Major mishaps among mobile offshore drilling units, 1955-1981: time trends and fatalities.

PubMed

Clemmer, D I; Diem, J E

1985-03-01

Major mishaps among mobile offshore drilling units worldwide from 1955-1981 were identified from industry and government sources. Based on annual numbers of rigs in service and typical staffing patterns, annual mishap rates and fatality rates for rig types and mishap categories were computed. While the frequency of major mishaps has increased in recent years, the mishap rate per 100 rig-years of service has remained stable. The overall stability obscures the fact that jack-up rigs have had an increasing mishap rate while the rate for other rig types combined has gradually declined. Although the fatal mishap rate has also remained constant, the annual fatality rate per 100 000 full time equivalent (FTE) workers has risen sharply. This can be attributed to increasing numbers of lives lost in environmental mishaps while deaths from operational mishaps have declined. There were 344 fatalities during the 27-year period. Although an average of some 13 deaths per year worldwide appears minimal, the relatively small size of the workforce gives this number significance particularly when it is noted that 'occupational' fatalities, those occurring in the course of routine operations, are not included. The overall fatality rate secondary to major mishaps was 84.3 per 100 000 FTE worker-years.

KSC-2011-6634

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- A NASA Fire Rescue Services vehicle and a Huey II helicopter support the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

KSC-2011-6645

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- Volunteers portraying injured Huey II helicopter crew members are assisted by NASA Fire Rescue personnel in support of the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

KSC-2011-6642

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- Volunteers, portraying their individual roles, stand beside a NASA Fire Rescue Services vehicle and a Huey II helicopter in support of the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

DOD (USAF) turbulence accidents and incidents

NASA Technical Reports Server (NTRS)

Miller, Douglas

1987-01-01

A summary of Air Force turbulence related mishaps for the last ten years of Air Force mishaps is presented from a perspective of where it has been, where it is now, and where it is going. In addition to accounts of major mishaps, a summary of what actions were taken to preclude future similar mishaps is presented. Also, a discussion of some of the things being done now and being planned for the future to prevent turbulence related mishaps is presented.

F-16 Class A mishaps in the U.S. Air Force, 1975-93.

PubMed

Knapp, C J; Johnson, R

1996-08-01

All USAF F-16 fighter Class A (major) aircraft mishaps from 1975-93 were analyzed, using records from the U.S. Air Force Safety Agency (AFSA). There were 190 Class A mishaps involving 204 F-16's and 217 aircrew during this 19-yr period. The overall Class A rate was 5.09 per 100,000 flight hours, more than double the overall USAF rate. The mishaps are categorized by year, month, time of day and model of aircraft in relation to mishap causes as determined and reported by AFSA. Formation position, phase of flight and primary cause of the mishap indicate that maneuvering, cruise and low-level phases account for the majority of the mishaps (71%), with air-to-air engagements associated with a higher proportion of pilot error (71%) than was air-to-ground (49%). Engine failure was the number one cause of mishaps (35%), and collision with the ground the next most frequent (24%). Pilot error was determined as causative in 55% of all the mishaps. Pilot error was often associated with other non-pilot related causes. Channelized attention, loss of situational awareness, and spatial disorientation accounted for approximately 30% of the total pilot error causes found. Pilot demographics, flight hour/sortie profiles, and aircrew injuries are also listed. Fatalities occurred in 27% of the mishaps, with 97% of those involving pilot errors.

Pilot error in air carrier mishaps: longitudinal trends among 558 reports, 1983-2002.

PubMed

Baker, Susan P; Qiang, Yandong; Rebok, George W; Li, Guohua

2008-01-01

Many interventions have been implemented in recent decades to reduce pilot error in flight operations. This study aims to identify longitudinal trends in the prevalence and patterns of pilot error and other factors in U.S. air carrier mishaps. National Transportation Safety Board investigation reports were examined for 558 air carrier mishaps during 1983-2002. Pilot errors and circumstances of mishaps were described and categorized. Rates were calculated per 10 million flights. The overall mishap rate remained fairly stable, but the proportion of mishaps involving pilot error decreased from 42% in 1983-87 to 25% in 1998-2002, a 40% reduction. The rate of mishaps related to poor decisions declined from 6.2 to 1.8 per 10 million flights, a 71% reduction; much of this decrease was due to a 76% reduction in poor decisions related to weather. Mishandling wind or runway conditions declined by 78%. The rate of mishaps involving poor crew interaction declined by 68%. Mishaps during takeoff declined by 70%, from 5.3 to 1.6 per 10 million flights. The latter reduction was offset by an increase in mishaps while the aircraft was standing, from 2.5 to 6.0 per 10 million flights, and during pushback, which increased from 0 to 3.1 per 10 million flights. Reductions in pilot errors involving decision making and crew coordination are important trends that may reflect improvements in training and technological advances that facilitate good decisions. Mishaps while aircraft are standing and during pushback have increased and deserve special attention.

Pilot Error in Air Carrier Mishaps: Longitudinal Trends Among 558 Reports, 1983–2002

PubMed Central

Baker, Susan P.; Qiang, Yandong; Rebok, George W.; Li, Guohua

2009-01-01

Background Many interventions have been implemented in recent decades to reduce pilot error in flight operations. This study aims to identify longitudinal trends in the prevalence and patterns of pilot error and other factors in U.S. air carrier mishaps. Method National Transportation Safety Board investigation reports were examined for 558 air carrier mishaps during 1983–2002. Pilot errors and circumstances of mishaps were described and categorized. Rates were calculated per 10 million flights. Results The overall mishap rate remained fairly stable, but the proportion of mishaps involving pilot error decreased from 42% in 1983–87 to 25% in 1998–2002, a 40% reduction. The rate of mishaps related to poor decisions declined from 6.2 to 1.8 per 10 million flights, a 71% reduction; much of this decrease was due to a 76% reduction in poor decisions related to weather. Mishandling wind or runway conditions declined by 78%. The rate of mishaps involving poor crew interaction declined by 68%. Mishaps during takeoff declined by 70%, from 5.3 to 1.6 per 10 million flights. The latter reduction was offset by an increase in mishaps while the aircraft was standing, from 2.5 to 6.0 per 10 million flights, and during pushback, which increased from 0 to 3.1 per 10 million flights. Conclusions Reductions in pilot errors involving decision making and crew coordination are important trends that may reflect improvements in training and technological advances that facilitate good decisions. Mishaps while aircraft are standing and during push-back have increased and deserve special attention. PMID:18225771

14 CFR 437.41 - Mishap response plan.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 4 2014-01-01 2014-01-01 false Mishap response plan. 437.41 Section 437.41 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF... Documentation § 437.41 Mishap response plan. An applicant must provide a mishap response plan that meets the...

14 CFR 437.41 - Mishap response plan.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 4 2013-01-01 2013-01-01 false Mishap response plan. 437.41 Section 437.41 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF... Documentation § 437.41 Mishap response plan. An applicant must provide a mishap response plan that meets the...

14 CFR 437.41 - Mishap response plan.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Mishap response plan. 437.41 Section 437.41 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF... Documentation § 437.41 Mishap response plan. An applicant must provide a mishap response plan that meets the...

14 CFR 437.41 - Mishap response plan.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 4 2011-01-01 2011-01-01 false Mishap response plan. 437.41 Section 437.41 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF... Documentation § 437.41 Mishap response plan. An applicant must provide a mishap response plan that meets the...

14 CFR 437.41 - Mishap response plan.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 4 2012-01-01 2012-01-01 false Mishap response plan. 437.41 Section 437.41 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF... Documentation § 437.41 Mishap response plan. An applicant must provide a mishap response plan that meets the...

Human Factors in Accidents Involving Remotely Piloted Aircraft

NASA Technical Reports Server (NTRS)

Merlin, Peter William

2013-01-01

This presentation examines human factors that contribute to RPA mishaps and provides analysis of lessons learned. RPA accident data from U.S. military and government agencies were reviewed and analyzed to identify human factors issues. Common contributors to RPA mishaps fell into several major categories: cognitive factors (pilot workload), physiological factors (fatigue and stress), environmental factors (situational awareness), staffing factors (training and crew coordination), and design factors (human machine interface).

The Use of a Poisson Regression to Evaluate Antihistamines and Fatal Aircraft Mishaps in Instrument Meteorological Conditions.

PubMed

Gildea, Kevin M; Hileman, Christy R; Rogers, Paul; Salazar, Guillermo J; Paskoff, Lawrence N

2018-04-01

Research indicates that first-generation antihistamine usage may impair pilot performance by increasing the likelihood of vestibular illusions, spatial disorientation, and/or cognitive impairment. Second- and third-generation antihistamines generally have fewer impairing side effects and are approved for pilot use. We hypothesized that toxicological findings positive for second- and third-generation antihistamines are less likely to be associated with pilots involved in fatal mishaps than first-generation antihistamines. The evaluated population consisted of 1475 U.S. civil pilots fatally injured between September 30, 2008, and October 1, 2014. Mishap factors evaluated included year, weather conditions, airman rating, recent airman flight time, quarter of year, and time of day. Due to the low prevalence of positive antihistamine findings, a count-based model was selected, which can account for rare outcomes. The means and variances were close for both regression models supporting the assumption that the data follow a Poisson distribution; first-generation antihistamine mishap airmen (N = 582, M = 0.17, S2 = 0.17) with second- and third-generation antihistamine mishap airmen (N = 116, M = 0.20, S2 = 0.18). The data indicate fewer airmen with second- and third-generation antihistamines than first-generation antihistamines in their system are fatally injured while flying in IMC conditions. Whether the lower incidence is a factor of greater usage of first-generation antihistamines versus second- and third-generation antihistamines by the pilot population or fewer deleterious side effects with second- and third-generation antihistamines is unclear. These results engender cautious optimism, but additional research is necessary to determine why these differences exist.Gildea KM, Hileman CR, Rogers P, Salazar GJ, Paskoff LN. The use of a Poisson regression to evaluate antihistamines and fatal aircraft mishaps in instrument meteorological conditions. Aerosp Med Hum Perform. 2018; 89(4):389-395.

Investigation of the Building M6-794 Roofing Fatality, Type A Mishap

NASA Technical Reports Server (NTRS)

Casper, John H.; French, Kristie; Tipton, David A.; Bennardo, C. P.; Miller, Darcy H.; Facemire, David L.

2006-01-01

The Building M6-794 Roofing Fatality Mishap Investigation Board (Board) was commissioned to gather information; analyze the facts; identify the proximate causes, root causes, and contributing factors relating to the mishap; and recommend appropriate actions to prevent a similar mishap from occurring in the future. During the investigation of this mishap, the Board also examined the fall protection policies of other NASA Centers and operating locations to gain an understanding of how those entities conduct fall protection, as well as the degree to which fall protection is standardized across the Agency.

Contingency Operations Support to NASA Johnson Space Center Medical Operations Division

NASA Technical Reports Server (NTRS)

Stepaniak, Philip; Patlach, Bob; Swann, Mark; Adams, Adrien

2005-01-01

The Wyle Laboratories Contingency Operations Group provides support to the NASA Johnson Space Center (JSC) Medical Operations Division in the event of a space flight vehicle accident or JSC mishap. Support includes development of Emergency Medical System (EMS) requirements, procedures, training briefings and real-time support of mishap investigations. The Contingency Operations Group is compliant with NASA documentation that provides guidance in these areas and maintains contact with the United States Department of Defense (DOD) to remain current on military plans to support NASA. The contingency group also participates in Space Operations Medical Support Training Courses (SOMSTC) and represents the NASA JSC Medical Operations Division at contingency exercises conducted worldwide by the DOD or NASA. The events of September 11, 2001 have changed how this country prepares and protects itself from possible terrorist attacks on high-profile targets. As a result, JSC is now considered a high-profile target and thus, must prepare for and develop a response to a Weapons of Mass Destruction (WMD) incident. The Wyle Laboratories Contingency Operations Group supports this plan, specifically the medical response, by providing expertise and manpower.

Airmen with mild traumatic brain injury (mTBI) at increased risk for subsequent mishaps.

PubMed

Whitehead, Casserly R; Webb, Timothy S; Wells, Timothy S; Hunter, Kari L

2014-02-01

Little is known regarding long-term performance decrements associated with mild Traumatic Brain Injury (mTBI). The goal of this study was to determine if individuals with an mTBI may be at increased risk for subsequent mishaps. Cox proportional hazards modeling was utilized to calculate hazard ratios for 518,958 active duty U.S. Air Force service members (Airmen) while controlling for varying lengths of follow-up and potentially confounding variables. Two non-mTBI comparison groups were used; the second being a subset of the original, both without head injuries two years prior to study entrance. Hazard ratios indicate that the causes of increased risk associated with mTBI do not resolve quickly. Additionally, outpatient mTBI injuries do not differ from other outpatient bodily injuries in terms of subsequent injury risk. These findings suggest that increased risk for subsequent mishaps are likely due to differences shared among individuals with any type of injury, including risk-taking behaviors, occupations, and differential participation in sports activities. Therefore, individuals who sustain an mTBI or injury have a long-term risk of additional mishaps. Differences shared among those who seek medical care for injuries may include risk-taking behaviors (Cherpitel, 1999; Turner & McClure, 2004; Turner, McClure, & Pirozzo, 2004), occupations, and differential participation in sports activities, among others. Individuals with an mTBI should be educated that they are at risk for subsequent injury. Historical data supported no lingering effects of mTBI, but more recent data suggest longer lasting effects. This study further adds that one of the longer term sequelae of mTBI may be an increased risk for subsequent mishap. Copyright © 2013 National Safety Council and Elsevier Ltd. All rights reserved.

Eastern minds in western cockpits: meta-analysis of human factors in mishaps from three nations.

PubMed

Li, Wen-Chin; Harris, Don; Chen, Aurora

2007-04-01

Aviation accident rates vary in different regions; Asia and Africa have higher rates than Europe and America. There has been a great deal of discussion about the role of culture in aviation mishaps; however, culture is rarely mentioned as a contributory factor in accidents. It is hypothesized that different cultures will show different patterns in the underlying causal factors in aircraft accidents. Using a meta-analysis of previously published results, this research examined statistical differences in the 18 categories of the Human Factors Analysis and Classification System (HFACS) across accidents in the Republic of China (Taiwan), India, and the United States. Seven HFACS categories exhibited significant differences between these three regions. These were mostly concerned with contributory factors at the higher organizational levels. The differences were related to organizational processes, organizational climate, resource management, inadequate supervision, physical/mental limitations, adverse mental states, and decision errors. Overall, the evidence from this research supports the observation that national cultures have an impact on aviation safety and adds further explanatory power with regards to why this should be so. The majority of the cultural issues identified seem to be associated with the style of management of the organizations rather than the operation of the aircraft per se.

Aircrew Automated Escape Systems (AAES) In-Service Usage Data Analyses. Volume 1. Papers Presented at the Annual SAFE Symposium (21st), San Antonio, Texas, 5,6,7,8 November 1983.

DTIC Science & Technology

1983-11-05

NECK INJURIES, ANTHROPOMETRY . MAINTENANCE, AIRCREW LIFE SUPPORT SYSTEMS, EJECTION INJURIES, FLIGHT SURGEON’S REPORT I ABSTRACT (Continue en reverse...AND TUMBLE: fACTORS INFLUENCING FREQUENCY AND SEVERITY OF NECK INJURIES SUS- TAINED BY EJECTEES; JFISNAP AIMCREW ANTHROPOMETRY ANALYSIS AND SCREENING...1979 ....................................... 1-281 U.S. Navy Aviation Mishap Aircrew Anthropometry ; 1 January 1969 through 31 December 1979

Event Reports Promoting Root Cause Analysis.

PubMed

Pandit, Swananda; Gong, Yang

2016-01-01

Improving health is the sole objective of medical care. Unfortunately, mishaps or patient safety events happen during the care. If the safety events were collected effectively, they would help identify patterns, underlying causes, and ultimately generate proactive and remedial solutions for prevention of recurrence. Based on the AHRQ Common Formats, we examine the quality of patient safety incident reports and describe the initial data requirement that can support and accelerate effective root cause analysis. The ultimate goal is to develop a knowledge base of patient safety events and their common solutions which can be readily available for sharing and learning.

Vehicle Assembly Building Fire Mishap Investigation Report. Volume I of V

NASA Technical Reports Server (NTRS)

Kight, Ira; Luciano, Steven; Stevens, Michael B.; Farley, W. Max; Collins, Bryce D.; Potterger, William C.; Levesque, Jodi

2005-01-01

On January 13, 2005, at approximately 1355, smoke was noticed on the 4th floor of D Tower in the Vehicle Assembly Building (VAB). Subsequently, a 911 call was made, a fire alarm pull station was activated, and the VAB was evacuated. The source of the smoke was determined to be a fire on the Low Bay M/N section roof near the Launch Control Center (LCC) Crossover. Due to the high visibility of the mishap, the KSC Center Director appointed a Mishap Investigation Board. Damage to government property was limited to the roof and a small number of ceiling tiles that were damaged by the fire fighters during the response. At the time of the mishap, there were hazardous commodities in the VAB including Solid Rocket Motors (SRMs) with open grain due to Solid Rocket Booster (SRB) igniter inspections. The Board agrees with the SGS Fire Services' theory that large amounts of smoke concentrated in the VAB D Tower and moved downward into the cable tunnel. The Board determined the proximate cause of this incident to be torching. HRI was installing a torch applied roof membrane which resulted in the ignition of combustible materials under the membrane near a wooden roof expansion joint. The torch applied roofing method is a universally accepted safe industry practice when applied to non-combustible surfaces. The combination of an open flame torch and combustible materiaLs presents an increased level of risk even with skilled applicators. The addition of high winds to this combination results in a risk the Board thinks can not be adequately mitigated. An appropriate risk assessment and analysis must be performed on the proposed roofing method to be used on high visibility facilities which represent unique national assets even when using common industry practices for repair and modification. The Board identified three root causes which contributed to or created the proximate cause and, if eliminated or modified, would have prevented the mishap: 1. Combustible materials in existing roof system 2. Wind speed and direction 3. Inadequate fire watch technique. Two contributing factors were identified which may have contributed to the occurrence but, if eliminated or modified, would not have prevented the occurrence: 1. HRI rushed to dry in and seal the roof on January 13 because heavy rain was predicted for the next day 2. No guidance on torching in windy conditions A total of 17 significant observations were noted during this investigation, which could lead to another mishap, or increase the severity of a mishap, but were not contributing factors in this mishap.

14 CFR 437.75 - Mishap reporting, responding, and investigating.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 4 2011-01-01 2011-01-01 false Mishap reporting, responding, and investigating. 437.75 Section 437.75 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION...) Notify within 24 hours the FAA's Office of Commercial Space Transportation if there is a mishap that does...

14 CFR 437.75 - Mishap reporting, responding, and investigating.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Mishap reporting, responding, and investigating. 437.75 Section 437.75 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION...) Notify within 24 hours the FAA's Office of Commercial Space Transportation if there is a mishap that does...

Manned Space Programs Accident/Incident Summaries (1970 - 1971)

NASA Technical Reports Server (NTRS)

1972-01-01

A compilation of 223 mishaps assembled from company and NASA records covering the Accident/Incident experience in 1970-1971 in the Manned Space Flight Programs is presented. It is the companion volume to NASA-CR-120998 which covered the years 1963-1969. The objectives of this summary is to make available to Government agencies and industrial firms the lessons learned from these mishaps. Each accident/incident summary has been reviewed by description, cause and recommended preventive action. The summaries have been categorized by the following ten systems: (1) Cryogenic; (2) Electrical; (3) Facility/GSE; (4) Fuel and Propellant; (5) Life Support; (6) Ordnance; (7) Pressure; (8) Propulsion; (9) Structural; and (10) Transport/Handling.

Ontology Development and Evolution in the Accident Investigation Domain

NASA Technical Reports Server (NTRS)

Carvalho, Robert; Berrios, Dan; Williams, James

2004-01-01

InvestiigationOrganizer (IO) is a collaborative semantic web system designed to support the conduct of mishap investigations. IO provides a common repository for a wide range of mishap related information, allowing investigators to integrate evidence, causal models, and investigation results. IO has been used to support investigations ranging from a small property damage case to the loss of the Space Shuttle Columbia. Through IO'S use in these investigations, we have learned significant lessons? about the application of ontologies and semantic systems to solving real-world problems. This paper will describe the development of the ontology within IO, from the initial development, its growth in response to user requests during use in investigations, and the recent work that was done to control the results of that growth. This paper will also describe the lessons learned from this experience and how they may apply to the implementaton of future ontologies and semantic systems.

Predicting and Reducing Driving Mishaps Among Drivers With Type 1 Diabetes

PubMed Central

Gonder-Frederick, Linda A.; Singh, Harsimran; Ingersoll, Karen S.; Banton, Tom; Grabman, Jesse H.; Schmidt, Karen; Clarke, William

2017-01-01

OBJECTIVE Two aims of this study were to develop and validate A) a metric to identify drivers with type 1 diabetes at high risk of future driving mishaps and B) an online intervention to reduce mishaps among high-risk drivers. RESEARCH DESIGN AND METHODS To achieve aim A, in study 1, 371 drivers with type 1 diabetes from three U.S. regions completed a series of established questionnaires about diabetes and driving. They recorded their driving mishaps over the next 12 months. Questionnaire items that uniquely discriminated drivers who did and did not have subsequent driving mishaps were assembled into the Risk Assessment of Diabetic Drivers (RADD) scale. In study 2, 1,737 drivers with type 1 diabetes from all 50 states completed the RADD online. Among these, 118 low-risk (LR) and 372 high-risk (HR) drivers qualified for and consented to participate in a 2-month treatment period followed by 12 monthly recordings of driving mishaps. To address aim B, HR participants were randomized to receive either routine care (RC) or the online intervention “DiabetesDriving.com” (DD.com). Half of the DD.com participants received a motivational interview (MI) at the beginning and end of the treatment period to boost participation and efficacy. All of the LR participants were assigned to RC. In both studies, the primary outcome variable was driving mishaps. RESULTS Related to aim A, in study 1, the RADD demonstrated 61% sensitivity and 75% specificity. Participants in the upper third of the RADD distribution (HR), compared with those in the lower third (LR), reported 3.03 vs. 0.87 mishaps/driver/year, respectively (P < 0.001). In study 2, HR and LR participants receiving RC reported 4.3 and 1.6 mishaps/driver/year, respectively (P < 0.001). Related to aim B, in study 2, MIs did not enhance participation or efficacy, so the DD.com and DD.com + MI groups were combined. DD.com participants reported fewer hypoglycemia-related driving mishaps than HR participants receiving RC (P = 0.01), but more than LR participants receiving RC, reducing the difference between the HR and LR participants receiving RC by 63%. HR drivers differed from LR drivers at baseline across a variety of hypoglycemia and driving parameters. CONCLUSIONS The RADD identified higher-risk drivers, and identification seemed relatively stable across time, samples, and procedures. This 11-item questionnaire could inform patients at higher risk, and their clinicians, that they should take preventive steps to reduce driving mishaps, which was accomplished in aim B using DD.com. PMID:28404657

Loss of Signal, Aeromedical Lessons Learned from the STS-107 Columbia Space Shuttle Mishap

NASA Technical Reports Server (NTRS)

Stepaniak, Phillip C.; Patlach, Robert

2014-01-01

Loss of Signal, a NASA publication to be available in May 2014 presents the aeromedical lessons learned from the Columbia accident that will enhance crew safety and survival on human space flight missions. These lessons were presented to limited audiences at three separate Aerospace Medical Association (AsMA) conferences: in 2004 in Anchorage, Alaska, on the causes of the accident; in 2005 in Kansas City, Missouri, on the response, recovery, and identification aspects of the investigation; and in 2011, again in Anchorage, Alaska, on future implications for human space flight. As we embark on the development of new spacefaring vehicles through both government and commercial efforts, the NASA Johnson Space Center Human Health and Performance Directorate is continuing to make this information available to a wider audience engaged in the design and development of future space vehicles. Loss of Signal summarizes and consolidates the aeromedical impacts of the Columbia mishap process-the response, recovery, identification, investigative studies, medical and legal forensic analysis, and future preparation that are needed to respond to spacecraft mishaps. The goal of this book is to provide an account of the aeromedical aspects of the Columbia accident and the investigation that followed, and to encourage aerospace medical specialists to continue to capture information, learn from it, and improve procedures and spacecraft designs for the safety of future crews. This poster presents an outline of Loss of Signal contents and highlights from each of five sections - the mission and mishap, the response, the investigation, the analysis and the future.

Factors Associated with Delayed Ejection in Mishaps Between 1993 and 2013.

PubMed

Miles, John E

2015-09-01

The purpose of this investigation was to identify factors associated with Air Force aviators delaying ejection during in-flight emergencies. The investigator reviewed all reports within the Air Force Safety Automated System describing mishaps that resulted in the destruction of Air Force ejection-seat equipped aircraft between 1993 and 2013. Crewmembers were classified as either timely or delayed ejectors based on altitude at onset of emergency, altitude at ejection, and a determination regarding whether or not the aircraft was controlled during the mishap sequence. Univariate analysis and multivariate logistic regression were used to explore the association between delayed ejection and multiple potential risk factors. In total, 366 crewmembers were involved in in-flight emergencies in ejection-seat-equipped aircraft that resulted in the loss of the aircraft; 201 (54.9%) of these crewmembers delayed ejection until their aircraft had descended below recommended minimum ejection altitudes. Multivariate analysis indicated that independent risk factors for delayed ejection included increased crewmember flight hours and a mechanical or human-factors related cause of the emergency versus bird strike or midair collision. This investigation provided quantitative assessments of factors associated with aviators delaying ejection during in-flight emergencies. Increased odds of delay among crewmembers with greater than 1500 total flight hours suggests that complacency and overconfidence may adversely influence the ejection decision to at least as great a degree as inexperience. Increased odds of delay during mechanical and human factors mishaps confirms previously reported hypotheses and reaffirms the importance of targeting these areas to reduce aviator injuries and fatalities.

Observational Mishaps - a Database

NASA Astrophysics Data System (ADS)

von Braun, K.; Chiboucas, K.; Hurley-Keller, D.

1999-05-01

We present a World-Wide-Web-accessible database of astronomical images which suffer from a variety of observational problems. These problems range from common phenomena, such as dust grains on filters and/or dewar window, to more exotic cases like, for instance, deflated support airbags underneath the primary mirror. The purpose of this database is to enable astronomers at telescopes to save telescope time by discovering the nature of the trouble they might be experiencing with the help of this online catalog. Every observational mishap contained in this collection is presented in the form of a GIF image, a brief explanation of the problem, and, to the extent possible, a suggestion of what might be done to solve the problem and improve the image quality.

Aircraft Mishap Exercise at SLF

NASA Image and Video Library

2018-02-14

NASA Kennedy Space Center's Flight Operations prepares to rehearse a helicopter crash-landing to test new and updated emergency procedures. Called the Aircraft Mishap Preparedness and Contingency Plan, the operation was designed to validate several updated techniques the center's first responders would follow, should they ever need to rescue a crew in case of a real accident. The mishap exercise took place at the center's Shuttle Landing Facility.

The Use of Crow-AMSAA Plots to Assess Mishap Trends

NASA Technical Reports Server (NTRS)

Dawson, Jeffrey W.

