for evaluation was intersection conflict warning systems (ICWSs). This strategy is i...

Aviation safety data accessibility study index: a report on the issues related to public interest in aviation safety data

DOT National Transportation Integrated Search

1997-01-20

This paper reviews aviation safety data and measurement issues relevant to the determination of the best means of providing safety information to the public while ensuring the integrity of the aviation safety system. In addition , the paper examines ...

Proposed system safety design and test requirements for the microlaser ordnance system

NASA Technical Reports Server (NTRS)

Stoltz, Barb A.; Waldo, Dale F.

1993-01-01

Safety for pyrotechnic ignition systems is becoming a major concern for the military. In the past twenty years, stray electromagnetic fields have steadily increased during peacetime training missions and have dramatically increased during battlefield missions. Almost all of the ordnance systems in use today depend on an electrical bridgewire for ignition. Unfortunately, the bridgewire is the cause of the majority of failure modes. The common failure modes include the following: broken bridgewires; transient RF power, which induces bridgewire heating; and cold temperatures, which contracts the explosive mix away from the bridgewire. Finding solutions for these failure modes is driving the costs of pyrotechnic systems up. For example, analyses are performed to verify that the system in the environment will not see more energy than 20 dB below the 'No-fire' level. Range surveys are performed to determine the operational, storage, and transportation RF environments. Cryogenic tests are performed to verify the bridgewire to mix interface. System requirements call for 'last minute installation,' 'continuity checks after installation,' and rotating safety devices to 'interrupt the explosive train.' As an alternative, MDESC has developed a new approach based upon our enabling laser diode technology. We believe that Microlaser initiated ordnance offers a unique solution to the bridgewire safety concerns. For this presentation, we will address, from a system safety viewpoint, the safety design and the test requirements for a Microlaser ordnance system. We will also review how this system could be compliant to MIL-STD-1576 and DOD-83578A and the additional necessary requirements.

33 CFR 96.220 - What makes up a safety management system?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 33 Navigation and Navigable Waters 1 2010-07-01 2010-07-01 false What makes up a safety management... SECURITY VESSEL OPERATING REGULATIONS RULES FOR THE SAFE OPERATION OF VESSELS AND SAFETY MANAGEMENT SYSTEMS Company and Vessel Safety Management Systems § 96.220 What makes up a safety management system? (a) The...

[B-BS and occupational health and safety management systems].

PubMed

Bacchetta, Adriano Paolo

2010-01-01

The objective of a SGSL is the "prevention" agreement as approach of "pro-active" toward the safety at work through the construction of an integrated managerial system in synergic an dynamic way with the business organization, according to continuous improvement principles. Nevertheless the adoption of a SGSL, not could guarantee by itself the obtainment of the full effectiveness than projected and every individual's adhesion to it, must guarantee it's personal involvement in proactive way, so that to succeed to actual really how much hypothesized to systemic level to increase the safety in firm. The objective of a behavioral safety process that comes to be integrated in a SGSL, it has the purpose to succeed in implementing in firm a process of cultural change that raises the workers social group fundamental safety value, producing an ample and full involvement of all in the activities of safety at work development. SGSL = Occupational Health and Safety Management System.

18 CFR 12.10 - Reporting safety-related incidents.

Code of Federal Regulations, 2010 CFR

2010-04-01

... report of any death or serious injury considered or alleged to be project related must also describe any... be verified in accordance with § 12.13. (3) Accidents that are not project-related may be reported by... COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS AND...

Development of a Comprehensive Database System for Safety Analyst

PubMed Central

Paz, Alexander; Veeramisti, Naveen; Khanal, Indira; Baker, Justin

2015-01-01

This study addressed barriers associated with the use of Safety Analyst, a state-of-the-art tool that has been developed to assist during the entire Traffic Safety Management process but that is not widely used due to a number of challenges as described in this paper. As part of this study, a comprehensive database system and tools to provide data to multiple traffic safety applications, with a focus on Safety Analyst, were developed. A number of data management tools were developed to extract, collect, transform, integrate, and load the data. The system includes consistency-checking capabilities to ensure the adequate insertion and update of data into the database. This system focused on data from roadways, ramps, intersections, and traffic characteristics for Safety Analyst. To test the proposed system and tools, data from Clark County, which is the largest county in Nevada and includes the cities of Las Vegas, Henderson, Boulder City, and North Las Vegas, was used. The database and Safety Analyst together help identify the sites with the potential for safety improvements. Specifically, this study examined the results from two case studies. The first case study, which identified sites having a potential for safety improvements with respect to fatal and all injury crashes, included all roadway elements and used default and calibrated Safety Performance Functions (SPFs). The second case study identified sites having a potential for safety improvements with respect to fatal and all injury crashes, specifically regarding intersections; it used default and calibrated SPFs as well. Conclusions were developed for the calibration of safety performance functions and the classification of site subtypes. Guidelines were provided about the selection of a particular network screening type or performance measure for network screening. PMID:26167531

Model-Driven Safety Analysis of Closed-Loop Medical Systems

PubMed Central

Pajic, Miroslav; Mangharam, Rahul; Sokolsky, Oleg; Arney, David; Goldman, Julian; Lee, Insup

2013-01-01

In modern hospitals, patients are treated using a wide array of medical devices that are increasingly interacting with each other over the network, thus offering a perfect example of a cyber-physical system. We study the safety of a medical device system for the physiologic closed-loop control of drug infusion. The main contribution of the paper is the verification approach for the safety properties of closed-loop medical device systems. We demonstrate, using a case study, that the approach can be applied to a system of clinical importance. Our method combines simulation-based analysis of a detailed model of the system that contains continuous patient dynamics with model checking of a more abstract timed automata model. We show that the relationship between the two models preserves the crucial aspect of the timing behavior that ensures the conservativeness of the safety analysis. We also describe system design that can provide open-loop safety under network failure. PMID:24177176

Model-Driven Safety Analysis of Closed-Loop Medical Systems.

PubMed

Pajic, Miroslav; Mangharam, Rahul; Sokolsky, Oleg; Arney, David; Goldman, Julian; Lee, Insup

2012-10-26

In modern hospitals, patients are treated using a wide array of medical devices that are increasingly interacting with each other over the network, thus offering a perfect example of a cyber-physical system. We study the safety of a medical device system for the physiologic closed-loop control of drug infusion. The main contribution of the paper is the verification approach for the safety properties of closed-loop medical device systems. We demonstrate, using a case study, that the approach can be applied to a system of clinical importance. Our method combines simulation-based analysis of a detailed model of the system that contains continuous patient dynamics with model checking of a more abstract timed automata model. We show that the relationship between the two models preserves the crucial aspect of the timing behavior that ensures the conservativeness of the safety analysis. We also describe system design that can provide open-loop safety under network failure.

The role of microbiological testing in systems for assuring the safety of beef.

PubMed

Brown, M H; Gill, C O; Hollingsworth, J; Nickelson, R; Seward, S; Sheridan, J J; Stevenson, T; Sumner, J L; Theno, D M; Usborne, W R; Zink, D

2000-12-05

The use of microbiological testing in systems for assuring the safety of beef was considered at a meeting arranged by the International Livestock Educational Foundation as part of the International Livestock Congress, TX, USA, during February, 2000. The 11 invited participants from industry and government research organizations concurred in concluding that microbiological testing is necessary for the implementation and maintenance of effective Hazard Analysis Critical Control Point (HACCP) systems, which are the only means of assuring the microbiological safety of beef; that microbiological testing for HACCP purposes must involve the enumeration of indicator organisms rather than the detection of pathogens; that the efficacy of process control should be assessed against performance criteria and food safety objectives that refer to the numbers of indicator organisms in product; that sampling procedures should allow indicator organisms to be enumerated at very low numbers; and that food safety objectives and microbiological criteria are better related to variables, rather than attributes sampling plans.

Defining the pharmaceutical system to support proactive drug safety.

PubMed

Lewis, Vicki R; Hernandez, Angelica; Meadors, Margaret

2013-02-01

The military, aviation, nuclear, and transportation industries have transformed their safety records by using a systems approach to safety and risk mitigation. This article creates a preliminary model of the U.S. pharmaceutical system using available literature including academic publications, policies, and guidelines established by regulatory bodies and drug industry trade publications. Drawing from the current literature, the goals, roles, and individualized processes of pharmaceutical subsystems will be defined. Defining the pharmaceutical system provides a vehicle to assess and address known problems within the system, and provides a means to conduct proactive risk analyses, which would create significant pharmaceutical safety advancement.

Requirements Analysis for the Army Safety Management Information System (ASMIS)

DTIC Science & Technology

1989-03-01

8217_>’ Telephone Number « .. PNL-6819 Limited Distribution Requirements Analysis for the Army Safety Management Information System (ASMIS) Final...PNL-6819 REQUIREMENTS ANALYSIS FOR THE ARMY SAFETY MANAGEMENT INFORMATION SYSTEM (ASMIS) FINAL REPORT J. S. Littlefield A. L. Corrigan March...accidents. This accident data is available under the Army Safety Management Information System (ASMIS) which is an umbrella for many databases

A system safety model for developmental aircraft programs

NASA Technical Reports Server (NTRS)

Amberboy, E. J.; Stokeld, R. L.

1982-01-01

Basic tenets of safety as applied to developmental aircraft programs are presented. The integration of safety into the project management aspects of planning, organizing, directing and controlling is illustrated by examples. The basis for project management use of safety and the relationship of these management functions to 'real-world' situations is presented. The rationale which led to the safety-related project decision and the lessons learned as they may apply to future projects are presented.

Advancing a sociotechnical systems approach to workplace safety--developing the conceptual framework.

PubMed

Carayon, Pascale; Hancock, Peter; Leveson, Nancy; Noy, Ian; Sznelwar, Laerte; van Hootegem, Geert

2015-01-01

Traditional efforts to deal with the enormous problem of workplace safety have proved insufficient, as they have tended to neglect the broader sociotechnical environment that surrounds workers. Here, we advocate a sociotechnical systems approach that describes the complex multi-level system factors that contribute to workplace safety. From the literature on sociotechnical systems, complex systems and safety, we develop a sociotechnical model of workplace safety with concentric layers of the work system, socio-organisational context and the external environment. The future challenges that are identified through the model are highlighted. Understanding the environmental, organisational and work system factors that contribute to workplace safety will help to develop more effective and integrated solutions to deal with persistent workplace safety problems. Solutions to improve workplace safety need to recognise the broad sociotechnical system and the respective interactions between the system elements and levels.

Safety Aspects of Big Cryogenic Systems Design

NASA Astrophysics Data System (ADS)

Chorowski, M.; Fydrych, J.; Poliński, J.

2010-04-01

Superconductivity and helium cryogenics are key technologies in the construction of large scientific instruments, like accelerators, fusion reactors or free electron lasers. Such cryogenic systems may contain more than hundred tons of helium, mostly in cold and high-density phases. In spite of the high reliability of the systems, accidental loss of the insulation vacuum, pipe rupture or rapid energy dissipation in the cold helium can not be overlooked. To avoid the danger of over-design pressure rise in the cryostats, they need to be equipped with a helium relief system. Such a system is comprised of safety valves, bursting disks and optionally cold or warm quench lines, collectors and storage tanks. Proper design of the helium safety relief system requires a good understanding of worst case scenarios. Such scenarios will be discussed, taking into account different possible failures of the cryogenic system. In any case it is necessary to estimate heat transfer through degraded vacuum superinsulation and mass flow through the valves and safety disks. Even if the design of the helium relief system does not foresee direct helium venting into the environment, an occasional emergency helium spill may happen. Helium propagation in the atmosphere and the origins of oxygen-deficiency hazards will be discussed.

The carrier safety measurement system (CSMS) effectiveness test by behavior analysis and safety improvement categories (BASICs)

DOT National Transportation Integrated Search

2014-01-24

The Carrier Safety Measurement System (CSMS) is the Federal Motor Carrier Safety Administrations (FMCSA's) workload prioritization tool. This tool is used to identify carriers with potential safety issues so that they are subject to interventions ...

Preventive Effects of Safety Helmets on Traumatic Brain Injury after Work-Related Falls

PubMed Central

Kim, Sang Chul; Ro, Young Sun; Shin, Sang Do; Kim, Joo Yeong

2016-01-01

Introduction: Work-related traumatic brain injury (TBI) caused by falls is a catastrophic event that leads to disabilities and high socio-medical costs. This study aimed to measure the magnitude of the preventive effect of safety helmets on clinical outcomes and to compare the effect across different heights of fall. Methods: We collected a nationwide, prospective database of work-related injury patients who visited the 10 emergency departments between July 2010 and October 2012. All of the adult patients who experienced work-related fall injuries were eligible, excluding cases with unknown safety helmet use and height of fall. Primary and secondary endpoints were intracranial injury and in-hospital mortality. We calculated adjusted odds ratios (AORs) of safety helmet use and height of fall for study outcomes, and adjusted for any potential confounders. Results: A total of 1298 patients who suffered from work-related fall injuries were enrolled. The industrial or construction area was the most common place of fall injury occurrence, and 45.0% were wearing safety helmets at the time of fall injuries. The safety helmet group was less likely to have intracranial injury comparing with the no safety helmet group (the adjusted odds ratios (ORs) (95% confidence interval (CI)): 0.42 (0.24–0.73)), however, there was no statistical difference of in-hospital mortality between two groups (the adjusted ORs (95% CI): 0.83 (0.34–2.03). In the interaction analysis, preventive effects of safety helmet on intracranial injury were significant within 4 m height of fall. Conclusions: A safety helmet is associated with prevention of intracranial injury resulting from work-related fall and the effect is preserved within 4 m height of fall. Therefore, wearing a safety helmet can be an intervention for protecting fall-related intracranial injury in the workplace. PMID:27801877

Preventive Effects of Safety Helmets on Traumatic Brain Injury after Work-Related Falls.

