Application of Function-Failure Similarity Method to Rotorcraft Component Design
NASA Technical Reports Server (NTRS)
Roberts, Rory A.; Stone, Robert E.; Tumer, Irem Y.; Clancy, Daniel (Technical Monitor)
2002-01-01
Performance and safety are the top concerns of high-risk aerospace applications at NASA. Eliminating or reducing performance and safety problems can be achieved with a thorough understanding of potential failure modes in the designs that lead to these problems. The majority of techniques use prior knowledge and experience as well as Failure Modes and Effects as methods to determine potential failure modes of aircraft. During the design of aircraft, a general technique is needed to ensure that every potential failure mode is considered, while avoiding spending time on improbable failure modes. In this work, this is accomplished by mapping failure modes to specific components, which are described by their functionality. The failure modes are then linked to the basic functions that are carried within the components of the aircraft. Using this technique, designers can examine the basic functions, and select appropriate analyses to eliminate or design out the potential failure modes. The fundamentals of this method were previously introduced for a simple rotating machine test rig with basic functions that are common to a rotorcraft. In this paper, this technique is applied to the engine and power train of a rotorcraft, using failures and functions obtained from accident reports and engineering drawings.
PV Degradation Curves: Non-Linearities and Failure Modes
DOE Office of Scientific and Technical Information (OSTI.GOV)
Jordan, Dirk C.; Silverman, Timothy J.; Sekulic, Bill
Photovoltaic (PV) reliability and durability have seen increased interest in recent years. Historically, and as a preliminarily reasonable approximation, linear degradation rates have been used to quantify long-term module and system performance. The underlying assumption of linearity can be violated at the beginning of the life, as has been well documented, especially for thin-film technology. Additionally, non-linearities in the wear-out phase can have significant economic impact and appear to be linked to different failure modes. In addition, associating specific degradation and failure modes with specific time series behavior will aid in duplicating these degradation modes in accelerated tests and, eventually,more » in service life prediction. In this paper, we discuss different degradation modes and how some of these may cause approximately linear degradation within the measurement uncertainty (e.g., modules that were mainly affected by encapsulant discoloration) while other degradation modes lead to distinctly non-linear degradation (e.g., hot spots caused by cracked cells or solder bond failures and corrosion). The various behaviors are summarized with the goal of aiding in predictions of what may be seen in other systems.« less
NASA Technical Reports Server (NTRS)
Rotem, Assa
1990-01-01
Laminated composite materials tend to fail differently under tensile or compressive load. Under tension, the material accumulates cracks and fiber fractures, while under compression, the material delaminates and buckles. Tensile-compressive fatigue may cause either of these failure modes depending on the specific damage occurring in the laminate. This damage depends on the stress ratio of the fatigue loading. Analysis of the fatigue behavior of the composite laminate under tension-tension, compression-compression, and tension-compression had led to the development of a fatigue envelope presentation of the failure behavior. This envelope indicates the specific failure mode for any stress ratio and number of loading cycles. The construction of the fatigue envelope is based on the applied stress-cycles to failure (S-N) curves of both tensile-tensile and compressive-compressive fatigue. Test results are presented to verify the theoretical analysis.
Teixeira, Flavia C; de Almeida, Carlos E; Saiful Huq, M
2016-01-01
The goal of this study was to evaluate the safety and quality management program for stereotactic radiosurgery (SRS) treatment processes at three radiotherapy centers in Brazil by using three industrial engineering tools (1) process mapping, (2) failure modes and effects analysis (FMEA), and (3) fault tree analysis. The recommendations of Task Group 100 of American Association of Physicists in Medicine were followed to apply the three tools described above to create a process tree for SRS procedure for each radiotherapy center and then FMEA was performed. Failure modes were identified for all process steps and values of risk priority number (RPN) were calculated from O, S, and D (RPN = O × S × D) values assigned by a professional team responsible for patient care. The subprocess treatment planning was presented with the highest number of failure modes for all centers. The total number of failure modes were 135, 104, and 131 for centers I, II, and III, respectively. The highest RPN value for each center is as follows: center I (204), center II (372), and center III (370). Failure modes with RPN ≥ 100: center I (22), center II (115), and center III (110). Failure modes characterized by S ≥ 7, represented 68% of the failure modes for center III, 62% for center II, and 45% for center I. Failure modes with RPNs values ≥100 and S ≥ 7, D ≥ 5, and O ≥ 5 were considered as high priority in this study. The results of the present study show that the safety risk profiles for the same stereotactic radiotherapy process are different at three radiotherapy centers in Brazil. Although this is the same treatment process, this present study showed that the risk priority is different and it will lead to implementation of different safety interventions among the centers. Therefore, the current practice of applying universal device-centric QA is not adequate to address all possible failures in clinical processes at different radiotherapy centers. Integrated approaches to device-centric and process specific quality management program specific to each radiotherapy center are the key to a safe quality management program.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Schubert, L; Westerly, D; Vinogradskiy, Y
Purpose: Collisions between treatment equipment and patients are potentially catastrophic. Modern technology now commonly involves automated remote motion during imaging and treatment, yet a systematic assessment to identify and mitigate collision risks has yet to be performed. Failure modes and effects analysis (FMEA) is a method of risk assessment that has been increasingly used in healthcare, yet can be resource intensive. This work presents an efficient approach to FMEA to identify collision risks and implement practical interventions within a modern radiation therapy department. Methods: Potential collisions (e.g. failure modes) were assessed for all treatment and simulation rooms by teams consistingmore » of physicists, therapists, and radiation oncologists. Failure modes were grouped into classes according to similar characteristics. A single group meeting was held to identify implementable interventions for the highest priority classes of failure modes. Results: A total of 60 unique failure modes were identified by 6 different teams of physicists, therapists, and radiation oncologists. Failure modes were grouped into four main classes: specific patient setups, automated equipment motion, manual equipment motion, and actions in QA or service mode. Two of these classes, unusual patient setups and automated machine motion, were identified as being high priority in terms severity of consequence and addressability by interventions. The two highest risk classes consisted of 33 failure modes (55% of the total). In a single one hour group meeting, 6 interventions were identified. Those interventions addressed 100% of the high risk classes of failure modes (55% of all failure modes identified). Conclusion: A class-based approach to FMEA was developed to efficiently identify collision risks and implement interventions in a modern radiation oncology department. Failure modes and interventions will be listed, and a comparison of this approach against traditional FMEA methods will be presented.« less
DOE Office of Scientific and Technical Information (OSTI.GOV)
Teixeira, Flavia C., E-mail: flavitiz@gmail.com; Almeida, Carlos E. de; Saiful Huq, M.
Purpose: The goal of this study was to evaluate the safety and quality management program for stereotactic radiosurgery (SRS) treatment processes at three radiotherapy centers in Brazil by using three industrial engineering tools (1) process mapping, (2) failure modes and effects analysis (FMEA), and (3) fault tree analysis. Methods: The recommendations of Task Group 100 of American Association of Physicists in Medicine were followed to apply the three tools described above to create a process tree for SRS procedure for each radiotherapy center and then FMEA was performed. Failure modes were identified for all process steps and values of riskmore » priority number (RPN) were calculated from O, S, and D (RPN = O × S × D) values assigned by a professional team responsible for patient care. Results: The subprocess treatment planning was presented with the highest number of failure modes for all centers. The total number of failure modes were 135, 104, and 131 for centers I, II, and III, respectively. The highest RPN value for each center is as follows: center I (204), center II (372), and center III (370). Failure modes with RPN ≥ 100: center I (22), center II (115), and center III (110). Failure modes characterized by S ≥ 7, represented 68% of the failure modes for center III, 62% for center II, and 45% for center I. Failure modes with RPNs values ≥100 and S ≥ 7, D ≥ 5, and O ≥ 5 were considered as high priority in this study. Conclusions: The results of the present study show that the safety risk profiles for the same stereotactic radiotherapy process are different at three radiotherapy centers in Brazil. Although this is the same treatment process, this present study showed that the risk priority is different and it will lead to implementation of different safety interventions among the centers. Therefore, the current practice of applying universal device-centric QA is not adequate to address all possible failures in clinical processes at different radiotherapy centers. Integrated approaches to device-centric and process specific quality management program specific to each radiotherapy center are the key to a safe quality management program.« less
Investigation of advanced fault insertion and simulator methods
NASA Technical Reports Server (NTRS)
Dunn, W. R.; Cottrell, D.
1986-01-01
The cooperative agreement partly supported research leading to the open-literature publication cited. Additional efforts under the agreement included research into fault modeling of semiconductor devices. Results of this research are presented in this report which is summarized in the following paragraphs. As a result of the cited research, it appears that semiconductor failure mechanism data is abundant but of little use in developing pin-level device models. Failure mode data on the other hand does exist but is too sparse to be of any statistical use in developing fault models. What is significant in the failure mode data is that, unlike classical logic, MSI and LSI devices do exhibit more than 'stuck-at' and open/short failure modes. Specifically they are dominated by parametric failures and functional anomalies that can include intermittent faults and multiple-pin failures. The report discusses methods of developing composite pin-level models based on extrapolation of semiconductor device failure mechanisms, failure modes, results of temperature stress testing and functional modeling. Limitations of this model particularly with regard to determination of fault detection coverage and latency time measurement are discussed. Indicated research directions are presented.
Failure of a laminated composite under tension-compression fatigue loading
NASA Technical Reports Server (NTRS)
Rotem, A.; Nelson, H. G.
1989-01-01
The fatigue behavior of composite laminates under tension-compression loading is analyzed and compared with behavior under tension-tension and compression-compression loading. It is shown that for meaningful fatigue conditions, the tension-compression case is the dominant one. Both tension and compression failure modes can occur under the reversed loading, and failure is dependent on the specific lay-up of the laminate and the difference between the tensile static strength and the absolute value of the compressive static strength. The use of a fatigue failure envelope for determining the fatigue life and mode of failure is proposed and demonstrated.
WE-G-BRA-08: Failure Modes and Effects Analysis (FMEA) for Gamma Knife Radiosurgery
DOE Office of Scientific and Technical Information (OSTI.GOV)
Xu, Y; Bhatnagar, J; Bednarz, G
2015-06-15
Purpose: To perform a failure modes and effects analysis (FMEA) study for Gamma Knife (GK) radiosurgery processes at our institution based on our experience with the treatment of more than 13,000 patients. Methods: A team consisting of medical physicists, nurses, radiation oncologists, neurosurgeons at the University of Pittsburgh Medical Center and an external physicist expert was formed for the FMEA study. A process tree and a failure mode table were created for the GK procedures using the Leksell GK Perfexion and 4C units. Three scores for the probability of occurrence (O), the severity (S), and the probability of no detectionmore » (D) for failure modes were assigned to each failure mode by each professional on a scale from 1 to 10. The risk priority number (RPN) for each failure mode was then calculated (RPN = OxSxD) as the average scores from all data sets collected. Results: The established process tree for GK radiosurgery consists of 10 sub-processes and 53 steps, including a sub-process for frame placement and 11 steps that are directly related to the frame-based nature of the GK radiosurgery. Out of the 86 failure modes identified, 40 failure modes are GK specific, caused by the potential for inappropriate use of the radiosurgery head frame, the imaging fiducial boxes, the GK helmets and plugs, and the GammaPlan treatment planning system. The other 46 failure modes are associated with the registration, imaging, image transfer, contouring processes that are common for all radiation therapy techniques. The failure modes with the highest hazard scores are related to imperfect frame adaptor attachment, bad fiducial box assembly, overlooked target areas, inaccurate previous treatment information and excessive patient movement during MRI scan. Conclusion: The implementation of the FMEA approach for Gamma Knife radiosurgery enabled deeper understanding of the overall process among all professionals involved in the care of the patient and helped identify potential weaknesses in the overall process.« less
Comparison of mode of failure between primary and revision total knee arthroplasties.
Liang, H; Bae, J K; Park, C H; Kim, K I; Bae, D K; Song, S J
2018-04-01
Cognizance of common reasons for failure in primary and revision TKA, together with their time course, facilitates prevention. However, there have been few reports specifically comparing modes of failure for primary vs. revision TKA using a single prosthesis. The goal of the study was to compare the survival rates, modes of failure, and time periods associated with each mode of failure, of primary vs. revision TKA. The survival rates, modes of failure, time period for each mode of failure, and risk factors would differ between primary and revision TKA. Data from a consecutive cohort comprising 1606 knees (1174 patients) of primary TKA patients, and 258 knees (224 patients) of revision TKA patients, in all of whom surgery involved a P.F.C ® prosthesis (Depuy, Johnson & Johnson, Warsaw, IN), was retrospectively reviewed. The mean follow-up periods of primary and revision TKAs were 9.2 and 9.8 years, respectively. The average 10- and 15-year survival rates for primary TKA were 96.7% (CI 95%,±0.7%) and 85.4% (CI 95%,±2.0%), and for revision TKA 91.4% (CI 95%,±2.5%) and 80.5% (CI 95%,±4.5%). Common modes of failure included polyethylene wear, loosening, and infection. The most common mode of failure was polyethylene wear in primary TKA, and infection in revision TKA. The mean periods (i.e., latencies) of polyethylene wear and loosening did not differ between primary and revision TKAs, but the mean period of infection was significantly longer for revision TKA (1.2 vs. 4.8 years, P=0.003). Survival rates decreased with time, particularly more than 10 years post-surgery, for both primary and revision TKAs. Continuous efforts are required to prevent and detect the various modes of failure during long-term follow-up. Greater attention is necessary to detect late infection-induced failure following revision TKA. Case-control study, Level III. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
CONFIG: Qualitative simulation tool for analyzing behavior of engineering devices
NASA Technical Reports Server (NTRS)
Malin, Jane T.; Basham, Bryan D.; Harris, Richard A.
1987-01-01
To design failure management expert systems, engineers mentally analyze the effects of failures and procedures as they propagate through device configurations. CONFIG is a generic device modeling tool for use in discrete event simulation, to support such analyses. CONFIG permits graphical modeling of device configurations and qualitative specification of local operating modes of device components. Computation requirements are reduced by focussing the level of component description on operating modes and failure modes, and specifying qualitative ranges of variables relative to mode transition boundaries. Simulation processing occurs only when modes change or variables cross qualitative boundaries. Device models are built graphically, using components from libraries. Components are connected at ports by graphical relations that define data flow. The core of a component model is its state transition diagram, which specifies modes of operation and transitions among them.
Prediction of mode of death in heart failure: the Seattle Heart Failure Model.
Mozaffarian, Dariush; Anker, Stefan D; Anand, Inder; Linker, David T; Sullivan, Mark D; Cleland, John G F; Carson, Peter E; Maggioni, Aldo P; Mann, Douglas L; Pitt, Bertram; Poole-Wilson, Philip A; Levy, Wayne C
2007-07-24
Prognosis and mode of death in heart failure patients are highly variable in that some patients die suddenly (often from ventricular arrhythmia) and others die of progressive failure of cardiac function (pump failure). Prediction of mode of death may facilitate decisions about specific medications or devices. We used the Seattle Heart Failure Model (SHFM), a validated prediction model for total mortality in heart failure, to assess the mode of death in 10,538 ambulatory patients with New York Heart Association class II to IV heart failure and predominantly systolic dysfunction enrolled in 6 randomized trials or registries. During 16,735 person-years of follow-up, 2014 deaths occurred, which included 1014 sudden deaths and 684 pump-failure deaths. Compared with a SHFM score of 0, patients with a score of 1 had a 50% higher risk of sudden death, patients with a score of 2 had a nearly 3-fold higher risk, and patients with a score of 3 or 4 had a nearly 7-fold higher risk (P<0.001 for all comparisons; 1-year area under the receiver operating curve, 0.68). Stratification of risk of pump-failure death was even more pronounced, with a 4-fold higher risk with a score of 1, a 15-fold higher risk with a score of 2, a 38-fold higher risk with a score of 3, and an 88-fold higher risk with a score of 4 (P<0.001 for all comparisons; 1-year area under the receiver operating curve, 0.85). The proportion of deaths caused by sudden death versus pump-failure death decreased from a ratio of 7:1 with a SHFM score of 0 to a ratio of 1:2 with a SHFM score of 4 (P trend <0.001). The SHFM score provides information about the likely mode of death among ambulatory heart failure patients. Investigation is warranted to determine whether such information might predict responses to or cost-effectiveness of specific medications or devices in heart failure patients.
EVALUATION OF SAFETY IN A RADIATION ONCOLOGY SETTING USING FAILURE MODE AND EFFECTS ANALYSIS
Ford, Eric C.; Gaudette, Ray; Myers, Lee; Vanderver, Bruce; Engineer, Lilly; Zellars, Richard; Song, Danny Y.; Wong, John; DeWeese, Theodore L.
2013-01-01
Purpose Failure mode and effects analysis (FMEA) is a widely used tool for prospectively evaluating safety and reliability. We report our experiences in applying FMEA in the setting of radiation oncology. Methods and Materials We performed an FMEA analysis for our external beam radiation therapy service, which consisted of the following tasks: (1) create a visual map of the process, (2) identify possible failure modes; assign risk probability numbers (RPN) to each failure mode based on tabulated scores for the severity, frequency of occurrence, and detectability, each on a scale of 1 to 10; and (3) identify improvements that are both feasible and effective. The RPN scores can span a range of 1 to 1000, with higher scores indicating the relative importance of a given failure mode. Results Our process map consisted of 269 different nodes. We identified 127 possible failure modes with RPN scores ranging from 2 to 160. Fifteen of the top-ranked failure modes were considered for process improvements, representing RPN scores of 75 and more. These specific improvement suggestions were incorporated into our practice with a review and implementation by each department team responsible for the process. Conclusions The FMEA technique provides a systematic method for finding vulnerabilities in a process before they result in an error. The FMEA framework can naturally incorporate further quantification and monitoring. A general-use system for incident and near miss reporting would be useful in this regard. PMID:19409731
Manger, Ryan P; Paxton, Adam B; Pawlicki, Todd; Kim, Gwe-Ya
2015-05-01
Surface image guided, Linac-based radiosurgery (SIG-RS) is a modern approach for delivering radiosurgery that utilizes optical stereoscopic imaging to monitor the surface of the patient during treatment in lieu of using a head frame for patient immobilization. Considering the novelty of the SIG-RS approach and the severity of errors associated with delivery of large doses per fraction, a risk assessment should be conducted to identify potential hazards, determine their causes, and formulate mitigation strategies. The purpose of this work is to investigate SIG-RS using the combined application of failure modes and effects analysis (FMEA) and fault tree analysis (FTA), report on the effort required to complete the analysis, and evaluate the use of FTA in conjunction with FMEA. A multidisciplinary team was assembled to conduct the FMEA on the SIG-RS process. A process map detailing the steps of the SIG-RS was created to guide the FMEA. Failure modes were determined for each step in the SIG-RS process, and risk priority numbers (RPNs) were estimated for each failure mode to facilitate risk stratification. The failure modes were ranked by RPN, and FTA was used to determine the root factors contributing to the riskiest failure modes. Using the FTA, mitigation strategies were formulated to address the root factors and reduce the risk of the process. The RPNs were re-estimated based on the mitigation strategies to determine the margin of risk reduction. The FMEA and FTAs for the top two failure modes required an effort of 36 person-hours (30 person-hours for the FMEA and 6 person-hours for two FTAs). The SIG-RS process consisted of 13 major subprocesses and 91 steps, which amounted to 167 failure modes. Of the 91 steps, 16 were directly related to surface imaging. Twenty-five failure modes resulted in a RPN of 100 or greater. Only one of these top 25 failure modes was specific to surface imaging. The riskiest surface imaging failure mode had an overall RPN-rank of eighth. Mitigation strategies for the top failure mode decreased the RPN from 288 to 72. Based on the FMEA performed in this work, the use of surface imaging for monitoring intrafraction position in Linac-based stereotactic radiosurgery (SRS) did not greatly increase the risk of the Linac-based SRS process. In some cases, SIG helped to reduce the risk of Linac-based RS. The FMEA was augmented by the use of FTA since it divided the failure modes into their fundamental components, which simplified the task of developing mitigation strategies.
Analysis and design of ion-implanted bubble memory devices
NASA Astrophysics Data System (ADS)
Wullert, J. R., II; Kryder, M. H.
1987-04-01
4-μm period ion-implanted contiguous disk bubble memory circuits, designed and fabricated at AT&T Bell Laboratories, Murray Hill, NJ, have been investigated. Quasistatic testing has provided information about both the operational bias field ranges and the exact failure modes. A variety of major loop layouts were investigated and two turns found to severely limit bias field margins are discussed. The generation process, using a hairpin nucleator, was tested and several interesting failure modes were uncovered. Propagation on four different minor loop paths was observed and each was found to have characteristic failure modes. The transfer processes, both into and out of the minor loops, were investigated at higher frequencies to avoid local heating due to long transfer pulses at low frequencies. Again specific failure modes were identified. Overall bias margins for the chip were 9% at 50 Oe drive field and were limited by transfer-in.
Failure detection and recovery in the assembly/contingency subsystem
NASA Technical Reports Server (NTRS)
Gantenbein, Rex E.
1993-01-01
The Assembly/Contingency Subsystem (ACS) is the primary communications link on board the Space Station. Any failure in a component of this system or in the external devices through which it communicates with ground-based systems will isolate the Station. The ACS software design includes a failure management capability (ACFM) that provides protocols for failure detection, isolation, and recovery (FDIR). The the ACFM design requirements as outlined in the current ACS software requirements specification document are reviewed. The activities carried out in this review include: (1) an informal, but thorough, end-to-end failure mode and effects analysis of the proposed software architecture for the ACFM; and (2) a prototype of the ACFM software, implemented as a C program under the UNIX operating system. The purpose of this review is to evaluate the FDIR protocols specified in the ACS design and the specifications themselves in light of their use in implementing the ACFM. The basis of failure detection in the ACFM is the loss of signal between the ground and the Station, which (under the appropriate circumstances) will initiate recovery to restore communications. This recovery involves the reconfiguration of the ACS to either a backup set of components or to a degraded communications mode. The initiation of recovery depends largely on the criticality of the failure mode, which is defined by tables in the ACFM and can be modified to provide a measure of flexibility in recovery procedures.
Accelerated fatigue durability of a high performance composite
NASA Technical Reports Server (NTRS)
Rotem, A.
1982-01-01
The fatigue behavior of multidirectional graphite-epoxy laminates was analyzed theoretically and experimentally in an effort to establish an accelerated testing methodology. Analysis of the failure mechanism in fatigue of the laminates led to the determination of the failure mode governing fracture. The nonlinear, cyclic-dependent shear modulus was used to calculate the changing stress field in the laminate during the fatigue loading. Fatigue tests were performed at three different temperatures: 25 C, 74 C, and 114 C. The prediction of the S-N curves was made based on the artificial static strength artificial static strength at a reference temperature and the fatigue functions associated with them. The prediction of an S-N curve at other temperatures was performed using shifting factors determined for the specific failure mode. For multidirectional laminates, different S-N curves at different temperatures could be predicted using these shifting factors. Different S-N curves at different temperatures occur only when the fatigue failure mode is matrix dominated. It was found that whenever the fatigue failure mode is fiber dominated, temperature, over the range investigated, had no influence on the fatigue life. These results permit the prediction of long-time, low temperature fatigue behavior from data obtained in short time, high temperature testing, for laminates governed by a matrix failure mode.
Failure mode and effect analysis-based quality assurance for dynamic MLC tracking systems
Sawant, Amit; Dieterich, Sonja; Svatos, Michelle; Keall, Paul
2010-01-01
Purpose: To develop and implement a failure mode and effect analysis (FMEA)-based commissioning and quality assurance framework for dynamic multileaf collimator (DMLC) tumor tracking systems. Methods: A systematic failure mode and effect analysis was performed for a prototype real-time tumor tracking system that uses implanted electromagnetic transponders for tumor position monitoring and a DMLC for real-time beam adaptation. A detailed process tree of DMLC tracking delivery was created and potential tracking-specific failure modes were identified. For each failure mode, a risk probability number (RPN) was calculated from the product of the probability of occurrence, the severity of effect, and the detectibility of the failure. Based on the insights obtained from the FMEA, commissioning and QA procedures were developed to check (i) the accuracy of coordinate system transformation, (ii) system latency, (iii) spatial and dosimetric delivery accuracy, (iv) delivery efficiency, and (v) accuracy and consistency of system response to error conditions. The frequency of testing for each failure mode was determined from the RPN value. Results: Failures modes with RPN≥125 were recommended to be tested monthly. Failure modes with RPN<125 were assigned to be tested during comprehensive evaluations, e.g., during commissioning, annual quality assurance, and after major software∕hardware upgrades. System latency was determined to be ∼193 ms. The system showed consistent and accurate response to erroneous conditions. Tracking accuracy was within 3%–3 mm gamma (100% pass rate) for sinusoidal as well as a wide variety of patient-derived respiratory motions. The total time taken for monthly QA was ∼35 min, while that taken for comprehensive testing was ∼3.5 h. Conclusions: FMEA proved to be a powerful and flexible tool to develop and implement a quality management (QM) framework for DMLC tracking. The authors conclude that the use of FMEA-based QM ensures efficient allocation of clinical resources because the most critical failure modes receive the most attention. It is expected that the set of guidelines proposed here will serve as a living document that is updated with the accumulation of progressively more intrainstitutional and interinstitutional experience with DMLC tracking. PMID:21302802
Independent Orbiter Assessment (IOA): Analysis of the remote manipulator system
NASA Technical Reports Server (NTRS)
Tangorra, F.; Grasmeder, R. F.; Montgomery, A. D.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbiter Remote Manipulator System (RMS) are documented. The RMS hardware and software are primarily required for deploying and/or retrieving up to five payloads during a single mission, capture and retrieve free-flying payloads, and for performing Manipulator Foot Restraint operations. Specifically, the RMS hardware consists of the following components: end effector; displays and controls; manipulator controller interface unit; arm based electronics; and the arm. The IOA analysis process utilized available RMS hardware drawings, schematics and documents for defining hardware assemblies, components and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 574 failure modes analyzed, 413 were determined to be PCIs.
Miles, Brad; Kolos, Elizabeth; Walter, William L; Appleyard, Richard; Shi, Angela; Li, Qing; Ruys, Andrew J
2015-06-01
Subject-specific finite element (FE) modeling methodology could predict peri-prosthetic femoral fracture (PFF) for cementless hip arthoplasty in the early postoperative period. This study develops methodology for subject-specific finite element modeling by using the element deactivation technique to simulate bone failure and validate with experimental testing, thereby predicting peri-prosthetic femoral fracture in the early postoperative period. Material assignments for biphasic and triphasic models were undertaken. Failure modeling with the element deactivation feature available in ABAQUS 6.9 was used to simulate a crack initiation and propagation in the bony tissue based upon a threshold of fracture strain. The crack mode for the biphasic models was very similar to the experimental testing crack mode, with a similar shape and path of the crack. The fracture load is sensitive to the friction coefficient at the implant-bony interface. The development of a novel technique to simulate bone failure by element deactivation of subject-specific finite element models could aid prediction of fracture load in addition to fracture risk characterization for PFF. Copyright © 2015 IPEM. Published by Elsevier Ltd. All rights reserved.
Integrated Testing and Maintenance Technologies.
1983-12-01
provides pilot cueing for mode failures of LRU’s. Equipment fail and status indicators are lighted displays that indicate specific failures within an...provided with appropriate display cueing only when a reversion results in some loss of capability or performance. Three forms of degraded mode advisories...are- a. Reversion to an alternative data source of equivalent accuracy with no pilot cueing . b. Reversion to an alternative data source of lesser
Independent Orbiter Assessment (IOA): Analysis of the mechanical actuation subsystem
NASA Technical Reports Server (NTRS)
Bacher, J. L.; Montgomery, A. D.; Bradway, M. W.; Slaughter, W. T.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Mechanical Actuation System (MAS) hardware. Specifically, the MAS hardware consists of the following components: Air Data Probe (ADP); Elevon Seal Panel (ESP); External Tank Umbilical (ETU); Ku-Band Deploy (KBD); Payload Bay Doors (PBD); Payload Bay Radiators (PBR); Personnel Hatches (PH); Vent Door Mechanism (VDM); and Startracker Door Mechanism (SDM). The IOA analysis process utilized available MAS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Aggarwal, R.K.; Litton, R.W.; Cornell, C.A.
1996-12-31
The performance of more than 3,000 offshore platforms in the Gulf of Mexico was observed during the passage of Hurricane Andrew in August 1992. This event provided an opportunity to test the procedures used for platform analysis and design. A global bias was inferred for overall platform capacity and loads in the Andrew Joint Industry Project (JIP) Phase 1. It was predicted that the pile foundations of several platforms should have failed, but did not. These results indicated that the biases specific to foundation failure modes may be higher than those of jacket failure modes. The biases in predictions ofmore » foundation failure modes were therefore investigated further in this study. The work included capacity analysis and calibration of predictions with the observed behavior for 3 jacket platforms and 3 caissons using Bayesian updating. Bias factors for two foundation failure modes, lateral shear and overturning, were determined for each structure. Foundation capacity estimates using conventional methods were found to be conservatively biased overall.« less
Carbon Fiber Strand Tensile Failure Dynamic Event Characterization
NASA Technical Reports Server (NTRS)
Johnson, Kenneth L.; Reeder, James
2016-01-01
There are few if any clear, visual, and detailed images of carbon fiber strand failures under tension useful for determining mechanisms, sequences of events, different types of failure modes, etc. available to researchers. This makes discussion of physics of failure difficult. It was also desired to find out whether the test article-to-test rig interface (grip) played a part in some failures. These failures have nothing to do with stress rupture failure, thus representing a source of waste for the larger 13-00912 investigation into that specific failure type. Being able to identify or mitigate any competing failure modes would improve the value of the 13-00912 test data. The beginnings of the solution to these problems lay in obtaining images of strand failures useful for understanding physics of failure and the events leading up to failure. Necessary steps include identifying imaging techniques that result in useful data, using those techniques to home in on where in a strand and when in the sequence of events one should obtain imaging data.
Ahmad, Tariq; Fiuzat, Mona; Neely, Ben; Neely, Megan; Pencina, Michael J.; Kraus, William E.; Zannad, Faiez; Whellan, David J.; Donahue, Mark; Piña, Ileana L.; Adams, Kirkwood; Kitzman, Dalane W.; O’Connor, Christopher M.; Felker, G. Michael
2014-01-01
Objective To determine whether biomarkers of myocardial stress and fibrosis improve prediction of mode of death in patients with chronic heart failure. Background The two most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of mode of death may facilitate treatment decisions. The relationship between NT-proBNP, galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown. Methods HF-ACTION was a randomized controlled trial of exercise training vs. usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (LVEF<35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox-proportional hazards modeling, and interaction testing was used to measure differential association between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP. Results After a median follow up of 2.5 years, there were 155 deaths: 49 from pump failure 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk of both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death but this relationship was attenuated after adjustment for clinical risk factors. Clinical variables along with NT-proBNP levels were stronger predictors of pump failure (C statistic: 0.87) than sudden cardiac death (C statistic: 0.73). Addition of ST2 and galectin-3 led to improved net risk classification of 11% for sudden cardiac death, but not pump failure. Conclusions Clinical predictors along with NT-proBNP levels were strong predictors of pump failure risk, with insignificant incremental contributions of ST2 and galectin-3. Predictability of sudden cardiac death risk was less robust and enhanced by information provided by novel biomarkers. PMID:24952693
Jones, Ryan T; Handsfield, Lydia; Read, Paul W; Wilson, David D; Van Ausdal, Ray; Schlesinger, David J; Siebers, Jeffrey V; Chen, Quan
2015-01-01
The clinical challenge of radiation therapy (RT) for painful bone metastases requires clinicians to consider both treatment efficacy and patient prognosis when selecting a radiation therapy regimen. The traditional RT workflow requires several weeks for common palliative RT schedules of 30 Gy in 10 fractions or 20 Gy in 5 fractions. At our institution, we have created a new RT workflow termed "STAT RAD" that allows clinicians to perform computed tomographic (CT) simulation, planning, and highly conformal single fraction treatment delivery within 2 hours. In this study, we evaluate the safety and feasibility of the STAT RAD workflow. A failure mode and effects analysis (FMEA) was performed on the STAT RAD workflow, including development of a process map, identification of potential failure modes, description of the cause and effect, temporal occurrence, and team member involvement in each failure mode, and examination of existing safety controls. A risk probability number (RPN) was calculated for each failure mode. As necessary, workflow adjustments were then made to safeguard failure modes of significant RPN values. After workflow alterations, RPN numbers were again recomputed. A total of 72 potential failure modes were identified in the pre-FMEA STAT RAD workflow, of which 22 met the RPN threshold for clinical significance. Workflow adjustments included the addition of a team member checklist, changing simulation from megavoltage CT to kilovoltage CT, alteration of patient-specific quality assurance testing, and allocating increased time for critical workflow steps. After these modifications, only 1 failure mode maintained RPN significance; patient motion after alignment or during treatment. Performing the FMEA for the STAT RAD workflow before clinical implementation has significantly strengthened the safety and feasibility of STAT RAD. The FMEA proved a valuable evaluation tool, identifying potential problem areas so that we could create a safer workflow. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
NASA Technical Reports Server (NTRS)
Wanthal, Steven; Schaefer, Joseph; Justusson, Brian; Hyder, Imran; Engelstad, Stephen; Rose, Cheryl
2017-01-01
The Advanced Composites Consortium is a US Government/Industry partnership supporting technologies to enable timeline and cost reduction in the development of certified composite aerospace structures. A key component of the consortium's approach is the development and validation of improved progressive damage and failure analysis methods for composite structures. These methods will enable increased use of simulations in design trade studies and detailed design development, and thereby enable more targeted physical test programs to validate designs. To accomplish this goal with confidence, a rigorous verification and validation process was developed. The process was used to evaluate analysis methods and associated implementation requirements to ensure calculation accuracy and to gage predictability for composite failure modes of interest. This paper introduces the verification and validation process developed by the consortium during the Phase I effort of the Advanced Composites Project. Specific structural failure modes of interest are first identified, and a subset of standard composite test articles are proposed to interrogate a progressive damage analysis method's ability to predict each failure mode of interest. Test articles are designed to capture the underlying composite material constitutive response as well as the interaction of failure modes representing typical failure patterns observed in aerospace structures.
Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes.
Sorrentino, Patricia
2016-01-01
The purpose of this article is to describe a quality improvement process using failure mode and effects analysis (FMEA) to evaluate systems handoff communication processes, improve emergency department (ED) throughput and reduce crowding through development of a standardized handoff, and, ultimately, improve patient safety. Risk of patient harm through ineffective communication during handoff transitions is a major reason for breakdown of systems. Complexities of ED processes put patient safety at risk. An increased incidence of submitted patient safety event reports for handoff communication failures between the ED and inpatient units solidified a decision to implement the use of FMEA to identify handoff failures to mitigate patient harm through redesign. The clinical nurse specialist implemented an FMEA. Handoff failure themes were created from deidentified retrospective reviews. Weekly meetings were held over a 3-month period to identify failure modes and determine cause and effect on the process. A functional block diagram process map tool was used to illustrate handoff processes. An FMEA grid was used to list failure modes and assign a risk priority number to quantify results. Multiple areas with actionable failures were identified. A majority of causes for high-priority failure modes were specific to communications. Findings demonstrate the complexity of transition and handoff processes. The FMEA served to identify and evaluate risk of handoff failures and provide a framework for process improvement. A focus on mentoring nurses to quality handoff processes so that it becomes habitual practice is crucial to safe patient transitions. Standardizing content and hardwiring within the system are best practice. The clinical nurse specialist is prepared to provide strong leadership to drive and implement system-wide quality projects.
Independent Orbiter Assessment (IOA): Analysis of the elevon subsystem
NASA Technical Reports Server (NTRS)
Wilson, R. E.; Riccio, J. R.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results for the Orbiter Elevon system hardware. The elevon actuators are located at the trailing edge of the wing surface. The proper function of the elevons is essential during the dynamic flight phases of ascent and entry. In the ascent phase of flight, the elevons are used for relieving high wing loads. For entry, the elevons are used to pitch and roll the vehicle. Specifically, the elevon system hardware comprises the following components: flow cutoff valve; switching valve; electro-hydraulic (EH) servoactuator; secondary delta pressure transducer; bypass valve; power valve; power valve check valve; primary actuator; primary delta pressure transducer; and primary actuator position transducer. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 25 failure modes analyzed, 18 were determined to be PCIs.
Independent Orbiter Assessment (IOA): Analysis of the guidance, navigation, and control subsystem
NASA Technical Reports Server (NTRS)
Trahan, W. H.; Odonnell, R. A.; Pietz, K. C.; Hiott, J. M.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) is presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results corresponding to the Orbiter Guidance, Navigation, and Control (GNC) Subsystem hardware are documented. The function of the GNC hardware is to respond to guidance, navigation, and control software commands to effect vehicle control and to provide sensor and controller data to GNC software. Some of the GNC hardware for which failure modes analysis was performed includes: hand controllers; Rudder Pedal Transducer Assembly (RPTA); Speed Brake Thrust Controller (SBTC); Inertial Measurement Unit (IMU); Star Tracker (ST); Crew Optical Alignment Site (COAS); Air Data Transducer Assembly (ADTA); Rate Gyro Assemblies; Accelerometer Assembly (AA); Aerosurface Servo Amplifier (ASA); and Ascent Thrust Vector Control (ATVC). The IOA analysis process utilized available GNC hardware drawings, workbooks, specifications, schematics, and systems briefs for defining hardware assemblies, components, and circuits. Each hardware item was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
Code development for ships -- A demonstration
DOE Office of Scientific and Technical Information (OSTI.GOV)
Ayyub, B.; Mansour, A.E.; White, G.
1996-12-31
A demonstration summary of a reliability-based structural design code for ships is presented for two ship types, a cruiser and a tanker. For both ship types, code requirements cover four failure modes: hull girder bulking, unstiffened plate yielding and buckling, stiffened plate buckling, and fatigue of critical detail. Both serviceability and ultimate limit states are considered. Because of limitation on the length, only hull girder modes are presented in this paper. Code requirements for other modes will be presented in future publication. A specific provision of the code will be a safety check expression. The design variables are to bemore » taken at their nominal values, typically values in the safe side of the respective distributions. Other safety check expressions for hull girder failure that include load combination factors, as well as consequence of failure factors, are considered. This paper provides a summary of safety check expressions for the hull girder modes.« less
NASA Astrophysics Data System (ADS)
Taylor, Gabriel James
The failure of electrical cables exposed to severe thermal fire conditions are a safety concern for operating commercial nuclear power plants (NPPs). The Nuclear Regulatory Commission (NRC) has promoted the use of risk-informed and performance-based methods for fire protection which resulted in a need to develop realistic methods to quantify the risk of fire to NPP safety. Recent electrical cable testing has been conducted to provide empirical data on the failure modes and likelihood of fire-induced damage. This thesis evaluated numerous aspects of the data. Circuit characteristics affecting fire-induced electrical cable failure modes have been evaluated. In addition, thermal failure temperatures corresponding to cable functional failures have been evaluated to develop realistic single point thermal failure thresholds and probability distributions for specific cable insulation types. Finally, the data was used to evaluate the prediction capabilities of a one-dimension conductive heat transfer model used to predict cable failure.
Cerebrospinal Fluid Shunting Complications in Children
Hanak, Brian W.; Bonow, Robert H.; Harris, Carolyn A.; Browd, Samuel R.
2018-01-01
Although cerebrospinal fluid (CSF) shunt placement is the most common procedure performed by pediatric neurosurgeons, shunts remain among the most failure-prone life-sustaining medical devices implanted in modern medical practice. This article provides an overview of the mechanisms of CSF shunt failure for the 3 most commonly employed definitive CSF shunts in the practice of pediatric neurosurgery: ventriculoperitoneal, ventriculopleural, and ventriculoatrial. The text has been partitioned into the broad modes of shunt failure: obstruction, infection, mechanical shunt failure, overdrainage, and distal catheter site-specific failures. Clinical management strategies for the various modes of shunt failure are discussed as are research efforts directed towards reducing shunt complication rates. As it is unlikely that CSF shunting will become an obsolete procedure in the foreseeable future, it is incumbent on the pediatric neurosurgery community to maintain focused efforts to improve our understanding of and management strategies for shunt failure and shunt-related morbidity. PMID:28249297
Failure modes and effects analysis (FMEA) for Gamma Knife radiosurgery.
Xu, Andy Yuanguang; Bhatnagar, Jagdish; Bednarz, Greg; Flickinger, John; Arai, Yoshio; Vacsulka, Jonet; Feng, Wenzheng; Monaco, Edward; Niranjan, Ajay; Lunsford, L Dade; Huq, M Saiful
2017-11-01
Gamma Knife radiosurgery is a highly precise and accurate treatment technique for treating brain diseases with low risk of serious error that nevertheless could potentially be reduced. We applied the AAPM Task Group 100 recommended failure modes and effects analysis (FMEA) tool to develop a risk-based quality management program for Gamma Knife radiosurgery. A team consisting of medical physicists, radiation oncologists, neurosurgeons, radiation safety officers, nurses, operating room technologists, and schedulers at our institution and an external physicist expert on Gamma Knife was formed for the FMEA study. A process tree and a failure mode table were created for the Gamma Knife radiosurgery procedures using the Leksell Gamma Knife Perfexion and 4C units. Three scores for the probability of occurrence (O), the severity (S), and the probability of no detection for failure mode (D) were assigned to each failure mode by 8 professionals on a scale from 1 to 10. An overall risk priority number (RPN) for each failure mode was then calculated from the averaged O, S, and D scores. The coefficient of variation for each O, S, or D score was also calculated. The failure modes identified were prioritized in terms of both the RPN scores and the severity scores. The established process tree for Gamma Knife radiosurgery consists of 10 subprocesses and 53 steps, including a subprocess for frame placement and 11 steps that are directly related to the frame-based nature of the Gamma Knife radiosurgery. Out of the 86 failure modes identified, 40 Gamma Knife specific failure modes were caused by the potential for inappropriate use of the radiosurgery head frame, the imaging fiducial boxes, the Gamma Knife helmets and plugs, the skull definition tools as well as other features of the GammaPlan treatment planning system. The other 46 failure modes are associated with the registration, imaging, image transfer, contouring processes that are common for all external beam radiation therapy techniques. The failure modes with the highest hazard scores are related to imperfect frame adaptor attachment, bad fiducial box assembly, unsecured plugs/inserts, overlooked target areas, and undetected machine mechanical failure during the morning QA process. The implementation of the FMEA approach for Gamma Knife radiosurgery enabled deeper understanding of the overall process among all professionals involved in the care of the patient and helped identify potential weaknesses in the overall process. The results of the present study give us a basis for the development of a risk based quality management program for Gamma Knife radiosurgery. © 2017 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.
Ahmad, Tariq; Fiuzat, Mona; Neely, Benjamin; Neely, Megan L; Pencina, Michael J; Kraus, William E; Zannad, Faiez; Whellan, David J; Donahue, Mark P; Piña, Ileana L; Adams, Kirkwood F; Kitzman, Dalane W; O'Connor, Christopher M; Felker, G Michael
2014-06-01
The aim of this study was to determine whether biomarkers of myocardial stress and fibrosis improve prediction of the mode of death in patients with chronic heart failure. The 2 most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of the mode of death may facilitate treatment decisions. The relationship between amino-terminal pro-brain natriuretic peptide (NT-proBNP), galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown. HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) was a randomized controlled trial of exercise training versus usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox proportional hazards modeling, and interaction testing was used to measure differential associations between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP. After a median follow-up period of 2.5 years, there were 155 deaths: 49 from pump failure, 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk for both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death, but this relationship was attenuated after adjustment for clinical risk factors. Clinical variables along with NT-proBNP levels were stronger predictors of pump failure (C statistic: 0.87) than sudden cardiac death (C statistic: 0.73). Addition of ST2 and galectin-3 led to improved net risk classification of 11% for sudden cardiac death, but not pump failure. Clinical predictors along with NT-proBNP levels were strong predictors of pump failure risk, with insignificant incremental contributions of ST2 and galectin-3. Predictability of sudden cardiac death risk was less robust and enhanced by information provided by novel biomarkers. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
SU-E-T-420: Failure Effects Mode Analysis for Trigeminal Neuralgia Frameless Radiosurgery
DOE Office of Scientific and Technical Information (OSTI.GOV)
Howe, J
2015-06-15
Purpose: Functional radiosurgery has been used successfully in the treatment of trigeminal neuralgia but presents significant challenges to ensuring the high prescription dose is delivered accurately. A review of existing practice should help direct the focus of quality improvement for this treatment regime. Method: Failure modes and effects analysis was used to identify the processes in preparing radiosurgery treatment for TN. The map was developed by a multidisciplinary team including: neurosurgeon, radiation oncology, physicist and therapist. Potential failure modes were identified for each step in the process map as well as potential causes and end effect. A risk priority numbermore » was assigned to each cause. Results: The process map identified 66 individual steps (see attached supporting document). Corrective actions were developed for areas of high risk priority number. Wrong site treatment is at higher risk for trigeminal neuralgia treatment due to the lack of site specific pathologic imaging on MR and CT – additional site specific checks were implemented to minimize the risk of wrong site treatment. Failed collision checks resulted from an insufficient collision model in the treatment planning system and a plan template was developed to address this problem. Conclusion: Failure modes and effects analysis is an effective tool for developing quality improvement in high risk radiotherapy procedures such as functional radiosurgery.« less
Failure Atlas for Rolling Bearings in Wind Turbines
DOE Office of Scientific and Technical Information (OSTI.GOV)
Tallian, T. E.
2006-01-01
This Atlas is structured as a supplement to the book: T.E. Tallian: Failure Atlas for Hertz Contact Machine Elements, 2nd edition, ASME Press New York, (1999). The content of the atlas comprises plate pages from the book that contain bearing failure images, application data, and descriptions of failure mode, image, and suspected failure causes. Rolling bearings are a critical component of the mainshaft system, gearbox and generator in the rapidly developing technology of power generating wind turbines. The demands for long service life are stringent; the design load, speed and temperature regimes are demanding and the environmental conditions including weather,more » contamination, impediments to monitoring and maintenance are often unfavorable. As a result, experience has shown that the rolling bearings are prone to a variety of failure modes that may prevent achievement of design lives. Morphological failure diagnosis is extensively used in the failure analysis and improvement of bearing operation. Accumulated experience shows that the failure appearance and mode of failure causation in wind turbine bearings has many distinguishing features. The present Atlas is a first effort to collect an interpreted database of specifically wind turbine related rolling bearing failures and make it widely available. This Atlas is structured as a supplement to the book: T. E. Tallian: Failure Atlas for Hertz Contact Machine Elements, 2d edition, ASME Press New York, (1999). The main body of that book is a comprehensive collection of self-contained pages called Plates, containing failure images, bearing and application data, and three descriptions: failure mode, image and suspected failure causes. The Plates are sorted by main failure mode into chapters. Each chapter is preceded by a general technical discussion of the failure mode, its appearance and causes. The Plates part is supplemented by an introductory part, describing the appearance classification and failure classification systems used, and by several indexes. The present Atlas is intended as a supplement to the book. It has the same structure but contains only Plate pages, arranged in chapters, each with a chapter heading page giving a short definition of the failure mode illustrated. Each Plate page is self contained, with images, bearing and application data, and descriptions of the failure mode, the images and the suspected causes. Images are provided in two resolutions: The text page includes 6 by 9 cm images. In addition, high resolution image files are attached, to be retrieved by clicking on their 'push pin' icon. While the material in the present Atlas is self-contained, it is nonetheless a supplement to the book and the complete interpretation of the terse image descriptions and of the system underlying the failure code presupposes familiarity with the book. Since this Atlas is a supplement to the book, its chapter numbering follows that of the book. Not all failure modes covered in the book have been found among the observed wind turbines. For that reason, and because of the omission of introductory matter, the chapter numbers in this Atlas are not a continuous sequence.« less
NASA Technical Reports Server (NTRS)
Brown, K. L.; Bertsch, P. J.
1986-01-01
Results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Generation (EPG)/Fuel Cell Powerplant (FCP) hardware. The EPG/FCP hardware is required for performing functions of electrical power generation and product water distribution in the Orbiter. Specifically, the EPG/FCP hardware consists of the following divisions: (1) Power Section Assembly (PSA); (2) Reactant Control Subsystem (RCS); (3) Thermal Control Subsystem (TCS); and (4) Water Removal Subsystem (WRS). The IOA analysis process utilized available EPG/FCP hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
Auxiliary feedwater system risk-based inspection guide for the Salem Nuclear Power Plant
DOE Office of Scientific and Technical Information (OSTI.GOV)
Pugh, R.; Gore, B.F. Vo, T.V.
In a study by the US Nuclear Regulatory Commission (NRC), Pacific Northwest Laboratory has developed and applied a methodology for deriving plant-specific risk-based inspection guidance for the auxiliary feedwater (AFW) system at pressurized water reactors that have not undergone probabilistic risk assessment (PRA). This methodology uses existing PRA results and plant operating experience information. Existing PRA-based inspection guidance information recently developed for the NRC for various plants was used to identify generic component failure modes. This information was then combined with plant-specific and industry-wide component information and failure data to identify failure modes and failure mechanisms for the AFW systemmore » at the selected plants. Salem was selected as the fifth plant for study. The product of this effort is a prioritized listing of AFW failures which have occurred at the plant and at other PWRs. This listing is intended for use by NRC inspectors in the preparation of inspection plans addressing AFW risk-important components at the Salem plant. 23 refs., 1 fig., 1 tab.« less
Independent Orbiter Assessment (IOA): Analysis of the body flap subsystem
NASA Technical Reports Server (NTRS)
Wilson, R. E.; Riccio, J. R.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbiter Body Flap (BF) subsystem hardware are documented. The BF is a large aerosurface located at the trailing edge of the lower aft fuselage of the Orbiter. The proper function of the BF is essential during the dynamic flight phases of ascent and entry. During the ascent phase of flight, the BF trails in a fixed position. For entry, the BF provides elevon load relief, trim control, and acts as a heat shield for the main engines. Specifically, the BF hardware comprises the following components: Power Drive Unit (PDU), rotary actuators, and torque tubes. The IOA analysis process utilized available BF hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 35 failure modes analyzed, 19 were determined to be PCIs.
WE-G-BRC-02: Risk Assessment for HDR Brachytherapy
DOE Office of Scientific and Technical Information (OSTI.GOV)
Mayadev, J.
2016-06-15
Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less
WE-G-BRC-01: Risk Assessment for Radiosurgery
DOE Office of Scientific and Technical Information (OSTI.GOV)
Kim, G.
2016-06-15
Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less
WE-G-BRC-03: Risk Assessment for Physics Plan Review
DOE Office of Scientific and Technical Information (OSTI.GOV)
Parker, S.
2016-06-15
Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less
DOE Office of Scientific and Technical Information (OSTI.GOV)
NONE
Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less
Le, Laetitia Minh Mai; Reitter, Delphine; He, Sophie; Bonle, Franck Té; Launois, Amélie; Martinez, Diane; Prognon, Patrice; Caudron, Eric
2017-12-01
Handling cytotoxic drugs is associated with chemical contamination of workplace surfaces. The potential mutagenic, teratogenic and oncogenic properties of those drugs create a risk of occupational exposure for healthcare workers, from reception of starting materials to the preparation and administration of cytotoxic therapies. The Security Failure Mode Effects and Criticality Analysis (FMECA) was used as a proactive method to assess the risks involved in the chemotherapy compounding process. FMECA was carried out by a multidisciplinary team from 2011 to 2016. Potential failure modes of the process were identified based on the Risk Priority Number (RPN) that prioritizes corrective actions. Twenty-five potential failure modes were identified. Based on RPN results, the corrective actions plan was revised annually to reduce the risk of exposure and improve practices. Since 2011, 16 specific measures were implemented successively. In six years, a cumulative RPN reduction of 626 was observed, with a decrease from 912 to 286 (-69%) despite an increase of cytotoxic compounding activity of around 23.2%. In order to anticipate and prevent occupational exposure, FMECA is a valuable tool to identify, prioritize and eliminate potential failure modes for operators involved in the cytotoxic drug preparation process before the failures occur. Copyright © 2017 Elsevier B.V. All rights reserved.
A Framework for Creating a Function-based Design Tool for Failure Mode Identification
NASA Technical Reports Server (NTRS)
Arunajadai, Srikesh G.; Stone, Robert B.; Tumer, Irem Y.; Clancy, Daniel (Technical Monitor)
2002-01-01
Knowledge of potential failure modes during design is critical for prevention of failures. Currently industries use procedures such as Failure Modes and Effects Analysis (FMEA), Fault Tree analysis, or Failure Modes, Effects and Criticality analysis (FMECA), as well as knowledge and experience, to determine potential failure modes. When new products are being developed there is often a lack of sufficient knowledge of potential failure mode and/or a lack of sufficient experience to identify all failure modes. This gives rise to a situation in which engineers are unable to extract maximum benefits from the above procedures. This work describes a function-based failure identification methodology, which would act as a storehouse of information and experience, providing useful information about the potential failure modes for the design under consideration, as well as enhancing the usefulness of procedures like FMEA. As an example, the method is applied to fifteen products and the benefits are illustrated.
Gingold-Belfer, Rachel; Niv, Yaron; Horev, Nehama; Gross, Shuli; Sahar, Nadav; Dickman, Ram
2017-04-01
Failure modes and effects analysis (FMEA) is used for the identification of potential risks in health care processes. We used a specific FMEA - based form for direct referral for colonoscopy and assessed it for procedurerelated perforations. Ten experts in endoscopy evaluated and computed the entire referral process, modes of preparation for the endoscopic procedure, the endoscopic procedure itself and the discharge process. We used FMEA assessing for likelihood of occurrence, detection and severity and calculated the risk profile number (RPN) for each of the above points. According to the highest RPN results we designed a specific open access referral form and then compared the occurrence of colonic perforations (between 2010 and 2013) in patients who were referred through the open access arm (Group 1) to those who had a prior clinical consultation (non-open access, Group 2). Our experts in endoscopy (5 physicians and 5 nurses) identified 3 categories of failure modes that, on average, reached the highest RPNs. We identified 9,558 colonoscopies in group 1, and 12,567 in group 2. Perforations were identified in three patients from the open access group (1:3186, 0.03%) and in 10 from group 2 (1:1256, 0.07%) (p = 0.024). Direct referral for colonoscopy saved 9,558 pre-procedure consultations and the sum of $850,000. The FMEA tool-based specific referral form facilitates a safe, time and money saving open access colonoscopy service. Our form may be adopted by other gastroenterological clinics in Israel.
Rodriguez-Gonzalez, Carmen Guadalupe; Martin-Barbero, Maria Luisa; Herranz-Alonso, Ana; Durango-Limarquez, Maria Isabel; Hernandez-Sampelayo, Paloma; Sanjurjo-Saez, Maria
2015-08-01
To critically evaluate the causes of preventable adverse drug events during the nurse medication administration process in inpatient units with computerized prescription order entry and profiled automated dispensing cabinets in order to prioritize interventions that need to be implemented and to evaluate the impact of specific interventions on the criticality index. This is a failure mode, effects and criticality analysis (FMECA) study. A multidisciplinary consensus committee composed of pharmacists, nurses and doctors evaluated the process of administering medications in a hospital setting in Spain. By analysing the process, all failure modes were identified and criticality was determined by rating severity, frequency and likelihood of failure detection on a scale of 1 to 10, using adapted versions of already published scales. Safety strategies were identified and prioritized. Through consensus, the committee identified eight processes and 40 failure modes, of which 20 were classified as high risk. The sum of the criticality indices was 5254. For the potential high-risk failure modes, 21 different potential causes were found resulting in 24 recommendations. Thirteen recommendations were prioritized and developed over a 24-month period, reducing total criticality from 5254 to 3572 (a 32.0% reduction). The recommendations with a greater impact on criticality were the development of an electronic medication administration record (-582) and the standardization of intravenous drug compounding in the unit (-168). Other improvements, such as barcode medication administration technology (-1033), were scheduled for a longer period of time because of lower feasibility. FMECA is a useful approach that can improve the medication administration process. © 2015 John Wiley & Sons, Ltd.
Independent Orbiter Assessment (IOA): Analysis of the DPS subsystem
NASA Technical Reports Server (NTRS)
Lowery, H. J.; Haufler, W. A.; Pietz, K. C.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis/Critical Items List (FMEA/CIL) is presented. The IOA approach features a top-down analysis of the hardware to independently determine failure modes, criticality, and potential critical items. The independent analysis results corresponding to the Orbiter Data Processing System (DPS) hardware are documented. The DPS hardware is required for performing critical functions of data acquisition, data manipulation, data display, and data transfer throughout the Orbiter. Specifically, the DPS hardware consists of the following components: Multiplexer/Demultiplexer (MDM); General Purpose Computer (GPC); Multifunction CRT Display System (MCDS); Data Buses and Data Bus Couplers (DBC); Data Bus Isolation Amplifiers (DBIA); Mass Memory Unit (MMU); and Engine Interface Unit (EIU). The IOA analysis process utilized available DPS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Due to the extensive redundancy built into the DPS the number of critical items are few. Those identified resulted from premature operation and erroneous output of the GPCs.
NASA Technical Reports Server (NTRS)
Patton, Jeff A.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Distribution and Control (EPD and C)/Electrical Power Generation (EPG) hardware. The EPD and C/EPG hardware is required for performing critical functions of cryogenic reactant storage, electrical power generation and product water distribution in the Orbiter. Specifically, the EPD and C/EPG hardware consists of the following components: Power Section Assembly (PSA); Reactant Control Subsystem (RCS); Thermal Control Subsystem (TCS); Water Removal Subsystem (WRS); and Power Reactant Storage and Distribution System (PRSDS). The IOA analysis process utilized available EPD and C/EPG hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
Probabilistic failure assessment with application to solid rocket motors
NASA Technical Reports Server (NTRS)
Jan, Darrell L.; Davidson, Barry D.; Moore, Nicholas R.
1990-01-01
A quantitative methodology is being developed for assessment of risk of failure of solid rocket motors. This probabilistic methodology employs best available engineering models and available information in a stochastic framework. The framework accounts for incomplete knowledge of governing parameters, intrinsic variability, and failure model specification error. Earlier case studies have been conducted on several failure modes of the Space Shuttle Main Engine. Work in progress on application of this probabilistic approach to large solid rocket boosters such as the Advanced Solid Rocket Motor for the Space Shuttle is described. Failure due to debonding has been selected as the first case study for large solid rocket motors (SRMs) since it accounts for a significant number of historical SRM failures. Impact of incomplete knowledge of governing parameters and failure model specification errors is expected to be important.
Faught, Jacqueline Tonigan; Balter, Peter A; Johnson, Jennifer L; Kry, Stephen F; Court, Laurence E; Stingo, Francesco C; Followill, David S
2017-11-01
The objective of this work was to assess both the perception of failure modes in Intensity Modulated Radiation Therapy (IMRT) when the linac is operated at the edge of tolerances given in AAPM TG-40 (Kutcher et al.) and TG-142 (Klein et al.) as well as the application of FMEA to this specific section of the IMRT process. An online survey was distributed to approximately 2000 physicists worldwide that participate in quality services provided by the Imaging and Radiation Oncology Core - Houston (IROC-H). The survey briefly described eleven different failure modes covered by basic quality assurance in step-and-shoot IMRT at or near TG-40 (Kutcher et al.) and TG-142 (Klein et al.) tolerance criteria levels. Respondents were asked to estimate the worst case scenario percent dose error that could be caused by each of these failure modes in a head and neck patient as well as the FMEA scores: Occurrence, Detectability, and Severity. Risk probability number (RPN) scores were calculated as the product of these scores. Demographic data were also collected. A total of 181 individual and three group responses were submitted. 84% were from North America. Most (76%) individual respondents performed at least 80% clinical work and 92% were nationally certified. Respondent medical physics experience ranged from 2.5 to 45 yr (average 18 yr). A total of 52% of individual respondents were at least somewhat familiar with FMEA, while 17% were not familiar. Several IMRT techniques, treatment planning systems, and linear accelerator manufacturers were represented. All failure modes received widely varying scores ranging from 1 to 10 for occurrence, at least 1-9 for detectability, and at least 1-7 for severity. Ranking failure modes by RPN scores also resulted in large variability, with each failure mode being ranked both most risky (1st) and least risky (11th) by different respondents. On average MLC modeling had the highest RPN scores. Individual estimated percent dose errors and severity scores positively correlated (P < 0.01) for each FM as expected. No universal correlations were found between the demographic information collected and scoring, percent dose errors or ranking. Failure modes investigated overall were evaluated as low to medium risk, with average RPNs less than 110. The ranking of 11 failure modes was not agreed upon by the community. Large variability in FMEA scoring may be caused by individual interpretation and/or experience, reflecting the subjective nature of the FMEA tool. © 2017 American Association of Physicists in Medicine.
Quantitative Approach to Failure Mode and Effect Analysis for Linear Accelerator Quality Assurance
DOE Office of Scientific and Technical Information (OSTI.GOV)
O'Daniel, Jennifer C., E-mail: jennifer.odaniel@duke.edu; Yin, Fang-Fang
Purpose: To determine clinic-specific linear accelerator quality assurance (QA) TG-142 test frequencies, to maximize physicist time efficiency and patient treatment quality. Methods and Materials: A novel quantitative approach to failure mode and effect analysis is proposed. Nine linear accelerator-years of QA records provided data on failure occurrence rates. The severity of test failure was modeled by introducing corresponding errors into head and neck intensity modulated radiation therapy treatment plans. The relative risk of daily linear accelerator QA was calculated as a function of frequency of test performance. Results: Although the failure severity was greatest for daily imaging QA (imaging vsmore » treatment isocenter and imaging positioning/repositioning), the failure occurrence rate was greatest for output and laser testing. The composite ranking results suggest that performing output and lasers tests daily, imaging versus treatment isocenter and imaging positioning/repositioning tests weekly, and optical distance indicator and jaws versus light field tests biweekly would be acceptable for non-stereotactic radiosurgery/stereotactic body radiation therapy linear accelerators. Conclusions: Failure mode and effect analysis is a useful tool to determine the relative importance of QA tests from TG-142. Because there are practical time limitations on how many QA tests can be performed, this analysis highlights which tests are the most important and suggests the frequency of testing based on each test's risk priority number.« less
NASA Technical Reports Server (NTRS)
Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.
1992-01-01
An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes, These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.
NASA Technical Reports Server (NTRS)
Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.
1992-01-01
An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.
Thermal barrier coating life prediction model development
NASA Technical Reports Server (NTRS)
Sheffler, K. D.; Demasi, J. T.
1985-01-01
A methodology was established to predict thermal barrier coating life in an environment simulative of that experienced by gas turbine airfoils. Specifically, work is being conducted to determine failure modes of thermal barrier coatings in the aircraft engine environment. Analytical studies coupled with appropriate physical and mechanical property determinations are being employed to derive coating life prediction model(s) on the important failure mode(s). An initial review of experimental and flight service components indicates that the predominant mode of TBC failure involves thermomechanical spallation of the ceramic coating layer. This ceramic spallation involves the formation of a dominant crack in the ceramic coating parallel to and closely adjacent to the metal-ceramic interface. Initial results from a laboratory test program designed to study the influence of various driving forces such as temperature, thermal cycle frequency, environment, and coating thickness, on ceramic coating spalling life suggest that bond coat oxidation damage at the metal-ceramic interface contributes significantly to thermomechanical cracking in the ceramic layer. Low cycle rate furnace testing in air and in argon clearly shows a dramatic increase of spalling life in the non-oxidizing environments.
Simplified analysis of timber rivet connections
Douglas C. Stahl; Marshall. Begel; Ronald W. Wolfe
2000-01-01
Timber rivets, fasteners for glulam and heavy timber construction, have been used in Canada for about thirty years and recently were adopted by the U.S. National Design Specification for Wood Construction (NDS). Rivet connections can exhibit two failure modes, one of which is fundamentally different from those of other dowel fasteners. Failure can occur when a volume...
Maximum likelihood estimation for life distributions with competing failure modes
NASA Technical Reports Server (NTRS)
Sidik, S. M.
1979-01-01
Systems which are placed on test at time zero, function for a period and die at some random time were studied. Failure may be due to one of several causes or modes. The parameters of the life distribution may depend upon the levels of various stress variables the item is subject to. Maximum likelihood estimation methods are discussed. Specific methods are reported for the smallest extreme-value distributions of life. Monte-Carlo results indicate the methods to be promising. Under appropriate conditions, the location parameters are nearly unbiased, the scale parameter is slight biased, and the asymptotic covariances are rapidly approached.
Structural analysis considerations for wind turbine blades
NASA Technical Reports Server (NTRS)
Spera, D. A.
1979-01-01
Approaches to the structural analysis of wind turbine blade designs are reviewed. Specifications and materials data are discussed along with the analysis of vibrations, loads, stresses, and failure modes.
Independent Orbiter Assessment (IOA): Analysis of the landing/deceleration subsystem
NASA Technical Reports Server (NTRS)
Compton, J. M.; Beaird, H. G.; Weissinger, W. D.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Landing/Deceleration Subsystem hardware. The Landing/Deceleration Subsystem is utilized to allow the Orbiter to perform a safe landing, allowing for landing-gear deploy activities, steering and braking control throughout the landing rollout to wheel-stop, and to allow for ground-handling capability during the ground-processing phase of the flight cycle. Specifically, the Landing/Deceleration hardware consists of the following components: Nose Landing Gear (NLG); Main Landing Gear (MLG); Brake and Antiskid (B and AS) Electrical Power Distribution and Controls (EPD and C); Nose Wheel Steering (NWS); and Hydraulics Actuators. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Due to the lack of redundancy in the Landing/Deceleration Subsystems there is a high number of critical items.
NASA Technical Reports Server (NTRS)
Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.
1992-01-01
An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with analytical modeling of failure phenomena to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in analytical modeling, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which analytical models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. State-of-the-art analytical models currently employed for designs failure prediction, or performance analysis are used in this methodology. The rationale for the statistical approach taken in the PFA methodology is discussed, the PFA methodology is described, and examples of its application to structural failure modes are presented. The engineering models and computer software used in fatigue crack growth and fatigue crack initiation applications are thoroughly documented.
NASA Technical Reports Server (NTRS)
Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.
1992-01-01
An improved methodology for quantitatively evaluating failure risk of spaceflights systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with analytical modeling of failure phenomena to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in analytical modeling, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which analytical models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. State-of-the-art analytical models currently employed for design, failure prediction, or performance analysis are used in this methodology. The rationale for the statistical approach taken in the PFA methodology is discussed, the PFA methodology is described, and examples of its application to structural failure modes are presented. The engineering models and computer software used in fatigue crack growth and fatigue crack initiation applications are thoroughly documented.
Risk Based Reliability Centered Maintenance of DOD Fire Protection Systems
1999-01-01
2.2.3 Failure Mode and Effect Analysis ( FMEA )............................ 2.2.4 Failure Mode Risk Characterization...Step 2 - System functions and functional failures definition Step 3 - Failure mode and effect analysis ( FMEA ) Step 4 - Failure mode risk...system). The Interface Location column identifies the location where the FMEA of the fire protection system began or stopped. For example, for the fire
Failure detection system risk reduction assessment
NASA Technical Reports Server (NTRS)
Aguilar, Robert B. (Inventor); Huang, Zhaofeng (Inventor)
2012-01-01
A process includes determining a probability of a failure mode of a system being analyzed reaching a failure limit as a function of time to failure limit, determining a probability of a mitigation of the failure mode as a function of a time to failure limit, and quantifying a risk reduction based on the probability of the failure mode reaching the failure limit and the probability of the mitigation.
Deriving Function-failure Similarity Information for Failure-free Rotorcraft Component Design
NASA Technical Reports Server (NTRS)
Roberts, Rory A.; Stone, Robert B.; Tumer, Irem Y.; Clancy, Daniel (Technical Monitor)
2002-01-01
Performance and safety are the top concerns of high-risk aerospace applications at NASA. Eliminating or reducing performance and safety problems can be achieved with a thorough understanding of potential failure modes in the design that lead to these problems. The majority of techniques use prior knowledge and experience as well as Failure Modes and Effects as methods to determine potential failure modes of aircraft. The aircraft design needs to be passed through a general technique to ensure that every potential failure mode is considered, while avoiding spending time on improbable failure modes. In this work, this is accomplished by mapping failure modes to certain components, which are described by their functionality. In turn, the failure modes are then linked to the basic functions that are carried within the components of the aircraft. Using the technique proposed in this paper, designers can examine the basic functions, and select appropriate analyses to eliminate or design out the potential failure modes. This method was previously applied to a simple rotating machine test rig with basic functions that are common to a rotorcraft. In this paper, this technique is applied to the engine and power train of a rotorcraft, using failures and functions obtained from accident reports and engineering drawings.