2011-01-01

Crow-AMSAA (CA) plots are used to model reliability growth. Use of CA plots has expanded into other areas, such as tracking events of interest to management, maintenance problems, and safety mishaps. Safety mishaps can often be successfully modeled using a Poisson probability distribution. CA plots show a Poisson process in log-log space. If the safety mishaps are a stable homogenous Poisson process, a linear fit to the points in a CA plot will have a slope of one. Slopes of greater than one indicate a nonhomogenous Poisson process, with increasing occurrence. Slopes of less than one indicate a nonhomogenous Poisson process, with decreasing occurrence. Changes in slope, known as "cusps," indicate a change in process, which could be an improvement or a degradation. After presenting the CA conceptual framework, examples are given of trending slips, trips and falls, and ergonomic incidents at NASA (from Agency-level data). Crow-AMSAA plotting is a robust tool for trending safety mishaps that can provide insight into safety performance over time.

Aircraft Mishap Exercise at SLF

NASA Image and Video Library

2018-02-14

Members of NASA Kennedy Space Center's Flight Operations team participate in a rehearsal of a helicopter crash-landing to test new and updated emergency procedures. Called the Aircraft Mishap Preparedness and Contingency Plan, the operation was designed to validate several updated techniques the center's first responders would follow, should they ever need to rescue a crew in case of a real accident. The mishap exercise took place at the center's Shuttle Landing Facility.

Aircraft Mishap Exercise at SLF

NASA Image and Video Library

2018-02-14

NASA Kennedy Space Center's Flight Operations team reviews procedures before beginning a rehearsal of a helicopter crash-landing to test new and updated emergency procedures. Called the Aircraft Mishap Preparedness and Contingency Plan, the operation was designed to validate several updated techniques the center's first responders would follow, should they ever need to rescue a crew in case of a real accident. The mishap exercise took place at the center's Shuttle Landing Facility.

Aircraft Mishap Exercise at SLF

NASA Image and Video Library

2018-02-14

Members of NASA Kennedy Space Center's Flight Operations team prepare for a rehearsal of a helicopter crash-landing to test new and updated emergency procedures. Called the Aircraft Mishap Preparedness and Contingency Plan, the operation was designed to validate several updated techniques the center's first responders would follow, should they ever need to rescue a crew in case of a real accident. The mishap exercise took place at the center's Shuttle Landing Facility.

Aircraft Mishap Exercise at SLF

NASA Image and Video Library

2018-02-14

A member of NASA Kennedy Space Center's Flight Operations team prepares for a rehearsal of a helicopter crash-landing to test new and updated emergency procedures. Called the Aircraft Mishap Preparedness and Contingency Plan, the operation was designed to validate several updated techniques the center's first responders would follow, should they ever need to rescue a crew in case of a real accident. The mishap exercise took place at the center's Shuttle Landing Facility.

Aircraft Mishap Exercise at SLF

NASA Image and Video Library

2018-02-14

An Aircraft Mishap Preparedness and Contingency Plan is underway at the Shuttle Landing Facility at NASA's Kennedy Space Center in Florida. The center's Flight Operations rehearsed a helicopter crash-landing to test new and updated emergency procedures. The operation was designed to validate several updated techniques the center's first responders would follow, should they ever need to rescue a crew in case of a real accident. The mishap exercise took place at the center's Shuttle Landing Facility.

X-31 Mishap: Lessons Learned

NASA Technical Reports Server (NTRS)

Larson, Richard R.

2007-01-01

The experimental X-31 High Angle of Attack Research Aircraft crashed during a 1995 test mission flight conducted by NASA at Edwards Air Force Base, California. The pilot lost control of the airplane and was forced to eject, sustaining a permanent back injury that ended his flying career. Prior to this incident the airplane had a perfect record of several hundred non-eventful flights supported by an experienced team. During the subsequent investigation by a mishap committee it was discovered that a series of cascading events contributed to this accident. Some of the identified contributing factors that resulted in this mishap are common to aircraft design and to flight-test in general. The mistakes and the solutions are presented here so that the flight-test community may consider and learn from them. The primary cause of the crash was icing and, ultimately, a complete blockage of the pitot-static nose probe. The icing was caused by a freak weather phenomenon that was neither expected nor known to exist on the day of the mishap. The normal probe had been replaced with a special Kiel probe to allow total pressure measurements of up to 70 degrees angle of attack for flight-test purposes. The Kiel probe did not include a heater, because it was assumed that the airplane would not be flown in the clouds or in conditions conducive to icing. This assumption was later proven to be incorrect. The iced Kiel probe caused incorrect gain scheduling in the flight control system, resulting in an unstable aircraft. This failure was essentially undetected because of a faulty design in the flight control system architecture. There were, however, also a number of other issues that lead up to this situation that never should have happened. This presentation discusses what the issues were that contributed to the incident. After the incident was investigated, some of these issues were addressed and some changes were made. The second X-31 aircraft flew the remainder of the flight tests, and the program was successfully completed without incident. This presentation also shows a video of the mishap including lessons learned, and the changes that were made to resume the flight-test program are presented.

A comparison of leading and lagging indicators of safety in naval aviation.

PubMed

O'Connor, Paul; Cowan, Shawn; Alton, Jeffrey

2010-07-01

The purpose of this paper is to examine the results of two different methods of identifying human factors safety concerns in U.S. Naval aviation. In both studies, the information was collected using the Department of Defense Human Factors Analysis and Classification System (DoD-HFACS). In the first study, aviation mishap data (a lagging indictor) was obtained on 47 F/A-18 and 16 H-60 mishaps. In the second study, the responses of 68 squadrons to a survey regarding the human factors issues that they considered to be of the greatest safety concern were examined (a leading indicator). First study results revealed that skill-based errors were the most commonly cited factors for both F/A-18 and H-60 mishaps (70.2% and 81.3%, respectively). More specifically, the most commonly used nanocodes were 'over control/ under control' (27.7% and 56.3%, respectively), 'breakdown in visual scan' (27.7% and 12.5%, respectively), and 'procedural errors' (23.4% and 37.6%, respectively). The second study identified that the main concern of F/A-18 and H-60 aviators was workload and operational tempo (identified by 85% of squadrons). It can be concluded that the nanocodes that were most commonly used to classify the causes of past mishaps were not identified as major concerns by the squadrons who responded to the survey. The findings from these studies emphasize the importance of examining a number of performance metrics to ensure that effective measures are being taken to improve safety.

Mishap risk control for advanced aerospace/composite materials

NASA Technical Reports Server (NTRS)

Olson, John M.

1994-01-01

Although advanced aerospace materials and advanced composites provide outstanding performance, they also present several unique post-mishap environmental, safety, and health concerns. The purpose of this paper is to provide information on some of the unique hazards and concerns associated with these materials when damaged by fire, explosion, or high-energy impact. Additionally, recommended procedures and precautions are addressed as they pertain to all phases of a composite aircraft mishap response, including fire-fighting, investigation, recovery, clean-up, and guidelines are general in nature and not application-specific. The goal of this project is to provide factual and realistic information which can be used to develop consistent and effective procedures and policies to minimize the potential environmental, safety, and health impacts of a composite aircraft mishap response effort.

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Quality within space exploration ground processing operations, the identification and or classification of underlying contributors and causes of human error must be identified, in order to manage human error.This presentation will provide a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

A Case Study of Small Group Decision-Making as Influenced by the Abilene Paradox: The ’Challenger’ Mishap

DTIC Science & Technology

1988-05-01

RESEARCH REPORT O A CASE STUDY OF SMALL GROUP DECISION-MAKING AS INFLUENCED BY THE ABILENE PARADOX: N THE " CHALLENGER " MISHAP COMMANDER JAMES Y...1.09_240 AIR WAR COLLEGE AIR UNIVERSITY A CASE STIJI)Y OF SMALL GROUP DECISION-MAKING AS INFLUENCED BY THE ABILENE PARADOX: THE " CHALLENGER " MISHAP by...representing the public and private sectors of leadership in our national space exploration program evaluated the risk associated with known discrepancies

Kennedy Space Center (KSC) Mishap Response Plan

NASA Technical Reports Server (NTRS)

Scarpa, Philip

2005-01-01

KSC Medical Operations, in exercising the KSC Psychological Triage Plan, provided crewmember family support following notification of the Columbia accident. KSC Medical Operations also provided field support in working with FEMA and EPA to assure adequate occupational medicine and environmental health care of KSC workers. In addition, the development of policy and procedures for handling and clearing biohazardous debris material in the KSC reconstruction hangar was prepared and implemented.

MISHAP Newsletter of the Minnesota Social History Project. August, 1978 through March, 1979.

ERIC Educational Resources Information Center

Crozier, William; And Others

This document contains eight newsletters prepared by the Minnesota Social History Project (MSHP), an experimental curriculum project in local social history. The newsletters offer classroom exercises, participant suggestions, and supportive essays designed for teachers working with the MSHP. The premise of the project is that "American history can…

When All the Ducks Line Up

NASA Technical Reports Server (NTRS)

Henwood, Bart E.

2007-01-01

This viewgraph presentation gives an overview of the N2NA Pylon overheat mishap. The contents include: 1) Investigation Process; 2) Bottom Line; 3) Event Description / Damage; 4) Causal Tree Analysis; 5) Significant Observations; and 6) Major Recommendations.

Multisensory cueing for enhancing orientation information during flight.

PubMed

Albery, William B

2007-05-01

The U.S. Air Force still regards spatial disorientation (SD) and loss of situational awareness (SA) as major contributing factors in operational Class A aircraft mishaps ($1M in aircraft loss and/or pilot fatality). Air Force Safety Agency data show 71 Class A SD mishaps from 1991-2004 in both fixed and rotary-wing aircraft. These mishaps resulted in 62 fatalities and an aircraft cost of over $2.OB. These losses account for 21 % of the USAF's Class A mishaps during that 14-yr period. Even non-mishap SD events negatively impact aircrew performance and reduce mission effectiveness. A multisensory system has been developed called the Spatial Orientation Retention Device (SORD) to enhance the aircraft attitude information to the pilot. SORD incorporates multisensory aids including helmet mounted symbology and tactile and audio cues. SORD has been prototyped and demonstrated in the Air Force Research Laboratory at Wright-Patterson AFB, OH. The technology has now been transitioned to a Rotary Wing Brownout program. This paper discusses the development of SORD and a potential application, including an augmented cognition application. Unlike automatic ground collision avoidance systems, SORD does not take over the aircraft if a pre-set altitude is broached by the pilot; rather, SORD provides complementary attitude cues to the pilot via the tactile, audio, and visual systems that allow the pilot to continue flying through disorienting conditions.

The elements of a commercial human spaceflight safety reporting system

NASA Astrophysics Data System (ADS)

Christensen, Ian

2017-10-01

In its report on the SpaceShipTwo accident the National Transportation Safety Board (NTSB) included in its recommendations that the Federal Aviation Administration (FAA) ;in collaboration with the commercial spaceflight industry, continue work to implement a database of lessons learned from commercial space mishap investigations and encourage commercial space industry members to voluntarily submit lessons learned.; In its official response to the NTSB the FAA supported this recommendation and indicated it has initiated an iterative process to put into place a framework for a cooperative safety data sharing process including the sharing of lessons learned, and trends analysis. Such a framework is an important element of an overall commercial human spaceflight safety system.

Information Extraction for System-Software Safety Analysis: Calendar Year 2007 Year-End Report

NASA Technical Reports Server (NTRS)

Malin, Jane T.

2008-01-01

This annual report describes work to integrate a set of tools to support early model-based analysis of failures and hazards due to system-software interactions. The tools perform and assist analysts in the following tasks: 1) extract model parts from text for architecture and safety/hazard models; 2) combine the parts with library information to develop the models for visualization and analysis; 3) perform graph analysis on the models to identify possible paths from hazard sources to vulnerable entities and functions, in nominal and anomalous system-software configurations; 4) perform discrete-time-based simulation on the models to investigate scenarios where these paths may play a role in failures and mishaps; and 5) identify resulting candidate scenarios for software integration testing. This paper describes new challenges in a NASA abort system case, and enhancements made to develop the integrated tool set.

14 CFR 431.45 - Mishap investigation plan and emergency response plan.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Mishap investigation plan and emergency response plan. 431.45 Section 431.45 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL...) Notification within 24 hours to the Associate Administrator for Commercial Space Transportation in the event of...

Residents' responses to medical error: coping, learning, and change.

PubMed

Engel, Kirsten G; Rosenthal, Marilynn; Sutcliffe, Kathleen M

2006-01-01

To explore the significant emotional challenges facing resident physicians in the setting of medical mishaps, as well as their approaches to coping with these difficult experiences. Twenty-six resident physicians were randomly selected from a single teaching hospital and participated in in-depth qualitative interviews. Transcripts were analyzed iteratively and themes identified. Residents expressed intense emotional responses to error events. Poor patient outcomes and greater perceived personal responsibility were associated with more intense reactions and greater personal anguish. For the great majority of residents, their ability to cope with these events was dependent on a combination of reassurance and opportunities for learning. Interactions with medical colleagues and supervisory physicians were critical to this coping process. Medical mishaps have a profound impact on resident physicians by eliciting intense emotional responses. It is critical that resident training programs recognize the personal and professional significance of these experiences for young physicians. Moreover, resident education must support the development of constructive coping skills by facilitating candid discussion and learning subsequent to these events.

Aeromedical Lessons from the Space Shuttle Columbia Accident Investigation

NASA Technical Reports Server (NTRS)

Pool, Sam L.

2005-01-01

This paper presents the aeromedical lessons learned from the Space Shuttle Columbia Accident Investigation. The contents include: 1) Introduction and Mission Response Team (MRT); 2) Primary Disaster Field Office (DFO); 3) Mishap Investigation Team (MIT); 4) Kennedy Space Center (KSC) Mishap Response Plan; 5) Armed Forces Institute of Pathology (AFIP); and 6) STS-107 Crew Surgeon.

The Autonomic Signature of Guilt in Children: A Thermal Infrared Imaging Study

PubMed Central

Ioannou, Stephanos; Ebisch, Sjoerd; Aureli, Tiziana; Bafunno, Daniela; Ioannides, Helene Alexi; Cardone, Daniela; Manini, Barbara; Romani, Gian Luca; Gallese, Vittorio; Merla, Arcangelo

2013-01-01

So far inferences on early moral development and higher order self conscious emotions have mostly been based on behavioral data. Emotions though, as far as arguments support, are multidimensional notions. Not only do they involve behavioral actions upon perception of an event, but they also carry autonomic physiological markers. The current study aimed to examine and characterise physiological signs that underlie self-conscious emotions in early childhood, while grounding them on behavioral analyses. For this purpose, the “mishap paradigm” was used as the most reliable method for evoking feelings of “guilt” in children and autonomic facial temperature variation were detected by functional Infrared Imaging (fIRI). Fifteen children (age: 39–42 months) participated in the study. They were asked to play with a toy, falsely informed that it was the experimenter's “favourite”, while being unaware that it was pre-planned to break. Mishap of the toy during engagement caused sympathetic arousal as shown by peripheral nasal vasoconstriction leading to a marked temperature drop, compared to baseline. Soothing after the mishap phase induced an increase in nose temperature, associated with parasympathetic activity suggesting that the child's distress was neutralized, or even overcompensated. Behavioral analyses reported signs of distress evoked by the paradigm, backing up the thermal observation. The results suggest that the integration of physiological elements should be crucial in research concerning socio-emotional development. fIRI is a non invasive and non contact method providing a powerful tool for inferring early moral emotional signs based on physiological observations of peripheral vasoconstriction, while preserving an ecological and natural context. PMID:24260220

Loss of Signal, Aeromedical Lessons Learned for the STS-I07 Columbia Space Shuttle Mishap

NASA Technical Reports Server (NTRS)

Patlach, Robert; Stepaniak, Philip C.; Lane, Helen W.

2014-01-01

Loss of Signal, a NASA publication to be available in May 2014, presents the aeromedical lessons learned from the Columbia accident that will enhance crew safety and survival on human space flight missions. These lessons were presented to limited audiences at three separate Aerospace Medical Association (AsMA) conferences: in 2004 in Anchorage, Alaska, on the causes of the accident; in 2005 in Kansas City, Missouri, on the response, recovery, and identification aspects of the investigation; and in 2011, again in Anchorage, Alaska, on future implications for human space flight. As we embark on the development of new spacefaring vehicles through both government and commercial efforts, the NASA Johnson Space Center Human Health and Performance Directorate is continuing to make this information available to a wider audience engaged in the design and development of future space vehicles. Loss of Signal summarizes and consolidates the aeromedical impacts of the Columbia mishap process-the response, recovery, identification, investigative studies, medical and legal forensic analysis, and future preparation that are needed to respond to spacecraft mishaps. The goals of this book are to provide an account of the aeromedical aspects of the Columbia accident and the investigation that followed, and to encourage aerospace medical specialists to continue to capture information, learn from it, and improve procedures and spacecraft designs for the safety of future crews.

A comparative analysis of liquefied petroleum gas (LPG) and kerosene related burns.

PubMed

Ahuja, Rajeev B; Dash, Jayant K; Shrivastava, Prabhat

2011-12-01

Previous studies from our department reflected a trend of decreasing incidence of burns culminating from rising income levels, which were bringing about a change in the cooking fuel in many urban households [1,2]. These studies also indicated a changing scenario of increased incidence of burns from LPG mishaps [2]. In the absence of much information on the subject we felt it rather imperative to comparatively study the pattern of burn injuries resulting from LPG and kerosene. This prospective study was conducted on the clinical database of consecutive patients admitted with burns sustained due to LPG and kerosene from 1st January 2009 to 31st May 2010 (17 months). Data recorded for each patient included; age, gender, religion, socioeconomic status, literacy level, type of family unit, marital status, type of dwelling unit, mode of injury and its exact mechanism, place of incident, level of cooking stove, extent of burns (%TBSA), presence of features of inhalation injury, number of patients affected in a single mishap, size of LPG cylinder used, length of hospital stay and mortality. Of 731 flame burn patients in this study, 395 (54%) were due to kerosene burns and 200 (27.4%) from LPG mishaps. Significantly, the majority of injuries, in both the groups, occurred in lower middle class families living as nuclear units, in a single room dwelling, without a separate kitchen. Majority of LPG burns (70.5%, 141 patients) resulted from a gas leak and 25.5% were from cooking negligence (51 patients). 50.5% of kerosene accidents were from 'stove mishaps' and 49% due to cooking negligence. In all kerosene accidents the stove was kept at floor level but in LPG group 20.6% had the stove placed on a platform. There was a slight difference in mean TBSA burns; 51% in kerosene group compared to 41.5% TBSA in LPG group. There were nine episodes in LPG group in which there were more than three burn victims admitted for treatment. Very importantly, 77% patients in LPG group were from a large cylinder (14.2 kg), which uses a rubber connecting tube. Mortality in kerosene group (50.6%) was far higher than in LPG group (33.5%). This study, from 200 LPG burn admissions, for the first time details the profile from LPG mishaps. It is very interesting to note that of all burns in the world the inequitable distribution bias towards LMICs (low and middle income countries) extends further towards low middle class families within the LMIC. A major risk factor is constrained living condition of a single room dwelling unit. Almost all burns from LPG mishaps were potentially preventable if more care had been practiced to ensure safety. Since majority of LPG mishaps were from gas leaks, either from the rubber tube (Fig. 1) or the stove valve, the observation of floor level cooking in 79.4% of LPG cases may be an economic compulsion of a single room dwelling unit without much impact on the injury pattern. The small LPG cylinder (5 kg) in which the burner is placed directly over the cylinder, as one unit without a connecting tube, is safer because it reduces the chances of a gas leak from an ill-fitting or a cracked rubber connecting tube (Fig. 2). Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.

24/7 Operational Effectiveness Toolset: Mishap Investigation Interface

DTIC Science & Technology

2008-10-01

analysis software product. The toolset was based upon the Sleep, Activity, Fatigue, and Task Effectiveness (SAFTE™; Hursh et al., 2004). The SAFTE...meeting was for the purpose of requirements analysis , in which the designers elicited task information from the SMEs. The second meeting included a...investigators who also served as our SMEs. The requirements analysis revealed how fatigue related information is entered into the report of an Air Force

The practical application of mishap data in Army aircraft system safety programs

NASA Technical Reports Server (NTRS)

Darrah, J. T., Jr.

1971-01-01

The means are discussed by which the the United States Army Board for Aviation Accident Research (USABAAR) now utilizes the vast store of historical accident data in the application of the system safety concept for developmental aircraft. USABAAR serves as the central agency for the Army Accident Prevention Program which includes the receipt, processing, and analysis of all data and information related to Army aircraft accident experience. It is pointed out that methods which served the cause of accident prevention so well in the past are no longer adequate and that traditional parameters used to measure mishap experience have become obsolete. USABAAR has developed, and recently put into use, completely revised accident reporting forms which greatly expand the scope and detail of information provided as a result of investigation. This and other factors which have resulted in an improved data system are discussed in detail.

Classification of Air Force Aviation Accidents: Mishap trends and Prevention

DTIC Science & Technology

2006-06-02

Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), ,Wpshngrton. DC...Masters, Stone, Babcock, & Rypka, 1974; Moroze & Snow, 1999), and those specifically Mishap Trends & Prevention 4 addressing HFACS (Shappell... Moroze , M. L. & M. P. Snow (1999). Causes and remedies of controlled flight into terrain in military and civil aviation. 1 0 th International

A method to compute SEU fault probabilities in memory arrays with error correction

NASA Technical Reports Server (NTRS)

Gercek, Gokhan

1994-01-01

With the increasing packing densities in VLSI technology, Single Event Upsets (SEU) due to cosmic radiations are becoming more of a critical issue in the design of space avionics systems. In this paper, a method is introduced to compute the fault (mishap) probability for a computer memory of size M words. It is assumed that a Hamming code is used for each word to provide single error correction. It is also assumed that every time a memory location is read, single errors are corrected. Memory is read randomly whose distribution is assumed to be known. In such a scenario, a mishap is defined as two SEU's corrupting the same memory location prior to a read. The paper introduces a method to compute the overall mishap probability for the entire memory for a mission duration of T hours.

U.S. Civil Rotorcraft Accidents, 1963 Through 1997

NASA Technical Reports Server (NTRS)

Harris, Franklin D.; Kasper, Eugene F.; Iseler, Laura E.

2000-01-01

Narrative summary data produced by the U.S. National Transportation Safety Board (NTSB) has been obtained and analyzed for all 8,436 U.S. civil registered rotorcraft accidents which occurred from mid-1963 through 1997. This analysis was based on the NTSB's assignment of each mishap into one of 21 "first event" categories. The number of U.S. civil registered rotorcraft as recorded by the Federal Aviation Administration (FAA) for the same period has also been obtained. Taken together, these data indicate the civil rotorcraft accident rate (on a per 1,000 registered rotorcraft basis) has decreased by almost a factor of 10 (i.e., from 130 accidents per 1,000 rotorcraft in 1964 to 13.4 per 1,000 in 1997). Analysis of the mishap data indicates over 70% of the rotorcraft accidents were associated with one of the following four NTSB "first event" categories: 2408 Loss of engine power (28.5%); 1,322 In-flight collisions with objects (15.7%); 1,114 Loss of control (13.2%); 1,083 Airframe/component/system failure or malfunction (12.8%).

Mishap Investigation Team (MIT) - Barksdale AFB, Louisiana

NASA Technical Reports Server (NTRS)

Stepaniak, Philip

2005-01-01

The Shuttle Program is organized to support a Shuttle mishap using the resources of the MIT. The afternoon of Feb. 1, 2003, the MIT deployed to Barksdale AFB. This location became the investigative center and interim storage location for crewmembers received from the Lufkin Disaster Field Office (DFO). Working under the leadership of the MIT Lead, the medical team executed a short-term plan that included search, recovery, and identification including coordination with the Armed Forces Institute of Pathology Temporary operations was set up at Barksdale Air Force Base for two weeks. During this time, coordination with the DFO field recovery teams, AFIP personnel, and the crew surgeons was on going. In addition, the crewmember families and NASA management were updated daily. The medical team also dealt with public reports and questions concerning biological and chemical hazards, which were coordinated with SPACEHAB, Inc., Kennedy Space Center (KSC) Medical Operations and the Johnson Space Center (JSC) Space Medicine office. After operations at Barksdale were concluded the medical team transitioned back to Houston and a long-term search, recovery and identification plan was developed.

Type 1 diabetic drivers with and without a history of recurrent hypoglycemia-related driving mishaps: physiological and performance differences during euglycemia and the induction of hypoglycemia.

PubMed

Cox, Daniel J; Kovatchev, Boris P; Anderson, Stacey M; Clarke, William L; Gonder-Frederick, Linda A

2010-11-01

Collisions are more common among drivers with type 1 diabetes than among their nondiabetic spouses. This increased risk appears to be attributable to a subgroup of drivers with type 1 diabetes. The hypothesis tested is that this vulnerable subgroup is more at risk for hypoglycemia and its disruptive effects on driving. Thirty-eight drivers with type 1 diabetes, 16 with (+history) and 22 without (-history) a recent history of recurrent hypoglycemia-related driving mishaps, drove a virtual reality driving simulator and watched a videotape of someone driving a simulator for 30-min periods. Driving and video testing occurred in a double-blind, randomized, crossover manner during euglycemia (5.5 mmol/l) and progressive hypoglycemia (3.9-2.5 mmol/l). Examiners were blind to which subjects were +/-history, whereas subjects were blind to their blood glucose levels and targets. During euglycemia, +history participants reported more autonomic and neuroglycopenic symptoms (P≤0.01) and tended to require more dextrose infusion to maintain euglycemia with the same insulin infusion (P<0.09). During progressive hypoglycemia, these subjects demonstrated less epinephrine release (P=0.02) and greater driving impairments (P=0.03). Findings support the speculation that there is a subgroup of type 1 diabetic drivers more vulnerable to experiencing hypoglycemia-related driving mishaps. This increased vulnerability may be due to more symptom "noise" (more symptoms during euglycemia), making it harder to detect hypoglycemia while driving; possibly greater carbohydrate utilization, rendering them more vulnerable to experiencing hypoglycemia; less hormonal counterregulation, leading to more profound hypoglycemia; and more neuroglycopenia, rendering them more vulnerable to impaired driving.

Endodontic management of contralateral mandibular first molars with six root canals

PubMed Central

Bhargav, Kambhampati; Sirisha, Kantheti; Jyothi, Mandava; Boddeda, Mohan Rao

2017-01-01

The knowledge of variations in root canal morphology is essential for a successful endodontic outcome. Contralateral mandibular molar with six root canals is a rare entity. Root canal treatment of mandibular molars with aberrant canal configuration can be diagnostically and technically challenging. While dealing with variant mandibular molars, mishaps may happen. This case report describes variations in contralateral mandibular molars and also an endodontic mishap while managing them. PMID:29259369

The Early Emergence of Guilt-Motivated Prosocial Behavior.

PubMed

Vaish, Amrisha; Carpenter, Malinda; Tomasello, Michael

2016-11-01

Guilt serves vital prosocial functions: It motivates transgressors to make amends, thus restoring damaged relationships. Previous developmental research on guilt has not clearly distinguished it from sympathy for a victim or a tendency to repair damage in general. The authors tested 2- and 3-year-old children (N = 62 and 64, respectively) in a 2 × 2 design, varying whether or not a mishap caused harm to someone and whether children themselves caused that mishap. Three-year-olds showed greatest reparative behavior when they had caused the mishap and it caused harm, thus showing a specific effect of guilt. Two-year-olds repaired more whenever harm was caused, no matter by whom, thus showing only an effect of sympathy. Guilt as a distinct motivator of prosocial behavior thus emerges by at least 3 years. © 2016 The Authors. Child Development © 2016 Society for Research in Child Development, Inc.