PubMed

Kim, Sang Chul; Ro, Young Sun; Shin, Sang Do; Kim, Joo Yeong

2016-10-29

Work-related traumatic brain injury (TBI) caused by falls is a catastrophic event that leads to disabilities and high socio-medical costs. This study aimed to measure the magnitude of the preventive effect of safety helmets on clinical outcomes and to compare the effect across different heights of fall. We collected a nationwide, prospective database of work-related injury patients who visited the 10 emergency departments between July 2010 and October 2012. All of the adult patients who experienced work-related fall injuries were eligible, excluding cases with unknown safety helmet use and height of fall. Primary and secondary endpoints were intracranial injury and in-hospital mortality. We calculated adjusted odds ratios (AORs) of safety helmet use and height of fall for study outcomes, and adjusted for any potential confounders. A total of 1298 patients who suffered from work-related fall injuries were enrolled. The industrial or construction area was the most common place of fall injury occurrence, and 45.0% were wearing safety helmets at the time of fall injuries. The safety helmet group was less likely to have intracranial injury comparing with the no safety helmet group (the adjusted odds ratios (ORs) (95% confidence interval (CI)): 0.42 (0.24-0.73)), however, there was no statistical difference of in-hospital mortality between two groups (the adjusted ORs (95% CI): 0.83 (0.34-2.03). In the interaction analysis, preventive effects of safety helmet on intracranial injury were significant within 4 m height of fall. A safety helmet is associated with prevention of intracranial injury resulting from work-related fall and the effect is preserved within 4 m height of fall. Therefore, wearing a safety helmet can be an intervention for protecting fall-related intracranial injury in the workplace.

Model Transformation for a System of Systems Dependability Safety Case

NASA Technical Reports Server (NTRS)

Murphy, Judy; Driskell, Stephen B.

2010-01-01

Software plays an increasingly larger role in all aspects of NASA's science missions. This has been extended to the identification, management and control of faults which affect safety-critical functions and by default, the overall success of the mission. Traditionally, the analysis of fault identification, management and control are hardware based. Due to the increasing complexity of system, there has been a corresponding increase in the complexity in fault management software. The NASA Independent Validation & Verification (IV&V) program is creating processes and procedures to identify, and incorporate safety-critical software requirements along with corresponding software faults so that potential hazards may be mitigated. This Specific to Generic ... A Case for Reuse paper describes the phases of a dependability and safety study which identifies a new, process to create a foundation for reusable assets. These assets support the identification and management of specific software faults and, their transformation from specific to generic software faults. This approach also has applications to other systems outside of the NASA environment. This paper addresses how a mission specific dependability and safety case is being transformed to a generic dependability and safety case which can be reused for any type of space mission with an emphasis on software fault conditions.

Examining the Relationship between Safety Management System Implementation and Safety Culture in Collegiate Flight Schools

ERIC Educational Resources Information Center

Robertson, Mike Fuller

2017-01-01

Safety Management Systems (SMS) are becoming the industry standard for safety management throughout the aviation industry. As the Federal Aviation Administration (FAA) continues to mandate SMS for different segments, the assessment of an organization's safety culture becomes more important. An SMS can facilitate the development of a strong…

European Workshop Industrical Computer Science Systems approach to design for safety

NASA Technical Reports Server (NTRS)

Zalewski, Janusz

1992-01-01

This paper presents guidelines on designing systems for safety, developed by the Technical Committee 7 on Reliability and Safety of the European Workshop on Industrial Computer Systems. The focus is on complementing the traditional development process by adding the following four steps: (1) overall safety analysis; (2) analysis of the functional specifications; (3) designing for safety; (4) validation of design. Quantitative assessment of safety is possible by means of a modular questionnaire covering various aspects of the major stages of system development.

Work stress and patient safety: observer-rated work stressors as predictors of characteristics of safety-related events reported by young nurses.

PubMed

Elfering, A; Semmer, N K; Grebner, S

This study investigates the link between workplace stress and the 'non-singularity' of patient safety-related incidents in the hospital setting. Over a period of 2 working weeks 23 young nurses from 19 hospitals in Switzerland documented 314 daily stressful events using a self-observation method (pocket diaries); 62 events were related to patient safety. Familiarity of safety-related events and probability of recurrence, as indicators of non-singularity, were the dependent variables in multilevel regression analyses. Predictor variables were both situational (self-reported situational control, safety compliance) and chronic variables (job stressors such as time pressure, or concentration demands and job control). Chronic work characteristics were rated by trained observers. The most frequent safety-related stressful events included incomplete or incorrect documentation (40.3%), medication errors (near misses 21%), delays in delivery of patient care (9.7%), and violent patients (9.7%). Familiarity of events and probability of recurrence were significantly predicted by chronic job stressors and low job control in multilevel regression analyses. Job stressors and low job control were shown to be risk factors for patient safety. The results suggest that job redesign to enhance job control and decrease job stressors may be an important intervention to increase patient safety.

Software-Based Safety Systems in Space - Learning from other Domains

NASA Astrophysics Data System (ADS)

Klicker, M.; Putzer, H.

2012-01-01

Increasing complexity and new emerging capabilities for manned and unmanned missions have been the hallmark of the past decades of space exploration. One of the drivers in this process was the ever increasing use of software and software-intensive systems to implement system functions necessary to the capabilities needed. The course of technological evolution suggests that this development will continue well into the future with a number of challenges for the safety community some of which shall be discussed in this paper. The current state of the art reveals a number of problems with developing and assessing safety critical software which explains the reluctance of the space community to rely on software-based safety measures to mitigate hazards. Among others, usually lack of trustworthy evidence of software integrity in all foreseeable situations and the difficulties to integrate software in the traditional safety analysis framework are cited. Experience from other domains and recent developments in modern software development methodologies and verification techniques are analysed for the suitability for space systems and an avionics architectural framework (see STANAG 4626) for the implementation of safety critical software is proposed. This is shown to create among other features the possibility of numerous degradation modes enhancing overall system safety and interoperability of computerized space systems. It also potentially simplifies international cooperation on a technical level by introducing a higher degree of compatibility. As software safety cannot be tested or argued into a system in hindsight, the development process and especially the architecture chosen are essential to establish safety properties for the software used to implement safety functions. The core of the safety argument revolves around the separation of different functions and software modules from each other by minimal coupling of functions and credible separation mechanisms in the

Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps.

PubMed

Weingarten, Toby N; Taenzer, Andreas H; Elkassabany, Nabil M; Le Wendling, Linda; Nin, Olga; Kent, Michael L

2018-05-02

In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Expert commentary. Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.

Commercial grade item (CGI) dedication of generators for nuclear safety related applications

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

Das, R.K.; Hajos, L.G.

1993-03-01

The number of nuclear safety related equipment suppliers and the availability of spare and replacement parts designed specifically for nuclear safety related application are shrinking rapidly. These have made it necessary for utilities to apply commercial grade spare and replacement parts in nuclear safety related applications after implementing proper acceptance and dedication process to verify that such items conform with the requirements of their use in nuclear safety related application. The general guidelines for the commercial grade item (CGI) acceptance and dedication are provided in US Nuclear Regulatory Commission (NRC) Generic Letters and Electric Power Research Institute (EPRI) Report NP-5652,more » Guideline for the Utilization of Commercial Grade Items in Nuclear Safety Related Applications. This paper presents an application of these generic guidelines for procurement, acceptance, and dedication of a commercial grade generator for use as a standby generator at Salem Generating Station Units 1 and 2. The paper identifies the critical characteristics of the generator which once verified, will provide reasonable assurance that the generator will perform its intended safety function. The paper also delineates the method of verification of the critical characteristics through tests and provide acceptance criteria for the test results. The methodology presented in this paper may be used as specific guidelines for reliable and cost effective procurement and dedication of commercial grade generators for use as standby generators at nuclear power plants.« less

Software Safety Analysis of a Flight Guidance System

NASA Technical Reports Server (NTRS)

Butler, Ricky W. (Technical Monitor); Tribble, Alan C.; Miller, Steven P.; Lempia, David L.

2004-01-01

This document summarizes the safety analysis performed on a Flight Guidance System (FGS) requirements model. In particular, the safety properties desired of the FGS model are identified and the presence of the safety properties in the model is formally verified. Chapter 1 provides an introduction to the entire project, while Chapter 2 gives a brief overview of the problem domain, the nature of accidents, model based development, and the four-variable model. Chapter 3 outlines the approach. Chapter 4 presents the results of the traditional safety analysis techniques and illustrates how the hazardous conditions associated with the system trace into specific safety properties. Chapter 5 presents the results of the formal methods analysis technique model checking that was used to verify the presence of the safety properties in the requirements model. Finally, Chapter 6 summarizes the main conclusions of the study, first and foremost that model checking is a very effective verification technique to use on discrete models with reasonable state spaces. Additional supporting details are provided in the appendices.

Consensus-based Recommendations for Research Priorities Related to Interventions to Safeguard Patient Safety in the Crowded Emergency Department

PubMed Central

Fee, Christopher; Hall, Kendall; Morrison, J. Bradley; Stephens, Robert; Cosby, Karen; Fairbanks, Rollin (Terry) J.; Youngberg, Barbara; Lenehan, Gail; Abualenain, Jameel; O’Connor, Kevin; Wears, Robert

2012-01-01

This article describes the results of the Interventions to Safeguard Safety breakout session of the 2011 Academic Emergency Medicine (AEM) consensus conference entitled “Interventions to Assure Quality in the Crowded Emergency Department.” Using a multistep nominal group technique, experts in emergency department (ED) crowding, patient safety, and systems engineering defined knowledge gaps and priority research questions related to the maintenance of safety in the crowded ED. Consensus was reached for seven research priorities related to interventions to maintain safety in the setting of a crowded ED. Included among these are: 1) How do routine corrective processes and compensating mechanism change during crowding? 2) What metrics should be used to determine ED safety? 3) How can checklists ensure safer care and what factors contribute to their success or failure? 4) What constitutes safe staffing levels / ratios? 5) How can we align emergency medicine (EM)-specific patient safety issues with national patient safety issues? 6) How can we develop metrics and skills to recognize when an ED is getting close to catastrophic overload conditions? and 7) What can EM learn from experts and modeling from fields outside of medicine to develop innovative solutions? These priorities have the potential to inform future clinical and human factors research and extramural funding decisions related to this important topic. PMID:22168192

Safety belt interlock system usage survey

DOT National Transportation Integrated Search

1976-08-01

This research is intended to measure the effectiveness of various use-inducing systems in increasing safety belt usage. Specifically, the objectives are: (1) to determine if the 1975 warning system issued in response to P.L. 93-492 is effective in in...

Managing Safety and Operations: The Effect of Joint Management System Practices on Safety and Operational Outcomes.

PubMed

Tompa, Emile; Robson, Lynda; Sarnocinska-Hart, Anna; Klassen, Robert; Shevchenko, Anton; Sharma, Sharvani; Hogg-Johnson, Sheilah; Amick, Benjamin C; Johnston, David A; Veltri, Anthony; Pagell, Mark

2016-03-01

The aim of this study was to determine whether management system practices directed at both occupational health and safety (OHS) and operations (joint management system [JMS] practices) result in better outcomes in both areas than in alternative practices. Separate regressions were estimated for OHS and operational outcomes using data from a survey along with administrative records on injuries and illnesses. Organizations with JMS practices had better operational and safety outcomes than organizations without these practices. They had similar OHS outcomes as those with operations-weak practices, and in some cases, better outcomes than organizations with safety-weak practices. They had similar operational outcomes as those with safety-weak practices, and better outcomes than those with operations-weak practices. Safety and operations appear complementary in organizations with JMS practices in that there is no penalty for either safety or operational outcomes.

Study of a safety margin system for powered-lift STOL aircraft

NASA Technical Reports Server (NTRS)

Heffley, R. K.; Jewell, W. F.

1978-01-01

A study was conducted to explore the feasibility of a safety margin system for powered-lift aircraft which require a backside piloting technique. The objective of the safety margin system was to present multiple safety margin criteria as a single variable which could be tracked manually or automatically and which could be monitored for the purpose of deriving safety margin status. The study involved a pilot-in-the-loop analysis of several safety margin system concepts and a simulation experiment to evaluate those concepts which showed promise of providing a good solution. A system was ultimately configured which offered reasonable compromises in controllability, status information content, and the ability to regulate the safety margin at some expense of the allowable low speed flight path envelope.

Lessons learnt from the development of the Patient Safety Incidents Reporting an Learning System for the Spanish National Health System: SiNASP.

PubMed

Vallejo-Gutiérrez, Paula; Bañeres-Amella, Joaquim; Sierra, Eduardo; Casal, Jesús; Agra, Yolanda

2014-01-01

To describe the development process and characteristics of a patient safety incidents reporting system to be implemented in the Spanish National Health System, based on the context and the needs of the different stakeholders. Literature review and analysis of most relevant reporting systems, identification of more than 100 stakeholder's (patients, professionals, regional governments representatives) expectations and requirements, analysis of the legal context, consensus of taxonomy, development of the software and pilot test. Patient Safety Events Reporting and Learning system (Sistema de Notificación y Aprendizajepara la Seguridad del Paciente, SiNASP) is a generic reporting system for all types of incidents related to patient safety, voluntary, confidential, non punitive, anonymous or nominative with anonimization, system oriented, with local analysis of cases and based on the WHO International Classification for Patient Safety. The electronic program has an on-line form for reporting, a software to manage the incidents and improvement plans, and a scoreboard with process indicators to monitor the system. The reporting system has been designed to respond to the needs and expectations identified by the stakeholders, taking into account the lessons learned from the previous notification systems, the characteristics of the National Health System and the existing legal context. The development process presented and the characteristics of the system provide a comprehensive framework that can be used for future deployments of similar patient safety systems. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.

Open-type ferry safety system design for using LNG fuel

NASA Astrophysics Data System (ADS)

Pagonis, D. N.; Livanos, G.; Theotokatos, G.; Peppa, S.; Themelis, N.