Capturing a failure of an ASIC in-situ, using infrared radiometry and image processing software
NASA Technical Reports Server (NTRS)
Ruiz, Ronald P.
2003-01-01
Failures in electronic devices can sometimes be tricky to locate-especially if they are buried inside radiation-shielded containers designed to work in outer space. Such was the case with a malfunctioning ASIC (Application Specific Integrated Circuit) that was drawing excessive power at a specific temperature during temperature cycle testing. To analyze the failure, infrared radiometry (thermography) was used in combination with image processing software to locate precisely where the power was being dissipated at the moment the failure took place. The IR imaging software was used to make the image of the target and background, appear as unity. As testing proceeded and the failure mode was reached, temperature changes revealed the precise location of the fault. The results gave the design engineers the information they needed to fix the problem. This paper describes the techniques and equipment used to accomplish this failure analysis.
NASA Astrophysics Data System (ADS)
Telesman, J.; Smith, T. M.; Gabb, T. P.; Ring, A. J.
2018-06-01
Cyclic near-threshold fatigue crack growth (FCG) behavior of two disk superalloys was evaluated and was shown to exhibit an unexpected sudden failure mode transition from a mostly transgranular failure mode at higher stress intensity factor ranges to an almost completely intergranular failure mode in the threshold regime. The change in failure modes was associated with a crossover of FCG resistance curves in which the conditions that produced higher FCG rates in the Paris regime resulted in lower FCG rates and increased ΔK th values in the threshold region. High-resolution scanning and transmission electron microscopy were used to carefully characterize the crack tips at these near-threshold conditions. Formation of stable Al-oxide followed by Cr-oxide and Ti-oxides was found to occur at the crack tip prior to formation of unstable oxides. To contrast with the threshold failure mode regime, a quantitative assessment of the role that the intergranular failure mode has on cyclic FCG behavior in the Paris regime was also performed. It was demonstrated that even a very limited intergranular failure content dominates the FCG response under mixed mode failure conditions.
Patel, Teresa; Fisher, Stanley P.
2016-01-01
Objective This study aimed to utilize failure modes and effects analysis (FMEA) to transform clinical insights into a risk mitigation plan for intrathecal (IT) drug delivery in pain management. Methods The FMEA methodology, which has been used for quality improvement, was adapted to assess risks (i.e., failure modes) associated with IT therapy. Ten experienced pain physicians scored 37 failure modes in the following categories: patient selection for therapy initiation (efficacy and safety concerns), patient safety during IT therapy, and product selection for IT therapy. Participants assigned severity, probability, and detection scores for each failure mode, from which a risk priority number (RPN) was calculated. Failure modes with the highest RPNs (i.e., most problematic) were discussed, and strategies were proposed to mitigate risks. Results Strategic discussions focused on 17 failure modes with the most severe outcomes, the highest probabilities of occurrence, and the most challenging detection. The topic of the highest‐ranked failure mode (RPN = 144) was manufactured monotherapy versus compounded combination products. Addressing failure modes associated with appropriate patient and product selection was predicted to be clinically important for the success of IT therapy. Conclusions The methodology of FMEA offers a systematic approach to prioritizing risks in a complex environment such as IT therapy. Unmet needs and information gaps are highlighted through the process. Risk mitigation and strategic planning to prevent and manage critical failure modes can contribute to therapeutic success. PMID:27477689
Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures.
Ashley, Laura; Armitage, Gerry
2010-12-01
To empirically compare 2 different commonly used failure mode and effects analysis (FMEA) scoring procedures with respect to their resultant failure mode scores and prioritization: a mathematical procedure, where scores are assigned independently by FMEA team members and averaged, and a consensus procedure, where scores are agreed on by the FMEA team via discussion. A multidisciplinary team undertook a Healthcare FMEA of chemotherapy administration. This included mapping the chemotherapy process, identifying and scoring failure modes (potential errors) for each process step, and generating remedial strategies to counteract them. Failure modes were scored using both an independent mathematical procedure and a team consensus procedure. Almost three-fifths of the 30 failure modes generated were scored differently by the 2 procedures, and for just more than one-third of cases, the score discrepancy was substantial. Using the Healthcare FMEA prioritization cutoff score, almost twice as many failure modes were prioritized by the consensus procedure than by the mathematical procedure. This is the first study to empirically demonstrate that different FMEA scoring procedures can score and prioritize failure modes differently. It found considerable variability in individual team members' opinions on scores, which highlights the subjective and qualitative nature of failure mode scoring. A consensus scoring procedure may be most appropriate for FMEA as it allows variability in individuals' scores and rationales to become apparent and to be discussed and resolved by the team. It may also yield team learning and communication benefits unlikely to result from a mathematical procedure.
Cubbon, Richard M; Ruff, Naomi; Groves, David; Eleuteri, Antonio; Denby, Christine; Kearney, Lorraine; Ali, Noman; Walker, Andrew M N; Jamil, Haqeel; Gierula, John; Gale, Chris P; Batin, Phillip D; Nolan, James; Shah, Ajay M; Fox, Keith A A; Sapsford, Robert J; Witte, Klaus K; Kearney, Mark T
2016-01-01
Objective We aimed to define the prognostic value of the heart rate range during a 24 h period in patients with chronic heart failure (CHF). Methods Prospective observational cohort study of 791 patients with CHF associated with left ventricular systolic dysfunction. Mode-specific mortality and hospitalisation were linked with ambulatory heart rate range (AHRR; calculated as maximum minus minimum heart rate using 24 h Holter monitor data, including paced and non-sinus complexes) in univariate and multivariate analyses. Findings were then corroborated in a validation cohort of 408 patients with CHF with preserved or reduced left ventricular ejection fraction. Results After a mean 4.1 years of follow-up, increasing AHRR was associated with reduced risk of all-cause, sudden, non-cardiovascular and progressive heart failure death in univariate analyses. After accounting for characteristics that differed between groups above and below median AHRR using multivariate analysis, AHRR remained strongly associated with all-cause mortality (HR 0.991/bpm increase in AHRR (95% CI 0.999 to 0.982); p=0.046). AHRR was not associated with the risk of any non-elective hospitalisation, but was associated with heart-failure-related hospitalisation. AHRR was modestly associated with the SD of normal-to-normal beats (R2=0.2; p<0.001) and with peak exercise-test heart rate (R2=0.33; p<0.001). Analysis of the validation cohort revealed AHRR to be associated with all-cause and mode-specific death as described in the derivation cohort. Conclusions AHRR is a novel and readily available prognosticator in patients with CHF, which may reflect autonomic tone and exercise capacity. PMID:26674986
Independent Orbiter Assessment (IOA): Analysis of the Orbiter Experiment (OEX) subsystem
NASA Technical Reports Server (NTRS)
Compton, J. M.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Experiments hardware. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. The Orbiter Experiments (OEX) Program consists of a multiple set of experiments for the purpose of gathering environmental and aerodynamic data to develop more accurate ground models for Shuttle performance and to facilitate the design of future spacecraft. This assessment only addresses currently manifested experiments and their support systems. Specifically this list consists of: Shuttle Entry Air Data System (SEADS); Shuttle Upper Atmosphere Mass Spectrometer (SUMS); Forward Fuselage Support System for OEX (FFSSO); Shuttle Infrared Laced Temperature Sensor (SILTS); Aerodynamic Coefficient Identification Package (ACIP); and Support System for OEX (SSO). There are only two potential critical items for the OEX, since the experiments only gather data for analysis post mission and are totally independent systems except for power. Failure of any experiment component usually only causes a loss of experiment data and in no way jeopardizes the crew or mission.
Analytical Method to Evaluate Failure Potential During High-Risk Component Development
NASA Technical Reports Server (NTRS)
Tumer, Irem Y.; Stone, Robert B.; Clancy, Daniel (Technical Monitor)
2001-01-01
Communicating failure mode information during design and manufacturing is a crucial task for failure prevention. Most processes use Failure Modes and Effects types of analyses, as well as prior knowledge and experience, to determine the potential modes of failures a product might encounter during its lifetime. When new products are being considered and designed, this knowledge and information is expanded upon to help designers extrapolate based on their similarity with existing products and the potential design tradeoffs. This paper makes use of similarities and tradeoffs that exist between different failure modes based on the functionality of each component/product. In this light, a function-failure method is developed to help the design of new products with solutions for functions that eliminate or reduce the potential of a failure mode. The method is applied to a simplified rotating machinery example in this paper, and is proposed as a means to account for helicopter failure modes during design and production, addressing stringent safety and performance requirements for NASA applications.
Failure Mode Identification Through Clustering Analysis
NASA Technical Reports Server (NTRS)
Arunajadai, Srikesh G.; Stone, Robert B.; Tumer, Irem Y.; Clancy, Daniel (Technical Monitor)
2002-01-01
Research has shown that nearly 80% of the costs and problems are created in product development and that cost and quality are essentially designed into products in the conceptual stage. Currently, failure identification procedures (such as FMEA (Failure Modes and Effects Analysis), FMECA (Failure Modes, Effects and Criticality Analysis) and FTA (Fault Tree Analysis)) and design of experiments are being used for quality control and for the detection of potential failure modes during the detail design stage or post-product launch. Though all of these methods have their own advantages, they do not give information as to what are the predominant failures that a designer should focus on while designing a product. This work uses a functional approach to identify failure modes, which hypothesizes that similarities exist between different failure modes based on the functionality of the product/component. In this paper, a statistical clustering procedure is proposed to retrieve information on the set of predominant failures that a function experiences. The various stages of the methodology are illustrated using a hypothetical design example.
NASA Technical Reports Server (NTRS)
Moore, N. R.; Ebbeler, D. H.; Newlin, L. E.; Sutharshana, S.; Creager, M.
1992-01-01
An improved methodology for quantitatively evaluating failure risk of spaceflight systems to assess flight readiness and identify risk control measures is presented. This methodology, called Probabilistic Failure Assessment (PFA), combines operating experience from tests and flights with engineering analysis to estimate failure risk. The PFA methodology is of particular value when information on which to base an assessment of failure risk, including test experience and knowledge of parameters used in engineering analyses of failure phenomena, is expensive or difficult to acquire. The PFA methodology is a prescribed statistical structure in which engineering analysis models that characterize failure phenomena are used conjointly with uncertainties about analysis parameters and/or modeling accuracy to estimate failure probability distributions for specific failure modes. These distributions can then be modified, by means of statistical procedures of the PFA methodology, to reflect any test or flight experience. Conventional engineering analysis models currently employed for design of failure prediction are used in this methodology. The PFA methodology is described and examples of its application are presented. Conventional approaches to failure risk evaluation for spaceflight systems are discussed, and the rationale for the approach taken in the PFA methodology is presented. The statistical methods, engineering models, and computer software used in fatigue failure mode applications are thoroughly documented.
A Summary of Taxonomies of Digital System Failure Modes Provided by the DigRel Task Group
DOE Office of Scientific and Technical Information (OSTI.GOV)
Chu T. L.; Yue M.; Postma, W.
2012-06-25
Recently, the CSNI directed WGRisk to set up a task group called DIGREL to initiate a new task on developing a taxonomy of failure modes of digital components for the purposes of PSA. It is an important step towards standardized digital I&C reliability assessment techniques for PSA. The objective of this paper is to provide a comparison of the failure mode taxonomies provided by the participants. The failure modes are classified in terms of their levels of detail. Software and hardware failure modes are discussed separately.
1984-10-26
test for independence; ons i ser, -, of the poduct life estimator; dependent risks; 119 ASRACT Coniinue on ’wme-se f nereiary-~and iaen r~f> by Worst...the failure times associated with different failure - modes when we really should use a bivariate (or multivariate) distribution, then what is the...dependencies may be present, then what is the magnitude of the estimation error? S The third specific aim will attempt to obtain bounds on the
On a common critical state in localized and diffuse failure modes
NASA Astrophysics Data System (ADS)
Zhu, Huaxiang; Nguyen, Hien N. G.; Nicot, François; Darve, Félix
2016-10-01
Accurately modeling the critical state mechanical behavior of granular material largely relies on a better understanding and characterizing the critical state fabric in different failure modes, i.e. localized and diffuse failure modes. In this paper, a mesoscopic scale is introduced, in which the organization of force-transmission paths (force-chains) and cells encompassed by contacts (meso-loops) can be taken into account. Numerical drained biaxial tests using a discrete element method are performed with different initial void ratios, in order to investigate the critical state fabric on the meso-scale in both localized and diffuse failure modes. According to the displacement and strain fields extracted from tests, the failure mode and failure area of each specimen are determined. Then convergent critical state void ratios are observed in failure area of specimens. Different mechanical features of two kinds of meso-structures (force-chains and meso-loops) are investigated, to clarify whether there exists a convergent meso-structure inside the failure area of granular material, as the signature of critical state. Numerical results support a positive answer. Failure area of both localized and diffuse failure modes therefore exhibits the same fabric in critical state. Hence, these two failure modes prove to be homological with respect to the concept of the critical state.
Reusable rocket engine intelligent control system framework design, phase 2
NASA Technical Reports Server (NTRS)
Nemeth, ED; Anderson, Ron; Ols, Joe; Olsasky, Mark
1991-01-01
Elements of an advanced functional framework for reusable rocket engine propulsion system control are presented for the Space Shuttle Main Engine (SSME) demonstration case. Functional elements of the baseline functional framework are defined in detail. The SSME failure modes are evaluated and specific failure modes identified for inclusion in the advanced functional framework diagnostic system. Active control of the SSME start transient is investigated, leading to the identification of a promising approach to mitigating start transient excursions. Key elements of the functional framework are simulated and demonstration cases are provided. Finally, the advanced function framework for control of reusable rocket engines is presented.
Improving the treatment planning and delivery process of Xoft electronic skin brachytherapy.
Manger, Ryan; Rahn, Douglas; Hoisak, Jeremy; Dragojević, Irena
2018-05-14
To develop an improved Xoft electronic skin brachytherapy process and identify areas of further improvement. A multidisciplinary team conducted a failure modes and effects analysis (FMEA) by developing a process map and a corresponding list of failure modes. The failure modes were scored for their occurrence, severity, and detectability, and a risk priority number (RPN) was calculated for each failure mode as the product of occurrence, severity, and detectability. Corrective actions were implemented to address the higher risk failure modes, and a revised process was generated. The RPNs of the failure modes were compared between the initial process and final process to assess the perceived benefits of the corrective actions. The final treatment process consists of 100 steps and 114 failure modes. The FMEA took approximately 20 person-hours (one physician, three physicists, and two therapists) to complete. The 10 most dangerous failure modes had RPNs ranging from 336 to 630. Corrective actions were effective at addressing most failure modes (10 riskiest RPNs ranging from 189 to 310), yet the RPNs were higher than those published for alternative systems. Many of these high-risk failure modes remained due to hardware design limitations. FMEA helps guide process improvement efforts by emphasizing the riskiest steps. Significant risks are apparent when using a Xoft treatment unit for skin brachytherapy due to hardware limitations such as the lack of several interlocks, a short source lifespan, and variability in source output. The process presented in this article is expected to reduce but not eliminate these risks. Copyright © 2018 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
Decomposition-Based Failure Mode Identification Method for Risk-Free Design of Large Systems
NASA Technical Reports Server (NTRS)
Tumer, Irem Y.; Stone, Robert B.; Roberts, Rory A.; Clancy, Daniel (Technical Monitor)
2002-01-01
When designing products, it is crucial to assure failure and risk-free operation in the intended operating environment. Failures are typically studied and eliminated as much as possible during the early stages of design. The few failures that go undetected result in unacceptable damage and losses in high-risk applications where public safety is of concern. Published NASA and NTSB accident reports point to a variety of components identified as sources of failures in the reported cases. In previous work, data from these reports were processed and placed in matrix form for all the system components and failure modes encountered, and then manipulated using matrix methods to determine similarities between the different components and failure modes. In this paper, these matrices are represented in the form of a linear combination of failures modes, mathematically formed using Principal Components Analysis (PCA) decomposition. The PCA decomposition results in a low-dimensionality representation of all failure modes and components of interest, represented in a transformed coordinate system. Such a representation opens the way for efficient pattern analysis and prediction of failure modes with highest potential risks on the final product, rather than making decisions based on the large space of component and failure mode data. The mathematics of the proposed method are explained first using a simple example problem. The method is then applied to component failure data gathered from helicopter, accident reports to demonstrate its potential.
Risk analysis of analytical validations by probabilistic modification of FMEA.
Barends, D M; Oldenhof, M T; Vredenbregt, M J; Nauta, M J
2012-05-01
Risk analysis is a valuable addition to validation of an analytical chemistry process, enabling not only detecting technical risks, but also risks related to human failures. Failure Mode and Effect Analysis (FMEA) can be applied, using a categorical risk scoring of the occurrence, detection and severity of failure modes, and calculating the Risk Priority Number (RPN) to select failure modes for correction. We propose a probabilistic modification of FMEA, replacing the categorical scoring of occurrence and detection by their estimated relative frequency and maintaining the categorical scoring of severity. In an example, the results of traditional FMEA of a Near Infrared (NIR) analytical procedure used for the screening of suspected counterfeited tablets are re-interpretated by this probabilistic modification of FMEA. Using this probabilistic modification of FMEA, the frequency of occurrence of undetected failure mode(s) can be estimated quantitatively, for each individual failure mode, for a set of failure modes, and the full analytical procedure. Copyright © 2012 Elsevier B.V. All rights reserved.
Berruyer, M; Atkinson, S; Lebel, D; Bussières, J-F
2016-01-01
Insulin is a high-alert drug. The main objective of this descriptive cross-sectional study was to evaluate the risks associated with insulin use in healthcare centers. The secondary objective was to propose corrective measures to reduce the main risks associated with the most critical failure modes in the analysis. We conducted a failure mode and effects analysis (FMEA) in obstetrics-gynecology, neonatology and pediatrics. Five multidisciplinary meetings occurred in August 2013. A total of 44 out of 49 failure modes were analyzed. Nine out of 44 (20%) failure modes were deemed critical, with a criticality score ranging from 540 to 720. Following the multidisciplinary meetings, everybody agreed that an FMEA was a useful tool to identify failure modes and their relative importance. This approach identified many corrective measures. This shared experience increased awareness of safety issues with insulin in our mother-child center. This study identified the main failure modes and associated corrective measures. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Epithelial and endothelial damage induced by mechanical ventilation modes.
Suki, Béla; Hubmayr, Rolf
2014-02-01
The adult respiratory distress syndrome (ARDS) is a common cause of respiratory failure with substantial impact on public health. Patients with ARDS generally require mechanical ventilation, which risks further lung damage. Recent improvements in ARDS outcomes have been attributed to reductions in deforming stress associated with lung protective mechanical ventilation modes and settings. The following review details the mechanics of the lung parenchyma at different spatial scales and the response of its resident cells to deforming stress in order to provide the biologic underpinnings of lung protective care. Although lung injury is typically viewed through the lens of altered barrier properties and mechanical ventilation-associated immune responses, in this review, we call attention to the importance of heterogeneity and the physical failure of the load bearing cell and tissue elements in the pathogenesis of ARDS. Specifically, we introduce a simple elastic network model to better understand the deformations of lung regions, intra-acinar alveoli and cells within a single alveolus, and consider the role of regional distension and interfacial stress-related injury for various ventilation modes. Heterogeneity of stiffness and intercellular and intracellular stress failure are fundamental components of ARDS and their development also depends on the ventilation mode.
Mechanical Failure Mode of Metal Nanowires: Global Deformation versus Local Deformation
Ho, Duc Tam; Im, Youngtae; Kwon, Soon-Yong; Earmme, Youn Young; Kim, Sung Youb
2015-01-01
It is believed that the failure mode of metal nanowires under tensile loading is the result of the nucleation and propagation of dislocations. Such failure modes can be slip, partial slip or twinning and therefore they are regarded as local deformation. Here we provide numerical and theoretical evidences to show that global deformation is another predominant failure mode of nanowires under tensile loading. At the global deformation mode, nanowires fail with a large contraction along a lateral direction and a large expansion along the other lateral direction. In addition, there is a competition between global and local deformations. Nanowires loaded at low temperature exhibit global failure mode first and then local deformation follows later. We show that the global deformation originates from the intrinsic instability of the nanowires and that temperature is a main parameter that decides the global or local deformation as the failure mode of nanowires. PMID:26087445
Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.
Wetterneck, Tosha B; Skibinski, Kathleen A; Roberts, Tanita L; Kleppin, Susan M; Schroeder, Mark E; Enloe, Myra; Rough, Steven S; Hundt, Ann Schoofs; Carayon, Pascale
2006-08-15
Failure mode and effects analysis (FMEA) was used to evaluate a smart i.v. pump as it was implemented into a redesigned medication-use process. A multidisciplinary team conducted a FMEA to guide the implementation of a smart i.v. pump that was designed to prevent pump programming errors. The smart i.v. pump was equipped with a dose-error reduction system that included a pre-defined drug library in which dosage limits were set for each medication. Monitoring for potential failures and errors occurred for three months postimplementation of FMEA. Specific measures were used to determine the success of the actions that were implemented as a result of the FMEA. The FMEA process at the hospital identified key failure modes in the medication process with the use of the old and new pumps, and actions were taken to avoid errors and adverse events. I.V. pump software and hardware design changes were also recommended. Thirteen of the 18 failure modes reported in practice after pump implementation had been identified by the team. A beneficial outcome of FMEA was the development of a multidisciplinary team that provided the infrastructure for safe technology implementation and effective event investigation after implementation. With the continual updating of i.v. pump software and hardware after implementation, FMEA can be an important starting place for safe technology choice and implementation and can produce site experts to follow technology and process changes over time. FMEA was useful in identifying potential problems in the medication-use process with the implementation of new smart i.v. pumps. Monitoring for system failures and errors after implementation remains necessary.
Failure Mode, Effects, and Criticality Analysis (FMECA)
1993-04-01
Preliminary Failure Modes, Effects and Criticality Analysis (FMECA) of the Brayton Isotope Power System Ground Demonstration System, Report No. TID 27301...No. TID/SNA - 3015, Aeroject Nuclear Systems Co., Sacramento, California: 1970. 95. Taylor , J.R. A Formalization of Failure Mode Analysis of Control...Roskilde, Denmark: 1973. 96. Taylor , J.R. A Semi-Automatic Method for Oualitative Failure Mode Analysis. Report No. RISO-M-1707. Available from a
NASA Astrophysics Data System (ADS)
Sin, Yongkun; Ayvazian, Talin; Brodie, Miles; Lingley, Zachary
2018-03-01
High-power single-mode (SM) and multi-mode (MM) InGaAs-AlGaAs strained quantum well (QW) lasers are critical components for both terrestrial and space satellite communications systems. Since these lasers predominantly fail by catastrophic and sudden degradation due to catastrophic optical damage (COD), it is especially crucial for space satellite applications to investigate reliability, failure modes, precursor signatures of failure, and degradation mechanisms of these lasers. Our group reported a new failure mode in MM and SM InGaAs-AlGaAs strained QW lasers in 2009 and 2016, respectively. Our group also reported in 2017 that bulk failure due to catastrophic optical bulk damage (COBD) is the dominant failure mode of both SM and MM lasers that were subject to long-term life-tests. For the present study, we continued our physics of failure investigation by performing long-term life-tests followed by failure mode analysis (FMA) using nondestructive and destructive micro-analytical techniques. We performed long-term accelerated life-tests on state-of-the-art SM and MM InGaAs- AlGaAs strained QW lasers under ACC mode. Our life-tests have accumulated over 25,000 test hours for SM lasers and over 35,000 test hours for MM lasers. We first employed electron beam induced current (EBIC) technique to identify failure modes of degraded SM lasers by observing dark line defects. All the SM failures that we studied showed catastrophic and sudden degradation and all of these failures were bulk failures. Since degradation mechanisms responsible for COBD are still not well understood, we also employed other techniques including focused ion beam (FIB) and high-resolution TEM to further study dark line defects and dislocations in post-aged lasers. Keywor
[Failure mode effect analysis applied to preparation of intravenous cytostatics].
Santos-Rubio, M D; Marín-Gil, R; Muñoz-de la Corte, R; Velázquez-López, M D; Gil-Navarro, M V; Bautista-Paloma, F J
2016-01-01
To proactively identify risks in the preparation of intravenous cytostatic drugs, and to prioritise and establish measures to improve safety procedures. Failure Mode Effect Analysis methodology was used. A multidisciplinary team identified potential failure modes of the procedure through a brainstorming session. The impact associated with each failure mode was assessed with the Risk Priority Number (RPN), which involves three variables: occurrence, severity, and detectability. Improvement measures were established for all identified failure modes, with those with RPN>100 considered critical. The final RPN (theoretical) that would result from the proposed measures was also calculated and the process was redesigned. A total of 34 failure modes were identified. The initial accumulated RPN was 3022 (range: 3-252), and after recommended actions the final RPN was 1292 (range: 3-189). RPN scores >100 were obtained in 13 failure modes; only the dispensing sub-process was free of critical points (RPN>100). A final reduction of RPN>50% was achieved in 9 failure modes. This prospective risk analysis methodology allows the weaknesses of the procedure to be prioritised, optimize use of resources, and a substantial improvement in the safety of the preparation of cytostatic drugs through the introduction of double checking and intermediate product labelling. Copyright © 2015 SECA. Published by Elsevier Espana. All rights reserved.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Pullum, Laura L; Symons, Christopher T
2011-01-01
Machine learning is used in many applications, from machine vision to speech recognition to decision support systems, and is used to test applications. However, though much has been done to evaluate the performance of machine learning algorithms, little has been done to verify the algorithms or examine their failure modes. Moreover, complex learning frameworks often require stepping beyond black box evaluation to distinguish between errors based on natural limits on learning and errors that arise from mistakes in implementation. We present a conceptual architecture, failure model and taxonomy, and failure modes and effects analysis (FMEA) of a semi-supervised, multi-modal learningmore » system, and provide specific examples from its use in a radiological analysis assistant system. The goal of the research described in this paper is to provide a foundation from which dependability analysis of systems using semi-supervised, multi-modal learning can be conducted. The methods presented provide a first step towards that overall goal.« less
Why Do Medial Unicompartmental Knee Arthroplasties Fail Today?
van der List, Jelle P; Zuiderbaan, Hendrik A; Pearle, Andrew D
2016-05-01
Failure rates are higher in medial unicompartmental knee arthroplasty (UKA) than total knee arthroplasty. To improve these failure rates, it is important to understand why medial UKA fail. Because individual studies lack power to show failure modes, a systematic review was performed to assess medial UKA failure modes. Furthermore, we compared cohort studies with registry-based studies, early with midterm and late failures and fixed-bearing with mobile-bearing implants. Databases of PubMed, EMBASE, and Cochrane and annual registries were searched for medial UKA failures. Studies were included when they reported >25 failures or when they reported early (<5 years), midterm (5-10 years), or late failures (>10 years). Thirty-seven cohort studies (4 level II studies and 33 level III studies) and 2 registry-based studies were included. A total of 3967 overall failures, 388 time-dependent failures, and 1305 implant design failures were identified. Aseptic loosening (36%) and osteoarthritis (OA) progression (20%) were the most common failure modes. Aseptic loosening (26%) was most common early failure mode, whereas OA progression was more commonly seen in midterm and late failures (38% and 40%, respectively). Polyethylene wear (12%) and instability (12%) were more common in fixed-bearing implants, whereas pain (14%) and bearing dislocation (11%) were more common in mobile-bearing implants. This level III systematic review identified aseptic loosening and OA progression as the major failure modes. Aseptic loosening was the main failure mode in early years and mobile-bearing implants, whereas OA progression caused most failures in late years and fixed-bearing implants. Copyright © 2016 Elsevier Inc. All rights reserved.
Mechanics of dual-mode dilative failure in subaqueous sediment deposits
NASA Astrophysics Data System (ADS)
You, Yao; Flemings, Peter; Mohrig, David
2014-07-01
We introduce dual-mode dilative failure with flume experiments. Dual-mode dilative failure combines slow and steady release of sediments by breaching with periodic sliding, which rapidly releases an internally coherent wedge of sediments. It occurs in dilative sandy deposits. This periodic slope failure results from cyclic evolution of the excess pore pressure in the deposit. Sliding generates large, transient, negative excess pore pressure that strengthens the deposit and allows breaching to occur. During breaching, negative excess pore pressure dissipates, the deposit weakens, and ultimately sliding occurs once again. We show that the sliding frequency is proportional to the coefficient of consolidation. We find that thicker deposits are more susceptible to dual-mode dilative failure. Discovery of dual-mode dilative failure provides a new mechanism to consider when interpreting the sedimentary deposits linked to submarine slope failures.
Common Cause Failures and Ultra Reliability
NASA Technical Reports Server (NTRS)
Jones, Harry W.
2012-01-01
A common cause failure occurs when several failures have the same origin. Common cause failures are either common event failures, where the cause is a single external event, or common mode failures, where two systems fail in the same way for the same reason. Common mode failures can occur at different times because of a design defect or a repeated external event. Common event failures reduce the reliability of on-line redundant systems but not of systems using off-line spare parts. Common mode failures reduce the dependability of systems using off-line spare parts and on-line redundancy.
A quality risk management model approach for cell therapy manufacturing.
Lopez, Fabio; Di Bartolo, Chiara; Piazza, Tommaso; Passannanti, Antonino; Gerlach, Jörg C; Gridelli, Bruno; Triolo, Fabio
2010-12-01
International regulatory authorities view risk management as an essential production need for the development of innovative, somatic cell-based therapies in regenerative medicine. The available risk management guidelines, however, provide little guidance on specific risk analysis approaches and procedures applicable in clinical cell therapy manufacturing. This raises a number of problems. Cell manufacturing is a poorly automated process, prone to operator-introduced variations, and affected by heterogeneity of the processed organs/tissues and lot-dependent variability of reagent (e.g., collagenase) efficiency. In this study, the principal challenges faced in a cell-based product manufacturing context (i.e., high dependence on human intervention and absence of reference standards for acceptable risk levels) are identified and addressed, and a risk management model approach applicable to manufacturing of cells for clinical use is described for the first time. The use of the heuristic and pseudo-quantitative failure mode and effect analysis/failure mode and critical effect analysis risk analysis technique associated with direct estimation of severity, occurrence, and detection is, in this specific context, as effective as, but more efficient than, the analytic hierarchy process. Moreover, a severity/occurrence matrix and Pareto analysis can be successfully adopted to identify priority failure modes on which to act to mitigate risks. The application of this approach to clinical cell therapy manufacturing in regenerative medicine is also discussed. © 2010 Society for Risk Analysis.
NASA Astrophysics Data System (ADS)
Baccar, D.; Söffker, D.
2017-11-01
Acoustic Emission (AE) is a suitable method to monitor the health of composite structures in real-time. However, AE-based failure mode identification and classification are still complex to apply due to the fact that AE waves are generally released simultaneously from all AE-emitting damage sources. Hence, the use of advanced signal processing techniques in combination with pattern recognition approaches is required. In this paper, AE signals generated from laminated carbon fiber reinforced polymer (CFRP) subjected to indentation test are examined and analyzed. A new pattern recognition approach involving a number of processing steps able to be implemented in real-time is developed. Unlike common classification approaches, here only CWT coefficients are extracted as relevant features. Firstly, Continuous Wavelet Transform (CWT) is applied to the AE signals. Furthermore, dimensionality reduction process using Principal Component Analysis (PCA) is carried out on the coefficient matrices. The PCA-based feature distribution is analyzed using Kernel Density Estimation (KDE) allowing the determination of a specific pattern for each fault-specific AE signal. Moreover, waveform and frequency content of AE signals are in depth examined and compared with fundamental assumptions reported in this field. A correlation between the identified patterns and failure modes is achieved. The introduced method improves the damage classification and can be used as a non-destructive evaluation tool.
Failure-Modes-And-Effects Analysis Of Software Logic
NASA Technical Reports Server (NTRS)
Garcia, Danny; Hartline, Thomas; Minor, Terry; Statum, David; Vice, David
1996-01-01
Rigorous analysis applied early in design effort. Method of identifying potential inadequacies and modes and effects of failures caused by inadequacies (failure-modes-and-effects analysis or "FMEA" for short) devised for application to software logic.
Failure Mode and Effects Analysis (FMEA) Introductory Overview
2012-06-14
Failure Mode and Effects Analysis ( FMEA ) Introductory Overview TARDEC Systems Engineering Risk Management Team POC: Kadry Rizk or Gregor Ratajczak...2. REPORT TYPE Briefing Charts 3. DATES COVERED 01-05-2012 to 23-05-2012 4. TITLE AND SUBTITLE Failure Mode and Effects Analysis ( FMEA ) 5a...18 WELCOME Welcome to “An introductory overview of Failure Mode and Effects Analysis ( FMEA )”, A brief concerning the use and benefits of FMEA
DOE Office of Scientific and Technical Information (OSTI.GOV)
Vile, D; Zhang, L; Cuttino, L
2016-06-15
Purpose: To create a quality assurance program based upon a risk-based assessment of a newly implemented SirSpheres Y-90 procedure. Methods: A process map was created for a newly implemented SirSpheres procedure at a community hospital. The process map documented each step of this collaborative procedure, as well as the roles and responsibilities of each member. From the process map, different potential failure modes were determined as well as any current controls in place. From this list, a full failure mode and effects analysis (FMEA) was performed by grading each failure mode’s likelihood of occurrence, likelihood of detection, and potential severity.more » These numbers were then multiplied to compute the risk priority number (RPN) for each potential failure mode. Failure modes were then ranked based on their RPN. Additional controls were then added, with failure modes corresponding to the highest RPNs taking priority. Results: A process map was created that succinctly outlined each step in the SirSpheres procedure in its current implementation. From this, 72 potential failure modes were identified and ranked according to their associated RPN. Quality assurance controls and safety barriers were then added for failure modes associated with the highest risk being addressed first. Conclusion: A quality assurance program was created from a risk-based assessment of the SirSpheres process. Process mapping and FMEA were effective in identifying potential high-risk failure modes for this new procedure, which were prioritized for new quality assurance controls. TG 100 recommends the fault tree analysis methodology to design a comprehensive and effective QC/QM program, yet we found that by simply introducing additional safety barriers to address high RPN failure modes makes the whole process simpler and safer.« less
Intralaminar and Interlaminar Progressive Failure Analysis of Composite Panels with Circular Cutouts
NASA Technical Reports Server (NTRS)
Goyal, Vinay K.; Jaunky, Navin; Johnson, Eric R.; Ambur, Damodar
2002-01-01
A progressive failure methodology is developed and demonstrated to simulate the initiation and material degradation of a laminated panel due to intralaminar and interlaminar failures. Initiation of intralaminar failure can be by a matrix-cracking mode, a fiber-matrix shear mode, and a fiber failure mode. Subsequent material degradation is modeled using damage parameters for each mode to selectively reduce lamina material properties. The interlaminar failure mechanism such as delamination is simulated by positioning interface elements between adjacent sublaminates. A nonlinear constitutive law is postulated for the interface element that accounts for a multi-axial stress criteria to detect the initiation of delamination, a mixed-mode fracture criteria for delamination progression, and a damage parameter to prevent restoration of a previous cohesive state. The methodology is validated using experimental data available in the literature on the response and failure of quasi-isotropic panels with centrally located circular cutouts loaded into the postbuckling regime. Very good agreement between the progressive failure analyses and the experimental results is achieved if the failure analyses includes the interaction of intralaminar and interlaminar failures.
Risk assessment of failure modes of gas diffuser liner of V94.2 siemens gas turbine by FMEA method
NASA Astrophysics Data System (ADS)
Mirzaei Rafsanjani, H.; Rezaei Nasab, A.
2012-05-01
Failure of welding connection of gas diffuser liner and exhaust casing is one of the failure modes of V94.2 gas turbines which are happened in some power plants. This defect is one of the uncertainties of customers when they want to accept the final commissioning of this product. According to this, the risk priority of this failure evaluated by failure modes and effect analysis (FMEA) method to find out whether this failure is catastrophic for turbine performance and is harmful for humans. By using history of 110 gas turbines of this model which are used in some power plants, the severity number, occurrence number and detection number of failure determined and consequently the Risk Priority Number (RPN) of failure determined. Finally, critically matrix of potential failures is created and illustrated that failure modes are located in safe zone.
An efficient scan diagnosis methodology according to scan failure mode for yield enhancement
NASA Astrophysics Data System (ADS)
Kim, Jung-Tae; Seo, Nam-Sik; Oh, Ghil-Geun; Kim, Dae-Gue; Lee, Kyu-Taek; Choi, Chi-Young; Kim, InSoo; Min, Hyoung Bok
2008-12-01
Yield has always been a driving consideration during fabrication of modern semiconductor industry. Statistically, the largest portion of wafer yield loss is defective scan failure. This paper presents efficient failure analysis methods for initial yield ramp up and ongoing product with scan diagnosis. Result of our analysis shows that more than 60% of the scan failure dies fall into the category of shift mode in the very deep submicron (VDSM) devices. However, localization of scan shift mode failure is very difficult in comparison to capture mode failure because it is caused by the malfunction of scan chain. Addressing the biggest challenge, we propose the most suitable analysis method according to scan failure mode (capture / shift) for yield enhancement. In the event of capture failure mode, this paper describes the method that integrates scan diagnosis flow and backside probing technology to obtain more accurate candidates. We also describe several unique techniques, such as bulk back-grinding solution, efficient backside probing and signal analysis method. Lastly, we introduce blocked chain analysis algorithm for efficient analysis of shift failure mode. In this paper, we contribute to enhancement of the yield as a result of the combination of two methods. We confirm the failure candidates with physical failure analysis (PFA) method. The direct feedback of the defective visualization is useful to mass-produce devices in a shorter time. The experimental data on mass products show that our method produces average reduction by 13.7% in defective SCAN & SRAM-BIST failure rates and by 18.2% in wafer yield rates.
NASA Astrophysics Data System (ADS)
Gan, Luping; Li, Yan-Feng; Zhu, Shun-Peng; Yang, Yuan-Jian; Huang, Hong-Zhong
2014-06-01
Failure mode, effects and criticality analysis (FMECA) and Fault tree analysis (FTA) are powerful tools to evaluate reliability of systems. Although single failure mode issue can be efficiently addressed by traditional FMECA, multiple failure modes and component correlations in complex systems cannot be effectively evaluated. In addition, correlated variables and parameters are often assumed to be precisely known in quantitative analysis. In fact, due to the lack of information, epistemic uncertainty commonly exists in engineering design. To solve these problems, the advantages of FMECA, FTA, fuzzy theory, and Copula theory are integrated into a unified hybrid method called fuzzy probability weighted geometric mean (FPWGM) risk priority number (RPN) method. The epistemic uncertainty of risk variables and parameters are characterized by fuzzy number to obtain fuzzy weighted geometric mean (FWGM) RPN for single failure mode. Multiple failure modes are connected using minimum cut sets (MCS), and Boolean logic is used to combine fuzzy risk priority number (FRPN) of each MCS. Moreover, Copula theory is applied to analyze the correlation of multiple failure modes in order to derive the failure probabilities of each MCS. Compared to the case where dependency among multiple failure modes is not considered, the Copula modeling approach eliminates the error of reliability analysis. Furthermore, for purpose of quantitative analysis, probabilities importance weight from failure probabilities are assigned to FWGM RPN to reassess the risk priority, which generalize the definition of probability weight and FRPN, resulting in a more accurate estimation than that of the traditional models. Finally, a basic fatigue analysis case drawn from turbine and compressor blades in aeroengine is used to demonstrate the effectiveness and robustness of the presented method. The result provides some important insights on fatigue reliability analysis and risk priority assessment of structural system under failure correlations.
Failure mode analysis to predict product reliability.
NASA Technical Reports Server (NTRS)
Zemanick, P. P.
1972-01-01
The failure mode analysis (FMA) is described as a design tool to predict and improve product reliability. The objectives of the failure mode analysis are presented as they influence component design, configuration selection, the product test program, the quality assurance plan, and engineering analysis priorities. The detailed mechanics of performing a failure mode analysis are discussed, including one suggested format. Some practical difficulties of implementation are indicated, drawn from experience with preparing FMAs on the nuclear rocket engine program.
Risk analysis by FMEA as an element of analytical validation.
van Leeuwen, J F; Nauta, M J; de Kaste, D; Odekerken-Rombouts, Y M C F; Oldenhof, M T; Vredenbregt, M J; Barends, D M
2009-12-05
We subjected a Near-Infrared (NIR) analytical procedure used for screening drugs on authenticity to a Failure Mode and Effects Analysis (FMEA), including technical risks as well as risks related to human failure. An FMEA team broke down the NIR analytical method into process steps and identified possible failure modes for each step. Each failure mode was ranked on estimated frequency of occurrence (O), probability that the failure would remain undetected later in the process (D) and severity (S), each on a scale of 1-10. Human errors turned out to be the most common cause of failure modes. Failure risks were calculated by Risk Priority Numbers (RPNs)=O x D x S. Failure modes with the highest RPN scores were subjected to corrective actions and the FMEA was repeated, showing reductions in RPN scores and resulting in improvement indices up to 5.0. We recommend risk analysis as an addition to the usual analytical validation, as the FMEA enabled us to detect previously unidentified risks.
Wang, Yimin; Bowman, Joel M
2013-10-21
We present a theory of mode-specific tunneling that makes use of the general tunneling path along the imaginary-frequency normal mode of the saddle point, Qim, and the associated relaxed potential, V(Qim) [Y. Wang and J. M. Bowman, J. Chem. Phys. 129, 121103 (2008)]. The novel aspect of the theory is the projection of the normal modes of a minimum onto the Qim path and the determination of turning points on V(Qim). From that projection, the change in tunneling upon mode excitation can be calculated. If the projection is zero, no enhancement of tunneling is predicted. In that case vibrationally adiabatic (VA) theory could apply. However, if the projection is large then VA theory is not applicable. The approach is applied to mode-specific tunneling in full-dimensional malonaldehyde, using an accurate full-dimensional potential energy surface. Results are in semi-quantitative agreement with experiment for modes that show large enhancement of the tunneling, relative to the ground state tunneling splitting. For the six out-of-plane modes, which have zero projection on the planar Qim path, VA theory does apply, and results from that theory agree qualitatively and even semi-quantitatively with experiment. We also verify the failure of simple VA theory for modes that show large enhancement of tunneling.
Predicting the Lifetimes of Nuclear Waste Containers
NASA Astrophysics Data System (ADS)
King, Fraser
2014-03-01
As for many aspects of the disposal of nuclear waste, the greatest challenge we have in the study of container materials is the prediction of the long-term performance over periods of tens to hundreds of thousands of years. Various methods have been used for predicting the lifetime of containers for the disposal of high-level waste or spent fuel in deep geological repositories. Both mechanical and corrosion-related failure mechanisms need to be considered, although until recently the interactions of mechanical and corrosion degradation modes have not been considered in detail. Failure from mechanical degradation modes has tended to be treated through suitable container design. In comparison, the inevitable loss of container integrity due to corrosion has been treated by developing specific corrosion models. The most important aspect, however, is to be able to justify the long-term predictions by demonstrating a mechanistic understanding of the various degradation modes.
Ye, Qing; Pan, Hao; Liu, Changhua
2015-01-01
This research proposes a novel framework of final drive simultaneous failure diagnosis containing feature extraction, training paired diagnostic models, generating decision threshold, and recognizing simultaneous failure modes. In feature extraction module, adopt wavelet package transform and fuzzy entropy to reduce noise interference and extract representative features of failure mode. Use single failure sample to construct probability classifiers based on paired sparse Bayesian extreme learning machine which is trained only by single failure modes and have high generalization and sparsity of sparse Bayesian learning approach. To generate optimal decision threshold which can convert probability output obtained from classifiers into final simultaneous failure modes, this research proposes using samples containing both single and simultaneous failure modes and Grid search method which is superior to traditional techniques in global optimization. Compared with other frequently used diagnostic approaches based on support vector machine and probability neural networks, experiment results based on F 1-measure value verify that the diagnostic accuracy and efficiency of the proposed framework which are crucial for simultaneous failure diagnosis are superior to the existing approach. PMID:25722717
Mod 1 wind turbine generator failure modes and effects analysis
NASA Technical Reports Server (NTRS)
1979-01-01
A failure modes and effects analysis (FMEA) was directed primarily at identifying those critical failure modes that would be hazardous to life or would result in major damage to the system. Each subsystem was approached from the top down, and broken down to successive lower levels where it appeared that the criticality of the failure mode warranted more detail analysis. The results were reviewed by specialists from outside the Mod 1 program, and corrective action taken wherever recommended.
NASA Astrophysics Data System (ADS)
Cao, Ri-hong; Cao, Ping; Lin, Hang; Pu, Cheng-zhi; Ou, Ke
2016-03-01
Joints and fissures with similar orientation or characteristics are common in natural rocks; the inclination and density of the fissures affect the mechanical properties and failure mechanism of the rock mass. However, the strength, crack coalescence pattern, and failure mode of rock specimens containing multi-fissures have not been studied comprehensively. In this paper, combining similar material testing and discrete element numerical method (PFC2D), the peak strength and failure characteristics of rock-like materials with multi-fissures are explored. Rock-like specimens were made of cement and sand and pre-existing fissures created by inserting steel shims into cement mortar paste and removing them during curing. The peak strength of multi-fissure specimens depends on the fissure angle α (which is measured counterclockwise from horizontal) and fissure number ( N f). Under uniaxial compressional loading, the peak strength increased with increasing α. The material strength was lowest for α = 25°, and highest for α = 90°. The influence of N f on the peak strength depended on α. For α = 25° and 45°, N f had a strong effect on the peak strength, while for higher α values, especially for the 90° sample, there were no obvious changes in peak strength with different N f. Under uniaxial compression, the coalescence modes between the fissures can be classified into three categories: S-mode, T-mode, and M-mode. Moreover, the failure mode can be classified into four categories: mixed failure, shear failure, stepped path failure, and intact failure. The failure mode of the specimen depends on α and N f. The peak strength and failure modes in the numerically simulated and experimental results are in good agreement.
NASA Astrophysics Data System (ADS)
Sin, Yongkun; Lingley, Zachary; Brodie, Miles; Presser, Nathan; Moss, Steven C.
2017-02-01
High-power single-mode (SM) and multi-mode (MM) InGaAs-AlGaAs strained quantum well (QW) lasers are critical components for both telecommunications and space satellite communications systems. However, little has been reported on failure modes and degradation mechanisms of high-power SM and MM InGaAs-AlGaAs strained QW lasers although it is crucial to understand failure modes and underlying degradation mechanisms in developing these lasers that meet lifetime requirements for space satellite systems, where extremely high reliability of these lasers is required. Our present study addresses the aforementioned issues by performing long-term life-tests followed by failure mode analysis (FMA) and physics of failure investigation. We performed long-term accelerated life-tests on state-of-the-art SM and MM InGaAs-AlGaAs strained QW lasers under ACC (automatic current control) mode. Our life-tests have accumulated over 25,000 test hours for SM lasers and over 35,000 test hours for MM lasers. FMA was performed on failed SM lasers using electron beam induced current (EBIC). This technique allowed us to identify failure types by observing dark line defects. All the SM failures we studied showed catastrophic and sudden degradation and all of these failures were bulk failures. Our group previously reported that bulk failure or COBD (catastrophic optical bulk damage) is the dominant failure mode of MM InGaAs-AlGaAs strained QW lasers. Since degradation mechanisms responsible for COBD are still not well understood, we also employed other techniques including focused ion beam (FIB) processing and high-resolution TEM to further study dark line defects and dislocations in post-aged lasers. Our long-term life-test results and FMA results are reported.
Cubbon, Richard M; Ruff, Naomi; Groves, David; Eleuteri, Antonio; Denby, Christine; Kearney, Lorraine; Ali, Noman; Walker, Andrew M N; Jamil, Haqeel; Gierula, John; Gale, Chris P; Batin, Phillip D; Nolan, James; Shah, Ajay M; Fox, Keith A A; Sapsford, Robert J; Witte, Klaus K; Kearney, Mark T
2016-02-01
We aimed to define the prognostic value of the heart rate range during a 24 h period in patients with chronic heart failure (CHF). Prospective observational cohort study of 791 patients with CHF associated with left ventricular systolic dysfunction. Mode-specific mortality and hospitalisation were linked with ambulatory heart rate range (AHRR; calculated as maximum minus minimum heart rate using 24 h Holter monitor data, including paced and non-sinus complexes) in univariate and multivariate analyses. Findings were then corroborated in a validation cohort of 408 patients with CHF with preserved or reduced left ventricular ejection fraction. After a mean 4.1 years of follow-up, increasing AHRR was associated with reduced risk of all-cause, sudden, non-cardiovascular and progressive heart failure death in univariate analyses. After accounting for characteristics that differed between groups above and below median AHRR using multivariate analysis, AHRR remained strongly associated with all-cause mortality (HR 0.991/bpm increase in AHRR (95% CI 0.999 to 0.982); p=0.046). AHRR was not associated with the risk of any non-elective hospitalisation, but was associated with heart-failure-related hospitalisation. AHRR was modestly associated with the SD of normal-to-normal beats (R(2)=0.2; p<0.001) and with peak exercise-test heart rate (R(2)=0.33; p<0.001). Analysis of the validation cohort revealed AHRR to be associated with all-cause and mode-specific death as described in the derivation cohort. AHRR is a novel and readily available prognosticator in patients with CHF, which may reflect autonomic tone and exercise capacity. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Rah, Jeong-Eun; Manger, Ryan P; Yock, Adam D; Kim, Gwe-Ya
2016-12-01
To examine the abilities of a traditional failure mode and effects analysis (FMEA) and modified healthcare FMEA (m-HFMEA) scoring methods by comparing the degree of congruence in identifying high risk failures. The authors applied two prospective methods of the quality management to surface image guided, linac-based radiosurgery (SIG-RS). For the traditional FMEA, decisions on how to improve an operation were based on the risk priority number (RPN). The RPN is a product of three indices: occurrence, severity, and detectability. The m-HFMEA approach utilized two indices, severity and frequency. A risk inventory matrix was divided into four categories: very low, low, high, and very high. For high risk events, an additional evaluation was performed. Based upon the criticality of the process, it was decided if additional safety measures were needed and what they comprise. The two methods were independently compared to determine if the results and rated risks matched. The authors' results showed an agreement of 85% between FMEA and m-HFMEA approaches for top 20 risks of SIG-RS-specific failure modes. The main differences between the two approaches were the distribution of the values and the observation that failure modes (52, 54, 154) with high m-HFMEA scores do not necessarily have high FMEA-RPN scores. In the m-HFMEA analysis, when the risk score is determined, the basis of the established HFMEA Decision Tree™ or the failure mode should be more thoroughly investigated. m-HFMEA is inductive because it requires the identification of the consequences from causes, and semi-quantitative since it allows the prioritization of high risks and mitigation measures. It is therefore a useful tool for the prospective risk analysis method to radiotherapy.
Cycles till failure of silver-zinc cells with competing failure modes - Preliminary data analysis
NASA Technical Reports Server (NTRS)
Sidik, S. M.; Leibecki, H. F.; Bozek, J. M.
1980-01-01
The data analysis of cycles to failure of silver-zinc electrochemical cells with competing failure modes is presented. The test ran 129 cells through charge-discharge cycles until failure; preliminary data analysis consisted of response surface estimate of life. Batteries fail through low voltage condition and an internal shorting condition; a competing failure modes analysis was made using maximum likelihood estimation for the extreme value life distribution. Extensive residual plotting and probability plotting were used to verify data quality and selection of model.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Younge, Kelly Cooper, E-mail: kyounge@med.umich.edu; Wang, Yizhen; Thompson, John
2015-04-01
Purpose: To improve the safety and efficiency of a new stereotactic radiosurgery program with the application of failure mode and effects analysis (FMEA) performed by a multidisciplinary team of health care professionals. Methods and Materials: Representatives included physicists, therapists, dosimetrists, oncologists, and administrators. A detailed process tree was created from an initial high-level process tree to facilitate the identification of possible failure modes. Group members were asked to determine failure modes that they considered to be the highest risk before scoring failure modes. Risk priority numbers (RPNs) were determined by each group member individually and then averaged. Results: A totalmore » of 99 failure modes were identified. The 5 failure modes with an RPN above 150 were further analyzed to attempt to reduce these RPNs. Only 1 of the initial items that the group presumed to be high-risk (magnetic resonance imaging laterality reversed) was ranked in these top 5 items. New process controls were put in place to reduce the severity, occurrence, and detectability scores for all of the top 5 failure modes. Conclusions: FMEA is a valuable team activity that can assist in the creation or restructuring of a quality assurance program with the aim of improved safety, quality, and efficiency. Performing the FMEA helped group members to see how they fit into the bigger picture of the program, and it served to reduce biases and preconceived notions about which elements of the program were the riskiest.« less
Clinical risk analysis with failure mode and effect analysis (FMEA) model in a dialysis unit.
Bonfant, Giovanna; Belfanti, Pietro; Paternoster, Giuseppe; Gabrielli, Danila; Gaiter, Alberto M; Manes, Massimo; Molino, Andrea; Pellu, Valentina; Ponzetti, Clemente; Farina, Massimo; Nebiolo, Pier E
2010-01-01
The aim of clinical risk management is to improve the quality of care provided by health care organizations and to assure patients' safety. Failure mode and effect analysis (FMEA) is a tool employed for clinical risk reduction. We applied FMEA to chronic hemodialysis outpatients. FMEA steps: (i) process study: we recorded phases and activities. (ii) Hazard analysis: we listed activity-related failure modes and their effects; described control measures; assigned severity, occurrence and detection scores for each failure mode and calculated the risk priority numbers (RPNs) by multiplying the 3 scores. Total RPN is calculated by adding single failure mode RPN. (iii) Planning: we performed a RPNs prioritization on a priority matrix taking into account the 3 scores, and we analyzed failure modes causes, made recommendations and planned new control measures. (iv) Monitoring: after failure mode elimination or reduction, we compared the resulting RPN with the previous one. Our failure modes with the highest RPN came from communication and organization problems. Two tools have been created to ameliorate information flow: "dialysis agenda" software and nursing datasheets. We scheduled nephrological examinations, and we changed both medical and nursing organization. Total RPN value decreased from 892 to 815 (8.6%) after reorganization. Employing FMEA, we worked on a few critical activities, and we reduced patients' clinical risk. A priority matrix also takes into account the weight of the control measures: we believe this evaluation is quick, because of simple priority selection, and that it decreases action times.
A streamlined failure mode and effects analysis.
Ford, Eric C; Smith, Koren; Terezakis, Stephanie; Croog, Victoria; Gollamudi, Smitha; Gage, Irene; Keck, Jordie; DeWeese, Theodore; Sibley, Greg
2014-06-01
Explore the feasibility and impact of a streamlined failure mode and effects analysis (FMEA) using a structured process that is designed to minimize staff effort. FMEA for the external beam process was conducted at an affiliate radiation oncology center that treats approximately 60 patients per day. A structured FMEA process was developed which included clearly defined roles and goals for each phase. A core group of seven people was identified and a facilitator was chosen to lead the effort. Failure modes were identified and scored according to the FMEA formalism. A risk priority number,RPN, was calculated and used to rank failure modes. Failure modes with RPN > 150 received safety improvement interventions. Staff effort was carefully tracked throughout the project. Fifty-two failure modes were identified, 22 collected during meetings, and 30 from take-home worksheets. The four top-ranked failure modes were: delay in film check, missing pacemaker protocol/consent, critical structures not contoured, and pregnant patient simulated without the team's knowledge of the pregnancy. These four failure modes had RPN > 150 and received safety interventions. The FMEA was completed in one month in four 1-h meetings. A total of 55 staff hours were required and, additionally, 20 h by the facilitator. Streamlined FMEA provides a means of accomplishing a relatively large-scale analysis with modest effort. One potential value of FMEA is that it potentially provides a means of measuring the impact of quality improvement efforts through a reduction in risk scores. Future study of this possibility is needed.
Tensile failure criteria for fiber composite materials
NASA Technical Reports Server (NTRS)
Rosen, B. W.; Zweben, C. H.
1972-01-01
The analysis provides insight into the failure mechanics of these materials and defines criteria which serve as tools for preliminary design material selection and for material reliability assessment. The model incorporates both dispersed and propagation type failures and includes the influence of material heterogeneity. The important effects of localized matrix damage and post-failure matrix shear stress transfer are included in the treatment. The model is used to evaluate the influence of key parameters on the failure of several commonly used fiber-matrix systems. Analyses of three possible failure modes were developed. These modes are the fiber break propagation mode, the cumulative group fracture mode, and the weakest link mode. Application of the new model to composite material systems has indicated several results which require attention in the development of reliable structural composites. Prominent among these are the size effect and the influence of fiber strength variability.
Health management system for rocket engines
NASA Technical Reports Server (NTRS)
Nemeth, Edward
1990-01-01
The functional framework of a failure detection algorithm for the Space Shuttle Main Engine (SSME) is developed. The basic algorithm is based only on existing SSME measurements. Supplemental measurements, expected to enhance failure detection effectiveness, are identified. To support the algorithm development, a figure of merit is defined to estimate the likelihood of SSME criticality 1 failure modes and the failure modes are ranked in order of likelihood of occurrence. Nine classes of failure detection strategies are evaluated and promising features are extracted as the basis for the failure detection algorithm. The failure detection algorithm provides early warning capabilities for a wide variety of SSME failure modes. Preliminary algorithm evaluation, using data from three SSME failures representing three different failure types, demonstrated indications of imminent catastrophic failure well in advance of redline cutoff in all three cases.
Detection of system failures in multi-axes tasks. [pilot monitored instrument approach
NASA Technical Reports Server (NTRS)
Ephrath, A. R.
1975-01-01
The effects of the pilot's participation mode in the control task on his workload level and failure detection performance were examined considering a low visibility landing approach. It is found that the participation mode had a strong effect on the pilot's workload, the induced workload being lowest when the pilot acted as a monitoring element during a coupled approach and highest when the pilot was an active element in the control loop. The effects of workload and participation mode on failure detection were separated. The participation mode was shown to have a dominant effect on the failure detection performance, with a failure in a monitored (coupled) axis being detected significantly faster than a comparable failure in a manually controlled axis.
Steinberger, Dina M; Douglas, Stephen V; Kirschbaum, Mark S
2009-09-01
A multidisciplinary team from the University of Wisconsin Hospital and Clinics transplant program used failure mode and effects analysis to proactively examine opportunities for communication and handoff failures across the continuum of care from organ procurement to transplantation. The team performed a modified failure mode and effects analysis that isolated the multiple linked, serial, and complex information exchanges occurring during the transplantation of one solid organ. Failure mode and effects analysis proved effective for engaging a diverse group of persons who had an investment in the outcome in analysis and discussion of opportunities to improve the system's resilience for avoiding errors during a time-pressured and complex process.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Hoisak, J; Manger, R; Dragojevic, I
Purpose: To perform a failure mode and effects analysis (FMEA) of the process for treating superficial skin cancers with the Xoft Axxent electronic brachytherapy (eBx) system, given the recent introduction of expanded quality control (QC) initiatives at our institution. Methods: A process map was developed listing all steps in superficial treatments with Xoft eBx, from the initial patient consult to the completion of the treatment course. The process map guided the FMEA to identify the failure modes for each step in the treatment workflow and assign Risk Priority Numbers (RPN), calculated as the product of the failure mode’s probability ofmore » occurrence (O), severity (S) and lack of detectability (D). FMEA was done with and without the inclusion of recent QC initiatives such as increased staffing, physics oversight, standardized source calibration, treatment planning and documentation. The failure modes with the highest RPNs were identified and contrasted before and after introduction of the QC initiatives. Results: Based on the FMEA, the failure modes with the highest RPN were related to source calibration, treatment planning, and patient setup/treatment delivery (Fig. 1). The introduction of additional physics oversight, standardized planning and safety initiatives such as checklists and time-outs reduced the RPNs of these failure modes. High-risk failure modes that could be mitigated with improved hardware and software interlocks were identified. Conclusion: The FMEA analysis identified the steps in the treatment process presenting the highest risk. The introduction of enhanced QC initiatives mitigated the risk of some of these failure modes by decreasing their probability of occurrence and increasing their detectability. This analysis demonstrates the importance of well-designed QC policies, procedures and oversight in a Xoft eBx programme for treatment of superficial skin cancers. Unresolved high risk failure modes highlight the need for non-procedural quality initiatives such as improved planning software and more robust hardware interlock systems.« less
Yang, F; Cao, N; Young, L; Howard, J; Logan, W; Arbuckle, T; Sponseller, P; Korssjoen, T; Meyer, J; Ford, E
2015-06-01
Though failure mode and effects analysis (FMEA) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge, its output has never been validated against data on errors that actually occur. The objective of this study was to perform FMEA of a stereotactic body radiation therapy (SBRT) treatment planning process and validate the results against data recorded within an incident learning system. FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, dosimetrists, and IT technologists. Potential failure modes were identified through a systematic review of the process map. Failure modes were rated for severity, occurrence, and detectability on a scale of one to ten and risk priority number (RPN) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that has been active for two and a half years. Differences between FMEA anticipated failure modes and existing incidents were identified. FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. Combining both methods yielded a total of 76 possible process failures, of which 13 (17%) were missed by FMEA while 43 (57%) identified by FMEA only. When scored for RPN, the 13 events missed by FMEA ranked within the lower half of all failure modes and exhibited significantly lower severity relative to those identified by FMEA (p = 0.02). FMEA, though valuable, is subject to certain limitations. In this study, FMEA failed to identify 17% of actual failure modes, though these were of lower risk. Similarly, an incident learning system alone fails to identify a large number of potentially high-severity process errors. Using FMEA in combination with incident learning may render an improved overview of risks within a process.
Modes of failure in disordered solids
NASA Astrophysics Data System (ADS)
Roy, Subhadeep; Biswas, Soumyajyoti; Ray, Purusattam
2017-12-01
The two principal ingredients determining the failure modes of disordered solids are the strength of heterogeneity and the length scale of the region affected in the solid following a local failure. While the latter facilitates damage nucleation, the former leads to diffused damage—the two extreme natures of the failure modes. In this study, using the random fiber bundle model as a prototype for disordered solids, we classify all failure modes that are the results of interplay between these two effects. We obtain scaling criteria for the different modes and propose a general phase diagram that provides a framework for understanding previous theoretical and experimental attempts of interpolation between these modes. As the fiber bundle model is a long-standing model for interpreting various features of stressed disordered solids, the general phase diagram can serve as a guiding principle in anticipating the responses of disordered solids in general.
Stingray Failure Mode, Effects and Criticality Analysis: WEC Risk Registers
Ken Rhinefrank
2016-07-25
Analysis method to systematically identify all potential failure modes and their effects on the Stingray WEC system. This analysis is incorporated early in the development cycle such that the mitigation of the identified failure modes can be achieved cost effectively and efficiently. The FMECA can begin once there is enough detail to functions and failure modes of a given system, and its interfaces with other systems. The FMECA occurs coincidently with the design process and is an iterative process which allows for design changes to overcome deficiencies in the analysis.Risk Registers for major subsystems completed according to the methodology described in "Failure Mode Effects and Criticality Analysis Risk Reduction Program Plan.pdf" document below, in compliance with the DOE Risk Management Framework developed by NREL.
Nanowire failure: long = brittle and short = ductile.
Wu, Zhaoxuan; Zhang, Yong-Wei; Jhon, Mark H; Gao, Huajian; Srolovitz, David J
2012-02-08
Experimental studies of the tensile behavior of metallic nanowires show a wide range of failure modes, ranging from ductile necking to brittle/localized shear failure-often in the same diameter wires. We performed large-scale molecular dynamics simulations of copper nanowires with a range of nanowire lengths and provide unequivocal evidence for a transition in nanowire failure mode with change in nanowire length. Short nanowires fail via a ductile mode with serrated stress-strain curves, while long wires exhibit extreme shear localization and abrupt failure. We developed a simple model for predicting the critical nanowire length for this failure mode transition and showed that it is in excellent agreement with both the simulation results and the extant experimental data. The present results provide a new paradigm for the design of nanoscale mechanical systems that demarcates graceful and catastrophic failure. © 2012 American Chemical Society
NASA Astrophysics Data System (ADS)
Faulconer, E. K.; Griffith, J.; Wood, B.; Acharyya, S.; Roberts, D.
2018-05-01
While the equivalence between online and traditional classrooms has been well-researched, very little of this includes college-level introductory Physics. Only one study explored Physics at the whole-class level rather than specific course components such as a single lab or a homework platform. In this work, we compared the failure rate, grade distribution, and withdrawal rates in an introductory undergraduate Physics course across several learning modes including traditional face-to-face instruction, synchronous video instruction, and online classes. Statistically significant differences were found for student failure rates, grade distribution, and withdrawal rates but yielded small effect sizes. Post-hoc pair-wise test was run to determine differences between learning modes. Online students had a significantly lower failure rate than students who took the class via synchronous video classroom. While statistically significant differences were found for grade distributions, the pair-wise comparison yielded no statistically significance differences between learning modes when using the more conservative Bonferroni correction in post-hoc testing. Finally, in this study, student withdrawal rates were lowest for students who took the class in person (in-person classroom and synchronous video classroom) than online. Students that persist in an online introductory Physics class are more likely to achieve an A than in other modes. However, the withdrawal rate is higher from online Physics courses. Further research is warranted to better understand the reasons for higher withdrawal rates in online courses. Finding the root cause to help eliminate differences in student performance across learning modes should remain a high priority for education researchers and the education community as a whole.
Analysis of Factors Affecting the Performance of RLV Thrust Cell Liners
NASA Technical Reports Server (NTRS)
Arnold, Steven M. (Technical Monitor); Butler, Daniel T., Jr.; Pinders, Marek-Jerzy
2004-01-01
The reusable launch vehicle (RLV) thrust cell liner, or thrust chamber, is a critical component of the Space Shuttle Main Engine (SSME). It is designed to operate in some of the most severe conditions seen in engineering practice. This requirement, in conjunction with experimentally observed 'dog-house' failure modes characterized by bulging and thinning of the cooling channel wall, provides the motivation to study the factors that influence RLV thrust cell liner performance. Factors or parameters believed to be directly related to the observed characteristic deformation modes leading to failure under in-service loading conditions are identified, and subsequently investigated using the cylindrical version of the higher-order theory for functionally graded materials in conjunction with the Robinson's unified viscoplasticity theory and the power-law creep model for modeling the response of the liner s constituents. Configurations are analyzed in which specific modifications in cooling channel wall thickness or constituent materials are made to determine the influence of these parameters on the deformations resulting in the observed failure modes in the outer walls of the cooling channel. The application of thermal barrier coatings and functional grading are also investigated within this context. Comparison of the higher-order theory results based on the Robinson and power-law creep model predictions has demonstrated that, using the available material parameters, the power-law creep model predicts more precisely the experimentally observed deformation leading to the 'dog-house' failure mode for multiple short cycles, while also providing much improved computational efficiency. However, for a single long cycle, both models predict virtually identical deformations. Increasing the power-law creep model coefficients produces appreciable deformations after just one long cycle that would normally be obtained after multiple cycles, thereby enhancing the efficiency of the analysis. This provides a basis for the development of an accelerated modeling procedure to further characterize dog-house deformation modes in RLV thrust cell liners. Additionally, the results presented herein have demonstrated that the mechanism responsible for deformation leading to 'dog-house' failure modes is driven by pressure, creep/relaxation and geometric effects.