Manned space programs accident/incident summaries (1963 - 1969)

NASA Technical Reports Server (NTRS)

1970-01-01

This summary is a compilation of 508 mishaps assembled from company and NASA records which cover several years of manned space flight activity. The purpose is to provide information to be applied towards accident prevention. The accident/incident summaries are categorized by the following ten systems: cryogenic; electrical; facility/GSE; fuel and propellant; life support; ordnance; pressure; propulsion; structural; and transport/handling. Each accident/incident summary has been summarized by description, cause and recommended preventive action.

KSC-2011-6643

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- The Cape Canaveral Spaceport Mobile Command Center vehicle participates in the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

NASA Headquarters Space Operations Center: Providing Situational Awareness for Spaceflight Contingency Response

NASA Technical Reports Server (NTRS)

Maxwell, Theresa G.; Bihner, William J.

2010-01-01

This paper discusses the NASA Headquarters mishap response process for the Space Shuttle and International Space Station programs, and how the process has evolved based on lessons learned from the Space Shuttle Challenger and Columbia accidents. It also describes the NASA Headquarters Space Operations Center (SOC) and its special role in facilitating senior management's overall situational awareness of critical spaceflight operations, before, during, and after a mishap, to ensure a timely and effective contingency response.

Review of hydrogen accidents and incidents in NASA operations

NASA Technical Reports Server (NTRS)

Ordin, P. M.

1974-01-01

A number of the accidents/incidents with hydrogen in NASA operations are reviewed. The cause factors for the mishaps are reviewed and show that although few accidents occurred, the number could have been further reduced if the established NASA rules and regulations had been followed. Requirements for effective safety codes and areas of study for hydrogen safety information are included. The report concludes with a compilation of 96 hydrogen mishaps; a description of the accidents and their causes.

Penetrating cardiac injuries in blunt chest wall trauma.

PubMed

Kanchan, Tanuj; Menezes, Ritesh G; Sirohi, Parmendra

2012-08-01

The present photocase illustrates the possible mechanism of direct cardiac injuries from broken sharp jagged fractured ends of ribs in blunt force trauma to the chest in run over traffic mishaps. We propose that the projecting fractured ends of the ribs penetrate the underlying thoracic organs due to the transient phenomenon of deformation of chest cavity under pressure in run over traffic mishaps. Copyright © 2012 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

KSC-2011-6637

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- NASA Fire Rescue personnel assist a volunteer portraying an injured Huey II helicopter crew member participating in the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

KSC-2011-6644

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- An ambulance and several NASA Fire Rescue Services vehicles arrive to assist a Huey II helicopter participating in the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

KSC-2011-6640

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- NASA Fire Rescue personnel assist volunteers portraying injured Huey II helicopter crew members participating in the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

KSC-2011-6639

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- NASA Fire Rescue personnel assist volunteers portraying injured Huey II helicopter crew members participating in the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

KSC-2011-6638

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- NASA Fire Rescue personnel assist volunteers portraying injured Huey II helicopter crew members participating in the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

KSC-2011-6636

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- A NASA Fire Rescue Services vehicle, ambulance and Huey II helicopter take part in the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

KSC-2011-6641

NASA Image and Video Library

2011-08-31

CAPE CANAVERAL, Fla. -- NASA Fire Rescue personnel assist volunteers portraying injured Huey II helicopter crew members participating in the aviation safety exercise during Emergency Response Safety Training at the Shuttle Landing Facility, Runway 33, at NASA’s Kennedy Space Center in Florida. The simulated helicopter mishap exercise was conducted to evaluate emergency response and mishap investigations of aircraft at Kennedy. Participants included Air Rescue Fire Fighters, Flight Operations, Disaster Preparedness, Security, and Safety. NASA mandates simulated aviation safety training take place every two years. Photo credit: NASA/Kim Shiflett

Development of a Squadron Premishap Training Program

DTIC Science & Technology

1994-03-01

an aircraft mishap notification checklist? 0 Yes 0 No Comment b. Did the SDO follow the aircraft mishap notification checklist provided in the...squadron premishap plan? o Yes 0 No Comment c. If so, is this checklist readily available to the squadron watch team and do they all know where to find it? O...Yes 0 No Comment d. Did the SDO verify that SAR, the crash/fire department, and medical were notified? o Yes 0 No Comment If not, make sure the SDO

Managing novel reproductive injuries in the law of tort: the curious case of destroyed sperm.

PubMed

Priaulx, Nicolette

2010-03-01

In view of developments in reproductive medicine, clinical mishaps in this domain are beginning to give rise to 'injuries' not easily accommodated within the English law of negligence. While 'personal injury' is typically understood as manifesting a deleterious 'physical' dimension, cases involving the negligent destruction of cryopreserved sperm, as recently litigated in Yearworth & Ors v Bristol NNN Trust (2009), and other media reported mishaps in fertility treatment do not straightforwardly possess this quality. Without modification, the traditional tortious conception of 'personal injury' in English law will not be able to address novel claims. Critically, however, nor do alternative modes of redress seem to offer ease of application. Focusing upon the controversial Yearworth case and exploring what is seen as an unpromising framing of loss, the note argues that there is now an urgent need to rethink what counts as 'personal injury'. Arguing for the formal recognition of'reproductive injury' as an independent head of damage in negligence, and illustrating the presence of judicial support for that approach, the comment suggests that in light of the difficult challenges that lie in the wake of Yearworth, such a development may be not only desirable but necessary.

A Historical Analysis of Crane Mishaps at Kennedy Space Center

NASA Technical Reports Server (NTRS)

Wolfe, Crystal

2014-01-01

Cranes and hoists are widely used in many areas. Crane accidents and handling mishaps are responsible for injuries, costly equipment damage, and program delays. Most crane accidents are caused by preventable factors. Understanding these factors is critical when designing cranes and preparing lift plans. Analysis of previous accidents provides insight into current recommendations for crane safety. Cranes and hoists are used throughout Kennedy Space Center to lift everything from machine components to critical flight hardware. Unless they are trained crane operators, most NASA employees and contractors do not need to undergo specialized crane training and may not understand the safety issues surrounding the use of cranes and hoists. A single accident with a crane or hoist can injure or kill people, cause severe equipment damage, and delay or terminate a program. Handling mishaps can also have a significant impact on the program. Simple mistakes like bouncing or jarring a load, or moving the crane down when it should go up, can damage fragile flight hardware and cause major delays in processing. Hazardous commodities (high pressure gas, hypergolic propellants, and solid rocket motors) can cause life safety concerns for the workers performing the lifting operations. Most crane accidents are preventable with the correct training and understanding of potential hazards. Designing the crane with human factors taken into account can prevent many accidents. Engineers are also responsible for preparing lift plans where understanding the safety issues can prevent or mitigate potential accidents. Cranes are widely used across many areas of KSC. Failure of these cranes often leads to injury, high damage costs, and significant delays in program objectives. Following a basic set of principles and procedures during design, fabrication, testing, regular use, and maintenance can significantly minimize many of these failures. As the accident analysis shows, load drops are often caused or influenced by human factors. Therefore, proper training and understanding of crane safety throughout the workforce is critical. It is important that the engineers designing the cranes, lift planners preparing the lift plans, operators performing the lifts, and training officers conducting the operator training all understand the problems that can happen with cranes and how to ensure the safety of the workforce and equipment being lifted.

KENNEDY SPACE CENTER, FLA. - The mission patch for STS-107 is displayed, left, on the outside of the RLV Hangar at KSC. The hangar is the site of the Columbia Reconstruction Project, where pieces of debris from Columbia are being collected and identified as part of the mishap investigation.

NASA Image and Video Library

2003-05-06

KENNEDY SPACE CENTER, FLA. - The mission patch for STS-107 is displayed, left, on the outside of the RLV Hangar at KSC. The hangar is the site of the Columbia Reconstruction Project, where pieces of debris from Columbia are being collected and identified as part of the mishap investigation.

NASA Weather Support 2017

NASA Technical Reports Server (NTRS)

Carroll, Matt

2017-01-01

In the mid to late 1980's, as NASA was studying ways to improve weather forecasting capabilities to reduce excessive weather launch delays and to reduce excessive weather Launch Commit Criteria (LCC) waivers, the Challenger Accident occurred and the AC-67 Mishap occurred.[1] NASA and USAF weather personnel had advance knowledge of extremely high levels of weather hazards that ultimately caused or contributed to both of these accidents. In both cases, key knowledge of the risks posed by violations of weather LCC was not in the possession of final decision makers on the launch teams. In addition to convening the mishap boards for these two lost missions, NASA convened expert meteorological boards focusing on weather support. These meteorological boards recommended the development of a dedicated organization with the highest levels of weather expertise and influence to support all of American spaceflight. NASA immediately established the Weather Support Office (WSO) in the Office of Space Flight (OSF), and in coordination with the United Stated Air Force (USAF), initiated an overhaul of the organization and an improvement in technology used for weather support as recommended. Soon after, the USAF established a senior civilian Launch Weather Officer (LWO) position to provide meteorological support and continuity of weather expertise and knowledge over time. The Applied Meteorology Unit (AMU) was established by NASA, USAF, and the National Weather Service to support initiatives to place new tools and methods into an operational status. At the end of the Shuttle Program, after several weather office reorganizations, the WSO function had been assigned to a weather branch at Kennedy Space Center (KSC). This branch was dismantled in steps due to further reorganization, loss of key personnel, and loss of budget line authority. NASA is facing the loss of sufficient expertise and leadership required to provide current levels of weather support. The recommendation proposed herein is to re-establish the WSO under a high level office, with funding set at about the same levels as today, with a revitalized charter and focus to allow for the WSO to operate as originally intended.

Possible Deficiencies in Predicting Transonic Aerodynamics on the X-43A

NASA Technical Reports Server (NTRS)

Labbe, Steven G.; Gilbert, Michael G.; Kehoe, Michael W.

2009-01-01

The initial X-43A flight test, June 2, 2001, resulted in a mishap and loss of the vehicle. A mishap investigation board (MIB) report and findings, including the established root cause, were publicly released on July, 23, 2003. The X-43A Flight 1 Hyper-X Launch Vehicle (HXLV) failed because the vehicle control system design was deficient for the trajectory flown due to inaccurate analytical models (Pegasus heritage and HXLV specific), which overestimated the (control) system margin ? X-43A Mishap Investigation Report, Vol. I. ? included as Reference 1. Several specific errors were noted, 1) HXLV aerodynamics ? failure to model changes to wing, fin and rudder airfoil shapes due to addition of thermal protection system (TPS); 2) Fin actuation system (FAS) modeling ? under prediction of the control surface hinge moments and FAS compliance; and 3) Parametric uncertainties ? insufficient variation in the aerodynamic, FAS and control system models. In response to the MIB findings, the X-43A program has been working RTF through an approved Corrective Action Plan (CAP) over the last two years.

Science of Test Research Consortium: Year Two Final Report

DTIC Science & Technology

2012-10-02

July 2012. Analysis of an Intervention for Small Unmanned Aerial System ( SUAS ) Accidents, submitted to Quality Engineering, LQEN-2012-0056. Stone... Systems Engineering. Wolf, S. E., R. R. Hill, and J. J. Pignatiello. June 2012. Using Neural Networks and Logistic Regression to Model Small Unmanned ...Human Retina. 6. Wolf, S. E. March 2012. Modeling Small Unmanned Aerial System Mishaps using Logistic Regression and Artificial Neural Networks. 7

Analysis of Spatial Disorientation Mishaps in the US Navy

DTIC Science & Technology

2003-02-01

optokinetic after- nystagmus (OKAN) and vestibular nystagmus . In: Baker R, Berthoz A, eds. Control of gaze by grain stem neurons, Amsterdam: Elsevier...of explaining by modeling. In: Baker R, Berthoz A, eds. Control of gaze by grain stem neurons, developments in neuroscience, Vol. 1. Amsterdam...Elsevier/North-Holland Biomedical Press, 49-58. Raphan T, Matsuo V, Cohen B. (1977) A velocity storage mechanism responsible for optokinetic nystagmus (OKN

Chronic stress as a factor in aircraft mishaps

NASA Technical Reports Server (NTRS)

Alkov, Robert A.

1988-01-01

Naval aviation is an unusually stressful career because of the inherent demands of the work. Stress is recognized as a cause of mishaps which involve pilot error. A questionnaire was adapted from Rahe and Homes' list of stressful life events in order to determine the relationship between pilot behavioral, personality, and life change factors on the one hand and responsibility for accidents on the other. A number of factors regarding interpersonal relationships, changes in personal behavior, personality factors, and life changes were found to discriminate between pilots who were and were not at fault in accidents.

A Human Factors Analysis of USAF Remotely Piloted Aircraft Mishaps

DTIC Science & Technology

2013-06-01

conditions or unsafe acts, where their respective removal would prevent a chain reaction from propagating, thus preventing the accident . This model...Force Col. Anthony Tvaryanas stated that “If you 19 really wanted to make a dent in preventing RPA accidents , the DoD needs to look at how they do...REFERENCES Greenwood, M. & Woods, H.M. (1919). The incidence of industrial accidents upon individuals with special reference to multiple accidents . (British

SpaceX leading investigation of mishap on This Week @NASA – July 3, 2015

NASA Image and Video Library

2015-07-03

SpaceX, with Federal Aviation Administration oversight, is leading the investigation of what caused the June 28 mishap shortly after the company’s Falcon 9 rocket and Dragon cargo spacecraft launched from Cape Canaveral Air Force Station in Florida. The flight was SpaceX’s seventh contracted resupply mission to the International Space Station. Although important supplies and cargo were lost aboard the Dragon, the station crew has sufficient supplies into the Fall. Also, Progress on crew access tower at Cape, New Horizons’ final flight path, Forever Remembered exhibit, Health and Safety Fair and NASA Week and the Essence Festival!

The X-ray Astronomy Recovery Mission

NASA Astrophysics Data System (ADS)

Tashiro, M.; Kelley, R.

2017-10-01

On 25 March 2016, the Japanese 6th X-ray astronomical satellite ASTRO-H (Hitomi), launched on February 17, lost communication after a series of mishap in its attitude control system. In response to the mishap the X-ray astronomy community and JAXA analyzed the direct and root cause of the mishap and investigated possibility of a recovery mission with the international collaborator NASA and ESA. Thanks to great effort of scientists, agencies, and governments, the X-ray Astronomy Recovery Mission (XARM) are proposed. The recovery mission is planned to resume high resolution X-ray spectroscopy with imaging realized by Hitomi under the international collaboration in the shortest time possible, simply by focusing one of the main science goals of Hitomi Resolving astrophysical problems by precise high-resolution X-ray spectroscopy'. XARM will carry a 6 x 6 pixelized X-ray micro-calorimeter on the focal plane of an X-ray mirror assembly, and an aligned X-ray CCD camera covering the same energy band and wider field of view, but no hard X-ray or soft gamma-ray instruments are onboard. In this paper, we introduce the science objectives, mission concept, and schedule of XARM.

Semantic-Web Technology: Applications at NASA

NASA Technical Reports Server (NTRS)

Ashish, Naveen

2004-01-01

We provide a description of work at the National Aeronautics and Space Administration (NASA) on building system based on semantic-web concepts and technologies. NASA has been one of the early adopters of semantic-web technologies for practical applications. Indeed there are several ongoing 0 endeavors on building semantics based systems for use in diverse NASA domains ranging from collaborative scientific activity to accident and mishap investigation to enterprise search to scientific information gathering and integration to aviation safety decision support We provide a brief overview of many applications and ongoing work with the goal of informing the external community of these NASA endeavors.

The Proficiency Puzzle: Maintaining Airmanship In America’s Mobility Force Since 9-11

DTIC Science & Technology

2013-06-01

minimums of the flying organization or business .17 The Air Force defines aircrew members as “proficient when they can perform tasks at the minimum...Empowering Human Performance – Where do we go from here?” PACDEFF (The Pacific and Australasian CRM Developers’ and Facilitators’ Forum) Conference, 2011... statistical analysis, but the results are still important. Since 11 September 2001, the C-17 community has experienced eight Class A mishaps.29

Failure Analysis Results and Corrective Actions Implemented for the Extravehicular Mobility Unit 3011 Water in the Helmet Mishap

NASA Technical Reports Server (NTRS)

Steele, John; Metselaar, Carol; Peyton, Barbara; Rector, Tony; Rossato, Robert; Macias, Brian; Weigel, Dana; Holder, Don

2015-01-01

Water entered the Extravehicular Mobility Unit (EMU) helmet during extravehicular activity (EVA) no. 23 aboard the International Space Station on July 16, 2013, resulting in the termination of the EVA approximately 1 hour after it began. It was estimated that 1.5 liters of water had migrated up the ventilation loop into the helmet, adversely impacting the astronaut's hearing, vision, and verbal communication. Subsequent on-board testing and ground-based test, tear-down, and evaluation of the affected EMU hardware components determined that the proximate cause of the mishap was blockage of all water separator drum holes with a mixture of silica and silicates. The blockages caused a failure of the water separator degassing function, which resulted in EMU cooling water spilling into the ventilation loop, migrating around the circulating fan, and ultimately pushing into the helmet. The root cause of the failure was determined to be ground-processing shortcomings of the Airlock Cooling Loop Recovery (ALCLR) Ion Filter Beds, which led to various levels of contaminants being introduced into the filters before they left the ground. Those contaminants were thereafter introduced into the EMU hardware on-orbit during ALCLR scrubbing operations. This paper summarizes the failure analysis results along with identified process, hardware, and operational corrective actions that were implemented as a result of findings from this investigation.

Failure Analysis Results and Corrective Actions Implemented for the EMU 3011 Water in the Helmet Mishap

NASA Technical Reports Server (NTRS)

Steele, John; Metselaar, Carol; Peyton, Barbara; Rector, Tony; Rossato, Robert; Macias, Brian; Weigel, Dana; Holder, Don

2015-01-01

During EVA (Extravehicular Activity) No. 23 aboard the ISS (International Space Station) on 07/16/2013 water entered the EMU (Extravehicular Mobility Unit) helmet resulting in the termination of the EVA (Extravehicular Activity) approximately 1-hour after it began. It was estimated that 1.5-L of water had migrated up the ventilation loop into the helmet, adversely impacting the astronauts hearing, vision and verbal communication. Subsequent on-board testing and ground-based TT and E (Test, Tear-down and Evaluation) of the affected EMU hardware components led to the determination that the proximate cause of the mishap was blockage of all water separator drum holes with a mixture of silica and silicates. The blockages caused a failure of the water separator function which resulted in EMU cooling water spilling into the ventilation loop, around the circulating fan, and ultimately pushing into the helmet. The root cause of the failure was determined to be ground-processing short-comings of the ALCLR (Airlock Cooling Loop Recovery) Ion Filter Beds which led to various levels of contaminants being introduced into the Filters before they left the ground. Those contaminants were thereafter introduced into the EMU hardware on-orbit during ALCLR scrubbing operations. This paper summarizes the failure analysis results along with identified process, hardware and operational corrective actions that were implemented as a result of findings from this investigation.

Development and analysis of insulation constructions for aerospace wiring applications

NASA Astrophysics Data System (ADS)

Slenski, George A.; Woodford, Lynn M.

1993-03-01

The Wright Laboratory Materials Directorate at WPAFB, Ohio recently completed a research and development program under contract with the McDonnell Douglas Aerospace Company, St. Louis, Missouri. Program objectives were to develop wire insulation performance requirements, evaluate candidate insulations, and prepare preliminary specification sheets on the most promising candidates. Aircraft wiring continues to be a high maintenance item and a major contributor to electrically-related aircraft mishaps. Mishap data on aircraft show that chafing of insulation is the most common mode of wire failure. Improved wiring constructions are expected to increase aircraft performance and decrease costs by reducing maintenance actions. In the laboratory program, new insulation constructions were identified that had overall improved performance in evaluation tests when compared to currently available MIL-W-81381 and MIL-W-22759 wiring. These insulations are principally aromatic polyimide and crosslinked ethylene tetrafluoroethylene (ETFE), respectively. Candidate insulations identified in preliminary specification sheets were principally fluoropolymers with a polyimide inner layer. Examples of insulation properties evaluated included flammability, high temperature mechanical and electrical performance, fluid immersion, and susceptibility to arc propagation under applied power chafing conditions. Potential next generation wire insulation materials are also reviewed.

Intelligent monitoring of critical pathological events during anesthesia.

PubMed

Gohil, Bhupendra; Gholamhhosseini, Hamid; Harrison, Michael J; Lowe, Andrew; Al-Jumaily, Ahmed

2007-01-01

Expert algorithms in the field of intelligent patient monitoring have rapidly revolutionized patient care thereby improving patient safety. Patient monitoring during anesthesia requires cautious attention by anesthetists who are monitoring many modalities, diagnosing clinically critical events and performing patient management tasks simultaneously. The mishaps that occur during day-to-day anesthesia causing disastrous errors in anesthesia administration were classified and studied by Reason [1]. Human errors in anesthesia account for 82% of the preventable mishaps [2]. The aim of this paper is to develop a clinically useful diagnostic alarm system for detecting critical events during anesthesia administration. The development of an expert diagnostic alarm system called ;RT-SAAM' for detecting critical pathological events in the operating theatre is presented. This system provides decision support to the anesthetist by presenting the diagnostic results on an integrative, ergonomic display and thus enhancing patient safety. The performance of the system was validated through a series of offline and real-time testing in the operation theatre. When detecting absolute hypovolaemia (AHV), moderate level of agreement was observed between RT-SAAM and the human expert (anesthetist) during surgical procedures. RT-SAAM is a clinically useful diagnostic tool which can be easily modified for diagnosing additional critical pathological events like relative hypovolaemia, fall in cardiac output, sympathetic response and malignant hyperpyrexia during surgical procedures. RT-SAAM is currently being tested at the Auckland City Hospital with ethical approval from the local ethics committees.

Genesis failure investigation report : JPL Failure Review Board, Avionics Sub-Team

NASA Technical Reports Server (NTRS)

Klein, John; Manning, Rob; Barry, Ed; Donaldson, Jim; Rivellini, Tom; Battel, Steven; Savino, Joe; Lee, Wayne; Dalton, Jerry; Underwood, Mark;

Review of X-43A Return to Flight Activities and Current Status

NASA Technical Reports Server (NTRS)

Reubush, David E.; Nguyen, Luat T.; Rausch, Vincent L.

2004-01-01

This paper provides an overview and status of the return to flight activities for the X-43A scramjet flight demonstrator after the first flight mishap. The first flight was attempted on June 2, 2001 and resulted in vehicle destruction by range safety when the booster went out of control early in the flight. In the time since the mishap much work has been done to examine the causes of the failure and make modifications to the booster to insure that the boost for the second flight will be successful. In addition, all other aspects of the flight have been examined to maximize the probability of a successful flight.

SFTYCHEF: A Consultative, Diagnostic Expert System for Trench Excavation Safety Analysis on Light Commercial Construction Projects.

DTIC Science & Technology

1987-03-30

Safe Trench Excavation ...... 2 Applicability to Solution via Expert System. 3 Background: Expert Systems ..................... 4 Definition of an...trench, drownings in the trench, and other mishaps which are the result of a lack of S C- proper consideration for safe construction practices. Although...the problem is not a new one, there is as yet no *" obvious method that will guarantee a safe trench. In addition, the expertise needed to provide case

Analysis of Helicopter Mishaps at Heliports, Airports and Unimproved Sites

DTIC Science & Technology

1991-01-01

Distance ___________ NM A Bearno a_________ ,.~ 400’n 4 Airport Category 5 Airport Certificatton (FAR M39 6 Emergency Plan Tested 7 Months Since...Emergency Plan Tested 1 0 Commerciai service ,0C Ful certrt,catio, 0 ye- 2 0 Reliever 2 [C Limireo certificatior I C 3 0 Ge’e-rai aviation None, Go to block...Aeriai application 8 1Public use 3, instructional (Incluaing air carrer training) 6 -IAerial observation 9 1Ferry A Soecit First PMot Information 87

NASA Medical Response to Human Spacecraft Accidents

NASA Technical Reports Server (NTRS)

Patlach, Robert

2010-01-01

Manned space flight is risky business. Accidents have occurred and may occur in the future. NASA's manned space flight programs, with all their successes, have had three fatal accidents, one at the launch pad and two in flight. The Apollo fire and the Challenger and Columbia accidents resulted in a loss of seventeen crewmembers. Russia's manned space flight programs have had three fatal accidents, one ground-based and two in flight. These accidents resulted in the loss of five crewmembers. Additionally, manned spacecraft have encountered numerous close calls with potential for disaster. The NASA Johnson Space Center Flight Safety Office has documented more than 70 spacecraft incidents, many of which could have become serious accidents. At the Johnson Space Center (JSC), medical contingency personnel are assigned to a Mishap Investigation Team. The team deploys to the accident site to gather and preserve evidence for the Accident Investigation Board. The JSC Medical Operations Branch has developed a flight surgeon accident response training class to capture the lessons learned from the Columbia accident. This presentation will address the NASA Mishap Investigation Team's medical objectives, planned response, and potential issues that could arise subsequent to a manned spacecraft accident. Educational Objectives are to understand the medical objectives and issues confronting the Mishap Investigation Team medical personnel subsequent to a human space flight accident.

Establishing operational stability--developing human infrastructure.

PubMed

Gomez, Max A; Byers, Ernest J; Stingley, Preston; Sheridan, Robert M; Hirsch, Joshua A

2010-12-01

Over the past year, Toyota has come under harsh scrutiny as a result of several recalls. These well publicized mishaps have not only done damage to Toyota's otherwise sterling reputation for quality but have also called into question the assertions from a phalanx of followers that Toyota's production system (generically referred to as TPS or Lean) is the best method by which to structure one's systems of operation. In this article, we discuss how Toyota, faced with the pressure to grow its business, did not appropriately cadence this growth with the continued development and maintenance of the process capabilities (vis a vis the development of human infrastructure) needed to adequately support that growth. We draw parallels between the pressure Toyota faced to grow its business and the pressure neurointerventional practices face to grow theirs, and offer a methodology to support that growth without sacrificing quality.

Postmortem computed tomography in victims of military air mishaps: radiological-pathological correlation of CT findings.

PubMed

Levy, Gad; Goldstein, Liav; Blachar, Arye; Apter, Sara; Barenboim, Erez; Bar-Dayan, Yaron; Shamis, Ari; Atar, Eli

2007-10-01

A thorough medical inquiry is included in every aviation mishap investigation. While the gold standard of this investigation is a forensic pathology examination, numerous reports stress the important role of computed tomography in the postmortem evaluation of trauma victims. To characterize the findings identified by postmortem CT and compare its performance to conventional autopsy in victims of military aviation mishaps, we analyzed seven postmortem CT examinations. Musculoskeletal injuries accounted for 57.8% of the traumatic findings identified by postmortem CT. The most frequent findings were fractures of the rib (47%), skull (9.6%) and facial bones (8.6%). Abnormally located air accounted for 24% of findings, for which CT was superior (3.5% detected by autopsy, 100% by postmortem CT, P < 0.001). The performance of autopsy in detecting injuries was superior (autopsy detected 85.8% of all injuries, postmortem CT detected 53.9%, P < 0.001), especially in the detection of superficial lesions (100% detected by autopsy, 10.5% by postmortem CT, P < 0.001) and solid organ injuries (100% by autopsy, 18.5% by postmortem CT, P < 0.001). Performance in the detection of musculoskeletal injuries was similar (91.3% for autopsy, 90.3% for postmortem CT, P = not significant). Postmortem CT and autopsy have distinct performance profiles, and although the first cannot replace the latter it is a useful complementary examination.