2016-12-01

In this feasibility study, we investigate the viability of using Liquefied Natural Gas (LNG) fuel in an open type Ro-Ro passenger ferry and the associated potential challenges with regard to the vessel safety systems. We recommend an appropriate methodology for converting existing ships to run on LNG fuel, discuss all the necessary modifications to the ship's safety systems, and also evaluate the relevant ship evacuation procedures. We outline the basic requirements with which the ship already complies for each safety system and analyze the additional restrictions that must be taken into consideration for the use of LNG fuel. Appropriate actions are recommended. Furthermore, we carry out a hazard identification study. Overall, we clearly demonstrate the technical feasibility of the investigated scenario. Minimal modifications to the ship's safety systems are required to comply with existing safety rules for this specific type of ship.

Patient safety - the role of human factors and systems engineering.

PubMed

Carayon, Pascale; Wood, Kenneth E

2010-01-01

Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety.

Patient Safety: The Role of Human Factors and Systems Engineering

PubMed Central

Carayon, Pascale; Wood, Kenneth E.

2011-01-01

Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety. PMID:20543237

Photovoltaic system criteria documents. Volume 5: Safety criteria for photovoltaic applications

NASA Technical Reports Server (NTRS)

Koenig, John C.; Billitti, Joseph W.; Tallon, John M.

1979-01-01

Methodology is described for determining potential safety hazards involved in the construction and operation of photovoltaic power systems and provides guidelines for the implementation of safety considerations in the specification, design and operation of photovoltaic systems. Safety verification procedures for use in solar photovoltaic systems are established.

NASA aviation safety reporting system

NASA Technical Reports Server (NTRS)

1976-01-01

During the second quarter of the Aviation Safety Reporting System (ASRS) operation, 1,497 reports were received from pilots, controllers, and others in the national aviation system. Details of the administration and results of the program to date are presented. Examples of alert bulletins disseminated to the aviation community are presented together with responses to those bulletins. Several reports received by ASRS are also presented to illustrate the diversity of topics covered by reports to the system.

Epistemic Questions and Answers for Software System Safety

NASA Technical Reports Server (NTRS)

Holloway, C. M.; Johnson, Chris W.

2010-01-01

System safety is primarily concerned with epistemic questions, that is, questions concerning knowledge and the degree of confidence that can be placed in that knowledge. For systems with which human experience is long, such as roads, bridges, and mechanical devices, knowledge about what is required to make the systems safe is deep and detailed. High confidence can be placed in the validity of that knowledge. For other systems, however, with which human experience is comparatively short, such as those that rely in part or in whole on software, knowledge about what is required to ensure safety tends to be shallow and general. The confidence that can be placed in the validity of that knowledge is consequently low. In a previous paper, we enumerated a collection of foundational epistemic questions concerning software system safety. In this paper, we review and refine the questions, discuss some difficulties that attend to answering the questions today, and speculate on possible research to improve the situation.

75 FR 68224 - Safety Management Systems for Part 121 Certificate Holders

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-05

... the general framework for an organization-wide safety management approach to air carrier operations... System? An SMS is an organization-wide approach to managing safety risk and assuring the effectiveness of... under 14 CFR part 121 to develop and implement a safety management system (SMS) to improve the safety of...

Manned space flight nuclear system safety. Volume 7: Literature review. Part 1: Literature search and evaluation

NASA Technical Reports Server (NTRS)

1972-01-01

A review of the literature used in conducting the manned space flight nuclear system safety study is presented. The objectives of the presentation are to identify and evaluate for potential application to study the existing related literature and to provide the information required to include the related literature in the NASA Aerospace Safety Research and Data Institute. More than 15,000 documents were evaluated and identification forms were prepared for 850 reports.

A review of wiring system safety in space power systems

NASA Technical Reports Server (NTRS)

Stavnes, Mark W.; Hammoud, Ahmad N.

1993-01-01

Wiring system failures have resulted from arc propagation in the wiring harnesses of current aerospace vehicles. These failures occur when the insulation becomes conductive upon the initiation of an arc. In some cases, the conductive path of the carbon arc track displays a high enough resistance such that the current is limited, and therefore may be difficult to detect using conventional circuit protection. Often, such wiring failures are not simply the result of insulation failure, but are due to a combination of wiring system factors. Inadequate circuit protection, unforgiving system designs, and careless maintenance procedures can contribute to a wiring system failure. This paper approaches the problem with respect to the overall wiring system, in order to determine what steps can be taken to improve the reliability, maintainability, and safety of space power systems. Power system technologies, system designs, and maintenance procedures which have led to past wiring system failures will be discussed. New technologies, design processes, and management techniques which may lead to improved wiring system safety will be introduced.

Systems Analysis of NASA Aviation Safety Program: Final Report

NASA Technical Reports Server (NTRS)

Jones, Sharon M.; Reveley, Mary S.; Withrow, Colleen A.; Evans, Joni K.; Barr, Lawrence; Leone, Karen

2013-01-01

A three-month study (February to April 2010) of the NASA Aviation Safety (AvSafe) program was conducted. This study comprised three components: (1) a statistical analysis of currently available civilian subsonic aircraft data from the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), and the Aviation Safety Information Analysis and Sharing (ASIAS) system to identify any significant or overlooked aviation safety issues; (2) a high-level qualitative identification of future safety risks, with an assessment of the potential impact of the NASA AvSafe research on the National Airspace System (NAS) based on these risks; and (3) a detailed, top-down analysis of the NASA AvSafe program using an established and peer-reviewed systems analysis methodology. The statistical analysis identified the top aviation "tall poles" based on NTSB accident and FAA incident data from 1997 to 2006. A separate examination of medical helicopter accidents in the United States was also conducted. Multiple external sources were used to develop a compilation of ten "tall poles" in future safety issues/risks. The top-down analysis of the AvSafe was conducted by using a modification of the Gibson methodology. Of the 17 challenging safety issues that were identified, 11 were directly addressed by the AvSafe program research portfolio.

Safety huddles to proactively identify and address electronic health record safety

PubMed Central

Menon, Shailaja; Singh, Hardeep; Giardina, Traber D; Rayburn, William L; Davis, Brenda P; Russo, Elise M

2017-01-01

Objective: Methods to identify and study safety risks of electronic health records (EHRs) are underdeveloped and largely depend on limited end-user reports. “Safety huddles” have been found useful in creating a sense of collective situational awareness that increases an organization’s capacity to respond to safety concerns. We explored the use of safety huddles for identifying and learning about EHR-related safety concerns. Design: Data were obtained from daily safety huddle briefing notes recorded at a single midsized tertiary-care hospital in the United States over 1 year. Huddles were attended by key administrative, clinical, and information technology staff. We conducted a content analysis of huddle notes to identify what EHR-related safety concerns were discussed. We expanded a previously developed EHR-related error taxonomy to categorize types of EHR-related safety concerns recorded in the notes. Results: On review of daily huddle notes spanning 249 days, we identified 245 EHR-related safety concerns. For our analysis, we defined EHR technology to include a specific EHR functionality, an entire clinical software application, or the hardware system. Most concerns (41.6%) involved “EHR technology working incorrectly,” followed by 25.7% involving “EHR technology not working at all.” Concerns related to “EHR technology missing or absent” accounted for 16.7%, whereas 15.9% were linked to “user errors.” Conclusions: Safety huddles promoted discussion of several technology-related issues at the organization level and can serve as a promising technique to identify and address EHR-related safety concerns. Based on our findings, we recommend that health care organizations consider huddles as a strategy to promote understanding and improvement of EHR safety. PMID:28031286

Research on public participant urban infrastructure safety monitoring system using smartphone

NASA Astrophysics Data System (ADS)

Zhao, Xuefeng; Wang, Niannian; Ou, Jinping; Yu, Yan; Li, Mingchu

2017-04-01

Currently more and more people concerned about the safety of major public security. Public participant urban infrastructure safety monitoring and investigation has become a trend in the era of big data. In this paper, public participant urban infrastructure safety protection system based on smart phones is proposed. The system makes it possible to public participant disaster data collection, monitoring and emergency evaluation in the field of disaster prevention and mitigation. Function of the system is to monitor the structural acceleration, angle and other vibration information, and extract structural deformation and implement disaster emergency communications based on smartphone without network. The monitoring data is uploaded to the website to create urban safety information database. Then the system supports big data analysis processing, the structure safety assessment and city safety early warning.

CSHM: Web-based safety and health monitoring system for construction management.

PubMed

Cheung, Sai On; Cheung, Kevin K W; Suen, Henry C H

2004-01-01

This paper describes a web-based system for monitoring and assessing construction safety and health performance, entitled the Construction Safety and Health Monitoring (CSHM) system. The design and development of CSHM is an integration of internet and database systems, with the intent to create a total automated safety and health management tool. A list of safety and health performance parameters was devised for the management of safety and health in construction. A conceptual framework of the four key components of CSHM is presented: (a) Web-based Interface (templates); (b) Knowledge Base; (c) Output Data; and (d) Benchmark Group. The combined effect of these components results in a system that enables speedy performance assessment of safety and health activities on construction sites. With the CSHM's built-in functions, important management decisions can theoretically be made and corrective actions can be taken before potential hazards turn into fatal or injurious occupational accidents. As such, the CSHM system will accelerate the monitoring and assessing of performance safety and health management tasks.

Safety management of a complex R&D ground operating system

NASA Technical Reports Server (NTRS)

Connors, J. F.; Maurer, R. A.

1975-01-01

A perspective on safety program management has been developed for a complex R&D operating system, such as the NASA-Lewis Research Center. Using a systems approach, hazardous operations are subjected to third-party reviews by designated area safety committees and are maintained under safety permit controls. To insure personnel alertness, emergency containment forces and employees are trained in dry-run emergency simulation exercises. The keys to real safety effectiveness are top management support and visibility of residual risks.

Basic Safety II. Apprentice Related Training Module.

ERIC Educational Resources Information Center

Rice, Eric; Spetz, Sally H.

One in a series of core instructional materials for apprentices to use during the first or second years of apprentice-related subjects training, this booklet deals with basic safety. The first section consists of an outline of the content and scope of the core materials as well as a self-assessment pretest. Covered in the four instructional…

New Automated System Available for Reporting Safety Concerns | Poster

Cancer.gov

A new system has been developed for reporting safety issues in the workplace. The Environment, Health, and Safety’s (EHS’) Safety Inspection and Issue Management System (SIIMS) is an online resource where any employee can report a problem or issue, said Siobhan Tierney, program manager at EHS.

Safety surrogate histograms (SSH): A novel real-time safety assessment of dilemma zone related conflicts at signalized intersections.

PubMed

Ghanipoor Machiani, Sahar; Abbas, Montasir

2016-11-01

Drivers' indecisiveness in dilemma zones (DZ) could result in crash-prone situations at signalized intersections. DZ is to the area ahead of an intersection in which drivers encounter a dilemma regarding whether to stop or proceed through the intersection when the signal turns yellow. An improper decision to stop by the leading driver, combined with the following driver deciding to go, can result in a rear-end collision, unless the following driver recognizes a collision is imminent and adjusts his or her behavior at or shortly after the onset of yellow. Considering the significance of DZ-related crashes, a comprehensive safety measure is needed to characterize the level of safety at signalized intersections. In this study, a novel safety surrogate measure was developed utilizing real-time radar field data. This new measure, called safety surrogate histogram (SSH), captures the degree and frequency of DZ-related conflicts at each intersection approach. SSH includes detailed information regarding the possibility of crashes, because it is calculated based on the vehicles conflicts. An example illustrating the application of the new methodology at two study sites in Virginia is presented and discussed, and a comparison is provided between SSH and other DZ-related safety surrogate measures mentioned in the literature. The results of the study reveal the efficacy of the SSH as complementary to existing surrogate measures. Copyright © 2015 Elsevier Ltd. All rights reserved.

Aviation Trends Related to Atmospheric Environment Safety Technologies Project Technical Challenges

NASA Technical Reports Server (NTRS)

Reveley, Mary S.; Withrow, Colleen A.; Barr, Lawrence C.; Evans, Joni K.; Leone, Karen M.; Jones, Sharon M.

2014-01-01

Current and future aviation safety trends related to the National Aeronautics and Space Administration's Atmospheric Environment Safety Technologies Project's three technical challenges (engine icing characterization and simulation capability; airframe icing simulation and engineering tool capability; and atmospheric hazard sensing and mitigation technology capability) were assessed by examining the National Transportation Safety Board (NTSB) accident database (1989 to 2008), incidents from the Federal Aviation Administration (FAA) accident/incident database (1989 to 2006), and literature from various industry and government sources. The accident and incident data were examined for events involving fixed-wing airplanes operating under Federal Aviation Regulation (FAR) Parts 121, 135, and 91 for atmospheric conditions related to airframe icing, ice-crystal engine icing, turbulence, clear air turbulence, wake vortex, lightning, and low visibility (fog, low ceiling, clouds, precipitation, and low lighting). Five future aviation safety risk areas associated with the three AEST technical challenges were identified after an exhaustive survey of a variety of sources and include: approach and landing accident reduction, icing/ice detection, loss of control in flight, super density operations, and runway safety.

Factors influencing workers to follow food safety management systems in meat plants in Ontario, Canada.

PubMed

Ball, Brita; Wilcock, Anne; Aung, May

2009-06-01

Small and medium sized food businesses have been slow to adopt food safety management systems (FSMSs) such as good manufacturing practices and Hazard Analysis Critical Control Point (HACCP). This study identifies factors influencing workers in their implementation of food safety practices in small and medium meat processing establishments in Ontario, Canada. A qualitative approach was used to explore in-plant factors that influence the implementation of FSMSs. Thirteen in-depth interviews in five meat plants and two focus group interviews were conducted. These generated 219 pages of verbatim transcripts which were analysed using NVivo 7 software. Main themes identified in the data related to production systems, organisational characteristics and employee characteristics. A socio-psychological model based on the theory of planned behaviour is proposed to describe how these themes and underlying sub-themes relate to FSMS implementation. Addressing the various factors that influence production workers is expected to enhance FSMS implementation and increase food safety.