SU-F-T-246: Evaluation of Healthcare Failure Mode And Effect Analysis For Risk Assessment
DOE Office of Scientific and Technical Information (OSTI.GOV)
Harry, T; University of California, San Diego, La Jolla, CA; Manger, R
Purpose: To evaluate the differences between the Veteran Affairs Healthcare Failure Modes and Effect Analysis (HFMEA) and the AAPM Task Group 100 Failure and Effect Analysis (FMEA) risk assessment techniques in the setting of a stereotactic radiosurgery (SRS) procedure were compared respectively. Understanding the differences in the techniques methodologies and outcomes will provide further insight into the applicability and utility of risk assessments exercises in radiation therapy. Methods: HFMEA risk assessment analysis was performed on a stereotactic radiosurgery procedure. A previous study from our institution completed a FMEA of our SRS procedure and the process map generated from this workmore » was used for the HFMEA. The process of performing the HFMEA scoring was analyzed, and the results from both analyses were compared. Results: The key differences between the two risk assessments are the scoring criteria for failure modes and identifying critical failure modes for potential hazards. The general consensus among the team performing the analyses was that scoring for the HFMEA was simpler and more intuitive then the FMEA. The FMEA identified 25 critical failure modes while the HFMEA identified 39. Seven of the FMEA critical failure modes were not identified by the HFMEA and 21 of the HFMEA critical failure modes were not identified by the FMEA. HFMEA as described by the Veteran Affairs provides guidelines on which failure modes to address first. Conclusion: HFMEA is a more efficient model for identifying gross risks in a process than FMEA. Clinics with minimal staff, time and resources can benefit from this type of risk assessment to eliminate or mitigate high risk hazards with nominal effort. FMEA can provide more in depth details but at the cost of elevated effort.« less
Failure mode and effects analysis drastically reduced potential risks in clinical trial conduct.
Lee, Howard; Lee, Heechan; Baik, Jungmi; Kim, Hyunjung; Kim, Rachel
2017-01-01
Failure mode and effects analysis (FMEA) is a risk management tool to proactively identify and assess the causes and effects of potential failures in a system, thereby preventing them from happening. The objective of this study was to evaluate effectiveness of FMEA applied to an academic clinical trial center in a tertiary care setting. A multidisciplinary FMEA focus group at the Seoul National University Hospital Clinical Trials Center selected 6 core clinical trial processes, for which potential failure modes were identified and their risk priority number (RPN) was assessed. Remedial action plans for high-risk failure modes (RPN >160) were devised and a follow-up RPN scoring was conducted a year later. A total of 114 failure modes were identified with an RPN score ranging 3-378, which was mainly driven by the severity score. Fourteen failure modes were of high risk, 11 of which were addressed by remedial actions. Rescoring showed a dramatic improvement attributed to reduction in the occurrence and detection scores by >3 and >2 points, respectively. FMEA is a powerful tool to improve quality in clinical trials. The Seoul National University Hospital Clinical Trials Center is expanding its FMEA capability to other core clinical trial processes.
A streamlined failure mode and effects analysis
DOE Office of Scientific and Technical Information (OSTI.GOV)
Ford, Eric C., E-mail: eford@uw.edu; Smith, Koren; Terezakis, Stephanie
Purpose: Explore the feasibility and impact of a streamlined failure mode and effects analysis (FMEA) using a structured process that is designed to minimize staff effort. Methods: FMEA for the external beam process was conducted at an affiliate radiation oncology center that treats approximately 60 patients per day. A structured FMEA process was developed which included clearly defined roles and goals for each phase. A core group of seven people was identified and a facilitator was chosen to lead the effort. Failure modes were identified and scored according to the FMEA formalism. A risk priority number,RPN, was calculated and usedmore » to rank failure modes. Failure modes with RPN > 150 received safety improvement interventions. Staff effort was carefully tracked throughout the project. Results: Fifty-two failure modes were identified, 22 collected during meetings, and 30 from take-home worksheets. The four top-ranked failure modes were: delay in film check, missing pacemaker protocol/consent, critical structures not contoured, and pregnant patient simulated without the team's knowledge of the pregnancy. These four failure modes hadRPN > 150 and received safety interventions. The FMEA was completed in one month in four 1-h meetings. A total of 55 staff hours were required and, additionally, 20 h by the facilitator. Conclusions: Streamlined FMEA provides a means of accomplishing a relatively large-scale analysis with modest effort. One potential value of FMEA is that it potentially provides a means of measuring the impact of quality improvement efforts through a reduction in risk scores. Future study of this possibility is needed.« less
SU-E-T-627: Failure Modes and Effect Analysis for Monthly Quality Assurance of Linear Accelerator
DOE Office of Scientific and Technical Information (OSTI.GOV)
Xie, J; Xiao, Y; Wang, J
2014-06-15
Purpose: To develop and implement a failure mode and effect analysis (FMEA) on routine monthly Quality Assurance (QA) tests (physical tests part) of linear accelerator. Methods: A systematic failure mode and effect analysis method was performed for monthly QA procedures. A detailed process tree of monthly QA was created and potential failure modes were defined. Each failure mode may have many influencing factors. For each factor, a risk probability number (RPN) was calculated from the product of probability of occurrence (O), the severity of effect (S), and detectability of the failure (D). The RPN scores are in a range ofmore » 1 to 1000, with higher scores indicating stronger correlation to a given influencing factor of a failure mode. Five medical physicists in our institution were responsible to discuss and to define the O, S, D values. Results: 15 possible failure modes were identified and all RPN scores of all influencing factors of these 15 failue modes were from 8 to 150, and the checklist of FMEA in monthly QA was drawn. The system showed consistent and accurate response to erroneous conditions. Conclusion: The influencing factors of RPN greater than 50 were considered as highly-correlated factors of a certain out-oftolerance monthly QA test. FMEA is a fast and flexible tool to develop an implement a quality management (QM) frame work of monthly QA, which improved the QA efficiency of our QA team. The FMEA work may incorporate more quantification and monitoring fuctions in future.« less
Consistency of FMEA used in the validation of analytical procedures.
Oldenhof, M T; van Leeuwen, J F; Nauta, M J; de Kaste, D; Odekerken-Rombouts, Y M C F; Vredenbregt, M J; Weda, M; Barends, D M
2011-02-20
In order to explore the consistency of the outcome of a Failure Mode and Effects Analysis (FMEA) in the validation of analytical procedures, an FMEA was carried out by two different teams. The two teams applied two separate FMEAs to a High Performance Liquid Chromatography-Diode Array Detection-Mass Spectrometry (HPLC-DAD-MS) analytical procedure used in the quality control of medicines. Each team was free to define their own ranking scales for the probability of severity (S), occurrence (O), and detection (D) of failure modes. We calculated Risk Priority Numbers (RPNs) and we identified the failure modes above the 90th percentile of RPN values as failure modes needing urgent corrective action; failure modes falling between the 75th and 90th percentile of RPN values were identified as failure modes needing necessary corrective action, respectively. Team 1 and Team 2 identified five and six failure modes needing urgent corrective action respectively, with two being commonly identified. Of the failure modes needing necessary corrective actions, about a third were commonly identified by both teams. These results show inconsistency in the outcome of the FMEA. To improve consistency, we recommend that FMEA is always carried out under the supervision of an experienced FMEA-facilitator and that the FMEA team has at least two members with competence in the analytical method to be validated. However, the FMEAs of both teams contained valuable information that was not identified by the other team, indicating that this inconsistency is not always a drawback. Copyright © 2010 Elsevier B.V. All rights reserved.
Independent Orbiter Assessment (IOA): Assessment of the mechanical actuation subsystem, volume 1
NASA Technical Reports Server (NTRS)
Bradway, M. W.; Slaughter, W. T.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine draft failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the proposed Post 51-L NASA FMEA/CIL baseline that was available. A resolution of each discrepancy from the comparison was provided through additional analysis as required. These discrepancies were flagged as issues, and recommendations were made based on the FMEA data available at the time. This report documents the results of that comparison for the Orbiter Mechanical Actuation System (MAS) hardware. Specifically, the MAS hardware consists of the following components: Air Data Probe (ADP); Elevon Seal Panel (ESP); External Tank Umbilical (ETU); Ku-Band Deploy (KBD); Payload Bay Doors (PBD); Payload Bay Radiators (PBR); Personnel Hatches (PH); Vent Door Mechanism (VDM); and Startracker Door Mechanism (SDM). Criticality was assigned based upon the severity of the effect for each failure mode.
Development of STS/Centaur failure probabilities liftoff to Centaur separation
NASA Technical Reports Server (NTRS)
Hudson, J. M.
1982-01-01
The results of an analysis to determine STS/Centaur catastrophic vehicle response probabilities for the phases of vehicle flight from STS liftoff to Centaur separation from the Orbiter are presented. The analysis considers only category one component failure modes as contributors to the vehicle response mode probabilities. The relevant component failure modes are grouped into one of fourteen categories of potential vehicle behavior. By assigning failure rates to each component, for each of its failure modes, the STS/Centaur vehicle response probabilities in each phase of flight can be calculated. The results of this study will be used in a DOE analysis to ascertain the hazard from carrying a nuclear payload on the STS.
Extended Testability Analysis Tool
NASA Technical Reports Server (NTRS)
Melcher, Kevin; Maul, William A.; Fulton, Christopher
2012-01-01
The Extended Testability Analysis (ETA) Tool is a software application that supports fault management (FM) by performing testability analyses on the fault propagation model of a given system. Fault management includes the prevention of faults through robust design margins and quality assurance methods, or the mitigation of system failures. Fault management requires an understanding of the system design and operation, potential failure mechanisms within the system, and the propagation of those potential failures through the system. The purpose of the ETA Tool software is to process the testability analysis results from a commercial software program called TEAMS Designer in order to provide a detailed set of diagnostic assessment reports. The ETA Tool is a command-line process with several user-selectable report output options. The ETA Tool also extends the COTS testability analysis and enables variation studies with sensor sensitivity impacts on system diagnostics and component isolation using a single testability output. The ETA Tool can also provide extended analyses from a single set of testability output files. The following analysis reports are available to the user: (1) the Detectability Report provides a breakdown of how each tested failure mode was detected, (2) the Test Utilization Report identifies all the failure modes that each test detects, (3) the Failure Mode Isolation Report demonstrates the system s ability to discriminate between failure modes, (4) the Component Isolation Report demonstrates the system s ability to discriminate between failure modes relative to the components containing the failure modes, (5) the Sensor Sensor Sensitivity Analysis Report shows the diagnostic impact due to loss of sensor information, and (6) the Effect Mapping Report identifies failure modes that result in specified system-level effects.
NASA Astrophysics Data System (ADS)
Zheng, W.; Gao, J. M.; Wang, R. X.; Chen, K.; Jiang, Y.
2017-12-01
This paper put forward a new method of technical characteristics deployment based on Reliability Function Deployment (RFD) by analysing the advantages and shortages of related research works on mechanical reliability design. The matrix decomposition structure of RFD was used to describe the correlative relation between failure mechanisms, soft failures and hard failures. By considering the correlation of multiple failure modes, the reliability loss of one failure mode to the whole part was defined, and a calculation and analysis model for reliability loss was presented. According to the reliability loss, the reliability index value of the whole part was allocated to each failure mode. On the basis of the deployment of reliability index value, the inverse reliability method was employed to acquire the values of technology characteristics. The feasibility and validity of proposed method were illustrated by a development case of machining centre’s transmission system.
Independent Orbiter Assessment (IOA): Analysis of the crew equipment subsystem
NASA Technical Reports Server (NTRS)
Sinclair, Susan; Graham, L.; Richard, Bill; Saxon, H.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical (PCIs) items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results coresponding to the Orbiter crew equipment hardware are documented. The IOA analysis process utilized available crew equipment hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 352 failure modes analyzed, 78 were determined to be PCIs.
Independent Orbiter Assessment (IOA): Analysis of the purge, vent and drain subsystem
NASA Technical Reports Server (NTRS)
Bynum, M. C., III
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter PV and D (Purge, Vent and Drain) Subsystem hardware. The PV and D Subsystem controls the environment of unpressurized compartments and window cavities, senses hazardous gases, and purges Orbiter/ET Disconnect. The subsystem is divided into six systems: Purge System (controls the environment of unpressurized structural compartments); Vent System (controls the pressure of unpressurized compartments); Drain System (removes water from unpressurized compartments); Hazardous Gas Detection System (HGDS) (monitors hazardous gas concentrations); Window Cavity Conditioning System (WCCS) (maintains clear windows and provides pressure control of the window cavities); and External Tank/Orbiter Disconnect Purge System (prevents cryo-pumping/icing of disconnect hardware). Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Four of the sixty-two failure modes analyzed were determined as single failures which could result in the loss of crew or vehicle. A possible loss of mission could result if any of twelve single failures occurred. Two of the criticality 1/1 failures are in the Window Cavity Conditioning System (WCCS) outer window cavity, where leakage and/or restricted flow will cause failure to depressurize/repressurize the window cavity. Two criticality 1/1 failures represent leakage and/or restricted flow in the Orbiter/ET disconnect purge network which prevent cryopumping/icing of disconnect hardware. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Mossahebi, S; Feigenberg, S; Nichols, E
Purpose: GammaPod™, the first stereotactic radiotherapy device for early stage breast cancer treatment, has been recently installed and commissioned at our institution. A multidisciplinary working group applied the failure mode and effects analysis (FMEA) approach to perform a risk analysis. Methods: FMEA was applied to the GammaPod™ treatment process by: 1) generating process maps for each stage of treatment; 2) identifying potential failure modes and outlining their causes and effects; 3) scoring the potential failure modes using the risk priority number (RPN) system based on the product of severity, frequency of occurrence, and detectability (ranging 1–10). An RPN of highermore » than 150 was set as the threshold for minimal concern of risk. For these high-risk failure modes, potential quality assurance procedures and risk control techniques have been proposed. A new set of severity, occurrence, and detectability values were re-assessed in presence of the suggested mitigation strategies. Results: In the single-day image-and-treat workflow, 19, 22, and 27 sub-processes were identified for the stages of simulation, treatment planning, and delivery processes, respectively. During the simulation stage, 38 potential failure modes were found and scored, in terms of RPN, in the range of 9-392. 34 potential failure modes were analyzed in treatment planning with a score range of 16-200. For the treatment delivery stage, 47 potential failure modes were found with an RPN score range of 16-392. The most critical failure modes consisted of breast-cup pressure loss and incorrect target localization due to patient upper-body alignment inaccuracies. The final RPN score of these failure modes based on recommended actions were assessed to be below 150. Conclusion: FMEA risk analysis technique was applied to the treatment process of GammaPod™, a new stereotactic radiotherapy technology. Application of systematic risk analysis methods is projected to lead to improved quality of GammaPod™ treatments. Ying Niu and Cedric Yu are affiliated with Xcision Medical Systems.« less
Interfacial characterization of flexible hybrid electronics
NASA Astrophysics Data System (ADS)
Najafian, Sara; Amirkhizi, Alireza V.; Stapleton, Scott
2018-03-01
Flexible Hybrid Electronics (FHEs) are the new generation of electronics combining flexible plastic film substrates with electronic devices. Besides the electrical features, design improvements of FHEs depend on the prediction of their mechanical and failure behavior. Debonding of electronic components from the flexible substrate is one of the most common and critical failures of these devices, therefore, the experimental determination of material and interface properties is of great importance in the prediction of failure mechanisms. Traditional interface characterization involves isolated shear and normal mode tests such as the double cantilever beam (DCB) and end notch flexure (ENF) tests. However, due to the thin, flexible nature of the materials and manufacturing restrictions, tests mirroring traditional interface characterization experiments may not always be possible. The ideal goal of this research is to design experiments such that each mode of fracture is isolated. However, due to the complex nonlinear nature of the response and small geometries of FHEs, design of the proper tests to characterize the interface properties can be significantly time and cost consuming. Hence numerical modeling has been implemented to design these novel characterization experiments. This research involves loading case and specimen geometry parametric studies using numerical modeling to design future experiments where either shear or normal fracture modes are dominant. These virtual experiments will provide a foundation for designing similar tests for many different types of flexible electronics and predicting the failure mechanism independent of the specific FHE materials.
Compendium of Mechanical Limit-States
NASA Technical Reports Server (NTRS)
Kowal, Michael
1996-01-01
A compendium was compiled and is described to provide a diverse set of limit-state relationships for use in demonstrating the application of probabilistic reliability methods to mechanical systems. The different limit-state relationships can be used to analyze the reliability of a candidate mechanical system. In determining the limit-states to be included in the compendium, a comprehensive listing of the possible failure modes that could affect mechanical systems reliability was generated. Previous literature defining mechanical modes of failure was studied, and cited failure modes were included. From this, classifications for failure modes were derived and are described in some detail.
Wong, Kam Cheong
2016-04-06
Clinicians use various clinical reasoning tools such as Ishikawa diagram to enhance their clinical experience and reasoning skills. Failure mode and effects analysis, which is an engineering methodology in origin, can be modified and applied to provide inputs into an Ishikawa diagram. The human biliary system is used to illustrate a modified failure mode and effects analysis. The anatomical and physiological processes of the biliary system are reviewed. Failure is defined as an abnormality caused by infective, inflammatory, obstructive, malignancy, autoimmune and other pathological processes. The potential failures, their effect(s), main clinical features, and investigation that can help a clinician to diagnose at each anatomical part and physiological process are reviewed and documented in a modified failure mode and effects analysis table. Relevant medical and surgical cases are retrieved from the medical literature and weaved into the table. A total of 80 clinical cases which are relevant to the modified failure mode and effects analysis for the human biliary system have been reviewed and weaved into a designated table. The table is the backbone and framework for further expansion. Reviewing and updating the table is an iterative and continual process. The relevant clinical features in the modified failure mode and effects analysis are then extracted and included in the relevant Ishikawa diagram. This article illustrates an application of engineering methodology in medicine, and it sows the seeds of potential cross-pollination between engineering and medicine. Establishing a modified failure mode and effects analysis can be a teamwork project or self-directed learning process, or a mix of both. Modified failure mode and effects analysis can be deployed to obtain inputs for an Ishikawa diagram which in turn can be used to enhance clinical experiences and clinical reasoning skills for clinicians, medical educators, and students.
Fokkinga, Wietske A; Kreulen, Cees M; Vallittu, Pekka K; Creugers, Nico H J
2004-01-01
This study sought to aggregate literature data on in vitro failure loads and failure modes of prefabricated fiber-reinforced composite (FRC) post systems and to compare them to those of prefabricated metal, custom-cast, and ceramic post systems. The literature was searched using MEDLINE from 1984 to 2003 for dental articles in English. Keywords used were (post or core or buildup or dowel) and (teeth or tooth). Additional inclusion/exclusion steps were conducted, each step by two independent readers: (1) Abstracts describing post-and-core techniques to reconstruct endodontically treated teeth and their mechanical and physical characteristics were included (descriptive studies or reviews were excluded); (2) articles that included FRC post systems were selected; (3) in vitro studies, single-rooted human teeth, prefabricated FRC posts, and composite as the core material were the selection criteria; and (4) failure loads and modes were extracted from the selected papers, and failure modes were dichotomized (distinction was made between "favorable failures," defined as reparable failures, and "unfavorable failures,"defined as irreparable [root] fractures). The literature search revealed 1,984 abstracts. Included were 244, 42, and 12 articles in the first, second, and third selection steps, respectively. Custom-cast post systems showed higher failure loads than prefabricated FRC post systems, whereas ceramic showed lower failure loads. Significantly more favorable failures occurred with prefabricated FRC post systems than with prefabricated and custom-cast metal post systems. The variable "post system" had a significant effect on mean failure loads. FRC post systems more frequently showed favorable failure modes than did metal post systems.
Composite Interlaminar Shear Fracture Toughness, G(sub 2c): Shear Measurement of Sheer Myth?
NASA Technical Reports Server (NTRS)
OBrien, T. Kevin
1997-01-01
The concept of G2c as a measure of the interlaminar shear fracture toughness of a composite material is critically examined. In particular, it is argued that the apparent G2c as typically measured is inconsistent with the original definition of shear fracture. It is shown that interlaminar shear failure actually consists of tension failures in the resin rich layers between plies followed by the coalescence of ligaments created by these failures and not the sliding of two planes relative to one another that is assumed in fracture mechanics theory. Several strain energy release rate solutions are reviewed for delamination in composite laminates and structural components where failures have been experimentally documented. Failures typically occur at a location where the mode 1 component accounts for at least one half of the total G at failure. Hence, it is the mode I and mixed-mode interlaminar fracture toughness data that will be most useful in predicting delamination failure in composite components in service. Although apparent G2c measurements may prove useful for completeness of generating mixed-mode criteria, the accuracy of these measurements may have very little influence on the prediction of mixed-mode failures in most structural components.
A case study in nonconformance and performance trend analysis
NASA Technical Reports Server (NTRS)
Maloy, Joseph E.; Newton, Coy P.
1990-01-01
As part of NASA's effort to develop an agency-wide approach to trend analysis, a pilot nonconformance and performance trending analysis study was conducted on the Space Shuttle auxiliary power unit (APU). The purpose of the study was to (1) demonstrate that nonconformance analysis can be used to identify repeating failures of a specific item (and the associated failure modes and causes) and (2) determine whether performance parameters could be analyzed and monitored to provide an indication of component or system degradation prior to failure. The nonconformance analysis of the APU did identify repeating component failures, which possibly could be reduced if key performance parameters were monitored and analyzed. The performance-trending analysis verified that the characteristics of hardware parameters can be effective in detecting degradation of hardware performance prior to failure.
75 FR 51931 - Airworthiness Directives; Dassault-Aviation Model FALCON 7X Airplanes
Federal Register 2010, 2011, 2012, 2013, 2014
2010-08-24
... root cause: A leakage failure mode of Transient Voltage Suppressor (TVS) diodes used on Power... condition is a leakage failure mode of TVS diodes used on PDCU cards or GCU cards in the PPDB, which in... discovery of a common root cause: A leakage failure mode of Transient Voltage Suppressor (TVS) diodes used...
Fundamental aspects of and failure modes in high-temperature composites
NASA Technical Reports Server (NTRS)
Chamis, Christos C.; Ginty, Carol A.
1990-01-01
Fundamental aspects of and attendant failure mechanisms for high temperature composites are summarized. These include: (1) in-situ matrix behavior; (2) load transfer; (3) limits on matrix ductility to survive a given number of cyclic loadings; (4) fundamental parameters which govern thermal stresses; (5) vibration stresses; and (6) impact resistance. The resulting guidelines are presented in terms of simple equations which are suitable for the preliminary assessment of the merits of a particular high temperature composite in a specific application.
NASA Astrophysics Data System (ADS)
Sawant, M.; Christou, A.
2012-12-01
While use of LEDs in Fiber Optics and lighting applications is common, their use in medical diagnostic applications is not very extensive. Since the precise value of light intensity will be used to interpret patient results, understanding failure modes [1-4] is very important. We used the Failure Modes and Effects Criticality Analysis (FMECA) tool to identify the critical failure modes of the LEDs. FMECA involves identification of various failure modes, their effects on the system (LED optical output in this context), their frequency of occurrence, severity and the criticality of the failure modes. The competing failure modes/mechanisms were degradation of: active layer (where electron-hole recombination occurs to emit light), electrodes (provides electrical contact to the semiconductor chip), Indium Tin Oxide (ITO) surface layer (used to improve current spreading and light extraction), plastic encapsulation (protective polymer layer) and packaging failures (bond wires, heat sink separation). A FMECA table is constructed and the criticality is calculated by estimating the failure effect probability (β), failure mode ratio (α), failure rate (λ) and the operating time. Once the critical failure modes were identified, the next steps were generation of prior time to failure distribution and comparing with our accelerated life test data. To generate the prior distributions, data and results from previous investigations were utilized [5-33] where reliability test results of similar LEDs were reported. From the graphs or tabular data, we extracted the time required for the optical power output to reach 80% of its initial value. This is our failure criterion for the medical diagnostic application. Analysis of published data for different LED materials (AlGaInP, GaN, AlGaAs), the Semiconductor Structures (DH, MQW) and the mode of testing (DC, Pulsed) was carried out. The data was categorized according to the materials system and LED structure such as AlGaInP-DH-DC, AlGaInP-MQW-DC, GaN-DH-DC, and GaN-DH-DC. Although the reported testing was carried out at different temperature and current, the reported data was converted to the present application conditions of the medical environment. Comparisons between the model data and accelerated test results carried out in the present are reported. The use of accelerating agent modeling and regression analysis was also carried out. We have used the Inverse Power Law model with the current density J as the accelerating agent and the Arrhenius model with temperature as the accelerating agent. Finally, our reported methodology is presented as an approach for analyzing LED suitability for the target medical diagnostic applications.
Waddell, J Neil; Payne, Alan G T; Swain, Michael V; Kieser, Jules A
2010-03-01
Soldered or cast bars are used as a standard of care in attachment systems supporting maxillary and mandibular implant overdentures. When failures of these bars occur, currently there is a lack of evidence in relation to their specific etiology, location, or nature. To investigate the failure process of a case series of six failed soldered bars, four intact soldered bars, and one intact cast milled bar, which had been supporting implant overdentures. A total of 11 different overdenture bars were removed from patients with different configuration of opposing arches. A failed bar (FB) group (n = 6) had failed soldered overdenture bars, which were recovered from patients following up to 2 years of wear before requiring prosthodontic maintenance and repair. An intact bar (IB) group (n = 5) had both soldered bars and a single cast milled bar, which had been worn by patients for 2 to 5 years prior to receiving other aspects of prosthodontic maintenance. All bars were examined using scanning electron microscopy to establish the possible mode of failure (FB) or to identify evidence of potential failure in the future (IB). Evidence of a progressive failure mode of corrosion fatigue and creep were observed on all the FB and IB usually around the solder areas and nonoxidizing gold cylinder. Fatigue and creep were also observed in all the IB. Where the level of corrosion was substantial, there was no evidence of wear from the matrices of the attachment system. Evidence of an instantaneous failure mode, ductile and brittle overload, was observed on the fracture surfaces of all the FB, within the solder and the nonoxidizing gold cylinders, at the solder/cylinder interface. Corrosion, followed by corrosion fatigue, appears to be a key factor in the onset of the failure process for overdenture bars in this case series of both maxillary and mandibular overdentures. Limited sample size and lack of standardization identify trends only but prevent broad interpretation of the findings.
Failure Modes in Capacitors When Tested Under a Time-Varying Stress
NASA Technical Reports Server (NTRS)
Liu, David (Donhang)
2011-01-01
Steady step surge testing (SSST) is widely applied to screen out potential power-on failures in solid tantalum capacitors. The test simulates the power supply's on and off characteristics. Power-on failure has been the prevalent failure mechanism for solid tantalum capacitors for decoupling applications. On the other hand, the SSST can also be reviewed as an electrically destructive test under a time-varying stress. It consists of rapidly charging the capacitor with incremental voltage increases, through a low resistance in series, until the capacitor under test is electrically shorted. Highly accelerated life testing (HALT) is usually a time-efficient method for determining the failure mechanism in capacitors; however, a destructive test under a time-varying stress like SSST is even more effective. It normally takes days to complete a HALT test, but it only takes minutes for a time-varying stress test to produce failures. The advantage of incorporating specific time-varying stress into a statistical model is significant in providing an alternative life test method for quickly revealing the failure modes in capacitors. In this paper, a time-varying stress has been incorporated into the Weibull model to characterize the failure modes. The SSST circuit and transient conditions to correctly test the capacitors is discussed. Finally, the SSST was applied for testing polymer aluminum capacitors (PA capacitors), Ta capacitors, and multi-layer ceramic capacitors with both precious metal electrode (PME) and base-metal-electrodes (BME). It appears that testing results are directly associated to the dielectric layer breakdown in PA and Ta capacitors and are independent on the capacitor values, the way the capacitors being built, and the manufactures. The testing results also reveal that ceramic capacitors exhibit breakdown voltages more than 20 times the rated voltage, and the breakdown voltages are inverse proportional to the dielectric layer thickness. The possibility of ceramic capacitors in front-end decoupling applications to block the surge noise from a power supply is also discussed.
Masini, Laura; Donis, Laura; Loi, Gianfranco; Mones, Eleonora; Molina, Elisa; Bolchini, Cesare; Krengli, Marco
2014-01-01
The aim of this study was to analyze the application of the failure modes and effects analysis (FMEA) to intracranial stereotactic radiation surgery (SRS) by linear accelerator in order to identify the potential failure modes in the process tree and adopt appropriate safety measures to prevent adverse events (AEs) and near-misses, thus improving the process quality. A working group was set up to perform FMEA for intracranial SRS in the framework of a quality assurance program. FMEA was performed in 4 consecutive tasks: (1) creation of a visual map of the process; (2) identification of possible failure modes; (3) assignment of a risk probability number (RPN) to each failure mode based on tabulated scores of severity, frequency of occurrence and detectability; and (4) identification of preventive measures to minimize the risk of occurrence. The whole SRS procedure was subdivided into 73 single steps; 116 total possible failure modes were identified and a score of severity, occurrence, and detectability was assigned to each. Based on these scores, RPN was calculated for each failure mode thus obtaining values from 1 to 180. In our analysis, 112/116 (96.6%) RPN values were <60, 2 (1.7%) between 60 and 125 (63, 70), and 2 (1.7%) >125 (135, 180). The 2 highest RPN scores were assigned to the risk of using the wrong collimator's size and incorrect coordinates on the laser target localizer frame. Failure modes and effects analysis is a simple and practical proactive tool for systematic analysis of risks in radiation therapy. In our experience of SRS, FMEA led to the adoption of major changes in various steps of the SRS procedure.
FMEA of manual and automated methods for commissioning a radiotherapy treatment planning system.
Wexler, Amy; Gu, Bruce; Goddu, Sreekrishna; Mutic, Maya; Yaddanapudi, Sridhar; Olsen, Lindsey; Harry, Taylor; Noel, Camille; Pawlicki, Todd; Mutic, Sasa; Cai, Bin
2017-09-01
To evaluate the level of risk involved in treatment planning system (TPS) commissioning using a manual test procedure, and to compare the associated process-based risk to that of an automated commissioning process (ACP) by performing an in-depth failure modes and effects analysis (FMEA). The authors collaborated to determine the potential failure modes of the TPS commissioning process using (a) approaches involving manual data measurement, modeling, and validation tests and (b) an automated process utilizing application programming interface (API) scripting, preloaded, and premodeled standard radiation beam data, digital heterogeneous phantom, and an automated commissioning test suite (ACTS). The severity (S), occurrence (O), and detectability (D) were scored for each failure mode and the risk priority numbers (RPN) were derived based on TG-100 scale. Failure modes were then analyzed and ranked based on RPN. The total number of failure modes, RPN scores and the top 10 failure modes with highest risk were described and cross-compared between the two approaches. RPN reduction analysis is also presented and used as another quantifiable metric to evaluate the proposed approach. The FMEA of a MTP resulted in 47 failure modes with an RPN ave of 161 and S ave of 6.7. The highest risk process of "Measurement Equipment Selection" resulted in an RPN max of 640. The FMEA of an ACP resulted in 36 failure modes with an RPN ave of 73 and S ave of 6.7. The highest risk process of "EPID Calibration" resulted in an RPN max of 576. An FMEA of treatment planning commissioning tests using automation and standardization via API scripting, preloaded, and pre-modeled standard beam data, and digital phantoms suggests that errors and risks may be reduced through the use of an ACP. © 2017 American Association of Physicists in Medicine.
FEMA and RAM Analysis for the Multi Canister Overpack (MCO) Handling Machine
DOE Office of Scientific and Technical Information (OSTI.GOV)
SWENSON, C.E.
2000-06-01
The Failure Modes and Effects Analysis and the Reliability, Availability, and Maintainability Analysis performed for the Multi-Canister Overpack Handling Machine (MHM) has shown that the current design provides for a safe system, but the reliability of the system (primarily due to the complexity of the interlocks and permissive controls) is relatively low. No specific failure modes were identified where significant consequences to the public occurred, or where significant impact to nearby workers should be expected. The overall reliability calculation for the MHM shows a 98.1 percent probability of operating for eight hours without failure, and an availability of the MHMmore » of 90 percent. The majority of the reliability issues are found in the interlocks and controls. The availability of appropriate spare parts and maintenance personnel, coupled with well written operating procedures, will play a more important role in successful mission completion for the MHM than other less complicated systems.« less
Application of failure mode and effect analysis in an assisted reproduction technology laboratory.
Intra, Giulia; Alteri, Alessandra; Corti, Laura; Rabellotti, Elisa; Papaleo, Enrico; Restelli, Liliana; Biondo, Stefania; Garancini, Maria Paola; Candiani, Massimo; Viganò, Paola
2016-08-01
Assisted reproduction technology laboratories have a very high degree of complexity. Mismatches of gametes or embryos can occur, with catastrophic consequences for patients. To minimize the risk of error, a multi-institutional working group applied failure mode and effects analysis (FMEA) to each critical activity/step as a method of risk assessment. This analysis led to the identification of the potential failure modes, together with their causes and effects, using the risk priority number (RPN) scoring system. In total, 11 individual steps and 68 different potential failure modes were identified. The highest ranked failure modes, with an RPN score of 25, encompassed 17 failures and pertained to "patient mismatch" and "biological sample mismatch". The maximum reduction in risk, with RPN reduced from 25 to 5, was mostly related to the introduction of witnessing. The critical failure modes in sample processing were improved by 50% in the RPN by focusing on staff training. Three indicators of FMEA success, based on technical skill, competence and traceability, have been evaluated after FMEA implementation. Witnessing by a second human operator should be introduced in the laboratory to avoid sample mix-ups. These findings confirm that FMEA can effectively reduce errors in assisted reproduction technology laboratories. Copyright © 2016 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
Failure mode and effects analysis drastically reduced potential risks in clinical trial conduct
Baik, Jungmi; Kim, Hyunjung; Kim, Rachel
2017-01-01
Background Failure mode and effects analysis (FMEA) is a risk management tool to proactively identify and assess the causes and effects of potential failures in a system, thereby preventing them from happening. The objective of this study was to evaluate effectiveness of FMEA applied to an academic clinical trial center in a tertiary care setting. Methods A multidisciplinary FMEA focus group at the Seoul National University Hospital Clinical Trials Center selected 6 core clinical trial processes, for which potential failure modes were identified and their risk priority number (RPN) was assessed. Remedial action plans for high-risk failure modes (RPN >160) were devised and a follow-up RPN scoring was conducted a year later. Results A total of 114 failure modes were identified with an RPN score ranging 3–378, which was mainly driven by the severity score. Fourteen failure modes were of high risk, 11 of which were addressed by remedial actions. Rescoring showed a dramatic improvement attributed to reduction in the occurrence and detection scores by >3 and >2 points, respectively. Conclusions FMEA is a powerful tool to improve quality in clinical trials. The Seoul National University Hospital Clinical Trials Center is expanding its FMEA capability to other core clinical trial processes. PMID:29089745
DOE Office of Scientific and Technical Information (OSTI.GOV)
Dennis, L.B.
1994-12-01
This research extends the existing knowledge of cross-ply metal matrix composites (MMC) to include fatigue behavior under strain-controlled fully reversed loading. This study investigated fatigue life, failure modes and damage mechanisms of the SCS-6/Ti-15-3, (O/9O)2s, MMC. The laminate was subjected to fully reversed fatigue at elevated temperature (427 deg C) at various strain levels. Stress, strain and modulus data were analyzed to characterize the macro-mechanical behavior of the composite. Microscopy and fractography were accomplished to identify and characterize the damage mechanisms at the microscopic level. Failure modes varied according to the maximum applied strain level showing either mixed mode (i.e.more » combination of both fiber and matrix dominated modes) or matrix dominated fatigue failures. As expected, higher strain loadings resulted in more ductility of the matrix at failure, evidenced by fracture surface features. For testing of the same composite laminate, the fatigue life under strain controlled mode slightly increased, compared to its load-controlled mode counterpart, using the effective strain range comparison basis. However, the respective fatigue life curves converged in the high cycle region, suggesting that the matrix dominated failure mode produces equivalent predicted fatigue lives for both control modes.« less
High-throughput sequencing: a failure mode analysis.
Yang, George S; Stott, Jeffery M; Smailus, Duane; Barber, Sarah A; Balasundaram, Miruna; Marra, Marco A; Holt, Robert A
2005-01-04
Basic manufacturing principles are becoming increasingly important in high-throughput sequencing facilities where there is a constant drive to increase quality, increase efficiency, and decrease operating costs. While high-throughput centres report failure rates typically on the order of 10%, the causes of sporadic sequencing failures are seldom analyzed in detail and have not, in the past, been formally reported. Here we report the results of a failure mode analysis of our production sequencing facility based on detailed evaluation of 9,216 ESTs generated from two cDNA libraries. Two categories of failures are described; process-related failures (failures due to equipment or sample handling) and template-related failures (failures that are revealed by close inspection of electropherograms and are likely due to properties of the template DNA sequence itself). Preventative action based on a detailed understanding of failure modes is likely to improve the performance of other production sequencing pipelines.
The sympathetic/parasympathetic imbalance in heart failure with reduced ejection fraction
Floras, John S.; Ponikowski, Piotr
2015-01-01
Cardiovascular autonomic imbalance, a cardinal phenotype of human heart failure, has adverse implications for symptoms during wakefulness and sleep; for cardiac, renal, and immune function; for exercise capacity; and for lifespan and mode of death. The objectives of this Clinical Review are to summarize current knowledge concerning mechanisms for disturbed parasympathetic and sympathetic circulatory control in heart failure with reduced ejection fraction and its clinical and prognostic implications; to demonstrate the patient-specific nature of abnormalities underlying this common phenotype; and to illustrate how such variation provides opportunities to improve or restore normal sympathetic/parasympathetic balance through personalized drug or device therapy. PMID:25975657
DOE Office of Scientific and Technical Information (OSTI.GOV)
Weber, E.R.
1983-09-01
The appendixes for the Saguaro Power Plant includes the following: receiver configuration selection report; cooperating modes and transitions; failure modes analysis; control system analysis; computer codes and simulation models; procurement package scope descriptions; responsibility matrix; solar system flow diagram component purpose list; thermal storage component and system test plans; solar steam generator tube-to-tubesheet weld analysis; pipeline listing; management control schedule; and system list and definitions.
Failure Modes and Effects Analysis (FMEA) Assistant Tool Feasibility Study
NASA Technical Reports Server (NTRS)
Flores, Melissa; Malin, Jane T.
2013-01-01
An effort to determine the feasibility of a software tool to assist in Failure Modes and Effects Analysis (FMEA) has been completed. This new and unique approach to FMEA uses model based systems engineering concepts to recommend failure modes, causes, and effects to the user after they have made several selections from pick lists about a component s functions and inputs/outputs. Recommendations are made based on a library using common failure modes identified over the course of several major human spaceflight programs. However, the tool could be adapted for use in a wide range of applications from NASA to the energy industry.
Failure Modes and Effects Analysis (FMEA) Assistant Tool Feasibility Study
NASA Astrophysics Data System (ADS)
Flores, Melissa D.; Malin, Jane T.; Fleming, Land D.
2013-09-01
An effort to determine the feasibility of a software tool to assist in Failure Modes and Effects Analysis (FMEA) has been completed. This new and unique approach to FMEA uses model based systems engineering concepts to recommend failure modes, causes, and effects to the user after they have made several selections from pick lists about a component's functions and inputs/outputs. Recommendations are made based on a library using common failure modes identified over the course of several major human spaceflight programs. However, the tool could be adapted for use in a wide range of applications from NASA to the energy industry.
Savannah River Site generic data base development
DOE Office of Scientific and Technical Information (OSTI.GOV)
Blanton, C.H.; Eide, S.A.
This report describes the results of a project to improve the generic component failure data base for the Savannah River Site (SRS). A representative list of components and failure modes for SRS risk models was generated by reviewing existing safety analyses and component failure data bases and from suggestions from SRS safety analysts. Then sources of data or failure rate estimates were identified and reviewed for applicability. A major source of information was the Nuclear Computerized Library for Assessing Reactor Reliability, or NUCLARR. This source includes an extensive collection of failure data and failure rate estimates for commercial nuclear powermore » plants. A recent Idaho National Engineering Laboratory report on failure data from the Idaho Chemical Processing Plant was also reviewed. From these and other recent sources, failure data and failure rate estimates were collected for the components and failure modes of interest. This information was aggregated to obtain a recommended generic failure rate distribution (mean and error factor) for each component failure mode.« less
Guyen, Olivier; Lewallen, David G; Cabanela, Miguel E
2008-07-01
The Osteonics constrained tripolar implant has been one of the most commonly used options to manage recurrent instability after total hip arthroplasty. Mechanical failures were expected and have been reported. The purpose of this retrospective review was to identify the observed modes of failure of this device. Forty-three failed Osteonics constrained tripolar implants were revised at our institution between September 1997 and April 2005. All revisions related to the constrained acetabular component only were considered as failures. All of the devices had been inserted for recurrent or intraoperative instability during revision procedures. Seven different methods of implantation were used. Operative reports and radiographs were reviewed to identify the modes of failure. The average time to failure of the forty-three implants was 28.4 months. A total of five modes of failure were observed: failure at the bone-implant interface (type I), which occurred in eleven hips; failure at the mechanisms holding the constrained liner to the metal shell (type II), in six hips; failure of the retaining mechanism of the bipolar component (type III), in ten hips; dislocation of the prosthetic head at the inner bearing of the bipolar component (type IV), in three hips; and infection (type V), in twelve hips. The mode of failure remained unknown in one hip that had been revised at another institution. The Osteonics constrained tripolar total hip arthroplasty implant is a complex device involving many parts. We showed that failure of this device can occur at most of its interfaces. It would therefore appear logical to limit its application to salvage situations.
NASA Technical Reports Server (NTRS)
McCarty, John P.; Lyles, Garry M.
1997-01-01
Propulsion system quality is defined in this paper as having high reliability, that is, quality is a high probability of within-tolerance performance or operation. Since failures are out-of-tolerance performance, the probability of failures and their occurrence is the difference between high and low quality systems. Failures can be described at 3 levels: the system failure (which is the detectable end of a failure), the failure mode (which is the failure process), and the failure cause (which is the start). Failure causes can be evaluated & classified by type. The results of typing flight history failures shows that most failures are in unrecognized modes and result from human error or noise, i.e. failures are when engineers learn how things really work. Although the study based on US launch vehicles, a sampling of failures from other countries indicates the finding has broad application. The parameters of the design of a propulsion system are not single valued, but have dispersions associated with the manufacturing of parts. Many tests are needed to find failures, if the dispersions are large relative to tolerances, which could contribute to the large number of failures in unrecognized modes.
A multidimensional anisotropic strength criterion based on Kelvin modes
NASA Astrophysics Data System (ADS)
Arramon, Yves Pierre
A new theory for the prediction of multiaxial strength of anisotropic elastic materials was proposed by Biegler and Mehrabadi (1993). This theory is based on the premise that the total elastic strain energy of an anisotropic material subjected to multiaxial stress can be decomposed into dilatational and deviatoric modes. A multidimensional strength criterion may thus be formulated by postulating that the failure would occur when the energy stored in one of these modes has reached a critical value. However, the logic employed by these authors to formulate a failure criterion based on this theory could not be extended to multiaxial stress. In this thesis, an alternate criterion is presented which redresses the biaxial restriction by reformulating the surfaces of constant modal energy as surfaces of constant eigenstress magnitude. The resulting failure envelope, in a multidimensional stress space, is piecewise smooth. Each facet of the envelope is expected to represent the locus of failure data by a particular Kelvin mode. It is further shown that the Kelvin mode theory alone provides an incomplete description of the failure of some materials, but that this weakness can be addressed by the introduction of a set of complementary modes. A revised theory which combines both Kelvin and complementary modes is thus proposed and applied seven example materials: an isotropic concrete, tetragonal paperboard, two orthotropic softwoods, two orthotropic hardwoods and an orthotropic cortical bone. The resulting failure envelopes for these examples were plotted and, with the exception of concrete, shown to produce intuitively correct failure predictions.
NASA Technical Reports Server (NTRS)
Dempsey, Paula J.
2014-01-01
This report documents the results of spiral bevel gear rig tests performed under a NASA Space Act Agreement with the Federal Aviation Administration (FAA) to support validation and demonstration of rotorcraft Health and Usage Monitoring Systems (HUMS) for maintenance credits via FAA Advisory Circular (AC) 29-2C, Section MG-15, Airworthiness Approval of Rotorcraft (HUMS) (Ref. 1). The overarching goal of this work was to determine a method to validate condition indicators in the lab that better represent their response to faults in the field. Using existing in-service helicopter HUMS flight data from faulted spiral bevel gears as a "Case Study," to better understand the differences between both systems, and the availability of the NASA Glenn Spiral Bevel Gear Fatigue Rig, a plan was put in place to design, fabricate and test comparable gear sets with comparable failure modes within the constraints of the test rig. The research objectives of the rig tests were to evaluate the capability of detecting gear surface pitting fatigue and other generated failure modes on spiral bevel gear teeth using gear condition indicators currently used in fielded HUMS. Nineteen final design gear sets were tested. Tables were generated for each test, summarizing the failure modes observed on the gear teeth for each test during each inspection interval and color coded based on damage mode per inspection photos. Gear condition indicators (CI) Figure of Merit 4 (FM4), Root Mean Square (RMS), +/- 1 Sideband Index (SI1) and +/- 3 Sideband Index (SI3) were plotted along with rig operational parameters. Statistical tables of the means and standard deviations were calculated within inspection intervals for each CI. As testing progressed, it became clear that certain condition indicators were more sensitive to a specific component and failure mode. These tests were clustered together for further analysis. Maintenance actions during testing were also documented. Correlation coefficients were calculated between each CI, component, damage state and torque. Results found test rig and gear design, type of fault and data acquisition can affect CI performance. Results found FM4, SI1 and SI3 can be used to detect macro pitting on two more gear or pinion teeth as long as it is detected prior to progressing to other components or transitioning to another failure mode. The sensitivity of RMS to system and operational conditions limit its reliability for systems that are not maintained at steady state. Failure modes that occurred due to scuffing or fretting were challenging to detect with current gear diagnostic tools, since the damage is distributed across all the gear and pinion teeth, smearing the impacting signatures typically used to differentiate between a healthy and damaged tooth contact. This is one of three final reports published on the results of this project. In the second report, damage modes experienced in the field will be mapped to the failure modes created in the test rig. The helicopter CI data will then be re-processed with the same analysis techniques applied to spiral bevel rig test data. In the third report, results from the rig and helicopter data analysis will be correlated. Observations, findings and lessons learned using sub-scale rig failure progression tests to validate helicopter gear condition indicators will be presented.
Global resilience analysis of water distribution systems.
Diao, Kegong; Sweetapple, Chris; Farmani, Raziyeh; Fu, Guangtao; Ward, Sarah; Butler, David
2016-12-01
Evaluating and enhancing resilience in water infrastructure is a crucial step towards more sustainable urban water management. As a prerequisite to enhancing resilience, a detailed understanding is required of the inherent resilience of the underlying system. Differing from traditional risk analysis, here we propose a global resilience analysis (GRA) approach that shifts the objective from analysing multiple and unknown threats to analysing the more identifiable and measurable system responses to extreme conditions, i.e. potential failure modes. GRA aims to evaluate a system's resilience to a possible failure mode regardless of the causal threat(s) (known or unknown, external or internal). The method is applied to test the resilience of four water distribution systems (WDSs) with various features to three typical failure modes (pipe failure, excess demand, and substance intrusion). The study reveals GRA provides an overview of a water system's resilience to various failure modes. For each failure mode, it identifies the range of corresponding failure impacts and reveals extreme scenarios (e.g. the complete loss of water supply with only 5% pipe failure, or still meeting 80% of demand despite over 70% of pipes failing). GRA also reveals that increased resilience to one failure mode may decrease resilience to another and increasing system capacity may delay the system's recovery in some situations. It is also shown that selecting an appropriate level of detail for hydraulic models is of great importance in resilience analysis. The method can be used as a comprehensive diagnostic framework to evaluate a range of interventions for improving system resilience in future studies. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.
NASA Astrophysics Data System (ADS)
Zhu, Qi-Zhi
2017-02-01
A proper criterion describing when material fails is essential for deep understanding and constitutive modeling of rock damage and failure by microcracking. Physically, such a criterion should be the global effect of local mechanical response and microstructure evolution inside the material. This paper aims at deriving a new mechanisms-based failure criterion for brittle rocks, based on micromechanical unilateral damage-friction coupling analyses rather than on the basic results from the classical linear elastic fracture mechanics. The failure functions respectively describing three failure modes (purely tensile mode, tensile-shear mode as well as compressive-shear mode) are achieved in a unified upscaling framework and illustrated in the Mohr plane and also in the plane of principal stresses. The strength envelope is proved to be continuous and smooth with a compressive to tensile strength ratio dependent on material properties. Comparisons with experimental data are finally carried out. By this work, we also provide a theoretical evidence on the hybrid failure and the smooth transition from tensile failure to compressive-shear failure.
The assessment of low probability containment failure modes using dynamic PRA
NASA Astrophysics Data System (ADS)
Brunett, Acacia Joann
Although low probability containment failure modes in nuclear power plants may lead to large releases of radioactive material, these modes are typically crudely modeled in system level codes and have large associated uncertainties. Conventional risk assessment techniques (i.e. the fault-tree/event-tree methodology) are capable of accounting for these failure modes to some degree, however, they require the analyst to pre-specify the ordering of events, which can vary within the range of uncertainty of the phenomena. More recently, dynamic probabilistic risk assessment (DPRA) techniques have been developed which remove the dependency on the analyst. Through DPRA, it is now possible to perform a mechanistic and consistent analysis of low probability phenomena, with the timing of the possible events determined by the computational model simulating the reactor behavior. The purpose of this work is to utilize DPRA tools to assess low probability containment failure modes and the driving mechanisms. Particular focus is given to the risk-dominant containment failure modes considered in NUREG-1150, which has long been the standard for PRA techniques. More specifically, this work focuses on the low probability phenomena occurring during a station blackout (SBO) with late power recovery in the Zion Nuclear Power Plant, a Westinghouse pressurized water reactor (PWR). Subsequent to the major risk study performed in NUREG-1150, significant experimentation and modeling regarding the mechanisms driving containment failure modes have been performed. In light of this improved understanding, NUREG-1150 containment failure modes are reviewed in this work using the current state of knowledge. For some unresolved mechanisms, such as containment loading from high pressure melt ejection and combustion events, additional analyses are performed using the accident simulation tool MELCOR to explore the bounding containment loads for realistic scenarios. A dynamic treatment in the characterization of combustible gas ignition is also presented in this work. In most risk studies, combustion is treated simplistically in that it is assumed an ignition occurs if the gas mixture achieves a concentration favorable for ignition under the premise that an adequate ignition source is available. However, the criteria affecting ignition (such as the magnitude, location and frequency of the ignition sources) are complicated. This work demonstrates a technique for characterizing the properties of an ignition source to determine a probability of ignition. The ignition model developed in this work and implemented within a dynamic framework is utilized to analyze the implications and risk significance of late combustion events. This work also explores the feasibility of using dynamic event trees (DETs) with a deterministic sampling approach to analyze low probability phenomena. The flexibility of this approach is demonstrated through the rediscretization of containment fragility curves used in construction of the DET to show convergence to a true solution. Such a rediscretization also reduces the computational burden introduced through extremely fine fragility curve discretization by subsequent refinement of fragility curve regions of interest. Another advantage of the approach is the ability to perform sensitivity studies on the cumulative distribution functions (CDFs) used to determine branching probabilities without the need for rerunning the simulation code. Through review of the NUREG-1150 containment failure modes using the current state of knowledge, it is found that some failure modes, such as Alpha and rocket, can be excluded from further studies; other failure modes, such as failure to isolate, bypass, high pressure melt ejection (HPME), combustion-induced failure and overpressurization are still concerns to varying degrees. As part of this analysis, scoping studies performed in MELCOR show that HPME and the resulting direct containment heating (DCH) do not impose a significant threat to containment integrity. Additional scoping studies regarding the effect of recovery actions on in-vessel hydrogen generation show that reflooding a partially degraded core do not significantly affect hydrogen generation in-vessel, and the NUREG-1150 assumption that insufficient hydrogen is generated in-vessel to produce an energetic deflagration is confirmed. The DET analyses performed in this work show that very late power recovery produces the potential for very energetic combustion events which are capable of failing containment with a non-negligible probability, and that containment cooling systems have a significant impact on core concrete attack, and therefore combustible gas generation ex-vessel. Ultimately, the overall risk of combustion-induced containment failure is low, but its conditional likelihood can have a significant effect on accident mitigation strategies. It is also shown in this work that DETs are particularly well suited to examine low probability events because of their ability to rediscretize CDFs and observe solution convergence.
Modeling of sheet metal fracture via cohesive zone model and application to spot welds
NASA Astrophysics Data System (ADS)
Wu, Joseph Z.
Even though the cohesive zone model (CZM) has been widely used to analyze ductile fracture, it is not yet clearly understood how to calibrate the cohesive parameters including the specific work of separation (the work of separation per unit crack area) and the peak stress. A systematic approach is presented to first determine the cohesive values for sheet metal and then apply the calibrated model to various structure problems including the failure of spot welds. Al5754-0 was chosen for this study since it is not sensitive to heat treatment so the effect of heat-affected-zone (HAZ) can be ignored. The CZM has been applied to successfully model both mode-I and mode-III fracture for various geometries including Kahn specimens, single-notch specimens, and deep double-notch specimens for mode-I and trouser specimens for mode-III. The mode-I fracture of coach-peel spot-weld nugget and the mixed-mode fracture of nugget pull-out have also been well simulated by the CZM. Using the mode-I average specific work of separation of 13 kJ/m2 identified in a previous work and the mode-III specific work of separation of 38 kJ/m 2 found in this thesis, the cohesive peak stress has been determined to range from 285 MPa to 600 MPa for mode-I and from 165 MPa to 280 MPa for mode-III, depending on the degree of plastic deformation. The uncertainty of these cohesive values has also been examined. It is concluded that, if the specific work of separation is a material constant, the peak stress changes with the degree of plastic deformation and is therefore geometry-dependent.
Lightning Pin Injection Testing on MOSFETS
NASA Technical Reports Server (NTRS)
Ely, Jay J.; Nguyen, Truong X.; Szatkowski, George N.; Koppen, Sandra V.; Mielnik, John J.; Vaughan, Roger K.; Wysocki, Philip F.; Celaya, Jose R.; Saha, Sankalita
2009-01-01
Lightning transients were pin-injected into metal-oxide-semiconductor field-effect transistors (MOSFETs) to induce fault modes. This report documents the test process and results, and provides a basis for subsequent lightning tests. MOSFETs may be present in DC-DC power supplies and electromechanical actuator circuits that may be used on board aircraft. Results show that unprotected MOSFET Gates are susceptible to failure, even when installed in systems in well-shielded and partial-shielded locations. MOSFET Drains and Sources are significantly less susceptible. Device impedance decreased (current increased) after every failure. Such a failure mode may lead to cascading failures, as the damaged MOSFET may allow excessive current to flow through other circuitry. Preliminary assessments on a MOSFET subjected to 20-stroke pin-injection testing demonstrate that Breakdown Voltage, Leakage Current and Threshold Voltage characteristics show damage, while the device continues to meet manufacturer performance specifications. The purpose of this research is to develop validated tools, technologies, and techniques for automated detection, diagnosis and prognosis that enable mitigation of adverse events during flight, such as from lightning transients; and to understand the interplay between lightning-induced surges and aging (i.e. humidity, vibration thermal stress, etc.) on component degradation.
Post-Servicing Mission 4 Flux Calibration of the STIS Echelle Modes
NASA Astrophysics Data System (ADS)
Azalee Bostroem, K.; Aloisi, A.; Proffitt, C.; Osten, R.; Bohlin, R.
2011-01-01
STIS echelle modes show a wavelength-dependent decline in sensitivity with time. While this trend is observed in all STIS spectroscopic modes, the echelle sensitivity is further affected by a time-dependent shift in the blaze function. To improve the echelle flux calibration, new baselines for the echelle sensitivities are derived from post-Servicing Mission 4 (SM4) observations of the Hubble Space Telescope standard star G191-B2B. We present how these baseline sensitivities compare to pre-failure trends. Specifically, where the new results differ from expectations and discuss anomalous results found in E140H monitoring observations are highlighted.
Cycles till failure of silver-zinc cells with completing failures modes: Preliminary data analysis
NASA Technical Reports Server (NTRS)
Sidik, S. M.; Leibecki, H. F.; Bozek, J. M.
1980-01-01
One hundred and twenty nine cells were run through charge-discharge cycles until failure. The experiment design was a variant of a central composite factorial in five factors. Preliminary data analysis consisted of response surface estimation of life. Batteries fail under two basic modes; a low voltage condition and an internal shorting condition. A competing failure modes analysis using maximum likelihood estimation for the extreme value life distribution was performed. Extensive diagnostics such as residual plotting and probability plotting were employed to verify data quality and choice of model.
Failure Modes and Effects Analysis (FMEA): A Bibliography
NASA Technical Reports Server (NTRS)
2000-01-01
Failure modes and effects analysis (FMEA) is a bottom-up analytical process that identifies process hazards, which helps managers understand vulnerabilities of systems, as well as assess and mitigate risk. It is one of several engineering tools and techniques available to program and project managers aimed at increasing the likelihood of safe and successful NASA programs and missions. This bibliography references 465 documents in the NASA STI Database that contain the major concepts, failure modes or failure analysis, in either the basic index of the major subject terms.
Researchers at NREL Find Fewer Failures of PV Panels and Different
10, 2017 Overall failure rates for photovoltaic (PV) solar panels have fallen dramatically when Failures of PV Panels and Different Degradation Modes in Systems Installed after 2000 Researchers at NREL Find Fewer Failures of PV Panels and Different Degradation Modes in Systems Installed after 2000 April
Orbiter subsystem hardware/software interaction analysis. Volume 8: Forward reaction control system
NASA Technical Reports Server (NTRS)
Becker, D. D.
1980-01-01
The results of the orbiter hardware/software interaction analysis for the AFT reaction control system are presented. The interaction between hardware failure modes and software are examined in order to identify associated issues and risks. All orbiter subsystems and interfacing program elements which interact with the orbiter computer flight software are analyzed. The failure modes identified in the subsystem/element failure mode and effects analysis are discussed.
Evaluating the operational risks of biomedical waste using failure mode and effects analysis.
Chen, Ying-Chu; Tsai, Pei-Yi
2017-06-01
The potential problems and risks of biomedical waste generation have become increasingly apparent in recent years. This study applied a failure mode and effects analysis to evaluate the operational problems and risks of biomedical waste. The microbiological contamination of biomedical waste seldom receives the attention of researchers. In this study, the biomedical waste lifecycle was divided into seven processes: Production, classification, packaging, sterilisation, weighing, storage, and transportation. Twenty main failure modes were identified in these phases and risks were assessed based on their risk priority numbers. The failure modes in the production phase accounted for the highest proportion of the risk priority number score (27.7%). In the packaging phase, the failure mode 'sharp articles not placed in solid containers' had the highest risk priority number score, mainly owing to its high severity rating. The sterilisation process is the main difference in the treatment of infectious and non-infectious biomedical waste. The failure modes in the sterilisation phase were mainly owing to human factors (mostly related to operators). This study increases the understanding of the potential problems and risks associated with biomedical waste, thereby increasing awareness of how to improve the management of biomedical waste to better protect workers, the public, and the environment.
Ritchie, R O; Dauskardt, R H; Pennisi, F J
1992-01-01
A scanning electron microscopy study is reported of the nature and morphology of fracture surfaces in pyrocarbons commonly used for the manufacture of mechanical heart-valve prostheses. Specifically, silicon-alloyed low-temperature-isotropic (LTI)-pyrolytic carbon is examined, both as a coating on graphite and as a monolithic material, following overload, stress corrosion (static fatigue), and cyclic fatigue failures in a simulated physiological environment of 37 degrees C Ringer's solution. It is found that, in contrast to most metallic materials yet in keeping with many ceramics, there are no distinct fracture morphologies in pyro-carbons which are characteristic of a specific mode of loading; fracture surfaces appear to be identical for both catastrophic and subcritical crack growth under either sustained or cyclic loading. We conclude that caution should be used in assigning the likely cause of failure of pyrolytic carbon heart-valve components using fractographic examination.
Determination of Turbine Blade Life from Engine Field Data
NASA Technical Reports Server (NTRS)
Zaretsky, Erwin V.; Litt, Jonathan S.; Hendricks, Robert C.; Soditus, Sherry M.
2013-01-01
It is probable that no two engine companies determine the life of their engines or their components in the same way or apply the same experience and safety factors to their designs. Knowing the failure mode that is most likely to occur minimizes the amount of uncertainty and simplifies failure and life analysis. Available data regarding failure mode for aircraft engine blades, while favoring low-cycle, thermal-mechanical fatigue (TMF) as the controlling mode of failure, are not definitive. Sixteen high-pressure turbine (HPT) T-1 blade sets were removed from commercial aircraft engines that had been commercially flown by a single airline and inspected for damage. Each set contained 82 blades. The damage was cataloged into three categories related to their mode of failure: (1) TMF, (2) Oxidation/erosion (O/E), and (3) Other. From these field data, the turbine blade life was determined as well as the lives related to individual blade failure modes using Johnson-Weibull analysis. A simplified formula for calculating turbine blade life and reliability was formulated. The L10 blade life was calculated to be 2427 cycles (11 077 hr). The resulting blade life attributed to O/E equaled that attributed to TMF. The category that contributed most to blade failure was Other. If there were no blade failures attributed to O/E and TMF, the overall blade L(sub 10) life would increase approximately 11 to 17 percent.
Sonuga-Barke, Edmund J S; Castellanos, F Xavier
2007-01-01
In traditional accounts, fluctuations in sustained and focused attention and associated attentional lapses during task performance are regarded as the result of failures of top-down and effortful higher order processes. The current paper reviews an alternative hypothesis: that spontaneous patterns of very low frequency (<0.1 Hz) coherence within a specific brain network ('default-mode network') thought to support a pattern of generalized task-non-specific cognition during rest, can persist or intrude into periods of active task-specific processing, producing periodic fluctuations in attention that compete with goal-directed activity. We review recent studies supporting the existence of the resting state default network, examine the mechanism underpinning it, describe the consequent temporally distinctive effects on cognition and behaviour of default-mode interference into active processing periods, and suggest some factors that might predispose to it. Finally, we explore the putative role of default-mode interference as a cause of performance variability in attention deficit/hyperactivity disorder.
NASA Technical Reports Server (NTRS)
Bales, Thomas T.
1992-01-01
Vugraphs are presented to show the use of refractory materials for the skin of the High speed Civil Transport (HSCT). Examples are given of skin temperature ranges, failure mode weight distribution, tensile properties as a function of temperature, and components to be constructed from composite materials. The responsibilities of various aircraft companies for specific aircraft components are defined.
49 CFR Appendix C to Part 236 - Safety Assurance Criteria and Processes
Code of Federal Regulations, 2010 CFR
2010-10-01
... system (all its elements including hardware and software) must be designed to assure safe operation with... unsafe errors in the software due to human error in the software specification, design, or coding phases... (hardware or software, or both) are used in combination to ensure safety. If a common mode failure exists...
Scanning electron microscope fractography of induced fatigue-damaged saline breast implants.
Brandon, H J; Jerina, K L; Savoy, T L; Wolf, C J
2006-01-01
Breast implant strength and durability is presently an important topic in biomaterials science. Research studies are being conducted to determine the mechanisms and rates of failure in order to assess the in vivo performance of breast implants. Fatigue life is a measure of breast implant durability since fatigue failure is a potential in vivo failure mechanism. This study describes the characterization of the fracture surface morphology of breast implant shell regions that have failed due to cyclic fatigue. Saline breast implants were fatigue tested to failure using a laboratory apparatus in which flat plates cyclically compressed the implants. The implants were unimplanted control devices of both textured and smooth saline implants. The failure surfaces of the fatigued shells were examined using scanning electron microscopy (SEM). The morphological features of the failure surfaces are described for implants with short and long fatigue lifetimes. The details of both the inside and outside surfaces of the shell at the failure location are described. Two different modes of failure were observed in both the textured and smooth shells. These modes depend on the magnitude of the cyclic load and corresponding number of fatigue cycles at failure. The first mode is a tear in the shell of about 18 mm in length, and the second mode is a pinhole approximately 1 mm in diameter. Details of the surface morphology for these two types of failure modes and shell thickness data are presented herein. There was no significant change in the crosslink density of the shell as a result of fatigue.
NASA Technical Reports Server (NTRS)
Hovland, H. J.; Mitchell, J. K.
1971-01-01
The soil deformation mode under the action of a rolling sphere (boulder) was determined, and a theory based on actual soil failure mechanism was developed which provides a remote reconnaissance technique for study of soil conditions using boulder track observations. The failure mechanism was investigated by using models and by testing an instrumented spherical wheel. The wheel was specifically designed to measure contact pressure, but it also provided information on the failure mechanism. Further tests included rolling some 200 spheres down sand slopes. Films were taken of the rolling spheres, and the tracks were measured. Implications of the results and reevaluation of the lunar boulder tracks are discussed.
UAV Swarm Behavior Modeling for Early Exposure of Failure Modes
2016-09-01
Systems Center Atlantic, for his patience with me through this two-year process. He worked with my schedule and was very understanding of the...emergence of new failure modes? The MP modeling environment provides a breakdown of all potential event traces. Given that the research questions call...for the revelation of potential failure modes, MP was selected as the modeling environment because it provides a substantial set of results and data
Independent Orbiter Assessment (IOA): Analysis of the pyrotechnics subsystem
NASA Technical Reports Server (NTRS)
Robinson, W. W.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Pyrotechnics hardware. The IOA analysis process utilized available pyrotechnics hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
Simulation Assisted Risk Assessment: Blast Overpressure Modeling
NASA Technical Reports Server (NTRS)
Lawrence, Scott L.; Gee, Ken; Mathias, Donovan; Olsen, Michael
2006-01-01
A probabilistic risk assessment (PRA) approach has been developed and applied to the risk analysis of capsule abort during ascent. The PRA is used to assist in the identification of modeling and simulation applications that can significantly impact the understanding of crew risk during this potentially dangerous maneuver. The PRA approach is also being used to identify the appropriate level of fidelity for the modeling of those critical failure modes. The Apollo launch escape system (LES) was chosen as a test problem for application of this approach. Failure modes that have been modeled and/or simulated to date include explosive overpressure-based failure, explosive fragment-based failure, land landing failures (range limits exceeded either near launch or Mode III trajectories ending on the African continent), capsule-booster re-contact during separation, and failure due to plume-induced instability. These failure modes have been investigated using analysis tools in a variety of technical disciplines at various levels of fidelity. The current paper focuses on the development and application of a blast overpressure model for the prediction of structural failure due to overpressure, including the application of high-fidelity analysis to predict near-field and headwinds effects.
A bivariate model for analyzing recurrent multi-type automobile failures
NASA Astrophysics Data System (ADS)
Sunethra, A. A.; Sooriyarachchi, M. R.
2017-09-01
The failure mechanism in an automobile can be defined as a system of multi-type recurrent failures where failures can occur due to various multi-type failure modes and these failures are repetitive such that more than one failure can occur from each failure mode. In analysing such automobile failures, both the time and type of the failure serve as response variables. However, these two response variables are highly correlated with each other since the timing of failures has an association with the mode of the failure. When there are more than one correlated response variables, the fitting of a multivariate model is more preferable than separate univariate models. Therefore, a bivariate model of time and type of failure becomes appealing for such automobile failure data. When there are multiple failure observations pertaining to a single automobile, such data cannot be treated as independent data because failure instances of a single automobile are correlated with each other while failures among different automobiles can be treated as independent. Therefore, this study proposes a bivariate model consisting time and type of failure as responses adjusted for correlated data. The proposed model was formulated following the approaches of shared parameter models and random effects models for joining the responses and for representing the correlated data respectively. The proposed model is applied to a sample of automobile failures with three types of failure modes and up to five failure recurrences. The parametric distributions that were suitable for the two responses of time to failure and type of failure were Weibull distribution and multinomial distribution respectively. The proposed bivariate model was programmed in SAS Procedure Proc NLMIXED by user programming appropriate likelihood functions. The performance of the bivariate model was compared with separate univariate models fitted for the two responses and it was identified that better performance is secured by the bivariate model. The proposed model can be used to determine the time and type of failure that would occur in the automobiles considered here.
NASA Technical Reports Server (NTRS)
Packard, Michael H.