Proceedings of the Conference on Flight Mechanics and System Design Lessons from Operational Experience Held at Athens, Greece on 10-13 May 1983.

DTIC Science & Technology

1983-10-01

of facts and allowed the tail rotor surrounding this mishap. to strike tree branches Particular attention should during night landing. be focused on...aeroplane. Attention was drawn particularly to the event shown in Figure 9 because of its magnitude. An analysis of the event carried out by W. Pinsker at...the JT9, so that the 747-236 with RB 211s suffered a greater deceleration than the 747-136 when the throttles were closed. When the pilots attention

Flight Systems Integration and Test

NASA Technical Reports Server (NTRS)

Wright, Michael R.

2011-01-01

Topics to be Covered in this presentation are: (1) Integration and Test (I&T) Planning (2) Integration and Test Flows (3) Overview of Typical Mission I&T (4) Supporting Elements (5) Lessons-Learned and Helpful Hints (6) I&T Mishaps and Failures (7) The Lighter Side of I&T and (8) Small-Group Activity. This presentation highlights a typical NASA "in-house" I&T program (1) For flight systems that are developed by NASA at a space flight center (like GSFC) (2) Requirements well-defined: qualification/acceptance, documentation, configuration management. (3) Factors: precedents, human flight, risk-aversion ("failure-phobia"), taxpayer dollars, jobs and (4) Some differences among NASA centers, but generally a resource-intensive process

Aerospace Safety Advisory Panel

NASA Technical Reports Server (NTRS)

2002-01-01

This Annual Report of the Aerospace Safety Advisory Panel (ASAP) presents results of activities during calendar year 2001. The year was marked by significant achievements in the Space Shuttle and International Space Station (ISS) programs and encouraging accomplishments by the Aerospace Technology Enterprise. Unfortunately, there were also disquieting mishaps with the X-43, a LearJet, and a wind tunnel. Each mishap was analyzed in an orderly process to ascertain causes and derive lessons learned. Both these accomplishments and the responses to the mishaps led the Panel to conclude that safety and risk management is currently being well served within NASA. NASA's operations evidence high levels of safety consciousness and sincere efforts to place safety foremost. Nevertheless, the Panel's safety concerns have never been greater. This dichotomy has arisen because the focus of most NASA programs has been directed toward program survival rather than effective life cycle planning. Last year's Annual Report focused on the need for NASA to adopt a realistically long planning horizon for the aging Space Shuttle so that safety would not erode. NASA's response to the report concurred with this finding. Nevertheless, there has been a greater emphasis on current operations to the apparent detriment of long-term planning. Budget cutbacks and shifts in priorities have severely limited the resources available to the Space Shuttle and ISS for application to risk-reduction and life-extension efforts. As a result, funds originally intended for long-term safety-related activities have been used for operations. Thus, while safety continues to be well served at present, the basis for future safety has eroded. Section II of this report develops this theme in more detail and presents several important, overarching findings and recommendations that apply to many if not all of NASA's programs. Section III of the report presents other significant findings, recommendations and supporting material applicable to specific program areas. Appendix A presents a list of Panel members. Appendix B contains the reaction of the ASAP to NASA's response to the calendar year 2000 findings and recommendations. In accordance with a practice started last year, this Appendix includes brief narratives as well as classifications of the responses as 'open,' 'closed,' or 'continuing.' Appendix C details the Panel's activities during the reporting period.

14 CFR 415.203 - Environmental information.

Code of Federal Regulations, 2012 CFR

2012-01-01

... parameters of any existing environmental impact statement that applies to that site; (d) A proposed payload that may have significant environmental impacts in the event of a mishap; and (e) Other factors as...

14 CFR 415.203 - Environmental information.

Code of Federal Regulations, 2013 CFR

2013-01-01

... parameters of any existing environmental impact statement that applies to that site; (d) A proposed payload that may have significant environmental impacts in the event of a mishap; and (e) Other factors as...

14 CFR 415.203 - Environmental information.

Code of Federal Regulations, 2011 CFR

2011-01-01

... parameters of any existing environmental impact statement that applies to that site; (d) A proposed payload that may have significant environmental impacts in the event of a mishap; and (e) Other factors as...

14 CFR 415.203 - Environmental information.

Code of Federal Regulations, 2014 CFR

2014-01-01

... parameters of any existing environmental impact statement that applies to that site; (d) A proposed payload that may have significant environmental impacts in the event of a mishap; and (e) Other factors as...

Tailoring a Human Reliability Analysis to Your Industry Needs

NASA Technical Reports Server (NTRS)

DeMott, D. L.

2016-01-01

Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.

KSC-03pd0270

NASA Image and Video Library

2003-02-05

KENNEDY SPACE CENTER, FLA. -- Members of the Recovery Management Team at KSC are at work in the Operations Support Building. They are part of the investigation into the accident that claimed orbiter Columbia and her crew of seven on Feb. 1, 2003, over East Texas as they returned to Earth after a 16-day research mission. Seated around the table (clockwise from far left) are Chris Hasselbring, Landing Operations, USA (co-chair of the Response Management Team); Don Maxwell, Safety, United Space Alliance (USA); Russ DeLoach, chief, Shuttle Mission Assurance Branch, NASA; George Jacobs, Shuttle Engineering; Jeff Campbell, Shuttle Engineering; Denny Gagen, Landing Recovery Manager (second co-chair of the team); and Dave Rainer, Launch and Landing Operations. The team is coordinating KSC technical support and assets to the Mishap Investigation Team in Barksdale, La., and providing support for the Recovery teams in Los Angeles, Texas, New Mexico, Arizona and California. In addition, the team is following up on local leads pertaining to potential debris in the KSC area. .

KSC-03pd0269

NASA Image and Video Library

2003-02-05

KENNEDY SPACE CENTER, FLA. -- Members of the Recovery Management Team at KSC are at work in the Operations Support Building. They are part of the investigation into the accident that claimed orbiter Columbia and her crew of seven on Feb. 1, 2003, over East Texas as they returned to Earth after a 16-day research mission. From left around the table are Don Maxwell, Safety, United Space Alliance (USA); Russ DeLoach, chief, Shuttle Mission Assurance Branch, NASA; George Jacobs, Shuttle Engineering; Jeff Campbell, Shuttle Engineering; Dave Rainer, Launch and Landing Operations; and the two co-chairs of the Response Management Team, Denny Gagen, Landing Recovery Manager, and Chris Hasselbring, Landing Operations, USA. The team is coordinating KSC technical support and assets to the Mishap Investigation Team in Barksdale, La., and providing support for the Recovery teams in Los Angeles, Texas, New Mexico, Arizona and California. In addition, the team is following up on local leads pertaining to potential debris in the KSC area. .

KSC-03pd0271

NASA Image and Video Library

2003-02-05

KENNEDY SPACE CENTER, FLA. - Two members of the Recovery Management Team at KSC are at work in the Operations Support Building. At left is Don Maxwell, Safety, United Space Alliance, and at right is Larry Ulmer, Safety, NASA. They are part of the investigation into the accident that claimed orbiter Columbia and her crew of seven on Feb. 1, 2003, over East Texas as they returned to Earth after a 16-day research mission. Other team members are Russ DeLoach, chief, Shuttle Mission Assurance Branch, NASA; George Jacobs, Shuttle Engineering; Jeff Campbell, Shuttle Engineering; Dave Rainer, Launch and Landing Operations; and the two co-chairs of the Response Management Team, Denny Gagen, Landing Recovery Manager, and Chris Hasselbring, Landing Operations, USA. The team is coordinating KSC technical support and assets to the Mishap Investigation Team in Barksdale, La., and providing support for the Recovery teams in Los Angeles, Texas, New Mexico, Arizona and California. In addition, the team is following up on local leads pertaining to potential debris in the KSC area. .

14 CFR 437.75 - Mishap reporting, responding, and investigating.

Code of Federal Regulations, 2012 CFR

2012-01-01

... value, (vii) A description of any hazardous materials involved in the event, whether on the reusable suborbital rocket or on the ground, (viii) Action taken by any person to contain the consequences of the...

14 CFR 437.75 - Mishap reporting, responding, and investigating.

Code of Federal Regulations, 2014 CFR

2014-01-01

... value, (vii) A description of any hazardous materials involved in the event, whether on the reusable suborbital rocket or on the ground, (viii) Action taken by any person to contain the consequences of the...

14 CFR 437.75 - Mishap reporting, responding, and investigating.

Code of Federal Regulations, 2013 CFR

2013-01-01

... value, (vii) A description of any hazardous materials involved in the event, whether on the reusable suborbital rocket or on the ground, (viii) Action taken by any person to contain the consequences of the...

Armed Forces Institute of Pathology (AFIP)

NASA Technical Reports Server (NTRS)

Mallak, Craig

2005-01-01

The AFIP and NASA relationship was developed in an effort to appropriately respond to a space shuttle mishap. This briefing discusses the AFIP/NASA relationship with special emphasis being placed on search, recovery and identification activities

Cleared for the visual approach: Human factor problems in air carrier operations

NASA Technical Reports Server (NTRS)

Monan, W. P.

1983-01-01

The study described herein, a set of 353 ASRS reports of unique aviation occurrences significantly involving visual approaches was examined to identify hazards and pitfalls embedded in the visual approach procedure and to consider operational practices that might help avoid future mishaps. Analysis of the report set identified nine aspects of the visual approach procedure that appeared to be predisposing conditions for inducing or exacerbating the effects of operational errors by flight crew members or controllers. Predisposing conditions, errors, and operational consequences of the errors are discussed. In a summary, operational policies that might mitigate the problems are examined.

[Compulsory reporting of accidents and injuries in somatic hospitals. Is the existing system adequate for quality assurance?].

PubMed

Molven, O

1992-10-10

Doctors in Norway are obliged by law to submit reports to central authorities about injuries and risk of injury arising from medical equipment and drugs. Deaths following health care procedures must be reported to the police, and major injuries to the County Medical Officer. Most hospitals have their own rules requiring health care providers to report all incidents resulting in injury or risk of injury. The author contends that fewer than 5% of the injuries are reported. Neither the law, nor the hospital rules, require that the incidents in general are evaluated, with feed-back to the care providers. Most incidents do not seem to be evaluated. There is much left to do, both in building a set of regulations and in implementing better hospital practice, by using records of injuries and mishaps to identify and prevent further mishaps.

KSC-07pd1044

NASA Image and Video Library

2007-05-02

KENNEDY SPACE CENTER, FLA. -- A train carrying space shuttle reusable solid rocket motor segments from the ATK Launch Systems manufacturing site in Brigham City,Utah, to NASA’s Kennedy Space Center in Florida was derailed May 2. At the site of the train mishap involving eight NASA solid rocket booster segment cars, a handling fixture has been attached to a box car being used as a spacer between the segment cars so that it can be removed from the rails. The solid rocket booster cars can be seen behind it. The train was traveling over the Meridian & Bigbee railroad near Pennington, Ala., at the time of the mishap.. The hardware was intended for use on shuttle Discovery's STS-120 mission in October and shuttle Atlantis's STS-122 mission in December. These segments are interchangeable, and ATK Launch Systems has replacement units that could be used for the shuttle flights, if necessary.

Understanding Risk Tolerance and Building an Effective Safety Culture

NASA Technical Reports Server (NTRS)

Loyd, David

2018-01-01

Estimates range from 65-90 percent of catastrophic mishaps are due to human error. NASA's human factors-related mishaps causes are estimated at approximately 75 percent. As much as we'd like to error-proof our work environment, even the most automated and complex technical endeavors require human interaction... and are vulnerable to human frailty. Industry and government are focusing not only on human factors integration into hazardous work environments, but also looking for practical approaches to cultivating a strong Safety Culture that diminishes risk. Industry and government organizations have recognized the value of monitoring leading indicators to identify potential risk vulnerabilities. NASA has adapted this approach to assess risk controls associated with hazardous, critical, and complex facilities. NASA's facility risk assessments integrate commercial loss control, OSHA (Occupational Safety and Health Administration) Process Safety, API (American Petroleum Institute) Performance Indicator Standard, and NASA Operational Readiness Inspection concepts to identify risk control vulnerabilities.

Aircraft mishap investigation with radiology-assisted autopsy: helicopter crash with control injury.

PubMed

Folio, R Les; Harcke, H Theodore; Luzi, Scott A

2009-04-01

Radiology-assisted autopsy traditionally has been plain film-based, but now is being augmented by computed tomography (CT). The authors present a two-fatality rotary wing crash scenario illustrating application of advanced radiographic techniques that can guide and supplement the forensic pathologist's physical autopsy. The radiographic findings also have the potential for use by the aircraft mishap investigation board. Prior to forensic autopsy, the two crash fatalities were imaged with conventional two-dimensional radiographs (digital technique) and with multidetector CT The CT data were used for multiplanar two-dimensional and three-dimensional (3D) image reconstruction. The forensic pathologist was provided with information about skeletal fractures, metal fragment location, and other pathologic findings of potential use in the physical autopsy. The radiologic autopsy served as a supplement to the physical autopsy and did not replace the traditional autopsy in these cases. Both individuals sustained severe blunt force trauma with multiple fractures of the skull, face, chest, pelvis, and extremities. Individual fractures differed; however, one individual showed hand and lower extremity injuries similar to those associated with control of the aircraft at the time of impact. The concept of "control injury" has been challenged by Campman et al., who found that control surface injuries have a low sensitivity and specificity for establishing who the pilot was in an accident. The application of new post mortem imaging techniques may help to resolve control injury questions. In addition, the combination of injuries in our cases may contribute to further understanding of control surface injury patterns in helicopter mishaps.

Diabetes and Driving Safety: Science, Ethics, Legality & Practice

PubMed Central

Cox, Daniel J.; Singh, Harsimran; Lorber, Daniel

2013-01-01

Diabetes affects over 25 million people in the United States, most of whom are over the age of 16 and many of whom are licensed to drive a motor vehicle. Safe operation of a motor vehicle requires complex interactions of cognitive and motor functions and medical conditions that affect these functions often will increase the risk of motor vehicle accidents (MVA). In the case of diabetes, hypoglycemia is the most common factor that has been shown to increase MVA rates. When people with diabetes are compared with non-diabetic controls, systematic analyses show that the relative risk of MVA is increased by between 12 and 19% (RRR 1.12-1.19). In comparison, the RRR for Attention Deficit Hyperactivity Disorder is 4.4 and for Sleep Apnea is 2.4. Epidemiologic research suggests that patients at risk for hypoglycemia-related MVAs may have some characteristics in common, including a history of severe hypoglycemia or of hypoglycemia-related driving mishaps. Experimental studies also have shown that people with a history of hypoglycemia-related driving mishaps have abnormal counter-regulatory responses to hypoglycemia and greater cognitive impairments during moderate hypoglycemia. There are medical, ethical and legal issues for health care professionals who care for people with diabetes regarding their patients’ risk of hypoglycemia-related driving mishaps. This includes identifying those at increased risk and counseling them on preventive measures, including more frequent blood glucose testing, delaying driving with low or low normal blood glucose, and carrying readily available emergency supplies in the vehicle for the treatment of hypoglycemia. PMID:23531955

76 FR 80956 - Information Collection Request to Office of Management and Budget; OMB Control Number: 1625-0011

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-27

..., self-addressed postcard or envelope. We will consider all comments and material received during the... or mishap with the permitted aid to navigation. Failure to provide the required contact information...

22. CRUNCH BOARD #2 HANGAR BAY FRAME 100 STARBOARD SIDETERM ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

22. CRUNCH BOARD #2 HANGAR BAY FRAME 100 STARBOARD SIDE-TERM CRUNCH REFERS TO HANGAR DECK MISHAPS WHICH RESULTED IN DAMAGE TO AIRCRAFT. - U.S.S. HORNET, Puget Sound Naval Shipyard, Sinclair Inlet, Bremerton, Kitsap County, WA

Safety Awareness & Communications Internship

NASA Technical Reports Server (NTRS)

Jefferson, Zanani

2015-01-01

The projects that I have worked on during my internships were updating the JSC Safety & Health Action Team JSAT Employee Guidebook, conducting a JSC mishap case study, preparing for JSC Today Close Call success stories, and assisting with event planning and awareness.

A guide to California's breaches. First year of state reporting requirement reveals common privacy violations.

PubMed

Dimick, Chris

2010-04-01

Effective January 1, 2009, California healthcare providers were required to report every breach of patient information to the state. They have sent a flood of mishaps and a steady stream of malicious acts.

Reducing errors through a web-based self-management support system.

PubMed

Ekstedt, Mirjam; Børøsund, Elin; Svenningsen, Ina K; Ruland, Cornelia M

2014-01-01

Web-based self-management support systems SMSS, can successfully assist a wide range of patients with information and self-management support. O or as a stand-alone service, are e-messages. This study describes how one component of a multi component SMSS, an e-message service, in which patients with breast cancer could direct questions to nurses, physicians or social workers at the hospital where they were being treated, had an influence on safety and continuity of care. Ninety-one dialogues consisting of 284 messages were analysed. The communications between patients and the healthcare team revealed that the e-messages service served as a means for quality assurance of information, for double-checking and for coordination of care. We give examples of how an e-mail service may improve patients' knowledge in a process of taking control over their own care - increasingly important in a time of growing complexity and specialization in healthcare. It remains to be tested whether an e-message service can improve continuity of care and prevent or mitigate medical mishaps.

Handle With Care: 10 Common School Accidents

ERIC Educational Resources Information Center

Bryer, Judith E.

1978-01-01

Accidents, mishaps, injuries can happen in any classroom, cafeteria, gym, hallway, playground and the teacher is probably the first adult to arrive on the scene. These guidelines on how to respond to 10 common school accidents explain what steps to take. (Author/RK)

Rates and causes of accidents for general aviation aircraft operating in a mountainous and high elevation terrain environment.

PubMed

Aguiar, Marisa; Stolzer, Alan; Boyd, Douglas D

2017-10-01

Flying over mountainous and/or high elevation terrain is challenging due to rapidly changeable visibility, gusty/rotor winds and downdrafts and the necessity of terrain avoidance. Herein, general aviation accident rates and mishap cause/factors were determined (2001-2014) for a geographical region characterized by such terrain. Accidents in single piston engine-powered aircraft for states west of the US continental divide characterized by mountainous terrain and/or high elevation (MEHET) were identified from the NTSB database. MEHET-related-mishaps were defined as satisfying any one, or more, criteria (controlled flight into terrain/obstacles (CFIT), downdrafts, mountain obscuration, wind-shear, gusting winds, whiteout, instrument meteorological conditions; density altitude, dust-devil) cited as factors/causal in the NTSB report. Statistics employed Poisson distribution and contingency tables. Although the MEHET-related accident rate declined (p<0.001) 57% across the study period, the high proportion of fatal accidents showed little (40-43%) diminution (χ 2 =0.935). CFIT and wind gusts/shear were the most frequent accident cause/factor categories. For CFIT accidents, half occurred in degraded visibility with only 9% operating under instrument flight rules (IFR) and the majority (85%) involving non-turbo-charged engine-powered aircraft. For wind-gust/shear-related accidents, 44% occurred with a cross-wind exceeding the maximum demonstrated aircraft component. Accidents which should have been survivable but which nevertheless resulted in a fatal outcome were characterized by poor accessibility (60%) and shoulder harness under-utilization (41%). Despite a declining MEHET-related accident rate, these mishaps still carry an elevated risk of a fatal outcome. Airmen should be encouraged to operate in this environment utilizing turbo-charged-powered airplanes and flying under IFR to assure terrain clearance. Copyright © 2017 Elsevier Ltd. All rights reserved.

Metabolic Demand of Driving Among Adults with Type 1 Diabetes Mellitus (T1DM)

PubMed Central

Cox, Daniel J.; Singh, Harsimran; Clarke, William L.; Anderson, Stacey M.; Kovatchev, Boris P.; Gonder-Frederick, Linda A.

2010-01-01

Recent research suggests that the frequency of driving mishaps is increased in people with Type 1 diabetes (T1DM) as compared to those with Type 2 diabetes or their non-diabetic spouses. This study involved a sample of T1DM drivers and was designed to investigate the metabolic and physiologic demands of driving compared to sitting passively. Participants (N=38) were divided into two groups: the -History group included those reporting no driving mishaps in the past two years, and the +History group included participants reporting at least two such mishaps in the past two years. Glucose utilization rates were determined in participants while: (a) they were driving a virtual reality driving simulator for 30 minutes, and (b) watching a 30-minute video. Blood glucose (BG) levels were maintained at similar levels during both procedures. Other biological variables including heart rate (HR) were monitored. Participants rated their hypoglycemia (low BG) symptoms before and after each of the two procedures. . Participants could self-treat if they perceived they were experiencing hypoglycemia. There were no differences between the two groups. However, glucose utilization rates were significantly higher during the driving scenario (3.83mg/kg/min + 1.7 vs. 3.37 mg/kg/min + 1.6, p=0.047). HR was significantly higher during the driving scenario. Drivers reported more autonomic symptoms during driving and 32% treated perceived hypoglycemia during driving. Driving a virtual reality simulator is associated with increased glucose utilization rates suggesting that driving per se has a metabolic cost and that BG should be measured prior to driving and periodically during long drives. PMID:21050619

KSC-03pd0272

NASA Image and Video Library

2003-02-05

KENNEDY SPACE CENTER, FLA. - Don Maxwell, Safety, United Space Alliance, checks a map of Texas during a meeting of the Recovery Management Team at KSC. The team is part of the investigation into the accident that claimed orbiter Columbia and her crew of seven on Feb. 1, 2003, over East Texas as they returned to Earth after a 16-day research mission. Other team members are Russ DeLoach, chief, Shuttle Mission Assurance Branch, NASA; George Jacobs, Shuttle Engineering; Jeff Campbell, Shuttle Engineering; Dave Rainer, Launch and Landing Operations; the two co-chairs of the Response Management Team, Denny Gagen, Landing Recovery Manager, Chris Hasselbring, Landing Operations, USA; and Larry Ulmer, Safety, NASA. The team is coordinating KSC technical support and assets to the Mishap Investigation Team in Barksdale, La., and providing support for the Recovery teams in Los Angeles, Texas, New Mexico, Arizona and California. In addition, the team is following up on local leads pertaining to potential debris in the KSC area. .

Safety in the skies : personnel and parties in NTSB aviation accident investigations : master volume

DOT National Transportation Integrated Search

2001-01-01

Recent high-profile commercial aviation mishaps have stretched the National Transportation Safety Board's (NTSB) resources to the limit and are testing the agency's ability to unravel the sorts of complex failures that lead to tragic accidents. In re...

An Assessment of the Relationship between Safety Climate and Mishap Risk in U.S. Naval Aviation

DTIC Science & Technology

2011-10-01

necessarily represent the opinion or position of the U.S. Navy, the Naval Postgraduate School, or the National University of Ireland, Galway . vi...Business & Economics National University of Ireland Galway , Ireland 9. Associate Professor Nita L. Shattuck

NASA Medical Response to Human Spacecraft Accidents

NASA Technical Reports Server (NTRS)

Patlach, Robert

2011-01-01

This slide presentation reviews NASA's role in the response to spacecraft accidents that involve human fatalities or injuries. Particular attention is given to the work of the Mishap Investigation Team (MIT), the first response to the accidents and the interface to the accident investigation board. The MIT does not investigate the accident, but the objective of the MIT is to gather, guard, preserve and document the evidence. The primary medical objectives of the MIT is to receive, analyze, identify, and transport human remains, provide assistance in the recovery effort, and to provide family Casualty Coordinators with latest recovery information. The MIT while it does not determine the cause of the accident, it acts as the fact gathering arm of the Mishap Investigation Board (MIB), which when it is activated may chose to continue to use the MIT as its field investigation resource. The MIT membership and the specific responsibilities and tasks of the flight surgeon is reviewed. The current law establishing the process is also reviewed.

32 CFR 811.1 - Exceptions.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 32 National Defense 6 2010-07-01 2010-07-01 false Exceptions. 811.1 Section 811.1 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE SALES AND SERVICES RELEASE, DISSEMINATION, AND... Force investigations of aircraft or missile mishaps according to AFI 91-204, Safety Investigations and...

32 CFR 811.1 - Exceptions.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 32 National Defense 6 2013-07-01 2013-07-01 false Exceptions. 811.1 Section 811.1 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE SALES AND SERVICES RELEASE, DISSEMINATION, AND... Force investigations of aircraft or missile mishaps according to AFI 91-204, Safety Investigations and...

32 CFR 811.1 - Exceptions.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 32 National Defense 6 2012-07-01 2012-07-01 false Exceptions. 811.1 Section 811.1 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE SALES AND SERVICES RELEASE, DISSEMINATION, AND... Force investigations of aircraft or missile mishaps according to AFI 91-204, Safety Investigations and...

32 CFR 811.1 - Exceptions.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 32 National Defense 6 2011-07-01 2011-07-01 false Exceptions. 811.1 Section 811.1 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE SALES AND SERVICES RELEASE, DISSEMINATION, AND... Force investigations of aircraft or missile mishaps according to AFI 91-204, Safety Investigations and...

32 CFR 811.1 - Exceptions.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 32 National Defense 6 2014-07-01 2014-07-01 false Exceptions. 811.1 Section 811.1 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE SALES AND SERVICES RELEASE, DISSEMINATION, AND... Force investigations of aircraft or missile mishaps according to AFI 91-204, Safety Investigations and...

Analysis of the Causes of Inflight Refueling Mishaps with the KC-135

DTIC Science & Technology

1989-09-01

Air Service. During the spring of 1923 in San Diego , California, a Do Havilland DH -4 biplane was modified S with a 50 foot home. This ’banker...The remaining 15 were considered to be fighter/attack aircraft. Overall, the F-4, B-52, C-141, and F- 106 were involved in over fifty percent of the...AIRCRAFT 1 2 3 4 5 6 7 TYPE AIRCRAFT F-4 34 0 8 6 0 8 3 59 21.15 B-52 18 0 10 4 1 6 0 39 13.98 C-141 14 0 1 1 3 4 2 25 8.96 F- 106 13 0 2 0 0 1 2 18

You Can't Reach for the Stars if You are Tripping Over the Ground! (Preventing Slips, Trips, and Falls)

NASA Technical Reports Server (NTRS)

Miller, Darcy; Raysich, Mark; Kirkland, Mary

2016-01-01

Although there are very few mishaps related to ground, vehicle or payload processing at the Kennedy Space Center (KSC), employees have experienced a significant number of injuries due to slips, trips, and falls outside of performing flight processing operations. Slips, trips, and falls are major causes of occupational injuries at KSC, the National Aeronautics and Space Administration (NASA), and in general industry. To help KSC employees avoid these injuries, and allow them to be fully productive, KSC launched an initiative in 2013 to reduce slips, trips, and falls. This initiative is based on a four-part model focusing on DATA analysis, HAZARD awareness, PREVENTIVE methods, and BALANCE.