Role of the law in ensuring work related road safety.

PubMed

Griffith, Richard; Tengnah, Cassam

2007-12-01

Some 150 deaths and serious injuries are caused each week by people who were driving in the course of their work. The police, health and safety executive and government are seeking to improve this startling statistic by ensuring that organizations, including NHS Trusts, comply with health and safety law and fulfil their duty to carry out an assessment of risks associated with work related driving and implement a policy to minimize those risks. Failing to comply could result in prosecution by the police and health and safety executive.

Enhancing the Safety, Security and Resilience of ICT and Scada Systems Using Action Research

NASA Astrophysics Data System (ADS)

Johnsen, Stig; Skramstad, Torbjorn; Hagen, Janne

This paper discusses the results of a questionnaire-based survey used to assess the safety, security and resilience of information and communications technology (ICT) and supervisory control and data acquisition (SCADA) systems used in the Norwegian oil and gas industry. The survey identifies several challenges, including the involvement of professionals with different backgrounds and expertise, lack of common risk perceptions, inadequate testing and integration of ICT and SCADA systems, poor information sharing related to undesirable incidents and lack of resilience in the design of technical systems. Action research is proposed as a process for addressing these challenges in a systematic manner and helping enhance the safety, security and resilience of ICT and SCADA systems used in oil and gas operations.

[The Spanish National Health System patient safety strategy, results for the period 2005-2007].

PubMed

Terol, E; Agra, Y; Fernández-Maíllo, M M; Casal, J; Sierra, E; Bandrés, B; García, M J; del Peso, P

2008-12-01

In 2005 the Spanish National Health System (SNHS) implemented a strategy aimed at improving patient safety in Spanish healthcare centres. Promote and develop knowledge of patient safety and a patient safety culture among health professionals and patients; design and implement adverse event information and reporting systems for learning purposes; introduce recommended safe practices in SNHS centres; promote patient safety research and public and patient involvement in patient safety policies. An Institutional Technical Committee was created with representatives from all the Spanish regions. All national organizations involved in healthcare quality and patient safety took part in the project. The strategy follows the WHO World Alliance for Patient Safety and Council of Europe recommendations. Budget allocated in the period 2005-2007: approximately EUR35 million. Around 5,000 health professionals were educated in PS concepts. Several studies were conducted on: adverse events in Hospitals and Primary Care, as well as studies to obtain information on health professionals' perceptions on safety, the use of medications and the situation regarding hospital-acquired infections. All the regions have introduced safe clinical practices related with the strategy. The strategy has been implemented in all the Spanish regions. Awareness was raised among health professionals and the public. A network of alliances has been set up with the regions, universities, schools, agencies and other organizations supporting the strategy.

Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis.

PubMed

2017-01-01

A patient safety learning system (sometimes called a critical incident reporting system) refers to structured reporting, collation, and analysis of critical incidents. To inform a provincial working group's recommendations for an Ontario Patient Safety Event Learning System, a systematic review was undertaken to determine design features that would optimize its adoption into the health care system and would inform implementation strategies. The objective of this review was to address two research questions: (a) what are the barriers to and facilitators of successful adoption of a patient safety learning system reported by health professionals and (b) what design components maximize successful adoption and implementation? To answer the first question, we used a published systematic review. To answer the second question, we used scoping study methodology. Common barriers reported in the literature by health care professionals included fear of blame, legal penalties, the perception that incident reporting does not improve patient safety, lack of organizational support, inadequate feedback, lack of knowledge about incident reporting systems, and lack of understanding about what constitutes an error. Common facilitators included a non-accusatory environment, the perception that incident reporting improves safety, clarification of the route of reporting and of how the system uses reports, enhanced feedback, role models (such as managers) using and promoting reporting, legislated protection of those who report, ability to report anonymously, education and training opportunities, and clear guidelines on what to report. Components of a patient safety learning system that increased successful adoption and implementation were emphasis on a blame-free culture that encourages reporting and learning, clear guidelines on how and what to report, making sure the system is user-friendly, organizational development support for data analysis to generate meaningful learning outcomes

30 CFR 250.1630 - Safety-system testing and records.

Code of Federal Regulations, 2010 CFR

2010-07-01

... AND GAS AND SULPHUR OPERATIONS IN THE OUTER CONTINENTAL SHELF Sulphur Operations § 250.1630 Safety... components, and the following: (1) Safety relief valves on the natural gas feed system for power plant... source. (2) The following safety devices (excluding electronic pressure transmitters and level sensors...

Classifying health information technology patient safety related incidents - an approach used in Wales.

PubMed

Warm, D; Edwards, P

2012-01-01

Interest in the field of patient safety incident reporting and analysis with respect to Health Information Technology (HIT) has been growing over recent years as the development, implementation and reliance on HIT systems becomes ever more prevalent. One of the rationales for capturing patient safety incidents is to learn from failures in the delivery of care and must form part of a feedback loop which also includes analysis; investigation and monitoring. With the advent of new technologies and organizational programs of delivery the emphasis is increasingly upon analyzing HIT incidents. This thematic review had two objectives, to test the applicability of a framework specifically designed to categorize HIT incidents and to review the Welsh incidents as communicated via the national incident reporting system in order to understand their implications for healthcare. The incidents were those reported as IT/ telecommunications failure/ overload. Incidents were searched for within a national reporting system using a standardized search strategy for incidents occurring between 1(st) January 2009 and 31(st) May 2011. 149 incident reports were identified and classified. The majority (77%) of which were machine related (technical problems) such as access problems; computer system down/too slow; display issues; and software malfunctions. A further 10% (n = 15) of incidents were down to human-computer interaction issues and 13% (n = 19) incidents, mainly telephone related, could not be classified using the framework being tested. On the basis of this review of incidents, it is recommended that the framework be expanded to include hardware malfunctions and the wrong record retrieved/missing data associated with a machine output error (as opposed to human error). In terms of the implications for clinical practice, the incidents reviewed highlighted critical issues including the access problems particularly relating to the use of mobile technologies.

Perceived crime and traffic safety is related to physical activity among adults in Nigeria.

PubMed

Oyeyemi, Adewale L; Adegoke, Babatunde O; Sallis, James F; Oyeyemi, Adetoyeje Y; De Bourdeaudhuij, Ilse

2012-05-17

Neighborhood safety is inconsistently related to physical activity, but is seldom studied in developing countries. This study examined associations between perceived neighborhood safety and physical activity among Nigerian adults. In a cross-sectional study, accelerometer-based physical activity (MVPA), reported walking, perceived crime and traffic safety were measured in 219 Nigerian adults. Logistic regression analysis was conducted, and the odds ratio for meeting health guidelines for MVPA and walking was calculated in relation to four safety variables, after adjustment for potential confounders. Sufficient MVPA was related to more perception of safety from traffic to walk (OR=2.28, CI=1.13- 6.25) and more safety from crime at night (OR=1.68, CI=1.07-3.64), but with less perception of safety from crime during the day to walk (OR=0.34, CI=0.06- 0.91). More crime safety during the day and night were associated with more walking. Perceived safety from crime and traffic were associated with physical activity among Nigerian adults. These findings provide preliminary evidence on the need to provide safe traffic and crime environments that will make it easier and more likely for African adults to be physically active.

Leading Edge. Volume 7, Number 3. Systems Safety Engineering

DTIC Science & Technology

2010-01-01

solvents during manu- facturing • Toxic gas and noise resulting from weapon firing • Cadmium exposure associated with han- dling of corroded equipment...California • System Safety certificate ◆ University of Southern California • Master of Science degree in Safety Sciences ◆ Indiana University of...Master of Science degree program in Health and Safety, with a Specialization in Occupa- tional Safety Management ◆ Indiana State University, Distance

Evaluating the effectiveness of active vehicle safety systems.

PubMed

Jeong, Eunbi; Oh, Cheol

2017-03-01

Advanced vehicle safety systems have been widely introduced in transportation systems and are expected to enhance traffic safety. However, these technologies mainly focus on assisting individual vehicles that are equipped with them, and less effort has been made to identify the effect of vehicular technologies on the traffic stream. This study proposed a methodology to assess the effectiveness of active vehicle safety systems (AVSSs), which represent a promising technology to prevent traffic crashes and mitigate injury severity. The proposed AVSS consists of longitudinal and lateral vehicle control systems, which corresponds to the Level 2 vehicle automation presented by the National Highway Safety Administration (NHTSA). The effectiveness evaluation for the proposed technology was conducted in terms of crash potential reduction and congestion mitigation. A microscopic traffic simulator, VISSIM, was used to simulate freeway traffic stream and collect vehicle-maneuvering data. In addition, an external application program interface, VISSIM's COM-interface, was used to implement the AVSS. A surrogate safety assessment model (SSAM) was used to derive indirect safety measures to evaluate the effectiveness of the AVSS. A 16.7-km freeway stretch between the Nakdong and Seonsan interchanges on Korean freeway 45 was selected for the simulation experiments to evaluate the effectiveness of AVSS. A total of five simulation runs for each evaluation scenario were conducted. For the non-incident conditions, the rear-end and lane-change conflicts were reduced by 78.8% and 17.3%, respectively, under the level of service (LOS) D traffic conditions. In addition, the average delay was reduced by 55.5%. However, the system's effectiveness was weakened in the LOS A-C categories. Under incident traffic conditions, the number of rear-end conflicts was reduced by approximately 9.7%. Vehicle delays were reduced by approximately 43.9% with 100% of market penetration rate (MPR). These results

Regulatory system reform of occupational health and safety in China.

PubMed

Wu, Fenghong; Chi, Yan

2015-01-01

With the explosive economic growth and social development, China's regulatory system of occupational health and safety now faces more and more challenges. This article reviews the history of regulatory system of occupational health and safety in China, as well as the current reform of this regulatory system in the country. Comprehensive, a range of laws, regulations and standards that promulgated by Chinese government, duties and responsibilities of the regulatory departments are described. Problems of current regulatory system, the ongoing adjustments and changes for modifying and improving regulatory system are discussed. The aim of reform and the incentives to drive forward more health and safety conditions in workplaces are also outlined.

Can cyclist safety be improved with intelligent transport systems?

PubMed

Silla, Anne; Leden, Lars; Rämä, Pirkko; Scholliers, Johan; Van Noort, Martijn; Bell, Daniel

2017-08-01

In recent years, Intelligent Transport Systems (ITS) have assisted in the decrease of road traffic fatalities, particularly amongst passenger car occupants. Vulnerable Road Users (VRUs) such as pedestrians, cyclists, moped riders and motorcyclists, however, have not been that much in focus when developing ITS. Therefore, there is a clear need for ITS which specifically address VRUs as an integrated element of the traffic system. This paper presents the results of a quantitative safety impact assessment of five systems that were estimated to have high potential to improve the safety of cyclists, namely: Blind Spot Detection (BSD), Bicycle to Vehicle communication (B2V), Intersection safety (INS), Pedestrian and Cyclist Detection System+Emergency Braking (PCDS+EBR) and VRU Beacon System (VBS). An ex-ante assessment method proposed by Kulmala (2010) targeted to assess the effects of ITS for cars was applied and further developed in this study to assess the safety impacts of ITS specifically designed for VRUs. The main results of the assessment showed that all investigated systems affect cyclist safety in a positive way by preventing fatalities and injuries. The estimates considering 2012 accident data and full penetration showed that the highest effects could be obtained by the implementation of PCDS+EBR and B2V, whereas VBS had the lowest effect. The estimated yearly reduction in cyclist fatalities in the EU-28 varied between 77 and 286 per system. A forecast for 2030, taking into accounts the estimated accident trends and penetration rates, showed the highest effects for PCDS+EBR and BSD. Copyright © 2016 Elsevier Ltd. All rights reserved.

Towards a Usability and Error "Safety Net": A Multi-Phased Multi-Method Approach to Ensuring System Usability and Safety.

PubMed

Kushniruk, Andre; Senathirajah, Yalini; Borycki, Elizabeth

2017-01-01

The usability and safety of health information systems have become major issues in the design and implementation of useful healthcare IT. In this paper we describe a multi-phased multi-method approach to integrating usability engineering methods into system testing to ensure both usability and safety of healthcare IT upon widespread deployment. The approach involves usability testing followed by clinical simulation (conducted in-situ) and "near-live" recording of user interactions with systems. At key stages in this process, usability problems are identified and rectified forming a usability and technology-induced error "safety net" that catches different types of usability and safety problems prior to releasing systems widely in healthcare settings.

Relatives in end-of-life care--part 2: a theory for enabling safety.

PubMed

Ohlén, Joakim; Andershed, Birgitta; Berg, Christina; Frid, Ingvar; Palm, Carl-Axel; Ternestedt, Britt-Marie; Segesten, Kerstin

2007-02-01

To develop a goal-oriented praxis theory for enabling safety for relatives when an adult or older patient is close to end-of-life. This is the second part of a project focusing on the situation and needs of relatives in end-of-life care. Our interpretation of the existing corpus of knowledge pertaining to the needs of close relatives in this situation showed the significance of relatives' need for safety. The theory was developed step-by-step, through triangulation of critical review of empirical research in the field, our own clinical experiences from end-of-life care, renewed literature searches and theoretical reasoning. The foundation for the theory is taken from the ethical intention of the philosopher Paul Ricoeur. From this, the theory focuses on relatives in the context of end-of-life care with the goal of enabling safety. This is proposed by four aphorisms functioning as safety enablers and these are directed towards the professional's approach and attitude, the relative's concern for the patient, the specific situation for the relative and the patient's end-of-life period as a period in the life of the relative. Implications for end-of-life practice are considered and include aspects for promotion of just institutions in end-of-life care, the significance of negotiated partnership in end-of-life care, enabling safety for relatives living in existential and practical uncertainty in connection with end-of-life care and diversity of relatives' preferences as they live through this particular period.