2002-01-01
Probabilistic Structural Analysis (PSA) is now commonly used for predicting the distribution of time/cycles to failure of turbine blades and other engine components. These distributions are typically based on fatigue/fracture and creep failure modes of these components. Additionally, reliability analysis is used for taking test data related to particular failure modes and calculating failure rate distributions of electronic and electromechanical components. How can these individual failure time distributions of structural, electronic and electromechanical component failure modes be effectively combined into a top level model for overall system evaluation of component upgrades, changes in maintenance intervals, or line replaceable unit (LRU) redesign? This paper shows an example of how various probabilistic failure predictions for turbine engine components can be evaluated and combined to show their effect on overall engine performance. A generic model of a turbofan engine was modeled using various Probabilistic Risk Assessment (PRA) tools (Quantitative Risk Assessment Software (QRAS) etc.). Hypothetical PSA results for a number of structural components along with mitigation factors that would restrict the failure mode from propagating to a Loss of Mission (LOM) failure were used in the models. The output of this program includes an overall failure distribution for LOM of the system. The rank and contribution to the overall Mission Success (MS) is also given for each failure mode and each subsystem. This application methodology demonstrates the effectiveness of PRA for assessing the performance of large turbine engines. Additionally, the effects of system changes and upgrades, the application of different maintenance intervals, inclusion of new sensor detection of faults and other upgrades were evaluated in determining overall turbine engine reliability.
Medication Safety of Five Oral Chemotherapies: A Proactive Risk Assessment
Weingart, Saul N.; Spencer, Justin; Buia, Stephanie; Duncombe, Deborah; Singh, Prabhjyot; Gadkari, Mrinalini; Connor, Maureen
2011-01-01
Purpose: Oral chemotherapies represent an emerging risk area in ambulatory oncology practice. To examine the hazards associated with five oral chemotherapies, we performed a proactive risk assessment. Methods: We convened interdisciplinary teams and conducted failure mode and effects analyses (FMEAs) for five oral chemotherapy agents: capecitabine, imatinib, temozolomide, 6-mercaptopurine, and an investigational agent. This involved the creation of process maps for each medication, identification of failure modes, selection of high-risk failure modes, and development of recommendations to mitigate these risks. We analyzed the number of steps and types of failure modes and compared this information across the study drugs. Results: Key vulnerabilities include patient education about drug handling and adverse effects, prescription writing, patient self-administration and medication adherence, and failure to monitor and manage toxicities. Many of these failure modes were common across the five oral chemotherapies, suggesting the presence of common targets for improvement. Streamlining the FMEA itself may promote the dissemination of this method. Conclusion: Each stage of the medication process poses risks to the safe use of oral chemotherapies. FMEAs may identify opportunities to improve medication safety and reduce the risk of patient harm. PMID:21532801
DOE Office of Scientific and Technical Information (OSTI.GOV)
Williams, M. W.
Type 308 CRE stainless steel weld specimens were subjected to metallographic and fractographic analysis after failure in elevated-temperature (593/sup 0/C) creep-fatigue tests. The failure mode for specimens tested under continuous-cycle fatigue conditions was predominantly transgranular. When the test cycle was modified to include a hold time at the maximum tensile strain, the failure mode became predominantly interphase. Sigma phase was observed within the delta-ferrite regions in the weld. However, the presence of sigma phase did not appear to affect the failure mode.
Preventing Spacecraft Failures Due to Tribological Problems
NASA Technical Reports Server (NTRS)
Fusaro, Robert L.
2001-01-01
Many mechanical failures that occur on spacecraft are caused by tribological problems. This publication presents a study that was conducted by the author on various preventatives, analyses, controls and tests (PACTs) that could be used to prevent spacecraft mechanical system failure. A matrix is presented in the paper that plots tribology failure modes versus various PACTs that should be performed before a spacecraft is launched in order to insure success. A strawman matrix was constructed by the author and then was sent out to industry and government spacecraft designers, scientists and builders of spacecraft for their input. The final matrix is the result of their input. In addition to the matrix, this publication describes the various PACTs that can be performed and some fundamental knowledge on the correct usage of lubricants for spacecraft applications. Even though the work was done specifically to prevent spacecraft failures the basic methodology can be applied to other mechanical system areas.
Compression failure of composite laminates
NASA Technical Reports Server (NTRS)
Pipes, R. B.
1983-01-01
This presentation attempts to characterize the compressive behavior of Hercules AS-1/3501-6 graphite-epoxy composite. The effect of varying specimen geometry on test results is examined. The transition region is determined between buckling and compressive failure. Failure modes are defined and analytical models to describe these modes are presented.
An improved method for risk evaluation in failure modes and effects analysis of CNC lathe
NASA Astrophysics Data System (ADS)
Rachieru, N.; Belu, N.; Anghel, D. C.
2015-11-01
Failure mode and effects analysis (FMEA) is one of the most popular reliability analysis tools for identifying, assessing and eliminating potential failure modes in a wide range of industries. In general, failure modes in FMEA are evaluated and ranked through the risk priority number (RPN), which is obtained by the multiplication of crisp values of the risk factors, such as the occurrence (O), severity (S), and detection (D) of each failure mode. However, the crisp RPN method has been criticized to have several deficiencies. In this paper, linguistic variables, expressed in Gaussian, trapezoidal or triangular fuzzy numbers, are used to assess the ratings and weights for the risk factors S, O and D. A new risk assessment system based on the fuzzy set theory and fuzzy rule base theory is to be applied to assess and rank risks associated to failure modes that could appear in the functioning of Turn 55 Lathe CNC. Two case studies have been shown to demonstrate the methodology thus developed. It is illustrated a parallel between the results obtained by the traditional method and fuzzy logic for determining the RPNs. The results show that the proposed approach can reduce duplicated RPN numbers and get a more accurate, reasonable risk assessment. As a result, the stability of product and process can be assured.
[Failure modes and effects analysis in the prescription, validation and dispensing process].
Delgado Silveira, E; Alvarez Díaz, A; Pérez Menéndez-Conde, C; Serna Pérez, J; Rodríguez Sagrado, M A; Bermejo Vicedo, T
2012-01-01
To apply a failure modes and effects analysis to the prescription, validation and dispensing process for hospitalised patients. A work group analysed all of the stages included in the process from prescription to dispensing, identifying the most critical errors and establishing potential failure modes which could produce a mistake. The possible causes, their potential effects, and the existing control systems were analysed to try and stop them from developing. The Hazard Score was calculated, choosing those that were ≥ 8, and a Severity Index = 4 was selected independently of the hazard Score value. Corrective measures and an implementation plan were proposed. A flow diagram that describes the whole process was obtained. A risk analysis was conducted of the chosen critical points, indicating: failure mode, cause, effect, severity, probability, Hazard Score, suggested preventative measure and strategy to achieve so. Failure modes chosen: Prescription on the nurse's form; progress or treatment order (paper); Prescription to incorrect patient; Transcription error by nursing staff and pharmacist; Error preparing the trolley. By applying a failure modes and effects analysis to the prescription, validation and dispensing process, we have been able to identify critical aspects, the stages in which errors may occur and the causes. It has allowed us to analyse the effects on the safety of the process, and establish measures to prevent or reduce them. Copyright © 2010 SEFH. Published by Elsevier Espana. All rights reserved.
Safety Strategies in an Academic Radiation Oncology Department and Recommendations for Action
Terezakis, Stephanie A.; Pronovost, Peter; Harris, Kendra; DeWeese, Theodore; Ford, Eric
2013-01-01
Background Safety initiatives in the United States continue to work on providing guidance as to how the average practitioner might make patients safer in the face of the complex process by which radiation therapy (RT), an essential treatment used in the management of many patients with cancer, is prepared and delivered. Quality control measures can uncover certain specific errors such as machine dose mis-calibration or misalignments of the patient in the radiation treatment beam. However, they are less effective at uncovering less common errors that can occur anywhere along the treatment planning and delivery process, and even when the process is functioning as intended, errors still occur. Prioritizing Risks and Implementing Risk-Reduction Strategies Activities undertaken at the radiation oncology department at the Johns Hopkins Hospital (Baltimore) include Failure Mode and Effects Analysis (FMEA), risk-reduction interventions, and voluntary error and near-miss reporting systems. A visual process map portrayed 269 RT steps occurring among four subprocesses—including consult, simulation, treatment planning, and treatment delivery. Two FMEAs revealed 127 and 159 possible failure modes, respectively. Risk-reduction interventions for 15 “top-ranked” failure modes were implemented. Since the error and near-miss reporting system’s implementation in the department in 2007, 253 events have been logged. However, the system may be insufficient for radiation oncology, for which a greater level of practice-specific information is required to fully understand each event. Conclusions The “basic science” of radiation treatment has received considerable support and attention in developing novel therapies to benefit patients. The time has come to apply the same focus and resources to ensuring that patients safely receive the maximal benefits possible. PMID:21819027
NASA Technical Reports Server (NTRS)
1974-01-01
Future operational concepts for the space transportation system were studied in terms of space shuttle upper stage failure contingencies possible during deployment, retrieval, or space servicing of automated satellite programs. Problems anticipated during mission planning were isolated using a modified 'fault tree' technique, normally used in safety analyses. A comprehensive space servicing hazard analysis is presented which classifies possible failure modes under the catagories of catastrophic collision, failure to rendezvous and dock, servicing failure, and failure to undock. The failure contingencies defined are to be taken into account during design of the upper stage.
Determination of Turbine Blade Life from Engine Field Data
NASA Technical Reports Server (NTRS)
Zaretsky, Erwin V.; Litt, Jonathan S.; Hendricks, Robert C.; Soditus, Sherry M.
2012-01-01
It is probable that no two engine companies determine the life of their engines or their components in the same way or apply the same experience and safety factors to their designs. Knowing the failure mode that is most likely to occur minimizes the amount of uncertainty and simplifies failure and life analysis. Available data regarding failure mode for aircraft engine blades, while favoring low-cycle, thermal mechanical fatigue as the controlling mode of failure, are not definitive. Sixteen high-pressure turbine (HPT) T-1 blade sets were removed from commercial aircraft engines that had been commercially flown by a single airline and inspected for damage. Each set contained 82 blades. The damage was cataloged into three categories related to their mode of failure: (1) Thermal-mechanical fatigue, (2) Oxidation/Erosion, and (3) "Other." From these field data, the turbine blade life was determined as well as the lives related to individual blade failure modes using Johnson-Weibull analysis. A simplified formula for calculating turbine blade life and reliability was formulated. The L(sub 10) blade life was calculated to be 2427 cycles (11 077 hr). The resulting blade life attributed to oxidation/erosion equaled that attributed to thermal-mechanical fatigue. The category that contributed most to blade failure was Other. If there were there no blade failures attributed to oxidation/erosion and thermal-mechanical fatigue, the overall blade L(sub 10) life would increase approximately 11 to 17 percent.
Independent Orbiter Assessment (IOA): Analysis of the communication and tracking subsystem
NASA Technical Reports Server (NTRS)
Gardner, J. R.; Robinson, W. M.; Trahan, W. H.; Daley, E. S.; Long, W. C.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Communication and Tracking hardware. The IOA analysis process utilized available Communication and Tracking hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
NASA Technical Reports Server (NTRS)
Schmeckpeper, K. R.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Electrical Power Distribution and Control (EPD and C) hardware. The EPD and C hardware performs the functions of distributing, sensing, and controlling 28 volt DC power and of inverting, distributing, sensing, and controlling 117 volt 400 Hz AC power to all Orbiter subsystems from the three fuel cells in the Electrical Power Generation (EPG) subsystem. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 1671 failure modes analyzed, 9 single failures were determined to result in loss of crew or vehicle. Three single failures unique to intact abort were determined to result in possible loss of the crew or vehicle. A possible loss of mission could result if any of 136 single failures occurred. Six of the criticality 1/1 failures are in two rotary and two pushbutton switches that control External Tank and Solid Rocket Booster separation. The other 6 criticality 1/1 failures are fuses, one each per Aft Power Control Assembly (APCA) 4, 5, and 6 and one each per Forward Power Control Assembly (FPCA) 1, 2, and 3, that supply power to certain Main Propulsion System (MPS) valves and Forward Reaction Control System (RCS) circuits.
NASA Technical Reports Server (NTRS)
1996-01-01
This Failure Modes and Effects Analysis (FMEA) is for the Advanced Microwave Sounding Unit-A (AMSU-A) instruments that are being designed and manufactured for the Meteorological Satellites Project (METSAT) and the Earth Observing System (EOS) integrated programs. The FMEA analyzes the design of the METSAT and EOS instruments as they currently exist. This FMEA is intended to identify METSAT and EOS failure modes and their effect on spacecraft-instrument and instrument-component interfaces. The prime objective of this FMEA is to identify potential catastrophic and critical failures so that susceptibility to the failures and their effects can be eliminated from the METSAT/EOS instruments.
Irradiation performance of HTGR recycle fissile fuel
DOE Office of Scientific and Technical Information (OSTI.GOV)
Homan, F.J.; Long, E.L. Jr.
1976-08-01
The irradiation performance of candidate HTGR recycle fissile fuel under accelerated testing conditions is reviewed. Failure modes for coated-particle fuels are described, and the performance of candidate recycle fissile fuels is discussed in terms of these failure modes. The bases on which UO/sub 2/ and (Th,U)O/sub 2/ were rejected as candidate recycle fissile fuels are outlined, along with the bases on which the weak-acid resin (WAR)-derived fissile fuel was selected as the reference recycle kernel. Comparisons are made relative to the irradiation behavior of WAR-derived fuels of varying stoichiometry and conclusions are drawn about the optimum stoichiometry and the rangemore » of acceptable values. Plans for future testing in support of specification development, confirmation of the results of accelerated testing by real-time experiments, and improvement in fuel performance and reliability are described.« less
CTS TEP thermal anomalies: Heat pipe system performance
NASA Technical Reports Server (NTRS)
Marcus, B. D.
1977-01-01
A part of the investigation is summarized of the thermal anomalies of the transmitter experiment package (TEP) on the Communications Technology Satellite (CTS) which were observed on four occasions in 1977. Specifically, the possible failure modes of the variable conductance heat pipe system (VCHPS) used for principal thermal control of the high-power traveling wave tube in the TEP are considered. Further, the investigation examines how those malfunctions may have given rise to the TEP thermal anomalies. Using CTS flight data information, ground test results, analysis conclusions, and other relevant information, the investigation concentrated on artery depriming as the most likely VCHPS failure mode. Included in the study as possible depriming mechanisms were freezing of the working fluid, Marangoni flow, and gas evolution within the arteries. The report concludes that while depriming of the heat pipe arteries is consistent with the bulk of the observed data, the factors which cause the arteries to deprime have yet to be identified.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Wong, S.; DiBiasio, A.; Gunther, W.
1993-09-01
The High Pressure Coolant Injection (HPCI) system has been examined from a risk perspective. A System Risk-Based Inspection Guide (S-RIG) has been developed as an aid to HPCI system inspections at the Browns Ferry Nuclear Power Plant, Units 1, 2 and 3. The role of. the HPCI system in mitigating accidents is discussed in this S-RIG, along with insights on identified risk-based failure modes which could prevent proper operation of the system. The S-RIG provides a review of industry-wide operating experience, including plant-specific illustrative examples to augment the PRA and operational considerations in identifying a catalogue of basic PRA failuremore » modes for the HPCI system. It is designed to be used as a reference for routine inspections, self-initiated safety system functional inspections (SSFIs), and the evaluation of risk significance of component failures at the nuclear power plant.« less
DOE Office of Scientific and Technical Information (OSTI.GOV)
Yang, F; Cao, N; Young, L
2014-06-15
Purpose: Though FMEA (Failure Mode and Effects Analysis) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge it has never been validated against actual incident learning data. The objective of this study was to perform an FMEA analysis of an SBRT (Stereotactic Body Radiation Therapy) treatment planning process and validate this against data recorded within an incident learning system. Methods: FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, and dosimetrists. Potential failure modes were identified through a systematic review of the workflow process. Failuremore » modes were rated for severity, occurrence, and detectability on a scale of 1 to 10 and RPN (Risk Priority Number) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that had been active for two years. Differences were identified. Results: FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. FMEA failed to anticipate 13 of these events, among which 3 were registered with severity ratings of severe or critical in the incident learning system. Combining both methods yielded a total of 76 failure modes, and when scored for RPN the 13 events missed by FMEA ranked within the middle half of all failure modes. Conclusion: FMEA, though valuable, is subject to certain limitations, among them the limited ability to anticipate all potential errors for a given process. This FMEA exercise failed to identify a significant number of possible errors (17%). Integration of FMEA with retrospective incident data may be able to render an improved overview of risks within a process.« less
Compression failure of angle-ply laminates
NASA Technical Reports Server (NTRS)
Peel, Larry D.; Hyer, Michael W.; Shuart, Mark J.
1991-01-01
The present work deals with modes and mechanisms of failure in compression of angle-ply laminates. Experimental results were obtained from 42 angle-ply IM7/8551-7a specimens with a lay-up of ((plus or minus theta)/(plus or minus theta)) sub 6s where theta, the off-axis angle, ranged from 0 degrees to 90 degrees. The results showed four failure modes, these modes being a function of off-axis angle. Failure modes include fiber compression, inplane transverse tension, inplane shear, and inplane transverse compression. Excessive interlaminar shear strain was also considered as an important mode of failure. At low off-axis angles, experimentally observed values were considerably lower than published strengths. It was determined that laminate imperfections in the form of layer waviness could be a major factor in reducing compression strength. Previously developed linear buckling and geometrically nonlinear theories were used, with modifications and enhancements, to examine the influence of layer waviness on compression response. The wavy layer is described by a wave amplitude and a wave length. Linear elastic stress-strain response is assumed. The geometrically nonlinear theory, in conjunction with the maximum stress failure criterion, was used to predict compression failure and failure modes for the angle-ply laminates. A range of wave length and amplitudes were used. It was found that for 0 less than or equal to theta less than or equal to 15 degrees failure was most likely due to fiber compression. For 15 degrees less than theta less than or equal to 35 degrees, failure was most likely due to inplane transverse tension. For 35 degrees less than theta less than or equal to 70 degrees, failure was most likely due to inplane shear. For theta less than 70 degrees, failure was most likely due to inplane transverse compression. The fiber compression and transverse tension failure modes depended more heavily on wave length than on wave amplitude. Thus using a single parameter, such as a ratio of wave amplitude to wave length, to describe waviness in a laminate would be inaccurate. Throughout, results for AS4/3502, studied previously, are included for comparison. At low off-axis angles, the AS4/3502 material system was found to be less sensitive to layer waviness than IM7/8551-7a. Analytical predictions were also obtained for laminates with waviness in only some of the layers. For this type of waviness, laminate compression strength could also be considered a function of which layers in the laminate were wavy, and where those wavy layers were. Overall, the geometrically nonlinear model correlates well with experimental results.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Cheong, S-K; Kim, J
Purpose: The aim of the study is the application of a Failure Modes and Effects Analysis (FMEA) to access the risks for patients undergoing a Low Dose Rate (LDR) Prostate Brachytherapy Treatment. Methods: FMEA was applied to identify all the sub processes involved in the stages of identifying patient, source handling, treatment preparation, treatment delivery, and post treatment. These processes characterize the radiation treatment associated with LDR Prostate Brachytherapy. The potential failure modes together with their causes and effects were identified and ranked in order of their importance. Three indexes were assigned for each failure mode: the occurrence rating (O),more » the severity rating (S), and the detection rating (D). A ten-point scale was used to score each category, ten being the number indicating most severe, most frequent, and least detectable failure mode, respectively. The risk probability number (RPN) was calculated as a product of the three attributes: RPN = O X S x D. The analysis was carried out by a working group (WG) at UPMC. Results: The total of 56 failure modes were identified including 32 modes before the treatment, 13 modes during the treatment, and 11 modes after the treatment. In addition to the protocols already adopted in the clinical practice, the prioritized risk management will be implanted to the high risk procedures on the basis of RPN score. Conclusion: The effectiveness of the FMEA method was established. The FMEA methodology provides a structured and detailed assessment method for the risk analysis of the LDR Prostate Brachytherapy Procedure and can be applied to other radiation treatment modes.« less
Microstructure-failure mode correlations in braided composites
NASA Technical Reports Server (NTRS)
Filatovs, G. J.; Sadler, Robert L.; El-Shiekh, Aly
1992-01-01
Explication of the fracture processes of braided composites is needed for modeling their behavior. Described is a systematic exploration of the relationship between microstructure, loading mode, and micro-failure mechanisms in carbon/epoxy braided composites. The study involved compression and fracture toughness tests and optical and scanning electron fractography, including dynamic in-situ testing. Principal failure mechanisms of low sliding, buckling, and unstable crack growth are correlated to microstructural parameters and loading modes; these are used for defining those microstructural conditions which are strength limiting.
Chapter 3: Photovoltaic Module Stability and Reliability
DOE Office of Scientific and Technical Information (OSTI.GOV)
Jordan, Dirk; Kurtz, Sarah
2017-01-01
Profits realized from investment in photovoltaic will benefit from decades of reliable operation. Service life prediction through accelerated tests is only possible if indoor tests duplicate power loss and failure modes observed in fielded systems. Therefore, detailing and quantifying power loss and failure modes is imperative. In the first section, we examine recent trends in degradation rates, the gradual power loss observed for different technologies, climates and other significant factors. In the second section, we provide a summary of the most commonly observed failure modes in fielded systems.
Design of Multiple Bolted Connections for Laminated Veneer Lumber
Borjen Yeh; Douglas Rammer; Jeff Linville
2014-01-01
The design of multiple bolted connections in accordance with Appendix E of the National Design Specification for Wood Construction (NDS) has incorporated provisions for evaluating localized member failure modes of row and group tear-out when the connections are closely spaced. Originally based on structural glued laminated timber (glulam) members made with all L1...
Availability Estimate of a Conceptual ESM System.
1979-06-01
affect mission operation.t A functional block level failure modes and effects analysis ( FMEA ) performed on the filter resulted in an assessed failure rate...is based on an FMEA of failures that disable the function (see Appendix A). A further 29 examination of the filter piece-parts reveals that the driver...Digital-to-analog converter DC Direct current DF Direction finding ESM Electronic Support Measures FMEA Failure modes and effects analysis FMPO
Peridynamics for failure and residual strength prediction of fiber-reinforced composites
NASA Astrophysics Data System (ADS)
Colavito, Kyle
Peridynamics is a reformulation of classical continuum mechanics that utilizes integral equations in place of partial differential equations to remove the difficulty in handling discontinuities, such as cracks or interfaces, within a body. Damage is included within the constitutive model; initiation and propagation can occur without resorting to special crack growth criteria necessary in other commonly utilized approaches. Predicting damage and residual strengths of composite materials involves capturing complex, distinct and progressive failure modes. The peridynamic laminate theory correctly predicts the load redistribution in general laminate layups in the presence of complex failure modes through the use of multiple interaction types. This study presents two approaches to obtain the critical peridynamic failure parameters necessary to capture the residual strength of a composite structure. The validity of both approaches is first demonstrated by considering the residual strength of isotropic materials. The peridynamic theory is used to predict the crack growth and final failure load in both a diagonally loaded square plate with a center crack, as well as a four-point shear specimen subjected to asymmetric loading. This study also establishes the validity of each approach by considering composite laminate specimens in which each failure mode is isolated. Finally, the failure loads and final failure modes are predicted in a laminate with various hole diameters subjected to tensile and compressive loads.
Independent Orbiter Assessment (IOA): Analysis of the auxiliary power unit
NASA Technical Reports Server (NTRS)
Barnes, J. E.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Auxiliary Power Unit (APU). The APUs are required to provide power to the Orbiter hydraulics systems during ascent and entry flight phases for aerosurface actuation, main engine gimballing, landing gear extension, and other vital functions. For analysis purposes, the APU system was broken down into ten functional subsystems. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. A preponderance of 1/1 criticality items were related to failures that allowed the hydrazine fuel to escape into the Orbiter aft compartment, creating a severe fire hazard, and failures that caused loss of the gas generator injector cooling system.
Ply-level failure analysis of a graphite/epoxy laminate under bearing-bypass loading
NASA Technical Reports Server (NTRS)
Naik, R. A.; Crews, J. H., Jr.
1988-01-01
A combined experimental and analytical study was conducted to investigate and predict the failure modes of a graphite/epoxy laminate subjected to combined bearing and bypass loading. Tests were conducted in a test machine that allowed the bearing-bypass load ratio to be controlled while a single-fastener coupon was loaded to failure in either tension or compression. Onset and ultimate failure modes and strengths were determined for each test case. The damage-onset modes were studied in detail by sectioning and micrographing the damaged specimens. A two-dimensional, finite-element analysis was conducted to determine lamina strains around the bolt hole. Damage onset consisted of matrix cracks, delamination, and fiber failures. Stiffness loss appeared to be caused by fiber failures rather than by matrix cracking and delamination. An unusual offset-compression mode was observed for compressive bearing-bypass laoding in which the specimen failed across its width along a line offset from the hole. The computed lamina strains in the fiber direction were used in a combined analytical and experimental approach to predict bearing-bypass diagrams for damage onset from a few simple tests.
Ply-level failure analysis of a graphite/epoxy laminate under bearing-bypass loading
NASA Technical Reports Server (NTRS)
Naik, R. A.; Crews, J. H., Jr.
1990-01-01
A combined experimental and analytical study was conducted to investigate and predict the failure modes of a graphite/epoxy laminate subjected to combined bearing and bypass loading. Tests were conducted in a test machine that allowed the bearing-bypass load ratio to be controlled while a single-fastener coupon was loaded to failure in either tension or compression. Onset and ultimate failure modes and strengths were determined for each test case. The damage-onset modes were studied in detail by sectioning and micrographing the damaged specimens. A two-dimensional, finite-element analysis was conducted to determine lamina strains around the bolt hole. Damage onset consisted of matrix cracks, delamination, and fiber failures. Stiffness loss appeared to be caused by fiber failures rather than by matrix cracking and delamination. An unusual offset-compression mode was observed for compressive bearing-bypass loading in which the specimen failed across its width along a line offset from the hole. The computed lamina strains in the fiber direction were used in a combined analytical and experimental approach to predict bearing-bypass diagrams for damage onset from a few simple tests.
Independent Orbiter Assessment (IOA): Assessment of the mechanical actuation subsystem, volume 2
NASA Technical Reports Server (NTRS)
Bradway, M. W.; Slaughter, W. T.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine draft failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the proposed Post 51-L NASA FMEA/CIL baseline that was available. A resolution of each discrepancy from the comparison was provided through additional analysis as required. These discrepancies were flagged as issues, and recommendations were made based on the FMEA data available at the time. This report documents the results of that comparison for the Orbiter Mechanical Actuation System (MAS) hardware. Specifically, the MAS hardware consists of the following components: Air Data Probe (ADP); Elevon Seal Panel (ESP); External Tank Umbilical (ETU); Ku-Band Deploy (KBD); Payload Bay Doors (PBD); Payload Bay Radiators (PBR); Personnel Hatches (PH); Vent Door Mechanism (VDM); and Startracker Door Mechanism (SDM). Criticality was assigned based upon the severity of the effect for each failure mode. Volume 2 continues the presentation of IOA analysis worksheets and contains the potential critical items list, detailed analysis, and NASA FMEA/CIL to IOA worksheet cross reference and recommendations.
A failure modes and effects analysis study for gynecologic high-dose-rate brachytherapy.
Mayadev, Jyoti; Dieterich, Sonja; Harse, Rick; Lentz, Susan; Mathai, Mathew; Boddu, Sunita; Kern, Marianne; Courquin, Jean; Stern, Robin L
2015-01-01
To improve the quality of our gynecologic brachytherapy practice and reduce reportable events, we performed a process analysis after the failure modes and effects analysis (FMEA). The FMEA included a multidisciplinary team specifically targeting the tandem and ring brachytherapy procedure. The treatment process was divided into six subprocesses and failure modes (FMs). A scoring guideline was developed based on published FMEA studies and assigned through team consensus. FMs were ranked according to overall and severity scores. FM ranking >5% of the highest risk priority number (RPN) score was selected for in-depth analysis. The efficiency of each existing quality assurance to detect each FM was analyzed. We identified 170 FMs, and 99 were scored. RPN scores ranged from 1 to 192. Of the 13 highest-ranking FMs with RPN scores >80, half had severity scores of 8 or 9, with no mode having severity of 10. Of these FM, the originating process steps were simulation (5), treatment planning (5), treatment delivery (2), and insertion (1). Our high-ranking FM focused on communication and the potential for applicator movement. Evaluation of the efficiency and the comprehensiveness of our quality assurance program showed coverage of all but three of the top 49 FMs ranked by RPN. This is the first reported FMEA process for a comprehensive gynecologic brachytherapy procedure overview. We were able to identify FMs that could potentially and severely impact the patient's treatment. We continue to adjust our quality assurance program based on the results of our FMEA analysis. Published by Elsevier Inc.
Modelling the failure behaviour of wind turbines
NASA Astrophysics Data System (ADS)
Faulstich, S.; Berkhout, V.; Mayer, J.; Siebenlist, D.
2016-09-01
Modelling the failure behaviour of wind turbines is an essential part of offshore wind farm simulation software as it leads to optimized decision making when specifying the necessary resources for the operation and maintenance of wind farms. In order to optimize O&M strategies, a thorough understanding of a wind turbine's failure behaviour is vital and is therefore being developed at Fraunhofer IWES. Within this article, first the failure models of existing offshore O&M tools are presented to show the state of the art and strengths and weaknesses of the respective models are briefly discussed. Then a conceptual framework for modelling different failure mechanisms of wind turbines is being presented. This framework takes into account the different wind turbine subsystems and structures as well as the failure modes of a component by applying several influencing factors representing wear and break failure mechanisms. A failure function is being set up for the rotor blade as exemplary component and simulation results have been compared to a constant failure rate and to empirical wind turbine fleet data as a reference. The comparison and the breakdown of specific failure categories demonstrate the overall plausibility of the model.
NASA Astrophysics Data System (ADS)
Ahn, Junkeon; Noh, Yeelyong; Park, Sung Ho; Choi, Byung Il; Chang, Daejun
2017-10-01
This study proposes a fuzzy-based FMEA (failure mode and effect analysis) for a hybrid molten carbonate fuel cell and gas turbine system for liquefied hydrogen tankers. An FMEA-based regulatory framework is adopted to analyze the non-conventional propulsion system and to understand the risk picture of the system. Since the participants of the FMEA rely on their subjective and qualitative experiences, the conventional FMEA used for identifying failures that affect system performance inevitably involves inherent uncertainties. A fuzzy-based FMEA is introduced to express such uncertainties appropriately and to provide flexible access to a risk picture for a new system using fuzzy modeling. The hybrid system has 35 components and has 70 potential failure modes, respectively. Significant failure modes occur in the fuel cell stack and rotary machine. The fuzzy risk priority number is used to validate the crisp risk priority number in the FMEA.
Utility of Failure Mode and Effect Analysis to Improve Safety in Suctioning by Orotracheal Tube.
Vázquez-Valencia, Agustín; Santiago-Sáez, Andrés; Perea-Pérez, Bernardo; Labajo-González, Elena; Albarrán-Juan, Maria Elena
2017-02-01
The objective of the study was to use the Failure Mode and Effect Analysis (FMEA) tool to analyze the technique of secretion suctioning on patients with an endotracheal tube who were admitted into an intensive care unit. Brainstorming was carried out within the service to determine the potential errors most frequent in the process. After this, the FMEA was applied, including its stages, prioritizing risk in accordance with the risk prioritization number (RPN), selecting improvement actions in which they have an RPN of more than 300. We obtained 32 failure modes, of which 13 surpassed an RPN of 300. After our result, 21 improvement actions were proposed for those failure modes with RPN scores above 300. FMEA allows us to ascertain possible failures so as to later propose improvement actions for those which have an RPN of more than 300. Copyright © 2016 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Sounds of Failure: Passive Acoustic Measurements of Excited Vibrational Modes
NASA Astrophysics Data System (ADS)
Brzinski, Theodore A.; Daniels, Karen E.
2018-05-01
Granular materials can fail through spontaneous events like earthquakes or brittle fracture. However, measurements and analytic models which forecast failure in this class of materials, while of both fundamental and practical interest, remain elusive. Materials including numerical packings of spheres, colloidal glasses, and granular materials have been known to develop an excess of low-frequency vibrational modes as the confining pressure is reduced. Here, we report experiments on sheared granular materials in which we monitor the evolving density of excited modes via passive monitoring of acoustic emissions. We observe a broadening of the distribution of excited modes coincident with both bulk and local plasticity, and evolution in the shape of the distribution before and after bulk failure. These results provide a new interpretation of the changing state of the material on its approach to stick-slip failure.
Sounds of Failure: Passive Acoustic Measurements of Excited Vibrational Modes.
Brzinski, Theodore A; Daniels, Karen E
2018-05-25
Granular materials can fail through spontaneous events like earthquakes or brittle fracture. However, measurements and analytic models which forecast failure in this class of materials, while of both fundamental and practical interest, remain elusive. Materials including numerical packings of spheres, colloidal glasses, and granular materials have been known to develop an excess of low-frequency vibrational modes as the confining pressure is reduced. Here, we report experiments on sheared granular materials in which we monitor the evolving density of excited modes via passive monitoring of acoustic emissions. We observe a broadening of the distribution of excited modes coincident with both bulk and local plasticity, and evolution in the shape of the distribution before and after bulk failure. These results provide a new interpretation of the changing state of the material on its approach to stick-slip failure.
Failure mode and effect analysis in blood transfusion: a proactive tool to reduce risks.
Lu, Yao; Teng, Fang; Zhou, Jie; Wen, Aiqing; Bi, Yutian
2013-12-01
The aim of blood transfusion risk management is to improve the quality of blood products and to assure patient safety. We utilize failure mode and effect analysis (FMEA), a tool employed for evaluating risks and identifying preventive measures to reduce the risks in blood transfusion. The failure modes and effects occurring throughout the whole process of blood transfusion were studied. Each failure mode was evaluated using three scores: severity of effect (S), likelihood of occurrence (O), and probability of detection (D). Risk priority numbers (RPNs) were calculated by multiplying the S, O, and D scores. The plan-do-check-act cycle was also used for continuous improvement. Analysis has showed that failure modes with the highest RPNs, and therefore the greatest risk, were insufficient preoperative assessment of the blood product requirement (RPN, 245), preparation time before infusion of more than 30 minutes (RPN, 240), blood transfusion reaction occurring during the transfusion process (RPN, 224), blood plasma abuse (RPN, 180), and insufficient and/or incorrect clinical information on request form (RPN, 126). After implementation of preventative measures and reassessment, a reduction in RPN was detected with each risk. The failure mode with the second highest RPN, namely, preparation time before infusion of more than 30 minutes, was shown in detail to prove the efficiency of this tool. FMEA evaluation model is a useful tool in proactively analyzing and reducing the risks associated with the blood transfusion procedure. © 2013 American Association of Blood Banks.
Fatigue failure of pb-free electronic packages under random vibration loads
NASA Astrophysics Data System (ADS)
Saravanan, S.; Prabhu, S.; Muthukumar, R.; Gowtham Raj, S.; Arun Veerabagu, S.
2018-03-01
The electronic equipment are used in several fields like, automotive, aerospace, consumer goods where they are subjected to vibration loads leading to failure of solder joints used in these equipment. This paper presents a methodology to predict the fatigue life of Pb-free surface mounted BGA packages subjected to random vibrations. The dynamic characteristics of the PCB, such as the natural frequencies, mode shapes and damping ratios were determined. Spectrum analysis was used to determine the stress response of the critical solder joint and the cumulative fatigue damage accumulated by the solder joint for a specific duration was determined.
Failure mechanism of hollow tree trunks due to cross-sectional flattening
Huang, Yan-San; Hsu, Fu-Lan; Lee, Chin-Mei
2017-01-01
Failure of hollow trees in urban areas is a worldwide concern, and it can be caused by different mechanisms, i.e. bending stresses or flattening-related failures. Here we derive a new analytical expression for predicting the bending moment for tangential cracking, and compare the breaking moment of various failure modes, including Brazier buckling, tangential cracking, shear failure and conventional bending failure, as a function of t/R ratio, where t and R are the trunk wall thickness and trunk radius, respectively, of a hollow tree. We use Taiwan red cypress as an example and show that its failure modes and the corresponding t/R ratios are: Brazier buckling (Mode I), tangential cracking followed by longitudinal splitting (Mode II) and conventional bending failure (Mode III) for 0 < t/R < 0.06, 0.06 < t/R < 0.27 and 0.27 < t/R < 1, respectively. The exact values of those ratios may vary within and among species, but the variation is much smaller than individual mechanical properties. Also, shear failure, another type of cracking due to maximum shear stress near the neutral axis of the tree trunk, is unlikely to occur since it requires much larger bending moments. Hence, we conclude that tangential cracking due to cross-sectional flattening, followed by longitudinal splitting, is dominant for hollow trunks. Our equations are applicable to analyse straight hollow tree trunks and plant stems, but are not applicable to those with side openings or those with only heart decay. Our findings provide insights for those managing trees in urban situations and those managing for conservation of hollow-dependent fauna in both urban and rural settings. PMID:28484616
Yousefinezhadi, Taraneh; Jannesar Nobari, Farnaz Attar; Goodari, Faranak Behzadi; Arab, Mohammad
2016-01-01
Introduction: In any complex human system, human error is inevitable and shows that can’t be eliminated by blaming wrong doers. So with the aim of improving Intensive Care Units (ICU) reliability in hospitals, this research tries to identify and analyze ICU’s process failure modes at the point of systematic approach to errors. Methods: In this descriptive research, data was gathered qualitatively by observations, document reviews, and Focus Group Discussions (FGDs) with the process owners in two selected ICUs in Tehran in 2014. But, data analysis was quantitative, based on failures’ Risk Priority Number (RPN) at the base of Failure Modes and Effects Analysis (FMEA) method used. Besides, some causes of failures were analyzed by qualitative Eindhoven Classification Model (ECM). Results: Through FMEA methodology, 378 potential failure modes from 180 ICU activities in hospital A and 184 potential failures from 99 ICU activities in hospital B were identified and evaluated. Then with 90% reliability (RPN≥100), totally 18 failures in hospital A and 42 ones in hospital B were identified as non-acceptable risks and then their causes were analyzed by ECM. Conclusions: Applying of modified PFMEA for improving two selected ICUs’ processes reliability in two different kinds of hospitals shows that this method empowers staff to identify, evaluate, prioritize and analyze all potential failure modes and also make them eager to identify their causes, recommend corrective actions and even participate in improving process without feeling blamed by top management. Moreover, by combining FMEA and ECM, team members can easily identify failure causes at the point of health care perspectives. PMID:27157162
NASA Technical Reports Server (NTRS)
Jegley, Dawn C.; Lopez, Osvaldo F.
1991-01-01
Experimentally determined axial compressive failure loads, strains and failure modes of composite flat panels and cylinders are presented. A comparison of two types of filament wound flat graphite-epoxy panels indicates that the winding pattern can influence structural response. A comparison of hand laid-up tape and filament wound composite cylinders indicates that fabrication method may not significantly influence the failure mode or average failure strain of thick-walled (radius-to-thickness ratio less than 15) graphite-epoxy cylinders. The interaction of manufacturing-induced features (fiber cross-overs) and low-speed impact damage for graphite-epoxy specimens is also presented. Filament would flat panels with many fiber cross-overs exhibited lower failure strains than filament wound panels without fiber cross-overs for all impact speeds examined. Graphite-thermoplastic cylinders exhibited a significantly different failure mode from the graphite-epoxy cylinders.
Independent Orbiter Assessment (IOA): Analysis of the active thermal control subsystem
NASA Technical Reports Server (NTRS)
Sinclair, S. K.; Parkman, W. E.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical (PCIs) items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results corresponding to the Orbiter Active Thermal Control Subsystem (ATCS) are documented. The major purpose of the ATCS is to remove the heat, generated during normal Shuttle operations from the Orbiter systems and subsystems. The four major components of the ATCS contributing to the heat removal are: Freon Coolant Loops; Radiator and Flow Control Assembly; Flash Evaporator System; and Ammonia Boiler System. In order to perform the analysis, the IOA process utilized available ATCS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 310 failure modes analyzed, 101 were determined to be PCIs.
Independent Orbiter Assessment (IOA): Analysis of the hydraulics/water spray boiler subsystem
NASA Technical Reports Server (NTRS)
Duval, J. D.; Davidson, W. R.; Parkman, William E.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results for the Orbiter Hydraulics/Water Spray Boiler Subsystem. The hydraulic system provides hydraulic power to gimbal the main engines, actuate the main engine propellant control valves, move the aerodynamic flight control surfaces, lower the landing gear, apply wheel brakes, steer the nosewheel, and dampen the external tank (ET) separation. Each hydraulic system has an associated water spray boiler which is used to cool the hydraulic fluid and APU lubricating oil. The IOA analysis process utilized available HYD/WSB hardware drawings, schematics and documents for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Of the 430 failure modes analyzed, 166 were determined to be PCIs.
NASA Astrophysics Data System (ADS)
Song, Lu-Kai; Wen, Jie; Fei, Cheng-Wei; Bai, Guang-Chen
2018-05-01
To improve the computing efficiency and precision of probabilistic design for multi-failure structure, a distributed collaborative probabilistic design method-based fuzzy neural network of regression (FR) (called as DCFRM) is proposed with the integration of distributed collaborative response surface method and fuzzy neural network regression model. The mathematical model of DCFRM is established and the probabilistic design idea with DCFRM is introduced. The probabilistic analysis of turbine blisk involving multi-failure modes (deformation failure, stress failure and strain failure) was investigated by considering fluid-structure interaction with the proposed method. The distribution characteristics, reliability degree, and sensitivity degree of each failure mode and overall failure mode on turbine blisk are obtained, which provides a useful reference for improving the performance and reliability of aeroengine. Through the comparison of methods shows that the DCFRM reshapes the probability of probabilistic analysis for multi-failure structure and improves the computing efficiency while keeping acceptable computational precision. Moreover, the proposed method offers a useful insight for reliability-based design optimization of multi-failure structure and thereby also enriches the theory and method of mechanical reliability design.
Numerical simulation of failure behavior of granular debris flows based on flume model tests.
Zhou, Jian; Li, Ye-xun; Jia, Min-cai; Li, Cui-na
2013-01-01
In this study, the failure behaviors of debris flows were studied by flume model tests with artificial rainfall and numerical simulations (PFC(3D)). Model tests revealed that grain sizes distribution had profound effects on failure mode, and the failure in slope of medium sand started with cracks at crest and took the form of retrogressive toe sliding failure. With the increase of fine particles in soil, the failure mode of the slopes changed to fluidized flow. The discrete element method PFC(3D) can overcome the hypothesis of the traditional continuous medium mechanic and consider the simple characteristics of particle. Thus, a numerical simulations model considering liquid-solid coupled method has been developed to simulate the debris flow. Comparing the experimental results, the numerical simulation result indicated that the failure mode of the failure of medium sand slope was retrogressive toe sliding, and the failure of fine sand slope was fluidized sliding. The simulation result is consistent with the model test and theoretical analysis, and grain sizes distribution caused different failure behavior of granular debris flows. This research should be a guide to explore the theory of debris flow and to improve the prevention and reduction of debris flow.
Instrumentation Cables Test Plan
DOE Office of Scientific and Technical Information (OSTI.GOV)
Muna, Alice Baca; LaFleur, Chris Bensdotter
A fire at a nuclear power plant (NPP) has the potential to damage structures, systems, and components important to safety, if not promptly detected and suppressed. At Browns Ferry Nuclear Power Plant on March 22, 1975, a fire in the reactor building damaged electrical power and control systems. Damage to instrumentation cables impeded the function of both normal and standby reactor coolant systems, and degraded the operators’ plant monitoring capability. This event resulted in additional NRC involvement with utilities to ensure that NPPs are properly protected from fire as intended by the NRC principle design criteria (i.e., general design criteriamore » 3, Fire Protection). Current guidance and methods for both deterministic and performance based approaches typically make conservative (bounding) assumptions regarding the fire-induced failure modes of instrumentation cables and those failure modes effects on component and system response. Numerous fire testing programs have been conducted in the past to evaluate the failure modes and effects of electrical cables exposed to severe thermal conditions. However, that testing has primarily focused on control circuits with only a limited number of tests performed on instrumentation circuits. In 2001, the Nuclear Energy Institute (NEI) and the Electric Power Research Institute (EPRI) conducted a series of cable fire tests designed to address specific aspects of the cable failure and circuit fault issues of concern1. The NRC was invited to observe and participate in that program. The NRC sponsored Sandia National Laboratories to support this participation, whom among other things, added a 4-20 mA instrumentation circuit and instrumentation cabling to six of the tests. Although limited, one insight drawn from those instrumentation circuits tests was that the failure characteristics appeared to depend on the cable insulation material. The results showed that for thermoset insulated cables, the instrument reading tended to drift and fluctuate, while the thermoplastic insulated cables, the instrument reading fell off-scale rapidly. From an operational point of view, the latter failure characteristics would likely be identified as a failure from the effects of fire, while the former may result in inaccurate readings.« less
Future research directions to improve fistula maturation and reduce access failure
Hu, Haidi; Patel, Sandeep; Hanisch, Jesse J.; Santana, Jeans M.; Hashimoto, Takuya; Bai, Hualong; Kudze, Tambudzai; Foster, Trenton R.; Guo, Jianming; Yatsula, Bogdan; Tsui, Janice; Dardik, Alan
2016-01-01
With the increasing prevalence of end stage renal disease there is a growing need for hemodialysis. Arteriovenous fistulae (AVF) are the preferred type of vascular access for hemodialysis but maturation and failure continue to present significant barriers to successful fistula use. AVF maturation integrates outward remodeling with vessel wall thickening in response to drastic hemodynamic changes, in the setting of uremia, systemic inflammation, oxidative stress and preexistent vascular pathology. AVF can fail due to both failure to mature adequately to support hemodialysis, as well as development of neointimal hyperplasia (NIH) that narrows the AVF lumen, typically near the fistula anastomosis. Failure due to NIH involves vascular cell activation and migration and extracellular matrix remodeling with complex interactions of growth factors, adhesion molecules, inflammatory mediators, and chemokines, all of which result in maladaptive remodeling. Different strategies have been proposed to prevent and treat AVF failure, based on current understanding of the modes and pathology of access failure; these approaches range from appropriate patient selection and use of alternative surgical strategies for fistula creation, to the use of novel interventional techniques or drugs to treat failing fistulae. Effective treatments to prevent or treat AVF failure requires a multidisciplinary approach involving nephrologists, vascular surgeons and interventional radiologists, allowing careful patient selection and the use of tailored systemic or localized interventions to improve patient-specific outcomes. This review provides contemporary information on the underlying mechanisms of AVF maturation and failure and discusses the broad spectrum of options that can be tailored for specific therapy. PMID:28779782
Future research directions to improve fistula maturation and reduce access failure.
Hu, Haidi; Patel, Sandeep; Hanisch, Jesse J; Santana, Jeans M; Hashimoto, Takuya; Bai, Hualong; Kudze, Tambudzai; Foster, Trenton R; Guo, Jianming; Yatsula, Bogdan; Tsui, Janice; Dardik, Alan
2016-12-01
With the increasing prevalence of end-stage renal disease, there is a growing need for hemodialysis. Arteriovenous fistulae (AVF) are the preferred type of vascular access for hemodialysis, but maturation and failure continue to present significant barriers to successful fistula use. AVF maturation integrates outward remodeling with vessel wall thickening in response to drastic hemodynamic changes in the setting of uremia, systemic inflammation, oxidative stress, and pre-existent vascular pathology. AVF can fail due to both failure to mature adequately to support hemodialysis and development of neointimal hyperplasia that narrows the AVF lumen, typically near the fistula anastomosis. Failure due to neointimal hyperplasia involves vascular cell activation and migration and extracellular matrix remodeling with complex interactions of growth factors, adhesion molecules, inflammatory mediators, and chemokines, all of which result in maladaptive remodeling. Different strategies have been proposed to prevent and treat AVF failure based on current understanding of the modes and pathology of access failure; these approaches range from appropriate patient selection and use of alternative surgical strategies for fistula creation, to the use of novel interventional techniques or drugs to treat failing fistulae. Effective treatments to prevent or treat AVF failure require a multidisciplinary approach involving nephrologists, vascular surgeons, and interventional radiologists, careful patient selection, and the use of tailored systemic or localized interventions to improve patient-specific outcomes. This review provides contemporary information on the underlying mechanisms of AVF maturation and failure and discusses the broad spectrum of options that can be tailored for specific therapy. Published by Elsevier Inc.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Rusu, I; Thomas, T; Roeske, J
Purpose: To identify areas of improvement in our liver stereotactic body radiation therapy (SBRT) program, using failure mode and effect analysis (FMEA). Methods: A multidisciplinary group consisting of one physician, three physicists, one dosimetrist and two therapists was formed. A process map covering 10 major stages of the liver SBRT program from the initial diagnosis to post treatment follow-up was generated. A total of 102 failure modes, together with their causes and effects, were identified. The occurrence (O), severity (S) and lack of detectability (D) were independently scored. The ranking was done using the risk probability number (RPN) defined asmore » the product of average O, S and D numbers for each mode. The scores were normalized to remove inter-observer variability, while preserving individual ranking order. Further, a correlation analysis on the overall agreement on rank order of all failure modes resulted in positive values for successive pairs of evaluators. The failure modes with the highest RPN value were considered for further investigation. Results: The average normalized RPN values for all modes were 39 with a range of 9 to 103. The FMEA analysis resulted in the identification of the top 10 critical failures modes as: Incorrect CT-MR registration, MR scan not performed in treatment position, patient movement between CBCT acquisition and treatment, daily IGRT QA not verified, incorrect or incomplete ITV delineation, OAR contours not verified, inaccurate normal liver effective dose (Veff) calculation, failure of bolus tracking for 4D CT scan, setup instructions not followed for treatment and plan evaluation metrics missed. Conclusion: The application of FMEA to our liver SBRT program led to the identification and possible improvement of areas affecting patient safety.« less
DOE Office of Scientific and Technical Information (OSTI.GOV)
Lah, J; Manger, R; Kim, G
Purpose: To examine the ability of traditional Failure mode and effects analysis (FMEA) and a light version of Healthcare FMEA (HFMEA), called Scenario analysis of FMEA (SAFER) by comparing their outputs in terms of the risks identified and their severity rankings. Methods: We applied two prospective methods of the quality management to surface image guided, linac-based radiosurgery (SIG-RS). For the traditional FMEA, decisions on how to improve an operation are based on risk priority number (RPN). RPN is a product of three indices: occurrence, severity and detectability. The SAFER approach; utilized two indices-frequency and severity-which were defined by a multidisciplinarymore » team. A criticality matrix was divided into 4 categories; very low, low, high and very high. For high risk events, an additional evaluation was performed. Based upon the criticality of the process, it was decided if additional safety measures were needed and what they comprise. Results: Two methods were independently compared to determine if the results and rated risks were matching or not. Our results showed an agreement of 67% between FMEA and SAFER approaches for the 15 riskiest SIG-specific failure modes. The main differences between the two approaches were the distribution of the values and the failure modes (No.52, 54, 154) that have high SAFER scores do not necessarily have high FMEA RPN scores. In our results, there were additional risks identified by both methods with little correspondence. In the SAFER, when the risk score is determined, the basis of the established decision tree or the failure mode should be more investigated. Conclusion: The FMEA method takes into account the probability that an error passes without being detected. SAFER is inductive because it requires the identification of the consequences from causes, and semi-quantitative since it allow the prioritization of risks and mitigation measures, and thus is perfectly applicable to clinical parts of radiotherapy.« less
Automatic Monitoring System Design and Failure Probability Analysis for River Dikes on Steep Channel
NASA Astrophysics Data System (ADS)
Chang, Yin-Lung; Lin, Yi-Jun; Tung, Yeou-Koung
2017-04-01
The purposes of this study includes: (1) design an automatic monitoring system for river dike; and (2) develop a framework which enables the determination of dike failure probabilities for various failure modes during a rainstorm. The historical dike failure data collected in this study indicate that most dikes in Taiwan collapsed under the 20-years return period discharge, which means the probability of dike failure is much higher than that of overtopping. We installed the dike monitoring system on the Chiu-She Dike which located on the middle stream of Dajia River, Taiwan. The system includes: (1) vertical distributed pore water pressure sensors in front of and behind the dike; (2) Time Domain Reflectometry (TDR) to measure the displacement of dike; (3) wireless floating device to measure the scouring depth at the toe of dike; and (4) water level gauge. The monitoring system recorded the variation of pore pressure inside the Chiu-She Dike and the scouring depth during Typhoon Megi. The recorded data showed that the highest groundwater level insides the dike occurred 15 hours after the peak discharge. We developed a framework which accounts for the uncertainties from return period discharge, Manning's n, scouring depth, soil cohesion, and friction angle and enables the determination of dike failure probabilities for various failure modes such as overtopping, surface erosion, mass failure, toe sliding and overturning. The framework was applied to Chiu-She, Feng-Chou, and Ke-Chuang Dikes on Dajia River. The results indicate that the toe sliding or overturning has the highest probability than other failure modes. Furthermore, the overall failure probability (integrate different failure modes) reaches 50% under 10-years return period flood which agrees with the historical failure data for the study reaches.
Pérez-González, A; González-Lluch, C; Sancho-Bru, J L; Rodríguez-Cervantes, P J; Barjau-Escribano, A; Forner-Navarro, L
2012-03-01
The aim of this study was to analyse the strength and failure mode of teeth restored with fibre posts under retention and flexural-compressive loads at different stages of the restoration and to analyse whether including a simulated ligament in the experimental setup has any effect on the strength or the failure mode. Thirty human maxillary central incisors were distributed in three different groups to be restored with simulation of different restoration stages (1: only post, 2: post and core, 3: post-core and crown), using Rebilda fibre posts. The specimens were inserted in resin blocks and loaded by means of a universal testing machine until failure under tension (stage 1) and 50º flexion (stages 2-3). Half the specimens in each group were restored using a simulated ligament between root dentine and resin block and the other half did not use this element. Failure in stage 1 always occurred at the post-dentine interface, with a mean failure load of 191·2 N. Failure in stage 2 was located mainly in the core or coronal dentine (mean failure load of 505·9 N). Failure in stage 3 was observed in the coronal dentine (mean failure load 397·4 N). Failure loads registered were greater than expected masticatory loads. Fracture modes were mostly reparable, thus indicating that this post is clinically valid at the different stages of restoration studied. The inclusion of the simulated ligament in the experimental system did not show a statistically significant effect on the failure load or the failure mode. © 2011 Blackwell Publishing Ltd.
Mechanical ventilation during extracorporeal membrane oxygenation.
Schmidt, Matthieu; Pellegrino, Vincent; Combes, Alain; Scheinkestel, Carlos; Cooper, D Jamie; Hodgson, Carol
2014-01-21
The timing of extracorporeal membrane oxygenation (ECMO) initiation and its outcome in the management of respiratory and cardiac failure have received considerable attention, but very little attention has been given to mechanical ventilation during ECMO. Mechanical ventilation settings in non-ECMO studies have been shown to have an effect on survival and may also have contributed to a treatment effect in ECMO trials. Protective lung ventilation strategies established for non-ECMO-supported respiratory failure patients may not be optimal for more severe forms of respiratory failure requiring ECMO support. The influence of positive end-expiratory pressure on the reduction of the left ventricular compliance may be a matter of concern for patients receiving ECMO support for cardiac failure. The objectives of this review were to describe potential mechanisms for lung injury during ECMO for respiratory or cardiac failure, to assess the possible benefits from the use of ultra-protective lung ventilation strategies and to review published guidelines and expert opinions available on mechanical ventilation-specific management of patients requiring ECMO, including mode and ventilator settings. Articles were identified through a detailed search of PubMed, Ovid, Cochrane databases and Google Scholar. Additional references were retrieved from the selected studies. Growing evidence suggests that mechanical ventilation settings are important in ECMO patients to minimize further lung damage and improve outcomes. An ultra-protective ventilation strategy may be optimal for mechanical ventilation during ECMO for respiratory failure. The effects of airway pressure on right and left ventricular afterload should be considered during venoarterial ECMO support of cardiac failure. Future studies are needed to better understand the potential impact of invasive mechanical ventilation modes and settings on outcomes.
Mechanical ventilation during extracorporeal membrane oxygenation
2014-01-01
The timing of extracorporeal membrane oxygenation (ECMO) initiation and its outcome in the management of respiratory and cardiac failure have received considerable attention, but very little attention has been given to mechanical ventilation during ECMO. Mechanical ventilation settings in non-ECMO studies have been shown to have an effect on survival and may also have contributed to a treatment effect in ECMO trials. Protective lung ventilation strategies established for non-ECMO-supported respiratory failure patients may not be optimal for more severe forms of respiratory failure requiring ECMO support. The influence of positive end-expiratory pressure on the reduction of the left ventricular compliance may be a matter of concern for patients receiving ECMO support for cardiac failure. The objectives of this review were to describe potential mechanisms for lung injury during ECMO for respiratory or cardiac failure, to assess the possible benefits from the use of ultra-protective lung ventilation strategies and to review published guidelines and expert opinions available on mechanical ventilation-specific management of patients requiring ECMO, including mode and ventilator settings. Articles were identified through a detailed search of PubMed, Ovid, Cochrane databases and Google Scholar. Additional references were retrieved from the selected studies. Growing evidence suggests that mechanical ventilation settings are important in ECMO patients to minimize further lung damage and improve outcomes. An ultra-protective ventilation strategy may be optimal for mechanical ventilation during ECMO for respiratory failure. The effects of airway pressure on right and left ventricular afterload should be considered during venoarterial ECMO support of cardiac failure. Future studies are needed to better understand the potential impact of invasive mechanical ventilation modes and settings on outcomes. PMID:24447458
Mechanics of rainfall-induced flow failure in unsaturated shallow slopes (Invited)
NASA Astrophysics Data System (ADS)
Buscarnera, G.
2013-12-01
The increase in pore water pressure due to rain infiltration can be a dominant component in the activation of slope instabilities. This work shows an application of the theory of material stability to the triggering analysis of this important class of natural hazards. The goal is to identify the mechanisms through which the process of rain infiltration promotes instabilities of the flow-type in the soil covers. The interplay between increase in pore water pressure and failure mechanisms is investigated at material point level. To account for multiple failure mechanisms, the second-order energy input is linked to the controllability theory and used to define different types of stability indices, each associated with a specific mode of slope failure. It is shown that the theory can be used to assess both shear failure and static liquefaction in saturated and unsaturated soil covers. In particular, it is shown that these instability modes are regulated by the hydro-mechanical characteristics of the soil covers, as well as by their mutual coupling. This finding discloses the importance of the constitutive functions that simulate the interaction between the response of the solid skeleton and the fluid-retention characteristics of the soil. As a consequence, they suggest that even material properties that are not be to directly associated with the shearing resistance (e.g., the potential for wetting compaction) may play a role in the initiation of catastrophic slope failures. According to the proposed interpretation, the process of pore pressure increase can be seen as the trigger of uncontrolled strains, which can anticipate the onset of frictional failure and promote a solid-to-fluid transition.
Determining the state-of-health of maintenance-free aircraft batteries
DOE Office of Scientific and Technical Information (OSTI.GOV)
Vutetakis, D.G.; Viswanathan, V.V.
1995-07-01
This paper presents an overview of methods to determine the state-of-health of maintenance-free aircraft batteries. The various failure modes of aircraft batteries are discussed, along with methods of detecting failed batteries. Specific examples of detection methods are presented for the F-16, F-18, AV-8B, B-1B, and B-52 aircraft batteries.
Formally specifying the logic of an automatic guidance controller
NASA Technical Reports Server (NTRS)
Guaspari, David
1990-01-01
The following topics are covered in viewgraph form: (1) the Penelope Project; (2) the logic of an experimental automatic guidance control system for a 737; (3) Larch/Ada specification; (4) some failures of informal description; (5) description of mode changes caused by switches; (6) intuitive description of window status (chosen vs. current); (7) design of the code; (8) and specifying the code.
Optoelectronic Devices with Complex Failure Modes
NASA Technical Reports Server (NTRS)
Johnston, A.
2000-01-01
This part of the NSREC-2000 Short Course discusses radiation effects in basic photonic devices along with effects in more complex optoelectronic devices where the overall radiation response depends on several factors, with the possibility of multiple failure modes.
Independent Orbiter Assessment (IOA): Analysis of the life support and airlock support subsystems
NASA Technical Reports Server (NTRS)
Arbet, Jim; Duffy, R.; Barickman, K.; Saiidi, Mo J.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Life Support System (LSS) and Airlock Support System (ALSS). Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. The LSS provides for the management of the supply water, collection of metabolic waste, management of waste water, smoke detection, and fire suppression. The ALSS provides water, oxygen, and electricity to support an extravehicular activity in the airlock.
Raygot, C G; Chai, J; Jameson, D L
2001-01-01
This study was undertaken to characterize the fracture resistance and mode of fracture of endodontically treated incisors restored with cast post-and-core, prefabricated stainless steel post, or carbon fiber-reinforced composite post systems. Ten endodontically treated teeth restored with each technique were subjected to a compressive load delivered at a 130-degree angle to the long axis until the first sign of failure was noted. The fracture load and the mode of fracture were recorded. The failure loads registered in the three groups were not significantly different. Between 70%, and 80% of teeth from any of the three groups displayed fractures that were located above the simulated bone level. The use of carbon fiber-reinforced composite posts did not change the fracture resistance or the failure mode of endodontically treated central incisors compared to the use of metallic posts.
a New Method for Fmeca Based on Fuzzy Theory and Expert System
NASA Astrophysics Data System (ADS)
Byeon, Yoong-Tae; Kim, Dong-Jin; Kim, Jin-O.
2008-10-01
Failure Mode Effects and Criticality Analysis (FMECA) is one of most widely used methods in modern engineering system to investigate potential failure modes and its severity upon the system. FMECA evaluates criticality and severity of each failure mode and visualize the risk level matrix putting those indices to column and row variable respectively. Generally, those indices are determined subjectively by experts and operators. However, this process has no choice but to include uncertainty. In this paper, a method for eliciting expert opinions considering its uncertainty is proposed to evaluate the criticality and severity. In addition, a fuzzy expert system is constructed in order to determine the crisp value of risk level for each failure mode. Finally, an illustrative example system is analyzed in the case study. The results are worth considering in deciding the proper policies for each component of the system.
Automated Mixed Traffic Vehicle (AMTV) technology and safety study
NASA Technical Reports Server (NTRS)
Johnston, A. R.; Peng, T. K. C.; Vivian, H. C.; Wang, P. K.
1978-01-01
Technology and safety related to the implementation of an Automated Mixed Traffic Vehicle (AMTV) system are discussed. System concepts and technology status were reviewed and areas where further development is needed are identified. Failure and hazard modes were also analyzed and methods for prevention were suggested. The results presented are intended as a guide for further efforts in AMTV system design and technology development for both near term and long term applications. The AMTV systems discussed include a low speed system, and a hybrid system consisting of low speed sections and high speed sections operating in a semi-guideway. The safety analysis identified hazards that may arise in a properly functioning AMTV system, as well as hardware failure modes. Safety related failure modes were emphasized. A risk assessment was performed in order to create a priority order and significant hazards and failure modes were summarized. Corrective measures were proposed for each hazard.
Space Shuttle Hot Cabin Emergency Responses
NASA Technical Reports Server (NTRS)
Stepaniak, P.; Effenhauser, R. K.; McCluskey, R.; Gillis, D. B.; Hamilton, D.; Kuznetz, L. H.
2005-01-01
Methods: Human thermal tolerance, countermeasures, and thermal model data were reviewed and compared to existing shuttle ECS failure temperature and humidity profiles for each failure mode. Increases in core temperature associated with cognitive impairment was identified, as was metabolic heat generation of crewmembers, temperature monitoring, and communication capabilities after partial power-down and other limiting factors. Orbiter landing strategies and a hydration and salt replacement protocol were developed to put wheels on deck in each failure mode prior to development of significant cognitive impairment or collapse of crewmembers. Thermal tradeoffs for use of the Advanced Crew Escape Suit (ACES), Liquid Cooling Garment, integrated G-suit and Quick Don Mask were examined. candidate solutions involved trade-offs or conflicts with cabin oxygen partial pressure limits, system power-downs to limit heat generation, risks of alternate and emergency landing sites or compromise of Mode V-VIII scenarios. Results: Rehydration and minimized cabin workloads are required in all failure modes. Temperature/humidity profiles increase rapidly in two failure modes, and deorbit is recommended without the ACES, ICU and g-suit. This latter configuration limits several shuttle approach and landing escape modes and requires communication modifications. Additional data requirements were identified and engineering simulations were recommended to develop more current shuttle temperature and humidity profiles. Discussion: After failure of the shuttle ECS, there is insufficient cooling capacity of the ACES to protect crewmembers from rising cabin temperature and humidity. The LCG is inadequate for cabin temperatures above 76 F. Current shuttle future life policy makes it unlikely that major engineering upgrades necessary to address this problem will occur.
Space Shuttle Stiffener Ring Foam Failure Analysis, a Non-Conventional Approach
NASA Technical Reports Server (NTRS)
Howard, Philip M.
2015-01-01
The Space Shuttle Program made use of the excellent properties of rigid polyurethane foam for cryogenic tank insulation and as structural protection on the solid rocket boosters. When foam applications de-bond, classical methods of failure analysis did not provide root cause of the failure of the foam. Realizing that foam is the ideal media to document and preserve its own mode of failure, thin sectioning was seen as a logical approach for foam failure analysis to observe the three dimensional morphology of the foam cells. The cell foam morphology provided a much greater understanding of the failure modes than previously achieved.
Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio
2012-01-01
Objective Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Design and setting Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. Primary outcome To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. Results In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. Conclusions FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children. PMID:23253870
Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio
2012-01-01
Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.
Plastic Pipe Failure, Risk, and Threat Analysis
DOT National Transportation Integrated Search
2009-04-29
The three primary failure modes that may be exhibited by polyethylene (PE) gas pipe materials were described in detail. The modes are: ductile rupture, slow crack growth (SCG), and rapid crack propagation (RCP). Short term mechanical tests were evalu...
Reusable Rocket Engine Maintenance Study
NASA Technical Reports Server (NTRS)
Macgregor, C. A.
1982-01-01
Approximately 85,000 liquid rocket engine failure reports, obtained from 30 years of developing and delivering major pump feed engines, were reviewed and screened and reduced to 1771. These were categorized into 16 different failure modes. Failure propagation diagrams were established. The state of the art of engine condition monitoring for in-flight sensors and between flight inspection technology was determined. For the 16 failure modes, the potential measurands and diagnostic requirements were identified, assessed and ranked. Eight areas are identified requiring advanced technology development.
Preliminary Failure Modes and Effects Analysis of the US DCLL Test Blanket Module
DOE Office of Scientific and Technical Information (OSTI.GOV)
Lee C. Cadwallader
2010-06-01
This report presents the results of a preliminary failure modes and effects analysis (FMEA) of a small tritium-breeding test blanket module design for the International Thermonuclear Experimental Reactor. The FMEA was quantified with “generic” component failure rate data, and the failure events are binned into postulated initiating event families and frequency categories for safety assessment. An appendix to this report contains repair time data to support an occupational radiation exposure assessment for test blanket module maintenance.
Preliminary Failure Modes and Effects Analysis of the US DCLL Test Blanket Module
DOE Office of Scientific and Technical Information (OSTI.GOV)
Lee C. Cadwallader
2007-08-01
This report presents the results of a preliminary failure modes and effects analysis (FMEA) of a small tritium-breeding test blanket module design for the International Thermonuclear Experimental Reactor. The FMEA was quantified with “generic” component failure rate data, and the failure events are binned into postulated initiating event families and frequency categories for safety assessment. An appendix to this report contains repair time data to support an occupational radiation exposure assessment for test blanket module maintenance.
A Predictive Framework to Elucidate Venous Stenosis: CFD & Shape Optimization.
Javid Mahmoudzadeh Akherat, S M; Cassel, Kevin; Boghosian, Michael; Hammes, Mary; Coe, Fredric
2017-07-01
The surgical creation of vascular accesses for renal failure patients provides an abnormally high flow rate conduit in the patient's upper arm vasculature that facilitates the hemodialysis treatment. These vascular accesses, however, are very often associated with complications that lead to access failure and thrombotic incidents, mainly due to excessive neointimal hyperplasia (NH) and subsequently stenosis. Development of a framework to monitor and predict the evolution of the venous system post access creation can greatly contribute to maintaining access patency. Computational fluid dynamics (CFD) has been exploited to inspect the non-homeostatic wall shear stress (WSS) distribution that is speculated to trigger NH in the patient cohort under investigation. Thereafter, CFD in liaison with a gradient-free shape optimization method has been employed to analyze the deformation modes of the venous system enduring non-physiological hemodynamics. It is observed that the optimally evolved shapes and their corresponding hemodynamics strive to restore the homeostatic state of the venous system to a normal, pre-surgery condition. It is concluded that a CFD-shape optimization coupling that seeks to regulate the WSS back to a well-defined physiological WSS target range can accurately predict the mode of patient-specific access failure.