Impact of Communication Barriers on Urban Development of Nowogród Bobrzański

NASA Astrophysics Data System (ADS)

Laskowski, Janusz; Juszczyk, Artur

2016-09-01

Network communication links is an indispensable element of development shaping. Any change in the way of using area should be preceded by an analysis of future impact taking into account the transport capacity. The development of buildings without adequate communication links leads to restrictions on object access, consequently it may lead to dangerous mishaps. Avoiding this type of situation is possible by carrying out sustainable development. The paper describes the relationship between the road system and urban layout on the example of Nowogród Bobrzański part of the city. One presented existing changes in the transportation system and its impact on local residents.

75 FR 68330 - Information Collection Requirement; Defense Federal Acquisition Regulation Supplement...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-05

... with DoD 4145.26-M, DoD Contractors' Safety Manual for Ammunition and Explosives, and minimize risk of mishaps; [cir] Identify the place of performance of all ammunition and explosives work; and [cir] Ensure... Conventional Arms, Ammunition, and Explosives. In addition, this information collection requires DoD...

Modeling of Helicopter Pilot Misperception During Overland Navigation

DTIC Science & Technology

2012-03-01

into obstacles in the terrain. The Navy Safety Center has adopted James Reason’s Swiss cheese model for understanding the underlying process that...results in mishaps (Reason, 2000). The Swiss cheese model relates a system to a stack of slices of Swiss cheese . Each slice of cheese is a layer of

Update of the space and launch insurance industry : Quarterly Launch Report : special report

DOT National Transportation Integrated Search

1998-01-01

Insurance is a basic requirement for the maintenance of a commercial space industry. Space activity mishaps can result in hundreds of millions of dollars of expenses. Two recent launch vehicles that failed (a Titan 4A and the initial Delta 3) were va...

Argument for a Joint Safety Reporting System

DTIC Science & Technology

2015-02-13

Process Manager for the HQ AF Safety Center (AFSEC) at Kirtland AFB, New Mexico . His primary duties included leadership and oversight of the day-to...Military Mishaps Functional Lead and Navy-Marine Corps Subject Matter Expert ( SME ) for the SIMWG, the DOD Force Risk Reduction system rolls up the service

Consequences of U.S. Navy Diving Mishaps: Air Embolism and Barotrauma.

DTIC Science & Technology

1985-12-01

diver), displacement of the intervertebral disc (I diver), and various combinations of hearing impairment, otitis ", media , otitis externa, and other...hospitalization for otitis media , otitis externa, and other diseases of the ear and mastoid process (8 days later)/ released from active duty (2 yrs, 4

14 CFR 415.41 - Accident investigation plan.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Accident investigation plan. 415.41 Section... Launch Range § 415.41 Accident investigation plan. An applicant must file an accident investigation plan... reporting and responding to launch accidents, launch incidents, or other mishaps, as defined by § 401.5 of...

14 CFR 415.41 - Accident investigation plan.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 4 2011-01-01 2011-01-01 false Accident investigation plan. 415.41 Section... Launch Range § 415.41 Accident investigation plan. An applicant must file an accident investigation plan... reporting and responding to launch accidents, launch incidents, or other mishaps, as defined by § 401.5 of...

Marshall Space Flight Center's Ruth Jones Speaks at Alabama Historically Black Colleges and Universities Roundtable Discussion

NASA Image and Video Library

2017-09-27

Marshall’s Ruth Jones, a mishap investigation specialist, told her NASA story and spoke about minority statistics in science, technology, engineering and mathematics (STEM). Jones also led a panel discussing how to engage, encourage and draw more minority students in to STEM fields and careers.

Development of the Nontechnical Skills for Officers of the Deck (NTSOD) Rating Form

DTIC Science & Technology

2010-12-01

organizational model of human error commonly described as the ‘ Swiss Cheese ’ model. This model allows for the identification of active failures and latent...complete list). The authors did identify organizational and management issues as underlying causes to mishaps, similar to Reason’s Swiss Cheese model. 24

14 CFR 431.45 - Mishap investigation plan and emergency response plan.

Code of Federal Regulations, 2011 CFR

2011-01-01

... shall also submit an emergency response plan (ERP) that contains procedures for informing the affected public of a planned RLV mission. An acceptable ERP satisfies the requirements of paragraph (e) of this section. The MIP and ERP shall be signed by an individual authorized to sign and certify the application...

Aircraft Survivability. Spring 2009

DTIC Science & Technology

2009-01-01

transport and civil General Aviation (GA) aircraft by mitigating impact injury and keeping the occupants conscious and able to evacuate quickly. The AmSafe...representatives from the Federal Aviation Agency (FAA), the National Transportation Safety Board (NTSB), National Aeronautics & Space Administration...NASA), and the National Highway Transportation Safety Administration (NHTSA) to address and identify combat and mishap expertise, methodologies

How To Catch a Shark and Other Stories about Teaching and Learning.

ERIC Educational Resources Information Center

Graves, Donald H.

This anthology of 32 autobiographical tales is based on both personal and professional experiences. The anthology's eclectic tales offer: recalled moments of childhood wonder; anecdotes about remarkable and not-so-remarkable students; lessons from the pulpit as well as the battlefield; and stories of painful loss, hilarious mishaps, and awesome…

Social Mishap Exposures for Social Anxiety Disorder: An Important Treatment Ingredient

ERIC Educational Resources Information Center

Fang, Angela; Sawyer, Alice T.; Asnaani, Anu; Hofmann, Stefan G.

2013-01-01

Conventional cognitive-behavioral therapy for social anxiety disorder, which is closely based on the treatment for depression, has been shown to be effective in numerous randomized placebo-controlled trials. Although this intervention is more effective than waitlist control group and placebo conditions, a considerable number of clients do not…

Negotiating Software Agreements: Avoid Contractual Mishaps and Get the Biggest Bang for Your Buck

ERIC Educational Resources Information Center

Riley, Sheila

2006-01-01

Purchasing software license and service agreements can be daunting for any district. Greg Lindner, director of information and technology services for the Elk Grove Unified School District in California, and Steve Midgley, program manager at the Stupski Foundation, provided several tips on contract negotiation. This article presents the tips…

Postoperative neurological deficits may occur despite unchanged intraoperative somatosensory evoked potentials.

PubMed

Lesser, R P; Raudzens, P; Lüders, H; Nuwer, M R; Goldie, W D; Morris, H H; Dinner, D S; Klem, G; Hahn, J F; Shetter, A G

1986-01-01

We describe 6 patients who demonstrated postoperative neurological deficits despite unchanged somatosensory evoked potentials during intraoperative monitoring. Although there is both experimental and clinical evidence that somatosensory evoked potentials are sensitive to some types of intraoperative mishap, the technique should be employed with an awareness of its possible limitations.

Disaster Response and Planning for Libraries, Third Edition

ERIC Educational Resources Information Center

Kahn, Miriam B.

2012-01-01

Fire, water, mold, construction problems, power-outages--mishaps like these can not only bring library services to a grinding halt, but can also destroy collections and even endanger employees. Preparing for the unexpected is the foundation of a library's best response. Expert Kahn comes to the rescue with this timely update of the best…

Laboratory accidents--a matter of attitude.

PubMed

Karim, N; Choe, C K

2000-12-01

This is a prospective study on accidents occurring in the Pathology laboratories of Hospital Ipoh over the 3-year period from January 1996 to October 1999. 15 mishaps were recorded. The location of the accidents were the histology (40%), microbiology (33%), haematology (20%) and cytology (7%) laboratories. No mishaps were reported from the clinical chemistry, blood bank and outpatient laboratories. Cuts by sharp objects were the most common injuries sustained (47%) followed by splashes and squirts by fluid such as blood or chemicals (27%). There was 1 case each of contact with biohazardous fluid, burn, allergy and accidental drinking of disinfectant. 67% of the accidents involved medical laboratory technicians, 20% involved attendants and the rest were medical officers and the junior laboratory technicians. Although the accidents reported appeared trivial, it is vital to document them and bring them to the attention of all concerned in the laboratory, in order to prevent major accidents and also because of medico-legal implications. The role of the Laboratory Safety Committee cannot be overemphasised. Modification of staff attitude is considered an important remedial goal.

Diabetes and driving safety: science, ethics, legality and practice.

PubMed

Cox, Daniel J; Singh, Harsimran; Lorber, Daniel

2013-04-01

Diabetes affects over 25 million people in the United States, most of whom are over the age of 16 and many of whom are licensed to drive a motor vehicle. Safe operation of a motor vehicle requires complex interactions of cognitive and motor functions and medical conditions that affect these functions often will increase the risk of motor vehicle accidents (MVA). In the case of diabetes, hypoglycemia is the most common factor that has been shown to increase MVA rates. When people with diabetes are compared with nondiabetic controls, systematic analyses show that the relative risk of MVA is increased by between 12% and 19% (Relative Risk Ratio 1.12-1.19). In comparison, the RRR for attention deficit hyperactivity disorder is 4.4 and for sleep apnea is 2.4. Epidemiologic research suggests that patients at risk for hypoglycemia-related MVAs may have some characteristics in common, including a history of severe hypoglycemia or of hypoglycemia-related driving mishaps. Experimental studies also have shown that people with a history of hypoglycemia-related driving mishaps have abnormal counter-regulatory responses to hypoglycemia and greater cognitive impairments during moderate hypoglycemia.

Aviation Safety Risk Modeling: Lessons Learned From Multiple Knowledge Elicitation Sessions

NASA Technical Reports Server (NTRS)

Luxhoj, J. T.; Ancel, E.; Green, L. L.; Shih, A. T.; Jones, S. M.; Reveley, M. S.

2014-01-01

Aviation safety risk modeling has elements of both art and science. In a complex domain, such as the National Airspace System (NAS), it is essential that knowledge elicitation (KE) sessions with domain experts be performed to facilitate the making of plausible inferences about the possible impacts of future technologies and procedures. This study discusses lessons learned throughout the multiple KE sessions held with domain experts to construct probabilistic safety risk models for a Loss of Control Accident Framework (LOCAF), FLightdeck Automation Problems (FLAP), and Runway Incursion (RI) mishap scenarios. The intent of these safety risk models is to support a portfolio analysis of NASA's Aviation Safety Program (AvSP). These models use the flexible, probabilistic approach of Bayesian Belief Networks (BBNs) and influence diagrams to model the complex interactions of aviation system risk factors. Each KE session had a different set of experts with diverse expertise, such as pilot, air traffic controller, certification, and/or human factors knowledge that was elicited to construct a composite, systems-level risk model. There were numerous "lessons learned" from these KE sessions that deal with behavioral aggregation, conditional probability modeling, object-oriented construction, interpretation of the safety risk results, and model verification/validation that are presented in this paper.

Preparing to Test

NASA Image and Video Library

2015-03-26

Stennis Space Center employees install a 96-inch valve during a recent upgrade of the high-pressure industrial water system that serves the site’s large rocket engine test stands. The upgraded system has a capacity to flow 335,000 gallons of water a minute, which is a critical element for testing. At Stennis, engines are anchored in place on large test stands and fired just as they are during an actual space flight. The fire and exhaust from the test is redirected out of the stand by a large flame trench. A water deluge system directs thousands of gallons of water needed to cool the exhaust. Water also must be available for fire suppression in the event of a mishap. The new system supports RS-25 engine testing on the A-1 Test Stand, as well as testing of the core stage of NASA’s new Space Launch System on the B-2 Test Stand at Stennis.

The astronaut and the banana peel: An EVA retriever scenario

NASA Technical Reports Server (NTRS)

Shapiro, Daniel G.

1989-01-01

To prepare for the problem of accidents in Space Station activities, the Extravehicular Activity Retriever (EVAR) robot is being constructed, whose purpose is to retrieve astronauts and tools that float free of the Space Station. Advanced Decision Systems is at the beginning of a project to develop research software capable of guiding EVAR through the retrieval process. This involves addressing problems in machine vision, dexterous manipulation, real time construction of programs via speech input, and reactive execution of plans despite the mishaps and unexpected conditions that arise in uncontrolled domains. The problem analysis phase of this work is presented. An EVAR scenario is used to elucidate major domain and technical problems. An overview of the technical approach to prototyping an EVAR system is also presented.

14 CFR 431.45 - Mishap investigation plan and emergency response plan.

Code of Federal Regulations, 2012 CFR

2012-01-01

... AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION LICENSING LAUNCH AND REENTRY OF A REUSABLE LAUNCH... materials, as defined in § 401.5 of this chapter, involved in the event, whether on the vehicle, payload, or... dissemination of up to date information to the public, and for doing so in advance of reentry or other landing...

14 CFR 431.45 - Mishap investigation plan and emergency response plan.

Code of Federal Regulations, 2013 CFR

2013-01-01

... AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION LICENSING LAUNCH AND REENTRY OF A REUSABLE LAUNCH... materials, as defined in § 401.5 of this chapter, involved in the event, whether on the vehicle, payload, or... dissemination of up to date information to the public, and for doing so in advance of reentry or other landing...

14 CFR 431.45 - Mishap investigation plan and emergency response plan.

Code of Federal Regulations, 2014 CFR

2014-01-01

... AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION LICENSING LAUNCH AND REENTRY OF A REUSABLE LAUNCH... materials, as defined in § 401.5 of this chapter, involved in the event, whether on the vehicle, payload, or... dissemination of up to date information to the public, and for doing so in advance of reentry or other landing...

Unmanned Aerial Vehicle Mishap Taxonomy for Range Safety Reviews

DTIC Science & Technology

2016-02-01

Wind /Turbulence ................................................................................................. 5-3 5.1.3 Rain...majority of ignition system failures was traced to the magneto and were primarily attributed to exposure to high engine temperature or loose wiring ...intervals were mentioned in reports as corrective actions for these scenarios. One instance of fuel nozzle failure in a turbine -powered UAV resulted in

Biking Is Booming

ERIC Educational Resources Information Center

Truesdell, William H.; Wicks, Carol A.

1978-01-01

One hundred thousand bicycle-motor vehicle accidents will occur this year. Close to 1,100 of the mishaps will result in death. Education is the first, last and best hope for cyclists and motorists alike and one facet of bike safety programs is teaching students to understand a machine they may take for granted. Here are some ideas for starters.…

The Demands of Nuclear Safety: Mishaps and USSTRATCOM

DTIC Science & Technology

2011-06-01

maintenance operation—the unexpected will occur. Scott D. Sagan On 30 August 2007 the unexpected occurred. Ironically, the safety problem did... Sagan , The Limits of Safety: Organizations, Accidents, and Nuclear Weapons (Princeton, NJ: Princeton University Press, 1993), 14, 48. 39 Sagan , Limits...1 Scott D. Sagan , The Limits of Safety: Organizations, Accidents, and Nuclear Weapons (Princeton, NJ: Princeton

School Leaders Building Capacity from Within: Resolving Competing Agendas Creatively

ERIC Educational Resources Information Center

Burrello, Leonard C.; Hoffman, Lauren; Murray, Lynn

2004-01-01

Anything built to last needs a clear plan, a solid foundation, the right tools, and strong structural integrity to withstand threatening elements that arise. Unfortunately, most school reform programs do not meet these basic requirements and crumble as quickly as they appear. To offset such mishaps, this guide empowers the reader to be an…

Supervision of School and Youth Groups on Lift-Served Ski Slopes: A Research Perspective

ERIC Educational Resources Information Center

Brookes, Andrew; Holmes, Peter

2014-01-01

Supervised practice is a common feature of many snow sports excursions to downhill ski resorts by school or youth groups, often in combination with lessons from a ski school. What is the role of supervision in preventing mishaps, injury, or fatalities? This article presents results of a search of published snow sports safety research for evidence…

Skylab: Its anguish and triumph - A memoir

NASA Technical Reports Server (NTRS)

Von Puttkamer, J.

1982-01-01

During its ascent to earth orbit, Skylab, launched May 14, 1973, sustained severe damage due to the premature deployment of its micrometeoroid shield. In this paper, a participating engineer describes how a thermal shield repair concept was developed and appropriate hardware was built and tested within 11 days of the mishap, and how the repair concept was sucessfully implemented in space to rescue Skylab.

Military Working Dog Campus Revitalization: Environmental Assessment

DTIC Science & Technology

2012-12-01

2- 11   2.5  OTHER ACTIONS ANNOUNCED FOR THE PROJECT AREAS AND SURROUNDING COMMUNITY ...Conservation and Recovery Act RFR Radio Frequency ROI region of influence SA Similarity of Appearance SAACC San Antonio Aviation Cadet Center SAWS...occurrence that has a high potential for becoming a mishap. o Laser or Radio Frequency (RFR) incidents or accidents. All incidents or accidents

Design Packing to Safely Mail Raw Spaghetti. Grades 3-5.

ERIC Educational Resources Information Center

Rushton, Erik; Ryan, Emily; Swift, Charles

This activity is designed to build creative skills based on an everyday problem. The scenario that sometimes packages are dropped and letters get bent is used. How can a special delivery be protected from such unfortunate mishaps? Students use their creative skills to determine a way to mail raw spaghetti. A way to safely package the raw spaghetti…

A Human Systems Integration Perspective to Evaluating Naval Aviation Mishaps and Developing Intervention Strategies

DTIC Science & Technology

2009-12-01

SWISS CHEESE ” MODEL........................................... 16 1. Errors and Violations...16 Figure 5. Reason’s Swiss Cheese Model (After: Reason, 1990, p. 208) ........... 20 Figure 6. The HFACS Swiss Cheese Model of...become more complex. E. REASON’S “ SWISS CHEESE ” MODEL Reason’s (1990) book, Human Error, is generally regarded as the seminal work on the subject

Modeling Small Unmanned Aerial System Mishaps Using Logistic Regression and Artificial Neural Networks

DTIC Science & Technology

2012-03-22

Faculty Department of Operational Sciences Graduate School of Engineering and Management Air Force Institute of Technology Air University...Air Education and Training Command In Partial Fulfillment of the Requirements for the Degree of Master of Science in Operations...this project was well defined. I would also like to thank my reader, Dr. Joseph Pignatiello, for his technical insights and helpful comments. Thanks

Lessons Learned from FY82 US Army Aviation Mishaps.

DTIC Science & Technology

1983-07-01

command action to ensure inexperienced instructor pilots recognize the problems associated with inexpe-rience, particularly those related to anticipating...and failed to remove tiedowns before flight. These actions were the result of a. improper attitude regarding the requirement to perform preflight...lack of self-discipline (improper Attitude ) by encouraging pilot to fly unauthorized maneuvers which exceeded he ability of the pilot and aircraft

A Model of Human Orientation and Self Motion Perception during Body Acceleration: The Orientation Modeling System

DTIC Science & Technology

2016-09-28

previous research and modeling results. The OMS and Perception Toolbox were used to perform a case study of an F18 mishap. Model results imply that...request documents from DTIC. Change of Address Organizations receiving reports from the U.S. Army Aeromedical Research Laboratory on automatic...54  Coriolis head movement during a coordinated turn. .............................................55  Case Study

[CLAVICLE FRACTURES IN CHILDREN--CIRCUMSTANCES AND CAUSES OF INJURY].

PubMed

Antabak, Anko; Matković, Nikša; Papeš, Dino; Karlo, Robert; Romić, Ivan; Fuchs, Nino; Madarić, Miroslav; Stilinović, Marina; Stanić, Lana; Luetić, Tomislav

2015-01-01

Clavicle fractures in children occur twice as often as in adults. During a child's growth period they account for 10-15% of all fractures sustained. The questions which should be asked are how these fractures are sustained and under which circumstances are the children injured. In the study 256 children with clavicle fractures treated during the period 2008-2013 were analyzed. The underlying cause and place of injuries were classified using the ICD-10 classification system, using environmental causes of injury. The circumstances were in each case accidental injury. Environmental causes were traffic accidents (V01-V99) or mishaps/accidents (W00-X59). Fracture injuries were caused in traffic accidents in 24 (9.4%), and in mishaps/accidents in 232 (90.6%) children. Of the injuries caused by mishaps/accidents, in 204 children these were caused by falls (W00-W19). In 123 of them the injuries were caused by falls from a ground level, and in 81 were from a greater height. Direct blow injuries, caused by another person or a blunt instrument, weere the causes of fractures seen in 28 children. Place of fracture sustainment was dominantly at home. This was followed by injuries sustained outside in recreational areas, while least were suffered at school or kindergarden facilities. Bicycle riding was the cause of clavicle fractures in 48 children, which was 18.7% of all fractures seen. Sports related injuries and fractures were seen in 47 (18.4%) out of 256 children: 30 in football, 10 in defensive sports (wrestling, judo, karate), three in hockey, while basketball and gymnastics accounted for two each. Preschool children were injured more often while in the care of their parents while school aged children were adaquately protected, but in after-school activities they were often injured. The most common injuries after school were those suffered in traffic accidents and recreational sports activities. In the adolescent period, the most common injuries seen were again those in traffic accidents, bicycle riding, recreational sports activities and injuries sustained at home.

Systems Engineering Technical Authority: A Path to Mission Success

NASA Technical Reports Server (NTRS)

Andary, James F.; So, Maria M.; Breindel, Barry

2008-01-01

The systems engineering of space missions to study planet Earth has been an important focus of the National Aeronautics and Space Administration (NASA) since its inception. But all space missions are becoming increasingly complex and this fact, reinforced by some major mishaps, has caused NASA to reevaluate their approach to achieving safety and mission success. A new approach ensures that there are adequate checks and balances in place to maximize the probability of safety and mission success. To this end the agency created the concept of Technical Authority which identifies a key individual accountable and responsible for the technical integrity of a flight mission as well as a project-independent reporting path. At the Goddard Space Flight Center (GSFC) this responsibility ultimately begins with the Mission Systems Engineer (MSE) for each satellite mission. This paper discusses the Technical Authority process and then describes some unique steps that are being taken at the GSFC to support these MSEs in meeting their responsibilities.

Investigation: revelations about Three Mile Island disaster raise doubts over nuclear plant safety: a special facing south investigation by Sue Sturgis.

PubMed

Sturgis, Sue

2009-01-01

A series of mishaps in a reactor at the Three Mile Island (TMI) nuclear plant led to the 1979 meltdown of almost half the uranium fuel and uncontrolled releases of radiation into the air and surrounding Susquehanna River. It was the single worst disaster ever to befall the U.S. nuclear power industry. Health physics technician Randall Thompson's story about what he witnessed while monitoring radiation there after the incident is being publicly disclosed for the first time. It is supported by a growing body of evidence and it contradicts the U.S. government's contention that the TMI accident posed no threat to the public. Thompson and his wife, a nuclear health physicist who also worked at TMI in the disaster's wake, warn that the government's failure to acknowledge the full scope of the disaster is leading officials to underestimate the risks posed by a new generation of nuclear power plants.

An Experience of Teaching of Astronomy in the 6th Year if Fundamental Education

NASA Astrophysics Data System (ADS)

Pereira, L. F.; Damasceno, L. E. F.; Nero, J. D.; Silva, S. J. S. da; Costa, M. B. C.; Aleixo, V. F. P.; Júnior, C. A. B. da S.

2017-12-01

This paper deals the question of astronomy teaching within the science discipline through: 1- analysis of the "Earth and Universe" axis of the National Curricular Parameters (NCPs); 2- profile of the professional who teaching the discipline; 3- analysis of the history and importance of experimentation for the teaching of Astronomy in Brazil. The main objective is to analyze the conception of students and teachers regarding the application of experimentation in the teaching of Astronomy in a hybrid class of 6º year with 14 students in the period recovery (07/2016) in an municipal public school of São Miguel of Guama-Pa. We highlight the teacher mishaps of the public school system and its difficulty in using teaching methodologies that go beyond the traditional, we emphasize, the problems with the training courses concerning the teaching of Astronomy and highlight the experimentation as tool indispensable in the construction of this teaching and learning process.

New Principles in Weapons.

DTIC Science & Technology

1980-10-10

mishaps. The oscillation frequency of infra - sonic waves is lower than 16 times per second and they are in- audible. In the air, their disseminating speed...chemistry methods to injure living targets. For example, the production of immense ultrasonic waves or infrasonic waves can cause headaches, vomiting...human body. Foreign statements, based on research and experiments carried out over a long period of time, report that the use of infrasonic wave weapons

Aircraft Mishap Fire Pattern Investigations

DTIC Science & Technology

1985-08-01

AD-AI61 094 AIRC1Arr WSWEA FlREg PATMEN INVESTIGATIONS . Joseph M. Kuchta Mining and industrial Cadre15143 Green latetrutiovalp 𔃻nco 54 Sewickley...ORGANIZATION REPORT NUMSER(S) AFWAL-TR-85-2057 6. NAME OF PERFORMING ORGANIZATION kb. OFFICE SYMBOL 7a. NAME OF MONITORING ORGANIZATION Mining and Industrial...IS OBSOLETE. Unc .assi fied SECURITY CLASSIFICATION OF THIS PAGE ( / FOREWARD This report was prepared by the Mining and Industrial Cadre of Green

2018 Ground Robotics Capabilities Conference and Exhibiton

DTIC Science & Technology

2018-04-11

Transportable Robot System (MTRS) Inc 1 Non -standard Equipment (approved) Explosive Ordnance Disposal Common Robotic System-Heavy (CRS-H) Inc 1 AROC: 3-Star...and engineering • AI risk mitigation methodologies and techniques are at best immature – E.g., V&V; Probabilistic software analytics; code level...controller to minimize potential UxS mishaps and unauthorized Command and Control (C2). • PSP-10 – Ensure that software systems which exhibit non

NASA: Assessments of Selected Large-Scale Projects

DTIC Science & Technology

2011-03-01

REPORT DATE MAR 2011 2. REPORT TYPE 3. DATES COVERED 00-00-2011 to 00-00-2011 4. TITLE AND SUBTITLE Assessments Of Selected Large-Scale Projects...Volatile EvolutioN MEP Mars Exploration Program MIB Mishap Investigation Board MMRTG Multi Mission Radioisotope Thermoelectric Generator MMS Magnetospheric...probes designed to explore the Martian surface, to satellites equipped with advanced sensors to study the earth , to telescopes intended to explore the

Passive cooling system for liquid metal cooled nuclear reactors with backup coolant flow path

DOEpatents

Hunsbedt, Anstein; Boardman, Charles E.

1993-01-01

A liquid metal cooled nuclear fission reactor plant having a passive auxiliary safety cooling system for removing residual heat resulting from fuel decay during reactor shutdown, or heat produced during a mishap. This reactor plant is enhanced by a backup or secondary passive safety cooling system which augments the primary passive auxiliary cooling system when in operation, and replaces the primary system when rendered inoperable.

The Relationship Between Naval Aviation Mishaps and Squadron Maintenance Safety Climate

DTIC Science & Technology

2006-12-01

automobile and personal safety. The Safety Department strives to ensure that safety is emphasized and is viewed by all squadron members as...Quessenberry & Boyer, 2004). These informal rules and personal values can influence the developed culture within a squadron, both positively and...management will lower morale and cause employees to get frustrated and pessimistic with the process in general. Reaction may also hold the person who

Aeronautical Decision Making for Student and Private Pilots.

DTIC Science & Technology

1987-05-01

you learn to gain voluntary control over your body to achieve the relaxation response. In autogenic training , you learn to shut down many bodily...Ahstruct "Aviation accident data indicate that the majority of aircraft mishaps are due to judgment error. This training manual is part of a project to...develop materials and techniques to help improve pilot decision making. Training programs using prototype versions of these materials have

[New use of pulse-oximeter as a prophylactic Stimulator to the wearer and a lifesaving tools for prevention of hypoxic mishaps].