Some Challenges in the Design of Human-Automation Interaction for Safety-Critical Systems

NASA Technical Reports Server (NTRS)

Feary, Michael S.; Roth, Emilie

2014-01-01

Increasing amounts of automation are being introduced to safety-critical domains. While the introduction of automation has led to an overall increase in reliability and improved safety, it has also introduced a class of failure modes, and new challenges in risk assessment for the new systems, particularly in the assessment of rare events resulting from complex inter-related factors. Designing successful human-automation systems is challenging, and the challenges go beyond good interface development (e.g., Roth, Malin, & Schreckenghost 1997; Christoffersen & Woods, 2002). Human-automation design is particularly challenging when the underlying automation technology generates behavior that is difficult for the user to anticipate or understand. These challenges have been recognized in several safety-critical domains, and have resulted in increased efforts to develop training, procedures, regulations and guidance material (CAST, 2008, IAEA, 2001, FAA, 2013, ICAO, 2012). This paper points to the continuing need for new methods to describe and characterize the operational environment within which new automation concepts are being presented. We will describe challenges to the successful development and evaluation of human-automation systems in safety-critical domains, and describe some approaches that could be used to address these challenges. We will draw from experience with the aviation, spaceflight and nuclear power domains.

Safety Systems

ERIC Educational Resources Information Center

Halligan, Tom

2009-01-01

Colleges across the country are rising to the task by implementing safety programs, response strategies, and technologies intended to create a secure environment for teachers and students. Whether it is preparing and responding to a natural disaster, health emergency, or act of violence, more schools are making campus safety a top priority. At…

Evaluating North Carolina Food Pantry Food Safety-Related Operating Procedures.

PubMed

Chaifetz, Ashley; Chapman, Benjamin

2015-11-01

Almost one in seven American households were food insecure in 2012, experiencing difficulty in providing enough food for all family members due to a lack of resources. Food pantries assist a food-insecure population through emergency food provision, but there is a paucity of information on the food safety-related operating procedures used in the pantries. Food pantries operate in a variable regulatory landscape; in some jurisdictions, they are treated equivalent to restaurants, while in others, they operate outside of inspection regimes. By using a mixed methods approach to catalog the standard operating procedures related to food in 105 food pantries from 12 North Carolina counties, we evaluated their potential impact on food safety. Data collected through interviews with pantry managers were supplemented with observed food safety practices scored against a modified version of the North Carolina Food Establishment Inspection Report. Pantries partnered with organized food bank networks were compared with those that operated independently. In this exploratory research, additional comparisons were examined for pantries in metropolitan areas versus nonmetropolitan areas and pantries with managers who had received food safety training versus managers who had not. The results provide a snapshot of how North Carolina food pantries operate and document risk mitigation strategies for foodborne illness for the vulnerable populations they serve. Data analysis reveals gaps in food safety knowledge and practice, indicating that pantries would benefit from more effective food safety training, especially focusing on formalizing risk management strategies. In addition, new tools, procedures, or policy interventions might improve information actualization by food pantry personnel.

New reactor technology: safety improvements in nuclear power systems.

PubMed

Corradini, M L

2007-11-01

Almost 450 nuclear power plants are currently operating throughout the world and supplying about 17% of the world's electricity. These plants perform safely, reliably, and have no free-release of byproducts to the environment. Given the current rate of growth in electricity demand and the ever growing concerns for the environment, nuclear power can only satisfy the need for electricity and other energy-intensive products if it can demonstrate (1) enhanced safety and system reliability, (2) minimal environmental impact via sustainable system designs, and (3) competitive economics. The U.S. Department of Energy with the international community has begun research on the next generation of nuclear energy systems that can be made available to the market by 2030 or earlier, and that can offer significant advances toward these challenging goals; in particular, six candidate reactor system designs have been identified. These future nuclear power systems will require advances in materials, reactor physics, as well as thermal-hydraulics to realize their full potential. However, all of these designs must demonstrate enhanced safety above and beyond current light water reactor systems if the next generation of nuclear power plants is to grow in number far beyond the current population. This paper reviews the advanced Generation-IV reactor systems and the key safety phenomena that must be considered to guarantee that enhanced safety can be assured in future nuclear reactor systems.

Advanced Range Safety System for High Energy Vehicles

NASA Technical Reports Server (NTRS)

Claxton, Jeffrey S.; Linton, Donald F.

2002-01-01

The advanced range safety system project is a collaboration between the National Aeronautics and Space Administration and the United States Air Force to develop systems that would reduce costs and schedule for safety approval for new classes of unmanned high-energy vehicles. The mission-planning feature for this system would yield flight profiles that satisfy the mission requirements for the user while providing an increased quality of risk assessment, enhancing public safety. By improving the speed and accuracy of predicting risks to the public, mission planners would be able to expand flight envelopes significantly. Once in place, this system is expected to offer the flexibility of handling real-time risk management for the high-energy capabilities of hypersonic vehicles including autonomous return-from-orbit vehicles and extended flight profiles over land. Users of this system would include mission planners of Space Launch Initiative vehicles, space planes, and other high-energy vehicles. The real-time features of the system could make extended flight of a malfunctioning vehicle possible, in lieu of an immediate terminate decision. With this improved capability, the user would have more time for anomaly resolution and potential recovery of a malfunctioning vehicle.

Advancing a sociotechnical systems approach to workplace safety – developing the conceptual framework

PubMed Central

Carayon, Pascale; Hancock, Peter; Leveson, Nancy; Noy, Ian; Sznelwar, Laerte; van Hootegem, Geert

2015-01-01

Traditional efforts to deal with the enormous problem of workplace safety have proved insufficient, as they have tended to neglect the broader sociotechnical environment that surrounds workers. Here, we advocate a sociotechnical systems approach that describes the complex multi-level system factors that contribute to workplace safety. From the literature on sociotechnical systems, complex systems and safety, we develop a sociotechnical model of workplace safety with concentric layers of the work system, socio-organisational context and the external environment. The future challenges that are identified through the model are highlighted. Practitioner Summary: Understanding the environmental, organisational and work system factors that contribute to workplace safety will help to develop more effective and integrated solutions to deal with persistent workplace safety problems. Solutions to improve workplace safety need to recognise the broad sociotechnical system and the respective interactions between the system elements and levels. PMID:25831959

14 CFR 415.127 - Flight safety system design and operation data.

Code of Federal Regulations, 2010 CFR

2010-01-01

... Expendable Launch Vehicle From a Non-Federal Launch Site § 415.127 Flight safety system design and operation...: flight termination system; command control system; tracking; telemetry; communications; flight safety... control system. (7) Flight termination system component storage, operating, and service life. A listing of...

Westinghouse Small Modular Reactor passive safety system response to postulated events

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

Smith, M. C.; Wright, R. F.

2012-07-01

The Westinghouse Small Modular Reactor (SMR) is an 800 MWt (>225 MWe) integral pressurized water reactor. This paper is part of a series of four describing the design and safety features of the Westinghouse SMR. This paper focuses in particular upon the passive safety features and the safety system response of the Westinghouse SMR. The Westinghouse SMR design incorporates many features to minimize the effects of, and in some cases eliminates the possibility of postulated accidents. The small size of the reactor and the low power density limits the potential consequences of an accident relative to a large plant. Themore » integral design eliminates large loop piping, which significantly reduces the flow area of postulated loss of coolant accidents (LOCAs). The Westinghouse SMR containment is a high-pressure, compact design that normally operates at a partial vacuum. This facilitates heat removal from the containment during LOCA events. The containment is submerged in water which also aides the heat removal and provides an additional radionuclide filter. The Westinghouse SMR safety system design is passive, is based largely on the passive safety systems used in the AP1000{sup R} reactor, and provides mitigation of all design basis accidents without the need for AC electrical power for a period of seven days. Frequent faults, such as reactivity insertion events and loss of power events, are protected by first shutting down the nuclear reaction by inserting control rods, then providing cold, borated water through a passive, buoyancy-driven flow. Decay heat removal is provided using a layered approach that includes the passive removal of heat by the steam drum and independent passive heat removal system that transfers heat from the primary system to the environment. Less frequent faults such as loss of coolant accidents are mitigated by passive injection of a large quantity of water that is readily available inside containment. An automatic depressurization system is

Obtaining Valid Safety Data for Software Safety Measurement and Process Improvement

NASA Technical Reports Server (NTRS)

Basili, Victor r.; Zelkowitz, Marvin V.; Layman, Lucas; Dangle, Kathleen; Diep, Madeline

2010-01-01

We report on a preliminary case study to examine software safety risk in the early design phase of the NASA Constellation spaceflight program. Our goal is to provide NASA quality assurance managers with information regarding the ongoing state of software safety across the program. We examined 154 hazard reports created during the preliminary design phase of three major flight hardware systems within the Constellation program. Our purpose was two-fold: 1) to quantify the relative importance of software with respect to system safety; and 2) to identify potential risks due to incorrect application of the safety process, deficiencies in the safety process, or the lack of a defined process. One early outcome of this work was to show that there are structural deficiencies in collecting valid safety data that make software safety different from hardware safety. In our conclusions we present some of these deficiencies.

30 CFR 7.103 - Safety system control test.

Code of Federal Regulations, 2014 CFR

2014-07-01

... sensors which will automatically activate the safety shutdown system and stop the engine before the... the temperature sensor in the exhaust gas stream which will automatically activate the safety shutdown... using a wet exhaust conditioner, determine the effectiveness of the temperature sensor in the exhaust...

30 CFR 7.103 - Safety system control test.

Code of Federal Regulations, 2013 CFR

2013-07-01

... sensors which will automatically activate the safety shutdown system and stop the engine before the... the temperature sensor in the exhaust gas stream which will automatically activate the safety shutdown... using a wet exhaust conditioner, determine the effectiveness of the temperature sensor in the exhaust...

30 CFR 7.103 - Safety system control test.

Code of Federal Regulations, 2012 CFR

2012-07-01

... sensors which will automatically activate the safety shutdown system and stop the engine before the... the temperature sensor in the exhaust gas stream which will automatically activate the safety shutdown... using a wet exhaust conditioner, determine the effectiveness of the temperature sensor in the exhaust...

78 FR 25488 - Qualification Tests for Safety-Related Actuators in Nuclear Power Plants

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-01

... NUCLEAR REGULATORY COMMISSION [NRC-2013-0079] Qualification Tests for Safety-Related Actuators in... regulatory guide (DG), DG-1235, ``Qualification Tests for Safety-Related Actuators in Nuclear Power Plants...-251- 7495, email: [email protected] . Both of the Office of Nuclear Regulatory Research, U.S. Nuclear...

Simulation of data safety components for corporative systems

NASA Astrophysics Data System (ADS)

Yaremko, Svetlana A.; Kuzmina, Elena M.; Savchuk, Tamara O.; Krivonosov, Valeriy E.; Smolarz, Andrzej; Arman, Abenov; Smailova, Saule; Kalizhanova, Aliya

2017-08-01

The article deals with research of designing data safety components for corporations by means of mathematical simulations and modern information technologies. Simulation of threats ranks has been done which is based on definite values of data components. The rules of safety policy for corporative information systems have been presented. The ways of realization of safety policy rules have been proposed on the basis of taken conditions and appropriate class of valuable data protection.

A Methodology for Validating Safety Heuristics Using Clinical Simulations: Identifying and Preventing Possible Technology-Induced Errors Related to Using Health Information Systems

PubMed Central

Borycki, Elizabeth; Kushniruk, Andre; Carvalho, Christopher

2013-01-01

Internationally, health information systems (HIS) safety has emerged as a significant concern for governments. Recently, research has emerged that has documented the ability of HIS to be implicated in the harm and death of patients. Researchers have attempted to develop methods that can be used to prevent or reduce technology-induced errors. Some researchers are developing methods that can be employed prior to systems release. These methods include the development of safety heuristics and clinical simulations. In this paper, we outline our methodology for developing safety heuristics specific to identifying the features or functions of a HIS user interface design that may lead to technology-induced errors. We follow this with a description of a methodological approach to validate these heuristics using clinical simulations. PMID:23606902

System analysis of vehicle active safety problem

NASA Astrophysics Data System (ADS)

Buznikov, S. E.

2018-02-01

The problem of the road transport safety affects the vital interests of the most of the population and is characterized by a global level of significance. The system analysis of problem of creation of competitive active vehicle safety systems is presented as an interrelated complex of tasks of multi-criterion optimization and dynamic stabilization of the state variables of a controlled object. Solving them requires generation of all possible variants of technical solutions within the software and hardware domains and synthesis of the control, which is close to optimum. For implementing the task of the system analysis the Zwicky “morphological box” method is used. Creation of comprehensive active safety systems involves solution of the problem of preventing typical collisions. For solving it, a structured set of collisions is introduced with its elements being generated also using the Zwicky “morphological box” method. The obstacle speed, the longitudinal acceleration of the controlled object and the unpredictable changes in its movement direction due to certain faults, the road surface condition and the control errors are taken as structure variables that characterize the conditions of collisions. The conditions for preventing typical collisions are presented as inequalities for physical variables that define the state vector of the object and its dynamic limits.

78 FR 9623 - Federal Motor Vehicle Safety Standards; Air Brake Systems

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-11

... [Docket No. NHTSA-2013-0011] RIN 2127-AL11 Federal Motor Vehicle Safety Standards; Air Brake Systems... rule that amended the Federal motor vehicle safety standard for air brake systems by requiring... published a final rule in the Federal Register amending Federal Motor Vehicle Safety Standard (FMVSS) No...

Why System Safety Professionals Should Read Accident Reports

NASA Technical Reports Server (NTRS)

Holloway, C. M.; Johnson, C. W.