NASA Astrophysics Data System (ADS)
Liu, Hu-Chen; Liu, Long; Li, Ping
2014-10-01
Failure mode and effects analysis (FMEA) has shown its effectiveness in examining potential failures in products, process, designs or services and has been extensively used for safety and reliability analysis in a wide range of industries. However, its approach to prioritise failure modes through a crisp risk priority number (RPN) has been criticised as having several shortcomings. The aim of this paper is to develop an efficient and comprehensive risk assessment methodology using intuitionistic fuzzy hybrid weighted Euclidean distance (IFHWED) operator to overcome the limitations and improve the effectiveness of the traditional FMEA. The diversified and uncertain assessments given by FMEA team members are treated as linguistic terms expressed in intuitionistic fuzzy numbers (IFNs). Intuitionistic fuzzy weighted averaging (IFWA) operator is used to aggregate the FMEA team members' individual assessments into a group assessment. IFHWED operator is applied thereafter to the prioritisation and selection of failure modes. Particularly, both subjective and objective weights of risk factors are considered during the risk evaluation process. A numerical example for risk assessment is given to illustrate the proposed method finally.
Deng, Xinyang; Jiang, Wen
2017-09-12
Failure mode and effect analysis (FMEA) is a useful tool to define, identify, and eliminate potential failures or errors so as to improve the reliability of systems, designs, and products. Risk evaluation is an important issue in FMEA to determine the risk priorities of failure modes. There are some shortcomings in the traditional risk priority number (RPN) approach for risk evaluation in FMEA, and fuzzy risk evaluation has become an important research direction that attracts increasing attention. In this paper, the fuzzy risk evaluation in FMEA is studied from a perspective of multi-sensor information fusion. By considering the non-exclusiveness between the evaluations of fuzzy linguistic variables to failure modes, a novel model called D numbers is used to model the non-exclusive fuzzy evaluations. A D numbers based multi-sensor information fusion method is proposed to establish a new model for fuzzy risk evaluation in FMEA. An illustrative example is provided and examined using the proposed model and other existing method to show the effectiveness of the proposed model.
Deng, Xinyang
2017-01-01
Failure mode and effect analysis (FMEA) is a useful tool to define, identify, and eliminate potential failures or errors so as to improve the reliability of systems, designs, and products. Risk evaluation is an important issue in FMEA to determine the risk priorities of failure modes. There are some shortcomings in the traditional risk priority number (RPN) approach for risk evaluation in FMEA, and fuzzy risk evaluation has become an important research direction that attracts increasing attention. In this paper, the fuzzy risk evaluation in FMEA is studied from a perspective of multi-sensor information fusion. By considering the non-exclusiveness between the evaluations of fuzzy linguistic variables to failure modes, a novel model called D numbers is used to model the non-exclusive fuzzy evaluations. A D numbers based multi-sensor information fusion method is proposed to establish a new model for fuzzy risk evaluation in FMEA. An illustrative example is provided and examined using the proposed model and other existing method to show the effectiveness of the proposed model. PMID:28895905
Guidelines for VCCT-Based Interlaminar Fatigue and Progressive Failure Finite Element Analysis
NASA Technical Reports Server (NTRS)
Deobald, Lyle R.; Mabson, Gerald E.; Engelstad, Steve; Prabhakar, M.; Gurvich, Mark; Seneviratne, Waruna; Perera, Shenal; O'Brien, T. Kevin; Murri, Gretchen; Ratcliffe, James;
2017-01-01
This document is intended to detail the theoretical basis, equations, references and data that are necessary to enhance the functionality of commercially available Finite Element codes, with the objective of having functionality better suited for the aerospace industry in the area of composite structural analysis. The specific area of focus will be improvements to composite interlaminar fatigue and progressive interlaminar failure. Suggestions are biased towards codes that perform interlaminar Linear Elastic Fracture Mechanics (LEFM) using Virtual Crack Closure Technique (VCCT)-based algorithms [1,2]. All aspects of the science associated with composite interlaminar crack growth are not fully developed and the codes developed to predict this mode of failure must be programmed with sufficient flexibility to accommodate new functional relationships as the science matures.
Room Temperature and Elevated Temperature Composite Sandwich Joint Testing
NASA Technical Reports Server (NTRS)
Walker, Sandra P.
1998-01-01
Testing of composite sandwich joint elements has been completed to verify the strength capacity of joints designed to carry specified running loads representative of a high speed civil transport wing. Static tension testing at both room and an elevated temperature of 350 F and fatigue testing at room temperature were conducted to determine strength capacity, fatigue life, and failure modes. Static tension test results yielded failure loads above the design loads for the room temperature tests, confirming the ability of the joint concepts tested to carry their design loads. However, strength reductions as large as 30% were observed at the elevated test temperature, where all failure loads were below the room temperature design loads for the specific joint designs tested. Fatigue testing resulted in lower than predicted fatigue lives.
NASA Astrophysics Data System (ADS)
Sin, Yongkun; Lingley, Zachary; Ayvazian, Talin; Brodie, Miles; Ives, Neil
2018-02-01
High-power single-mode (SM) and multi-mode (MM) InGaAs-AlGaAs strained quantum well (QW) lasers are critical components for both terrestrial and space satellite communications systems. Since these lasers predominantly fail by catastrophic and sudden degradation due to COD, it is especially crucial for space satellite applications to investigate reliability, failure modes, and degradation mechanisms of these lasers. Our group reported a new failure mode in MM and SM InGaAs-AlGaAs strained QW lasers in 2009 and 2016, respectively. Our group also reported in 2017 that bulk failure due to catastrophic optical bulk damage (COBD) is the dominant failure mode of both SM and MM lasers that were subject to long-term life-tests. For the present study, we report root causes investigation of COBD by performing long-term lifetests followed by failure mode analysis (FMA) using various micro-analytical techniques including electron beam induced current (EBIC), time-resolved electroluminescence (EL), focused ion beam (FIB), high-resolution transmission electron microscopy (TEM), and deep level transient spectroscopy (DLTS). Our life-tests with accumulated test hours of over 25,000 hours for SM lasers and over 35,000 hours for MM lasers generated a number of COBD failures with various failure times. EBIC techniques were employed to study dark line defects (DLDs) generated in SM COBD failures stressed under different test conditions. FIB and high-resolution TEM were employed to prepare cross sectional and plan view TEM specimens to study DLD areas (dislocations) in post-aged SM lasers. Time-resolved EL techniques were employed to study initiation and progressions of dark spots and dark lines in real time as MM lasers were aged. Lastly, to investigate precursor signatures of failure and degradation mechanisms responsible for COBD in both SM and MM lasers, we employed DLTS techniques to study a role that electron traps (non-radiative recombination centers) play in degradation of these lasers. Our in-depth root causes investigation results are reported.
Thermal barrier coating life prediction model
NASA Technical Reports Server (NTRS)
Pilsner, B. H.; Hillery, R. V.; Mcknight, R. L.; Cook, T. S.; Kim, K. S.; Duderstadt, E. C.
1986-01-01
The objectives of this program are to determine the predominant modes of degradation of a plasma sprayed thermal barrier coating system, and then to develop and verify life prediction models accounting for these degradation modes. The program is divided into two phases, each consisting of several tasks. The work in Phase 1 is aimed at identifying the relative importance of the various failure modes, and developing and verifying life prediction model(s) for the predominant model for a thermal barrier coating system. Two possible predominant failure mechanisms being evaluated are bond coat oxidation and bond coat creep. The work in Phase 2 will develop design-capable, causal, life prediction models for thermomechanical and thermochemical failure modes, and for the exceptional conditions of foreign object damage and erosion.
Analysis of the STS-126 Flow Control Valve Structural-Acoustic Coupling Failure
NASA Technical Reports Server (NTRS)
Jones, Trevor M.; Larko, Jeffrey M.; McNelis, Mark E.
2010-01-01
During the Space Transportation System mission STS-126, one of the main engine's flow control valves incurred an unexpected failure. A section of the valve broke off during liftoff. It is theorized that an acoustic mode of the flowing fuel, coupled with a structural mode of the valve, causing a high cycle fatigue failure. This report documents the analysis efforts conducted in an attempt to verify this theory. Hand calculations, computational fluid dynamics, and finite element methods are all implemented and analyses are performed using steady-state methods in addition to transient analysis methods. The conclusion of the analyses is that there is a critical acoustic mode that aligns with a structural mode of the valve
[Failure mode and effects analysis to improve quality in clinical trials].
Mañes-Sevilla, M; Marzal-Alfaro, M B; Romero Jiménez, R; Herranz-Alonso, A; Sanchez Fresneda, M N; Benedi Gonzalez, J; Sanjurjo-Sáez, M
The failure mode and effects analysis (FMEA) has been used as a tool in risk management and quality improvement. The objective of this study is to identify the weaknesses in processes in the clinical trials area, of a Pharmacy Department (PD) with great research activity, in order to improve the safety of the usual procedures. A multidisciplinary team was created to analyse each of the critical points, identified as possible failure modes, in the development of clinical trial in the PD. For each failure mode, the possible cause and effect were identified, criticality was calculated using the risk priority number and the possible corrective actions were discussed. Six sub-processes were defined in the development of the clinical trials in PD. The FMEA identified 67 failure modes, being the dispensing and prescription/validation sub-processes the most likely to generate errors. All the improvement actions established in the AMFE were implemented in the Clinical Trials area. The FMEA is a useful tool in proactive risk management because it allows us to identify where we are making mistakes and analyze the causes that originate them, to prioritize and to adopt solutions to risk reduction. The FMEA improves process safety and quality in PD. Copyright © 2018 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.
Independent Orbiter Assessment (IOA): Analysis of the displays and controls subsystem
NASA Technical Reports Server (NTRS)
Trahan, W. H.; Prust, E. E.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Orbiter Displays and Controls (D and C) subsystem hardware. The function of the D and C hardware is to provide the crew with the monitor, command, and control capabilities required for management of all normal and contingency mission and flight operations. The D and C hardware for which failure modes analysis was performed consists of the following: Acceleration Indicator (G-METER); Head Up Display (HUD); Display Driver Unit (DDU); Alpha/Mach Indicator (AMI); Horizontal Situation Indicator (HSI); Attitude Director Indicator (ADI); Propellant Quantity Indicator (PQI); Surface Position Indicator (SPI); Altitude/Vertical Velocity Indicator (AVVI); Caution and Warning Assembly (CWA); Annunciator Control Assembly (ACA); Event Timer (ET); Mission Timer (MT); Interior Lighting; and Exterior Lighting. Each hardware item was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
NASA Technical Reports Server (NTRS)
Arbet, J. D.; Duffy, R. E.; Barickman, K.; Saiidi, M. J.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Life Support and Airlock Support Systems (LSS and ALSS) hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the NASA FMEA/CIL baseline with proposed Post 51-L updates included. The discrepancies were flagged for potential future resolution. This report documents the results of that comparison for the Orbiter LSS and ALSS hardware. The IOA product for the LSS and ALSS analysis consisted of 511 failure mode worksheets that resulted in 140 potential critical items. Comparison was made to the NASA baseline which consisted of 456 FMEAs and 101 CIL items. The IOA analysis identified 39 failure modes, 6 of which were classified as CIL items, for components not covered by the NASA FMEAs. It was recommended that these failure modes be added to the NASA FMEA baseline. The overall assessment produced agreement on all but 301 FMEAs which caused differences in 111 CIL items.
Risk management of key issues of FPSO
NASA Astrophysics Data System (ADS)
Sun, Liping; Sun, Hai
2012-12-01
Risk analysis of key systems have become a growing topic late of because of the development of offshore structures. Equipment failures of offloading system and fire accidents were analyzed based on the floating production, storage and offloading (FPSO) features. Fault tree analysis (FTA), and failure modes and effects analysis (FMEA) methods were examined based on information already researched on modules of relex reliability studio (RRS). Equipment failures were also analyzed qualitatively by establishing a fault tree and Boolean structure function based on the shortage of failure cases, statistical data, and risk control measures examined. Failure modes of fire accident were classified according to the different areas of fire occurrences during the FMEA process, using risk priority number (RPN) methods to evaluate their severity rank. The qualitative analysis of FTA gave the basic insight of forming the failure modes of FPSO offloading, and the fire FMEA gave the priorities and suggested processes. The research has practical importance for the security analysis problems of FPSO.
Matrix Dominated Failure of Fiber-Reinforced Composite Laminates Under Static and Dynamic Loading
NASA Astrophysics Data System (ADS)
Schaefer, Joseph Daniel
Hierarchical material systems provide the unique opportunity to connect material knowledge to solving specific design challenges. Representing the quickest growing class of hierarchical materials in use, fiber-reinforced polymer composites (FRPCs) offer superior strength and stiffness-to-weight ratios, damage tolerance, and decreasing production costs compared to metals and alloys. However, the implementation of FRPCs has historically been fraught with inadequate knowledge of the material failure behavior due to incomplete verification of recent computational constitutive models and improper (or non-existent) experimental validation, which has severely slowed creation and development. Noted by the recent Materials Genome Initiative and the Worldwide Failure Exercise, current state of the art qualification programs endure a 20 year gap between material conceptualization and implementation due to the lack of effective partnership between computational coding (simulation) and experimental characterization. Qualification processes are primarily experiment driven; the anisotropic nature of composites predisposes matrix-dominant properties to be sensitive to strain rate, which necessitates extensive testing. To decrease the qualification time, a framework that practically combines theoretical prediction of material failure with limited experimental validation is required. In this work, the Northwestern Failure Theory (NU Theory) for composite lamina is presented as the theoretical basis from which the failure of unidirectional and multidirectional composite laminates is investigated. From an initial experimental characterization of basic lamina properties, the NU Theory is employed to predict the matrix-dependent failure of composites under any state of biaxial stress from quasi-static to 1000 s-1 strain rates. It was found that the number of experiments required to characterize the strain-rate-dependent failure of a new composite material was reduced by an order of magnitude, and the resulting strain-rate-dependence was applicable for a large class of materials. The presented framework provides engineers with the capability to quickly identify fiber and matrix combinations for a given application and determine the failure behavior over the range of practical loadings cases. The failure-mode-based NU Theory may be especially useful when partnered with computational approaches (which often employ micromechanics to determine constituent and constitutive response) to provide accurate validation of the matrix-dominated failure modes experienced by laminates during progressive failure.
Takahashi, Masao; Badenco, Nicolas; Monteau, Jacques; Gandjbakhch, Estelle; Extramiana, Fabrice; Urena, Marina; Karam, Nicole; Marijon, Eloi; Algalarrondo, Vincent; Teiger, Emmanuel; Lellouche, Nicolas
2018-03-14
This study aimed to assess the impact of pacemaker mode programming on clinical outcomes in patients with high-degree atrioventricular conduction disturbance (AVCD) after transcatheter aortic valve implantation (TAVI). Although high-degree AVCD after TAVI can receive pacemaker, recovery of the AVCD is often observed. Specific pacemaker algorithms (AAI-DDD mode switch) are available which favor spontaneous atrioventricular conduction. Of 1,621 consecutive multi-center TAVI patients, 269 (16.4%) received pacemaker. We retrospectively included 91 patients with persistent high-degree AVCD at hospital discharge. Pacemaker dependency was defined as absence, inadequate intrinsic ventricular rhythm, or ventricular pacing time > 95% on pacemaker interrogation during follow-up. Comparison of heart failure hospitalization and death between conventional DDD (cDDD) and other modes was examined (AAI-DDD and VVI). During a mean follow-up duration of 13 months, the pacemaker dependency rate was 52.8%. Patients with cDDD mode (N = 36: 40.0%) had significantly more pacemaker dependency. Multivariate analysis showed that cDDD mode was independently associated with pacemaker dependency (odds ratio = 3.63, P = 0.03). Moreover, cDDD patients had a significant higher incidence of heart failure hospitalization (Hospitalization: cDDD vs. others = 45.4% vs. 18.2%, P = 0.03) and had a higher incidence of mortality (Death: cDDD vs. the others = 27.0% vs. 4.4%, P = 0.06). Up to half of patients implanted for high-degree AVCD after TAVI had conduction recovery. Patients with cDDD programming at hospital discharge had more pacemaker dependency and a worse cardiac prognosis. Thus, pacemaker mode should be systematically set to promote spontaneous atrioventricular conduction in patients with pacemaker implantation after TAVI. © 2018 Wiley Periodicals, Inc.
Deep geothermal: The ‘Moon Landing’ mission in the unconventional energy and minerals space
Regenauer-Lieb, Klaus; Bunger, Andrew; Chua, Hui Tong; ...
2015-01-30
Deep geothermal from the hot crystalline basement has remained an unsolved frontier for the geothermal industry for the past 30 years. This poses the challenge for developing a new unconventional geomechanics approach to stimulate such reservoirs. While a number of new unconventional brittle techniques are still available to improve stimulation on short time scales, the astonishing richness of failure modes of longer time scales in hot rocks has so far been overlooked. These failure modes represent a series of microscopic processes: brittle microfracturing prevails at low temperatures and fairly high deviatoric stresses, while upon increasing temperature and decreasing applied stressmore » or longer time scales, the failure modes switch to transgranular and intergranular creep fractures. Accordingly, fluids play an active role and create their own pathways through facilitating shear localization by a process of time-dependent dissolution and precipitation creep, rather than being a passive constituent by simply following brittle fractures that are generated inside a shear zone caused by other localization mechanisms. We lay out a new paradigm for reservoir stimulation by reactivating pre-existing faults at reservoir scale in a reservoir scale aseismic, ductile manner. A side effect of the new “soft” stimulation method is that owing to the design specification of a macroscopic ductile response, the proposed method offers the potential of a safer control over the stimulation process compared to conventional stimulation protocols such as currently employed in shale gas reservoirs.« less
Giardina, M; Castiglia, F; Tomarchio, E
2014-12-01
Failure mode, effects and criticality analysis (FMECA) is a safety technique extensively used in many different industrial fields to identify and prevent potential failures. In the application of traditional FMECA, the risk priority number (RPN) is determined to rank the failure modes; however, the method has been criticised for having several weaknesses. Moreover, it is unable to adequately deal with human errors or negligence. In this paper, a new versatile fuzzy rule-based assessment model is proposed to evaluate the RPN index to rank both component failure and human error. The proposed methodology is applied to potential radiological over-exposure of patients during high-dose-rate brachytherapy treatments. The critical analysis of the results can provide recommendations and suggestions regarding safety provisions for the equipment and procedures required to reduce the occurrence of accidental events.
NASA Technical Reports Server (NTRS)
Hall, Steven R.; Walker, Bruce K.
1990-01-01
A new failure detection and isolation algorithm for linear dynamic systems is presented. This algorithm, the Orthogonal Series Generalized Likelihood Ratio (OSGLR) test, is based on the assumption that the failure modes of interest can be represented by truncated series expansions. This assumption leads to a failure detection algorithm with several desirable properties. Computer simulation results are presented for the detection of the failures of actuators and sensors of a C-130 aircraft. The results show that the OSGLR test generally performs as well as the GLR test in terms of time to detect a failure and is more robust to failure mode uncertainty. However, the OSGLR test is also somewhat more sensitive to modeling errors than the GLR test.
Validation of Commercial Fiber Optic Components for Aerospace Environments
NASA Technical Reports Server (NTRS)
Ott, Melanie N.
2005-01-01
Full qualification for commercial photonic parts as defined by the Military specification system in the past, is not feasible. Due to changes in the photonic components industry and the Military specification system that NASA had relied upon so heavily in the past, an approach to technology validation of commercial off the shelf parts had to be devised. This approach involves knowledge of system requirements, environmental requirements and failure modes of the particular components under consideration. Synthesizing the criteria together with the major known failure modes to formulate a test plan is an effective way of establishing knowledge based "qualification". Although this does not provide the type of reliability assurance that the Military specification system did in the past, it is an approach that allows for increased risk mitigation. The information presented will introduce the audience to the technology validation approach that is currently applied at NASA for the usage of commercial-off-the-shelf (COTS) fiber optic components for space flight environments. The focus will be on how to establish technology validation criteria for commercial fiber products such that continued reliable performance is assured under the harsh environmental conditions of typical missions. The goal of this presentation is to provide the audience with an approach to formulating a COTS qualification test plan for these devices. Examples from past NASA missions will be discussed.
Rienzi, L; Bariani, F; Dalla Zorza, M; Albani, E; Benini, F; Chamayou, S; Minasi, M G; Parmegiani, L; Restelli, L; Vizziello, G; Costa, A Nanni
2017-08-01
Can traceability of gametes and embryos be ensured during IVF? The use of a simple and comprehensive traceability system that includes the most susceptible phases during the IVF process minimizes the risk of mismatches. Mismatches in IVF are very rare but unfortunately possible with dramatic consequences for both patients and health care professionals. Traceability is thus a fundamental aspect of the treatment. A clear process of patient and cell identification involving witnessing protocols has to be in place in every unit. To identify potential failures in the traceability process and to develop strategies to mitigate the risk of mismatches, previously failure mode and effects analysis (FMEA) has been used effectively. The FMEA approach is however a subjective analysis, strictly related to specific protocols and thus the results are not always widely applicable. To reduce subjectivity and to obtain a widespread comprehensive protocol of traceability, a multicentre centrally coordinated FMEA was performed. Seven representative Italian centres (three public and four private) were selected. The study had a duration of 21 months (from April 2015 to December 2016) and was centrally coordinated by a team of experts: a risk analysis specialist, an expert embryologist and a specialist in human factor. Principal investigators of each centre were first instructed about proactive risk assessment and FMEA methodology. A multidisciplinary team to perform the FMEA analysis was then formed in each centre. After mapping the traceability process, each team identified the possible causes of mistakes in their protocol. A risk priority number (RPN) for each identified potential failure mode was calculated. The results of the FMEA analyses were centrally investigated and consistent corrective measures suggested. The teams performed new FMEA analyses after the recommended implementations. In each centre, this study involved: the laboratory director, the Quality Control & Quality Assurance responsible, Embryologist(s), Gynaecologist(s), Nurse(s) and Administration. The FMEA analyses were performed according to the Joint Commission International. The FMEA teams identified seven main process phases: oocyte collection, sperm collection, gamete processing, insemination, embryo culture, embryo transfer and gamete/embryo cryopreservation. A mean of 19.3 (SD ± 5.8) associated process steps and 41.9 (SD ± 12.4) possible failure modes were recognized per centre. A RPN ≥15 was calculated in a mean of 6.4 steps (range 2-12, SD ± 3.60). A total of 293 failure modes were centrally analysed 45 of which were considered at medium/high risk. After consistent corrective measures implementation and re-evaluation, a significant reduction in the RPNs in all centres (RPN <15 for all steps) was observed. A simple and comprehensive traceability system was designed as the result of the seven FMEA analyses. The validity of FMEA is in general questionable due to the subjectivity of the judgments. The design of this study has however minimized this risk by introducing external experts for the analysis of the FMEA results. Specific situations such as sperm/oocyte donation, import/export and pre-implantation genetic testing were not taken into consideration. Finally, this study is only limited to the analysis of failure modes that may lead to mismatches, other possible procedural mistakes are not accounted for. Every single IVF centre should have a clear and reliable protocol for identification of patients and traceability of cells during manipulation. The results of this study can support IVF groups in better recognizing critical steps in their protocols, understanding identification and witnessing process, and in turn enhancing safety by introducing validated corrective measures. This study was designed by the Italian Society of Embryology Reproduction and Research (SIERR) and funded by the Italian National Transplant Centre (CNT) of the Italian National Institute of Health (ISS). The authors have no conflicts of interest. N/A. © The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com
Influence of Weathering Depth and Fracture Intensity to Cut-slope Movements
NASA Astrophysics Data System (ADS)
Yoon, W. S.; Choi, J. W.; Jeong, U.; Kim, J. H.
2003-04-01
Generally, Failure modes in cut slopes are triggered by combination of various failure factors which have different effects on failure modes according to ground condition. It is, therefore, important to identify the behavioural characteristic of cut slope in that they reflect the failure mechanism. From the careful field investigation for 373 road cuts along the national highway in Korea, we analysed various types of failure modes for different ground conditions. The ground conditions which control failure modes of cut slopes and their related failure factors are dependent on weathering (or soil) depth and intensity of discontinuities in cut slopes. Firstly, the ratio of the soil depth and slope height (soil depth ratio; SR) is important parameter to classify ground conditions into soil-like masses and rock masses. When a SR value is greater than 0.4, sliding failures on discontinuities do not occur. In this case, weathering condition, slope gradient and external rainfall play a key role on failure factors of cut-slope. The proposed 0.4, therefore, is the critical SR value to identify the soil-like masses and rock masses. Secondly, Intensity of discontinuities is expressed by block size ratio (BR), which is defined by the ratio of block size index (Ib; ISRM (1978)) and slope height. For a rock slope (SR<0.4), when BR is greater than 0.01, key failure modes in a cut slope are wedge sliding, fall and topple. In this case, attitudes and shear strength of discontinuities play an important role on behaviour of cut-slope. When BR is less than 0.01, however, behaviour of cut slope shows circular sliding and surface failure like soil-like mass. To sum up, we could divide the ground conditions in cut-slope into 3 classes on the basis of SR (soil depth ratio) and BR (block size ratio); JRM (joint rock mass), HRM (highly fractured rock mass) and SLM (soil-like mass). Moreover, to evaluate the stability of cut-slope reasonably, it needs new evaluating categories having different weighting factors for each ground condition.
Lamey, M; Carlone, M; Alasti, H; Bissonnette, J P; Borg, J; Breen, S; Coolens, C; Heaton, R; Islam, M; van Proojen, M; Sharpe, M; Stanescu, T; Jaffray, D
2012-07-01
An online Magnetic Resonance guided Radiation Therapy (MRgRT) system is under development. The system is comprised of an MRI with the capability of travel between and into HDR brachytherapy and external beam radiation therapy vaults. The system will provide on-line MR images immediately prior to radiation therapy. The MR images will be registered to a planning image and used for image guidance. With the intention of system safety we have performed a failure modes and effects analysis. A process tree of the facility function was developed. Using the process tree as well as an initial design of the facility as guidelines possible failure modes were identified, for each of these failure modes root causes were identified. For each possible failure the assignment of severity, detectability and occurrence scores was performed. Finally suggestions were developed to reduce the possibility of an event. The process tree consists of nine main inputs and each of these main inputs consisted of 5 - 10 sub inputs and tertiary inputs were also defined. The process tree ensures that the overall safety of the system has been considered. Several possible failure modes were identified and were relevant to the design, construction, commissioning and operating phases of the facility. The utility of the analysis can be seen in that it has spawned projects prior to installation and has lead to suggestions in the design of the facility. © 2012 American Association of Physicists in Medicine.
Procedure for Failure Mode, Effects, and Criticality Analysis (FMECA)
NASA Technical Reports Server (NTRS)
1966-01-01
This document provides guidelines for the accomplishment of Failure Mode, Effects, and Criticality Analysis (FMECA) on the Apollo program. It is a procedure for analysis of hardware items to determine those items contributing most to system unreliability and crew safety problems.
NASA Astrophysics Data System (ADS)
Takahashi, Masakazu; Nanba, Reiji; Fukue, Yoshinori
This paper proposes operational Risk Management (RM) method using Failure Mode and Effects Analysis (FMEA) for drug manufacturing computerlized system (DMCS). The quality of drug must not be influenced by failures and operational mistakes of DMCS. To avoid such situation, DMCS has to be conducted enough risk assessment and taken precautions. We propose operational RM method using FMEA for DMCS. To propose the method, we gathered and compared the FMEA results of DMCS, and develop a list that contains failure modes, failures and countermeasures. To apply this list, we can conduct RM in design phase, find failures, and conduct countermeasures efficiently. Additionally, we can find some failures that have not been found yet.
Sensitivity and specificity of diagnostic ultrasound in the diagnosis of phrenic neuropathy.
Boon, Andrea J; Sekiguchi, Hiroshi; Harper, Caitlin J; Strommen, Jeffrey A; Ghahfarokhi, Leili S; Watson, James C; Sorenson, Eric J
2014-09-30
To determine the sensitivity and specificity of B-mode ultrasound in the diagnosis of neuromuscular diaphragmatic dysfunction, including phrenic neuropathy. A prospective study of patients with dyspnea referred to the EMG laboratory over a 2-year time frame for evaluation of neuromuscular respiratory failure who were recruited consecutively and examined with ultrasound for possible diaphragm dysfunction. Sonographic outcome measures were absolute thickness of the diaphragm and degree of increased thickness with maximal inspiration. The comparison standard for diagnosis of diaphragm dysfunction was the final clinical diagnosis of clinicians blinded to the diaphragm ultrasound results, but taking into account other diagnostic workup, including chest radiographs, fluoroscopy, phrenic nerve conduction studies, diaphragm EMG, and/or pulmonary function tests. Of 82 patients recruited over a 2-year period, 66 were enrolled in the study. Sixteen patients were excluded because of inconclusive or insufficient reference testing. One hemidiaphragm could not be adequately visualized; therefore, hemidiaphragm assessment was conducted in a total of 131 hemidiaphragms in 66 patients. Of the 82 abnormal hemidiaphragms, 76 had abnormal sonographic findings (atrophy or decreased contractility). Of the 49 normal hemidiaphragms, none had a false-positive ultrasound. Diaphragmatic ultrasound was 93% sensitive and 100% specific for the diagnosis of neuromuscular diaphragmatic dysfunction. B-mode ultrasound imaging of the diaphragm is a highly sensitive and specific tool for diagnosis of neuromuscular diaphragm dysfunction. This study provides Class II evidence that diaphragmatic ultrasound performed by well-trained individuals accurately identifies patients with neuromuscular diaphragmatic respiratory failure (sensitivity 93%; specificity 100%). © 2014 American Academy of Neurology.
A review on mode-I interlaminar fracture toughness of fibre reinforced composites
NASA Astrophysics Data System (ADS)
Nasuha, N.; Azmi, A. I.; Tan, C. L.
2017-10-01
Composite material has been growing rapidly throughout the year for its unique properties in comparisons with metal. Recently, there has been a growth on studying the way to reduce the delamination failure, which is the primary challenge on laminated fibre composite. This failure can degrade the strength of composite materials, hence loses its function. In this review, database search was performed using the keywords search on “interlaminar fracture toughness”, “double cantilever beam”, “delamination resistance” and “Mode-I GIC”. The searches were performed on Google Scholar, Scopus and Web of Science with further cross-referencing with other databases. Most relevant studies were selected for review and referencing by the author. This review paper gives a brief explanation on Mode-I interlaminar fracture toughness of composite material. This fracture mode is the most common modes on studying the delamination failure.
Babiker, Amir; Amer, Yasser S; Osman, Mohamed E; Al-Eyadhy, Ayman; Fatani, Solafa; Mohamed, Sarar; Alnemri, Abdulrahman; Titi, Maher A; Shaikh, Farheen; Alswat, Khalid A; Wahabi, Hayfaa A; Al-Ansary, Lubna A
2018-02-01
Implementation of clinical practice guidelines (CPGs) has been shown to reduce variation in practice and improve health care quality and patients' safety. There is a limited experience of CPG implementation (CPGI) in the Middle East. The CPG program in our institution was launched in 2009. The Quality Management department conducted a Failure Mode and Effect Analysis (FMEA) for further improvement of CPGI. This is a prospective study of a qualitative/quantitative design. Our FMEA included (1) process review and recording of the steps and activities of CPGI; (2) hazard analysis by recording activity-related failure modes and their effects, identification of actions required, assigned severity, occurrence, and detection scores for each failure mode and calculated the risk priority number (RPN) by using an online interactive FMEA tool; (3) planning: RPNs were prioritized, recommendations, and further planning for new interventions were identified; and (4) monitoring: after reduction or elimination of the failure mode. The calculated RPN will be compared with subsequent analysis in post-implementation phase. The data were scrutinized from a feedback of quality team members using a FMEA framework to enhance the implementation of 29 adapted CPGs. The identified potential common failure modes with the highest RPN (≥ 80) included awareness/training activities, accessibility of CPGs, fewer advocates from clinical champions, and CPGs auditing. Actions included (1) organizing regular awareness activities, (2) making CPGs printed and electronic copies accessible, (3) encouraging senior practitioners to get involved in CPGI, and (4) enhancing CPGs auditing as part of the quality sustainability plan. In our experience, FMEA could be a useful tool to enhance CPGI. It helped us to identify potential barriers and prepare relevant solutions. © 2017 John Wiley & Sons, Ltd.
Dehnavieh, Reza; Ebrahimipour, Hossein; Molavi-Taleghani, Yasamin; Vafaee-Najar, Ali; Noori Hekmat, Somayeh; Esmailzdeh, Hamid
2014-12-25
Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, therefore this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology. This cross-sectional study analyzed the failure mode and effects of blood transfusion process by a mixture of quantitative-qualitative method. The proactive HFMEA was used to identify and analyze the potential failures of the process. The information of the items in HFMEA forms was collected after obtaining a consensus of experts' panel views via the interview and focus group discussion sessions. The Number of 77 failure modes were identified for 24 sub-processes enlisted in 8 processes of blood transfusion. Totally 13 failure modes were identified as non-acceptable risk (a hazard score above 8) in the blood transfusion process and were transferred to the decision tree. Root causes of high risk modes were discussed in cause-effect meetings and were classified based on the UK national health system (NHS) approved classifications model. Action types were classified in the form of acceptance (11.6%), control (74.2%) and elimination (14.2%). Recommendations were placed in 7 categories using TRIZ ("Theory of Inventive Problem Solving.") The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency.
Dehnavieh, Reza; Ebrahimipour, Hossein; Molavi-Taleghani, Yasamin; Vafaee-Najar, Ali; Hekmat, Somayeh Noori; Esmailzdeh, Hamid
2015-01-01
Introduction: Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, therefore this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology. Methodology: This cross-sectional study analyzed the failure mode and effects of blood transfusion process by a mixture of quantitative-qualitative method. The proactive HFMEA was used to identify and analyze the potential failures of the process. The information of the items in HFMEA forms was collected after obtaining a consensus of experts’ panel views via the interview and focus group discussion sessions. Results: The Number of 77 failure modes were identified for 24 sub-processes enlisted in 8 processes of blood transfusion. Totally 13 failure modes were identified as non-acceptable risk (a hazard score above 8) in the blood transfusion process and were transferred to the decision tree. Root causes of high risk modes were discussed in cause-effect meetings and were classified based on the UK national health system (NHS) approved classifications model. Action types were classified in the form of acceptance (11.6%), control (74.2%) and elimination (14.2%). Recommendations were placed in 7 categories using TRIZ (“Theory of Inventive Problem Solving.”) Conclusion: The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency. PMID:25560332
Sghaireen, Mohd G
2015-06-01
The material of choice for implant-supported restorations is affected by esthetic requirements and type of abutment. This study compares the fracture resistance of different types of implant abutments and implant-supported restorations and their mode of failure. Forty-five Oraltronics Pitt-Easy implants (Oraltronics Dental Implant Technology GmbH, Bremen, Germany) (4 mm diameter, 10 mm length) were embedded in clear autopolymerizing acrylic resin. The implants were randomly divided into three groups, A, B and C, of 15 implants each. In group A, titanium abutments and metal-ceramic crowns were used. In group B, zirconia ceramic abutments and In-Ceram Alumina crowns were used. In group C, zirconia ceramic abutments and IPS Empress Esthetic crowns were used. Specimens were tested to failure by applying load at 130° from horizontal plane using an Instron Universal Testing Machine. Subsequently, the mode of failure of each specimen was identified. Fracture resistance was significantly different between groups (p < .05). The highest fracture loads were associated with metal-ceramic crowns supported by titanium abutments (p = .000). IPS Empress crowns supported by zirconia abutments had the lowest fracture loads (p = .000). Fracture modes of metal-ceramic crowns supported by titanium abutments included screw fracture and screw bending. Fracture of both crown and abutment was the dominant mode of failure of In-Ceram/IPS Empress crowns supported by zirconia abutments. Metal-ceramic crowns supported by titanium abutments were more resistant to fracture than In-Ceram crowns supported by zirconia abutments, which in turn were more resistant to fracture than IPS Empress crowns supported by zirconia abutments. In addition, failure modes of restorations supported by zirconia abutments were more catastrophic than those for restorations supported by titanium abutments. © 2013 Wiley Periodicals, Inc.
Reliability modelling and analysis of thermal MEMS
NASA Astrophysics Data System (ADS)
Muratet, Sylvaine; Lavu, Srikanth; Fourniols, Jean-Yves; Bell, George; Desmulliez, Marc P. Y.
2006-04-01
This paper presents a MEMS reliability study methodology based on the novel concept of 'virtual prototyping'. This methodology can be used for the development of reliable sensors or actuators and also to characterize their behaviour in specific use conditions and applications. The methodology is demonstrated on the U-shaped micro electro thermal actuator used as test vehicle. To demonstrate this approach, a 'virtual prototype' has been developed with the modeling tools MatLab and VHDL-AMS. A best practice FMEA (Failure Mode and Effect Analysis) is applied on the thermal MEMS to investigate and assess the failure mechanisms. Reliability study is performed by injecting the identified defaults into the 'virtual prototype'. The reliability characterization methodology predicts the evolution of the behavior of these MEMS as a function of the number of cycles of operation and specific operational conditions.
On the Mechanical Properties and Microstructure of Nitinol forBiomedical Stent Applications
DOE Office of Scientific and Technical Information (OSTI.GOV)
Robertson, Scott W.
2006-01-01
This dissertation was motivated by the alarming number of biomedical device failures reported in the literature, coupled with the growing trend towards the use of Nitinol for endovascular stents. The research is aimed at addressing two of the primary failure modes in Nitinol endovascular stents: fatigue-crack growth and overload fracture. The small dimensions of stents, coupled with their complex geometries and variability among manufacturers, make it virtually impossible to determine generic material constants associated with specific devices. Instead, the research utilizes a hybrid of standard test techniques (fracture mechanics and x-ray micro-diffraction) and custom-designed testing apparatus for the determination ofmore » the fracture properties of specimens that are suitable representations of self-expanding Nitinol stents. Specifically, the role of texture (crystallographic alignment of atoms) and the austenite-to-martensite phase transformation on the propagation of cracks in Nitinol was evaluated under simulated body conditions and over a multitude of stresses and strains. The results determined through this research were then used to create conservative safe operating and inspection criteria to be used by the biomedical community for the determination of specific device vulnerability to failure by fracture and/or fatigue.« less
NASA Technical Reports Server (NTRS)
Smart, Christian
1998-01-01
During 1997, a team from Hernandez Engineering, MSFC, Rocketdyne, Thiokol, Pratt & Whitney, and USBI completed the first phase of a two year Quantitative Risk Assessment (QRA) of the Space Shuttle. The models for the Shuttle systems were entered and analyzed by a new QRA software package. This system, termed the Quantitative Risk Assessment System(QRAS), was designed by NASA and programmed by the University of Maryland. The software is a groundbreaking PC-based risk assessment package that allows the user to model complex systems in a hierarchical fashion. Features of the software include the ability to easily select quantifications of failure modes, draw Event Sequence Diagrams(ESDs) interactively, perform uncertainty and sensitivity analysis, and document the modeling. This paper illustrates both the approach used in modeling and the particular features of the software package. The software is general and can be used in a QRA of any complex engineered system. The author is the project lead for the modeling of the Space Shuttle Main Engines (SSMEs), and this paper focuses on the modeling completed for the SSMEs during 1997. In particular, the groundrules for the study, the databases used, the way in which ESDs were used to model catastrophic failure of the SSMES, the methods used to quantify the failure rates, and how QRAS was used in the modeling effort are discussed. Groundrules were necessary to limit the scope of such a complex study, especially with regard to a liquid rocket engine such as the SSME, which can be shut down after ignition either on the pad or in flight. The SSME was divided into its constituent components and subsystems. These were ranked on the basis of the possibility of being upgraded and risk of catastrophic failure. Once this was done the Shuttle program Hazard Analysis and Failure Modes and Effects Analysis (FMEA) were used to create a list of potential failure modes to be modeled. The groundrules and other criteria were used to screen out the many failure modes that did not contribute significantly to the catastrophic risk. The Hazard Analysis and FMEA for the SSME were also used to build ESDs that show the chain of events leading from the failure mode occurence to one of the following end states: catastrophic failure, engine shutdown, or siccessful operation( successful with respect to the failure mode under consideration).
Linear quadratic servo control of a reusable rocket engine
NASA Technical Reports Server (NTRS)
Musgrave, Jeffrey L.
1991-01-01
A design method for a servo compensator is developed in the frequency domain using singular values. The method is applied to a reusable rocket engine. An intelligent control system for reusable rocket engines was proposed which includes a diagnostic system, a control system, and an intelligent coordinator which determines engine control strategies based on the identified failure modes. The method provides a means of generating various linear multivariable controllers capable of meeting performance and robustness specifications and accommodating failure modes identified by the diagnostic system. Command following with set point control is necessary for engine operation. A Kalman filter reconstructs the state while loop transfer recovery recovers the required degree of robustness while maintaining satisfactory rejection of sensor noise from the command error. The approach is applied to the design of a controller for a rocket engine satisfying performance constraints in the frequency domain. Simulation results demonstrate the performance of the linear design on a nonlinear engine model over all power levels during mainstage operation.
NASA Technical Reports Server (NTRS)
Gotch, S. M.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NAA FMEA/CIL documentation. The independent analysis results corresponding to the Orbiter Electrical Power Generation (EPG)/Power Reactants Storage and Distribution (PRSD) System Hardware is documented. The EPG/PRSD hardware is required for performing critical functions of cryogenic hydrogen and oxygen storage and distribution to the Fuel Cell Powerplants (FCP) and Atmospheric Revitalization Pressure Control Subsystem (ARPCS). Specifically, the EPG/PRSD hardware consists of the following: Hydryogen (H2) tanks; Oxygen (O2) tanks; H2 Relief Valve/Filter Packages (HRVFP); O2 Relief Valve/Filter Packages (ORVFP); H2 Valve Modules (HVM); O2 Valve Modules (OVM); and O2 and H2 lines, components, and fittings.
NASA Technical Reports Server (NTRS)
Wilson, R. E.; Riccio, J. R.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Ascent Thrust Vector Control (ATVC) Actuator hardware are documented. The function of the Ascent Thrust Vector Control Actuators (ATVC) is to gimbal the main engines to provide for attitude and flight path control during ascent. During first stage flight, the SRB nozzles provide nearly all the steering. After SRB separation, the Orbiter is steered by gimbaling of its main engines. There are six electrohydraulic servoactuators, one pitch and one yaw for each of the three main engines. Each servoactuator is composed of four electrohydraulic servovalve assemblies, one second stage power spool valve assembly, one primary piston assembly and a switching valve. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. Critical failures resulting in loss of ATVC were mainly due to loss of hydraulic fluid, fluid contamination and mechanical failures.
Failure mode and effects analysis of witnessing protocols for ensuring traceability during IVF.
Rienzi, Laura; Bariani, Fiorenza; Dalla Zorza, Michela; Romano, Stefania; Scarica, Catello; Maggiulli, Roberta; Nanni Costa, Alessandro; Ubaldi, Filippo Maria
2015-10-01
Traceability of cells during IVF is a fundamental aspect of treatment, and involves witnessing protocols. Failure mode and effects analysis (FMEA) is a method of identifying real or potential breakdowns in processes, and allows strategies to mitigate risks to be developed. To examine the risks associated with witnessing protocols, an FMEA was carried out in a busy IVF centre, before and after implementation of an electronic witnessing system (EWS). A multidisciplinary team was formed and moderated by human factors specialists. Possible causes of failures, and their potential effects, were identified and risk priority number (RPN) for each failure calculated. A second FMEA analysis was carried out after implementation of an EWS. The IVF team identified seven main process phases, 19 associated process steps and 32 possible failure modes. The highest RPN was 30, confirming the relatively low risk that mismatches may occur in IVF when a manual witnessing system is used. The introduction of the EWS allowed a reduction in the moderate-risk failure mode by two-thirds (highest RPN = 10). In our experience, FMEA is effective in supporting multidisciplinary IVF groups to understand the witnessing process, identifying critical steps and planning changes in practice to enable safety to be enhanced. Copyright © 2015 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
NASA Technical Reports Server (NTRS)
Satyanarayana, Arunkumar; Bogert, Philip B.; Chunchu, Prasad B.
2007-01-01
The influence of delamination on the progressing damage path and initial failure load in composite laminates is investigated. Results are presented from a numerical and an experimental study of center-notched tensile-loaded coupons. The numerical study includes two approaches. The first approach considers only intralaminar (fiber breakage and matrix cracking) damage modes in calculating the progression of the damage path. In the second approach, the model is extended to consider the effect of interlaminar (delamination) damage modes in addition to the intralaminar damage modes. The intralaminar damage is modeled using progressive damage analysis (PDA) methodology implemented with the VUMAT subroutine in the ABAQUS finite element code. The interlaminar damage mode has been simulated using cohesive elements in ABAQUS. In the experimental study, 2-3 specimens each of two different stacking sequences of center-notched laminates are tensile loaded. The numerical results from the two different modeling approaches are compared with each other and the experimentally observed results for both laminate types. The comparisons reveal that the second modeling approach, where the delamination damage mode is included together with the intralaminar damage modes, better simulates the experimentally observed damage modes and damage paths, which were characterized by splitting failures perpendicular to the notch tips in one or more layers. Additionally, the inclusion of the delamination mode resulted in a better prediction of the loads at which the failure took place, which were higher than those predicted by the first modeling approach which did not include delaminations.
Fatigue damage accumulation in various metal matrix composites
NASA Technical Reports Server (NTRS)
Johnson, W. S.
1987-01-01
The purpose of this paper is to review some of the latest understanding of the fatigue behavior of continuous fiber reinforced metal matrix composites. The emphasis is on the development of an understanding of different fatigue damage mechanisms and why and how they occur. The fatigue failure modes in continuous fiber reinforced metal matrix composites are controlled by the three constituents of the system: fiber, matrix, and fiber/matrix interface. The relative strains to fatigue failure of the fiber and matrix will determine the failure mode. Several examples of matrix, fiber, and self-similar damage growth dominated fatigue damage are given for several metal matrix composite systems. Composite analysis, failure modes, and damage modeling are discussed. Boron/aluminum, silicon-carbide/aluminum, FP/aluminum, and borsic/titanium metal matrix composites are discussed.
NASA Technical Reports Server (NTRS)
Bueno, R.; Chow, E.; Gershwin, S. B.; Willsky, A. S.
1975-01-01
The research is reported on the problems of failure detection and reliable system design for digital aircraft control systems. Failure modes, cross detection probability, wrong time detection, application of performance tools, and the GLR computer package are discussed.
NASA Technical Reports Server (NTRS)
Saiidi, M. J.; Duffy, R. E.; Mclaughlin, T. D.
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis/Critical Items List (FMEA/CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results corresponding to the Orbiter Atmospheric Revitalization and Pressure Control Subsystem (ARPCS) are documented. The ARPCS hardware was categorized into the following subdivisions: (1) Atmospheric Make-up and Control (including the Auxiliary Oxygen Assembly, Oxygen Assembly, and Nitrogen Assembly); and (2) Atmospheric Vent and Control (including the Positive Relief Vent Assembly, Negative Relief Vent Assembly, and Cabin Vent Assembly). The IOA analysis process utilized available ARPCS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode.
Independent Orbiter Assessment (IOA): FMEA/CIL assessment
NASA Technical Reports Server (NTRS)
Saiidi, Mo J.; Swain, L. J.; Compton, J. M.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. Direction was given by the Orbiter and GFE Projects Office to perform the hardware analysis and assessment using the instructions and ground rules defined in NSTS 22206. The IOA analysis features a top-down approach to determine hardware failure modes, criticality, and potential critical items. To preserve independence, the anlaysis was accomplished without reliance upon the results contained within the NASA and prime contractor FMEA/CIL documentation. The assessment process compares the independently derived failure modes and criticality assignments to the proposed NASA Post 51-L FMEA/CIL documentation. When possible, assessment issues are discussed and resolved with the NASA subsystem managers. The assessment results for each subsystem are summarized. The most important Orbiter assessment finding was the previously unknown stuck autopilot push-button criticality 1/1 failure mode, having a worst case effect of loss of crew/vehicle when a microwave landing system is not active.
NASA Astrophysics Data System (ADS)
Li, Hui; Ou, Jinping
2008-07-01
A number of researchers have been focused on structural vibration control in the past three decades over the world and fruit achievements have been made. This paper introduces the recent advances in structural vibration control including passive, active and semiactive control in mainland China. Additionally, the co-author extends the structural vibration control to failure mode control. The research on the failure mode control is also involved in this paper. For passive control, this paper introduces full scale tests of buckling-restrained braces conducted to investigate the performance of the dampers and the second-editor of the Code of Seismic Design for Buildings. For active control, this paper introduces the HMD system for wind-induced vibration control of the Guangzhou TV tower. For semiactive control, the smart damping devices, algorithms for semi-active control, design methods and applications of semi-active control for structures are introduced in this paper. The failure mode control for bridges is also introduced.
Failure Maps for Rectangular 17-4PH Stainless Steel Sandwiched Foam Panels
NASA Technical Reports Server (NTRS)
Raj, S. V.; Ghosn, L. J.
2007-01-01
A new and innovative concept is proposed for designing lightweight fan blades for aircraft engines using commercially available 17-4PH precipitation hardened stainless steel. Rotating fan blades in aircraft engines experience a complex loading state consisting of combinations of centrifugal, distributed pressure and torsional loads. Theoretical failure plastic collapse maps, showing plots of the foam relative density versus face sheet thickness, t, normalized by the fan blade span length, L, have been generated for rectangular 17-4PH sandwiched foam panels under these three loading modes assuming three failure plastic collapse modes. These maps show that the 17-4PH sandwiched foam panels can fail by either the yielding of the face sheets, yielding of the foam core or wrinkling of the face sheets depending on foam relative density, the magnitude of t/L and the loading mode. The design envelop of a generic fan blade is superimposed on the maps to provide valuable insights on the probable failure modes in a sandwiched foam fan blade.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Kang, D. I.; Han, S. H.
A PSA analyst has been manually determining fire-induced component failure modes and modeling them into the PSA logics. These can be difficult and time-consuming tasks as they need much information and many events are to be modeled. KAERI has been developing the IPRO-ZONE (interface program for constructing zone effect table) to facilitate fire PSA works for identifying and modeling fire-induced component failure modes, and to construct a one top fire event PSA model. With the output of the IPRO-ZONE, the AIMS-PSA, and internal event one top PSA model, one top fire events PSA model is automatically constructed. The outputs ofmore » the IPRO-ZONE include information on fire zones/fire scenarios, fire propagation areas, equipment failure modes affected by a fire, internal PSA basic events corresponding to fire-induced equipment failure modes, and fire events to be modeled. This paper introduces the IPRO-ZONE, and its application results to fire PSA of Ulchin Unit 3 and SMART(System-integrated Modular Advanced Reactor). (authors)« less
DOE Office of Scientific and Technical Information (OSTI.GOV)
Younge, K C; Lee, C I; Feng, M
2015-06-15
Purpose: To improve the safety and quality of a dual-vendor microsphere brachytherapy program with failure mode and effects analysis (FMEA). Methods: A multidisciplinary team including physicists, dosimetrists, a radiation oncologist, an interventional radiologist, and radiation safety personnel performed an FMEA for our dual-vendor microsphere brachytherapy program employing SIR-Spheres (Sirtex Medical Limited, Australia) and Theraspheres (BTG, England). We developed a program process tree and step-by-step instructions which were used to generate a comprehensive list of failure modes. These modes were then ranked according to severity, occurrence rate, and detectability. Risk priority numbers (RPNs) were calculated by multiplying these three scores together.more » Three different severity scales were created: one each for harmful effects to the patient, staff, or the institution. Each failure mode was ranked on one or more of these scales. Results: The group identified 164 failure modes for the microsphere program. 113 of these were ranked using the patient severity scale, 52 using the staff severity scale, and 50 using the institution severity scale. The highest ranked items on the patient severity scale were an error in the automated dosimetry worksheet (RPN = 297.5), and the incorrect target specified on the planning study (RPN = 135). Some failure modes ranked differently between vendors, especially those corresponding to dose vial preparation because of the different methods used. Based on our findings, we made several improvements to our QA program, including documentation to easily identify which product is being used, an additional hand calculation during planning, and reorganization of QA steps before treatment delivery. We will continue to periodically review and revise the FMEA. Conclusion: We have applied FMEA to our dual-vendor microsphere brachytherapy program to identify potential key weaknesses in the treatment chain. Our FMEA results were used to improve the effectiveness of our overall microsphere program.« less
Processing Mode Causally Influences Emotional Reactivity
Watkins, Ed; Moberly, Nicholas J.; Moulds, Michelle L.
2008-01-01
Three studies are reported showing that emotional responses to stress can be modified by systematic prior practice in adopting particular processing modes. Participants were induced to think about positive and negative scenarios in a mode either characteristic of or inconsistent with the abstract-evaluative mind-set observed in depressive rumination, via explicit instructions (Experiments 1 and 2) and via implicit induction of interpretative biases (Experiment 3), before being exposed to a failure experience. In all three studies, participants trained into the mode antithetical to depressive rumination demonstrated less emotional reactivity following failure than participants trained into the mode consistent with depressive rumination. These findings provide evidence consistent with the hypothesis that processing mode modifies emotional reactivity and support the processing-mode theory of rumination. PMID:18540752
Microcircuit failure analysis using the SEM. [Scanning Electron Microscopes
NASA Technical Reports Server (NTRS)
Nicolas, D. P.
1974-01-01
The scanning electron microscope adds a new dimension to the knowledge that can be obtained from a failed microcircuit. When used with conventional techniques, SEM assists and clarifies the analysis, but it does not replace light microscopy. The most advantageous features for microcircuit analysis are long working distances and great depth of field. Manufacturer related failure modes of microcircuits are metallization defects, poor bonding, surface and particle contamination, and design and fabrication faults. User related failure modes are caused by abuse, such as overstress. The Physics of Failure Procedure followed by the Astrionics Laboratory in failure analysis is described, which is designed to obtain maximum information available from each step.
NASA Technical Reports Server (NTRS)
Ratcliffe, James G.
2004-01-01
The edge crack torsion (ECT) test is designed to initiate mode III delamination growth in composite laminates. The test has undergone several design changes during its development. The objective of this paper was to determine the suitability of the current ECT test design a mode III fracture test. To this end, ECT tests were conducted on specimens manufactured from IM7/8552 and S2/8552 tape laminates. Three-dimensional finite element analyses were performed. The analysis results were used to calculate the distribution of mode I, mode II, and mode III strain energy release rate along the delamination front. The results indicated that mode IIIdominated delamination growth would be initiated from the specimen center. However, in specimens of both material types, the measured values of GIIIc exhibited significant dependence on delamination length. Load-displacement response of the specimens exhibited significant deviation from linearity before specimen failure. X-radiographs of a sample of specimens revealed that damage was initiated in the specimens prior to failure. Further inspection of the failure surfaces is required to identify the damage and determine that mode III delamination is initiated in the specimens.
Model-OA wind turbine generator - Failure modes and effects analysis
NASA Technical Reports Server (NTRS)
Klein, William E.; Lali, Vincent R.
1990-01-01
The results failure modes and effects analysis (FMEA) conducted for wind-turbine generators are presented. The FMEA was performed for the functional modes of each system, subsystem, or component. The single-point failures were eliminated for most of the systems. The blade system was the only exception. The qualitative probability of a blade separating was estimated at level D-remote. Many changes were made to the hardware as a result of this analysis. The most significant change was the addition of the safety system. Operational experience and need to improve machine availability have resulted in subsequent changes to the various systems, which are also reflected in this FMEA.
Effects of soil-engineering properties on the failure mode of shallow landslides
McKenna, Jonathan Peter; Santi, Paul Michael; Amblard, Xavier; Negri, Jacquelyn
2012-01-01
Some landslides mobilize into flows, while others slide and deposit material immediately down slope. An index based on initial dry density and fine-grained content of soil predicted failure mode of 96 landslide initiation sites in Oregon and Colorado with 79% accuracy. These material properties can be used to identify potential sources for debris flows and for slides. Field data suggest that loose soils can evolve from dense soils that dilate upon shearing. The method presented herein to predict failure mode is most applicable for shallow (depth 8), with few to moderate fines (fine-grained content <18%), and with liquid limits <40.
Weighting and Bayes Nets for Rollup of Surveillance Metrics
DOE Office of Scientific and Technical Information (OSTI.GOV)
Henson, Kriste; Sentz, Kari; Hamada, Michael
2012-04-30
The LANL IKE team proposes that the surveillance metrics for several data stream that are used to detect the same failure mode be weighted. Similarly, the failure mode metrics are weighted to obtain a subsystem metric. E.g., if there n data streams (nodes 1-n), the failure mode (node 0) metric is obtained as M{sub 0} = w{sub 1}M{sub 1} + {hor_ellipsis} + w{sub n}M{sub n}, where {Sigma}{sub i=1}{sup n} w{sub i} = 1. This proposal has been implemented with Bayes Nets using the Netica/IKE software by specifying an appropriate conditional probability table (CPT). This CPT is calculated using the samemore » form as (1), where the data stream metrics for the true (T) and false (F) states are replaced by 1 and 0, respectively. Then using this CPT, the failure mode metric calculated by Netica/IKE equals (1). This result has two nice features. First, the rollup Bayes nets is doing can be easily explained. Second, because Bayes Nets can implement this rollup using Netica/IKE, then data marshalling (allocating next year's budget) can be studied. A proof that the claim 'failure mode metric calculated by Netica/IKE equals (1)' for n = 2 and n = 3 follows as well as the sketch of a proof by induction for general n.« less
Independent Orbiter Assessment (IOA): Analysis of the orbiter main propulsion system
NASA Technical Reports Server (NTRS)
Mcnicoll, W. J.; Mcneely, M.; Holden, K. A.; Emmons, T. E.; Lowery, H. J.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbiter Main Propulsion System (MPS) hardware are documented. The Orbiter MPS consists of two subsystems: the Propellant Management Subsystem (PMS) and the Helium Subsystem. The PMS is a system of manifolds, distribution lines and valves by which the liquid propellants pass from the External Tank (ET) to the Space Shuttle Main Engines (SSMEs) and gaseous propellants pass from the SSMEs to the ET. The Helium Subsystem consists of a series of helium supply tanks and their associated regulators, check valves, distribution lines, and control valves. The Helium Subsystem supplies helium that is used within the SSMEs for inflight purges and provides pressure for actuation of SSME valves during emergency pneumatic shutdowns. The balance of the helium is used to provide pressure to operate the pneumatically actuated valves within the PMS. Each component was evaluated and analyzed for possible failure modes and effects. Criticalities were assigned based on the worst possible effect of each failure mode. Of the 690 failure modes analyzed, 349 were determined to be PCIs.
Magnezi, Racheli; Hemi, Asaf; Hemi, Rina
2016-01-01
Background Risk management in health care systems applies to all hospital employees and directors as they deal with human life and emergency routines. There is a constant need to decrease risk and increase patient safety in the hospital environment. The purpose of this article is to review the laboratory testing procedures for parathyroid hormone and adrenocorticotropic hormone (which are characterized by short half-lives) and to track failure modes and risks, and offer solutions to prevent them. During a routine quality improvement review at the Endocrine Laboratory in Tel Hashomer Hospital, we discovered these tests are frequently repeated unnecessarily due to multiple failures. The repetition of the tests inconveniences patients and leads to extra work for the laboratory and logistics personnel as well as the nurses and doctors who have to perform many tasks with limited resources. Methods A team of eight staff members accompanied by the Head of the Endocrine Laboratory formed the team for analysis. The failure mode and effects analysis model (FMEA) was used to analyze the laboratory testing procedure and was designed to simplify the process steps and indicate and rank possible failures. Results A total of 23 failure modes were found within the process, 19 of which were ranked by level of severity. The FMEA model prioritizes failures by their risk priority number (RPN). For example, the most serious failure was the delay after the samples were collected from the department (RPN =226.1). Conclusion This model helped us to visualize the process in a simple way. After analyzing the information, solutions were proposed to prevent failures, and a method to completely avoid the top four problems was also developed. PMID:27980440
Independent Orbiter Assessment (IOA): Analysis of the nose wheel steering subsystem
NASA Technical Reports Server (NTRS)
Mediavilla, Anthony Scott
1986-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbiter Nose Wheel Steering (NWS) hardware are documented. The NWS hardware provides primary directional control for the Orbiter vehicle during landing rollout. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the severity of the effect for each failure mode. The original NWS design was envisioned as a backup system to differential braking for directional control of the Orbiter during landing rollout. No real effort was made to design the NWS system as fail operational. The brakes have much redundancy built into their design but the poor brake/tire performance has forced the NSTS to upgrade NWS to the primary mode of directional control during rollout. As a result, a large percentage of the NWS system components have become Potential Critical Items (PCI).
Automatisms in EMIR instrument to improve operation, safety and maintenance
NASA Astrophysics Data System (ADS)
Fernández Izquierdo, Patricia; Núñez Cagigal, Miguel; Barreto Rodríguez, Roberto; Martínez Rey, Noelia; Santana Tschudi, Samuel; Barreto Cabrera, Maria; Patrón Recio, Jesús; Garzón López, Francisco
2014-08-01
EMIR is the NIR imager and multiobject spectrograph being built as a common user instrument for the 10-m class GTC. Big cryogenic instruments demand a reliable design and a specific hardware and software to increase its safety and productivity. EMIR vacuum, cooling and heating systems are monitored and partially controlled by a Programmable Logic Controller (PLC) in industrial format with a touch screen. The PLC aids the instrument operator in the maintenance tasks recovering autonomously vacuum if required or proposing preventive maintenance actions. The PLC and its associated hardware improve EMIR safety having immediate reactions against eventual failure modes in the instrument or in external supplies, including hardware failures during the heating procedure or failure in the PLC itself. EMIR PLC provides detailed information periodically about status and alarms of vacuum and cooling components or external supplies.
Human versus automation in responding to failures: an expected-value analysis
NASA Technical Reports Server (NTRS)
Sheridan, T. B.; Parasuraman, R.
2000-01-01
A simple analytical criterion is provided for deciding whether a human or automation is best for a failure detection task. The method is based on expected-value decision theory in much the same way as is signal detection. It requires specification of the probabilities of misses (false negatives) and false alarms (false positives) for both human and automation being considered, as well as factors independent of the choice--namely, costs and benefits of incorrect and correct decisions as well as the prior probability of failure. The method can also serve as a basis for comparing different modes of automation. Some limiting cases of application are discussed, as are some decision criteria other than expected value. Actual or potential applications include the design and evaluation of any system in which either humans or automation are being considered.
Investigation of a ceramic matrix composite under strain controlled fatigue condition
DOE Office of Scientific and Technical Information (OSTI.GOV)
Gudaitis, J.J.; Mall, S.
The fatigue behavior along with damage mechanisms and failure modes of a fiber reinforced ceramic matrix composite with a cross-ply lay-up was investigated under strain controlled mode. Two fatigue conditions involving tension-tension and tension-compression cycling were employed. The strain range versus fatigue life curves for both fatigue conditions were in agreement with each other. However, damage mechanisms and failure modes were different for both cases.
Li, Xixi; He, Mei; Wang, Haiyan
2017-01-01
Abstract In this study, failure mode and effect analysis (FMEA), a proactive tool, was applied to reduce errors associated with the process which begins with assessment of patient and ends with treatment of complications. The aim of this study is to assess whether FMEA implementation will significantly reduce the incidence of catheter-related bloodstream infections (CRBSIs) in intensive care unit. The FMEA team was constructed. A team of 15 medical staff from different departments were recruited and trained. Their main responsibility was to analyze and score all possible processes of central venous catheterization failures. Failure modes with risk priority number (RPN) ≥100 (top 10 RPN scores) were deemed as high-priority-risks, meaning that they needed immediate corrective action. After modifications were put, the resulting RPN was compared with the previous one. A centralized nursing care system was designed. A total of 25 failure modes were identified. High-priority risks were “Unqualified medical device sterilization” (RPN, 337), “leukopenia, very low immunity” (RPN, 222), and “Poor hand hygiene Basic diseases” (RPN, 160). The corrective measures that we took allowed a decrease in the RPNs, especially for the high-priority risks. The maximum reduction was approximately 80%, as observed for the failure mode “Not creating the maximal barrier for patient.” The averaged incidence of CRBSIs was reduced from 5.19% to 1.45%, with 3 months of 0 infection rate. The FMEA can effectively reduce incidence of CRBSIs, improve the security of central venous catheterization technology, decrease overall medical expenses, and improve nursing quality. PMID:29390515
Failure Modes and Effects Analysis of bilateral same-day cataract surgery
Shorstein, Neal H.; Lucido, Carol; Carolan, James; Liu, Liyan; Slean, Geraldine; Herrinton, Lisa J.
2017-01-01
PURPOSE To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN Retrospective cohort study. METHODS Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry. Potential failures in human factors and communication (modes) were identified. Rates of endophthalmitis, toxic anterior segment syndrome (TASS), and unintended intraocular lens (IOL) implantation were assessed in eyes having bilateral same-day surgery from 2010 through 2014. RESULTS The study comprised 4754 eyes. The analysis identified 15 significant potential failure modes. These included lapses in instrument processing and compounding error of intracameral antibiotic that could lead to endophthalmitis or TASS and ambiguous documentation of IOL selection by surgeons, which could lead to unintended IOL implantation. Of the study sample, 1 eye developed endophthalmitis, 1 eye had unintended IOL implantation (rates, 2 per 10 000; 95% confidence intervals [CI] 0.1–12.0 per 10 000), and no eyes developed TASS (upper 95% CI, 8 per 10 000). Recommendations included improving oversight of cleaning and sterilization practices, separating lots of compounded drugs for each eye, and enhancing IOL verification procedures. CONCLUSIONS Potential failure modes and recommended actions in bilateral same-day cataract surgery were determined using a FMEA. These findings might help improve the reliability and safety of bilateral same-day cataract surgery based on current evidence and standards. PMID:28410711
Space tug propulsion system failure mode, effects and criticality analysis
NASA Technical Reports Server (NTRS)
Boyd, J. W.; Hardison, E. P.; Heard, C. B.; Orourke, J. C.; Osborne, F.; Wakefield, L. T.
1972-01-01
For purposes of the study, the propulsion system was considered as consisting of the following: (1) main engine system, (2) auxiliary propulsion system, (3) pneumatic system, (4) hydrogen feed, fill, drain and vent system, (5) oxygen feed, fill, drain and vent system, and (6) helium reentry purge system. Each component was critically examined to identify possible failure modes and the subsequent effect on mission success. Each space tug mission consists of three phases: launch to separation from shuttle, separation to redocking, and redocking to landing. The analysis considered the results of failure of a component during each phase of the mission. After the failure modes of each component were tabulated, those components whose failure would result in possible or certain loss of mission or inability to return the Tug to ground were identified as critical components and a criticality number determined for each. The criticality number of a component denotes the number of mission failures in one million missions due to the loss of that component. A total of 68 components were identified as critical with criticality numbers ranging from 1 to 2990.
Sleeve Expansion of Bolt Holes in Railroad Rail : Volume I, Description and Planning
DOT National Transportation Integrated Search
1980-02-01
The most predominant failure mode of rails with bolt joints is a web crack initiating at the rail bolt hole. This failure mode is of a classical fatigue nature induced by web stress concentration around the bolt hole. This program was conducted to ap...