PubMed

Morioka, Tohru; Terasaki, Hidenori

2014-03-01

Pulse-oximeter has been widely used for the clinical assessment of physical status of a patient and as an alarming tool of hypoxia to medical personnel at the bedside or in the observation center. However, it has never been used for direct stimulation of the wearer. We considered innovation of pulse-oximeter as a prophylactic alarm-oximeter for the wearer. If SPO2 goes down to unfavorable level, the alarm-oximeter starts to send signal through a control box to a stimulator, such as an electrical nerve stimulator, a cold thermal tip, or mechanical device like a vibrator or compressor. The dermal stimulator is usually fixed to the right or left wrist with a Velcro band. The control box is affixed to the wristband by using Velcro. The alarm may be sent to an earphone or speaker with a verbal command like "take a deep breath". Alarm-oximeter will be combined to an oxygen inhaler or mechanical ventilatory assist device, or a drug administration system through electric line or wireless transmitter to start or change its function before the arrival of medical personnel. It will prevent hypoxic mishaps during medical intervention or sleep apnea syndrome. It will be also applicable to stop snoring.

Survey of the use of transport by recipients of a regional Electric Indoor/Outdoor Powered (EPIOC) wheelchair service.

PubMed

Belcher, M J H; Frank, A O

2004-05-20

To determine the extent to which Electric Indoor/Outdoor Powered wheelchair (EPIOC) users travel in vehicles, their concerns about safety, any accidents occurring during transportation and difficulties with their equipment. All 268 EPIOC users on the departmental database were sent a purpose-designed postal questionnaire asking whether the respondent:--used the chair during transportation and in what type of vehicle; understood clamping processes; had a 'mishap' or an 'accident'; felt safe during transportation and wished to comment. Replies from two mailings resulted in 203 usable replies (76%). Responses and comments were entered into an Excel database. Thirty-seven (18%) users did not use any transport. Of the 170 (82%) who did: 51% used Dial-a-Ride, 44% taxis, 41% ambulances, 37% local authority transport, 34% cars and others 17%. Twenty-one (12%) experienced 'mishaps'--8 toppled out of their chairs and 6 reported clamping-related accidents. Headrests were only used by 69 (41%). Thirty-four (19%) of 182 expressing a view about 'feeling safe' felt unsafe sometimes. Wheelchair users often feel vulnerable when being transported by public providers. Risks of vehicular travel by wheelchair users could be reduced with appropriate equipment and regular review of NHS prescriptions, education of users, wheelchair services and transport providers.

Russian roulette

NASA Astrophysics Data System (ADS)

Showstack, Randy

Following a recent collision, fire, series of computer and power failures, and other mishaps on the Russian space station, Mir, the U.S. Congress held a hearing on September 18 to question the safety of American astronauts staying aboard the aging spacecraft.“There has been sufficient evidence put before this hearing to raise doubts about the safety of continued American long-term presence on the Mir,” said House Science Committee Chairman Rep. James Sensenbrenner (R-Wisc.) at the hearing.

DoD Traffic Safety Program. Change 1

DTIC Science & Technology

2010-04-02

powered and non-powered scooters, skateboards, roller skates , in- line skates , and other similar equipment not meeting DOT motor vehicle standards for...DoD civilian personnel in a duty status, on or off a DoD installation. d. All persons in or on a Government-owned or -leased motor vehicle...Glossary. 4. POLICY. It is DoD policy to: a. Eliminate motor vehicle-related mishaps and the resulting deaths, injuries, and property damage

Circumstances surrounding deaths from accidental poisoning 1974-80.

PubMed Central

Craft, A W

1983-01-01

The deaths of 99 children under 5 years of age were studied through the coroners' records. Sixty nine deaths were caused by medicines--most of which were prescribed for mother, were recently dispensed, and currently in use. Household products accounted for 11 deaths, lead poisoning for 6, carbon monoxide for 5 and 'medical mishaps' for 8. Prevention lies in both education and more effective and selective use of child resistant containers. PMID:6870339

Advertising/public relations campaign to combat the negative economic impact caused by the nuclear mishap at Three Mile Island, Pennsylvania. Final report

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

Not Available

The Commonwealth of Pennsylvania, through the Department of Commerce, conducted a media advertising campaign to offset the negative implications and effects of the Three Mile Island incident. The emphasis of the campaign has been directed toward a friendly, all-clear image for Pennsylvania. The travel industry of the entire Commonwealth of Pennsylvania is the chief beneficiary of the proposed project.

U.S. Military Aviation Mishaps In Japan and Okinawan Political Controversy

DTIC Science & Technology

2015-12-01

political controversy over U.S. bases in Japan, the American presence in the island country has proven its strategic advantages for the United States...CONTEMPORARY OKINAWAN HISTORY Located approximately 400 miles south of mainland Japan, Okinawa is the largest island in the Ryukyu Island chain. In the 17th...century, Okinawa served as tributary state to both China and Japan. Commerce brought additional influences to the island , helping to shape a

Liquid metal cooled nuclear reactor plant system

DOEpatents

Hunsbedt, Anstein; Boardman, Charles E.

1993-01-01

A liquid metal cooled nuclear reactor having a passive cooling system for removing residual heat resulting for fuel decay during reactor shutdown, or heat produced during a mishap. The reactor system is enhanced with sealing means for excluding external air from contact with the liquid metal coolant leaking from the reactor vessel during an accident. The invention also includes a silo structure which resists attack by leaking liquid metal coolant, and an added unique cooling means.

Development of Rating Instruments and Procedures for Aviation Mishap Investigation

DTIC Science & Technology

1992-06-01

8217 9U SYSTEM INADEOUACIES I TASK ERRORS___ ___ ______ 01 Lack of postive comnmunication technique (transmission, acknowlegentefft, or confirmation) uaing...Information required by X X X the iiyinq crow member Or, Aaruming coolrni of the aircraft or making controi Inputs without postive transfer of controis X...Investigation Division, explained why this could not be done immediately and what his charter from the command level of the USASC was with respect to

Human Reliability and the Cost of Doing Business

NASA Technical Reports Server (NTRS)

DeMott, Diana

2014-01-01

Most businesses recognize that people will make mistakes and assume errors are just part of the cost of doing business, but does it need to be? Companies with high risk, or major consequences, should consider the effect of human error. In a variety of industries, Human Errors have caused costly failures and workplace injuries. These have included: airline mishaps, medical malpractice, administration of medication and major oil spills have all been blamed on human error. A technique to mitigate or even eliminate some of these costly human errors is the use of Human Reliability Analysis (HRA). Various methodologies are available to perform Human Reliability Assessments that range from identifying the most likely areas for concern to detailed assessments with human error failure probabilities calculated. Which methodology to use would be based on a variety of factors that would include: 1) how people react and act in different industries, and differing expectations based on industries standards, 2) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 3) type and availability of data and 4) how the industry views risk & reliability influences ( types of emergencies, contingencies and routine tasks versus cost based concerns). The Human Reliability Assessments should be the first step to reduce, mitigate or eliminate the costly mistakes or catastrophic failures. Using Human Reliability techniques to identify and classify human error risks allows a company more opportunities to mitigate or eliminate these risks and prevent costly failures.

A gap analysis of meteorological requirements for commercial space operators

NASA Astrophysics Data System (ADS)

Stapleton, Nicholas James

Commercial space companies will soon be the primary method of launching people and supplies into orbit. Among the critical aspects of space launches are the meteorological concerns. Laws and regulations pertaining to meteorological considerations have been created to ensure the safety of the space industry and those living around spaceports; but, are they adequate? Perhaps the commercial space industry can turn to the commercial aviation industry to help answer that question. Throughout its history, the aviation industry has dealt with lessons learned from mishaps due to failures in understanding the significance of weather impacts on operations. Using lessons from the aviation industry, the commercial space industry can preempt such accidents and maintain viability as an industry. Using Lanicci's Strategic Planning Model, this study identified the weather needs of the commercial space industry by conducting three gap analyses. First, a comparative analysis was done between laws and regulations in commercial aviation and those in the commercial space industry pertaining to meteorological support, finding a "legislative gap" between the two industries, as no legal guarantee is in place to ensure weather products remain available to the commercial space industry. A second analysis was conducted between the meteorological services provided for the commercial aviation industry and commercial space industry, finding a gap at facilities not located at an established launch facility or airport. At such facilities, many weather observational technologies would not be present, and would need to be purchased by the company operating the spaceport facility. A third analysis was conducted between the meteorological products and regulations that are currently in existence, and those needed for safe operations within the commercial space industry, finding gaps in predicting lightning, electric field charge, and space weather. Recommendations to address these deficiencies have been generated for the Federal Aviation Administration, U.S. Congress, commercial space launch companies, and areas are identified for further research.

Hazard Analysis for Pneumatic Flipper Suitport/Z-1 Manned Evaluation, Chamber B, Building 32. Revision: Basic

NASA Technical Reports Server (NTRS)

2012-01-01

One of the characteristics of an effective safety program is the recognition and control of hazards before mishaps or failures occur. Conducting potentially hazardous tests necessitates a thorough hazard analysis in order to protect our personnel from injury and our equipment from damage. The purpose of this hazard analysis is to define and address the potential hazards and controls associated with the Z1 Suit Port Test in Chamber B located in building 32, and to provide the applicable team of personnel with the documented results. It is imperative that each member of the team be familiar with the hazards and controls associated with his/her particular tasks, assignments, and activities while interfacing with facility test systems, equipment, and hardware. The goal of this hazard analysis is to identify all hazards that have the potential to harm personnel and/or damage facility equipment, flight hardware, property, or harm the environment. This analysis may also assess the significance and risk, when applicable, of lost test objectives when substantial monetary value is involved. The hazards, causes, controls, verifications, and risk assessment codes have been documented on the hazard analysis work sheets in appendix A of this document. The preparation and development of this report is in accordance with JPR 1700.1, JSC Safety and Health Handbook.

Safety Auditing and Assessments

NASA Technical Reports Server (NTRS)

Goodin, James Ronald (Ronnie)

2005-01-01

Safety professionals typically do not engage in audits and independent assessments with the vigor as do our quality brethren. Taking advantage of industry and government experience conducting value added Independent Assessments or Audits benefits a safety program. Most other organizations simply call this process "internal audits." Sources of audit training are presented and compared. A relation of logic between audit techniques and mishap investigation is discussed. An example of an audit process is offered. Shortcomings and pitfalls of auditing are covered.

Safety Auditing and Assessments

NASA Astrophysics Data System (ADS)

Goodin, Ronnie

2005-12-01

Safety professionals typically do not engage in audits and independent assessments with the vigor as do our quality brethren. Taking advantage of industry and government experience conducting value added Independent Assessments or Audits benefits a safety program. Most other organizations simply call this process "internal audits." Sources of audit training are presented and compared. A relation of logic between audit techniques and mishap investigation is discussed. An example of an audit process is offered. Shortcomings and pitfalls of auditing are covered.

Group 3 Unmanned Aircraft Systems Maintenance Challenges Within The Naval Aviation Enterprise

DTIC Science & Technology

2017-12-01

cross winds . We again went through the mishap processes and reviewed training and maintenance records. A couple months later, there was a third crash...gas turbine engines powering aircraft with humans on board (DON, 2017). Group 3 unmanned aircraft utilize a sealed fuel system. The tank is filled...aircraft do not use gas turbine engines. They use either rotary Wankle or piston driven engines with much simpler fuel delivery systems such as carburetors

The Naval Flight Surgeon’s Pocket Reference to Aircraft Mishap Investigation. Fifth Edition

DTIC Science & Technology

2001-01-01

plant was developing thrust. h. If and when ejection was attempted. 58 i. Phase of flight at impact (e.g., recovery, stall, spin, inverted). 21...illuminated light bulbs at impact. j. Trim settings. k. Power plant malfunctions. l. Thrust at impact (demanded versus actual). m. Propeller RPM...carboxyhemoglobin. Carboxyhemoglobin levels in nonsmokers (in a minimally polluted area) range from 0.5% to 0.8%. 2. CO levels in the blood (assuming

Passive cooling system for top entry liquid metal cooled nuclear reactors

DOEpatents

Boardman, Charles E.; Hunsbedt, Anstein; Hui, Marvin M.

1992-01-01

A liquid metal cooled nuclear fission reactor plant having a top entry loop joined satellite assembly with a passive auxiliary safety cooling system for removing residual heat resulting from fuel decay during shutdown, or heat produced during a mishap. This satellite type reactor plant is enhanced by a backup or secondary passive safety cooling system which augments the primary passive auxiliary cooling system when in operation, and replaces the primary cooling system when rendered inoperative.

Development of Multisensory Orientation Technology for Reducing Spatial Disorientation Mishaps

DTIC Science & Technology

2006-07-01

taps a person on the shoulder in order to gain their attention. The tactors confer information to the wearer by presenting localized vibrations or...179 BK<~Left itee:5kK eft Thr?;FrWc kg~it (r~e:Bb.-x Regh~ ... Exe85rx 21 Be: Left Th eýnr ihgý,;BeckR;t Abt-:LetPeR1a n;. Sedl om 86 F’k Left i’ee

KSC-03PD-1076

NASA Technical Reports Server (NTRS)

2003-01-01

KENNEDY SPACE CENTER, FLA. - Pieces of Columbia debris are photographed by a KSC photographer. More than 70,000 items, weighing 78,000 pounds, about 36 percent of the Shuttle by weight, have been delivered to KSC for use in the mishap investigation. Ground teams have completed 78 percent of their primary search area, and airborne crews finished 80 percent of their assigned area. Search teams have completed 98 percent of the underwater searches in Lake Nacogdoches and Toledo Bend Reservoir.

Index to Army Times 1988

DTIC Science & Technology

1992-08-01

LAW AND LEGISLATION Army family gets $1.56 million for medical mishap. Army Times; Dec. 26, 1988; 49(20): p. 11. House passes military malpractice suit...Times; May 16, 1938; 48(40): p. 24. 79 MALPRACTICE Com4puter databank will raise aler’ on doctors with malpractice woes. Army Times; Oct. 24, 1988; 49...Special pay for doctors . Army Times; Dec. 26, 1988; 49(20): p. 20. PHYSICIANS--SUPPLY AND DEMANO Women-oriented specialties fail to make medical

Evaluation of burn injuries related to liquefied petroleum gas.

PubMed

Tarim, Mehmet Akin

2014-01-01

Liquefied petroleum gas (LPG) is a fuel that is widely used for domestic, agricultural, and industrial purposes. LPG is also commonly used in restaurants, industries, and cars; however, the home continues to be the main site for accidents. In Turkey, the increased usage of LPG as a cooking or heating fuel has resulted in many burn injuries from LPG mishaps. Between January 2000 and June 2011, 56 LPG-burned patients were compared with 112 flame-burned patients. There were no significant differences with respect to the mean age, sex, hospitalization time, and mortality in both groups. In the LPG-caused burn cases, 41 burns (73.2%) occurred at home, seven (12.5) were work-related mishaps, and eight (14.3) were associated with car accidents. The majority of the LPG burns (82%, 46 patients) resulted from a gas leak, and 18% of them were related to the failure to close LPG tubes in the patients' kitchens (10 patients). Burns to the face and neck (82 vs 67%, P = .039) and upper (62 vs 23%, P = .000) and lower (70 vs 45%, P = .002) extremities were significantly higher in LPG-caused burn cases than flame-burned cases. General awareness regarding the risk of LPG and first aid for burns appears to be lacking. The LPG delivery system should be standardized throughout countries that widely use LPG.

The Anaesthesia Gas Supply System

PubMed Central

Das, Sabyasachi; Chattopadhyay, Subhrajyoti; Bose, Payel

2013-01-01

The anaesthesia gas supply system is designed to provide a safe, cost-effective and convenient system for the delivery of medical gases at the point of-use. The doctrine of the anaesthesia gas supply system is based on four essential principles: Identity, continuity, adequacy and quality. Knowledge about gas supply system is an integral component of safe anaesthetic practice. Mishaps involving the malfunction or misuse of medical gas supply to operating theatres have cost many lives. The medical gases used in anaesthesia and intensive care are oxygen, nitrous oxide, medical air, entonox, carbon dioxide and heliox. Oxygen is one of the most widely used gases for life-support and respiratory therapy besides anaesthetic procedures. In this article, an effort is made to describe the production, storage and delivery of anaesthetic gases. The design of anaesthesia equipment must take into account the local conditions such as climate, demand and power supply. The operational policy of the gas supply system should have a backup plan to cater to the emergency need of the hospital, in the event of the loss of the primary source of supply. PMID:24249882

The NASA Engineering and Safety Center (NESC) GN and C Technical Discipline Team (TDT): Its Purpose, Practices and Experiences

NASA Technical Reports Server (NTRS)

Dennehy, Cornelius J.

2008-01-01

This paper will briefly define the vision, mission, and purpose of the NESC organization. The role of the GN&C TDT will then be described in detail along with an overview of how this team operates and engages in its objective engineering and safety assessments of critical NASA projects. This paper will then describe key issues and findings from several of the recent GN&C-related independent assessments and consultations performed and/or supported by the NESC GN&C TDT. Among the examples of the GN&C TDT s work that will be addressed in this paper are the following: the Space Shuttle Orbiter Repair Maneuver (ORM) assessment, the ISS CMG failure root cause assessment, the Demonstration of Autonomous Rendezvous Technologies (DART) spacecraft mishap consultation, the Phoenix Mars lander thruster-based controllability consultation, the NASA in-house Crew Exploration Vehicle (CEV) Smart Buyer assessment and the assessment of key engineering considerations for the Design, Development, Test & Evaluation (DDT&E) of robust and reliable GN&C systems for human-rated spacecraft.

Morpheus 1.5A Lander Failure Investigation Results

NASA Technical Reports Server (NTRS)

Munday, Steve; Olansen, John

2013-01-01

On August 9th, 2012, the Morpheus 1.5 Vertical Testbed (VTB) crashed during Free Flight 2 (FF2) at KSC SLF, resulting in the loss of 1.5 VTB hardware. JSC/KSC Morpheus team immediately executed the pre-rehearsed Emergency Action Plan to protect personnel and property, so damage was limited to 1.5 VTB hardware. JSC/KSC Morpheus team secured data and mapped & recovered debris. Project had pre-declared loss of VTB to be a test failure, not a mishap.

Skylab 2 Farewell View from the Departing Skylab Command/Service Module

NASA Image and Video Library

1973-06-22

SL2-07-667 (22 June 1973) --- This overhead view of the Skylab Space Station was taken from the Departing Skylab Command/Service Module during the Skylab 2's final fly-around inspection. The single solar panel is quite evident as well as the parasol solar shield, rigged to replace the missing micrometeoroid shield. Both the second solar panel and the micrometeoroid shield were torn away during a mishap in the original Skylab 1 liftoff and orbital insertion. Photo credit: NASA

Skylab 2 Farewell View from the Departing Skylab Command/Service Module

NASA Image and Video Library

1973-06-22

SL2-07-651 (22 June 1973) --- This overhead view of the Skylab Space Station was taken from the Departing Skylab Command/Service Module during the Skylab 2's final fly-around inspection. The single solar panel is quite evident as well as the parasol solar shield, rigged to replace the missing micrometeoroid shield. Both the second solar panel and the micrometeoroid shield were torn away during a mishap in the original Skylab 1 liftoff and orbital insertion. Photo credit: NASA

Pitch control margin at high angle of attack - Quantitative requirements (flight test correlation with simulation predictions)

NASA Technical Reports Server (NTRS)

Lackey, J.; Hadfield, C.

1992-01-01

Recent mishaps and incidents on Class IV aircraft have shown a need for establishing quantitative longitudinal high angle of attack (AOA) pitch control margin design guidelines for future aircraft. NASA Langley Research Center has conducted a series of simulation tests to define these design guidelines. Flight test results have confirmed the simulation studies in that pilot rating of high AOA nose-down recoveries were based on the short-term response interval in the forms of pitch acceleration and rate.

Hazard Analysis for Building 34 Vacuum Glove Box Assembly

NASA Technical Reports Server (NTRS)

Meginnis, Ian

2014-01-01

One of the characteristics of an effective safety program is the recognition and control of hazards before mishaps or failures occur. Conducting potentially hazardous tests necessitates a thorough hazard analysis in order to prevent injury to personnel, and to prevent damage to facilities and equipment. The primary purpose of this hazard analysis is to define and address the potential hazards and controls associated with the Building 34 Vacuum Glove Box Assembly, and to provide the applicable team of personnel with the documented results. It is imperative that each member of the team be familiar with the hazards and controls associated with his/her particular tasks, assignments and activities while interfacing with facility test systems, equipment and hardware. In fulfillment of the stated purposes, the goal of this hazard analysis is to identify all hazards that have the potential to harm personnel, damage the facility or its test systems or equipment, test articles, Government or personal property, or the environment. This analysis may also assess the significance and risk, when applicable, of lost test objectives when substantial monetary value is involved. The hazards, causes, controls, verifications, and risk assessment codes have been documented on the hazard analysis work sheets in Appendix A of this document. The preparation and development of this report is in accordance with JPR 1700.1, "JSC Safety and Health Handbook" and JSC 17773 Rev D "Instructions for Preparation of Hazard Analysis for JSC Ground Operations".

[Critical incidents].

PubMed

Scheidegger, D

2005-03-01

In medicine real severe mishaps are rare. On the other hand critical incidents are frequent. Anonymous critical incident reporting systems allow us to learn from these mishaps. This learning process will make our daily clinical work safer Unfortunately, before these systems can be used efficiently our professional culture has to be changed. Everyone in medicine has to admit that errors do occur to see the need for an open discussion. If we really want to learn from errors, we cannot punish the individual, who reported his or her mistake. The interest is primarily in what has happened and why it has happened and not who has committed this mistake. The cause for critical incidents in medicine is in over 80% the human factor Poor communication, work under enormous stress, conflicts and hierarchies are the main cause. This has been known for many years, therefore have already 15 years ago high-tech industries, like e.g. aviation, started to invest in special courses on team training. Medicine is a typical profession were until now only the individual performance decided about the professional career Communication, conflict management, stress management, decision making, risk management, team and team resource management were subjects that have never been taught during our preor postgraduate education. These points are the most important ones for an optimal teamwork. A multimodular course designed together with Swissair (Human Aspect Development medical, HADmedical) helps to cover, as in aviation, the soft factor and behavioural education in medicine and to prepare professionals in health care to work as a real team.

A comparison of the teamwork attitudes and knowledge of Irish surgeons and U.S Naval aviators.

PubMed

O'Connor, Paul; Ryan, Stephen; Keogh, Ivan

2012-10-01

Poor teamwork skills are contributors to poor performance and mishaps in high risk work settings, including the operating theatre. A questionnaire was used to assess the attitudes towards, and knowledge of, Irish surgeons (n = 72) towards the human factors that contribute to mishaps and poor teamwork in high risk environments. The responses were compared to those obtained from U.S. Naval aviators (n = 552 for the attitude questions, and n = 172 for the knowledge test). U.S. Naval aviators were found to be significantly more knowledgeable, and held attitudes that were significantly more positive towards effective teamworking than the surgeons. Moreover, 78.9% of Senior House Officers and Registrars stated that junior personnel were frequently afraid to speak-up (compared with 31.3% of Consultants). Only 7.3% of surgeons stated that an adequate pre-operative brief team brief was frequently conducted, and only 15% stated that an adequate post-operative team brief was frequently conducted. It is suggested that the human factors training currently provided to surgeons in Ireland is a positive first step. However, there is a need to stress the importance of assertiveness in juniors, listening in seniors, and more reinforcement of good teamworking behaviours in the operating theatre. Copyright © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Technical Findings, Lessons Learned, and Recommendations Resulting from the Helios Prototype Vehicle Mishap

NASA Technical Reports Server (NTRS)

Noll, Thomas E.; Ishmael, Stephen D.; Henwood, Bart; Perez-Davis, Marla E.; Tiffany, Geary C.; Madura, John; Gaier, Matthew; Brown, John M.; Wierzbanowski, Ted

2007-01-01

The Helios Prototype was originally planned to be two separate vehicles, but because of resource limitations only one vehicle was developed to demonstrate two missions. The vehicle consisted of two configurations, one for each mission. One configuration, designated HP01, was designed to operate at extremely high altitudes using batteries and high-efficiency solar cells spread across the upper surface of its 247-foot wingspan. On August 13, 2001, the HP01 configuration reached an altitude of 96,863 feet, a world record for sustained horizontal flight by a winged aircraft. The other configuration, designated HP03, was designed for long-duration flight. The plan was to use the solar cells to power the vehicle's electric motors and subsystems during the day and to use a modified commercial hydrogen-air fuel cell system for use during the night. The aircraft design used wing dihedral, engine power, elevator control surfaces, and a stability augmentation and control system to provide aerodynamic stability and control. At about 30 minutes into the second flight of HP03, the aircraft encountered a disturbance in the way of turbulence and morphed into an unexpected, persistent, high dihedral configuration. As a result of the persistent high dihedral, the aircraft became unstable in a very divergent pitch mode in which the airspeed excursions from the nominal flight speed about doubled every cycle of the oscillation. The aircraft s design airspeed was subsequently exceeded and the resulting high dynamic pressures caused the wing leading edge secondary structure on the outer wing panels to fail and the solar cells and skin on the upper surface of the wing to rip away. As a result, the vehicle lost its ability to maintain lift, fell into the Pacific Ocean within the confines of the U.S. Navy's Pacific Missile Range Facility, and was destroyed. This paper describes the mishap and its causes, and presents the technical recommendations and lessons learned for improving the design, analysis, and testing methods and techniques required for this class of vehicle.

Risk perceptions and trust following the 2010 and 2011 Icelandic volcanic ash crises.

PubMed

Eiser, J Richard; Donovan, Amy; Sparks, R Stephen J

2015-02-01

Eruptions at the Icelandic volcanoes of Eyjafjallajökull (2010) and Grimsvötn (2011) produced plumes of ash posing hazards to air traffic over northern Europe. In imposing restrictions on air traffic, regulators needed to balance the dangers of accidents or aircraft damage against the cost and inconvenience to travelers and industry. Two surveys examined how members of the public viewed the necessity of the imposed restrictions and their trust in different agencies as estimators of the level of risk. Study 1 was conducted with 213 British citizens (112 males, 101 females), who completed questionnaires while waiting for flights at London City Airport during May 2012. Study 2 involved an online survey of 301 Icelandic citizens (172 males, 127 females, 2 undeclared gender) during April 2012. In both samples, there was general support for the air traffic restrictions, especially among those who gave higher estimates of the likelihood of an air accident or mishap having otherwise happened. However, in both countries, the (minority of) respondents who had personally experienced travel disruption were less convinced that these restrictions were all necessary. Scientists, the International Civil Aviation Organization, and (in Iceland) the Icelandic Department of Civil Protection were all highly trusted, and seen as erring on the side of caution in their risk estimates. Airlines were seen as more likely to underestimate any risk. We conclude that perceptions of the balance between risk and caution in judgments under uncertainty are influenced by one's own motives and those attributed to others. © 2014 Society for Risk Analysis.

Validation (not just verification) of Deep Space Missions

NASA Technical Reports Server (NTRS)

Duren, Riley M.