2006-01-01

System safety professionals, both researchers and practitioners, who regularly read accident reports reap important benefits. These benefits include an improved ability to separate myths from reality, including both myths about specific accidents and ones concerning accidents in general; an increased understanding of the consequences of unlikely events, which can help inform future designs; a greater recognition of the limits of mathematical models; and guidance on potentially relevant research directions that may contribute to safety improvements in future systems.

Information systems in food safety management.

PubMed

McMeekin, T A; Baranyi, J; Bowman, J; Dalgaard, P; Kirk, M; Ross, T; Schmid, S; Zwietering, M H

2006-12-01

Information systems are concerned with data capture, storage, analysis and retrieval. In the context of food safety management they are vital to assist decision making in a short time frame, potentially allowing decisions to be made and practices to be actioned in real time. Databases with information on microorganisms pertinent to the identification of foodborne pathogens, response of microbial populations to the environment and characteristics of foods and processing conditions are the cornerstone of food safety management systems. Such databases find application in: Identifying pathogens in food at the genus or species level using applied systematics in automated ways. Identifying pathogens below the species level by molecular subtyping, an approach successfully applied in epidemiological investigations of foodborne disease and the basis for national surveillance programs. Predictive modelling software, such as the Pathogen Modeling Program and Growth Predictor (that took over the main functions of Food Micromodel) the raw data of which were combined as the genesis of an international web based searchable database (ComBase). Expert systems combining databases on microbial characteristics, food composition and processing information with the resulting "pattern match" indicating problems that may arise from changes in product formulation or processing conditions. Computer software packages to aid the practical application of HACCP and risk assessment and decision trees to bring logical sequences to establishing and modifying food safety management practices. In addition there are many other uses of information systems that benefit food safety more globally, including: Rapid dissemination of information on foodborne disease outbreaks via websites or list servers carrying commentary from many sources, including the press and interest groups, on the reasons for and consequences of foodborne disease incidents. Active surveillance networks allowing rapid dissemination

Regulatory system reform of occupational health and safety in China

PubMed Central

WU, Fenghong; CHI, Yan

2015-01-01

With the explosive economic growth and social development, China’s regulatory system of occupational health and safety now faces more and more challenges. This article reviews the history of regulatory system of occupational health and safety in China, as well as the current reform of this regulatory system in the country. Comprehensive, a range of laws, regulations and standards that promulgated by Chinese government, duties and responsibilities of the regulatory departments are described. Problems of current regulatory system, the ongoing adjustments and changes for modifying and improving regulatory system are discussed. The aim of reform and the incentives to drive forward more health and safety conditions in workplaces are also outlined. PMID:25843565

Perceived crime and traffic safety is related to physical activity among adults in Nigeria

PubMed Central

2012-01-01

Background Neighborhood safety is inconsistently related to physical activity, but is seldom studied in developing countries. This study examined associations between perceived neighborhood safety and physical activity among Nigerian adults. Methods In a cross-sectional study, accelerometer-based physical activity (MVPA), reported walking, perceived crime and traffic safety were measured in 219 Nigerian adults. Logistic regression analysis was conducted, and the odds ratio for meeting health guidelines for MVPA and walking was calculated in relation to four safety variables, after adjustment for potential confounders. Results Sufficient MVPA was related to more perception of safety from traffic to walk (OR=2.28, CI=1.13- 6.25) and more safety from crime at night (OR=1.68, CI=1.07-3.64), but with less perception of safety from crime during the day to walk (OR=0.34, CI=0.06- 0.91). More crime safety during the day and night were associated with more walking. Conclusions Perceived safety from crime and traffic were associated with physical activity among Nigerian adults. These findings provide preliminary evidence on the need to provide safe traffic and crime environments that will make it easier and more likely for African adults to be physically active. PMID:22520066

Loosely Coupled GPS-Aided Inertial Navigation System for Range Safety

NASA Technical Reports Server (NTRS)

Heatwole, Scott; Lanzi, Raymond J.

2010-01-01

The Autonomous Flight Safety System (AFSS) aims to replace the human element of range safety operations, as well as reduce reliance on expensive, downrange assets for launches of expendable launch vehicles (ELVs). The system consists of multiple navigation sensors and flight computers that provide a highly reliable platform. It is designed to ensure that single-event failures in a flight computer or sensor will not bring down the whole system. The flight computer uses a rules-based structure derived from range safety requirements to make decisions whether or not to destroy the rocket.

78 FR 67206 - Qualification Tests for Safety-Related Actuators in Nuclear Power Plants

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-08

... NUCLEAR REGULATORY COMMISSION [NRC-2013-0079] Qualification Tests for Safety-Related Actuators in..., ``Qualification Tests for Safety-Related Actuators in Nuclear Power Plants.'' This RG is being revised to provide... power plants. This RG is proposed Revision 1 of RG 1.73, ``Qualification Tests of Electric Valve...

Factors related to increasing safety belt use in states with safety belt use laws : second annual report to Congress

DOT National Transportation Integrated Search

1989-01-01

This report is the second in a series of four annual reports to the Congress on provisions of state safety belt use laws and other programmatic factors related to increasing safety belt use levels. The first Congressional Report reviewed what was kno...

33 CFR 96.230 - What objectives must a safety management system meet?

Code of Federal Regulations, 2010 CFR

2010-07-01

... management system meet? 96.230 Section 96.230 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY VESSEL OPERATING REGULATIONS RULES FOR THE SAFE OPERATION OF VESSELS AND SAFETY MANAGEMENT SYSTEMS Company and Vessel Safety Management Systems § 96.230 What objectives must a safety...

Safety Assessment of Dangerous Goods Transport Enterprise Based on the Relative Entropy Aggregation in Group Decision Making Model

PubMed Central

Wu, Jun; Li, Chengbing; Huo, Yueying

2014-01-01

Safety of dangerous goods transport is directly related to the operation safety of dangerous goods transport enterprise. Aiming at the problem of the high accident rate and large harm in dangerous goods logistics transportation, this paper took the group decision making problem based on integration and coordination thought into a multiagent multiobjective group decision making problem; a secondary decision model was established and applied to the safety assessment of dangerous goods transport enterprise. First of all, we used dynamic multivalue background and entropy theory building the first level multiobjective decision model. Secondly, experts were to empower according to the principle of clustering analysis, and combining with the relative entropy theory to establish a secondary rally optimization model based on relative entropy in group decision making, and discuss the solution of the model. Then, after investigation and analysis, we establish the dangerous goods transport enterprise safety evaluation index system. Finally, case analysis to five dangerous goods transport enterprises in the Inner Mongolia Autonomous Region validates the feasibility and effectiveness of this model for dangerous goods transport enterprise recognition, which provides vital decision making basis for recognizing the dangerous goods transport enterprises. PMID:25477954

Safety assessment of dangerous goods transport enterprise based on the relative entropy aggregation in group decision making model.

PubMed

Wu, Jun; Li, Chengbing; Huo, Yueying

2014-01-01

Safety of dangerous goods transport is directly related to the operation safety of dangerous goods transport enterprise. Aiming at the problem of the high accident rate and large harm in dangerous goods logistics transportation, this paper took the group decision making problem based on integration and coordination thought into a multiagent multiobjective group decision making problem; a secondary decision model was established and applied to the safety assessment of dangerous goods transport enterprise. First of all, we used dynamic multivalue background and entropy theory building the first level multiobjective decision model. Secondly, experts were to empower according to the principle of clustering analysis, and combining with the relative entropy theory to establish a secondary rally optimization model based on relative entropy in group decision making, and discuss the solution of the model. Then, after investigation and analysis, we establish the dangerous goods transport enterprise safety evaluation index system. Finally, case analysis to five dangerous goods transport enterprises in the Inner Mongolia Autonomous Region validates the feasibility and effectiveness of this model for dangerous goods transport enterprise recognition, which provides vital decision making basis for recognizing the dangerous goods transport enterprises.

A brief review of the occurrence, use, and safety of food-related nanomaterials.

PubMed

Magnuson, Bernadene A; Jonaitis, Tomas S; Card, Jeffrey W

2011-08-01

Nanotechnology and nanomaterials have tremendous potential to enhance the food supply through novel applications, including nutrient and bioactive absorption and delivery systems; ingredient functionality; improved colors and flavors; microbial, allergen, and contaminant detection and control; and food packaging properties and performance. To determine the current state of knowledge regarding the safety of these potential uses of nanomaterials, an appraisal of the published literature on the safety of food-related nanomaterials was undertaken. A method of assessment of reliability of toxicology studies was developed to conduct this appraisal. The review of the toxicology literature on oral exposure to food-related nanomaterials found that the number of studies is limited. Exposure to nanomaterials in the human food chain may occur not only through intentional uses in food manufacturing, but also via uses in agricultural production and carry over from use in other industries. Although a number of analytical methods are useful in physicochemical characterization of manufactured nanomaterials, new methods may be needed to more fully detect and characterize nanomaterials incorporated into foods and in other media. There is a need for additional toxicology studies of sufficient quality and duration on different types of nanomaterials to further our understanding of the characteristics of nanomaterials that affect safety of oral exposure resulting from use in various food applications. © 2011 Institute of Food Technologists®

Editorial: emerging issues in sociotechnical systems thinking and workplace safety.

PubMed

Noy, Y Ian; Hettinger, Lawrence J; Dainoff, Marvin J; Carayon, Pascale; Leveson, Nancy G; Robertson, Michelle M; Courtney, Theodore K

2015-01-01

The burden of on-the-job accidents and fatalities and the harm of associated human suffering continue to present an important challenge for safety researchers and practitioners. While significant improvements have been achieved in recent decades, the workplace accident rate remains unacceptably high. This has spurred interest in the development of novel research approaches, with particular interest in the systemic influences of social/organisational and technological factors. In response, the Hopkinton Conference on Sociotechnical Systems and Safety was organised to assess the current state of knowledge in the area and to identify research priorities. Over the course of several months prior to the conference, leading international experts drafted collaborative, state-of-the-art reviews covering various aspects of sociotechnical systems and safety. These papers, presented in this special issue, cover topics ranging from the identification of key concepts and definitions to sociotechnical characteristics of safe and unsafe organisations. This paper provides an overview of the conference and introduces key themes and topics. Sociotechnical approaches to workplace safety are intended to draw practitioners' attention to the critical influence that systemic social/organisational and technological factors exert on safety-relevant outcomes. This paper introduces major themes addressed in the Hopkinton Conference within the context of current workplace safety research and practice challenges.

Editorial: emerging issues in sociotechnical systems thinking and workplace safety

PubMed Central

Noy, Y. Ian; Hettinger, Lawrence J.; Dainoff, Marvin J.; Carayon, Pascale; Leveson, Nancy G.; Robertson, Michelle M.; Courtney, Theodore K.

2015-01-01

The burden of on-the-job accidents and fatalities and the harm of associated human suffering continue to present an important challenge for safety researchers and practitioners. While significant improvements have been achieved in recent decades, the workplace accident rate remains unacceptably high. This has spurred interest in the development of novel research approaches, with particular interest in the systemic influences of social/organisational and technological factors. In response, the Hopkinton Conference on Sociotechnical Systems and Safety was organised to assess the current state of knowledge in the area and to identify research priorities. Over the course of several months prior to the conference, leading international experts drafted collaborative, state-of-the-art reviews covering various aspects of sociotechnical systems and safety. These papers, presented in this special issue, cover topics ranging from the identification of key concepts and definitions to sociotechnical characteristics of safe and unsafe organisations. This paper provides an overview of the conference and introduces key themes and topics. Practitioner Summary: Sociotechnical approaches to workplace safety are intended to draw practitioners' attention to the critical influence that systemic social/organisational and technological factors exert on safety-relevant outcomes. This paper introduces major themes addressed in the Hopkinton Conference within the context of current workplace safety research and practice challenges. PMID:25819595

Evaluation of the Quality of Occupational Health and Safety Management Systems Based on Key Performance Indicators in Certified Organizations.

PubMed

Mohammadfam, Iraj; Kamalinia, Mojtaba; Momeni, Mansour; Golmohammadi, Rostam; Hamidi, Yadollah; Soltanian, Alireza

2017-06-01

Occupational Health and Safety Management Systems are becoming more widespread in organizations. Consequently, their effectiveness has become a core topic for researchers. This paper evaluates the performance of the Occupational Health and Safety Assessment Series 18001 specification in certified companies in Iran. The evaluation is based on a comparison of specific criteria and indictors related to occupational health and safety management practices in three certified and three noncertified companies. Findings indicate that the performance of certified companies with respect to occupational health and safety management practices is significantly better than that of noncertified companies. Occupational Health and Safety Assessment Series 18001-certified companies have a better level of occupational health and safety; this supports the argument that Occupational Health and Safety Management Systems play an important strategic role in health and safety in the workplace.

Improving patient safety by instructional systems design

PubMed Central

Battles, J B

2006-01-01

Education and training are important elements in patient safety, both as a potential contributing factor to risks and hazards of healthcare associated injury or harm and as an intervention to be used in eliminating or preventing such harm. All too often we have relied on training as the only interventions for patient safety without examining other alternatives or realizing that, in some cases, the training systems themselves are part of the problem. One way to ensure safety by design is to apply established design principles to education and training. Instructional systems design (ISD) is a systematic method of development of education and training programs for improved learner performance. The ISD process involves five integrated steps: analysis, development, design, implementation, and evaluation (ADDIE). The application of ISD using the ADDIE approach can eliminate or prevent education and training from being a contributing factor of health associated injury or harm, and can also be effective in preventing injury or harm. PMID:17142604

Software for the occupational health and safety integrated management system

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

Vătăsescu, Mihaela

2015-03-10

This paper intends to present the design and the production of a software for the Occupational Health and Safety Integrated Management System with the view to a rapid drawing up of the system documents in the field of occupational health and safety.