DOE Office of Scientific and Technical Information (OSTI.GOV)
Ciocca, Mario, E-mail: mario.ciocca@cnao.it; Cantone, Marie-Claire; Veronese, Ivan
2012-02-01
Purpose: Failure mode and effects analysis (FMEA) represents a prospective approach for risk assessment. A multidisciplinary working group of the Italian Association for Medical Physics applied FMEA to electron beam intraoperative radiation therapy (IORT) delivered using mobile linear accelerators, aiming at preventing accidental exposures to the patient. Methods and Materials: FMEA was applied to the IORT process, for the stages of the treatment delivery and verification, and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system,more » based on the product of three parameters (severity, frequency of occurrence and detectability, each ranging from 1 to 10); 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. Results: Twenty-four subprocesses were identified. Ten potential failure modes were found and scored, in terms of RPN, in the range of 42-216. The most critical failure modes consisted of internal shield misalignment, wrong Monitor Unit calculation and incorrect data entry at treatment console. Potential causes of failure included shield displacement, human errors, such as underestimation of CTV extension, mainly because of lack of adequate training and time pressures, failure in the communication between operators, and machine malfunctioning. The main effects of failure were represented by CTV underdose, wrong dose distribution and/or delivery, unintended normal tissue irradiation. As additional safety measures, the utilization of a dedicated staff for IORT, double-checking of MU calculation and data entry and finally implementation of in vivo dosimetry were suggested. Conclusions: FMEA appeared as a useful tool for prospective evaluation of patient safety in radiotherapy. The application of this method to IORT lead to identify three safety measures for risk mitigation.« less
Redundancy for electric motors in spacecraft applications
NASA Technical Reports Server (NTRS)
Smith, Robert J.; Flew, Alastair R.
1986-01-01
The parts of electric motors which should be duplicated in order to provide maximum reliability in spacecraft application are identified. Various common types of redundancy are described. The advantages and disadvantages of each are noted. The principal types are illustrated by reference to specific examples. For each example, constructional details, basic performance data and failure modes are described, together with a discussion of the suitability of particular redundancy techniques to motor types.
Automated Iodine Monitoring System Development (AIMS). [shuttle prototype
NASA Technical Reports Server (NTRS)
1975-01-01
The operating principle of the automated iodine monitoring/controller system (AIMS) is described along with several design modifications. The iodine addition system is also discussed along with test setups and calibration; a facsimile of the optical/mechanical portion of the iodine monitor was fabricated and tested. The appendices include information on shuttle prototype AIMS, preliminary prime item development specifications, preliminary failure modes and effects analysis, and preliminary operating and maintenance instructions.
Algorithm for Determination of Orion Ascent Abort Mode Achievability
NASA Technical Reports Server (NTRS)
Tedesco, Mark B.
2011-01-01
For human spaceflight missions, a launch vehicle failure poses the challenge of returning the crew safely to earth through environments that are often much more stressful than the nominal mission. Manned spaceflight vehicles require continuous abort capability throughout the ascent trajectory to protect the crew in the event of a failure of the launch vehicle. To provide continuous abort coverage during the ascent trajectory, different types of Orion abort modes have been developed. If a launch vehicle failure occurs, the crew must be able to quickly and accurately determine the appropriate abort mode to execute. Early in the ascent, while the Launch Abort System (LAS) is attached, abort mode selection is trivial, and any failures will result in a LAS abort. For failures after LAS jettison, the Service Module (SM) effectors are employed to perform abort maneuvers. Several different SM abort mode options are available depending on the current vehicle location and energy state. During this region of flight the selection of the abort mode that maximizes the survivability of the crew becomes non-trivial. To provide the most accurate and timely information to the crew and the onboard abort decision logic, on-board algorithms have been developed to propagate the abort trajectories based on the current launch vehicle performance and to predict the current abort capability of the Orion vehicle. This paper will provide an overview of the algorithm architecture for determining abort achievability as well as the scalar integration scheme that makes the onboard computation possible. Extension of the algorithm to assessing abort coverage impacts from Orion design modifications and launch vehicle trajectory modifications is also presented.
NASA Astrophysics Data System (ADS)
Lee, Tae-Hee; Park, Ka-Young; Kim, Ji-Tae; Seo, Yongho; Kim, Ki Buem; Song, Sun-Ju; Park, Byoungnam; Park, Jun-Young
2015-02-01
This study focuses on mechanisms and symptoms of several simulated failure modes, which may have significant influences on the long-term durability and operational stability of intermediate temperature-solid oxide fuel cells (IT-SOFCs), including fuel/oxidation starvation by breakdown of fuel/air supply components and wet and dry cycling atmospheres. Anode-supported IT-SOFCs consisting of a Ba0.5Sr0.5Co0.8Fe0.2O3-δ (BSCF)-Nd0.1Ce0.9O2-δ (NDC) composite cathode with an NDC electrolyte on a Ni-NDC anode substrate are fabricated via dry-pressings followed by the co-firing method. Comprehensive and systematic research based on the failure mode and effect analysis (FMEA) of anode-supported IT-SOFCs is conducted using various electrochemical and physiochemical analysis techniques to extend our understanding of the major mechanisms of performance deterioration under SOFC operating conditions. The fuel-starvation condition in the fuel-pump failure mode causes irreversible mechanical degradation of the electrolyte and cathode interface by the dimensional expansion of the anode support due to the oxidation of Ni metal to NiO. In contrast, the BSCF cathode shows poor stability under wet and dry cycling modes of cathode air due to the strong electroactivity of SrO with H2O. On the other hand, the air-depletion phenomena under air-pump failure mode results in the recovery of cell performance during the long-term operation without the visible microstructural transformation through the reduction of anode overvoltage.
Bonnabry, P; Cingria, L; Sadeghipour, F; Ing, H; Fonzo-Christe, C; Pfister, R
2005-01-01
Background: Until recently, the preparation of paediatric parenteral nutrition formulations in our institution included re-transcription and manual compounding of the mixture. Although no significant clinical problems have occurred, re-engineering of this high risk activity was undertaken to improve its safety. Several changes have been implemented including new prescription software, direct recording on a server, automatic printing of the labels, and creation of a file used to pilot a BAXA MM 12 automatic compounder. The objectives of this study were to compare the risks associated with the old and new processes, to quantify the improved safety with the new process, and to identify the major residual risks. Methods: A failure modes, effects, and criticality analysis (FMECA) was performed by a multidisciplinary team. A cause-effect diagram was built, the failure modes were defined, and the criticality index (CI) was determined for each of them on the basis of the likelihood of occurrence, the severity of the potential effect, and the detection probability. The CIs for each failure mode were compared for the old and new processes and the risk reduction was quantified. Results: The sum of the CIs of all 18 identified failure modes was 3415 for the old process and 1397 for the new (reduction of 59%). The new process reduced the CIs of the different failure modes by a mean factor of 7. The CI was smaller with the new process for 15 failure modes, unchanged for two, and slightly increased for one. The greatest reduction (by a factor of 36) concerned re-transcription errors, followed by readability problems (by a factor of 30) and chemical cross contamination (by a factor of 10). The most critical steps in the new process were labelling mistakes (CI 315, maximum 810), failure to detect a dosage or product mistake (CI 288), failure to detect a typing error during the prescription (CI 175), and microbial contamination (CI 126). Conclusions: Modification of the process resulted in a significant risk reduction as shown by risk analysis. Residual failure opportunities were also quantified, allowing additional actions to be taken to reduce the risk of labelling mistakes. This study illustrates the usefulness of prospective risk analysis methods in healthcare processes. More systematic use of risk analysis is needed to guide continuous safety improvement of high risk activities. PMID:15805453
Bonnabry, P; Cingria, L; Sadeghipour, F; Ing, H; Fonzo-Christe, C; Pfister, R E
2005-04-01
Until recently, the preparation of paediatric parenteral nutrition formulations in our institution included re-transcription and manual compounding of the mixture. Although no significant clinical problems have occurred, re-engineering of this high risk activity was undertaken to improve its safety. Several changes have been implemented including new prescription software, direct recording on a server, automatic printing of the labels, and creation of a file used to pilot a BAXA MM 12 automatic compounder. The objectives of this study were to compare the risks associated with the old and new processes, to quantify the improved safety with the new process, and to identify the major residual risks. A failure modes, effects, and criticality analysis (FMECA) was performed by a multidisciplinary team. A cause-effect diagram was built, the failure modes were defined, and the criticality index (CI) was determined for each of them on the basis of the likelihood of occurrence, the severity of the potential effect, and the detection probability. The CIs for each failure mode were compared for the old and new processes and the risk reduction was quantified. The sum of the CIs of all 18 identified failure modes was 3415 for the old process and 1397 for the new (reduction of 59%). The new process reduced the CIs of the different failure modes by a mean factor of 7. The CI was smaller with the new process for 15 failure modes, unchanged for two, and slightly increased for one. The greatest reduction (by a factor of 36) concerned re-transcription errors, followed by readability problems (by a factor of 30) and chemical cross contamination (by a factor of 10). The most critical steps in the new process were labelling mistakes (CI 315, maximum 810), failure to detect a dosage or product mistake (CI 288), failure to detect a typing error during the prescription (CI 175), and microbial contamination (CI 126). Modification of the process resulted in a significant risk reduction as shown by risk analysis. Residual failure opportunities were also quantified, allowing additional actions to be taken to reduce the risk of labelling mistakes. This study illustrates the usefulness of prospective risk analysis methods in healthcare processes. More systematic use of risk analysis is needed to guide continuous safety improvement of high risk activities.
Combined investigation of Eddy current and ultrasonic techniques for composite materials NDE
NASA Technical Reports Server (NTRS)
Davis, C. W.; Nath, S.; Fulton, J. P.; Namkung, M.
1993-01-01
Advanced composites are not without trade-offs. Their increased designability brings an increase in the complexity of their internal geometry and, as a result, an increase in the number of failure modes associated with a defect. When two or more isotropic materials are combined in a composite, the isotropic material failure modes may also combine. In a laminate, matrix delamination, cracking and crazing, and voids and porosity, will often combine with fiber breakage, shattering, waviness, and separation to bring about ultimate structural failure. This combining of failure modes can result in defect boundaries of different sizes, corresponding to the failure of each structural component. This paper discusses a dual-technology NDE (Non Destructive Evaluation) (eddy current (EC) and ultrasonics (UT)) study of graphite/epoxy (gr/ep) laminate samples. Eddy current and ultrasonic raster (Cscan) imaging were used together to characterize the effects of mechanical impact damage, high temperature thermal damage and various types of inserts in gr/ep laminate samples of various stacking sequences.
Space Shuttle Stiffener Ring Foam Failure, a Non-Conventional Approach
NASA Technical Reports Server (NTRS)
Howard, Philip M.
2007-01-01
The Space Shuttle makes use of the excellent properties of rigid polyurethane foam for cryogenic tank insulation and as structural protection on the solid rocket boosters. When foam applications debond, classical methods of analysis do not always provide root cause of the failure of the foam. Realizing that foam is the ideal media to document and preserve its own mode of failure, thin sectioning was seen as a logical approach for foam failure analysis. Thin sectioning in two directions, both horizontal and vertical to the application, was chosen to observe the three dimensional morphology of the foam cells. The cell foam morphology provided a much greater understanding of the failure modes than previously achieved.
Development of a Two-Wheel Contingency Mode for the MAP Spacecraft
NASA Technical Reports Server (NTRS)
Starin, Scott R.; ODonnell, James R., Jr.; Bauer, Frank H. (Technical Monitor)
2002-01-01
In the event of a failure of one of MAP's three reaction wheel assemblies (RWAs), it is not possible to achieve three-axis, full-state attitude control using the remaining two wheels. Hence, two of the attitude control algorithms implemented on the MAP spacecraft will no longer be usable in their current forms: Inertial Mode, used for slewing to and holding inertial attitudes, and Observing Mode, which implements the nominal dual-spin science mode. This paper describes the effort to create a complete strategy for using software algorithms to cope with a RWA failure. The discussion of the design process will be divided into three main subtopics: performing orbit maneuvers to reach and maintain an orbit about the second Earth-Sun libration point in the event of a RWA failure, completing the mission using a momentum-bias two-wheel science mode, and developing a new thruster-based mode for adjusting the inertially fixed momentum bias. In this summary, the philosophies used in designing these changes is shown; the full paper will supplement these with algorithm descriptions and testing results.
Robot Position Sensor Fault Tolerance
NASA Technical Reports Server (NTRS)
Aldridge, Hal A.
1997-01-01
Robot systems in critical applications, such as those in space and nuclear environments, must be able to operate during component failure to complete important tasks. One failure mode that has received little attention is the failure of joint position sensors. Current fault tolerant designs require the addition of directly redundant position sensors which can affect joint design. A new method is proposed that utilizes analytical redundancy to allow for continued operation during joint position sensor failure. Joint torque sensors are used with a virtual passive torque controller to make the robot joint stable without position feedback and improve position tracking performance in the presence of unknown link dynamics and end-effector loading. Two Cartesian accelerometer based methods are proposed to determine the position of the joint. The joint specific position determination method utilizes two triaxial accelerometers attached to the link driven by the joint with the failed position sensor. The joint specific method is not computationally complex and the position error is bounded. The system wide position determination method utilizes accelerometers distributed on different robot links and the end-effector to determine the position of sets of multiple joints. The system wide method requires fewer accelerometers than the joint specific method to make all joint position sensors fault tolerant but is more computationally complex and has lower convergence properties. Experiments were conducted on a laboratory manipulator. Both position determination methods were shown to track the actual position satisfactorily. A controller using the position determination methods and the virtual passive torque controller was able to servo the joints to a desired position during position sensor failure.
Design and Demonstration of Emergency Control Modes for Enhanced Engine Performance
NASA Technical Reports Server (NTRS)
Liu, Yuan; Litt, Jonathan S.; Guo, Ten-Huei
2013-01-01
A design concept is presented for developing control modes that enhance aircraft engine performance during emergency flight scenarios. The benefits of increased engine performance to overall vehicle survivability during these situations may outweigh the accompanied elevated risk of engine failure. The objective involves building control logic that can consistently increase engine performance beyond designed maximum levels based on an allowable heightened probability of failure. This concept is applied to two previously developed control modes: an overthrust mode that increases maximum engine thrust output and a faster response mode that improves thrust response to dynamic throttle commands. This paper describes the redesign of these control modes and presents simulation results demonstrating both enhanced engine performance and robust maintenance of the desired elevated risk level.
Assessment of Crack Path Prediction in Non-Proportional Mixed-Mode Fatigue
NASA Technical Reports Server (NTRS)
Highsmith, Shelby, Jr.; Johnson, Steve; Swanson, Gregory; Sayyah, Tarek; Pettit, Richard
2008-01-01
Non-proportional mixed-mode loading is present in many systems and a growing crack can experience any manner of mixed-mode loading. Prediction of the resulting crack path is important when assessing potential failure modes or when performing a failure investigation. Current crack path selection criteria are presented along with data for Inconel 718 under non-proportional mixed-mode loading. Mixed-mode crack growth can transition between path deflection mechanisms with very different orientations. Non-proportional fatigue loadings lack a single parameter for input to current crack path criteria. Crack growth transitions were observed in proportional and non-proportional FCG tests. Different paths displayed distinct fracture surface morphologies. New crack path drivers & transition criteria must be developed.
NASA Technical Reports Server (NTRS)
Raju, Ivatury S; Glaessgen, Edward H.; Mason, Brian H; Krishnamurthy, Thiagarajan; Davila, Carlos G
2005-01-01
A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. From the analyses conducted and presented in this paper, the following conclusions were drawn. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985-certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003- subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs. I.
Structural Analysis of the Right Rear Lug of American Airlines Flight 587
NASA Technical Reports Server (NTRS)
Raju, Ivatury S.; Glaessgen, Edward H.; Mason, Brian H.; Krishnamurthy, Thiagarajan; Davila, Carlos G.
2006-01-01
A detailed finite element analysis of the right rear lug of the American Airlines Flight 587 - Airbus A300-600R was performed as part of the National Transportation Safety Board s failure investigation of the accident that occurred on November 12, 2001. The loads experienced by the right rear lug are evaluated using global models of the vertical tail, local models near the right rear lug, and a global-local analysis procedure. The right rear lug was analyzed using two modeling approaches. In the first approach, solid-shell type modeling is used, and in the second approach, layered-shell type modeling is used. The solid-shell and the layered-shell modeling approaches were used in progressive failure analyses (PFA) to determine the load, mode, and location of failure in the right rear lug under loading representative of an Airbus certification test conducted in 1985 (the 1985-certification test). Both analyses were in excellent agreement with each other on the predicted failure loads, failure mode, and location of failure. The solid-shell type modeling was then used to analyze both a subcomponent test conducted by Airbus in 2003 (the 2003-subcomponent test) and the accident condition. Excellent agreement was observed between the analyses and the observed failures in both cases. The moment, Mx (moment about the fuselage longitudinal axis), has significant effect on the failure load of the lugs. Higher absolute values of Mx give lower failure loads. The predicted load, mode, and location of the failure of the 1985- certification test, 2003-subcomponent test, and the accident condition are in very good agreement. This agreement suggests that the 1985-certification and 2003-subcomponent tests represent the accident condition accurately. The failure mode of the right rear lug for the 1985-certification test, 2003-subcomponent test, and the accident load case is identified as a cleavage-type failure. For the accident case, the predicted failure load for the right rear lug from the PFA is greater than 1.98 times the limit load of the lugs.
Systematic Destruction of Electronic Parts for Aid in Electronic Failure Analysis
NASA Technical Reports Server (NTRS)
Decker, S. E.; Rolin, T. D.; McManus, P. D.
2012-01-01
NASA analyzes electrical, electronic, and electromechanical (EEE) parts used in space vehicles to understand failure modes of these components. Operational amplifiers and transistors are two examples of EEE parts critical to NASA missions that can fail due to electrical overstress (EOS). EOS is the result of voltage or current over time conditions that exceeds a component s specification limit. The objective of this study was to provide known voltage pulses over well-defined time intervals to determine the type and extent of damage imparted to the device. The amount of current was not controlled but measured so that pulse energy was determined. The damage was ascertained electrically using curve trace plots and optically using various metallographic techniques. The resulting data can be used to build a database of physical evidence to compare to damaged components removed from flight avionics. The comparison will provide the avionics failure analyst necessary information about voltage and times that caused flight or test failures when no other electrical data is available.
Validation of accelerated ageing of Thales rotary Stirling cryocoolers for the estimation of MTTF
NASA Astrophysics Data System (ADS)
Seguineau, C.,; Cauquil, J.-M.; Martin, J.-Y.; Benschop, T.
2016-05-01
The cooled IR detectors are used in a wide range of applications. Most of the time, the cryocoolers are one of the components dimensioning the lifetime of the system. The current market needs tend to reliability figures higher than 15,000hrs in "standard conditions". Field returns are hardly useable mostly because of the uncertain environmental conditions of use, or the differences in user profiles. A previous paper explains how Thales Cryogenics has developed an approach based on accelerated ageing and statistical analysis [1]. The aim of the current paper is to compare results obtained on accelerated ageing on one side, and on the other side, specific field returns where the conditions of use are well known. The comparison between prediction and effective failure rate is discussed. Moreover, a specific focus is done on how some new applications of cryocoolers (continuous operation at a specific temperature) can increase the MTTF. Some assumptions are also exposed on how the failure modes, effects and criticality analysis evolves for continuous operation at a specific temperature and compared to experimental data.
Product Support Manager Guidebook
2011-04-01
package is being developed using supportability analysis concepts such as Failure Mode, Effects and Criticality Analysis (FMECA), Fault Tree Analysis ( FTA ...Analysis (LORA) Condition Based Maintenance + (CBM+) Fault Tree Analysis ( FTA ) Failure Mode, Effects, and Criticality Analysis (FMECA) Maintenance Task...Reporting and Corrective Action System (FRACAS), Fault Tree Analysis ( FTA ), Level of Repair Analysis (LORA), Maintenance Task Analysis (MTA
Mumcu, Emre; Erdemir, Ugur; Topcu, Fulya Toksoy
2010-05-01
By means of a micro push-out test, this study compared the bond strengths of two types of fiber-reinforced posts cemented with luting cements based on two currently available adhesive approaches as well as evaluated their failure modes. Sixty extracted single-rooted human maxillary central incisor and canine teeth were sectioned below the cementoenamel junction, and the roots were endodontically treated. Following standardized post space preparation, the roots were divided into two fiber post groups and then further into three subgroups of 10 specimens each according to the luting cements. A push-out test was performed to measure regional bond strengths, and the fracture modes were evaluated using a stereomicroscope. At the root section, there were no statistically significant differences (p>0.05) in push-out bond strength among the tested luting cements. Nevertheless, the push-out bond strength values of glass fiber-reinforced posts were higher than those of carbon fiber-reinforced posts, irrespective of the adhesive approach used. On failure mode, the predominant failure mode was adhesive failure between dentin and the luting cement.
Precursory changes in seismic velocity for the spectrum of earthquake failure modes
Scuderi, M.M.; Marone, C.; Tinti, E.; Di Stefano, G.; Collettini, C.
2016-01-01
Temporal changes in seismic velocity during the earthquake cycle have the potential to illuminate physical processes associated with fault weakening and connections between the range of fault slip behaviors including slow earthquakes, tremor and low frequency earthquakes1. Laboratory and theoretical studies predict changes in seismic velocity prior to earthquake failure2, however tectonic faults fail in a spectrum of modes and little is known about precursors for those modes3. Here we show that precursory changes of wave speed occur in laboratory faults for the complete spectrum of failure modes observed for tectonic faults. We systematically altered the stiffness of the loading system to reproduce the transition from slow to fast stick-slip and monitored ultrasonic wave speed during frictional sliding. We find systematic variations of elastic properties during the seismic cycle for both slow and fast earthquakes indicating similar physical mechanisms during rupture nucleation. Our data show that accelerated fault creep causes reduction of seismic velocity and elastic moduli during the preparatory phase preceding failure, which suggests that real time monitoring of active faults may be a means to detect earthquake precursors. PMID:27597879
Independent Orbiter Assessment (IOA): Analysis of the orbital maneuvering system
NASA Technical Reports Server (NTRS)
Prust, C. D.; Paul, D. J.; Burkemper, V. J.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The independent analysis results for the Orbital Maneuvering System (OMS) hardware are documented. The OMS provides the thrust to perform orbit insertion, orbit circularization, orbit transfer, rendezvous, and deorbit. The OMS is housed in two independent pods located one on each side of the tail and consists of the following subsystems: Helium Pressurization; Propellant Storage and Distribution; Orbital Maneuvering Engine; and Electrical Power Distribution and Control. The IOA analysis process utilized available OMS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluted and analyzed for possible failure modes and effects. Criticality was asigned based upon the severity of the effect for each failure mode.
Angermann, Christiane E; Störk, Stefan; Gelbrich, Götz; Faller, Hermann; Jahns, Roland; Frantz, Stefan; Loeffler, Markus; Ertl, Georg
2012-01-01
Trials investigating efficacy of disease management programs (DMP) in heart failure reported contradictory results. Features rendering specific interventions successful are often ill defined. We evaluated the mode of action and effects of a nurse-coordinated DMP (HeartNetCare-HF, HNC). Patients hospitalized for systolic heart failure were randomly assigned to HNC or usual care (UC). Besides telephone-based monitoring and education, HNC addressed individual problems raised by patients, pursued networking of health care providers and provided training for caregivers. End points were time to death or rehospitalization (combined primary), heart failure symptoms, and quality of life (SF-36). Of 1007 consecutive patients, 715 were randomly assigned (HNC: n=352; UC: n=363; age, 69±12 years; 29% female; 40% New York Heart Association class III-IV). Within 180 days, 130 HNC and 137 UC patients reached the primary end point (hazard ratio, 1.02; 95% confidence interval, 0.81-1.30; P=0.89), since more HNC patients were readmitted. Overall, 32 HNC and 52 UC patients died (1 UC patient and 4 HNC patients after dropout); thus, uncensored hazard ratio was 0.62 (0.40-0.96; P=0.03). HNC patients improved more regarding New York Heart Association class (P=0.05), physical functioning (P=0.03), and physical health component (P=0.03). Except for HNC, health care utilization was comparable between groups. However, HNC patients requested counseling for noncardiac problems even more frequently than for cardiovascular or heart-failure-related issues. The primary end point of this study was neutral. However, mortality risk and surrogates of well-being improved significantly. Quantitative assessment of patient requirements suggested that besides (tele)monitoring individualized care considering also noncardiac problems should be integrated in efforts to achieve more sustainable improvement in heart failure outcomes. URL: http://www.controlled-trials.com. Unique identifier: ISRCTN23325295.
Failure mode analysis in adrenal vein sampling: a single-center experience.
Trerotola, Scott O; Asmar, Melissa; Yan, Yan; Fraker, Douglas L; Cohen, Debbie L
2014-10-01
To analyze failure modes in a high-volume adrenal vein sampling (AVS) practice in an effort to identify preventable causes of nondiagnostic sampling. A retrospective database was constructed containing 343 AVS procedures performed over a 10-year period. Each nondiagnostic AVS procedure was reviewed for failure mode and correlated with results of any repeat AVS. Data collected included selectivity index, lateralization index, adrenalectomy outcomes if performed, and details of AVS procedure. All AVS procedures were performed after cosyntropin stimulation, using sequential technique. AVS was nondiagnostic in 12 of 343 (3.5%) primary procedures and 2 secondary procedures. Failure was right-sided in 8 (57%) procedures, left-sided in 4 (29%) procedures, bilateral in 1 procedure, and neither in 1 procedure (laboratory error). Failure modes included diluted sample from correctly identified vein (n = 7 [50%]; 3 right and 4 left), vessel misidentified as adrenal vein (n = 3 [21%]; all right), failure to locate an adrenal vein (n = 2 [14%]; both right), cosyntropin stimulation failure (n = 1 [7%]; diagnostic by nonstimulated criteria), and laboratory error (n = 1 [7%]; specimen loss). A second AVS procedure was diagnostic in three of five cases (60%), and a third AVS procedure was diagnostic in one of one case (100%). Among the eight patients in whom AVS ultimately was not diagnostic, four underwent adrenalectomy based on diluted AVS samples, and one underwent adrenalectomy based on imaging; all five experienced improvement in aldosteronism. A substantial percentage of AVS failures occur on the left, all related to dilution. Even when technically nondiagnostic per strict criteria, some "failed" AVS procedures may be sufficient to guide therapy. Repeat AVS has a good yield. Copyright © 2014 SIR. Published by Elsevier Inc. All rights reserved.
Introduction to Concurrent Engineering: Electronic Circuit Design and Production Applications
1992-09-01
STD-1629. Failure mode distribution data for many different types of parts may be found in RAC publication FMD -91. FMEA utilizes inductive logic in a...contrasts with a Fault Tree Analysis ( FTA ) which utilizes deductive logic in a "top down" approach. In FTA , a system failure is assumed and traced down...Analysis ( FTA ) is a graphical method of risk analysis used to identify critical failure modes within a system or equipment. Utilizing a pictorial approach
NASA Technical Reports Server (NTRS)
Platt, M. E.; Lewis, E. E.; Boehm, F.
1991-01-01
A Monte Carlo Fortran computer program was developed that uses two variance reduction techniques for computing system reliability applicable to solving very large highly reliable fault-tolerant systems. The program is consistent with the hybrid automated reliability predictor (HARP) code which employs behavioral decomposition and complex fault-error handling models. This new capability is called MC-HARP which efficiently solves reliability models with non-constant failures rates (Weibull). Common mode failure modeling is also a specialty.
An investigation of gear mesh failure prediction techniques. M.S. Thesis - Cleveland State Univ.
NASA Technical Reports Server (NTRS)
Zakrajsek, James J.
1989-01-01
A study was performed in which several gear failure prediction methods were investigated and applied to experimental data from a gear fatigue test apparatus. The primary objective was to provide a baseline understanding of the prediction methods and to evaluate their diagnostic capabilities. The methods investigated use the signal average in both the time and frequency domain to detect gear failure. Data from eleven gear fatigue tests were recorded at periodic time intervals as the gears were run from initiation to failure. Four major failure modes, consisting of heavy wear, tooth breakage, single pits, and distributed pitting were observed among the failed gears. Results show that the prediction methods were able to detect only those gear failures which involved heavy wear or distributed pitting. None of the methods could predict fatigue cracks, which resulted in tooth breakage, or single pits. It is suspected that the fatigue cracks were not detected because of limitations in data acquisition rather than in methodology. Additionally, the frequency response between the gear shaft and the transducer was found to significantly affect the vibration signal. The specific frequencies affected were filtered out of the signal average prior to application of the methods.
Independent Orbiter Assessment (IOA): Analysis of the manned maneuvering unit
NASA Technical Reports Server (NTRS)
Bailey, P. S.
1986-01-01
Results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the hardware to determine failure modes, criticality, and potential critical items (PCIs). To preserve indepedence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. This report documents the independent analysis results corresponding to the Manned Maneuvering Unit (MMU) hardware. The MMU is a propulsive backpack, operated through separate hand controllers that input the pilot's translational and rotational maneuvering commands to the control electronics and then to the thrusters. The IOA analysis process utilized available MMU hardware drawings and schematics for defining hardware subsystems, assemblies, components, and hardware items. Final levels of detail were evaluated and analyzed for possible failure modes and effects. Criticality was assigned based upon the worst case severity of the effect for each identified failure mode. The IOA analysis of the MMU found that the majority of the PCIs identified are resultant from the loss of either the propulsion or control functions, or are resultant from inability to perform an immediate or future mission. The five most severe criticalities identified are all resultant from failures imposed on the MMU hand controllers which have no redundancy within the MMU.
SU-E-T-87: A TG-100 Approach for Quality Improvement of Associated Dosimetry Equipment
DOE Office of Scientific and Technical Information (OSTI.GOV)
Manger, R; Pawlicki, T; Kim, G
2015-06-15
Purpose: Dosimetry protocols devote so much time to the discussion of ionization chamber choice, use and performance that is easy to forget about the importance of the associated dosimetry equipment (ADE) in radiation dosimetry - barometer, thermometer, electrometer, phantoms, triaxial cables, etc. Improper use and inaccuracy of these devices may significantly affect the accuracy of radiation dosimetry. The purpose of this study is to evaluate the risk factors in the monthly output dosimetry procedure and recommend corrective actions using a TG-100 approach. Methods: A failure mode and effects analysis (FMEA) of the monthly linac output check procedure was performed tomore » determine which steps and failure modes carried the greatest risk. In addition, a fault tree analysis (FTA) was performed to expand the initial list of failure modes making sure that none were overlooked. After determining the failure modes with the highest risk priority numbers (RPNs), 11 physicists were asked to score corrective actions based on their ease of implementation and potential impact. The results were aggregated into an impact map to determine the implementable corrective actions. Results: Three of the top five failure modes were related to the thermometer and barometer. The two highest RPN-ranked failure modes were related to barometric pressure inaccuracy due to their high lack-of-detectability scores. Six corrective actions were proposed to address barometric pressure inaccuracy, and the survey results found the following two corrective actions to be implementable: 1) send the barometer for recalibration at a calibration laboratory and 2) check the barometer accuracy against the local airport and correct for elevation. Conclusion: An FMEA on monthly output measurements displayed the importance of ADE for accurate radiation dosimetry. When brainstorming for corrective actions, an impact map is helpful for visualizing the overall impact versus the ease of implementation.« less
Creating and evaluating a data-driven curriculum for central venous catheter placement.
Duncan, James R; Henderson, Katherine; Street, Mandie; Richmond, Amy; Klingensmith, Mary; Beta, Elio; Vannucci, Andrea; Murray, David
2010-09-01
Central venous catheter placement is a common procedure with a high incidence of error. Other fields requiring high reliability have used Failure Mode and Effects Analysis (FMEA) to prioritize quality and safety improvement efforts. To use FMEA in the development of a formal, standardized curriculum for central venous catheter training. We surveyed interns regarding their prior experience with central venous catheter placement. A multidisciplinary team used FMEA to identify high-priority failure modes and to develop online and hands-on training modules to decrease the frequency, diminish the severity, and improve the early detection of these failure modes. We required new interns to complete the modules and tracked their progress using multiple assessments. Survey results showed new interns had little prior experience with central venous catheter placement. Using FMEA, we created a curriculum that focused on planning and execution skills and identified 3 priority topics: (1) retained guidewires, which led to training on handling catheters and guidewires; (2) improved needle access, which prompted the development of an ultrasound training module; and (3) catheter-associated bloodstream infections, which were addressed through training on maximum sterile barriers. Each module included assessments that measured progress toward recognition and avoidance of common failure modes. Since introducing this curriculum, the number of retained guidewires has fallen more than 4-fold. Rates of catheter-associated infections have not yet declined, and it will take time before ultrasound training will have a measurable effect. The FMEA provided a process for curriculum development. Precise definitions of failure modes for retained guidewires facilitated development of a curriculum that contributed to a dramatic decrease in the frequency of this complication. Although infections and access complications have not yet declined, failure mode identification, curriculum development, and monitored implementation show substantial promise for improving patient safety during placement of central venous catheters.
Characterization of mode 1 and mixed-mode failure of adhesive bonds between composite adherends
NASA Technical Reports Server (NTRS)
Mall, S.; Johnson, W. S.
1985-01-01
A combined experimental and analytical investigation of an adhesively bonded composite joint was conducted to characterize both the static and fatigue beyond growth mechanism under mode 1 and mixed-mode 1 and 2 loadings. Two bonded systems were studied: graphite/epoxy adherends bonded with EC 3445 and FM-300 adhesives. For each bonded system, two specimen types were tested: a double-cantilever-beam specimen for mode 1 loading and a cracked-lapshear specimen for mixed-mode 1 and 2 loading. In all specimens tested, failure occurred in the form of debond growth. Debonding always occurred in a cohesive manner with EC 3445 adhesive. The FM-300 adhesive debonded in a cohesive manner under mixed-mode 1 and 2 loading, but in a cohesive, adhesive, or combined cohesive and adhesive manner under mode 1 loading. Total strain-energy release rate appeared to be the driving parameter for debond growth under static and fatigue loadings.
Li, Xixi; He, Mei; Wang, Haiyan
2017-12-01
In this study, failure mode and effect analysis (FMEA), a proactive tool, was applied to reduce errors associated with the process which begins with assessment of patient and ends with treatment of complications. The aim of this study is to assess whether FMEA implementation will significantly reduce the incidence of catheter-related bloodstream infections (CRBSIs) in intensive care unit.The FMEA team was constructed. A team of 15 medical staff from different departments were recruited and trained. Their main responsibility was to analyze and score all possible processes of central venous catheterization failures. Failure modes with risk priority number (RPN) ≥100 (top 10 RPN scores) were deemed as high-priority-risks, meaning that they needed immediate corrective action. After modifications were put, the resulting RPN was compared with the previous one. A centralized nursing care system was designed.A total of 25 failure modes were identified. High-priority risks were "Unqualified medical device sterilization" (RPN, 337), "leukopenia, very low immunity" (RPN, 222), and "Poor hand hygiene Basic diseases" (RPN, 160). The corrective measures that we took allowed a decrease in the RPNs, especially for the high-priority risks. The maximum reduction was approximately 80%, as observed for the failure mode "Not creating the maximal barrier for patient." The averaged incidence of CRBSIs was reduced from 5.19% to 1.45%, with 3 months of 0 infection rate.The FMEA can effectively reduce incidence of CRBSIs, improve the security of central venous catheterization technology, decrease overall medical expenses, and improve nursing quality. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
Delamination modeling of laminate plate made of sublaminates
NASA Astrophysics Data System (ADS)
Kormaníková, Eva; Kotrasová, Kamila
2017-07-01
The paper presents the mixed-mode delamination of plates made of sublaminates. To this purpose an opening load mode of delamination is proposed as failure model. The failure model is implemented in ANSYS code to calculate the mixed-mode delamination response as energy release rate. The analysis is based on interface techniques. Within the interface finite element modeling there are calculated the individual components of damage parameters as spring reaction forces, relative displacements and energy release rates along the lamination front.
Light water reactor lower head failure analysis
DOE Office of Scientific and Technical Information (OSTI.GOV)
Rempe, J.L.; Chavez, S.A.; Thinnes, G.L.
1993-10-01
This document presents the results from a US Nuclear Regulatory Commission-sponsored research program to investigate the mode and timing of vessel lower head failure. Major objectives of the analysis were to identify plausible failure mechanisms and to develop a method for determining which failure mode would occur first in different light water reactor designs and accident conditions. Failure mechanisms, such as tube ejection, tube rupture, global vessel failure, and localized vessel creep rupture, were studied. Newly developed models and existing models were applied to predict which failure mechanism would occur first in various severe accident scenarios. So that a broadermore » range of conditions could be considered simultaneously, calculations relied heavily on models with closed-form or simplified numerical solution techniques. Finite element techniques-were employed for analytical model verification and examining more detailed phenomena. High-temperature creep and tensile data were obtained for predicting vessel and penetration structural response.« less
NASA Technical Reports Server (NTRS)
Jegley, Dawn C.
1989-01-01
Results of a series of tests to determine the effects of adhesive interleaving and discontinuous plies (plies with end-to-end gaps) on the displacements, failure loads and failure modes of graphite-epoxy laminates subjected to transverse normal loads are presented. Adhesive interleaving can be used to contain local damage within a group of plies, i.e., to arrest crack propagation on the interlaminate level, and it can increase the amount of normal displacement the laminate can withstand before failure. However, the addition of adhesive interleaving to a laminate does not significantly increase its load carrying capability. A few discontinuous plies in a laminate can reduce the normal displacement and load at failure by 10 to 40 percent compared to a laminate with no discontinuous plies, but the presence of the ply discontinuities does not generally change the failure location or the failure mode of the laminate.
Sarter, Nadine B; Mumaw, Randall J; Wickens, Christopher D
2007-06-01
The objective of the study was to examine pilots' automation monitoring strategies and performance on highly automated commercial flight decks. A considerable body of research and operational experience has documented breakdowns in pilot-automation coordination on modern flight decks. These breakdowns are often considered symptoms of monitoring failures even though, to date, only limited and mostly anecdotal data exist concerning pilots' monitoring strategies and performance. Twenty experienced B-747-400 airline pilots flew a 1-hr scenario involving challenging automation-related events on a full-mission simulator. Behavioral, mental model, and eye-tracking data were collected. The findings from this study confirm that pilots monitor basic flight parameters to a much greater extent than visual indications of the automation configuration. More specifically, they frequently fail to verify manual mode selections or notice automatic mode changes. In other cases, they do not process mode annunciations in sufficient depth to understand their implications for aircraft behavior. Low system observability and gaps in pilots' understanding of complex automation modes were shown to contribute to these problems. Our findings describe and explain shortcomings in pilot's automation monitoring strategies and performance based on converging behavioral, eye-tracking, and mental model data. They confirm that monitoring failures are one major contributor to breakdowns in pilot-automation interaction. The findings from this research can inform the design of improved training programs and automation interfaces that support more effective system monitoring.
NASA Technical Reports Server (NTRS)
Vanschalkwyk, Christiaan Mauritz
1991-01-01
Many applications require that a control system must be tolerant to the failure of its components. This is especially true for large space-based systems that must work unattended and with long periods between maintenance. Fault tolerance can be obtained by detecting the failure of the control system component, determining which component has failed, and reconfiguring the system so that the failed component is isolated from the controller. Component failure detection experiments that were conducted on an experimental space structure, the NASA Langley Mini-Mast are presented. Two methodologies for failure detection and isolation (FDI) exist that do not require the specification of failure modes and are applicable to both actuators and sensors. These methods are known as the Failure Detection Filter and the method of Generalized Parity Relations. The latter method was applied to three different sensor types on the Mini-Mast. Failures were simulated in input-output data that were recorded during operation of the Mini-Mast. Both single and double sensor parity relations were tested and the effect of several design parameters on the performance of these relations is discussed. The detection of actuator failures is also treated. It is shown that in all the cases it is possible to identify the parity relations directly from input-output data. Frequency domain analysis is used to explain the behavior of the parity relations.
Vivanti, Refael; Joskowicz, Leo; Lev-Cohain, Naama; Ephrat, Ariel; Sosna, Jacob
2018-03-10
Radiological longitudinal follow-up of tumors in CT scans is essential for disease assessment and liver tumor therapy. Currently, most tumor size measurements follow the RECIST guidelines, which can be off by as much as 50%. True volumetric measurements are more accurate but require manual delineation, which is time-consuming and user-dependent. We present a convolutional neural networks (CNN) based method for robust automatic liver tumor delineation in longitudinal CT studies that uses both global and patient specific CNNs trained on a small database of delineated images. The inputs are the baseline scan and the tumor delineation, a follow-up scan, and a liver tumor global CNN voxel classifier built from radiologist-validated liver tumor delineations. The outputs are the tumor delineations in the follow-up CT scan. The baseline scan tumor delineation serves as a high-quality prior for the tumor characterization in the follow-up scans. It is used to evaluate the global CNN performance on the new case and to reliably predict failures of the global CNN on the follow-up scan. High-scoring cases are segmented with a global CNN; low-scoring cases, which are predicted to be failures of the global CNN, are segmented with a patient-specific CNN built from the baseline scan. Our experimental results on 222 tumors from 31 patients yield an average overlap error of 17% (std = 11.2) and surface distance of 2.1 mm (std = 1.8), far better than stand-alone segmentation. Importantly, the robustness of our method improved from 67% for stand-alone global CNN segmentation to 100%. Unlike other medical imaging deep learning approaches, which require large annotated training datasets, our method exploits the follow-up framework to yield accurate tumor tracking and failure detection and correction with a small training dataset. Graphical abstract Flow diagram of the proposed method. In the offline mode (orange), a global CNN is trained as a voxel classifier to segment liver tumor as in [31]. The online mode (blue) is used for each new case. The input is baseline scan with delineation and the follow-up CT scan to be segmented. The main novelty is the ability to predict failures by trying the system on the baseline scan and the ability to correct them using the patient-specific CNN.
Application of failure mode and effect analysis in a radiology department.
Thornton, Eavan; Brook, Olga R; Mendiratta-Lala, Mishal; Hallett, Donna T; Kruskal, Jonathan B
2011-01-01
With increasing deployment, complexity, and sophistication of equipment and related processes within the clinical imaging environment, system failures are more likely to occur. These failures may have varying effects on the patient, ranging from no harm to devastating harm. Failure mode and effect analysis (FMEA) is a tool that permits the proactive identification of possible failures in complex processes and provides a basis for continuous improvement. This overview of the basic principles and methodology of FMEA provides an explanation of how FMEA can be applied to clinical operations in a radiology department to reduce, predict, or prevent errors. The six sequential steps in the FMEA process are explained, and clinical magnetic resonance imaging services are used as an example for which FMEA is particularly applicable. A modified version of traditional FMEA called Healthcare Failure Mode and Effect Analysis, which was introduced by the U.S. Department of Veterans Affairs National Center for Patient Safety, is briefly reviewed. In conclusion, FMEA is an effective and reliable method to proactively examine complex processes in the radiology department. FMEA can be used to highlight the high-risk subprocesses and allows these to be targeted to minimize the future occurrence of failures, thus improving patient safety and streamlining the efficiency of the radiology department. RSNA, 2010
2013-01-01
Background A multidisciplinary and multi-institutional working group applied the Failure Mode and Effects Analysis (FMEA) approach to the actively scanned proton beam radiotherapy process implemented at CNAO (Centro Nazionale di Adroterapia Oncologica), aiming at preventing accidental exposures to the patient. Methods FMEA was applied to the treatment planning stage and consisted of three steps: i) identification of the involved sub-processes; ii) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system, iii) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. Results Thirty-four sub-processes were identified, twenty-two of them were judged to be potentially prone to one or more failure modes. A total of forty-four failure modes were recognized, 52% of them characterized by an RPN score equal to 80 or higher. The threshold of 125 for RPN was exceeded in five cases only. The most critical sub-process appeared related to the delineation and correction of artefacts in planning CT data. Failures associated to that sub-process were inaccurate delineation of the artefacts and incorrect proton stopping power assignment to body regions. Other significant failure modes consisted of an outdated representation of the patient anatomy, an improper selection of beam direction and of the physical beam model or dose calculation grid. The main effects of these failures were represented by wrong dose distribution (i.e. deviating from the planned one) delivered to the patient. Additional strategies for risk mitigation, easily and immediately applicable, consisted of a systematic information collection about any known implanted prosthesis directly from each patient and enforcing a short interval time between CT scan and treatment start. Moreover, (i) the investigation of dedicated CT image reconstruction algorithms, (ii) further evaluation of treatment plan robustness and (iii) implementation of independent methods for dose calculation (such as Monte Carlo simulations) may represent novel solutions to increase patient safety. Conclusions FMEA is a useful tool for prospective evaluation of patient safety in proton beam radiotherapy. The application of this method to the treatment planning stage lead to identify strategies for risk mitigation in addition to the safety measures already adopted in clinical practice. PMID:23705626
Song, Z Q; Ni, Y; Peng, L M; Liang, H Y; He, L H
2016-03-31
Bioinspired discontinuous nanolaminate design becomes an efficient way to mitigate the strength-ductility tradeoff in brittle materials via arresting the crack at the interface followed by controllable interface failure. The analytical solution and numerical simulation based on the nonlinear shear-lag model indicates that propagation of the interface failure can be unstable or stable when the interfacial shear stress between laminae is uniform or highly localized, respectively. A dimensionless key parameter defined by the ratio of two characteristic lengths governs the transition between the two interface-failure modes, which can explain the non-monotonic size-dependent mechanical properties observed in various laminate composites.
Failure modes and effects analysis automation
NASA Technical Reports Server (NTRS)
Kamhieh, Cynthia H.; Cutts, Dannie E.; Purves, R. Byron
1988-01-01
A failure modes and effects analysis (FMEA) assistant was implemented as a knowledge based system and will be used during design of the Space Station to aid engineers in performing the complex task of tracking failures throughout the entire design effort. The three major directions in which automation was pursued were the clerical components of the FMEA process, the knowledge acquisition aspects of FMEA, and the failure propagation/analysis portions of the FMEA task. The system is accessible to design, safety, and reliability engineers at single user workstations and, although not designed to replace conventional FMEA, it is expected to decrease by many man years the time required to perform the analysis.
Remote Structural Health Monitoring and Advanced Prognostics of Wind Turbines
DOE Office of Scientific and Technical Information (OSTI.GOV)
Douglas Brown; Bernard Laskowski
The prospect of substantial investment in wind energy generation represents a significant capital investment strategy. In order to maximize the life-cycle of wind turbines, associated rotors, gears, and structural towers, a capability to detect and predict (prognostics) the onset of mechanical faults at a sufficiently early stage for maintenance actions to be planned would significantly reduce both maintenance and operational costs. Advancement towards this effort has been made through the development of anomaly detection, fault detection and fault diagnosis routines to identify selected fault modes of a wind turbine based on available sensor data preceding an unscheduled emergency shutdown. Themore » anomaly detection approach employs spectral techniques to find an approximation of the data using a combination of attributes that capture the bulk of variability in the data. Fault detection and diagnosis (FDD) is performed using a neural network-based classifier trained from baseline and fault data recorded during known failure conditions. The approach has been evaluated for known baseline conditions and three selected failure modes: pitch rate failure, low oil pressure failure and a gearbox gear-tooth failure. Experimental results demonstrate the approach can distinguish between these failure modes and normal baseline behavior within a specified statistical accuracy.« less
Rapid repair of severely earthquake-damaged bridge piers with flexural-shear failure mode
NASA Astrophysics Data System (ADS)
Sun, Zhiguo; Wang, Dongsheng; Du, Xiuli; Si, Bingjun
2011-12-01
An experimental study was conducted to investigate the feasibility of a proposed rapid repair technique for severely earthquake-damaged bridge piers with flexural-shear failure mode. Six circular pier specimens were first tested to severe damage in flexural-shear mode and repaired using early-strength concrete with high-fluidity and carbon fiber reinforced polymers (CFRP). After about four days, the repaired specimens were tested to failure again. The seismic behavior of the repaired specimens was evaluated and compared to the original specimens. Test results indicate that the proposed repair technique is highly effective. Both shear strength and lateral displacement of the repaired piers increased when compared to the original specimens, and the failure mechanism of the piers shifted from flexural-shear failure to ductile flexural failure. Finally, a simple design model based on the Seible formulation for post-earthquake repair design was compared to the experimental results. It is concluded that the design equation for bridge pier strengthening before an earthquake could be applicable to seismic repairs after an earthquake if the shear strength contribution of the spiral bars in the repaired piers is disregarded and 1.5 times more FRP sheets is provided.
22nd Annual Logistics Conference and Exhibition
2006-04-20
Prognostics & Health Management at GE Dr. Piero P.Bonissone Industrial AI Lab GE Global Research NCD Select detection model Anomaly detection results...Mode 213 x Failure mode histogram 2130014 Anomaly detection from event-log data Anomaly detection from event-log data Diagnostics/ Prognostics Using...Failure Monitoring & AssessmentTactical C4ISR Sense Respond 7 •Diagnostics, Prognostics and health management
2012-06-01
Visa Investigate Data Breach March 30, 2012 Visa and MasterCard are investigating whether a data security breach at one of the main companies that...30). MasterCard and Visa Investigate Data Breach . New York Times . Stamatis, D. (2003). Failure Mode Effect Analysis: FMEA from Theory to Execution
Independent Orbiter Assessment (IOA): Assessment of the EPD and C/remote manipulator system FMEA/CIL
NASA Technical Reports Server (NTRS)
Robinson, W. W.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Electrical Power Distribution and Control (EPD and C)/Remote Manipulator System (RMS) hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA analysis of the EPD and C/RMS hardware initially generated 345 failure mode worksheets and identified 117 Potential Critical Items (PCIs) before starting the assessment process. These analysis results were compared to the proposed NASA Post 51-L baseline of 132 FMEAs and 66 CIL items.
Investigation of precipitate refinement in Mg alloys by an analytical composite failure model
DOE Office of Scientific and Technical Information (OSTI.GOV)
Tabei, Ali; Li, Dongsheng; Lavender, Curt A.
2015-10-01
An analytical model is developed to simulate precipitate refinement in second phase strengthened magnesium alloys. The model is developed based on determination of the stress fields inside elliptical precipitates embedded in a rate dependent inelastic matrix. The stress fields are utilized to determine the failure mode that governs the refinement behavior. Using an AZ31 Mg alloy as an example, the effects the applied load, aspect ratio and orientation of the particle is studied on the macroscopic failure of a single α-Mg17Al12 precipitate. Additionally, a temperature dependent version of the corresponding constitutive law is used to incorporate the effects of temperature.more » In plane strain compression, an extensional failure mode always fragments the precipitates. The critical strain rate at which the precipitates start to fail strongly depends on the orientation of the precipitate with respect to loading direction. The results show that the higher the aspect ratio is, the easier the precipitate fractures. Precipitate shape is another factor influencing the failure response. In contrast to elliptical precipitates with high aspect ratio, spherical precipitates are strongly resistant to sectioning. In pure shear loading, in addition to the extensional mode of precipitate failure, a shearing mode may get activated depending on orientation and aspect ratio of the precipitate. The effect of temperature in relation to strain rate was also verified for plane strain compression and pure shear loading cases.« less
A comparative critical study between FMEA and FTA risk analysis methods
NASA Astrophysics Data System (ADS)
Cristea, G.; Constantinescu, DM
2017-10-01
Today there is used an overwhelming number of different risk analyses techniques with acronyms such as: FMEA (Failure Modes and Effects Analysis) and its extension FMECA (Failure Mode, Effects, and Criticality Analysis), DRBFM (Design Review by Failure Mode), FTA (Fault Tree Analysis) and and its extension ETA (Event Tree Analysis), HAZOP (Hazard & Operability Studies), HACCP (Hazard Analysis and Critical Control Points) and What-if/Checklist. However, the most used analysis techniques in the mechanical and electrical industry are FMEA and FTA. In FMEA, which is an inductive method, information about the consequences and effects of the failures is usually collected through interviews with experienced people, and with different knowledge i.e., cross-functional groups. The FMEA is used to capture potential failures/risks & impacts and prioritize them on a numeric scale called Risk Priority Number (RPN) which ranges from 1 to 1000. FTA is a deductive method i.e., a general system state is decomposed into chains of more basic events of components. The logical interrelationship of how such basic events depend on and affect each other is often described analytically in a reliability structure which can be visualized as a tree. Both methods are very time-consuming to be applied thoroughly, and this is why it is oftenly not done so. As a consequence possible failure modes may not be identified. To address these shortcomings, it is proposed to use a combination of FTA and FMEA.
Veronese, Ivan; De Martin, Elena; Martinotti, Anna Stefania; Fumagalli, Maria Luisa; Vite, Cristina; Redaelli, Irene; Malatesta, Tiziana; Mancosu, Pietro; Beltramo, Giancarlo; Fariselli, Laura; Cantone, Marie Claire
2015-06-13
A multidisciplinary and multi-institutional working group applied the Failure Mode and Effects Analysis (FMEA) approach to assess the risks for patients undergoing Stereotactic Body Radiation Therapy (SBRT) treatments for lesions located in spine and liver in two CyberKnife® Centres. The various sub-processes characterizing the SBRT treatment were identified to generate the process trees of both the treatment planning and delivery phases. This analysis drove to the identification and subsequent scoring of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system. Novel solutions aimed to increase patient safety were accordingly considered. The process-tree characterising the SBRT treatment planning stage was composed with a total of 48 sub-processes. Similarly, 42 sub-processes were identified in the stage of delivery to liver tumours and 30 in the stage of delivery to spine lesions. All the sub-processes were judged to be potentially prone to one or more failure modes. Nineteen failures (i.e. 5 in treatment planning stage, 5 in the delivery to liver lesions and 9 in the delivery to spine lesions) were considered of high concern in view of the high RPN and/or severity index value. The analysis of the potential failures, their causes and effects allowed to improve the safety strategies already adopted in the clinical practice with additional measures for optimizing quality management workflow and increasing patient safety.
Spacecraft Parachute Recovery System Testing from a Failure Rate Perspective
NASA Technical Reports Server (NTRS)
Stewart, Christine E.
2013-01-01
Spacecraft parachute recovery systems, especially those with a parachute cluster, require testing to identify and reduce failures. This is especially important when the spacecraft in question is human-rated. Due to the recent effort to make spaceflight affordable, the importance of determining a minimum requirement for testing has increased. The number of tests required to achieve a mature design, with a relatively constant failure rate, can be estimated from a review of previous complex spacecraft recovery systems. Examination of the Apollo parachute testing and the Shuttle Solid Rocket Booster recovery chute system operation will clarify at which point in those programs the system reached maturity. This examination will also clarify the risks inherent in not performing a sufficient number of tests prior to operation with humans on-board. When looking at complex parachute systems used in spaceflight landing systems, a pattern begins to emerge regarding the need for a minimum amount of testing required to wring out the failure modes and reduce the failure rate of the parachute system to an acceptable level for human spaceflight. Not only a sufficient number of system level testing, but also the ability to update the design as failure modes are found is required to drive the failure rate of the system down to an acceptable level. In addition, sufficient data and images are necessary to identify incipient failure modes or to identify failure causes when a system failure occurs. In order to demonstrate the need for sufficient system level testing prior to an acceptable failure rate, the Apollo Earth Landing System (ELS) test program and the Shuttle Solid Rocket Booster Recovery System failure history will be examined, as well as some experiences in the Orion Capsule Parachute Assembly System will be noted.
Blaker, Carina L; Little, Christopher B; Clarke, Elizabeth C
2017-08-01
Anterior cruciate ligament (ACL) tears are a common knee injury with a known but poorly understood association with secondary joint injuries and post-traumatic osteoarthritis (OA). Female sex and age are known risk factors for ACL injury but these variables are rarely explored in mouse models of injury. This study aimed to further characterize a non-surgical ACL injury model to determine its clinical relevance across a wider range of mouse specifications. Cadaveric and anesthetized C57BL/6 mice (9-52 weeks of age) underwent joint loading to investigate the effects of age, sex, and body mass on ACL injury mechanisms. The ACL injury load (whole joint load required to rupture the ACL) was measured from force-displacement data, and mode of failure was assessed using micro-dissection and histology. ACL injury load was found to increase with body mass and age (p < 0.001) but age was not significant when controlling for mass. Sex had no effect. In contrast, the mode of ACL failure varied with both age and sex groups. Avulsion fractures (complete or mixed with mid-substance tears) were common in all age groups but the proportion of mixed and mid-substance failures increased with age. Females were more likely than males to have a major avulsion relative to a mid-substance tear (p < 0.01). This data compliments studies in human cadaveric knees, and provides a basis for determining the severity of joint injury relative to a major ACL tear in mice, and for selecting joint loading conditions in future experiments using this model. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1754-1763, 2017. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Dynamic Structural Fault Detection and Identification
NASA Technical Reports Server (NTRS)
Smith, Timothy; Reichenbach, Eric; Urnes, James M.
2009-01-01
Aircraft structures are designed to guarantee safety of flight in some required operational envelope. When the aircraft becomes structurally impaired, safety of flight may not be guaranteed within that previously safe operational envelope. In this case the safe operational envelope must be redefined in-flight and a means to prevent excursion from this new envelope must be implemented. A specific structural failure mode that may result in a reduced safe operating envelope, the exceedance of which could lead to catastrophic structural failure of the aircraft, will be addressed. The goal of the DFEAP program is the detection of this failure mode coupled with flight controls adaptation to limit critical loads in the damaged aircraft structure. The DFEAP program is working with an F/A-18 aircraft model. The composite wing skins are bonded to metallic spars in the wing substructure. Over time, it is possible that this bonding can deteriorate due to fatigue. In this case, the ability of the wing spar to transfer loading between the wing skins is reduced. This failure mode can translate to a reduced allowable compressive strain on the wing skin and could lead to catastrophic wing buckling if load limiting of the wing structure is not applied. The DFEAP program will make use of a simplified wing strain model for the healthy aircraft. The outputs of this model will be compared in real-time to onboard strain measurements at several locations on the aircraft wing. A damage condition is declared at a given location when the strain measurements differ sufficiently from the strain model. Parameter identification of the damaged structure wing strain parameters will be employed to provide load limiting control adaptation for the aircraft. This paper will discuss the simplified strain models used in the implementation and their interaction with the strain sensor measurements. Also discussed will be the damage detection and identification schemes employed and the means by which the damaged aircraft parameters will be used to provide load limiting that keeps the aircraft within the safe operational envelope.
Hover, Alexander R; Sistrunk, William W; Cavagnol, Robert M; Scarrow, Alan; Finley, Phillip J; Kroencke, Audrey D; Walker, Judith L
2014-01-01
Mercy Hospital Springfield is a tertiary care facility with 32 000 discharges and 15 000 inpatient surgeries in 2011. From June 2009 through January 2011, a stable inpatient elective neurosurgery infection rate of 2.15% was observed. The failure mode and effects analysis (FMEA) methodology to reduce inpatient neurosurgery infections was utilized. Following FMEA implementation, overall elective neurosurgery infection rates were reduced to 1.51% and sustained through May 2012. Compared with baseline, the post-FMEA deep-space and organ infection rate was reduced by 41% (P = .052). Overall hospital inpatient clean surgery infection rates for the same time frame did not decrease to the same extent, suggesting a specific effect of the FMEA. The study team believes that the FMEA interventions resulted in 14 fewer expected infections, $270 270 in savings, a 168-day reduction in expected length of stay, and 22 fewer readmissions. Given the serious morbidity and cost of health care-associated infections, the study team concludes that FMEA implementation was clinically cost-effective. © 2013 by the American College of Medical Quality.
Socket position determines hip resurfacing 10-year survivorship.
Amstutz, Harlan C; Le Duff, Michel J; Johnson, Alicia J
2012-11-01
Modern metal-on-metal hip resurfacing arthroplasty designs have been used for over a decade. Risk factors for short-term failure include small component size, large femoral head defects, low body mass index, older age, high level of sporting activity, and component design, and it is established there is a surgeon learning curve. Owing to failures with early surgical techniques, we developed a second-generation technique to address those failures. However, it is unclear whether the techniques affected the long-term risk factors. We (1) determined survivorship for hips implanted with the second-generation cementing technique; (2) identified the risk factors for failure in these patients; and (3) determined the effect of the dominant risk factors on the observed modes of failure. We retrospectively reviewed the first 200 hips (178 patients) implanted using our second-generation surgical technique, which consisted of improvements in cleaning and drying the femoral head before and during cement application. There were 129 men and 49 women. Component orientation and contact patch to rim distance were measured. We recorded the following modes of failure: femoral neck fracture, femoral component loosening, acetabular component loosening, wear, dislocation, and sepsis. The minimum followup was 25 months (mean, 106.5 months; range, 25-138 months). Twelve hips were revised. Kaplan-Meier survivorship was 98.0% at 5 years and 94.3% at 10 years. The only variable associated with revision was acetabular component position. Contact patch to rim distance was lower in hips that dislocated, were revised for wear, or were revised for acetabular loosening. The dominant modes of failure were related to component wear or acetabular component loosening. Acetabular component orientation, a factor within the surgeon's control, determines the long-term success of our current hip resurfacing techniques. Current techniques have changed the modes of failure from aseptic femoral failure to wear or loosening of the acetabular component. Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Burgess, Robert M.; Post, Matthew B.; Buttner, William J.
Pressure relief devices (PRDs ) are used to protect high pressure systems from burst failure caused by overpressurization. Codes and standards require the use of PRDs for the safe design of many pressurized systems. These systems require high reliability due to the risks associated with a burst failure. Hydrogen service can increase the risk of PRD failure due to material property degradation caused by hydrogen attack. The National Renewable Energy Laboratory (NREL) has conducted an accelerated life test on a conventional spring loaded PRD. Based on previous failures in the field, the nozzles specific to these PRDs are of particularmore » interest. A nozzle in a PRD is a small part that directs the flow of fluid toward the sealing surface to maintain the open state of the valve once the spring force is overcome. The nozzle in this specific PRD is subjected to the full tensile force of the fluid pressure. These nozzles are made from 440C material, which is a type of hardened steel that is commonly chosen for high pressure applications because of its high strength properties. In a hydrogen environment, however, 440C is considered a worst case material since hydrogen attack results in a loss of almost all ductility and thus 440C is prone to fatigue and material failure. Accordingly, 440C is not recommended for hydrogen service. Conducting an accelerated life test on a PRD with 440C material provides information on necessary and sufficient conditions required to produce crack initiation and failure. The accelerated life test also provides information on other PRD failure modes that are somewhat statistically random in nature.« less
Comparison of two different modes of molecular adsorbent recycling systems for liver dialysis.
Soo, Euan; Sanders, Anja; Heckert, Karlheinz; Vinke, Tobias; Schaefer, Franz; Schmitt, Claus Peter
2016-11-01
In children acute liver failure is a rare but life-threatening condition from which two-thirds do not recover with supportive therapy. Treatment is limited by the availability of liver transplants. Molecular adsorbent recirculating system (MARS) dialysis is a bridge to transplantation that enhances the chances of survival during the waiting period for a transplant, although it cannot improve survival. Open albumin dialysis (OPAL) is a new mode of albumin dialysis developed to further improve dialysis efficiency. We report a paediatric case of acute-on-chronic liver failure and compare the two modes of albumin dialysis, namely, the MARS and OPAL, used to treat this patient's cholestatic pruritus. Removal of total and direct bilirubin, ammonia and bile acids were measured by serial blood tests. There was an increased removal of bile acids with the OPAL mode, whereas the removal of total and direct bilirubin and ammonia was similar in both modes. The patient reported better improvement in pruritus following OPAL compared to dialysis with the MARS. OPAL may offer a better solution than the MARS in the treatment of refractory pruritus in liver failure.
Chopper-controlled discharge life cycling studies on lead-acid batteries
NASA Technical Reports Server (NTRS)
Kraml, J. J.; Ames, E. P.
1982-01-01
State-of-the-art 6 volt lead-acid golf car batteries were tested. A daily charge/discharge cycling to failure points under various chopper controlled pulsed dc and continuous current load conditions was undertaken. The cycle life and failure modes were investigated for depth of discharge, average current chopper frequency, and chopper duty cycle. It is shown that battery life is primarily and inversely related to depth of discharge and discharge current. Failure mode is characterized by a gradual capacity loss with consistent evidence of cell element aging.
NASA Technical Reports Server (NTRS)
White, A. L.
1983-01-01
This paper examines the reliability of three architectures for six components. For each architecture, the probabilities of the failure states are given by algebraic formulas involving the component fault rate, the system recovery rate, and the operating time. The dominant failure modes are identified, and the change in reliability is considered with respect to changes in fault rate, recovery rate, and operating time. The major conclusions concern the influence of system architecture on failure modes and parameter requirements. Without this knowledge, a system designer may pick an inappropriate structure.
NASA Technical Reports Server (NTRS)
Khan, P.; Epp, L.
2006-01-01
Results of prototype hardware activities related to a 120-W, 32-GHz (Ka-band) solid-state power amplifier (SSPA) architecture study are presented. Spurious mode suppression and the power-handling capability of a prototype 24-way radial combiner and a prototype 2-way septum binary combiner were investigated. Experimental data indicate that a commercial absorptive filter, designed to pass the circular TE01 mode, effectively suppressed the higher-order modes generated by a narrowband, flower-petal-type mode transducer. However, the same filter was not effective in suppressing higher-order modes generated by the broadband Marie mode transducer that is used in the prototype waveguide radial combiner. Should greater filtering be required by a particular SSPA application, a broadband mode filter that can suppress specifically those higher-order modes that are generated by the Marie transducer will need to be developed. A back-to-back configuration of the prototype radial combiner was tested with drive power up to approximately 50 W. No anomalous behavior was observed. Power measurements of the septum combiner indicate that up to 10-W radio frequency (RF) can be dissipated in the integrated resistive element before a permanent performance shift is observed. Thus, a given adder (a single-stage, 2-way combiner) can safely combine two 20-W sources, and the adder will not be damaged in the event of a source failure. This result is used to calculate the maximum source power that can be safely combined as a function of the number of sources combined and the number of source failures allowed in a multi-stage combiner. The analysis shows that SSPA power >140 W can be generated by power combining 16 sources producing 10 W each. In this configuration, up to three sources could fail with the guarantee that the combiner would not be damaged. Finally, a modified prototype septum combiner design was verified. The improved design reduced the assembly time from over 2 hours to about 15 minutes per adder.
Using Combined SFTA and SFMECA Techniques for Space Critical Software
NASA Astrophysics Data System (ADS)
Nicodemos, F. G.; Lahoz, C. H. N.; Abdala, M. A. D.; Saotome, O.
2012-01-01
This work addresses the combined Software Fault Tree Analysis (SFTA) and Software Failure Modes, Effects and Criticality Analysis (SFMECA) techniques applied to space critical software of satellite launch vehicles. The combined approach is under research as part of the Verification and Validation (V&V) efforts to increase software dependability and as future application in other projects under development at Instituto de Aeronáutica e Espaço (IAE). The applicability of such approach was conducted on system software specification and applied to a case study based on the Brazilian Satellite Launcher (VLS). The main goal is to identify possible failure causes and obtain compensating provisions that lead to inclusion of new functional and non-functional system software requirements.
Evaluation of the split cantilever beam for Mode 3 delamination testing
NASA Technical Reports Server (NTRS)
Martin, Roderick H.
1989-01-01
A test rig for testing a thick split cantilever beam for scissoring delamination (mode 3) fracture toughness was developed. A 3-D finite element analysis was conducted on the test specimen to determine the strain energy release rate, G, distribution along the delamination front. The virtual crack closure technique was used to calculate the G components resulting from interlaminar tension, GI, interlaminar sliding shear, GII, and interlaminar tearing shear, GIII. The finite element analysis showed that at the delamination front no GI component existed, but a GII component was present in addition to a GIII component. Furthermore, near the free edges, the GII component was significantly higher than the GIII component. The GII/GIII ratio was found to increase with delamination length but was insensitive to the beam depth. The presence of GII at the delamination front was verified experimentally by examination of the failure surfaces. At the center of the beam, where the failure was in mode 3, there was significant fiber bridging. However, at the edges of the beam where the failure was in mode 3, there was no fiber bridging and mode 2 shear hackles were observed. Therefore, it was concluded that the split cantilever beam configuration does not represent a pure mode 3 test. The experimental work showed that the mode 2 fracture toughness, GIIc, must be less than the mode 3 fracture toughness, GIIIc. Therefore, a conservative approach to characterizing mode 3 delamination is to equate GIIIc to GIIc.
NASA Technical Reports Server (NTRS)
Ames, B. E.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) is presented. The IOA effort first completed an analysis of the Electrical Power Generation/Power Reactant Storage and Distribution (EPG/PRSD) subsystem hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the NASA FMEA/CIL baselines with proposed Post 51-L updates included. A resolution of each discrepancy from the comparison is provided through additional analysis as required. The results of that comparison are documented for the Orbiter EPG/PRSD hardware. The comparison produced agreement on all but 27 FMEAs and 9 CIL items. The discrepancy between the number of IOA findings and NASA FMEAs can be partially explained by the different approaches used by IOA and NASA to group failure modes together to form one FMEA. Also, several IOA items represented inner tank components and ground operations failure modes which were not in the NASA baseline.