2006-01-01

ion & Validation (V&V) is a widely recognized and critical systems engineering function. However, the often used definition 'Verification proves the design is right; validation proves it is the right design' is rather vague. And while Verification is a reasonably well standardized systems engineering process, Validation is a far more abstract concept and the rigor and scope applied to it varies widely between organizations and individuals. This is reflected in the findings in recent Mishap Reports for several NASA missions, in which shortfalls in Validation (not just Verification) were cited as root- or contributing-factors in catastrophic mission loss. Furthermore, although there is strong agreement in the community that Test is the preferred method for V&V, many people equate 'V&V' with 'Test', such that Analysis and Modeling aren't given comparable attention. Another strong motivator is a realization that the rapid growth in complexity of deep-space missions (particularly Planetary Landers and Space Observatories given their inherent unknowns) is placing greater demands on systems engineers to 'get it right' with Validation.

KSC-2009-1827

NASA Image and Video Library

2009-02-24

VANDENBERG AIR FORCE BASE, Calif. -- NASA’s Orbiting Carbon Observatory and its Taurus booster lift off Feb. 24 from Vandenberg Air Force Base in California at 4:55 a.m. EST. A contingency was declared a few minutes later and the satellite failed to reach orbit after liftoff. Preliminary indications are that the fairing on the Taurus XL launch vehicle failed to separate. The fairing is a clamshell structure that encapsulates the satellite as it travels through the atmosphere. A Mishap Investigation Board is being set up to determine the cause of the launch failure. Photo courtesy of Orbital Sciences

KSC-03PD-1072

NASA Technical Reports Server (NTRS)

2003-01-01

KENNEDY SPACE CENTER, FLA. -- Workers continue to place pieces of Columbia debris on the floor of the KSC RLV Hangar. Shipped from Barksdale Air Force Base, Shreveport, La., more than 70,000 items, weighing 78,000 pounds, about 36 percent of the Shuttle by weight, have been delivered to KSC for use in the mishap investigation. Ground teams have completed 78 percent of their primary search area, and airborne crews finished 80 percent of their assigned area. Search teams have completed 98 percent of the underwater searches in Lake Nacogdoches and Toledo Bend Reservoir.

KSC-03PD-1074

NASA Technical Reports Server (NTRS)

2003-01-01

KENNEDY SPACE CENTER, FLA. -- A worker in the KSC RLV Hangar, collection site of the debris from Columbia, examines a recovered piece before bagging it. Shipped from Barksdale Air Force Base, Shreveport, La., more than 70,000 items, weighing 78,000 pounds, about 36 percent of the Shuttle by weight, have been delivered to KSC for use in the mishap investigation. Ground teams have completed 78 percent of their primary search area, and airborne crews finished 80 percent of their assigned area. Search teams have completed 98 percent of the underwater searches in Lake Nacogdoches and Toledo Bend Reservoir.

KSC-03PD-1077

NASA Technical Reports Server (NTRS)

2003-01-01

KENNEDY SPACE CENTER, FLA. -- Members of the Columbia Reconstruction Project Team look over pieces of debris on the floor of the KSC RLV Hangar. Shipped from Barksdale Air Force Base, Shreveport, La., more than 70,000 items, weighing 78,000 pounds, about 36 percent of the Shuttle by weight, have been delivered to KSC for use in the mishap investigation. Ground teams have completed 78 percent of their primary search area, and airborne crews finished 80 percent of their assigned area. Search teams have completed 98 percent of the underwater searches in Lake Nacogdoches and Toledo Bend Reservoir.

KSC-03PD-1073

NASA Technical Reports Server (NTRS)

2003-01-01

KENNEDY SPACE CENTER, FLA. -- Debris pieces of all sizes lie on the floor of the KSC RLV Hangar. Shipped from Barksdale Air Force Base, Shreveport, La., more than 70,000 items, weighing 78,000 pounds, about 36 percent of the Shuttle by weight, have been delivered to KSC for use in the mishap investigation. Ground teams have completed 78 percent of their primary search area, and airborne crews finished 80 percent of their assigned area. Search teams have completed 98 percent of the underwater searches in Lake Nacogdoches and Toledo Bend Reservoir.

KSC-03PD-1075

NASA Technical Reports Server (NTRS)

2003-01-01

KENNEDY SPACE CENTER, FLA. -- Members of the Columbia Reconstruction Project Team look over pieces of debris in the KSC RLV Hangar. Shipped from Barksdale Air Force Base, Shreveport, La., more than 70,000 items, weighing 78,000 pounds, about 36 percent of the Shuttle by weight, have been delivered to KSC for use in the mishap investigation. Ground teams have completed 78 percent of their primary search area, and airborne crews finished 80 percent of their assigned area. Search teams have completed 98 percent of the underwater searches in Lake Nacogdoches and Toledo Bend Reservoir.

Saturn Apollo Program

NASA Image and Video Library

1965-07-10

Marshall Space Flight Center's rocket development has always included component testing. Pictured here is a Cell 114-B burn stack. The C114-B is part of the gas generators used to test heat exchanges for the F-1 engine. On the initial firing of the C114-B the spark ignition would not light. The rocket propellant mixed with the liquid oxygen gelled creating a bomb. After several attempts at ignition, the spark ignited and blew up the stand. Subsequent testings were completed on newly constructed stands and no further mishaps were reported.

KSC-03pd1074

NASA Image and Video Library

2003-04-14

KENNEDY SPACE CENTER, FLA. -- A worker in the KSC RLV Hangar, collection site of the debris from Columbia, examines a recovered piece before bagging it. Shipped from Barksdale Air Force Base, Shreveport, La., more than 70,000 items, weighing 78,000 pounds, about 36 percent of the Shuttle by weight, have been delivered to KSC for use in the mishap investigation. Ground teams have completed 78 percent of their primary search area, and airborne crews finished 80 percent of their assigned area. Search teams have completed 98 percent of the underwater searches in Lake Nacogdoches and Toledo Bend Reservoir.

NASA's Lessons Learned and Technical Standards: A Logical Marriage

NASA Technical Reports Server (NTRS)

Gill, Paul; Vaughan, William W.; Garcia, Danny; Weinstein, Richard

2001-01-01

Lessons Learned have been the basis for our accomplishments throughout the ages. They have been passed down from father to son, mother to daughter, teacher to pupil, and older to younger worker. Lessons Learned have also been the basis for NASA's accomplishments for more than forty years. Both government and industry have long recognized the need to systematically document and utilize the knowledge gained from past experiences in order to avoid the repetition of failures and mishaps. Lessons Learned have formed the foundation for discoveries, inventions, improvements, textbooks, and Technical Standards.

Report on Automated Semantic Analysis of Scientific and Engineering Codes

NASA Technical Reports Server (NTRS)

Stewart. Maark E. M.; Follen, Greg (Technical Monitor)

2001-01-01

The loss of the Mars Climate Orbiter due to a software error reveals what insiders know: software development is difficult and risky because, in part, current practices do not readily handle the complex details of software. Yet, for scientific software development the MCO mishap represents the tip of the iceberg; few errors are so public, and many errors are avoided with a combination of expertise, care, and testing during development and modification. Further, this effort consumes valuable time and resources even when hardware costs and execution time continually decrease. Software development could use better tools! This lack of tools has motivated the semantic analysis work explained in this report. However, this work has a distinguishing emphasis; the tool focuses on automated recognition of the fundamental mathematical and physical meaning of scientific code. Further, its comprehension is measured by quantitatively evaluating overall recognition with practical codes. This emphasis is necessary if software errors-like the MCO error-are to be quickly and inexpensively avoided in the future. This report evaluates the progress made with this problem. It presents recommendations, describes the approach, the tool's status, the challenges, related research, and a development strategy.

Mechanisms of flag-football injuries reported to the HQ Air Force Safety Center a 10-year descriptive study, 1993-2002.

PubMed

Burnham, Bruce R; Copley, G Bruce; Shim, Matthew J; Kemp, Philip A; Jones, Bruce H

2010-01-01

Flag (touch or intramural) football is a popular sport among the U.S. Air Force (USAF) active duty population and causes a substantial number of lost-workday injuries. The purpose of this study is to describe the mechanisms of flag-football injuries to better identify effective countermeasures. The data were derived from safety reports obtained from the USAF Ground Safety Automated System. Flag-football injuries for the years 1993-2002 that resulted in at least one lost workday were included in the study conducted in 2003. Narrative data were systematically reviewed for 32,812 USAF mishap reports; these were then coded in order to categorize and summarize mechanisms associated with flag football and other sports and occupational injuries. Nine hundred and forty-four mishap reports involving active duty USAF members playing flag football met the criteria for inclusion into this study. Eight mechanisms of injury were identified. The eight mechanisms accounted for 90% of all flag-football injuries. One scenario (contact with another player) accounted for 42% of all flag-football injuries. The most common mechanisms of injury caused by playing flag football can be identified using the detailed information found in safety reports. These scenarios are essential to developing evidence-based countermeasures. Results for flag football suggest that interventions that prevent player contact injuries deserve further research and evaluation. The broader implications of this study are that military safety data can be used to identify potentially modifiable mechanisms of injury for specific activities such as flag football. Published by Elsevier Inc.

Apology for errors: whose responsibility?

PubMed

Leape, Lucian L

2012-01-01

When things go wrong during a medical procedure, patients' expectations are fairly straightforward: They expect an explanation of what happened, an apology if an error was made, and assurance that something will be done to prevent it from happening to another patient. Patients have a right to full disclosure; it is also therapeutic in relieving their anxiety. But if they have been harmed by our mistake, they also need an apology to maintain trust. Apology conveys respect, mutual suffering, and responsibility. Meaningful apology requires that the patient's physician and the institution both take responsibility, show remorse, and make amends. As the patient's advocate, the physician must play the lead role. However, as custodian of the systems, the hospital has primary responsibility for the mishap, for preventing that error in the future, and for compensation. The responsibility for making all this happen rests with the CEO. The hospital must have policies and practices that ensure that every injured patient is treated the way we would want to be treated ourselves--openly, honestly, with compassion, and, when indicated, with an apology and compensation. To make that happen, hospitals need to greatly expand training of physicians and others, and develop support programs for patients and caregivers.

The long-term storage of blood for transfusion using an improved container for freezing the red cells in liquid nitrogen

PubMed Central

Jenkins, W. J.; Blagdon, J.

1971-01-01

Considerable experience has been gained in the operation of a bank of blood frozen in liquid nitrogen. The procedure for freezing and recovering the red cells is, in principle, that described by Krijnen, Kuivenhoven, and de Wit (1970). An improved metal freezing container offers greater freedom from liquid nitrogen leaks and hence, bacterial contamination. Over 500 units of blood have been preserved and used for transfusions without mishap, and many advantages are seen in this relatively economical method for the long-term storage of blood. Images PMID:5130533

Fallout: The experiences of a medical team in the care of a Marshallese population accidently exposed to fallout radiation

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

Conard, R.A.

1992-09-01

This report presents an historical account of the experiences of the Brookhaven Medical Team in the examination and treatment of the Marshallese people following their accidental exposure to radioactive fallout in 1954. This is the first time that a population has been heavily exposed to radioactive fallout, and even though this was a tragic mishap, the medical findings have provided valuable information for other accidents involving fallout such as the recent reactor accident at Chernobyl. Noteworthy has been the unexpected importance of radioactive iodine in the fallout in producing thyroid abnormalities.

KSC-03PD-1095

NASA Technical Reports Server (NTRS)

2003-01-01

KENNEDY SPACE CENTER, FLA. -- A member of the Columbia Reconstruction Project Team examines a piece of Columbia debris on the floor of the KSC RLV Hangar. Shipped from Barksdale Air Force Base, Shreveport, La., more than 70,000 items, weighing 78,000 pounds, about 36 percent of the Shuttle by weight, have been delivered to KSC for use in the mishap investigation. Ground teams have completed 78 percent of their primary search area, and airborne crews finished 80 percent of their assigned area. Search teams have completed 98 percent of the underwater searches in Lake Nacogdoches and Toledo Bend Reservoir.

Assessment of the USAF Aircraft Accident Investigation Board (AIB) Report on the F-22A Mishap of November 16, 2010

DTIC Science & Technology

2013-02-06

because the actual times were recorded by the pilots in Zulu time and do not match the local times printed on the sheet. The evidence is not clear. The...million square miles. The area is home to nearly two billion people who live in 44 countries. PACAF maintains a forward presence to help ensure...actual  times  were  recorded  by  the  pilots  in   Zulu  time  and  do  not  match  the  local  times  printed

Fallout: The experiences of a medical team in the care of a Marshallese population accidentally exposed to fallout radiation

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

Conard, R.A.

1991-12-31

This report presents an historical account of the experiences of the Brookhaven Medical team in the examination and treatment of the Marshallese people following their accidental exposure to radioactive fallout in 1954. This is the first time that a population has been heavily exposed to radioactive fallout, and even though this was a tragic mishap, the medical findings have provided valuable information for other accidents involving fallout such as the recent reactor accident at Chernobyl. Particularly important has been the unexpected importance of radioactive iodine in the fallout in producing thyroid abnormalities.

Fallout: The experiences of a medical team in the care of a Marshallese population accidentally exposed to fallout radiation

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

Conard, R.A.

1991-01-01

This report presents an historical account of the experiences of the Brookhaven Medical team in the examination and treatment of the Marshallese people following their accidental exposure to radioactive fallout in 1954. This is the first time that a population has been heavily exposed to radioactive fallout, and even though this was a tragic mishap, the medical findings have provided valuable information for other accidents involving fallout such as the recent reactor accident at Chernobyl. Particularly important has been the unexpected importance of radioactive iodine in the fallout in producing thyroid abnormalities.

Commercial UAV operations in civil airspace

NASA Astrophysics Data System (ADS)

Newcome, Laurence R.

2000-11-01

The Federal Aviation Administration is often portrayed as the major impediment to unmanned aerial vehicle expansion into civil government and commercial markets. This paper describes one company's record for successfully negotiating the FAA regulations and obtaining authorizations for several types of UAVs to fly commercial reconnaissance missions in civil airspace. The process and criteria for obtaining such authorizations are described. The mishap records of the Pioneer, Predator and Hunter UAVs are examined in regard to their impact on FAA rule making. The paper concludes with a discussion of the true impediments to UAV penetration of commercial markets to date.

First aid in the dental practice: an overview.

PubMed

Jevon, P

2016-06-24

First aid encompasses a wide range of scenarios ranging from simple reassurance following a minor mishap to dealing with a life-threatening emergency. Dentists may need to provide first aid in their dental practice to a patient, relative or member of staff. This article provides an overview to first aid in the dental practice, including priorities, responsibilities when providing first aid, assessment of the environment and the casualty (primary survey &secondary survey). The new A3 'First Aid in the Workplace' poster is now available and is included as an insert in this issue (BDJ Vol. 220, Issue 12).

Introduction and Mission Response Team (MRT)

NASA Technical Reports Server (NTRS)

Pool, Sam

2005-01-01

On February 1, 2003 the Space Shuttle Columbia, returning to Earth with a crew of seven astronauts, disintegrated along a track extending from California to Louisiana. Observers on the ground filmed breakup of the spacecraft. Debris fell along a 567 statute mile track from Littlefield, Texas to Fort Polk, Louisiana; the largest ever recorded debris field. At the time of the accident the National Aeronautics and Space Administration (NASA) flight surgeon on-duty at the Mission Control Center (MCC) in Houston, Texas initiated the medical contingency response. The DOD surgeon at Patrick Air Force Base was notified, NASA medical personnel were recalled and the services of Armed Forces Institute of Pathology (AFIP) were requested. Subsequent to the accident the NASA flight surgeons that had supported the crew on orbit now provided medical support to the crewmember s families. Federal Emergency Management Agency (FEMA), the National Transportation Safety Board (NTSB), the Federal Bureau of Investigation (FBI) and numerous other federal, state and local agencies along with the citizens of Texas and Louisiana responded to the disaster. Search and recovery was managed from a Disaster Field Office (DFO) established in Lufkin, Texas. Mishap Investigation Team (MIT) medical operations were managed from Barksdale Air Force Base, Louisiana. Accident investigation teams (Columbia Accident Investigation Task Force (CAITF) and Columbia Accident Investigation Board (CAIB)) appointed immediately after the disaster included current and former authorities in space medicine. In August 2003, the CAIB concluded its investigation and released its findings in a report published in February 2004.

Point-of-Care Ultrasound for Pulmonary Concerns in Remote Spaceflight Triage Environments.

PubMed

Johansen, Benjamin D; Blue, Rebecca S; Castleberry, Tarah L; Antonsen, Erik L; Vanderploeg, James M

2018-02-01

With the development of the commercial space industry, growing numbers of spaceflight participants will engage in activities with a risk for pulmonary injuries, including pneumothorax, ebullism, and decompression sickness, as well as other concomitant trauma. Medical triage capabilities for mishaps involving pulmonary conditions have not been systematically reviewed. Recent studies have advocated the use of point-of-care ultrasound to screen for lung injury or illness. The operational utility of portable ultrasound systems in disaster relief and other austere settings may be relevant to commercial spaceflight. A systematic review of published literature was conducted concerning the use of point-of-care pulmonary ultrasound techniques in austere environments, including suggested examination protocols for triage and diagnosis. Recent studies support the utility of pulmonary ultrasound examinations when performed by skilled operators, and comparability of the results to computed tomography and chest radiography for certain conditions, with important implications for trauma management in austere environments. Pulmonary injury and illness are among the potential health risks facing spaceflight participants. Implementation of point-of-care ultrasound protocols could aid in the rapid diagnosis, triage, and treatment of such conditions. Though operator-dependent, ultrasound, with proper training, experience, and equipment, could be a valuable tool in the hands of a first responder supporting remote spaceflight operations.Johansen BD, Blue RS, Castleberry TL, Antonsen EL, Vanderploeg JM. Point-of-care ultrasound for pulmonary concerns in remote spaceflight triage environments. Aerosp Med Hum Perform. 2018; 89(2):122-129.

DES daughters in France: experts' points of view on the various genital, uterine and obstetric pathologies, and in utero DES exposure.

PubMed

Clement, R; Guilbaud, E; Barrios, L; Rougé-Maillart, C; Jousset, N; Rodat, O

2014-10-01

Compensation of diethylstilbestrol exposure depends on the judicial system. In France, girls having been exposed to diethylstilbestrol are currently being compensated, and each exposure victim is being evaluated. Fifty-nine expert evaluations were studied to determine the causal relation between exposure to diethylstilbestrol and the pathologies attributable to diethylstilbestrol. The following were taken into consideration: age at the first signs of the pathology; age of the sufferer at the time of evaluation; the pathologies grouped into five categories: fertility disorders - cancers - mishaps during pregnancy - psychosomatic complaints - pathologies of "3rd generation DES victims"; submission of proof of DES exposure; the degree of causality determined (direct, indirect, ruled out). 61% of the cases related to fertility disorders, 28.8% to cancer pathologies (clear-cell adenocarcinoma), 18.6% to mishaps during pregnancy, 8.5% to disorders resulting from preterm delivery, and 3.4% to psychosomatic disorders. Some cases involved a combination of two types of complaints. Indirect causality was determined in 47.1% of the cases involving primary sterility, in 66.7% involving secondary sterility, and in 5 out of 6 cases of total sterility. There is direct causality between in utero diethylstilbestrol exposure and vaginal or cervical clear cell adenocarcinoma. Causality is indirect in the case of disorders linked to prematurity in third generation victims. Causality was determined by the experts on the basis of scientific criteria which attribute the presenting pathologies to diethylstilbestrol exposure. When other risk factors come into play, or when exposure is indirect (third generation), this causality is diminished. © IMechE 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Implementation of a Regional Virtual Tumor Board: A Prospective Study Evaluating Feasibility and Provider Acceptance

PubMed Central

Marshall, Christy L.; Petersen, Nancy J.; Naik, Aanand D.; Velde, Nancy Vander; Artinyan, Avo; Albo, Daniel; Berger, David H.

2014-01-01

Abstract Background: Tumor board (TB) conferences facilitate multidisciplinary cancer care and are associated with overall improved outcomes. Because of shortages of the oncology workforce and limited access to TB conferences, multidisciplinary care is not available at every institution. This pilot study assessed the feasibility and acceptance of using telemedicine to implement a virtual TB (VTB) program within a regional healthcare network. Materials and Methods: The VTB program was implemented through videoconference technology and electronic medical records between the Houston (TX) Veterans Affairs Medical Center (VAMC) (referral center) and the New Orleans (LA) VAMC (referring center). Feasibility was assessed as the proportion of completed VTB encounters, rate of technological failures/mishaps, and presentation duration. Validated surveys for confidence and satisfaction were administered to 36 TB participants to assess acceptance (1–5 point Likert scale). Secondary outcomes included preliminary data on VTB utilization and its effectiveness in providing access to quality cancer care within the region. Results: Ninety TB case presentations occurred during the study period, of which 14 (15%) were VTB cases. Although one VTB encounter had a technical mishap during presentation, all scheduled encounters were completed (100% completion rate). Case presentations took longer for VTB than for regular TB cases (p=0.0004). However, VTB was highly accepted with mean scores for satisfaction and confidence of 4.6. Utilization rate of VTB was 75%, and its effectiveness was equivalent to that observed for non-VTB cases. Conclusions: Implementation of VTB is feasible and highly accepted by its participants. Future studies should focus on widespread implementation and validating the effectiveness of this model. PMID:24845366

A Silent Safety Program

NASA Technical Reports Server (NTRS)

Goodin, James Ronald

2006-01-01

NASA's Columbia Accident Investigation Board (CAIB) referred 8 times to the NASA "Silent Safety Program." This term, "Silent Safety Program" was not an original observation but first appeared in the Rogers Commission's Investigation of the Challenger Mishap. The CAIB on page 183 of its report in the paragraph titled 'Encouraging Minority Opinion,' stated "The Naval Reactor Program encourages minority opinions and "bad news." Leaders continually emphasize that when no minority opinions are present, the responsibility for a thorough and critical examination falls to management. . . Board interviews revealed that it is difficult for minority and dissenting opinions to percolate up through the agency's hierarchy. . ." The first question and perhaps the only question is - what is a silent safety program? Well, a silent safety program may be the same as the dog that didn't bark in Sherlock Holmes' "Adventure of the Silver Blaze" because system safety should behave as a devil's advocate for the program barking on every occasion to insure a critical review inclusion. This paper evaluates the NASA safety program and provides suggestions to prevent the recurrence of the silent safety program alluded to in the Challenger Mishap Investigation. Specifically targeted in the CAM report, "The checks and balances the safety system was meant to provide were not working." A silent system safety program is not unique to NASA but could emerge in any and every organization. Principles developed by Irving Janis in his book, Groupthink, listed criteria used to evaluate an organization's cultural attributes that allows a silent safety program to evolve. If evidence validates Jams's criteria, then Jams's recommendations for preventing groupthink can also be used to improve a critical evaluation and thus prevent the development of a silent safety program.

Aeroservoelastic Stability Analysis of the X-43A Stack

NASA Technical Reports Server (NTRS)

Pak, Chan-gi

2008-01-01

The first air launch attempt of an X-43A stack, consisting of the booster, adapter and Hyper-X research vehicle, ended in failure shortly after the successful drop from the National Aeronautics and Space Administration Dryden Flight Research Center (Edwards, California) B-52B airplane and ignition of the booster. The stack was observed to begin rolling and yawing violently upon reaching transonic speeds, and the grossly oscillating fins of the booster separated shortly thereafter. The flight then had to be terminated with the stack out of control. Very careful linear flutter and aeroservoelastic analyses were subsequently performed as reported herein to numerically duplicate the observed instability. These analyses properly identified the instability mechanism and demonstrated the importance of including the flight control laws, rigid-body modes, structural flexible modes and control surface flexible modes. In spite of these efforts, however, the predicted instability speed remained more than 25 percent higher than that observed in flight. It is concluded that transonic shock phenomena, which linear analyses cannot take into account, are also important for accurate prediction of this mishap instability.

Finding of No Significant Impact: Environmental Assessment Construction of Hangar Addition Building 820 Tinker Air Force Base, Oklahoma

DTIC Science & Technology

2012-03-06

and topsoil cover was constructed over the trenched art::a in August 1990, the landfill wa’i capped in 1998 to 1999, and long-tt::rm groundwater...Controls and Continuous Me tering, February 20 12 ~ - 12 • • • • /,1/l//"fii/111(𔃻/(CI/ ·fs.\\t’.H/1/1’//l L"nnronmcntal Comt •quenu’ • Energy...lnstmction 9 1-202, The U.S. Air Force Mishap Prevention Program, August . USAF. 20 I 0. U nited States Air Force. Spill Pre,•ention and Emergency Response

The Psychology of Safety

NASA Technical Reports Server (NTRS)

Anderson, Brenda Lindley

2011-01-01

Many studies of mishaps show that human error is a factor in a significant majority of accidents. Trying to decide how to change human behavior to be safer is generally the biggest challenge of any safety program. However, understanding the human psyche is the first step to changing behavior. Many studies focus on the before and after of an accident, but what about the thoughts of a person in the commission of an unsafe act? This is a less understood area. Examining it reveals why it is not well comprehended. This paper attempts to examine a part of the thought process, with an eye to helping influence people to less hurtful actions.

Design for Minimum Risk

NASA Technical Reports Server (NTRS)

Wetherholt, Jon; Heimann, Timothy J.

2010-01-01

Design for Minimum Risk (DFMR) is a term used by NASA programs as an expansion of the general hazard reduction process where if an identified hazard cannot be eliminated, the design is modified to reduce the associated mishap risk to an acceptable level. DFMR is a set of specific requirements to minimize risk. DFMR is not well understood and there are many misconceptions concerning the meaning and use. This paper will provide insight into the use of DFMR for space applications; it s comparison to other hazard mitigation strategies and examples of how the approach has been used in the past. It will also highlight documents used by NASA on various programs to determine DFMR.

NASA’s Wallops Flight Facility Completes Initial Assessment after Orbital Launch Mishap

NASA Image and Video Library

2017-12-08

An aerial view of the Wallops Island launch facilities taken by the Wallops Incident Response Team Oct. 29 following the failed launch attempt of Orbital Science Corp.'s Antares rocket Oct. 28. Credit: NASA/Terry Zaperach --- The Wallops Incident Response Team completed today an initial assessment of Wallops Island, Virginia, following the catastrophic failure of Orbital Science Corp.’s Antares rocket shortly after liftoff at 6:22 p.m. EDT Tuesday, Oct. 28, from Pad 0A of the Mid-Atlantic Regional Spaceport at NASA’s Wallops Flight Facility in Virginia. “I want to praise the launch team, range safety, all of our emergency responders and those who provided mutual aid and support on a highly-professional response that ensured the safety of our most important resource -- our people,” said Bill Wrobel, Wallops director. “In the coming days and weeks ahead, we'll continue to assess the damage on the island and begin the process of moving forward to restore our space launch capabilities. There's no doubt in my mind that we will rebound stronger than ever.” The initial assessment is a cursory look; it will take many more weeks to further understand and analyze the full extent of the effects of the event. A number of support buildings in the immediate area have broken windows and imploded doors. A sounding rocket launcher adjacent to the pad, and buildings nearest the pad, suffered the most severe damage. At Pad 0A the initial assessment showed damage to the transporter erector launcher and lightning suppression rods, as well as debris around the pad. The Wallops team also met with a group of state and local officials, including the Virginia Department of Environmental Quality, the Virginia Department of Emergency Management, the Virginia Marine Police, and the U.S. Coast Guard. The Wallops environmental team also is conducting assessments at the site. Preliminary observations are that the environmental effects of the launch failure were largely contained within the southern third of Wallops Island, in the area immediately adjacent to the pad. Immediately after the incident, the Wallops’ industrial hygienist collected air samples at the Wallops mainland area, the Highway 175 causeway, and on Chincoteague Island. No hazardous substances were detected at the sampled locations. Additional air, soil and water samples will be collected from the incident area as well as at control sites for comparative analysis. The Coast Guard and Virginia Marine Resources Commission reported today they have not observed any obvious signs of water pollution, such as oil sheens. Furthermore, initial assessments have not revealed any obvious impacts to fish or wildlife resources. The Incident Response Team continues to monitor and assess. Following the initial assessment, the response team will open the area of Wallops Island, north of the island flagpole opposite of the launch pad location, to allow the U.S. Navy to return back to work. Anyone who finds debris or damage to their property in the vicinity of the launch mishap is cautioned to stay away from it and call the Incident Response Team at 757-824-1295. Further updates on the situation and the progress of the ongoing investigation will be available at: www.orbital.com and www.nasa.gov/orbital NASA image use policy. NASA Goddard Space Flight Center enables NASA’s mission through four scientific endeavors: Earth Science, Heliophysics, Solar System Exploration, and Astrophysics. Goddard plays a leading role in NASA’s accomplishments by contributing compelling scientific knowledge to advance the Agency’s mission. Follow us on Twitter Like us on Facebook Find us on Instagram

Cygnus Arrives Safely to ISS on This Week @NASA – October 28, 2016

NASA Image and Video Library

2016-10-28

On Oct. 23, Orbital ATK’s Cygnus cargo spacecraft safely arrived at the International Space Station – six days after being launched on an Antares rocket from NASA’s Wallops Flight Facility, in Virginia. The successful trip to orbit is the return of rocket launches to the space station from Virginia, following the loss of an Antares and a Cygnus spacecraft during a launch mishap in October 2014. The Cygnus delivered more than 5,100 pounds of science investigations, food and supplies to the crew onboard the station. Also, Next Space Station Crew Trains in Russia, Solar Hazards in Exploration, Preparing for Orion Water Recovery Test and more!