Overview of Design, Lifecycle, and Safety for Computer-Based Systems

NASA Technical Reports Server (NTRS)

Torres-Pomales, Wilfredo

2015-01-01

This document describes the need and justification for the development of a design guide for safety-relevant computer-based systems. This document also makes a contribution toward the design guide by presenting an overview of computer-based systems design, lifecycle, and safety.

18 CFR 12.10 - Reporting safety-related incidents.

Code of Federal Regulations, 2011 CFR

2011-04-01

...-related incidents. 12.10 Section 12.10 Conservation of Power and Water Resources FEDERAL ENERGY REGULATORY COMMISSION, DEPARTMENT OF ENERGY REGULATIONS UNDER THE FEDERAL POWER ACT SAFETY OF WATER POWER PROJECTS AND... providing a copy of a clipping from a newspaper article, if available. (4) For the purposes of this...

49 CFR 191.23 - Reporting safety-related conditions.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., controls, or processes gas or LNG. (4) Any material defect or physical damage that impairs the... strength. (5) Any malfunction or operating error that causes the pressure of a pipeline or LNG facility... structural integrity of an LNG storage tank. (8) Any safety-related condition that could lead to an imminent...

Mines Systems Safety Improvement Using an Integrated Event Tree and Fault Tree Analysis

NASA Astrophysics Data System (ADS)

Kumar, Ranjan; Ghosh, Achyuta Krishna

2017-04-01

Mines systems such as ventilation system, strata support system, flame proof safety equipment, are exposed to dynamic operational conditions such as stress, humidity, dust, temperature, etc., and safety improvement of such systems can be done preferably during planning and design stage. However, the existing safety analysis methods do not handle the accident initiation and progression of mine systems explicitly. To bridge this gap, this paper presents an integrated Event Tree (ET) and Fault Tree (FT) approach for safety analysis and improvement of mine systems design. This approach includes ET and FT modeling coupled with redundancy allocation technique. In this method, a concept of top hazard probability is introduced for identifying system failure probability and redundancy is allocated to the system either at component or system level. A case study on mine methane explosion safety with two initiating events is performed. The results demonstrate that the presented method can reveal the accident scenarios and improve the safety of complex mine systems simultaneously.

Reflections on system safety and the law

NASA Technical Reports Server (NTRS)

Hayes, D. F., Sr.

1971-01-01

The application of law to the determination of what constitutes safeness is discussed. The numerous factors are analyzed which enter into the decisions of courts in deciding what is safe and what is unsafe. It is pointed out that as technology changes, legal interpretations of safety also change. Arguements are given for the use of system safety techniques and better engineering analyses as instruments of defense against liability.

14 CFR 25.1709 - System safety: EWIS.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 1 2010-01-01 2010-01-01 false System safety: EWIS. 25.1709 Section 25.1709 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION AIRCRAFT AIRWORTHINESS STANDARDS: TRANSPORT CATEGORY AIRPLANES Electrical Wiring Interconnection Systems (EWIS) § 25.1709...

Safety management of a complex R and D ground operating system

NASA Technical Reports Server (NTRS)

Connors, J. F.; Maurer, R. A.

1975-01-01

A perspective on safety program management was developed for a complex R&D operating system, such as the NASA-Lewis Research Center. Using a systems approach, hazardous operations are subjected to third-party reviews by designated-area safety committees and are maintained under safety permit controls. To insure personnel alertness, emergency containment forces and employees are trained in dry-run emergency simulation exercises. The keys to real safety effectiveness are top management support and visibility of residual risks.

Ex-ante assessment of the safety effects of intelligent transport systems.

PubMed

Kulmala, Risto

2010-07-01

There is a need to develop a comprehensive framework for the safety assessment of Intelligent Transport Systems (ITS). This framework should: (1) cover all three dimensions of road safety-exposure, crash risk and consequence, (2) cover, in addition to the engineering effect, also the effects due to behavioural adaptation and (3) be compatible with the other aspects of state of the art road safety theories. A framework based on nine ITS safety mechanisms is proposed and discussed with regard to the requirements set to the framework. In order to illustrate the application of the framework in practice, the paper presents a method based on the framework and the results from applying that method for twelve intelligent vehicle systems in Europe. The framework is also compared to two recent frameworks applied in the safety assessment of intelligent vehicle safety systems. Copyright 2010 Elsevier Ltd. All rights reserved.

Integration of functional safety systems on the Daniel K. Inouye Solar Telescope

NASA Astrophysics Data System (ADS)

Williams, Timothy R.; Hubbard, Robert P.; Shimko, Steve

2016-07-01

The Daniel K. Inouye Solar Telescope (DKIST) was envisioned from an early stage to incorporate a functional safety system to ensure the safety of personnel and equipment within the facility. Early hazard analysis showed the need for a functional safety system. The design used a distributed approach in which each major subsystem contains a PLC-based safety controller. This PLC-based system complies with the latest international standards for functional safety. The use of a programmable controller also allows for flexibility to incorporate changes in the design of subsystems without adversely impacting safety. Various subsystems were built by different contractors and project partners but had to function as a piece of the overall control system. Using distributed controllers allows project contractors and partners to build components as standalone subsystems that then need to be integrated into the overall functional safety system. Recently factory testing was concluded on the major subsystems of the facility. Final integration of these subsystems is currently underway on the site. Building on lessons learned in early factory tests, changes to the interface between subsystems were made to improve the speed and ease of integration of the entire system. Because of the distributed design each subsystem can be brought online as it is delivered and assembled rather than waiting until the entire facility is finished. This enhances safety during the risky period of integration and testing. The DKIST has implemented a functional safety system that has allowed construction of subsystems in geographically diverse locations but that function cohesively once they are integrated into the facility currently under construction.

Information system equality for food security--implementation of the food safety control system in Taiwan.

PubMed

Chen, Shaun C; Hsu, Guoo-Shyng Wang; Chiu, Chihwei P

2009-01-01

Food security plays a central role in governing agricultural policies in Taiwan. In addition to overuse or the illegal use of pesticide, meat leanness promoters, animal drugs and melamine in the food supply; as well as foodborne illness draws the greatest public concern due to incidents that occur every year in Taiwan. The present report demonstrates the implementation of a food safety control system in Taiwan. In order to control foodborne outbreaks effectively, the central government of the Department of Health of Taiwan launched the food safety control system which includes both the good hygienic practice (GHP) and the HACCP plan, in the last decade. From 1998 to the present, 302 food affiliations that implemented the system have been validated and accredited by a well-established audit system. The implementation of a food safety control system in compliance with international standards is of crucial importance to ensure complete safety and the high quality of foods, not only for domestic markets, but also for international trade.

30 CFR 585.810 - What must I include in my Safety Management System?

Code of Federal Regulations, 2013 CFR

2013-07-01

..., COPs and GAPs Safety Management Systems § 585.810 What must I include in my Safety Management System? You must submit a description of the Safety Management System you will use with your COP (provided...

30 CFR 585.810 - What must I include in my Safety Management System?

Code of Federal Regulations, 2014 CFR

2014-07-01

..., COPs and GAPs Safety Management Systems § 585.810 What must I include in my Safety Management System? You must submit a description of the Safety Management System you will use with your COP (provided...

30 CFR 585.810 - What must I include in my Safety Management System?

Code of Federal Regulations, 2012 CFR

2012-07-01

..., COPs and GAPs Safety Management Systems § 585.810 What must I include in my Safety Management System? You must submit a description of the Safety Management System you will use with your COP (provided...

23 CFR 973.212 - Indian lands safety management system (SMS).

Code of Federal Regulations, 2010 CFR

2010-04-01

... implementation of public information and education activities on safety needs, programs, and countermeasures... 23 Highways 1 2010-04-01 2010-04-01 false Indian lands safety management system (SMS). 973.212... HIGHWAYS MANAGEMENT SYSTEMS PERTAINING TO THE BUREAU OF INDIAN AFFAIRS AND THE INDIAN RESERVATION ROADS...

Assessment of Safety Standards for Automotive Electronic Control Systems

DOT National Transportation Integrated Search

2016-06-01

This report summarizes the results of a study that assessed and compared six industry and government safety standards relevant to the safety and reliability of automotive electronic control systems. These standards include ISO 26262 (Road Vehicles - ...

Rationales for home safety promotion in the Iranian primary healthcare system: results from a pilot study.

PubMed

Mohammadi, R; Ekman, R; Svanström, L; Gooya, M M

2006-01-01

To analyse the prerequisites for a nationwide primary healthcare (PHC) home safety promotion programme in Iran. Injury is a major public health problem throughout the world, currently accounting for one-seventh of all premature deaths and disabilities. Within 20 years, it is estimated that the proportion will increase to one-fifth. The present healthcare system in Iran was started in 1979, with a major focus on easy access to services and prevention. The system is based on the 'health house', which is run by community health workers. A survey shows that 36% of injuries occur in the home environment. A pilot phase of the Home Safety Promotion Programme was initiated in 1994, and included safety checking at home for fences, kitchens, drugs and poisons, heaters, electricity, and stairs and ladders. The pilot study covered 478,551 households out of the 12 million (approximately) in Iran. Sixty-nine supervisors were involved individually, assembled into eight focus groups. Household safety increased by 10-20% over the 4 years of the study. The frequency of home visits changed from annual to seasonal, since all participants agreed that there were seasonal differences in safety problems. The supervisors showed a high level of knowledge of injury as a public health problem, and also positive attitudes towards doing something about safety on the basis of a PHC scheme. The role of a surveillance system was highlighted, and it was suggested that such a system should be added to the programme. Based on our preliminary findings, there were reasons to obtain a policy decision concerning a national programme for safety promotion before extending the pilot scheme to the whole country. A national safety programme was decided upon following completion of the pilot study. It includes a home-related-injury surveillance system that is mandatory in rural areas and voluntary in some cities.

Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study.

PubMed

Rhodes, Penny; Campbell, Stephen; Sanders, Caroline

2016-04-01

Patient safety research has tended to focus on hospital settings, although most clinical encounters occur in primary care, and to emphasize practitioner errors, rather than patients' own understandings of safety. To explore patients' understandings of safety in primary care. Qualitative interviews were conducted with patients recruited from general practices in northwest England. Participants were asked basic socio-demographic information; thereafter, topics were largely introduced by interviewees themselves. Transcripts were coded and analysed using NVivo10 (qualitative data software), following a process of constant comparison. Thirty-eight people (14 men, 24 women) from 19 general practices in rural, small town and city locations were interviewed. Many of their concerns (about access, length of consultation, relationship continuity) have been discussed in terms of quality, but, in the interviews, were raised as matters of safety. Three broad themes were identified: (i) trust and psycho-social aspects of professional-patient relationships; (ii) choice, continuity, access, and the temporal underpinnings of safety; and (iii) organizational and systems-level tensions constraining safety. Conceptualizations of safety included common reliance on a bureaucratic framework of accreditation, accountability, procedural rules and regulation, but were also individual and context-dependent. For patients, safety is not just a property of systems, but personal and contingent and is realized in the interaction between doctor and patient. However, it is the systems approach that has dominated safety thinking, and patients' individualistic and relational conceptualizations are poorly accommodated within current service organization. © 2015 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Integrated Response Time Evaluation Methodology for the Nuclear Safety Instrumentation System

NASA Astrophysics Data System (ADS)

Lee, Chang Jae; Yun, Jae Hee

2017-06-01

Safety analysis for a nuclear power plant establishes not only an analytical limit (AL) in terms of a measured or calculated variable but also an analytical response time (ART) required to complete protective action after the AL is reached. If the two constraints are met, the safety limit selected to maintain the integrity of physical barriers used for preventing uncontrolled radioactivity release will not be exceeded during anticipated operational occurrences and postulated accidents. Setpoint determination methodologies have actively been developed to ensure that the protective action is initiated before the process conditions reach the AL. However, regarding the ART for a nuclear safety instrumentation system, an integrated evaluation methodology considering the whole design process has not been systematically studied. In order to assure the safety of nuclear power plants, this paper proposes a systematic and integrated response time evaluation methodology that covers safety analyses, system designs, response time analyses, and response time tests. This methodology is applied to safety instrumentation systems for the advanced power reactor 1400 and the optimized power reactor 1000 nuclear power plants in South Korea. The quantitative evaluation results are provided herein. The evaluation results using the proposed methodology demonstrate that the nuclear safety instrumentation systems fully satisfy corresponding requirements of the ART.

Factors related to increasing safety belt use in states with safety belt use laws : second annual report to Congress, 1988.

DOT National Transportation Integrated Search

1989-01-01

This report. is the second in a series of four annual reports to the : Congress on provisions of state safety belt use laws and other : programmatic factors related to increasing safety belt use levels. : The first Congressional Report reviewed what ...

14 CFR 415.127 - Flight safety system design and operation data.

Code of Federal Regulations, 2013 CFR

2013-01-01

... system and subsystems design and operational requirements. (c) Flight safety system diagram. An applicant... subsystems. The diagram must include the following subsystems defined in part 417, subpart D of this chapter... data processing, display, and recording system; and flight safety official console. (d) Subsystem...

14 CFR 415.127 - Flight safety system design and operation data.

Code of Federal Regulations, 2011 CFR

2011-01-01

... system and subsystems design and operational requirements. (c) Flight safety system diagram. An applicant... subsystems. The diagram must include the following subsystems defined in part 417, subpart D of this chapter... data processing, display, and recording system; and flight safety official console. (d) Subsystem...

14 CFR 415.127 - Flight safety system design and operation data.

Code of Federal Regulations, 2012 CFR

2012-01-01

... system and subsystems design and operational requirements. (c) Flight safety system diagram. An applicant... subsystems. The diagram must include the following subsystems defined in part 417, subpart D of this chapter... data processing, display, and recording system; and flight safety official console. (d) Subsystem...

14 CFR 415.127 - Flight safety system design and operation data.

Code of Federal Regulations, 2014 CFR

2014-01-01

... system and subsystems design and operational requirements. (c) Flight safety system diagram. An applicant... subsystems. The diagram must include the following subsystems defined in part 417, subpart D of this chapter... data processing, display, and recording system; and flight safety official console. (d) Subsystem...