New understandings of failure modes in SSL luminaires
NASA Astrophysics Data System (ADS)
Shepherd, Sarah D.; Mills, Karmann C.; Yaga, Robert; Johnson, Cortina; Davis, J. Lynn
2014-09-01
As SSL products are being rapidly introduced into the market, there is a need to develop standard screening and testing protocols that can be performed quickly and provide data surrounding product lifetime and performance. These protocols, derived from standard industry tests, are known as ALTs (accelerated life tests) and can be performed in a timeframe of weeks to months instead of years. Accelerated testing utilizes a combination of elevated temperature and humidity conditions as well as electrical power cycling to control aging of the luminaires. In this study, we report on the findings of failure modes for two different luminaire products exposed to temperature-humidity ALTs. LEDs are typically considered the determining component for the rate of lumen depreciation. However, this study has shown that each luminaire component can independently or jointly influence system performance and reliability. Material choices, luminaire designs, and driver designs all have significant impacts on the system reliability of a product. From recent data, it is evident that the most common failure modes are not within the LED, but instead occur within resistors, capacitors, and other electrical components of the driver. Insights into failure modes and rates as a result of ALTs are reported with emphasis on component influence on overall system reliability.
NASA Astrophysics Data System (ADS)
Ataş, Akın; Gautam, Mayank; Soutis, Constantinos; Potluri, Prasad
2017-04-01
Experimental behaviour of bolted joints in triaxial braided (0°/±45°) carbon fibre/epoxy composite laminates with drilled and moulded-in fastener holes has been investigated in this paper. Braided laminates were manufactured by vacuum infusion process using 12 K T700S carbon fibres (for bias and axial tows) and Araldite LY-564 epoxy resin. Moulded-in fastener holes were formed using guide pins which were inserted in the braided structure prior to the vacuum infusion process. The damage mechanism of the specimens was investigated using ultrasonic C-Scan technique. The specimens were dimensioned to obtain a bearing mode of failure. The bearing strength of the specimens with moulded-in hole was reduced in comparison to the specimens with drilled hole, due to the increased fibre misalignment angle following the pin insertion procedure. An improvement on the bearing strength of moulded-in hole specimens might be developed if the specimen dimensions would be prepared for a net-tension mode of failure where the fibre misalignment would not have an effect as significant as in the case of bearing failure mode, but this mode should be avoided since it leads to sudden catastrophic failures.
NASA Technical Reports Server (NTRS)
Telesman, J.; Smith, T. M.; Gabb, T. P.; Ring, A. J.
2017-01-01
An investigation of high temperature cyclic fatigue crack growth (FCG) threshold behavior of two advanced nickel disk alloys was conducted. The focus of the study was the unusual crossover effect in the near-threshold region of these type of alloys where conditions which produce higher crack growth rates in the Paris regime, produce higher resistance to crack growth in the near threshold regime. It was shown that this crossover effect is associated with a sudden change in the fatigue failure mode from a predominant transgranular mode in the Paris regime to fully intergranular mode in the threshold fatigue crack growth region. This type of a sudden change in the fracture mechanisms has not been previously reported and is surprising considering that intergranular failure is typically associated with faster crack growth rates and not the slow FCG rates of the near-threshold regime. By characterizing this behavior as a function of test temperature, environment and cyclic frequency, it was determined that both the crossover effect and the onset of intergranular failure are caused by environmentally driven mechanisms which have not as yet been fully identified. A plausible explanation for the observed behavior is proposed.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nygren, K. E.; Bertsch, K. M.; Wang, S.
The influence of internal hydrogen on the tensile properties of an equi-molar FeNiCoCrMn alloy results in a significant reduction of ductility, which is accompanied by a change in the fracture mode from ductile microvoid coalescence to intergranular failure. The introduction of 146.9 mass ppm of hydrogen reduced the plastic strain to failure from 0.67 in the uncharged case to 0.34 and 0.51 in hydrogen-charged specimens. This reduction in ductility and the transition in failure mode are clear indications that this alloy exhibits the classic signs of being susceptible to hydrogen embrittlement. The results are discussed in terms of the hydrogen-enhancedmore » plasticity mechanism and its influence on hydrogen-induced intergranular failure. Furthermore, a new additional constraint that further promotes intergranular failure is introduced for the first time.« less
Niv, Yaron; Itskoviz, David; Cohen, Michal; Hendel, Hagit; Bar-Giora, Yonit; Berkov, Evgeny; Weisbord, Irit; Leviron, Yifat; Isasschar, Assaf; Ganor, Arian
Failure modes and effects analysis (FMEA) is a tool used to identify potential risks in health care processes. We used the FMEA tool for improving the process of consultation in an academic medical center. A team of 10 staff members-5 physicians, 2 quality experts, 2 organizational consultants, and 1 nurse-was established. The consultation process steps, from ordering to delivering, were computed. Failure modes were assessed for likelihood of occurrence, detection, and severity. A risk priority number (RPN) was calculated. An interventional plan was designed according to the highest RPNs. Thereafter, we compared the percentage of completed computer-based documented consultations before and after the intervention. The team identified 3 main categories of failure modes that reached the highest RPNs: initiation of consultation by a junior staff physician without senior approval, failure to document the consultation in the computerized patient registry, and asking for consultation on the telephone. An interventional plan was designed, including meetings to update knowledge of the consultation request process, stressing the importance of approval by a senior physician, training sessions for closing requests in the patient file, and reporting of telephone requests. The number of electronically documented consultation results and recommendations significantly increased (75%) after intervention. FMEA is an important and efficient tool for improving the consultation process in an academic medical center.
Mukundan, Rangachary; Baker, Andrew M.; Kusoglu, Ahmet; ...
2018-03-01
A combined chemical/mechanical accelerated stress test (AST) was developed for proton exchange membrane (PEM) fuel cells based on relative humidity cycling (RHC) between dry and saturated gases at open circuit voltage (OCV). Membrane degradation and failure were investigated using scanning electron microscopy and small- and wide-angle X-ray scattering. Changes to membrane thickness, hydrophilic domain spacing, and crystallinity were observed to be most similar between field-operated cells and OCV RHC ASTs, where local thinning and divot-type defects are the primary failure modes. While RHC in air also reproduces these failure modes, it is not aggressive enough to differentiate between different membranemore » types in >1,333 hours (55 days) of testing. Conversely, steady-state OCV tests result in significant ionomer morphology changes and global thinning, which do not replicate field degradation and failure modes. It is inferred that during the OCV RHC AST, the decay of the membrane's mechanical properties is accelerated such that materials can be evaluated in hundreds, instead of thousands, of hours, while replicating the degradation and failure modes of field operation; associated AST protocols are recommended as OCV RHC at 90°C for 500 hours with wet/dry cycle durations of 30s/45s and 2m/2m for automotive and bus operation, respectively.« less
Failure modes and conditions of a cohesive, spherical body due to YORP spin-up
NASA Astrophysics Data System (ADS)
Hirabayashi, Masatoshi
2015-12-01
This paper presents transition of the failure mode of a cohesive, spherical body due to The Yarkovsky-O'Keefe-Radzievskii-Paddack (YORP) spin-up. On the assumption that the distribution of materials in the body is homogeneous, failed regions first appearing in the body at different spin rates are predicted by comparing the yield condition of an elastic stress in the body. It is found that as the spin rate increases, the locations of the failed regions move from the equatorial surface to the central region. To avoid such failure modes, the body should have higher cohesive strength. The results by this model are consistent with those by a plastic finite element model. Then, this model and a two-layered-cohesive model first proposed by Hirabayashi et al. are used to classify possible evolution and disruption of a spherical body. There are three possible pathways to disruption. First, because of a strong structure, failure of the central region is dominant and eventually leads to a breakup into multiple components. Secondly, a weak surface and a weak interior make the body oblate. Thirdly, a strong internal core prevents the body from failing and only allows surface shedding. This implies that observed failure modes may highly depend on the internal structure of an asteroid, which could provide crucial information for giving constraints on the physical properties.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Mukundan, Rangachary; Baker, Andrew M.; Kusoglu, Ahmet
A combined chemical/mechanical accelerated stress test (AST) was developed for proton exchange membrane (PEM) fuel cells based on relative humidity cycling (RHC) between dry and saturated gases at open circuit voltage (OCV). Membrane degradation and failure were investigated using scanning electron microscopy and small- and wide-angle X-ray scattering. Changes to membrane thickness, hydrophilic domain spacing, and crystallinity were observed to be most similar between field-operated cells and OCV RHC ASTs, where local thinning and divot-type defects are the primary failure modes. While RHC in air also reproduces these failure modes, it is not aggressive enough to differentiate between different membranemore » types in >1,333 hours (55 days) of testing. Conversely, steady-state OCV tests result in significant ionomer morphology changes and global thinning, which do not replicate field degradation and failure modes. It is inferred that during the OCV RHC AST, the decay of the membrane's mechanical properties is accelerated such that materials can be evaluated in hundreds, instead of thousands, of hours, while replicating the degradation and failure modes of field operation; associated AST protocols are recommended as OCV RHC at 90°C for 500 hours with wet/dry cycle durations of 30s/45s and 2m/2m for automotive and bus operation, respectively.« less
Risk based approach for design and optimization of stomach specific delivery of rifampicin.
Vora, Chintan; Patadia, Riddhish; Mittal, Karan; Mashru, Rajashree
2013-10-15
The research envisaged focuses on risk management approach for better recognizing the risks, ways to mitigate them and propose a control strategy for the development of rifampicin gastroretentive tablets. Risk assessment using failure mode and effects analysis (FMEA) was done to depict the effects of specific failure modes related to respective formulation/process variable. A Box-Behnken design was used to investigate the effect of amount of sodium bicarbonate (X1), pore former HPMC (X2) and glyceryl behenate (X3) on percent drug release at 1st hour (Q1), 4th hour (Q4), 8th hour (Q8) and floating lag time (min). Main effects and interaction plots were generated to study effects of variables. Selection of the optimized formulation was done using desirability function and overlay contour plots. The optimized formulation exhibited Q1 of 20.9%, Q4 of 59.1%, Q8 of 94.8% and floating lag time of 4.0 min. Akaike information criteria and Model selection criteria revealed that the model was best described by Korsmeyer-Peppas power law. The residual plots demonstrated no existence of non-normality, skewness or outliers. The composite desirability for optimized formulation computed using equations and software were 0.84 and 0.86 respectively. FTIR, DSC and PXRD studies ruled out drug polymer interaction due to thermal treatment. Copyright © 2013 Elsevier B.V. All rights reserved.
Contact method to allow benign failure in ceramic capacitor having self-clearing feature
Myers, John D; Taylor, Ralph S
2012-06-26
A capacitor exhibiting a benign failure mode has a first electrode layer, a first ceramic dielectric layer deposited on a surface of the first electrode, and a second electrode layer disposed on the ceramic dielectric layer, wherein selected areas of the ceramic dielectric layer have additional dielectric material of sufficient thickness to exhibit a higher dielectric breakdown voltage than the remaining majority of the dielectric layer. The added thickness of the dielectric layer in selected areas allows lead connections to be made at the selected areas of greater dielectric thickness while substantially eliminating a risk of dielectric breakdown and failure at the lead connections, whereby the benign failure mode is preserved.
Is it possible to identify a trend in problem/failure data
NASA Technical Reports Server (NTRS)
Church, Curtis K.
1990-01-01
One of the major obstacles in identifying and interpreting a trend is the small number of data points. Future trending reports will begin with 1983 data. As the problem/failure data are aggregated by year, there are just seven observations (1983 to 1989) for the 1990 reports. Any statistical inferences with a small amount of data will have a large degree of uncertainty. Consequently, a regression technique approach to identify a trend is limited. Though trend determination by failure mode may be unrealistic, the data may be explored for consistency or stability and the failure rate investigated. Various alternative data analysis procedures are briefly discussed. Techniques that could be used to explore problem/failure data by failure mode are addressed. The data used are taken from Section One, Space Shuttle Main Engine, of the Calspan Quarterly Report dated April 2, 1990.
Probabilistic safety analysis of earth retaining structures during earthquakes
NASA Astrophysics Data System (ADS)
Grivas, D. A.; Souflis, C.
1982-07-01
A procedure is presented for determining the probability of failure of Earth retaining structures under static or seismic conditions. Four possible modes of failure (overturning, base sliding, bearing capacity, and overall sliding) are examined and their combined effect is evaluated with the aid of combinatorial analysis. The probability of failure is shown to be a more adequate measure of safety than the customary factor of safety. As Earth retaining structures may fail in four distinct modes, a system analysis can provide a single estimate for the possibility of failure. A Bayesian formulation of the safety retaining walls is found to provide an improved measure for the predicted probability of failure under seismic loading. The presented Bayesian analysis can account for the damage incurred to a retaining wall during an earthquake to provide an improved estimate for its probability of failure during future seismic events.
Kapur, Ajay; Goode, Gina; Riehl, Catherine; Zuvic, Petrina; Joseph, Sherin; Adair, Nilda; Interrante, Michael; Bloom, Beatrice; Lee, Lucille; Sharma, Rajiv; Sharma, Anurag; Antone, Jeffrey; Riegel, Adam; Vijeh, Lili; Zhang, Honglai; Cao, Yijian; Morgenstern, Carol; Montchal, Elaine; Cox, Brett; Potters, Louis
2013-01-01
By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice. PMID:24380074
Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards.
Ofek, Fanny; Magnezi, Racheli; Kurzweil, Yaffa; Gazit, Inbal; Berkovitch, Sofia; Tal, Orna
2016-01-01
Intravenous potassium chloride (IV KCl) solutions are widely used in hospitals for treatment of hypokalemia. As ampoules of concentrated KCL must be diluted before use, critical incidents have been associated with its preparation and administration. Currently, we have introduced ready-to-use diluted KCl infusion solutions to minimize the use of high-alert concentrated KCl. Since this process may be associated with considerable risks, we embraced a proactive hazard analysis as a tool to implement a change in high-alert drug usage in a hospital setting. Failure mode and effect analysis (FMEA) is a systematic tool to analyze and identify risks in system operations. We used FMEA to examine the hazards associated with the implementation of the ready-to-use solutions. A multidisciplinary team analyzed the risks by identifying failure modes, conducting a hazard analysis and calculating the criticality index (CI) for each failure mode. A 1-day survey was performed as an evaluation step after a trial run period of approximately 4 months. Six major possible risks were identified. The most severe risks were prioritized and specific recommendations were formulated. Out of 28 patients receiving IV KCl on the day of the survey, 22 received the ready-to-use solutions and 6 received the concentrated solutions as instructed. Only 1 patient received inappropriate ready-to-use KCl. Using the FMEA tool in our study has proven once again that by creating a gradient of severity of potential vulnerable elements, we are able to proactively promote safer and more efficient processes in health care systems. This article presents a utilization of this method for implementing a change in hospital policy regarding the routine use of IV KCl.
Experimental Investigation on the Joining of Aluminum Alloy Sheets Using Improved Clinching Process.
Chen, Chao; Zhao, Shengdun; Han, Xiaolan; Zhao, Xuzhe; Ishida, Tohru
2017-08-01
Aluminum alloy sheets have been widely used to build the thin-walled structures by mechanical clinching technology in recent years. However, there is an exterior protrusion located on the lower sheet and a pit on the upper sheet, which may restrict the application of the clinching technology in visible areas. In the present study, an improved clinched joint used to join aluminum alloy sheets was investigated by experimental method. The improved clinching process used for joining aluminum alloy evolves through four phases: (a) localized deformation; (b) drawing; (c) backward extrusion; and (d) mechanical interlock forming. A flat surface can be produced using the improved clinching process. Shearing strength, tensile strength, material flow, main geometrical parameters, and failure mode of the improved clinched joint were investigated. The sheet material was compressed to flow radially and upward using a punch, which generated a mechanical interlock by producing severe localized plastic deformation. The neck thickness and interlock of the improved clinched joint were increased by increasing the forming force, which also contributed to increase the strength of the clinched joint. The improved clinched joint can get high shearing strength and tensile strength. Three main failure modes were observed in the failure process, which were neck fracture mode, button separation mode, and mixed failure mode. The improved clinched joint has better joining quality to join aluminum alloy sheets on the thin-walled structures.
Experimental Investigation on the Joining of Aluminum Alloy Sheets Using Improved Clinching Process
Chen, Chao; Zhao, Shengdun; Han, Xiaolan; Zhao, Xuzhe; Ishida, Tohru
2017-01-01
Aluminum alloy sheets have been widely used to build the thin-walled structures by mechanical clinching technology in recent years. However, there is an exterior protrusion located on the lower sheet and a pit on the upper sheet, which may restrict the application of the clinching technology in visible areas. In the present study, an improved clinched joint used to join aluminum alloy sheets was investigated by experimental method. The improved clinching process used for joining aluminum alloy evolves through four phases: (a) localized deformation; (b) drawing; (c) backward extrusion; and (d) mechanical interlock forming. A flat surface can be produced using the improved clinching process. Shearing strength, tensile strength, material flow, main geometrical parameters, and failure mode of the improved clinched joint were investigated. The sheet material was compressed to flow radially and upward using a punch, which generated a mechanical interlock by producing severe localized plastic deformation. The neck thickness and interlock of the improved clinched joint were increased by increasing the forming force, which also contributed to increase the strength of the clinched joint. The improved clinched joint can get high shearing strength and tensile strength. Three main failure modes were observed in the failure process, which were neck fracture mode, button separation mode, and mixed failure mode. The improved clinched joint has better joining quality to join aluminum alloy sheets on the thin-walled structures. PMID:28763027
NASA Technical Reports Server (NTRS)
Wolitz, K.; Brockmann, W.; Fischer, T.
1979-01-01
Acoustic emission analysis as a quasi-nondestructive test method makes it possible to differentiate clearly, in judging the total behavior of fiber-reinforced plastic composites, between critical failure modes (in the case of unidirectional composites fiber fractures) and non-critical failure modes (delamination processes or matrix fractures). A particular advantage is that, for varying pressure demands on the composites, the emitted acoustic pulses can be analyzed with regard to their amplitude distribution. In addition, definite indications as to how the damages occurred can be obtained from the time curves of the emitted acoustic pulses as well as from the particular frequency spectrum. Distinct analogies can be drawn between the various analytical methods with respect to whether the failure modes can be classified as critical or non-critical.
Research on Application of FMECA in Missile Equipment Maintenance Decision
NASA Astrophysics Data System (ADS)
Kun, Wang
2018-03-01
Fault mode effects and criticality analysis (FMECA) is a method widely used in engineering. Studying the application of FMEA technology in military equipment maintenance decision-making, can help us build a better equipment maintenance support system, and increase the using efficiency of weapons and equipment. Through Failure Modes, Effects and Criticality Analysis (FMECA) of equipment, known and potential failure modes and their causes are found out, and the influence on the equipment performance, operation success, personnel security are determined. Furthermore, according to the synthetical effects of the severity of effects and the failure probability, possible measures for prevention and correction are put forward. Through replacing or adjusting the corresponding parts, corresponding maintenance strategy is decided for preventive maintenance of equipment, which helps improve the equipment reliability.
NASA Astrophysics Data System (ADS)
Hirai, T.; Bekris, N.; Coad, J. P.; Grisolia, C.; Linke, J.; Maier, H.; Matthews, G. F.; Philipps, V.; Wessel, E.
2009-07-01
Vacuum plasma spray tungsten (VPS-W) coating created on a carbon fibre reinforced composite (CFC) was tested under two thermal load schemes in the electron beam facility to examine the operation limits and failure modes. In cyclic ELM-like short transient thermal loads, the VPS-W coating was destroyed sub-layer by sub-layer at 0.33 GW/m 2 for 1 ms pulse duration. At longer single pulses, simulating steady-state thermal loads, the coating was destroyed at surface temperatures above 2700 °C by melting of the rhenium containing multilayer at the interface between VPS-W and CFC. The operation limits and failure modes of the VPS-W coating in the thermal load schemes are discussed in detail.
Independent Orbiter Assessment (IOA): Assessment of the Orbiter Experiment (OEX) subsystem
NASA Technical Reports Server (NTRS)
Compton, J. M.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Orbiter Experiments (OEX) hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the NASA FMEA/CIL baseline with proposed Post 51-L updates included. A resolution of each discrepancy from the comparison is provided through additional analysis as required. The results of that comparison for the Orbiter OEX hardware are documented. The IOA product for the OEX analysis consisted of 82 failure mode worksheets that resulted in two potential critical items being identified.
NASA Astrophysics Data System (ADS)
Singh, A. K.; Delfs, J.; Goerke, U.; Kolditz, O.
2013-12-01
Carbon dioxide Capture and Storage (CCS) technology is known for disposing a specific amount of CO2 from industrial release of flue gases into a suitable storage where it stays for a defined period of time in a safe way. Types of storage sites for CO2 are depleted hydrocarbon reservoirs, unmineable coal seams and saline aquifers. In this poster, we address the problem of CO2 sequestration into deep saline aquifers. The main advantage of this kind of site for the CO2 sequestration is its widespread geographic distribution. However, saline aquifers are very poorly characterized and typically located at one kilometer depth below the earth's surface. To demonstrate that supercritical CO2 injection into deep saline aquifers is technically and environmentally safe, it is required to perform thermo-hydro-mechanical analysis of failure moods with numerical models. In the poster, we present simple process-catching benchmark for testing the scenario of compressed CO2 injection into a multi- layered saline aquifer.The pores of the deformable matrix are initially filled with saline water at hydrostatic pressure and geothermal temperature conditions. This benchmark investigates (i) how the mechanical and thermal stresses enhance the permeability for CO2 migration; and (ii) subsequent failures mode, i.e., tensile, and shear failures. The tensile failure occurs when pore fluid pressure exceeds the principle stress whereas the Mohr-Coulomb failure criterion defines the shear failure mode. The thermo-hydro-mechanical (THM) model is based on a ';multi-componential flow' module . The coupled system of balance equations is solvedin the monolithic way. The Galerkin finite element approach is used for spatial discretization, whereas temporal discretization is performed with a generalized single step scheme. This numerical module has been implemented in the open-source scientific software OpenGeoSys.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Bonzon, L. L.; Hente, D. B.; Kukreti, B. M.
The seismic-fragility response of naturally-aged, nuclear station, safety-related batteries is of interest for two reasons: (1) to determine actual failure modes and thresholds; and (2) to determine the validity of using the electrical capacity of individual cells as an indicator of the end-of-life of a battery, given a seismic event. This report covers the first test series of an extensive program using 12-year old, lead-calcium, Gould NCX-2250 cells, from the James A. Fitzpatrick Nuclear Power Station operated by the New York Power Authority. Seismic tests with three cell configurations were performed using a triaxial shake table: single-cell tests, rigidly mounted;more » multi-cell (three) tests, mounted in a typical battery rack; and single-cell tests specifically aimed towards examining propagation of pre-existing case cracks. In general the test philosophy was to monitor the electrical properties including discharge capacity of cells through a graduated series of g-level step increases until either the shake-table limits were reached or until electrical failure of the cells occurred. Of nine electrically active cells, six failed during seismic testing over a range of imposed g-level loads in excess of a 1-g ZPA. Post-test examination revealed a common failure mode, the cracking at the abnormally brittle, positive lead bus-bar/post interface; further examination showed that the failure zone was extremely coarse grained and extensively corroded. Presently accepted accelerated-aging methods for qualifying batteries, per IEEE Std. 535-1979, are based on plate growth, but these naturally-aged 12-year old cells showed no significant plate growth.« less
Pilot performance in zero-visibility precision approach. Ph.D. Thesis
NASA Technical Reports Server (NTRS)
Ephrath, A. R.
1975-01-01
The pilot's short-term decisions regarding performance assessment and failure monitoring is examined. The performance of airline pilots who flew simulated zero-visibility landing approaches is reported. Results indicate that the pilot's mode of participation in the control task has a strong effect on his workload, the induced workload being lowest when the pilot acts as a monitor during a coupled approach and highest when the pilot is an active element in the control loop. A marked increase in workload at altitudes below 500 ft. is documented at all participation modes; this increase is inversely related to distance-to-go. The participation mode is shown to have a dominant effect on failure-detection performance, with a failure in a monitored (coupled) axis being detected faster than a comparable failure in a manually-controlled axis. Touchdown performance is also documented. It is concluded that the conventional instrument panel and its associated displays are inadequate for zero-visibility operations in the final phases of the landing approach.
Predictions of High Strain Rate Failure Modes in Layered Aluminum Composites
NASA Astrophysics Data System (ADS)
Khanikar, Prasenjit; Zikry, M. A.
2014-01-01
A dislocation density-based crystalline plasticity formulation, specialized finite-element techniques, and rational crystallographic orientation relations were used to predict and characterize the failure modes associated with the high strain rate behavior of aluminum layered composites. Two alloy layers, a high strength alloy, aluminum 2195, and an aluminum alloy 2139, with high toughness, were modeled with representative microstructures that included precipitates, dispersed particles, and different grain boundary distributions. Different layer arrangements were investigated for high strain rate applications and the optimal arrangement was with the high toughness 2139 layer on the bottom, which provided extensive shear strain localization, and the high strength 2195 layer on the top for high strength resistance The layer thickness of the bottom high toughness layer also affected the bending behavior of the roll-bonded interface and the potential delamination of the layers. Shear strain localization, dynamic cracking, and delamination are the mutually competing failure mechanisms for the layered metallic composite, and control of these failure modes can be used to optimize behavior for high strain rate applications.
Fatigue Failure Modes of the Grain Size Transition Zone in a Dual Microstructure Disk
NASA Technical Reports Server (NTRS)
Gabb, Timothy P.; Kantzos, Pete T.; Palsa, Bonnie; Telesman, Jack; Gayda, John; Sudbrack, Chantal K.
2012-01-01
Mechanical property requirements vary with location in nickel-based superalloy disks. In order to maximize the associated mechanical properties, heat treatment methods have been developed for producing tailored grain microstructures. In this study, fatigue failure modes of a grain size transition zone in a dual microstructure disk were evaluated. A specialized heat treatment method was applied to produce varying grain microstructure in the bore to rim portions of a powder metallurgy processed nickel-based superalloy disk. The transition in grain size was concentrated in a zone of the disk web, between the bore and rim. Specimens were extracted parallel and transversely across this transition zone, and multiple fatigue tests were performed at 427 C and 704 C. Grain size distributions were characterized in the specimens, and related to operative failure initiation modes. Mean fatigue life decreased with increasing maximum grain size, going out through the transition zone. The scatter in limited tests of replicates was comparable for failures of uniform gage specimens in all transition zone locations examined.
Piccioni, Chiara; Di Carlo, Stefano; Capogreco, Mario
2017-01-01
Aim of this study was to investigate a specific airborne particle abrasion pretreatment on dentin and its effects on microtensile bond strengths of four commercial total-etch adhesives. Midcoronal occlusal dentin of extracted human molars was used. Teeth were randomly assigned to 4 groups according to the adhesive system used: OptiBond FL (FL), OptiBond Solo Plus (SO), Prime & Bond (PB), and Riva Bond LC (RB). Specimens from each group were further divided into two subgroups: control specimens were treated with adhesive procedures; abraded specimens were pretreated with airborne particle abrasion using 50 μm Al2O3 before adhesion. After bonding procedures, composite crowns were incrementally built up. Specimens were sectioned perpendicular to adhesive interface to produce multiple beams, which were tested under tension until failure. Data were statistically analysed. Failure mode analysis was performed. Overall comparison showed significant increase in bond strength (p < 0.001) between abraded and no-abraded specimens, independently of brand. Intrabrand comparison showed statistical increase when abraded specimens were tested compared to no-abraded ones, with the exception of PB that did not show such difference. Distribution of failure mode was relatively uniform among all subgroups. Surface treatment by airborne particle abrasion with Al2O3 particles can increase the bond strength of total-etch adhesives. PMID:29392128
Failure mode and effect analysis: improving intensive care unit risk management processes.
Askari, Roohollah; Shafii, Milad; Rafiei, Sima; Abolhassani, Mohammad Sadegh; Salarikhah, Elaheh
2017-04-18
Purpose Failure modes and effects analysis (FMEA) is a practical tool to evaluate risks, discover failures in a proactive manner and propose corrective actions to reduce or eliminate potential risks. The purpose of this paper is to apply FMEA technique to examine the hazards associated with the process of service delivery in intensive care unit (ICU) of a tertiary hospital in Yazd, Iran. Design/methodology/approach This was a before-after study conducted between March 2013 and December 2014. By forming a FMEA team, all potential hazards associated with ICU services - their frequency and severity - were identified. Then risk priority number was calculated for each activity as an indicator representing high priority areas that need special attention and resource allocation. Findings Eight failure modes with highest priority scores including endotracheal tube defect, wrong placement of endotracheal tube, EVD interface, aspiration failure during suctioning, chest tube failure, tissue injury and deep vein thrombosis were selected for improvement. Findings affirmed that improvement strategies were generally satisfying and significantly decreased total failures. Practical implications Application of FMEA in ICUs proved to be effective in proactively decreasing the risk of failures and corrected the control measures up to acceptable levels in all eight areas of function. Originality/value Using a prospective risk assessment approach, such as FMEA, could be beneficial in dealing with potential failures through proposing preventive actions in a proactive manner. The method could be used as a tool for healthcare continuous quality improvement so that the method identifies both systemic and human errors, and offers practical advice to deal effectively with them.
Shabanpour, Reza; Mousavi, Niloufar; Ghodsi, Safoura; Alikhasi, Marzieh
2015-08-01
The purpose of the current study was to compare the fracture resistance and mode of failure of zirconia and titanium abutments with different diameters. Fourteen groups of abutments including prefabricated zirconia, copy-milled zirconia and titanium abutments of an implant system (XiVE, Dentsply) were prepared in different diameters. An increasing vertical load was applied to each specimen until failure occurred. Fracture resistance was measured in each group using the universal testing machine. Moreover, the failure modes were studied and categorized as abutment screw fracture, connection area fracture, abutment body fracture, abutment body distortion, screw distortion and connection area distortion. Groups were statistically compared using univariate and post-hoc tests. The level of statistical significance was set at 5%. Fabrication method (p = 0.03) and diameter (p < 0.001) had significant effect on the fracture resistance of abutments. Fracture resistance of abutments with 5.5 mm diameter was higher than other diameters (p < 0.001). The observed modes of failure were dependent on the abutment material as well. All of the prefabricated titanium abutments fractured within the abutment screw. Abutment screw distortion, connection area fracture, and abutment body fracture were the common failure type in other groups. Diameter had a significant effect on fracture resistance of implant abutments, as abutments with greater diameters were more resistant to static loads. Copy-milled abutments showed lower fracture resistance as compared to other experimental groups. Although zirconia abutments have received great popularity among clinicians and even patients selecting them for narrow implants should be with caution.
Baldassarri, Marta; Zhang, Yu; Thompson, Van P.; Rekow, Elizabeth D.; Stappert, Christian F. J.
2011-01-01
Summary Objectives To compare fatigue failure modes and reliability of hand-veneered and over-pressed implant-supported three-unit zirconium-oxide fixed-dental-prostheses(FDPs). Methods Sixty-four custom-made zirconium-oxide abutments (n=32/group) and thirty-two zirconium-oxide FDP-frameworks were CAD/CAM manufactured. Frameworks were veneered with hand-built up or over-pressed porcelain (n=16/group). Step-stress-accelerated-life-testing (SSALT) was performed in water applying a distributed contact load at the buccal cusp-pontic-area. Post failure examinations were carried out using optical (polarized-reflected-light) and scanning electron microscopy (SEM) to visualize crack propagation and failure modes. Reliability was compared using cumulative-damage step-stress analysis (Alta-7-Pro, Reliasoft). Results Crack propagation was observed in the veneering porcelain during fatigue. The majority of zirconium-oxide FDPs demonstrated porcelain chipping as the dominant failure mode. Nevertheless, fracture of the zirconium-oxide frameworks was also observed. Over-pressed FDPs failed earlier at a mean failure load of 696 ± 149 N relative to hand-veneered at 882 ± 61 N (profile I). Weibull-stress-number of cycles-unreliability-curves were generated. The reliability (2-sided at 90% confidence bounds) for a 400N load at 100K cycles indicated values of 0.84 (0.98-0.24) for the hand-veneered FDPs and 0.50 (0.82-0.09) for their over-pressed counterparts. Conclusions Both zirconium-oxide FDP systems were resistant under accelerated-life-time-testing. Over-pressed specimens were more susceptible to fatigue loading with earlier veneer chipping. PMID:21557985
Reliability Coupled Sensitivity Based Design Approach for Gravity Retaining Walls
NASA Astrophysics Data System (ADS)
Guha Ray, A.; Baidya, D. K.
2012-09-01
Sensitivity analysis involving different random variables and different potential failure modes of a gravity retaining wall focuses on the fact that high sensitivity of a particular variable on a particular mode of failure does not necessarily imply a remarkable contribution to the overall failure probability. The present paper aims at identifying a probabilistic risk factor ( R f ) for each random variable based on the combined effects of failure probability ( P f ) of each mode of failure of a gravity retaining wall and sensitivity of each of the random variables on these failure modes. P f is calculated by Monte Carlo simulation and sensitivity analysis of each random variable is carried out by F-test analysis. The structure, redesigned by modifying the original random variables with the risk factors, is safe against all the variations of random variables. It is observed that R f for friction angle of backfill soil ( φ 1 ) increases and cohesion of foundation soil ( c 2 ) decreases with an increase of variation of φ 1 , while R f for unit weights ( γ 1 and γ 2 ) for both soil and friction angle of foundation soil ( φ 2 ) remains almost constant for variation of soil properties. The results compared well with some of the existing deterministic and probabilistic methods and found to be cost-effective. It is seen that if variation of φ 1 remains within 5 %, significant reduction in cross-sectional area can be achieved. But if the variation is more than 7-8 %, the structure needs to be modified. Finally design guidelines for different wall dimensions, based on the present approach, are proposed.
Application of failure mode and effects analysis (FMEA) to pretreatment phases in tomotherapy.
Broggi, Sara; Cantone, Marie Claire; Chiara, Anna; Di Muzio, Nadia; Longobardi, Barbara; Mangili, Paola; Veronese, Ivan
2013-09-06
The aim of this paper was the application of the failure mode and effects analysis (FMEA) approach to assess the risks for patients undergoing radiotherapy treatments performed by means of a helical tomotherapy unit. FMEA was applied to the preplanning imaging, volume determination, and treatment planning stages of the tomotherapy process and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system; and 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. A total of 74 failure modes were identified: 38 in the stage of preplanning imaging and volume determination, and 36 in the stage of planning. The threshold of 125 for RPN was exceeded in four cases: one case only in the phase of preplanning imaging and volume determination, and three cases in the stage of planning. The most critical failures appeared related to (i) the wrong or missing definition and contouring of the overlapping regions, (ii) the wrong assignment of the overlap priority to each anatomical structure, (iii) the wrong choice of the computed tomography calibration curve for dose calculation, and (iv) the wrong (or not performed) choice of the number of fractions in the planning station. On the basis of these findings, in addition to the safety strategies already adopted in the clinical practice, novel solutions have been proposed for mitigating the risk of these failures and to increase patient safety.
Advances on the Failure Analysis of the Dam-Foundation Interface of Concrete Dams.
Altarejos-García, Luis; Escuder-Bueno, Ignacio; Morales-Torres, Adrián
2015-12-02
Failure analysis of the dam-foundation interface in concrete dams is characterized by complexity, uncertainties on models and parameters, and a strong non-linear softening behavior. In practice, these uncertainties are dealt with a well-structured mixture of experience, best practices and prudent, conservative design approaches based on the safety factor concept. Yet, a sound, deep knowledge of some aspects of this failure mode remain unveiled, as they have been offset in practical applications by the use of this conservative approach. In this paper we show a strategy to analyse this failure mode under a reliability-based approach. The proposed methodology of analysis integrates epistemic uncertainty on spatial variability of strength parameters and data from dam monitoring. The purpose is to produce meaningful and useful information regarding the probability of occurrence of this failure mode that can be incorporated in risk-informed dam safety reviews. In addition, relationships between probability of failure and factors of safety are obtained. This research is supported by a more than a decade of intensive professional practice on real world cases and its final purpose is to bring some clarity, guidance and to contribute to the improvement of current knowledge and best practices on such an important dam safety concern.
Advances on the Failure Analysis of the Dam—Foundation Interface of Concrete Dams
Altarejos-García, Luis; Escuder-Bueno, Ignacio; Morales-Torres, Adrián
2015-01-01
Failure analysis of the dam-foundation interface in concrete dams is characterized by complexity, uncertainties on models and parameters, and a strong non-linear softening behavior. In practice, these uncertainties are dealt with a well-structured mixture of experience, best practices and prudent, conservative design approaches based on the safety factor concept. Yet, a sound, deep knowledge of some aspects of this failure mode remain unveiled, as they have been offset in practical applications by the use of this conservative approach. In this paper we show a strategy to analyse this failure mode under a reliability-based approach. The proposed methodology of analysis integrates epistemic uncertainty on spatial variability of strength parameters and data from dam monitoring. The purpose is to produce meaningful and useful information regarding the probability of occurrence of this failure mode that can be incorporated in risk-informed dam safety reviews. In addition, relationships between probability of failure and factors of safety are obtained. This research is supported by a more than a decade of intensive professional practice on real world cases and its final purpose is to bring some clarity, guidance and to contribute to the improvement of current knowledge and best practices on such an important dam safety concern. PMID:28793709
Landslides and dam damage resulting from the Jiuzhaigou earthquake (8 August 2017), Sichuan, China
Wang, Yun-sheng; Luo, Yong-hong; Li, Jia; Zhang, Xin; Shen, Tong
2018-01-01
At 21.19 on 8 August 2017, an Ms 7.0 earthquake struck the Jiuzhaigou scenic spot in northwestern Sichuan Province, China. The Jiuzhaigou earthquake is a strike-slip earthquake with a focal depth of 20 km at 33.20° N and 103.82° E, and was caused by two concealed faults. According to emergency investigations and remote sensing interpretations, the Jiuzhaigou earthquake triggered 1780 landslides, damaged one dam (Nuorilang Waterfall) and broke one dam (Huohua Lake). The landslides mainly occurred in the Rize Valley and Shuzheng Valley and in Jiuzhai Paradise. The landslides involved hanging wall and back-slope effects, and the slope angle, slope aspect, seismic faults and valley trend were obviously related to the occurrence of the landslides. Specifically, most of the landslides were shallow landslides, rockfalls and rock avalanches and were small in scale. The failure modes of landslides mainly include wedge rock mass failure, residual deposit failure, relaxed rock mass failure and weathered rock mass failure. The initial low stability of the dam coupled with the topographic effect, back-slope effect and excess pore water pressure led to damage to the Nuorilang Waterfall dam. PMID:29657755
Landslides and dam damage resulting from the Jiuzhaigou earthquake (8 August 2017), Sichuan, China
NASA Astrophysics Data System (ADS)
Zhao, Bo; Wang, Yun-sheng; Luo, Yong-hong; Li, Jia; Zhang, Xin; Shen, Tong
2018-03-01
At 21.19 on 8 August 2017, an Ms 7.0 earthquake struck the Jiuzhaigou scenic spot in northwestern Sichuan Province, China. The Jiuzhaigou earthquake is a strike-slip earthquake with a focal depth of 20 km at 33.20° N and 103.82° E, and was caused by two concealed faults. According to emergency investigations and remote sensing interpretations, the Jiuzhaigou earthquake triggered 1780 landslides, damaged one dam (Nuorilang Waterfall) and broke one dam (Huohua Lake). The landslides mainly occurred in the Rize Valley and Shuzheng Valley and in Jiuzhai Paradise. The landslides involved hanging wall and back-slope effects, and the slope angle, slope aspect, seismic faults and valley trend were obviously related to the occurrence of the landslides. Specifically, most of the landslides were shallow landslides, rockfalls and rock avalanches and were small in scale. The failure modes of landslides mainly include wedge rock mass failure, residual deposit failure, relaxed rock mass failure and weathered rock mass failure. The initial low stability of the dam coupled with the topographic effect, back-slope effect and excess pore water pressure led to damage to the Nuorilang Waterfall dam.
Landslides and dam damage resulting from the Jiuzhaigou earthquake (8 August 2017), Sichuan, China.
Zhao, Bo; Wang, Yun-Sheng; Luo, Yong-Hong; Li, Jia; Zhang, Xin; Shen, Tong
2018-03-01
At 21.19 on 8 August 2017, an Ms 7.0 earthquake struck the Jiuzhaigou scenic spot in northwestern Sichuan Province, China. The Jiuzhaigou earthquake is a strike-slip earthquake with a focal depth of 20 km at 33.20° N and 103.82° E, and was caused by two concealed faults. According to emergency investigations and remote sensing interpretations, the Jiuzhaigou earthquake triggered 1780 landslides, damaged one dam (Nuorilang Waterfall) and broke one dam (Huohua Lake). The landslides mainly occurred in the Rize Valley and Shuzheng Valley and in Jiuzhai Paradise. The landslides involved hanging wall and back-slope effects, and the slope angle, slope aspect, seismic faults and valley trend were obviously related to the occurrence of the landslides. Specifically, most of the landslides were shallow landslides, rockfalls and rock avalanches and were small in scale. The failure modes of landslides mainly include wedge rock mass failure, residual deposit failure, relaxed rock mass failure and weathered rock mass failure. The initial low stability of the dam coupled with the topographic effect, back-slope effect and excess pore water pressure led to damage to the Nuorilang Waterfall dam.
Failure mode analysis of silicon-based intracortical microelectrode arrays in non-human primates
Barrese, James C; Rao, Naveen; Paroo, Kaivon; Triebwasser, Corey; Vargas-Irwin, Carlos; Franquemont, Lachlan; Donoghue, John P
2016-01-01
Objective Brain–computer interfaces (BCIs) using chronically implanted intracortical microelectrode arrays (MEAs) have the potential to restore lost function to people with disabilities if they work reliably for years. Current sensors fail to provide reliably useful signals over extended periods of time for reasons that are not clear. This study reports a comprehensive retrospective analysis from a large set of implants of a single type of intracortical MEA in a single species, with a common set of measures in order to evaluate failure modes. Approach Since 1996, 78 silicon MEAs were implanted in 27 monkeys (Macaca mulatta). We used two approaches to find reasons for sensor failure. First, we classified the time course leading up to complete recording failure as acute (abrupt) or chronic (progressive). Second, we evaluated the quality of electrode recordings over time based on signal features and electrode impedance. Failure modes were divided into four categories: biological, material, mechanical, and unknown. Main results Recording duration ranged from 0 to 2104 days (5.75 years), with a mean of 387 days and a median of 182 days (n = 78). Sixty-two arrays failed completely with a mean time to failure of 332 days (median = 133 days) while nine array experiments were electively terminated for experimental reasons (mean = 486 days). Seven remained active at the close of this study (mean = 753 days). Most failures (56%) occurred within a year of implantation, with acute mechanical failures the most common class (48%), largely because of connector issues (83%). Among grossly observable biological failures (24%), a progressive meningeal reaction that separated the array from the parenchyma was most prevalent (14.5%). In the absence of acute interruptions, electrode recordings showed a slow progressive decline in spike amplitude, noise amplitude, and number of viable channels that predicts complete signal loss by about eight years. Impedance measurements showed systematic early increases, which did not appear to affect recording quality, followed by a slow decline over years. The combination of slowly falling impedance and signal quality in these arrays indicate that insulating material failure is the most significant factor. Significance This is the first long-term failure mode analysis of an emerging BCI technology in a large series of non-human primates. The classification system introduced here may be used to standardize how neuroprosthetic failure modes are evaluated. The results demonstrate the potential for these arrays to record for many years, but achieving reliable sensors will require replacing connectors with implantable wireless systems, controlling the meningeal reaction, and improving insulation materials. These results will focus future research in order to create clinical neuroprosthetic sensors, as well as valuable research tools, that are able to safely provide reliable neural signals for over a decade. PMID:24216311
Failure mode analysis of silicon-based intracortical microelectrode arrays in non-human primates
NASA Astrophysics Data System (ADS)
Barrese, James C.; Rao, Naveen; Paroo, Kaivon; Triebwasser, Corey; Vargas-Irwin, Carlos; Franquemont, Lachlan; Donoghue, John P.
2013-12-01
Objective. Brain-computer interfaces (BCIs) using chronically implanted intracortical microelectrode arrays (MEAs) have the potential to restore lost function to people with disabilities if they work reliably for years. Current sensors fail to provide reliably useful signals over extended periods of time for reasons that are not clear. This study reports a comprehensive retrospective analysis from a large set of implants of a single type of intracortical MEA in a single species, with a common set of measures in order to evaluate failure modes. Approach. Since 1996, 78 silicon MEAs were implanted in 27 monkeys (Macaca mulatta). We used two approaches to find reasons for sensor failure. First, we classified the time course leading up to complete recording failure as acute (abrupt) or chronic (progressive). Second, we evaluated the quality of electrode recordings over time based on signal features and electrode impedance. Failure modes were divided into four categories: biological, material, mechanical, and unknown. Main results. Recording duration ranged from 0 to 2104 days (5.75 years), with a mean of 387 days and a median of 182 days (n = 78). Sixty-two arrays failed completely with a mean time to failure of 332 days (median = 133 days) while nine array experiments were electively terminated for experimental reasons (mean = 486 days). Seven remained active at the close of this study (mean = 753 days). Most failures (56%) occurred within a year of implantation, with acute mechanical failures the most common class (48%), largely because of connector issues (83%). Among grossly observable biological failures (24%), a progressive meningeal reaction that separated the array from the parenchyma was most prevalent (14.5%). In the absence of acute interruptions, electrode recordings showed a slow progressive decline in spike amplitude, noise amplitude, and number of viable channels that predicts complete signal loss by about eight years. Impedance measurements showed systematic early increases, which did not appear to affect recording quality, followed by a slow decline over years. The combination of slowly falling impedance and signal quality in these arrays indicates that insulating material failure is the most significant factor. Significance. This is the first long-term failure mode analysis of an emerging BCI technology in a large series of non-human primates. The classification system introduced here may be used to standardize how neuroprosthetic failure modes are evaluated. The results demonstrate the potential for these arrays to record for many years, but achieving reliable sensors will require replacing connectors with implantable wireless systems, controlling the meningeal reaction, and improving insulation materials. These results will focus future research in order to create clinical neuroprosthetic sensors, as well as valuable research tools, that are able to safely provide reliable neural signals for over a decade.
Mechanism of electromigration failure in Damascene processed copper interconnects
NASA Astrophysics Data System (ADS)
Michael, Nancy Lyn
2002-11-01
A major unresolved issue in Cu interconnect reliability is the interface role in the failure mechanism of real structures. The present study investigates failure in single-level damascene Cu interconnects with variations in interface condition, passivation and barrier, and linewidth. In the first phase, accelerated electromigration testing of 0.25mum Cu interconnects capped with SiN or SiCN, shows that lifetime and failure mode vary with capping layer. The first mode, seen primarily in SiN samples, is characterized by gradual resistance increase and extensive interface damage, believed to result from failure led by interface electromigration. The competing failure mode, found in SiCN capped samples, is characterized by abrupt resistance increase and localized voiding. The second phase fixes SiCN as the capping material and varies barrier material and line width. The three barrier materials, Ta, TaN, and Ta/TaN, produce similar lifetime statistics and failure is abrupt. Line width, however, does have a strong influence on failure time. The line width/grain size ratio ranged from 0.53 to 2.2 but does not correlate with mean time to failure (MTF). The strong dependence on interface fraction, combined with the conclusion from phase one that interface electromigration is not rate controlling, suggests another mechanism related to the interface is a controlling factor. The possibility that contamination and defects at the interface are key to this failure mode was investigated using electro-thermal fatigue (ETF). In ETF, where lines are simultaneously subjected to thermal cycling and constant current, damage caused by thermal stress is accelerated. Tests reveal that in 80 nm lines, transient failure occurs at times far below MTF in electromigration tests at higher temperatures. Failure found in ETF is clearly a result of damage growth due to thermal/mechanical stress rather than electromigration. At the stress levels created by the moderate ETF test conditions, the only place voids are likely to nucleate and grow is at pre-existing defects and impurities. In narrower lines, where smaller voids can cause catastrophic damage, defects have a greater effect on MTF. Results from this investigation suggest that impurities and defects in the Cu and at the interface, must be carefully controlled to make reliable narrow Cu interconnects.
NASA Technical Reports Server (NTRS)
Pineda, Evan J.; Waas, Anthony M.
2011-01-01
A thermodynamically-based work potential theory for modeling progressive damage and failure in fiber-reinforced laminates is presented. The current, multiple-internal state variable (ISV) formulation, enhanced Schapery theory (EST), utilizes separate ISVs for modeling the effects of damage and failure. Damage is considered to be the effect of any structural changes in a material that manifest as pre-peak non-linearity in the stress versus strain response. Conversely, failure is taken to be the effect of the evolution of any mechanisms that results in post-peak strain softening. It is assumed that matrix microdamage is the dominant damage mechanism in continuous fiber-reinforced polymer matrix laminates, and its evolution is controlled with a single ISV. Three additional ISVs are introduced to account for failure due to mode I transverse cracking, mode II transverse cracking, and mode I axial failure. Typically, failure evolution (i.e., post-peak strain softening) results in pathologically mesh dependent solutions within a finite element method (FEM) setting. Therefore, consistent character element lengths are introduced into the formulation of the evolution of the three failure ISVs. Using the stationarity of the total work potential with respect to each ISV, a set of thermodynamically consistent evolution equations for the ISVs is derived. The theory is implemented into commercial FEM software. Objectivity of total energy dissipated during the failure process, with regards to refinements in the FEM mesh, is demonstrated. The model is also verified against experimental results from two laminated, T800/3900-2 panels containing a central notch and different fiber-orientation stacking sequences. Global load versus displacement, global load versus local strain gage data, and macroscopic failure paths obtained from the models are compared to the experiments.
NASA Technical Reports Server (NTRS)
Pineda, Evan J.; Waas, Anthony M.
2012-01-01
A thermodynamically-based work potential theory for modeling progressive damage and failure in fiber-reinforced laminates is presented. The current, multiple-internal state variable (ISV) formulation, enhanced Schapery theory (EST), utilizes separate ISVs for modeling the effects of damage and failure. Damage is considered to be the effect of any structural changes in a material that manifest as pre-peak non-linearity in the stress versus strain response. Conversely, failure is taken to be the effect of the evolution of any mechanisms that results in post-peak strain softening. It is assumed that matrix microdamage is the dominant damage mechanism in continuous fiber-reinforced polymer matrix laminates, and its evolution is controlled with a single ISV. Three additional ISVs are introduced to account for failure due to mode I transverse cracking, mode II transverse cracking, and mode I axial failure. Typically, failure evolution (i.e., post-peak strain softening) results in pathologically mesh dependent solutions within a finite element method (FEM) setting. Therefore, consistent character element lengths are introduced into the formulation of the evolution of the three failure ISVs. Using the stationarity of the total work potential with respect to each ISV, a set of thermodynamically consistent evolution equations for the ISVs is derived. The theory is implemented into commercial FEM software. Objectivity of total energy dissipated during the failure process, with regards to refinements in the FEM mesh, is demonstrated. The model is also verified against experimental results from two laminated, T800/3900-2 panels containing a central notch and different fiber-orientation stacking sequences. Global load versus displacement, global load versus local strain gage data, and macroscopic failure paths obtained from the models are compared to the experiments.
Life Cycle Costing: A Working Level Approach
1981-06-01
Effects Analysis ( FMEA ) ...... ................ .. 59 Logistics Performance Factors (LPFs) 60 Planning the Use of Life Cycle Cost in the Demonstration...form. Failure Mode and Effects Analysis ( FMEA ). Description. FMEA is a technique that attempts to improve the design of any particular unit. The FMEA ...failure modes and also eliminate extra parts or ones that are used to achieve more performance than is necessary (16:5-14]. Advantages. FMEA forces
DOE Office of Scientific and Technical Information (OSTI.GOV)
Spirydovich, S; Huq, M
2014-06-15
Purpose: The improvement of quality in healthcare can be assessed by Failure Mode and Effects Analysis (FMEA). In radiation oncology, FMEA, as applied to the billing CPT code 77336, can improve both charge capture and, most importantly, quality of the performed services. Methods: We created an FMEA table for the process performed under CPT code 77336. For a given process step, each member of the assembled team (physicist, dosimetrist, and therapist) independently assigned numerical values for: probability of occurrence (O, 1–10), severity (S, 1–10), and probability of detection (D, 1–10) for every failure mode cause and effect combination. The riskmore » priority number, RPN, was then calculated as a product of O, S and D from which an average RPN was calculated for each combination mentioned above. A fault tree diagram, with each process sorted into 6 categories, was created with linked RPN. For processes with high RPN recommended actions were assigned. 2 separate R and V systems (Lantis and EMR-based ARIA) were considered. Results: We identified 9 potential failure modes and corresponding 19 potential causes of these failure modes all resulting in unjustified 77336 charge and compromised quality of care. In Lantis, the range of RPN was 24.5–110.8, and of S values – 2–10. The highest ranking RPN of 110.8 came from the failure mode described as “end-of-treatment check not done before the completion of treatment”, and the highest S value of 10 (RPN=105) from “overrides not checked”. For the same failure modes, within ARIA electronic environment with its additional controls, RPN values were significantly lower (44.3 for end-of-treatment missing check and 20.0 for overrides not checked). Conclusion: Our work has shown that when charge capture was missed that also resulted in some services not being performed. Absence of such necessary services may result in sub-optimal quality of care rendered to patients.« less
López-Tarjuelo, Juan; Bouché-Babiloni, Ana; Santos-Serra, Agustín; Morillo-Macías, Virginia; Calvo, Felipe A; Kubyshin, Yuri; Ferrer-Albiach, Carlos
2014-11-01
Industrial companies use failure mode and effect analysis (FMEA) to improve quality. Our objective was to describe an FMEA and subsequent interventions for an automated intraoperative electron radiotherapy (IOERT) procedure with computed tomography simulation, pre-planning, and a fixed conventional linear accelerator. A process map, an FMEA, and a fault tree analysis are reported. The equipment considered was the radiance treatment planning system (TPS), the Elekta Precise linac, and TN-502RDM-H metal-oxide-semiconductor-field-effect transistor in vivo dosimeters. Computerized order-entry and treatment-automation were also analyzed. Fifty-seven potential modes and effects were identified and classified into 'treatment cancellation' and 'delivering an unintended dose'. They were graded from 'inconvenience' or 'suboptimal treatment' to 'total cancellation' or 'potentially wrong' or 'very wrong administered dose', although these latter effects were never experienced. Risk priority numbers (RPNs) ranged from 3 to 324 and totaled 4804. After interventions such as double checking, interlocking, automation, and structural changes the final total RPN was reduced to 1320. FMEA is crucial for prioritizing risk-reduction interventions. In a semi-surgical procedure like IOERT double checking has the potential to reduce risk and improve quality. Interlocks and automation should also be implemented to increase the safety of the procedure. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
NASA Astrophysics Data System (ADS)
Roquer, T.; Arancibia, G.; Rowland, J. V.; Iturrieta, P. C.; Morata, D.; Cembrano, J. M.
2017-12-01
Paleofluid-transporting systems can be recognized as meshes of fracture-filled veins in eroded zones of extinct hydrothermal systems. Here we conducted meso-microstructural analysis and mechanical modeling from two exhumed exposures of the faults governing regional tectonics of the Southern Andes: the Liquiñe-Ofqui Fault System (LOFS) and the Andean Transverse Faults (ATF). A total of 107 fractures in both exposures were analyzed. The ATF specific segment shows two tectonic solutions that can be modeled as Andersonian and non-Andersonian tectonic regimes: (1) shear (mode II/III) failure occurs at differential stresses > 28 MPa and fluid pressures < 40-80% lithostatic in the Andersonian regime; and (2) sporadic hybrid extensional + shear (modes I + II/III) failure occurs at differential stresses < 20 MPa and anomalously high fluid pressures > 85-98% lithostatic in the non-Andersonian regime. Additionally, the LOFS exposure cyclically fails in extension (mode I) or extension + shear (modes I + II/III) in the Andersonian regime, at differential stresses < 28 MPa and fluid pressures > 40-80% lithostatic. In areas of spatial interaction between ATF and LOFS, these conditions might favor: (1) the storage of overpressured fluids in hydrothermal systems associated with the ATF faults, and (2) continuous fluid flow through vertical conduits in the LOFS faults. These observations suggest that such intersections are highly probable locations for concentrated hydrothermal activity, which must be taken into consideration for further geothermal exploration. ACKNOWLEDGEMENTS. PhD CONICYT grants, Centro de Excelencia en Geotermia de los Andes (CEGA-FONDAP/CONICYT Project #15090013), FONDECYT Project #1130030 and Project CONICYT REDES #140036.
NASA Astrophysics Data System (ADS)
Sun, Zhi; Hu, Xiaozhi; Shi, Shanshan; Guo, Xu; Zhang, Yupeng; Chen, Haoran
2016-10-01
Edge delamination is frequently observed in carbon fiber reinforced plastic (CFRP) laminates after machining, due to the low fracture toughness of the resin interfaces between carbon fiber plies. In this study, the effects of incorporating tough aramid fibers into the brittle CFRP system are quantified by measuring the residual properties of bolted CFRP. By adding short-aramid-fiber interleaves in CFRP laminates, the residual tensile strength have been substantially increased by 14 % for twill-weave laminates and 45 % for unidirectional laminates respectively. Moreover, tensile failure was observed as the major mode of toughened laminates, in contrast to shear failure of plain laminates. The qualitative FEM results agreed well with the experimental results that edge delamination would cause relatively higher shear stress and therefore alter the failure mode from tensile failure to shear failure.
Ageing and degradation determines failure mode on sea urchin spines.
Merino, Monica; Vicente, Erika; Gonzales, Karen N; Torres, Fernando G
2017-09-01
Sea urchin spines are an example of a hard natural composite with mineral and organic phases. The role of the organic phase in the response to mechanical stress was assessed by promoting the degradation of such spines by exposing them to ageing and ultraviolet (UV) irradiation. Thermal and structural characterization of the irradiated samples show that this UV irradiation treatment promotes degradation of the organic and inorganic phase of spines. Uniaxial compression tests carried out on aged and UV irradiated samples showed that both treatments affected the mechanical properties of the spines. Scanning electron microscopy (SEM) images of failed specimens were used to analyze the failure mechanisms of the compressed spines. The analysis of the fracture surfaces showed that the failure mechanisms of spines were modified as a consequence of UV irradiation, leading in the last case to mostly brittle fracture surfaces. We suggest that the proteins responsible for the formation of calcite also determine the mechanical properties and the failure mode of spines. This system can be used as a model for the study of the failure modes of other natural and synthetic hard composites. Copyright © 2017 Elsevier B.V. All rights reserved.
Long-term lumen depreciation behavior and failure modes of multi-die array LEDs
NASA Astrophysics Data System (ADS)
Jayawardena, Asiri; Marcus, Daniel; Prugue, Ximena; Narendran, Nadarajah
2013-09-01
One of the main advantages of multi-die array light-emitting diodes (LEDs) is their high flux density. However, a challenge for using such a product in lighting fixture applications is the heat density and the need for thermal management to keep the junction temperatures of all the dies low for long-term reliable performance. Ten multi-die LED array samples for each product from four different manufacturers were subjected to lumen maintenance testing (as described in IES-LM-80-08), and their resulting lumen depreciation and failure modes were studied. The products were tested at the maximum case (or pin) temperature reported by the respective manufacturer by appropriately powering the LEDs. In addition, three samples for each product from two different manufacturers were subjected to rapid thermal cycling, and the resulting lumen depreciation and failure modes were studied. The results showed that the exponential lumen decay model using long-term lumen maintenance data as recommended in IES TM-21 does not fit for all package types. The failure of a string of dies and single die failure in a string were observed in some of the packages.
NASA Technical Reports Server (NTRS)
Garg, A.; Ishaei, O.
1983-01-01
Efforts to characterize and differentiate between two major failure processes in graphite/epoxy composites - transverse cracking and Mode I delamination are described. Representative laminates were tested in uniaxial tension and flexure. The failure processes were monitored and identified by acoustic emission (AE). The effect of moisture on AE was also investigated. Each damage process was found to have a distinctive AE output that is significantly affected by moisture conditions. It is concluded that AE can serve as a useful tool for detecting and identifying failure modes in composite structures in laboratory and in service environments.
Final Report: System Reliability Model for Solid-State Lighting (SSL) Luminaires
DOE Office of Scientific and Technical Information (OSTI.GOV)
Davis, J. Lynn
2017-05-31
The primary objectives of this project was to develop and validate reliability models and accelerated stress testing (AST) methodologies for predicting the lifetime of integrated SSL luminaires. This study examined the likely failure modes for SSL luminaires including abrupt failure, excessive lumen depreciation, unacceptable color shifts, and increased power consumption. Data on the relative distribution of these failure modes were acquired through extensive accelerated stress tests and combined with industry data and other source of information on LED lighting. This data was compiled and utilized to build models of the aging behavior of key luminaire optical and electrical components.
TSS-1R Failure Mode Evaluation
NASA Technical Reports Server (NTRS)
Vaughn, Jason A.; McCollum, Matthew B.; Kamenetzky, Rachel R.
1997-01-01
Soon after the break of the tether during the Tethered Satellite System (TSS-1R) mission in February, 1996, a Tiger Team was assembled at the George C. Marshall Space Flight Center to determine the tether failure mode. One possible failure scenario was the Kevlar' strength member of the tether failed because of degradation due to electrical discharge or electrical arcing. During the next several weeks, extensive electrical discharge testing in low vacuum and plasma environments was conducted in an attempt to reproduce the electrical activity recorded by on-board science instruments during the mission. The results of these tests are presented in this paper.
Quasi-static analysis of elastic behavior for some systems having higher fracture densities.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Berryman, J.G.; Aydin, A.
2009-10-15
Elastic behavior of geomechanical systems with interacting (but not intersecting) fractures is treated using generalizations of the Backus and the Schoenberg-Muir methods for analyzing layered systems whose layers are intrinsically anisotropic due to locally aligned fractures. By permitting the axis of symmetry of the locally anisotropic compliance matrix for individual layers to differ from that of the layering direction, we derive analytical formulas for interacting fractured regions with arbitrary orientations to each other. This procedure provides a systematic tool for studying how contiguous, but not yet intersecting, fractured domains interact, and provides a direct (though approximate) means of predicting whenmore » and how such interactions lead to more dramatic weakening effects and ultimately to failure of these complicated systems. The method permits decomposition of the system elastic behavior into specific eigenmodes that can all be analyzed, and provides a better understanding about which of these specific modes are expected to be most important to the evolving failure process.« less
Using minimal spanning trees to compare the reliability of network topologies
NASA Technical Reports Server (NTRS)
Leister, Karen J.; White, Allan L.; Hayhurst, Kelly J.
1990-01-01
Graph theoretic methods are applied to compute the reliability for several types of networks of moderate size. The graph theory methods used are minimal spanning trees for networks with bi-directional links and the related concept of strongly connected directed graphs for networks with uni-directional links. A comparison is conducted of ring networks and braided networks. The case is covered where just the links fail and the case where both links and nodes fail. Two different failure modes for the links are considered. For one failure mode, the link no longer carries messages. For the other failure mode, the link delivers incorrect messages. There is a description and comparison of link-redundancy versus path-redundancy as methods to achieve reliability. All the computations are carried out by means of a fault tree program.
Failure Mechanisms of Hollow Fiber Supported Ionic Liquid Membranes
Zeh, Matthew; Wickramanayake, Shan; Hopkinson, David
2016-01-01
Hollow fiber supported ionic liquid membranes (SILMs) were tested using the bubble point method to investigate potential failure modes, including the maximum transmembrane pressure before loss of the ionic liquid from the support. Porous hollow fiber supports were fabricated with different pore morphologies using Matrimid® and Torlon® as the polymeric material and 1-hexyl-3-methylimidalzolium bis(trifluoromethylsulfonyl)imide ([C6mim][Tf2N]) as the ionic liquid (IL) component. Hollow fiber SILMs were tested for their maximum pressure before failure, with pressure applied either from the bore side or shell side. It was found that the membranes exhibited one or more of three different modes of failure when pressurized: liquid loss (occurring at the bubble point), rupture, and collapse. PMID:27023620
Nucleation versus percolation: Scaling criterion for failure in disordered solids
NASA Astrophysics Data System (ADS)
Biswas, Soumyajyoti; Roy, Subhadeep; Ray, Purusattam
2015-05-01
One of the major factors governing the mode of failure in disordered solids is the effective range R over which the stress field is modified following a local rupture event. In a random fiber bundle model, considered as a prototype of disordered solids, we show that the failure mode is nucleation dominated in the large system size limit, as long as R scales slower than Lζ, with ζ =2 /3 . For a faster increase in R , the failure properties are dominated by the mean-field critical point, where the damages are uncorrelated in space. In that limit, the precursory avalanches of all sizes are obtained even in the large system size limit. We expect these results to be valid for systems with finite (normalizable) disorder.
Preparation Torque Limit for Composites Joined with Mechanical Fasteners
NASA Technical Reports Server (NTRS)
Thomas, Frank P.; Yi, Zhao
2005-01-01
Current design guidelines for determining torque ranges for composites are based on tests and analysis from isotropic materials. Properties of composites are not taken into account. No design criteria based upon a systematic analytical and test analyses is available. This paper is to study the maximum torque load a composite component could carry prior to any failure. Specifically, the torque-tension tests are conducted. NDT techniques including acoustic emission, thermography and photomicroscopy are also utilized to characterize the damage modes.
Joint Test Protocol: Environmentally Friendly Zirconium Oxide Pretreatment Demonstration
2013-12-01
coatings . Loss of paint adhesion is the primary failure mode on aluminum and steel. 3.7.3 Test Methodology The test methodology for pencil hardness...conversion pretreatment coatings . Loss of paint adhesion is the primary failure mode on aluminum and steel. 3.8.3 Test Methodology The test...SUPPLEMENTARY NOTES 14. ABSTRACT There is a need to implement innovative and cost- effective replacement technologies to address the multiple health, safety
Semi-Autonomous Control with Cyber-Pain for Artificial Muscles and Smart Structures
2010-09-15
avoid some key failure modes. Our approach has built on our developments in dynamic self-sensing and realistic simulation of DEA electromechanics...local controller) to avoid some key failure modes. Our approach has built on our developments in dynamic self-sensing and realistic simulation of DEA...strains [4]. In its natural state long polymer backbones are entangled with intermittent cross-links tying neighbouring backbones together. The soft
NASA Technical Reports Server (NTRS)
Robinson, W. W.
1987-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA approach features a top-down analysis of the Electrical Power Distribution and Control (EPD and C)/Remote Manipulator System (RMS) hardware to determine failure modes, criticality, and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained in the NASA FMEA/CIL documentation. This report documents the results of the independent analysis of the EPD and C/RMS (both port and starboard) hardware. The EPD and C/RMS subsystem hardware provides the electrical power and power control circuitry required to safely deploy, operate, control, and stow or guillotine and jettison two (one port and one starboard) RMSs. The EPD and C/RMS subsystem is subdivided into the four following functional divisions: Remote Manipulator Arm; Manipulator Deploy Control; Manipulator Latch Control; Manipulator Arm Shoulder Jettison; and Retention Arm Jettison. The IOA analysis process utilized available EPD and C/RMS hardware drawings and schematics for defining hardware assemblies, components, and hardware items. Each level of hardware was evaluated and analyzed for possible failure modes and effects. Criticality was assigned based on the severity of the effect for each failure mode.
Ashley, Laura; Armitage, Gerry; Taylor, Julie
2017-03-01
Failure Modes and Effects Analysis (FMEA) is a prospective quality assurance methodology increasingly used in healthcare, which identifies potential vulnerabilities in complex, high-risk processes and generates remedial actions. We aimed, for the first time, to apply FMEA in a social care context to evaluate the process for recognising and referring children exposed to domestic abuse within one Midlands city safeguarding area in England. A multidisciplinary, multi-agency team of 10 front-line professionals undertook the FMEA, using a modified methodology, over seven group meetings. The FMEA included mapping out the process under evaluation to identify its component steps, identifying failure modes (potential errors) and possible causes for each step and generating corrective actions. In this article, we report the output from the FMEA, including illustrative examples of the failure modes and corrective actions generated. We also present an analysis of feedback from the FMEA team and provide future recommendations for the use of FMEA in appraising social care processes and practice. Although challenging, the FMEA was unequivocally valuable for team members and generated a significant number of corrective actions locally for the safeguarding board to consider in its response to children exposed to domestic abuse. © 2016 John Wiley & Sons Ltd.