Archetypes for Organisational Safety

NASA Technical Reports Server (NTRS)

Marais, Karen; Leveson, Nancy G.

2003-01-01

We propose a framework using system dynamics to model the dynamic behavior of organizations in accident analysis. Most current accident analysis techniques are event-based and do not adequately capture the dynamic complexity and non-linear interactions that characterize accidents in complex systems. In this paper we propose a set of system safety archetypes that model common safety culture flaws in organizations, i.e., the dynamic behaviour of organizations that often leads to accidents. As accident analysis and investigation tools, the archetypes can be used to develop dynamic models that describe the systemic and organizational factors contributing to the accident. The archetypes help clarify why safety-related decisions do not always result in the desired behavior, and how independent decisions in different parts of the organization can combine to impact safety.

75 FR 15620 - Federal Motor Vehicle Safety Standards; Air Brake Systems

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-30

... fully develop improved brake systems and also to ensure vehicle control and stability while braking... [Docket No. NHTSA 2009-0175] RIN 2127-AK62 Federal Motor Vehicle Safety Standards; Air Brake Systems... Federal motor vehicle safety standard for air brake systems by requiring substantial improvements in...

Analysis of developed transition road safety barrier systems.

PubMed

Soltani, Mehrtash; Moghaddam, Taher Baghaee; Karim, Mohamed Rehan; Sulong, N H Ramli

2013-10-01

Road safety barriers protect vehicles from roadside hazards by redirecting errant vehicles in a safe manner as well as providing high levels of safety during and after impact. This paper focused on transition safety barrier systems which were located at the point of attachment between a bridge and roadside barriers. The aim of this study was to provide an overview of the behavior of transition systems located at upstream bridge rail with different designs and performance levels. Design factors such as occupant risk and vehicle trajectory for different systems were collected and compared. To achieve this aim a comprehensive database was developed using previous studies. The comparison showed that Test 3-21, which is conducted by impacting a pickup truck with speed of 100 km/h and angle of 25° to transition system, was the most severe test. Occupant impact velocity and ridedown acceleration for heavy vehicles were lower than the amounts for passenger cars and pickup trucks, and in most cases higher occupant lateral impact ridedown acceleration was observed on vehicles subjected to higher levels of damage. The best transition system was selected to give optimum performance which reduced occupant risk factors using the similar crashes in accordance with Test 3-21. Copyright © 2013 Elsevier Ltd. All rights reserved.

The Rated Voltage Determination of DC Building Power Supply System Considering Human Beings Safety

NASA Astrophysics Data System (ADS)

Wang, Zhicheng; Yu, Kansheng; Xie, Guoqiang; Zou, Jin

2018-01-01

Generally two-level voltages are adopted for DC building power supply system. From the point of view of human beings safety, only the lower level voltage which may be contacted barehanded is discussed in this paper based on the related safety thresholds of human beings current effect. For several voltage levels below 100V recommended by IEC, the body current and current density of human electric shock under device normal work condition, as well as effect of unidirectional single impulse currents of short durations are calculated and analyzed respectively. Finally, DC 60V is recommended as the lower level rating voltage through the comprehensive consideration of technical condition and cost of safety criteria.

23 CFR 971.212 - Federal lands safety management system (SMS).

Code of Federal Regulations, 2011 CFR

2011-04-01

.... (b) The SMS may be based on the guidance in “Safety Management Systems: Good Practices for Development and Implementation.”3 3 “Safety Management Systems: Good Practices for Development and... various levels of complexity depending on the nature of the facility and/or network involved. (e) The SMS...

23 CFR 971.212 - Federal lands safety management system (SMS).

Code of Federal Regulations, 2013 CFR

2013-04-01

.... (b) The SMS may be based on the guidance in “Safety Management Systems: Good Practices for Development and Implementation.”3 3 “Safety Management Systems: Good Practices for Development and... various levels of complexity depending on the nature of the facility and/or network involved. (e) The SMS...

23 CFR 971.212 - Federal lands safety management system (SMS).

Code of Federal Regulations, 2010 CFR

2010-04-01

.... (b) The SMS may be based on the guidance in “Safety Management Systems: Good Practices for Development and Implementation.”3 3 “Safety Management Systems: Good Practices for Development and... various levels of complexity depending on the nature of the facility and/or network involved. (e) The SMS...

23 CFR 971.212 - Federal lands safety management system (SMS).

Code of Federal Regulations, 2012 CFR

2012-04-01

.... (b) The SMS may be based on the guidance in “Safety Management Systems: Good Practices for Development and Implementation.”3 3 “Safety Management Systems: Good Practices for Development and... various levels of complexity depending on the nature of the facility and/or network involved. (e) The SMS...

23 CFR 971.212 - Federal lands safety management system (SMS).

Code of Federal Regulations, 2014 CFR

2014-04-01

.... (b) The SMS may be based on the guidance in “Safety Management Systems: Good Practices for Development and Implementation.”3 3 “Safety Management Systems: Good Practices for Development and... various levels of complexity depending on the nature of the facility and/or network involved. (e) The SMS...

Evaluation and review of the safety management system implementation in the Royal Thai Air Force

NASA Astrophysics Data System (ADS)

Chaiwan, Sakkarin

This study was designed to determine situation and effectiveness of the safety management system currently implemented in the Royal Thai Air Force. Reviewing the ICAO's SMS and the RTAF's SMS was conducted to identify similarities and differences between the two safety management systems. Later, the researcher acquired safety statistics from the RTAF Safety Center to investigate effectiveness of its safety system. The researcher also collected data to identify other factors affecting effectiveness of the safety system during conducting in-depth interviews. Findings and Conclusions: The study shows that the Royal Thai Air Force has never applied the International Civil Aviation Organization's Safety management System to its safety system. However, the RTAF's SMS and the ICAO's SMS have been developed based on the same concepts. These concepts are from Richard H. Woods's book, Aviation safety programs: A management handbook. However, the effectiveness of the Royal Thai Air Force's safety system is in good stance. An accident rate has been decreasing regularly but there are no known factors to describe the increasing rate, according to the participants' opinion. The participants have informed that there are many issues to be resolved to improve the RTAF's safety system. Those issues are cooperation among safety center's staffs, attitude toward safety of the RTAF senior commanders, and safety standards.

The new car assessment program: does it predict the relative safety of vehicles in actual crashes?

PubMed

Nirula, Ram; Mock, Charles N; Nathens, Avery B; Grossman, David C

2004-10-01

Federal motor vehicle safety standards are based on crash test dummy analyses that estimate the relative risk of traumatic brain injury (TBI) and severe thoracic injury (STI) by quantifying head (Head Injury Criterion [HIC]) and chest (Chest Gravity Score [CGS]) acceleration. The New Car Assessment Program (NCAP) combines these probabilities to yield the vehicle's five-star rating. The validity of the NCAP system as it relates to an actual motor vehicle crash (MVC) remains undetermined. We therefore sought to determine whether HIC and CGS accurately predict TBI and STI in actual crashes, and compared the NCAP five-star rating system to the rates of TBI and/or STI in actual MVCs. We analyzed frontal crashes with restrained drivers from the 1994 to 1998 National Automotive Sampling System. The relationship of HIC and CGS to the probabilities of TBI and STI derived from crash tests were respectively compared with the HIC-TBI and CGS-STI risk relationships observed in actual crashes while controlling for covariates. Receiver operating characteristic curves determined the sensitivity and specificity of HIC and CGS as predictors of TBI and STI, respectively. Estimates of the likelihood of TBI and/or STI (in actual MVCs) were compared with the expected probabilities of TBI and STI (determined by crash test analysis), as they relate to NCAP ratings. The crash tests overestimate TBI likelihood at HIC scores >800 and underestimate it at scores <500. STI likelihood is overestimated when CGS exceeds 40 g. Receiver operating characteristic curves demonstrated poor sensitivity and specificity of HIC and CGS in predicting injury. The actual MVC injury probability estimates did not vary between vehicles of different NCAP rating. HIC and CGS are poor predictors of TBI and STI in actual MVCs. The NCAP five-star rating system is unable to differentiate vehicles of varying crashworthiness in actual MVCs. More sensitive parameters need to be developed and incorporated into vehicle

Quality and Safety Education for Nurses (QSEN): The Key is Systems Thinking.

PubMed

Dolansky, Mary A; Moore, Shirley M

2013-09-30

Over a decade has passed since the Institute of Medicine's reports on the need to improve the American healthcare system, and yet only slight improvement in quality and safety has been reported. The Quality and Safety Education for Nurses (QSEN) initiative was developed to integrate quality and safety competencies into nursing education. The current challenge is for nurses to move beyond the application of QSEN competencies to individual patients and families and incorporate systems thinking in quality and safety education and healthcare delivery. This article provides a history of QSEN and proposes a framework in which systems thinking is a critical aspect in the application of the QSEN competencies. We provide examples of how using this framework expands nursing focus from individual care to care of the system and propose ways to teach and measure systems thinking. The conclusion calls for movement from personal effort and individual care to a focus on care of the system that will accelerate improvement of healthcare quality and safety.

Systemic safety of bevacizumab versus ranibizumab for neovascular age-related macular degeneration

PubMed Central

Moja, Lorenzo; Lucenteforte, Ersilia; Kwag, Koren H; Bertele, Vittorio; Campomori, Annalisa; Chakravarthy, Usha; D’Amico, Roberto; Dickersin, Kay; Kodjikian, Laurent; Lindsley, Kristina; Loke, Yoon; Maguire, Maureen; Martin, Daniel F; Mugelli, Alessandro; Mühlbauer, Bernd; Püntmann, Isabel; Reeves, Barnaby; Rogers, Chris; Schmucker, Christine; Subramanian, Manju L; Virgili, Gianni

2014-01-01

Background Neovascular age-related macular degeneration (AMD) is the leading cause of legal blindness in elderly populations of industrialised countries. Bevacizumab (Avastin®) and ranibizumab (Lucentis®) are targeted biological drugs (a monoclonal antibody) that inhibit vascular endothelial growth factor, an angiogenic cytokine that promotes vascular leakage and growth, thereby preventing its pathological angiogenesis. Ranibizumab is approved for intravitreal use to treat neovascular AMD, while bevacizumab is approved for intravenous use as a cancer therapy. However, due to the biological similarity of the two drugs, bevacizumab is widely used off-label to treat neovascular AMD. Objectives To assess the systemic safety of intravitreal bevacizumab (brand name Avastin®; Genentech/Roche) compared with intravitreal ranibizumab (brand name Lucentis®; Novartis/Genentech) in people with neovascular AMD. Primary outcomes were death and All serious systemic adverse events (All SSAEs), the latter as a composite outcome in accordance with the International Conference on Harmonisation Good Clinical Practice. Secondary outcomes examined specific SSAEs: fatal and non-fatal myocardial infarctions, strokes, arteriothrombotic events, serious infections, and events grouped in some Medical Dictionary for Regulatory Activities System Organ Classes (MedDRA SOC). We assessed the safety at the longest available follow-up to a maximum of two years. Search methods We searched CENTRAL, MEDLINE, EMBASE and other online databases up to 27 March 2014. We also searched abstracts and clinical study presentations at meetings, trial registries, and contacted authors of included studies when we had questions. Selection criteria Randomised controlled trials (RCTs) directly comparing intravitreal bevacizumab (1.25 mg) and ranibizumab (0.5 mg) in people with neovascular AMD, regardless of publication status, drug dose, treatment regimen, or follow-up length, and whether the SSAEs of interest were

Context-aware system for pre-triggering irreversible vehicle safety actuators.

PubMed

Böhmländer, Dennis; Dirndorfer, Tobias; Al-Bayatti, Ali H; Brandmeier, Thomas

2017-06-01

New vehicle safety systems have led to a steady improvement of road safety and a reduction in the risk of suffering a major injury in vehicle accidents. A huge leap forward in the development of new vehicle safety systems are actuators that have to be activated irreversibly shortly before a collision in order to mitigate accident consequences. The triggering decision has to be based on measurements of exteroceptive sensors currently used in driver assistance systems. This paper focuses on developing a novel context-aware system designed to detect potential collisions and to trigger safety actuators even before an accident occurs. In this context, the analysis examines the information that can be collected from exteroceptive sensors (pre-crash data) to predict a certain collision and its severity to decide whether a triggering is entitled or not. A five-layer context-aware architecture is presented, that is able to collect contextual information about the vehicle environment and the actual driving state using different sensors, to perform reasoning about potential collisions, and to trigger safety functions upon that information. Accident analysis is used in a data model to represent uncertain knowledge and to perform reasoning. A simulation concept based on real accident data is introduced to evaluate the presented system concept. Copyright © 2017 Elsevier Ltd. All rights reserved.

A system to improve medication safety in the setting of acute kidney injury: initial provider response.

PubMed

McCoy, Allison B; McCoy, Allison Beck; Peterson, Josh F; Gadd, Cynthia S; Gadd, Cindy; Danciu, Ioana; Waitman, Lemuel R

2008-11-06

Clinical decision support systems can decrease common errors related to inappropriate or excessive dosing for nephrotoxic or renally cleared drugs. We developed a comprehensive medication safety intervention with varying levels of workflow intrusiveness within computerized provider order entry to continuously monitor for and alert providers about early-onset acute kidney injury. Initial provider response to the interventions shows potential success in improving medication safety and suggests future enhancements to increase effectiveness.

33 CFR 96.240 - What functional requirements must a safety management system meet?

Code of Federal Regulations, 2010 CFR

2010-07-01

... a safety management system meet? 96.240 Section 96.240 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY VESSEL OPERATING REGULATIONS RULES FOR THE SAFE OPERATION OF VESSELS AND SAFETY MANAGEMENT SYSTEMS Company and Vessel Safety Management Systems § 96.240 What functional...