A clinical comparison between a new dual-chamber pacing mode-AAIsafeR and DDD mode.
Xue-Jun, Ren; Zhihong, Han; Ye, Wang; Huifeng, Du; Jinrong, Zhang; Fang, Chen; Jihong, Guo
2010-02-01
The aim of this study was to compare the cross-follow-up results in DDD or AAISafeR mode and to describe the safety and effectiveness of this pacing mode. The Symphony 2450/2550 cardiac pacemakers were implanted in 30 patients with sick sinus syndrome between February 2006 and September 2006. They were randomized to the DDD mode or AAISafeR mode for 3 months and then crossed over to the alternate pacing modality for an additional 3 months. No AAISafeR-related adverse event was observed. All documented episodes of paroxysmal atrial ventricular block caused the immediate switch of the pacing mode from AAI to DDD. The cumulative percent ventricular pacing was significantly reduced in the AAISafeR mode compared with the DDD mode (0.9% [0%-3%] versus 51.3% [2%-91%] P = 0.001; 2.94% [0%-18%] versus 41.18% [0%-65%] P = 0.0001). After 3 months in DDD mode, left atrial diameter, left ventricular enddiastolic diameter, and left ventricular end-systolic diameter increased significantly and left ventricular ejection fraction decreased. However, no obvious changes appeared in 3 months of AAISafeR mode. Switches to DDD occurred during follow-up in 21 patients due to different-degree atrial ventricular block. The AAISafeR mode substantially reduces the amount of unnecessary right ventricular pacing in the bradycardia population and effectively prevents the deleterious effects on cardiac performance. An international randomized study will further ascertain the efficacy of this new pacing mode specifically in the prevention of heart failure hospitalization and atrial fibrillation.
Mixed-mode cyclic debonding of adhesively bonded composite joints. M.S. Thesis
NASA Technical Reports Server (NTRS)
Rezaizadeh, M. A.; Mall, S.
1985-01-01
A combined experimental-analytical investigation to characterize the cyclic failure mechanism of a simple composite-to-composite bonded joint is conducted. The cracked lap shear (CLS) specimens of graphite/epoxy adherend bonded with EC-3445 adhesive are tested under combined mode 1 and 2 loading. In all specimens tested, fatigue failure occurs in the form of cyclic debonding. The cyclic debond growth rates are measured. The finite element analysis is employed to compute the mode 1, mode 2, and total strain energy release rates (i.e., GI, GII, and GT). A wide range of mixed-mode loading, i.e., GI/GII ranging from 0.03 to 0.38, is obtained. The total strain energy release rate, G sub T, appeared to be the driving parameter for cyclic debonding in the tested composite bonded system.
Ultrasonic Spot Welding of a Rare-Earth Containing ZEK100 Magnesium Alloy: Effect of Welding Energy
NASA Astrophysics Data System (ADS)
Macwan, A.; Chen, D. L.
2016-04-01
Ultrasonic spot welding was used to join a low rare-earth containing ZEK100 Mg alloy at different levels of welding energy, and tensile lap shear tests were conducted to evaluate the failure strength in relation to the microstructural changes. It was observed that dynamic recrystallization occurred in the nugget zone; the grain size increased and microhardness decreased with increasing welding energy arising from the increasing interface temperature and strain rate. The weld interface experienced severe plastic deformation at a high strain rate from ~500 to ~2100 s-1 with increasing welding energy from 500 to 2000 J. A relationship between grain size and Zener-Hollomon parameter, and a Hall-Petch-type relationship between microhardness and grain size were established. The tensile lap shear strength and failure energy were observed to first increase with increasing welding energy, reach the maximum values at 1500 J, and then decrease with a further increase in the welding energy. The samples welded at a welding energy ≤1500 J exhibited an interfacial failure mode, while nugget pull-out occurred in the samples welded at a welding energy above 1500 J. The fracture surfaces showed typical shear failure. Low-temperature tests at 233 K (-40 °C) showed no significant effect on the strength and failure mode of joints welded at the optimal welding energy of 1500 J. Elevated temperature tests at 453 K (180 °C) revealed a lower failure load but a higher failure energy due to the increased deformability, and showed a mixed mode of partial interfacial failure and partial nugget pull-out.
Türk, Murat; Aydoğdu, Müge; Gürsel, Gül
2018-01-01
Different outcomes and success rates of non-invasive positive pressure ventilation (NPPV) in patients with acute hypercapnic respiratory failure (AHRF) still pose a significant problem in intensive care units. Previous studies investigating different modes, body positioning, and obesity-associated hypoventilation in patients with chronic respiratory failure showed that these factors may affect ventilator mechanics to achieve a better minute ventilation. This study tried to compare pressure support (BiPAP-S) and average volume targeted pressure support (AVAPS-S) modes in patients with acute or acute-on-chronic hypercapnic respiratory failure. In addition, short-term effects of body position and obesity within both modes were analyzed. We conducted a randomized controlled study in a 7-bed intensive care unit. The course of blood gas analysis and differences in ventilation variables were compared between BiPAP-S (n=33) and AVAPS-S (n=29), and between semi-recumbent and lateral positions in both modes. No difference was found in the length of hospital stay and the course of PaCO2, pH, and HCO3 levels between the modes. There was a mean reduction of 5.7±4.1 mmHg in the PaCO2 levels in the AVAPS-S mode, and 2.7±2.3 mmHg in the BiPAP-S mode per session (p<0.05). Obesity didn't have any effect on the course of PaCO2 in both the modes. Body positioning had no notable effect in both modes. Although the decrease in the PaCO2 levels in the AVAPS-S mode per session was remarkably high, the course was similar in both modes. Furthermore, obesity and body positioning had no prominent effect on the PaCO2 response and ventilator mechanics. Post hoc power analysis showed that the sample size was not adequate to detect a significant difference between the modes.
Zellner, Eric M; Hedlund, Cheryl S; Kraus, Karl H; Burton, Andrew F; Kieves, Nina R
2016-06-15
OBJECTIVE To compare suture placement time, tension at skin separation and suture line failure, and mode of failure among 4 suture patterns. DESIGN Randomized trial. SAMPLE 60 skin specimens from the pelvic limbs of 30 purpose-bred Beagles. PROCEDURES Skin specimens were harvested within 2 hours after euthanasia and tested within 6 hours after harvest. An 8-cm incision was made in each specimen and sutured with 1 of 4 randomly assigned suture patterns (simple interrupted, cruciate, intradermal, or subdermal). Suture placement time and percentage of skin apposition were evaluated. Specimens were mounted in a calibrated material testing machine and distracted until suture line failure. Tensile strength at skin-edge separation and suture-line failure and mode of failure were compared among the 4 patterns. RESULTS Mean suture placement time for the cruciate pattern was significantly less than that for other patterns. Percentage of skin apposition did not differ among the 4 patterns. Mean tensile strength at skin-edge separation and suture-line failure for the simple interrupted and cruciate patterns were significantly higher than those for the intradermal and subdermal patterns. Mean tensile strength at skin-edge separation and suture-line failure did not differ significantly between the intradermal and subdermal patterns or the simple interrupted and cruciate patterns. The primary mode of failure for the simple interrupted pattern was suture breakage, whereas that for the cruciate, intradermal, and subdermal patterns was tissue failure. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested external skin sutures may be preferred for closure of incisions under tension to reduce risk of dehiscence.
NASA Astrophysics Data System (ADS)
Liu, Shuhuan; Du, Xuecheng; Du, Xiaozhi; Zhang, Yao; Mubashiru, Lawal Olarewaju; Luo, Dongyang; yuan, Yuan; Deng, Tianxiang; Li, Zhuoqi; Zang, Hang; Li, Yonghong; He, Chaohui; Ma, Yingqi; Shangguan, Shipeng
2017-09-01
The impacts of the external dynamic memory (DDR3) failures on the performance of 28 nm Xilinx Zynq-7010 SoC based system (MicroZed) were investigated with two sets of 1064 nm laser platforms. The failure sensitive area distributionsons on the back surface of the test DDR3 were primarily localized with a CW laser irradiation platform. During the CW laser scanning on the back surface of the DDR3 of the test board system, various failure modes except SEU and SEL (MBU, SEFI, data storage address error, rebooting, etc) were found in the testing embedded modules (ALU, PL, Register, Cache and DMA, etc) of SoC. Moreover, the experimental results demonstrated that there were 16 failure sensitive blocks symmetrically distributed on the back surface of the DDR3 with every sensitive block area measured was about 1 mm × 0.5 mm. The influence factors on the failure modes of the embedded modules were primarily analyzed and the SEE characteristics of DDR3 induced by the picoseconds pulsed laser were tested. The failure modes of DDR3 found were SEU, SEFI, SEL, test board rebooting by itself, unknown data, etc. Furthermore, the time interval distributions of failure occurrence in DDR3 changes with the pulsed laser irradiation energy and the CPU operating frequency were measured and compared. Meanwhile, the failure characteristics of DDR3 induced by pulsed laser irradiation were primarily explored. The measured results and the testing techniques designed in this paper provide some reference information for evaluating the reliability of the test system or other similar electronic system in harsh environment.
Failure behavior of glass ionomer cement under Hertzian indentation.
Wang, Yan; Darvell, B W
2008-09-01
To investigate the load-bearing capacity and failure mode of various types of glass ionomer cement (GIC) under Hertzian indentation, exploring the relationship between the failure behavior and formulation, and examining claims of filler-reinforcement of GIC. Discs 2mm thick, 10mm diameter, 8-18 replicates, were fabricated for two filler-reinforced GICs, four unmodified and unreinforced GICs, and four resin-modified GICs, with a dental silver amalgam and a filled-resin restorative material for comparison. Testing was at 23 degrees C, wet, after 7d storage at 37 degrees C in artificial saliva at pH 6, using a 20mm diameter hard steel ball and filled-nylon substrate (E: 10GPa). First failure was detected acoustically; mode was determined visually. At least 1/3 of specimens in each case were examined under scanning electronic microscope for corroboration. Reinforced and unmodified-unreinforced GICs were indistinguishable by failure load (one-way analysis of variance, P=0.425, overall 260+/-70N) and mode. Failure loads for resin-modified GICs were 360-1150N, amalgam approximately 680N, and filled resin approximately 1200N. Resin-modified GICs tended to be tougher (incomplete fracture), all others gave complete fracture (radial cracking). The stronger materials (two resin-modified GICs and filled resin) showed some cone cracking. While resin-modified GICs showed various extents of increase of failure load over that of the plain GICs, consistent with the hybrid chemistry, filler-reinforcement was not evident for the two claimed products, consistent with structural and theoretical expectations.
Failure analysis in the identification of synergies between cleaning monitoring methods.
Whiteley, Greg S; Derry, Chris; Glasbey, Trevor
2015-02-01
The 4 monitoring methods used to manage the quality assurance of cleaning outcomes within health care settings are visual inspection, microbial recovery, fluorescent marker assessment, and rapid ATP bioluminometry. These methods each generate different types of information, presenting a challenge to the successful integration of monitoring results. A systematic approach to safety and quality control can be used to interrogate the known qualities of cleaning monitoring methods and provide a prospective management tool for infection control professionals. We investigated the use of failure mode and effects analysis (FMEA) for measuring failure risk arising through each cleaning monitoring method. FMEA uses existing data in a structured risk assessment tool that identifies weaknesses in products or processes. Our FMEA approach used the literature and a small experienced team to construct a series of analyses to investigate the cleaning monitoring methods in a way that minimized identified failure risks. FMEA applied to each of the cleaning monitoring methods revealed failure modes for each. The combined use of cleaning monitoring methods in sequence is preferable to their use in isolation. When these 4 cleaning monitoring methods are used in combination in a logical sequence, the failure modes noted for any 1 can be complemented by the strengths of the alternatives, thereby circumventing the risk of failure of any individual cleaning monitoring method. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
NASA Technical Reports Server (NTRS)
1971-01-01
The reliability of semiconductor devices as influenced by the reliability of wire bonds used in the assembly of the devices is investigated. The specific type of failure dealt with involves fracture of wire bonds as a result of repeated flexure of the wire at the heel of the bond when the devices are operated in an on-off mode. The mechanism of failure is one of induced fracture of the wire. To improve the reliability of a chosen transistor, one-mil diameter wires of aluminum with various alloy additions were studied using an accelerated fatigue testing machine. In addition, the electroprobe was used to study the metallurgy of the wires as to microstructure and kinetics of the growth of insoluble phases. Thermocompression and ultrasonic bonding techniques were also investigated.
Application of failure mode and effects analysis (FMEA) to pretreatment phases in tomotherapy
Broggi, Sara; Cantone, Marie Claire; Chiara, Anna; Muzio, Nadia Di; Longobardi, Barbara; Mangili, Paola
2013-01-01
The aim of this paper was the application of the failure mode and effects analysis (FMEA) approach to assess the risks for patients undergoing radiotherapy treatments performed by means of a helical tomotherapy unit. FMEA was applied to the preplanning imaging, volume determination, and treatment planning stages of the tomotherapy process and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system; and 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. A total of 74 failure modes were identified: 38 in the stage of preplanning imaging and volume determination, and 36 in the stage of planning. The threshold of 125 for RPN was exceeded in four cases: one case only in the phase of preplanning imaging and volume determination, and three cases in the stage of planning. The most critical failures appeared related to (i) the wrong or missing definition and contouring of the overlapping regions, (ii) the wrong assignment of the overlap priority to each anatomical structure, (iii) the wrong choice of the computed tomography calibration curve for dose calculation, and (iv) the wrong (or not performed) choice of the number of fractions in the planning station. On the basis of these findings, in addition to the safety strategies already adopted in the clinical practice, novel solutions have been proposed for mitigating the risk of these failures and to increase patient safety. PACS number: 87.55.Qr PMID:24036868
Experimental Spin Testing of Integrally Damped Composite Plates
NASA Technical Reports Server (NTRS)
Kosmatka, John
1998-01-01
The experimental behavior of spinning laminated composite pretwisted plates (turbo-fan blade-like) with small (less than 10% by volume) integral viscoelastic damping patches was investigated at NASA-Lewis Research Center. Ten different plate sets were experimentally spin tested and the resulting data was analyzed. The first-four plate sets investigated tailoring patch locations and definitions to damp specific modes on spinning flat graphite/epoxy plates as a function of rotational speed. The remaining six plate sets investigated damping patch size and location on specific modes of pretwisted (30 degrees) graphite/epoxy plates. The results reveal that: (1) significant amount of damping can be added using a small amount of damping material, (2) the damped plates experienced no failures up to the tested 28,000 g's and 750,000 cycles, (3) centrifugal loads caused an increase in bending frequencies and corresponding reductions in bending damping levels that are proportional to the bending stiffness increase, and (4) the centrifugal loads caused a decrease in torsion natural frequency and increase in damping levels of pretwisted composite plates.
Failure Analysis of Alumina Reinforced Aluminum Microtruss and Tube Composites
NASA Astrophysics Data System (ADS)
Chien, Hsueh Fen (Karen)
The energy absorption capacity of cellular materials can be dramatically increased by applying a structural coating. This thesis examined the failure mechanisms of alumina reinforced 3003 aluminum alloy microtrusses and tubes. Alumina coatings were produced by hard anodizing and by plasma electrolytic oxidation (PEO). The relatively thin and discontinuous oxide coating at the hinge acted as a localized weak spot which triggered a chain reaction of failure, including oxide fracture, oxide spallation, oxide penetration to the aluminum core and severe local plastic deformation of the core. For the PEO microtrusses, delamination occurred within the oxide coating resulting in a global strut buckling failure mode. A new failure mode for the anodized tubes was observed: (i) axisymmetric folding of the aluminum core, (ii) longitudinal fracture, and (iii) alumina pulverization. Overall, the alumina coating enhanced the buckling resistance of the composites, while the aluminum core supported the oxide during the damage propagation.
Failure mechanisms of laminates transversely loaded by bolt push-through
NASA Technical Reports Server (NTRS)
Waters, W. A., Jr.; Williams, J. G.
1985-01-01
Stiffened composite panels proposed for fuselage and wing design utilize a variety of stiffener-to-skin attachment concepts including mechanical fasteners. The attachment concept is an important factor influencing the panel's strength and can govern its performance following local damage. Mechanical fasteners can be an effective method for preventing stiffener-skin separation. One potential failure mode for bolted panels occurs when the bolts pull through the stiffener attachment flange or skin. The resulting loss of support by the skin to the stiffener and by the stiffener to the skin can result in local buckling and subsequent panel collapse. The characteristic failure modes associated with bolt push-through failure are described and the results of a parametric study of the effects that different material systems, boundary conditions, and laminates have on the forces and displacements required to cause damage and bolt pushthrough failure are presented.
Hydrogen embrittlement in compositionally complex FeNiCoCrMn FCC solid solution alloy
Nygren, K. E.; Bertsch, K. M.; Wang, S.; ...
2018-02-01
The influence of internal hydrogen on the tensile properties of an equi-molar FeNiCoCrMn alloy results in a significant reduction of ductility, which is accompanied by a change in the fracture mode from ductile microvoid coalescence to intergranular failure. The introduction of 146.9 mass ppm of hydrogen reduced the plastic strain to failure from 0.67 in the uncharged case to 0.34 and 0.51 in hydrogen-charged specimens. This reduction in ductility and the transition in failure mode are clear indications that this alloy exhibits the classic signs of being susceptible to hydrogen embrittlement. The results are discussed in terms of the hydrogen-enhancedmore » plasticity mechanism and its influence on hydrogen-induced intergranular failure. Furthermore, a new additional constraint that further promotes intergranular failure is introduced for the first time.« less
Lunar Module Electrical Power System Design Considerations and Failure Modes
NASA Technical Reports Server (NTRS)
Interbartolo, Michael
2009-01-01
This slide presentation reviews the design and redesign considerations of the Apollo lunar module electrical power system. Included in the work are graphics showing the lunar module power system. It describes the in-flight failures, and the lessons learned from these failures.
Recent advances in computational structural reliability analysis methods
NASA Astrophysics Data System (ADS)
Thacker, Ben H.; Wu, Y.-T.; Millwater, Harry R.; Torng, Tony Y.; Riha, David S.
1993-10-01
The goal of structural reliability analysis is to determine the probability that the structure will adequately perform its intended function when operating under the given environmental conditions. Thus, the notion of reliability admits the possibility of failure. Given the fact that many different modes of failure are usually possible, achievement of this goal is a formidable task, especially for large, complex structural systems. The traditional (deterministic) design methodology attempts to assure reliability by the application of safety factors and conservative assumptions. However, the safety factor approach lacks a quantitative basis in that the level of reliability is never known and usually results in overly conservative designs because of compounding conservatisms. Furthermore, problem parameters that control the reliability are not identified, nor their importance evaluated. A summary of recent advances in computational structural reliability assessment is presented. A significant level of activity in the research and development community was seen recently, much of which was directed towards the prediction of failure probabilities for single mode failures. The focus is to present some early results and demonstrations of advanced reliability methods applied to structural system problems. This includes structures that can fail as a result of multiple component failures (e.g., a redundant truss), or structural components that may fail due to multiple interacting failure modes (e.g., excessive deflection, resonate vibration, or creep rupture). From these results, some observations and recommendations are made with regard to future research needs.
Recent advances in computational structural reliability analysis methods
NASA Technical Reports Server (NTRS)
Thacker, Ben H.; Wu, Y.-T.; Millwater, Harry R.; Torng, Tony Y.; Riha, David S.
1993-01-01
The goal of structural reliability analysis is to determine the probability that the structure will adequately perform its intended function when operating under the given environmental conditions. Thus, the notion of reliability admits the possibility of failure. Given the fact that many different modes of failure are usually possible, achievement of this goal is a formidable task, especially for large, complex structural systems. The traditional (deterministic) design methodology attempts to assure reliability by the application of safety factors and conservative assumptions. However, the safety factor approach lacks a quantitative basis in that the level of reliability is never known and usually results in overly conservative designs because of compounding conservatisms. Furthermore, problem parameters that control the reliability are not identified, nor their importance evaluated. A summary of recent advances in computational structural reliability assessment is presented. A significant level of activity in the research and development community was seen recently, much of which was directed towards the prediction of failure probabilities for single mode failures. The focus is to present some early results and demonstrations of advanced reliability methods applied to structural system problems. This includes structures that can fail as a result of multiple component failures (e.g., a redundant truss), or structural components that may fail due to multiple interacting failure modes (e.g., excessive deflection, resonate vibration, or creep rupture). From these results, some observations and recommendations are made with regard to future research needs.
Debonding Stress Concentrations in a Pressurized Lobed Sandwich-Walled Generic Cryogenic Tank
NASA Technical Reports Server (NTRS)
Ko, William L.
2004-01-01
A finite-element stress analysis has been conducted on a lobed composite sandwich tank subjected to internal pressure and cryogenic cooling. The lobed geometry consists of two obtuse circular walls joined together with a common flat wall. Under internal pressure and cryogenic cooling, this type of lobed tank wall will experience open-mode (a process in which the honeycomb is stretched in the depth direction) and shear stress concentrations at the junctures where curved wall changes into flat wall (known as a curve-flat juncture). Open-mode and shear stress concentrations occur in the honeycomb core at the curve-flat junctures and could cause debonding failure. The levels of contributions from internal pressure and temperature loading to the open-mode and shear debonding failure are compared. The lobed fuel tank with honeycomb sandwich walls has been found to be a structurally unsound geometry because of very low debonding failure strengths. The debonding failure problem could be eliminated if the honeycomb core at the curve-flat juncture is replaced with a solid core.
A Diagnostic Approach for Electro-Mechanical Actuators in Aerospace Systems
NASA Technical Reports Server (NTRS)
Balaban, Edward; Saxena, Abhinav; Bansal, Prasun; Goebel, Kai Frank; Stoelting, Paul; Curran, Simon
2009-01-01
Electro-mechanical actuators (EMA) are finding increasing use in aerospace applications, especially with the trend towards all all-electric aircraft and spacecraft designs. However, electro-mechanical actuators still lack the knowledge base accumulated for other fielded actuator types, particularly with regard to fault detection and characterization. This paper presents a thorough analysis of some of the critical failure modes documented for EMAs and describes experiments conducted on detecting and isolating a subset of them. The list of failures has been prepared through an extensive Failure Modes and Criticality Analysis (FMECA) reference, literature review, and accessible industry experience. Methods for data acquisition and validation of algorithms on EMA test stands are described. A variety of condition indicators were developed that enabled detection, identification, and isolation among the various fault modes. A diagnostic algorithm based on an artificial neural network is shown to operate successfully using these condition indicators and furthermore, robustness of these diagnostic routines to sensor faults is demonstrated by showing their ability to distinguish between them and component failures. The paper concludes with a roadmap leading from this effort towards developing successful prognostic algorithms for electromechanical actuators.
Folded fabric tunes rock deformation and failure mode in the upper crust.
Agliardi, F; Dobbs, M R; Zanchetta, S; Vinciguerra, S
2017-11-10
The micro-mechanisms of brittle failure affect the bulk mechanical behaviour and permeability of crustal rocks. In low-porosity crystalline rocks, these mechanisms are related to mineralogy and fabric anisotropy, while confining pressure, temperature and strain rates regulate the transition from brittle to ductile behaviour. However, the effects of folded anisotropic fabrics, widespread in orogenic settings, on the mechanical behaviour of crustal rocks are largely unknown. Here we explore the deformation and failure behaviour of a representative folded gneiss, by combining the results of triaxial deformation experiments carried out while monitoring microseismicity with microstructural and damage proxies analyses. We show that folded crystalline rocks in upper crustal conditions exhibit dramatic strength heterogeneity and contrasting failure modes at identical confining pressure and room temperature, depending on the geometrical relationships between stress and two different anisotropies associated to the folded rock fabric. These anisotropies modulate the competition among quartz- and mica-dominated microscopic damage processes, resulting in transitional brittle to semi-brittle modes under P and T much lower than expected. This has significant implications on scales relevant to seismicity, energy resources, engineering applications and geohazards.
Stocker, Elena; Toschkoff, Gregor; Sacher, Stephan; Khinast, Johannes G
2014-11-20
The purpose of this study is to evaluate the use of computer simulations for generating quantitative knowledge as a basis for risk ranking and mechanistic process understanding, as required by ICH Q9 on quality risk management systems. In this specific publication, the main focus is the demonstration of a risk assessment workflow, including a computer simulation for the generation of mechanistic understanding of active tablet coating in a pan coater. Process parameter screening studies are statistically planned under consideration of impacts on a potentially critical quality attribute, i.e., coating mass uniformity. Based on computer simulation data the process failure mode and effects analysis of the risk factors is performed. This results in a quantitative criticality assessment of process parameters and the risk priority evaluation of failure modes. The factor for a quantitative reassessment of the criticality and risk priority is the coefficient of variation, which represents the coating mass uniformity. The major conclusion drawn from this work is a successful demonstration of the integration of computer simulation in the risk management workflow leading to an objective and quantitative risk assessment. Copyright © 2014. Published by Elsevier B.V.
Lunar Module ECS (Environmental Control System) - Design Considerations and Failure Modes. Part 1
NASA Technical Reports Server (NTRS)
Interbartolo, Michael
2009-01-01
Design considerations and failure modes for the Lunar Module (LM) Environmental Control System (ECS) are described. An overview of the the oxygen supply and cabin pressurization, atmosphere revitalization, water management and heat transport systems are provided. Design considerations including reliability, flight instrumentation, modularization and the change to the use of batteries instead of fuel cells are discussed. A summary is provided for the LM ECS general testing regime.
NASA Technical Reports Server (NTRS)
LaBel, Kenneth A.; Ladbury, Ray; Oldhamm, Timothy
2010-01-01
As NASA has evolved it's usage of spaceflight computing, memory applications have followed as well. In this slide presentation, the history of NASA's memories from magnetic core and tape recorders to current semiconductor approaches is discussed. There is a brief description of current functional memory usage in NASA space systems followed by a description of potential radiation-induced failure modes along with considerations for reliable system design.
The practical impact of elastohydrodynamic lubrication
NASA Technical Reports Server (NTRS)
Anderson, W. J.
1978-01-01
The use of elastohydrodynamics in the analysis of rolling element bearings is discussed. Relationships for minimum film thickness and tractive force were incorporated into computer codes and used for bearing performance prediction. The lambda parameter (ratio of film thickness to composite surface roughness) was shown to be important in predicting bearing life and failure mode. Results indicate that at values of lambda below 3 failure modes other than the classic subsurface initiated fatigue can occur.
NASA Astrophysics Data System (ADS)
Varzakas, Theodoros H.; Arvanitoyannis, Ioannis S.
Failure Mode and Effect Analysis (FMEA) model has been applied for the risk assessment of poultry slaughtering and manufacturing. In this work comparison of ISO22000 analysis with HACCP is carried out over poultry slaughtering, processing and packaging. Critical Control points and Prerequisite programs (PrPs) have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram and fishbone diagram).
Fault detection and diagnosis using neural network approaches
NASA Technical Reports Server (NTRS)
Kramer, Mark A.
1992-01-01
Neural networks can be used to detect and identify abnormalities in real-time process data. Two basic approaches can be used, the first based on training networks using data representing both normal and abnormal modes of process behavior, and the second based on statistical characterization of the normal mode only. Given data representative of process faults, radial basis function networks can effectively identify failures. This approach is often limited by the lack of fault data, but can be facilitated by process simulation. The second approach employs elliptical and radial basis function neural networks and other models to learn the statistical distributions of process observables under normal conditions. Analytical models of failure modes can then be applied in combination with the neural network models to identify faults. Special methods can be applied to compensate for sensor failures, to produce real-time estimation of missing or failed sensors based on the correlations codified in the neural network.
Experimental Robot Position Sensor Fault Tolerance Using Accelerometers and Joint Torque Sensors
NASA Technical Reports Server (NTRS)
Aldridge, Hal A.; Juang, Jer-Nan
1997-01-01
Robot systems in critical applications, such as those in space and nuclear environments, must be able to operate during component failure to complete important tasks. One failure mode that has received little attention is the failure of joint position sensors. Current fault tolerant designs require the addition of directly redundant position sensors which can affect joint design. The proposed method uses joint torque sensors found in most existing advanced robot designs along with easily locatable, lightweight accelerometers to provide a joint position sensor fault recovery mode. This mode uses the torque sensors along with a virtual passive control law for stability and accelerometers for joint position information. Two methods for conversion from Cartesian acceleration to joint position based on robot kinematics, not integration, are presented. The fault tolerant control method was tested on several joints of a laboratory robot. The controllers performed well with noisy, biased data and a model with uncertain parameters.
Independent Orbiter Assessment (IOA): Assessment of the active thermal control system
NASA Technical Reports Server (NTRS)
Sinclair, S. K.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Active Thermal Control System (ATCS) hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the available NASA FMEA/CIL data. Discrepancies from the comparison were documented, and where enough information was available, recommendations for resolution of the discrepancies were made. This report documents the results of that comparison for the Orbiter ATCS hardware. The IOA product for the ATCS independent analysis consisted of 310 failure mode worksheets that resulted in 101 potential critical items (PCI) being identified. A comparison was made to the available NASA data which consisted of 252 FMEAs and 109 CIL items.
Dielectric elastomer membranes undergoing inhomogeneous deformation
NASA Astrophysics Data System (ADS)
He, Tianhu; Zhao, Xuanhe; Suo, Zhigang
2009-10-01
Dielectric elastomers are capable of large deformation subject to an electric voltage and are promising for use as actuators, sensors, and generators. Because of large deformation, nonlinear equations of states, and diverse modes of failure, modeling the process of electromechanical transduction has been challenging. This paper studies a membrane of a dielectric elastomer deformed into an out-of-plane axisymmetric shape, a configuration used in a family of commercial devices known as the universal muscle actuators. The kinematics of deformation and charging, together with thermodynamics, leads to equations that govern the state of equilibrium. Numerical results indicate that the field in the membrane can be very inhomogeneous, and that the membrane is susceptible to several modes of failure, including electrical breakdown, loss of tension, and rupture by stretch. Care is needed in the design to balance the requirements of averting various modes of failure while using the material efficiently.
Independent Orbiter Assessment (IOA): Assessment of the crew equipment subsystem
NASA Technical Reports Server (NTRS)
Saxon, H.; Richard, Bill; Sinclair, S. K.
1988-01-01
The results of the Independent Orbiter Assessment (IOA) of the Failure Modes and Effects Analysis (FMEA) and Critical Items List (CIL) are presented. The IOA effort first completed an analysis of the Crew Equipment hardware, generating draft failure modes and potential critical items. To preserve independence, this analysis was accomplished without reliance upon the results contained within the NASA FMEA/CIL documentation. The IOA results were then compared to the NASA FMEA/CIL baseline with proposed Post 51-L updates included. A resolution of each discrepancy from the comparison is provided through additional analysis as required. This report documents the results of that comparison for the Orbiter Crew Equipment hardware. The IOA product for the Crew Equipment analysis consisted of 352 failure mode worksheets that resulted in 78 potential critical items being identified. Comparison was made to the NASA baseline which consisted of 351 FMEAs and 82 CIL items.
Advanced Technology Blade testing on the XV-15 Tilt Rotor Research Aircraft
NASA Technical Reports Server (NTRS)
Wellman, Brent
1992-01-01
The XV-15 Tilt Rotor Research Aircraft has just completed the first series of flight tests with the Advanced Technology Blade (ATB) rotor system. The ATB are designed specifically for flight research and provide the ability to alter blade sweep and tip shape. A number of problems were encountered from first installation through envelope expansion to airplane mode flight that required innovative solutions to establish a suitable flight envelope. Prior to operation, the blade retention hardware had to be requalified to a higher rated centrifugal load, because the blade weight was higher than expected. Early flights in the helicopter mode revealed unacceptably high vibratory control system loads which required a temporary modification of the rotor controls to achieve higher speed flight and conversion to airplane mode. The airspeed in airplane mode was limited, however, because of large static control loads. Furthermore, analyses based on refined ATB blade mass and inertia properties indicated a previously unknown high-speed blade mode instability, also requiring airplane-mode maximum airspeed to be restricted. Most recently, a structural failure of an ATB cuff (root fairing) assembly retention structure required a redesign of the assembly. All problems have been addressed and satisfactory solutions have been found to allow continued productive flight research of the emerging tilt rotor concept.
A Selection of Composites Simulation Practices at NASA Langley Research Center
NASA Technical Reports Server (NTRS)
Ratcliffe, James G.
2007-01-01
One of the major areas of study at NASA Langley Research Center is the development of technologies that support the use of advanced composite materials in aerospace applications. Amongst the supporting technologies are analysis tools used to simulate the behavior of these materials. This presentation will discuss a number of examples of analysis tools and simulation practices conducted at NASA Langley. The presentation will include examples of damage tolerance analyses for both interlaminar and intralaminar failure modes. Tools for modeling interlaminar failure modes include fracture mechanics and cohesive methods, whilst tools for modeling intralaminar failure involve the development of various progressive failure analyses. Other examples of analyses developed at NASA Langley include a thermo-mechanical model of an orthotropic material and the simulation of delamination growth in z-pin reinforced laminates.
Some failure modes and analysis techniques for terrestrial solar cell modules
NASA Technical Reports Server (NTRS)
Shumka, A.; Stern, K. H.
1978-01-01
Analysis data are presented on failed/defective silicon solar cell modules of various types and produced by different manufacturers. The failure mode (e.g., internal short and open circuits, output power degradation, isolation resistance degradation, etc.) are discussed in detail and in many cases related to the type of technology used in the manufacture of the modules; wherever applicable, appropriate corrective actions are recommended. Consideration is also given to some failure analysis techniques that are applicable to such modules, including X-ray radiography, capacitance measurement, cell shunt resistance measurement by the shadowing technique, steady-state illumination test station for module performance illumination, laser scanning techniques, and the SEM.
Failure mechanics in low-velocity impacts on thin composite plates
NASA Technical Reports Server (NTRS)
Elber, W.
1983-01-01
Eight-ply quasi-isotropic composite plates of Thornel 300 graphite in Narmco 5208 epoxy resin (T300/5208) were tested to establish the degree of equivalence between low-velocity impact and static testing. Both the deformation and failure mechanics under impact were representable by static indentation tests. Under low-velocity impacts such as tool drops, the dominant deformation mode of the plates was the first, or static, mode. Higher modes are excited on contact, but they decay significantly by the time the first-mode load reaches a maximum. The delamination patterns were observed by X-ray analysis. The areas of maximum delamination patterns were observed by X-ray analysis. The areas of maximum delamination coincided with the areas of highest peel stresses. The extent of delamination was similar for static and impact tests. Fiber failure damage was established by tensile tests on small fiber bundles obtained by deplying test specimens. The onset of fiber damage was in internal plies near the lower surface of the plates. The distribution and amount of fiber damage was similar fo impact and static tests.
Geological constraints on the mechanism of tectonic tremor
NASA Astrophysics Data System (ADS)
Kirkpatrick, J. D.
2016-12-01
Observations of tectonic tremor in a wide variety of tectonic settings suggest that transitional behavior involving contemporaneous shear fracture and aseismic creep transients occurs in many major faults. Seismological and geophysical data indicate shear failure on critically stressed faults, likely under low effective stress conditions, are consistent characteristics, even though rock types and grain scale deformation mechanisms vary at these different locations. Geological observations could add additional insight into the specific failure mechanisms if the structures that form during tremor episodes can be identified. Exhumed shear zones often contain folded, boudinaged and/or dynamically recrystallized veins that record cyclical fracture and viscous deformation representing mixed bulk rheology. Examples from a Cretaceous transpressional continental shear zone in the Sierra Nevada, CA, include quartz-filled veins meters to tens of meters long with millimeters to centimeters of shear offset that preferentially developed along foliation planes in a high strain zone. Ambient temperatures during deformation were 400-600°C, and opening mode vein orientations and abundance suggest fluid pressure was near lithostatic at times. The orientation and spatial distribution of the veins indicate they formed under differential stress large enough for shear failure with pore pressures sufficiently high for the rocks to be critically stressed along mechanically weak foliation planes. Bulk deformation of the surrounding rock was accommodated viscously by crystal plastic deformation mechanisms. The mode of fracturing and overall behavior of the system was controlled by the local competition between the rates of stress recovery following fracture and stress drop, and pore pressure build up. The inferred mixed rheology recorded by the veins is phenomenologically similar to tremor. These shear fractures, and the conditions of failure they record, could be comparable to the mechanism that produces tectonic tremor.
14 CFR 417.309 - Flight safety system analysis.
Code of Federal Regulations, 2012 CFR
2012-01-01
... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...
14 CFR 417.309 - Flight safety system analysis.
Code of Federal Regulations, 2010 CFR
2010-01-01
... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...
14 CFR 417.309 - Flight safety system analysis.
Code of Federal Regulations, 2013 CFR
2013-01-01
... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...
14 CFR 417.309 - Flight safety system analysis.
Code of Federal Regulations, 2014 CFR
2014-01-01
... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...
14 CFR 417.309 - Flight safety system analysis.
Code of Federal Regulations, 2011 CFR
2011-01-01
... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...
NASA Technical Reports Server (NTRS)
Ratcliffe, James G.
2004-01-01
The edge crack torsion (ECT) test is designed to initiate mode III delamination growth in composite laminates. An ECT specimen is a rectangular laminate, containing an edge delamination at the laminate mid-plane. Torsion load is applied to the specimens, resulting in relative transverse shear sliding of the delaminated faces. The test data reduction schemes are intended to yield initiation values of critical mode III strain energy release rate, G(sub IIIc), that are constant with delamination length. The test has undergone several design changes during its development. The objective of this paper was to determine the suitability of the current ECT test design as a mode III fracture test. To this end, ECT tests were conducted on specimens manufactured from IM7/8552 and specimens made from S2/8552 tape laminates. Several specimens, each with different delamination lengths are tested. Detailed, three-dimensional finite element analyses of the specimens were performed. The analysis results were used to calculate the distribution of mode I, mode II, and mode III strain energy release rate along the delamination front. The results indicated that mode III-dominated delamination growth would be initiated from the specimen center. However, in specimens of both material types, the measured values of G(sub IIIc) exhibited significant dependence on delamination length. Furthermore, there was a large amount of scatter in the data. Load-displacement response of the specimens exhibited significant deviation from linearity before specimen failure. X-radiographs of a sample of specimens revealed that damage was initiated in the specimens prior to failure. Further inspection of the failure surfaces is required to identify the damage and determine that mode III delamination is initiated in the specimens.
Sliding Mode Control of the X-33 with an Engine Failure
NASA Technical Reports Server (NTRS)
Shtessel, Yuri B.; Hall, Charles E.
2000-01-01
Ascent flight control of the X-3 is performed using two XRS-2200 linear aerospike engines. in addition to aerosurfaces. The baseline control algorithms are PID with gain scheduling. Flight control using an innovative method. Sliding Mode Control. is presented for nominal and engine failed modes of flight. An easy to implement, robust controller. requiring no reconfiguration or gain scheduling is demonstrated through high fidelity flight simulations. The proposed sliding mode controller utilizes a two-loop structure and provides robust. de-coupled tracking of both orientation angle command profiles and angular rate command profiles in the presence of engine failure, bounded external disturbances (wind gusts) and uncertain matrix of inertia. Sliding mode control causes the angular rate and orientation angle tracking error dynamics to be constrained to linear, de-coupled, homogeneous, and vector valued differential equations with desired eigenvalues. Conditions that restrict engine failures to robustness domain of the sliding mode controller are derived. Overall stability of a two-loop flight control system is assessed. Simulation results show that the designed controller provides robust, accurate, de-coupled tracking of the orientation angle command profiles in the presence of external disturbances and vehicle inertia uncertainties, as well as the single engine failed case. The designed robust controller will significantly reduce the time and cost associated with flying new trajectory profiles or orbits, with new payloads, and with modified vehicles
[Bond strengths of absorbable polylactic acid root canal post with three different adhesives].
Pan, Hui; Cheng, Can; Hu, Jia; Liu, He; Sun, Zhi-hui
2015-12-18
To find absorbable adhesives with suitable bonding properties for the absorbable polylactic acid root canal post. To test and compare the bond strengths of absorbable polylactic acid root canal post with three different adhesives. The absorbable polylactic acid root canal posts were used to restore the extracted teeth, using 3 different adhesives: cyanoacrylates, fibrin sealant and glass ionomer cement. The teeth were prepared into slices for micro-push-out test. The bond strength was statistically analyzed using ANOVA. The specimens were examined using microscope and the failure mode was divided into four categories: cohesive failure between absorbable polylactic acid root canal posts and adhesives, cohesive failure between dentin and adhesives, failure within the adhesives and failure within the absorbable polylactic acid root canal posts. The bond strength of cyanoacrylates [(16.83 ± 6.97) MPa] and glass ionomer cement [(12.10 ± 5.09) MPa] were significantly higher than fibrin sealant [(1.17 ± 0.50) MPa], P<0.001. There was no significant difference between cyanoacrylates and glass ionomer cement (P=0.156). In the group of cyanoacrylates, the cohesive failure between the absorbable polylactic acid root canal posts and the adhesives was 25.0%, the cohesive failure between the dentin and the adhesives was 16.7%, the failure within the adhesives was 33.3%, and the failure within the absorbable polylactic acid root canal posts was 25.0%. In the group of fibrin sealant, the cohesive failure between the absorbable polylactic acid root canal posts and the adhesives was 66.7%, the cohesive failure between the dentin and the adhesives was 22.2%, the failure within the adhesives was 11.1%. In the group of glass ionomer cement, the cohesive failure between the absorbable polylactic acid root canal posts and the adhesives was 87.5%, the failure within the adhesives was 12.5%. The major failure mode in fibrin sealant and glass ionomer cement was the cohesive failure between the absorbable polylactic acid root canal posts and the adhesives. No major failure modes were found in the group of cyanoacrylates. The bond strength of fibrin sealant is low, which cannot meet the requirement of clinical use. The bond strengths of cyanoacrylates and glass ionomer cement are suitable for clinical use. The cyanoacrylates are a kind of absorbable adhesive which has suitable bonding properties for the absorbable polylactic acid root canal post.
Multi-mode reliability-based design of horizontal curves.
Essa, Mohamed; Sayed, Tarek; Hussein, Mohamed
2016-08-01
Recently, reliability analysis has been advocated as an effective approach to account for uncertainty in the geometric design process and to evaluate the risk associated with a particular design. In this approach, a risk measure (e.g. probability of noncompliance) is calculated to represent the probability that a specific design would not meet standard requirements. The majority of previous applications of reliability analysis in geometric design focused on evaluating the probability of noncompliance for only one mode of noncompliance such as insufficient sight distance. However, in many design situations, more than one mode of noncompliance may be present (e.g. insufficient sight distance and vehicle skidding at horizontal curves). In these situations, utilizing a multi-mode reliability approach that considers more than one failure (noncompliance) mode is required. The main objective of this paper is to demonstrate the application of multi-mode (system) reliability analysis to the design of horizontal curves. The process is demonstrated by a case study of Sea-to-Sky Highway located between Vancouver and Whistler, in southern British Columbia, Canada. Two noncompliance modes were considered: insufficient sight distance and vehicle skidding. The results show the importance of accounting for several noncompliance modes in the reliability model. The system reliability concept could be used in future studies to calibrate the design of various design elements in order to achieve consistent safety levels based on all possible modes of noncompliance. Copyright © 2016 Elsevier Ltd. All rights reserved.
Enhanced Component Performance Study: Motor-Driven Pumps 1998–2014
DOE Office of Scientific and Technical Information (OSTI.GOV)
Schroeder, John Alton
2016-02-01
This report presents an enhanced performance evaluation of motor-driven pumps at U.S. commercial nuclear power plants. The data used in this study are based on the operating experience failure reports from fiscal year 1998 through 2014 for the component reliability as reported in the Institute of Nuclear Power Operations (INPO) Consolidated Events Database (ICES). The motor-driven pump failure modes considered for standby systems are failure to start, failure to run less than or equal to one hour, and failure to run more than one hour; for normally running systems, the failure modes considered are failure to start and failure tomore » run. An eight hour unreliability estimate is also calculated and trended. The component reliability estimates and the reliability data are trended for the most recent 10-year period while yearly estimates for reliability are provided for the entire active period. Statistically significant increasing trends were identified in pump run hours per reactor year. Statistically significant decreasing trends were identified for standby systems industry-wide frequency of start demands, and run hours per reactor year for runs of less than or equal to one hour.« less
Experimental Study On The Effect Of Micro-Cracks On Brazilian Tensile Strength
NASA Astrophysics Data System (ADS)
Wang, Xiangyu
2015-12-01
For coal mine ground control issues, it is necessary to propose a failure criteria accounting for the transversely isotropic behaviors of rocks. Hence, it is very helpful to provide experimental data for the validation of the failure criteria. In this paper, the method for preparing transversely isotropic specimens and the scheme of the Brazilian tensile strength test are presented. Results obtained from Brazilian split tests under dry and water-saturated conditions reflect the effect of the development direction β of the structural plane, such as the bedding fissure, on the tensile strength, ultimate displacement, failure mode, and the whole splitting process. The results show that the tensile strength decreases linearly with increasing β. The softening coefficient of the tensile strength shows a sinusoidal function. The values of the slope and inflection point for the curve vary at the different stages of the Brazilian test. The failure mode of the rock specimen presented in this paper generally coincides with the standard Brazilian splitting failure mode. Based on the test results, the major influencing factors for the Brazilian splitting strength are analyzed and a mathematical model for solving the Brazilian splitting strength is proposed. The findings in this paper would greatly benefit the coal mine ground control studies when the surrounding rocks of interest show severe transversely isotropic behaviors.
NASA Technical Reports Server (NTRS)
Reveley, Mary S.; Briggs, Jeffrey L.; Evans, Joni K.; Jones, Sharon M.; Kurtoglu, Tolga; Leone, Karen M.; Sandifer, Carl E.
2011-01-01
Causal factors in aviation accidents and incidents related to system/component failure/malfunction (SCFM) were examined for Federal Aviation Regulation Parts 121 and 135 operations to establish future requirements for the NASA Aviation Safety Program s Integrated Vehicle Health Management (IVHM) Project. Data analyzed includes National Transportation Safety Board (NSTB) accident data (1988 to 2003), Federal Aviation Administration (FAA) incident data (1988 to 2003), and Aviation Safety Reporting System (ASRS) incident data (1993 to 2008). Failure modes and effects analyses were examined to identify possible modes of SCFM. A table of potential adverse conditions was developed to help evaluate IVHM research technologies. Tables present details of specific SCFM for the incidents and accidents. Of the 370 NTSB accidents affected by SCFM, 48 percent involved the engine or fuel system, and 31 percent involved landing gear or hydraulic failure and malfunctions. A total of 35 percent of all SCFM accidents were caused by improper maintenance. Of the 7732 FAA database incidents affected by SCFM, 33 percent involved landing gear or hydraulics, and 33 percent involved the engine and fuel system. The most frequent SCFM found in ASRS were turbine engine, pressurization system, hydraulic main system, flight management system/flight management computer, and engine. Because the IVHM Project does not address maintenance issues, and landing gear and hydraulic systems accidents are usually not fatal, the focus of research should be those SCFMs that occur in the engine/fuel and flight control/structures systems as well as power systems.
Yamazaki, Hiroshi; O'Leary, Stephen; Moran, Michelle; Briggs, Robert
2014-04-01
Accurate diagnosis of cochlear implant failures is important for management; however, appropriate strategies to assess possible device failures are not always clear. The purpose of this study is to understand correlation between causes of device failure and the presenting clinical symptoms as well as results of in situ integrity testing and to propose effective strategies for diagnosis of device failure. Retrospective case review. Cochlear implant center at a tertiary referral hospital. Twenty-seven cases with suspected device failure of Cochlear Nucleus systems (excluding CI512 failures) on the basis of deterioration in auditory perception from January 2000 to September 2012 in the Melbourne cochlear implant clinic. Clinical presentations and types of abnormalities on in situ integrity testing were compared with modes of device failure detected by returned device analysis. Sudden deterioration in auditory perception was always observed in cases with "critical damage": either fracture of the integrated circuit or most or all of the electrode wires. Subacute or gradually progressive deterioration in auditory perception was significantly associated with a more limited number of broken electrode wires. Cochlear implant mediated auditory and nonauditory symptoms were significantly associated with an insulation problem. An algorithm based on the time course of deterioration in auditory perception and cochlear implant-mediated auditory and nonauditory symptoms was developed on the basis of these retrospective analyses, to help predict the mode of device failure. In situ integrity testing, which included close monitoring of device function in routine programming sessions as well as repeating the manufacturer's integrity test battery, was sensitive enough to detect malfunction in all suspected device failures, and each mode of device failure showed a characteristic abnormality on in situ integrity testing. Our clinical manifestation-based algorithm combined with in situ integrity testing may be useful for accurate diagnosis and appropriate management of device failure. Close monitoring of device function in routine programming sessions as well as repeating the manufacturer's integrity test battery is important if the initial in situ integrity testing is inconclusive because objective evidence of failure in the implanted device is essential to recommend explantation/reimplantation.
A Study of Energy Management Systems and its Failure Modes in Smart Grid Power Distribution
NASA Astrophysics Data System (ADS)
Musani, Aatif
The subject of this thesis is distribution level load management using a pricing signal in a smart grid infrastructure. The project relates to energy management in a spe-cialized distribution system known as the Future Renewable Electric Energy Delivery and Management (FREEDM) system. Energy management through demand response is one of the key applications of smart grid. Demand response today is envisioned as a method in which the price could be communicated to the consumers and they may shift their loads from high price periods to the low price periods. The development and deployment of the FREEDM system necessitates controls of energy and power at the point of end use. In this thesis, the main objective is to develop the control model of the Energy Management System (EMS). The energy and power management in the FREEDM system is digitally controlled therefore all signals containing system states are discrete. The EMS is modeled as a discrete closed loop transfer function in the z-domain. A breakdown of power and energy control devices such as EMS components may result in energy con-sumption error. This leads to one of the main focuses of the thesis which is to identify and study component failures of the designed control system. Moreover, H-infinity ro-bust control method is applied to ensure effectiveness of the control architecture. A focus of the study is cyber security attack, specifically bad data detection in price. Test cases are used to illustrate the performance of the EMS control design, the effect of failure modes and the application of robust control technique. The EMS was represented by a linear z-domain model. The transfer function be-tween the pricing signal and the demand response was designed and used as a test bed. EMS potential failure modes were identified and studied. Three bad data detection meth-odologies were implemented and a voting policy was used to declare bad data. The run-ning mean and standard deviation analysis method proves to be the best method to detect bad data. An H-infinity robust control technique was applied for the first time to design discrete EMS controller for the FREEDM system.
Stiffness and strength of fiber reinforced polymer composite bridge deck systems
NASA Astrophysics Data System (ADS)
Zhou, Aixi
This research investigates two principal characteristics that are of primary importance in Fiber Reinforced Polymer (FRP) bridge deck applications: STIFFNESS and STRENGTH. The research was undertaken by investigating the stiffness and strength characteristics of the multi-cellular FRP bridge deck systems consisting of pultruded FRP shapes. A systematic analysis procedure was developed for the stiffness analysis of multi-cellular FRP deck systems. This procedure uses the Method of Elastic Equivalence to model the cellular deck as an equivalent orthotropic plate. The procedure provides a practical method to predict the equivalent orthotropic plate properties of cellular FRP decks. Analytical solutions for the bending analysis of single span decks were developed using classical laminated plate theory. The analysis procedures can be extended to analyze continuous FRP decks. It can also be further developed using higher order plate theories. Several failure modes of the cellular FRP deck systems were recorded and analyzed through laboratory and field tests and Finite Element Analysis (FEA). Two schemes of loading patches were used in the laboratory test: a steel patch made according to the ASSHTO's bridge testing specifications; and a tire patch made from a real truck tire reinforced with silicon rubber. The tire patch was specially designed to simulate service loading conditions by modifying real contact loading from a tire. Our research shows that the effects of the stiffness and contact conditions of loading patches are significant in the stiffness and strength testing of FRP decks. Due to the localization of load, a simulated tire patch yields larger deflection than the steel patch under the same loading level. The tire patch produces significantly different failure compared to the steel patch: a local bending mode with less damage for the tire patch; and a local punching-shear mode for the steel patch. A deck failure function method is proposed for predicting the failure of FRP decks. Using developed laminated composite theories and FEA techniques, a strength analysis procedure containing ply-level information was proposed and detailed for FRP deck systems. The behavior of the deck's unsupported (free) edges was also investigated using ply-level FEA.
NASA Astrophysics Data System (ADS)
Trimarchi, Giancarlo; Zhang, Xiuwen; DeVries Vermeer, Michael J.; Cantwell, Jacqueline; Poeppelmeier, Kenneth R.; Zunger, Alex
2015-10-01
Theoretical sorting of stable and synthesizable "missing compounds" from those that are unstable is a crucial step in the discovery of previously unknown functional materials. This active research area often involves high-throughput (HT) examination of the total energy of a given compound in a list of candidate formal structure types (FSTs), searching for those with the lowest energy within that list. While it is well appreciated that local relaxation methods based on a fixed list of structure types can lead to inaccurate geometries, this approach is widely used in HT studies because it produces answers faster than global optimization methods (that vary lattice vectors and atomic positions without local restrictions). We find, however, a different failure mode of the HT protocol: specific crystallographic classes of formal structure types each correspond to a series of chemically distinct "daughter structure types" (DSTs) that have the same space group but possess totally different local bonding configurations, including coordination types. Failure to include such DSTs in the fixed list of examined candidate structures used in contemporary high-throughput approaches can lead to qualitative misidentification of the stable bonding pattern, not just quantitative inaccuracies. In this work, we (i) clarify the understanding of the general DST-FST relationship, thus improving current discovery HT approaches, (ii) illustrate this failure mode for RbCuS and RbCuSe (the latter being a yet unreported compound and is predicted here) by developing a synthesis method and accelerated crystal-structure determination, and (iii) apply the genetic-algorithm-based global space-group optimization (GSGO) approach which is not vulnerable to the failure mode of HT searches of fixed lists, demonstrating a correct identification of the stable DST. The broad impact of items (i)-(iii) lies in the demonstrated predictive ability of a more comprehensive search strategy than what is currently used—use HT calculations as the preliminary broad screening followed by unbiased GSGO of the final candidates.
Fabric controls on the brittle failure of folded gneiss and schist
NASA Astrophysics Data System (ADS)
Agliardi, Federico; Zanchetta, Stefano; Crosta, Giovanni B.
2014-12-01
We experimentally studied the brittle failure behaviour of folded gneiss and schist. Rock fabric and petrography were characterised by meso-structural analyses, optical microscopy, X-ray diffraction, and SEM imaging. Uniaxial compression, triaxial compression and indirect tension laboratory tests were performed to characterise their strength and stress-strain behaviour. Fracture patterns generated in compression were resolved in 3D through X-ray computed tomography at different resolutions (30 to 625 μm). Uniaxial compression tests revealed relatively low and scattered values of unconfined compressive strength (UCS) and Young's modulus, with no obvious relationships with the orientation of foliation. Samples systematically failed in four brittle modes, involving different combinations of shear fractures along foliation or parallel to fold axial planes, or the development of cm-scale shear zones. Fracture quantification and microstructural analysis show that different failure modes occur depending on the mutual geometrical arrangement and degree of involvement of two distinct physical anisotropies, i.e. the foliation and the fold axial planes. The Axial Plane Anisotropy (APA) is related to micro-scale grain size reduction and shape preferred orientation within quartz-rich domains, and to mechanical rotation or initial crenulation cleavage within phyllosilicate-rich domains at fold hinge zones. In quartz-rich rocks (gneiss), fracture propagation through quartz aggregates forming the APA corresponds to higher fracture energy and strength than found for fracture through phyllosilicate-rich domains. This results in a strong dependence of strength on the failure mode. Conversely, in phyllosilicate-rich rocks (schist), all the failure modes are dominated by the strength of phyllosilicates, resulting in a sharp reduction of strength anisotropy.
Effect of ozone gas on the shear bond strength to enamel
PIRES, Patrícia Teixeira; FERREIRA, João Cardoso; OLIVEIRA, Sofia Arantes; SILVA, Mário Jorge; MELO, Paulo Ribeiro
2013-01-01
Ozone is an important disinfecting agent, however its influence on enamel adhesion has not yet been clarified. Objective: Evaluate the influence of ozone pretreatment on the shear strength of an etch-and-rinse and a self-etch system to enamel and analyze the respective failure modes. Material and Methods: Sixty sound bovine incisors were used. Specimens were randomly assigned to four experimental groups (n=15): Group G1 (Excite® with ozone) and group G3 (AdheSE® with ozone) were prepared with ozone gas from the HealOzone unit (Kavo®) for 20 s prior to adhesion, and groups G2 (Excite®) and G4 (AdheSE®) were used as control. Teeth were bisected and polished to simulate a smear layer just before the application of the adhesive systems. The adhesives were applied according to the manufacturer's instructions to a standardized 3 mm diameter surface, and a composite (Synergy D6, Coltene Whaledent) cylinder with 2 mm increments was build. Specimens were stored in 100% humidity for 24 h at 37º C and then subjected to a thermal cycling regimen of 500 cycles. Shear bond tests were performed with a Watanabe device in a universal testing machine at 5 mm/min. The failure mode was analyzed under scanning electron microscope. Means and standard deviation of shear bond strength (SBS) were calculated and difference between the groups was analyzed using ANOVA, Kolmogorov-Smirnov, Levene and Bonferroni. Chi-squared statistical tests were used to evaluate the failure modes. Results: Mean bond strength values and failure modes were as follows: G1- 26.85±6.18 MPa (33.3% of adhesive cohesive failure); G2 - 27.95±5.58 MPa (53.8% of adhesive failures between enamel and adhesive); G3 - 15.0±3.84 MPa (77.8% of adhesive failures between enamel and adhesive) and G4 - 13.1±3.68 MPa (36.4% of adhesive failures between enamel and adhesive). Conclusions: Shear bond strength values of both adhesives tested on enamel were not influenced by the previous application of ozone gas. PMID:23739859
Effect of ozone gas on the shear bond strength to enamel.
Pires, Patrícia Teixeira; Ferreira, João Cardoso; Oliveira, Sofia Arantes; Silva, Mário Jorge; Melo, Paulo Ribeiro
2013-01-01
Ozone is an important disinfecting agent, however its influence on enamel adhesion has not yet been clarified. Evaluate the influence of ozone pretreatment on the shear strength of an etch-and-rinse and a self-etch system to enamel and analyze the respective failure modes. Sixty sound bovine incisors were used. Specimens were randomly assigned to four experimental groups (n=15): Group G1 (Excite® with ozone) and group G3 (AdheSE® with ozone) were prepared with ozone gas from the HealOzone unit (Kavo®) for 20 s prior to adhesion, and groups G2 (Excite®) and G4 (AdheSE®) were used as control. Teeth were bisected and polished to simulate a smear layer just before the application of the adhesive systems. The adhesives were applied according to the manufacturer's instructions to a standardized 3 mm diameter surface, and a composite (Synergy D6, Coltene Whaledent) cylinder with 2 mm increments was build. Specimens were stored in 100% humidity for 24 h at 37°C and then subjected to a thermal cycling regimen of 500 cycles. Shear bond tests were performed with a Watanabe device in a universal testing machine at 5 mm/min. The failure mode was analyzed under scanning electron microscope. Means and standard deviation of shear bond strength (SBS) were calculated and difference between the groups was analyzed using ANOVA, Kolmogorov-Smirnov, Levene and Bonferroni. Chi-squared statistical tests were used to evaluate the failure modes. Mean bond strength values and failure modes were as follows: G1--26.85±6.18 MPa (33.3% of adhesive cohesive failure); G2--27.95±5.58 MPa (53.8% of adhesive failures between enamel and adhesive); G3--15.0±3.84 MPa (77.8% of adhesive failures between enamel and adhesive) and G4--13.1±3.68 MPa (36.4% of adhesive failures between enamel and adhesive). Shear bond strength values of both adhesives tested on enamel were not influenced by the previous application of ozone gas.
Fractography, NDE, and fracture mechanics applications in failure analysis studies
DOE Office of Scientific and Technical Information (OSTI.GOV)
Morin, C.R.; Shipley, R.J.; Wilkinson, J.A.
1994-10-01
While identification of the precise mode of a failure can lead logically to the underlying cause, a thorough failure investigation requires much more than just the identification of a specific metallurgical mechanism, for example, fatigue, creep, stress corrosion cracking, etc. Failures involving fracture provide good illustrations of this concept. An initial step in characterizing fracture surfaces is often the identification of an origin or origins. However, the analysis should not stop there. If the origin is associated with a discontinuity, the manner in which it was formed must also be addressed. The stresses that would have existed at the originmore » must be determined and compared with material properties to determine whether or not a crack should have initiated and propagated during normal operation. Many critical components are inspected throughout their lives by nondestructive methods. When a crack progresses to failure, its nondetection at earlier inspections must also be understood. Careful study of the fracture surface combined with crack growth analysis based on fracture mechanics can provide an estimate of the crack length at the times of previous inspections. An important issue often overlooked in such studies is how processing of parts during manufacture or rework affects the probability of detection of such cracks. The ultimate goal is to understand thoroughly the progression of the failure, to understand the root cause(s), and to design appropriate corrective action(s) to minimize recurrence.« less
Anchorage strength models for end-debonding predictions in RC beams strengthened with FRP composites
NASA Astrophysics Data System (ADS)
Nardini, V.; Guadagnini, M.; Valluzzi, M. R.
2008-05-01
The increase in the flexural capacity of RC beams obtained by externally bonding FRP composites to their tension side is often limited by the premature and brittle debonding of the external reinforcement. An in-depth understanding of this complex failure mechanism, however, has not yet been achieved. With specific regard to end-debonding failure modes, extensive experimental observations reported in the literature highlight the important distinction, often neglected in strength models proposed by researchers, between the peel-off and rip-off end-debonding types of failure. The peel-off failure is generally characterized by a failure plane located within the first few millimetres of the concrete cover, whilst the rip-off failure penetrates deeper into the concrete cover and propagates along the tensile steel reinforcement. A new rip-off strength model is described in this paper. The model proposed is based on the Chen and Teng peel-off model and relies upon additional theoretical considerations. The influence of the amount of the internal tensile steel reinforcement and the effective anchorage length of FRP are considered and discussed. The validity of the new model is analyzed further through comparisons with test results, findings of a numerical investigation, and a parametric study. The new rip-off strength model is assessed against a database comprising results from 62 beams tested by various researchers and is shown to yield less conservative results.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Xie, J; Wang, J; P, J
2016-06-15
Purpose: To optimize the clinical processes of radiotherapy and to reduce the radiotherapy risks by implementing the powerful risk management tools of failure mode and effects analysis(FMEA) and PDCA(plan-do-check-act). Methods: A multidiciplinary QA(Quality Assurance) team from our department consisting of oncologists, physicists, dosimetrists, therapists and administrator was established and an entire workflow QA process management using FMEA and PDCA tools was implemented for the whole treatment process. After the primary process tree was created, the failure modes and Risk priority numbers(RPNs) were determined by each member, and then the RPNs were averaged after team discussion. Results: 3 of 9 failuremore » modes with RPN above 100 in the practice were identified in the first PDCA cycle, which were further analyzed to investigate the RPNs: including of patient registration error, prescription error and treating wrong patient. New process controls reduced the occurrence, or detectability scores from the top 3 failure modes. Two important corrective actions reduced the highest RPNs from 300 to 50, and the error rate of radiotherapy decreased remarkably. Conclusion: FMEA and PDCA are helpful in identifying potential problems in the radiotherapy process, which was proven to improve the safety, quality and efficiency of radiation therapy in our department. The implementation of the FMEA approach may improve the understanding of the overall process of radiotherapy while may identify potential flaws in the whole process. Further more, repeating the PDCA cycle can bring us closer to the goal: higher safety and accuracy radiotherapy.« less
Fracture and Failure in Micro- and Nano-Scale
NASA Astrophysics Data System (ADS)
Charitidis, Costas A.
Indentation and scratch in micro- and nano-scale are the most commonly used techniques for quantifying thin film and systems properties. Among them are different failure modes such as deformation, friction, fracture toughness, fatigue. Failure modes can be activated either by a cycle of indentation or by scratching of the samples to provide an estimation of the fracture toughness and interfacial fracture energies. In the present study, we report on the failure and fracture modes in two cases of engineering materials; that is transparent SiOx thin films onto poly(ethylene terephthalate) (PET) membranes and glass-ceramic materials. The SiOx/PET system meets the demands regarding scratch-resistance, wettability, biocompatibility, gas transmission, or friction, while maintaining the bulk characteristics of PET (such as easy processing, good mechanical properties, reasonably low permeability to oxygen and carbon dioxide gases (barrier properties), and good chemical coupling with antibacterial coatings). Glass-ceramic materials, since their first accidental production in the mid fifties by S.D. Stookey, have been used in a vast area of applications, from household cooktops and stoves, to missile nose cones and mirror mounts of orbital telescopes and from decorative wall coverings to medical applications. The fracture modes, namely transgranular and intergranular modes in glass-ceramic materials have paid less attention in literature comparing with ceramic materials. In the former case the crack paves its way irrespectively of the direction of the grain boundaries, i.e., the interfaces between the different phases. In the latter case the crack preferentially follows them, i.e., debonds the interfaces.
Compressive Properties of Metal Matrix Syntactic Foams in Free and Constrained Compression
NASA Astrophysics Data System (ADS)
Orbulov, Imre Norbert; Májlinger, Kornél
2014-06-01
Metal matrix syntactic foam (MMSF) blocks were produced by an inert gas-assisted pressure infiltration technique. MMSFs are advanced hollow sphere reinforced-composite materials having promising application in the fields of aviation, transport, and automotive engineering, as well as in civil engineering. The produced blocks were investigated in free and constrained compression modes, and besides the characteristic mechanical properties, their deformation mechanisms and failure modes were studied. In the tests, the chemical composition of the matrix material, the size of the reinforcing ceramic hollow spheres, the applied heat treatment, and the compression mode were considered as investigation parameters. The monitored mechanical properties were the compressive strength, the fracture strain, the structural stiffness, the fracture energy, and the overall absorbed energy. These characteristics were strongly influenced by the test parameters. By the proper selection of the matrix and the reinforcement and by proper design, the mechanical properties of the MMSFs can be effectively tailored for specific and given applications.
NASA Technical Reports Server (NTRS)
Gaier, James R.; Siamidis, John; Larkin, Elizabeth M. G.
2010-01-01
The National Aeronautics and Space Administration (NASA) is currently developing a new universal docking mechanism for future space exploration missions called the Low Impact Docking System (LIDS). A candidate LIDS main interface seal design is a composite assembly of silicone elastomer seals vacuum molded into grooves in an electroless nickel plated aluminum retainer. The strength of the silicone-tometal bond is a critical consideration for the new system, especially due to the presence of small areas of disbond created during the molding process. In the work presented herein, seal-to-retainer bonds of subscale seal specimens with different sizes of intentional disbond were destructively tensile tested. Nominal specimens without intentional disbonds were also tested. Tension was applied either uniformly on the entire seal circumference or locally in one short circumferential length. Bond failure due to uniform tension produced a wide scatter of observable failure modes and measured load-displacement behaviors. Although the preferable failure mode for the seal-to-retainer bond is cohesive failure of the elastomer material, the dominant observed failure mode under the uniform loading condition was found to be the less desirable adhesive failure of the bond in question. The uniform tension case results did not show a correlation between disbond size and bond strength. Localized tension was found to produce failure either as immediate tearing of the elastomer material outside the bond region or as complete peel-out of the seal in one piece. The obtained results represent a valuable benchmark for comparison in the future between adhesion loads under various separation conditions and composite seal bond strength.
Fractography can be used to analyze failure modes in polytetrafluoroethylene
NASA Technical Reports Server (NTRS)
Nerren, B. H.
1969-01-01
Fractographic principles used for analyzing failure in metals are applied to the analysis of the microstructure and fracture of polytetrafluoroethylene. This material is used as seals in cryogenic systems.