Interdependence theory of tissue failure: bulk and boundary effects.

PubMed

Suma, Daniel; Acun, Aylin; Zorlutuna, Pinar; Vural, Dervis Can

2018-02-01

The mortality rate of many complex multicellular organisms increases with age, which suggests that net ageing damage is accumulative, despite remodelling processes. But how exactly do these little mishaps in the cellular level accumulate and spread to become a systemic catastrophe? To address this question we present experiments with synthetic tissues, an analytical model consistent with experiments, and a number of implications that follow the analytical model. Our theoretical framework describes how shape, curvature and density influences the propagation of failure in a tissue subjected to oxidative damage. We propose that ageing is an emergent property governed by interaction between cells, and that intercellular processes play a role that is at least as important as intracellular ones.

Interdependence theory of tissue failure: bulk and boundary effects

NASA Astrophysics Data System (ADS)

Suma, Daniel; Acun, Aylin; Zorlutuna, Pinar; Vural, Dervis Can

2018-02-01

The mortality rate of many complex multicellular organisms increases with age, which suggests that net ageing damage is accumulative, despite remodelling processes. But how exactly do these little mishaps in the cellular level accumulate and spread to become a systemic catastrophe? To address this question we present experiments with synthetic tissues, an analytical model consistent with experiments, and a number of implications that follow the analytical model. Our theoretical framework describes how shape, curvature and density influences the propagation of failure in a tissue subjected to oxidative damage. We propose that ageing is an emergent property governed by interaction between cells, and that intercellular processes play a role that is at least as important as intracellular ones.

An Extensible Information Grid for Risk Management

NASA Technical Reports Server (NTRS)

Maluf, David A.; Bell, David G.

2003-01-01

This paper describes recent work on developing an extensible information grid for risk management at NASA - a RISK INFORMATION GRID. This grid is being developed by integrating information grid technology with risk management processes for a variety of risk related applications. To date, RISK GRID applications are being developed for three main NASA processes: risk management - a closed-loop iterative process for explicit risk management, program/project management - a proactive process that includes risk management, and mishap management - a feedback loop for learning from historical risks that escaped other processes. This is enabled through an architecture involving an extensible database, structuring information with XML, schemaless mapping of XML, and secure server-mediated communication using standard protocols.

Navy Exploitation of SeaWiFS and MODIS Satellite Imagery for Detection of Desert Dust Storms Over Land and Water

NASA Astrophysics Data System (ADS)

Miller, S. D.

2002-12-01

The United States Navy gives serious consideration to the subject of dust detection. In a recent study of Naval aviation mishaps over the period 1990-1998 (Cantu, 2001), it was found that 70% were associated with visibility problems and accounted for annual equipment losses of nearly 50 million dollars. This figure does not include the tax dollars lost in jettisoned or off-target ordnance owing to obscured targets or failure of laser-guided systems in the presence of significant dust. Nor can it account for the loss of life during a subset of these mishaps. As such, a strong research emphasis has been placed on detecting and quantifying dust over data-sparse/denied parts of the world. The prolific and complex dust climatology of Southwest Asia has posed considerable challenges to Navy operations over the course of Operation Enduring Freedom. In an effort to support the ongoing needs of the Meteorology/Oceanography (METOC) officers afloat, the Satellite Applications Section of the Naval Research Laboratory (NRL) Marine Meteorology Division has developed a novel approach to enhancing significant dust events that appeals to high spatial and spectral resolution satellite data currently available from state of the art ocean/atmospheric radiometers. This paper summarizes progress made on daytime enhancements of desert dust storms over both land and ocean using multispectral imagery from the Moderate Resolution Imaging Spectroradiometer (MODIS; aboard Earth Observing System Terra and Aqua platforms) and the Sea-viewing Wide Field-of-view Sensor (SeaWiFS; aboard the NASA/Orbimage SeaStar platform). The approach leverages the multi-spectral visible capability of these sensors to distinguish dust from clouds over water bodies, and the high spatial resolution required to refine the fine-scale structures that often accompany these events. The MODIS algorithm combines this information with that of several near-to-far infrared channels, taking advantage of unique spectral properties of dust found in these regimes, to extend the capability to detection of dust over land (bright backgrounds). An account for enhancement contamination in the presence of sun glint is also provided in these products. The SeaWiFS and MODIS telemetries are made available to NRL in near real-time, with product turn-around ranging from 3-6 hours from initial capture. An unprecedented intra-agency collaboration forged between NOAA, NASA (Goddard Space Flight Center), and the Department of Defense has resulted in the recent availability of a global Terra MODIS data stream, with the companion Aqua telemetry soon to follow. Preliminary METOC feedback regarding these products has been overwhelmingly positive, and provides the impetus for continued refinement. Examples of the current product's capabilities and limitations will be presented.

Hyperbaric and hypobaric chamber fires: a 73-year analysis.

PubMed

Sheffield, P J; Desautels, D A

1997-09-01

Fire can be catastrophic in the confined space of a hyperbaric chamber. From 1923 to 1996, 77 human fatalities occurred in 35 hyperbaric chamber fires, three human fatalities in a pressurized Apollo Command Module, and two human fatalities in three hypobaric chamber fires reported in Asia, Europe, and North America. Two fires occurred in diving bells, eight occurred in recompression (or decompression) chambers, and 25 occurred in clinical hyperbaric chambers. No fire fatalities were reported in the clinical hyperbaric chambers of North America. Chamber fires before 1980 were principally caused by electrical ignition. Since 1980, chamber fires have been primarily caused by prohibited sources of ignition that an occupant carried inside the chamber. Each fatal chamber fire has occurred in an enriched oxygen atmosphere (> 28% oxygen) and in the presence of abundant burnable material. Chambers pressurized with air (< 23.5% oxygen) had the only survivors. Information in this report was obtained from the literature and from the Undersea and Hyperbaric Medical Society's Chamber Experience and Mishap Database. This epidemiologic review focuses on information learned from critical analyses of chamber fires and how it can be applied to safe operation of hypobaric and hyperbaric chambers.

Arabian, Asian, western: a cross-cultural comparison of aircraft accidents from human factor perspectives.

PubMed

Al-Wardi, Yousuf

2017-09-01

Rates of aviation accident differ in different regions; and national culture has been implicated as a factor. This invites a discussion about the role of national culture in aviation accidents. This study makes a cross-cultural comparison between Oman, Taiwan and the USA. A cross-cultural comparison was acquired using data from three studies, including this study, by applying the Human Factors Analysis and Classification System (HFACS) framework. The Taiwan study presented 523 mishaps with 1762 occurrences of human error obtained from the Republic of China Air Force. The study from the USA carried out for commercial aviation had 119 accidents with 245 instances of human error. This study carried out in Oman had a total of 40 aircraft accidents with 129 incidences. Variations were found between Oman, Taiwan and the USA at the levels of organisational influence and unsafe supervision. Seven HFACS categories showed significant differences between the three countries (p < 0.05). Although not given much consideration, national culture can have an impact on aviation safety. This study revealed that national culture plays a role in aircraft accidents related to human factors that cannot be disregarded.

Automated validation of patient safety clinical incident classification: macro analysis.

PubMed

Gupta, Jaiprakash; Patrick, Jon

2013-01-01

Patient safety is the buzz word in healthcare. Incident Information Management System (IIMS) is electronic software that stores clinical mishaps narratives in places where patients are treated. It is estimated that in one state alone over one million electronic text documents are available in IIMS. In this paper we investigate the data density available in the fields entered to notify an incident and the validity of the built in classification used by clinician to categories the incidents. Waikato Environment for Knowledge Analysis (WEKA) software was used to test the classes. Four statistical classifier based on J48, Naïve Bayes (NB), Naïve Bayes Multinominal (NBM) and Support Vector Machine using radial basis function (SVM_RBF) algorithms were used to validate the classes. The data pool was 10,000 clinical incidents drawn from 7 hospitals in one state in Australia. In first part of the study 1000 clinical incidents were selected to determine type and number of fields worth investigating and in the second part another 5448 clinical incidents were randomly selected to validate 13 clinical incident types. Result shows 74.6% of the cells were empty and only 23 fields had content over 70% of the time. The percentage correctly classified classes on four algorithms using categorical dataset ranged from 42 to 49%, using free-text datasets from 65% to 77% and using both datasets from 72% to 79%. Kappa statistic ranged from 0.36 to 0.4. for categorical data, from 0.61 to 0.74. for free-text and from 0.67 to 0.77 for both datasets. Similar increases in performance in the 3 experiments was noted on true positive rate, precision, F-measure and area under curve (AUC) of receiver operating characteristics (ROC) scores. The study demonstrates only 14 of 73 fields in IIMS have data that is usable for machine learning experiments. Irrespective of the type of algorithms used when all datasets are used performance was better. Classifier NBM showed best performance. We think the classifier can be improved further by reclassifying the most confused classes and there is scope to apply text mining tool on patient safety classifications.

Medical Response, Search and Recovery during the Space Shuttle Columbia Accident Investigation

NASA Technical Reports Server (NTRS)

Stepaniak, Philip C.

2010-01-01

On February 1, 2003, the Space Shuttle Columbia broke apart during atmospheric re-entry on mission STS-107. After an event such as this, with high visibility and international interest, the operational challenge of recovering the crewmembers could not be underestimated. The Space Shuttle Program is organized to respond to a vehicle mishap using the resources of the Mishap Investigation Team (MIT). On the afternoon of Feb. 1, 2003, the MIT deployed to Barksdale Air Force Base (AFB), Louisiana. This location became the investigative center and interim storage location for crewmembers received from the Lufkin, Texas Disaster Field Office (DFO). The Lufkin DFO served as the primary area for all operations, including staging assets and deploying field teams for search, recovery and security of crewmember remains. More than 2,000 people from numerous organizations were involved with the recovery of the crew. All seven crewmembers of STS-107 were recovered and ceremonial last rights were administered. Astronaut and military personnel escorted the crew with honor to the MIT at Barksdale AFB, Louisiana. At Barksdale AFB a temporary morgue was established in an aircraft hangar and operated for approximately two weeks during which time coordination with the DFO field recovery teams, Armed Forces Institute of Pathology (AFIP) medical personnel, and the crew surgeons was on going. Families of crewmembers and NASA management were notified daily of the current findings. Working under the leadership of the MIT Lead, the medical team developed and executed a short-term plan to identify and relocate the crew with a military honor guard and protocol to the medical examiner at the Armed Forces Port Mortuary, Dover AFB, Delaware. After operations at Barksdale AFB were concluded the medical team transitioned back to Houston and a long-term plan was developed and implemented which involved the Air Force Mortuary Affairs at Randolph AFB, Texas. This plan was coordinated with search teams in the field, Barksdale AFB Mortuary Affairs, KSC security, AFIP, and the crew surgeons at JSC.

Advancing the integration of hospital IT. Pitfalls and perspectives when replacing specialized software for high-risk environments with enterprise system extensions.

PubMed

Engelmann, Carsten; Ametowobla, Dzifa

2017-05-17

Planning and controlling surgical operations hugely impacts upon productivity, patient safety, and surgeons' careers. Established, specialized software for this task is being increasingly replaced by "Operating Room (OR)-modules" appended to enterprise-wide resource planning (ERP) systems. As a result, usability problems are re-emerging and require developers' attention. Systematic evaluation of the functionality and social repercussions of a global, market-leading IT business control system (SAP R3, Germany), adapted for real-time OR process steering. Field study involving document analyses, interviews, and a 73-item survey addressed to 77 qualified (> 1-year system experience) senior planning executives (end users; "planners") working in surgical departments of university hospitals. Planners reported that 57% of electronic operation requests contained contradictory information. Key screens contained clinically irrelevant areas (36 +/- 29%). Compared to the legacy system, users reported either no improvements or worse performance, in regard to co-ordination of OR stakeholders, intra-day program changes, and safety. Planners concluded that the ERP-planning module was "non-intuitive" (66%), increased planning work (56%, p=0.002), and did not impact upon either organizational mishap spectrum or frequency. Interviews evidenced intra-institutional power shifts due to increased system complexity. Planners resented e.g. a trend towards increased personal culpability for mishap. Highly complex enterprise system extensions may not be directly suited to specific process steering tasks in a high risk/low error-environment like the OR. In view of surgeons' high primary task load, the repeated call for simpler IT is an imperative for ERP extensions. System design should consider a) that current OR IT suffers from an input limitation regarding planning-relevant real-time data, and b) that there are social processes that strongly affect planning and particularly ERP use beyond algorithms. Real improvement of clinical IT tools requires their independent evaluation according to standards developed for pharmaceutical subjects.

NASA Tech Briefs, October 2010

NASA Technical Reports Server (NTRS)

2010-01-01

Topics covered include: Hybrid Architecture Active Wavefront Sensing and Control; Carbon-Nanotube-Based Chemical Gas Sensor; Aerogel-Positronium Technology for the Detection of Small Quantities of Organic and/or Toxic Materials; Graphene-Based Reversible Nano-Switch/Sensor Schottky Diode; Inductive Non-Contact Position Sensor; High-Temperature Surface-Acoustic-Wave Transducer; Grid-Sphere Electrodes for Contact with Ionospheric Plasma; Enabling IP Header Compression in COTS Routers via Frame Relay on a Simplex Link; Ka-Band SiGe Receiver Front-End MMIC for Transponder Applications; Robust Optimization Design Algorithm for High-Frequency TWTs; Optimal and Local Connectivity Between Neuron and Synapse Array in the Quantum Dot/Silicon Brain; Method and Circuit for In-Situ Health Monitoring of Solar Cells in Space; BGen: A UML Behavior Network Generator Tool; Platform for Post-Processing Waveform-Based NDE; Electrochemical Hydrogen Peroxide Generator; Fabrication of Single, Vertically Aligned Carbon Nanotubes in 3D Nanoscale Architectures; Process to Create High-Fidelity Lunar Dust Simulants; Lithium-Ion Electrolytes Containing Phosphorous-Based, Flame-Retardant Additives; InGaP Heterojunction Barrier Solar Cells; Straight-Pore Microfilter with Efficient Regeneration; Determining Shear Stress Distribution in a Laminate; Self-Adjusting Liquid Injectors for Combustors; Handling Qualities Prediction of an F-16XL-Based Reduced Sonic Boom Aircraft; Tele-Robotic ATHLETE Controller for Kinematics - TRACK; Three-Wheel Brush-Wheel Sampler; Heterodyne Interferometer Angle Metrology; Aligning Astronomical Telescopes via Identification of Stars; Generation of Optical Combs in a WGM Resonator from a Bichromatic Pump; Large-Format AlGaN PIN Photodiode Arrays for UV Images; Fiber-Coupled Planar Light-Wave Circuit for Seed Laser Control in High Spectral Resolution Lidar Systems; On Calculating the Zero-Gravity Surface Figure of a Mirror; Optical Modification of Casimir Forces for Improved Function of Micro- and Nano-Scale Devices; Analysis, Simulation, and Verification of Knowledge-Based, Rule-Based, and Expert Systems; Core and Off-Core Processes in Systems Engineering; Digital Reconstruction Supporting Investigation of Mishaps; and Template Matching Approach to Signal Prediction.

Impact of identity theft on methods of identification.

PubMed

McLemore, Jerri; Hodges, Walker; Wyman, Amy

2011-06-01

Responsibility for confirming a decedent's identity commonly falls on the shoulders of the coroner or medical examiner. Misidentification of bodies results in emotional turmoil for the next-of-kin and can negatively impact the coroner's or medical examiner's career. To avoid such mishaps, the use of scientific methods to establish a positive identification is advocated. The use of scientific methods of identification may not be reliable in cases where the decedent had assumed the identity of another person. Case studies of erroneously identified bodies due to identity theft from the state medical examiner offices in Iowa and New Mexico are presented. This article discusses the scope and major concepts of identity theft and how identity theft prevents the guarantee of a positive identification.

Interdependence theory of tissue failure: bulk and boundary effects

PubMed Central

Suma, Daniel; Acun, Aylin; Zorlutuna, Pinar

2018-01-01

The mortality rate of many complex multicellular organisms increases with age, which suggests that net ageing damage is accumulative, despite remodelling processes. But how exactly do these little mishaps in the cellular level accumulate and spread to become a systemic catastrophe? To address this question we present experiments with synthetic tissues, an analytical model consistent with experiments, and a number of implications that follow the analytical model. Our theoretical framework describes how shape, curvature and density influences the propagation of failure in a tissue subjected to oxidative damage. We propose that ageing is an emergent property governed by interaction between cells, and that intercellular processes play a role that is at least as important as intracellular ones. PMID:29515857

[Value of ultrasonically-guided liver puncture biopsy in the diagnosis of primary liver cancer. Apropos of 84 cases].

PubMed

Peghini, M; Eynard, J P; Vergne, R; Seurat, P; Barabe, P; Aubry, P; Diallo, A; Gueye, P M

1987-01-01

Ultrasonographicaly guided fine needle aspiration of liver was performed in 84 patients having a confirmed HCC. This technics utilizes a CHIBA type fine needle, after blood coagulation tests have been checked. Out of 84 fine needle aspirations performed: 64 were positive (76,2%), 9 negative (10,7%), 11 (13,19%) were questionable (6) or nonanalysable (5). It is ascertained that the sensibility of this technics is over 75%. It should be possible to improve it by repeating such an exam in previously negative patients. The causes of failure are discussed. Tolerance of the technics is good. It is attraumatic, and of very easily performance. No accident, no mishap was noted.

Fighting Testing ACAT/FRRP: Automatic Collision Avoidance Technology/Fighter Risk Reduction Project

NASA Technical Reports Server (NTRS)

Skoog, Mark A.

2009-01-01

This slide presentation reviews the work of the Flight testing Automatic Collision Avoidance Technology/Fighter Risk Reduction Project (ACAT/FRRP). The goal of this project is to develop common modular architecture for all aircraft, and to enable the transition of technology from research to production as soon as possible to begin to reduce the rate of mishaps. The automated Ground Collision Avoidance System (GCAS) system is designed to prevent collision with the ground, by avionics that project the future trajectory over digital terrain, and request an evasion maneuver at the last instance. The flight controls are capable of automatically performing a recovery. The collision avoidance is described in the presentation. Also included in the presentation is a description of the flight test.

Fiber Optic Wing Shape Sensing on NASA's Ikhana UAV

NASA Technical Reports Server (NTRS)

Richards, Lance; Parker, Allen R.; Ko, William L.; Piazza, Anthony

2008-01-01

This document discusses the development of fiber optic wing shape sensing on NASA's Ikhana vehicle. The Dryden Flight Research Center's Aerostructures Branch initiated fiber-optic instrumentation development efforts in the mid-1990s. Motivated by a failure to control wing dihedral resulting in a mishap with the Helios aircraft, new wing displacement techniques were developed. Research objectives for Ikhana included validating fiber optic sensor measurements and real-time wing shape sensing predictions; the validation of fiber optic mathematical models and design tools; assessing technical viability and, if applicable, developing methodology and approaches to incorporate wing shape measurements within the vehicle flight control system; and, developing and flight validating approaches to perform active wing shape control using conventional control surfaces and active material concepts.

NASA Hydrogen Peroxide Propellant Hazards Technical Manual

NASA Technical Reports Server (NTRS)

Baker, David L.; Greene, Ben; Frazier, Wayne

2005-01-01

The Fire, Explosion, Compatibility and Safety Hazards of Hydrogen Peroxide NASA technical manual was developed at the NASA Johnson Space Center White Sands Test Facility. NASA Technical Memorandum TM-2004-213151 covers topics concerning high concentration hydrogen peroxide including fire and explosion hazards, material and fluid reactivity, materials selection information, personnel and environmental hazards, physical and chemical properties, analytical spectroscopy, specifications, analytical methods, and material compatibility data. A summary of hydrogen peroxide-related accidents, incidents, dose calls, mishaps and lessons learned is included. The manual draws from art extensive literature base and includes recent applicable regulatory compliance documentation. The manual may be obtained by United States government agencies from NASA Johnson Space Center and used as a reference source for hazards and safe handling of hydrogen peroxide.

Beware of "black swans" and "perfect storms:" the principle of plenitude and office-based anesthesia.

PubMed

Treasure, Trevor E

2014-08-01

A paradigm shift in the training, practice, and study of office-based anesthesia is necessary for our specialty. Practice improvement plans are required to prevent low-probability-high-consequence anesthesia mishaps in our offices. A scarcity of statistical data exists regarding the true risk of office-based anesthesia in oral and maxillofacial surgery. Effective proactive risk management mandates accurate data to correctly outline the problem before solutions can be implemented. Only by learning from our mistakes, will we be able to reduce errors and improve patient safety: "The only real mistake is the one from which we learn nothing"--John Powell. Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Orbiter Payload Bay Bucket Hoist Mishap...An Accident We Should Never Forget

NASA Technical Reports Server (NTRS)

Lytle, Bradford P.

2009-01-01

This slide presentation reviews the accident that occurred in 1985 when a bay bucket hoist fell from its stowed position. This accident damaged the orbiter, injured a technician, and delayed the launch. The accident was investigated, and the cause of the accident was determined to be the practice of two-blocking. Two-blocking is the result of hoisting beyond the intended safe upper limit of hook travel to the point of solid contact between the load block and the upper block or hoist/trolley structure. The usual result is immediate failure of the wire rope, due to the ropes being cut by the grooves of the drum or sheaves. The design of the hoist, the inspection, and the operator training were all in part responsible for this failure.

Kerr-McGee and the NRC: from Indian country to Silkwood to Gore.

PubMed

Baer, H

1990-01-01

By focusing upon the Nuclear Regulatory Commission's appraisal of the Kerr-McGee Corporation's safety record in the Four Corners area and at two facilities in Oklahoma, this article examines the political economy of nuclear regulation in American society. Particular attention is given to the agency's response to intervenor groups which protested various operations at Kerr-McGee facility in Gore, Oklahoma, both prior to and following the accidental rupture of a cylinder containing uranium hexafluoride. Despite a consistent record of violations and nuclear mishaps by Kerr-McGee, the Nuclear Regulatory Commission permitted the company to essentially monitor its own activities. Rather than protecting workers and the public from the hazards of the nuclear industry, state regulation attempts to legitimize and defuse public opposition to its endeavors.

jsc2018m000297_Investigation_Seeks_to_Create_Self-Assembling_Materials-MP4

NASA Image and Video Library

2018-05-14

Investigation Seeks to Create Self-Assembling Materials------ As we travel farther into space, clever solutions to problems like engine part malfunctions and other possible mishaps will be a vital part of the planning process. 3D printing, or additive manufacturing, is an emerging technology that may be used to custom-create mission-critical parts. An integral piece of this process is understanding how particle shape, size distribution and packing behavior affect the manufacturing process. The Advanced Colloids Experiment-Temperature-7 investigation (ACE-T-7) aboard the International Space Station explores the feasibility of creating self-assembling microscopic particles for use in the manufacturing of materials during spaceflight. Read more about ACE-T-& here: https://www.nasa.gov/feature/investigation-seeks-to-create-self-assembling-materials

Project Morpheus: Morpheus 1.5A Lander Failure Investigation Results

NASA Technical Reports Server (NTRS)

Devolites, Jennifer L.; Olansen, Jon B.; Munday, Stephen R.

2013-01-01

On August 9, 2012 the Morpheus 1.5A vehicle crashed shortly after lift off from the Kennedy Space Center. The loss was limited to the vehicle itself which was pre-declared to be a test failure and not a mishap. The Morpheus project is demonstrating advanced technologies for in space and planetary surface vehicles including: autonomous flight control, landing site hazard identification and safe site selection, relative surface and hazard navigation, precision landing, modular reusable flight software, and high performance, non-toxic, cryogenic liquid Oxygen and liquid Methane integrated main engine and attitude control propulsion system. A comprehensive failure investigation isolated the fault to the Inertial Measurement Unit (IMU) data path to the flight computer. Several improvements have been identified and implemented for the 1.5B and 1.5C vehicles.

Driving with diabetes: precaution, not prohibition, is the proper approach.

PubMed

Kohrman, Daniel B

2013-03-01

Safety issues posed by driving with diabetes are primarily related to severe hypoglycemia, yet some public authorities rely on categorical restrictions on drivers with diabetes. This approach is misguided. Regulation of all drivers with diabetes, or all drivers using insulin, ignores the diversity of people with diabetes and fails to focus on the subpopulation posing the greatest risk. Advances in diabetes care technology and understanding of safety consequences of diabetes have expanded techniques available to limit risks of driving with diabetes. New means of insulin administration and blood glucose monitoring offer greater ease of anticipating and preventing hypoglycemia, and thus, limit driving risk for persons with diabetes. So too do less sophisticated steps taken by people with diabetes and the health care professionals they consult. These include adoption and endorsement of safety-sensitive behaviors, such as testing before a drive and periodic testing on longer trips. Overall, and in most individual cases, driving risks for persons with diabetes are less than those routinely tolerated by our society. Examples include freedom to drive in dangerous conditions and lax regulation of drivers in age and medical cohorts with elevated overall rates of driving mishaps. Data linking specific diabetes symptoms or features with driving risk are quite uncertain. Hence, there is much to recommend: a focus on technological advances, human precautions, and identifying individuals with diabetes with a specific history of driving difficulty. By contrast, available evidence does not support unfocused regulation of all or most drivers with diabetes. © 2013 Diabetes Technology Society.

Driving with Diabetes: Precaution, Not Prohibition, Is the Proper Approach

PubMed Central

Kohrman, Daniel B.

2013-01-01

Safety issues posed by driving with diabetes are primarily related to severe hypoglycemia, yet some public authorities rely on categorical restrictions on drivers with diabetes. This approach is misguided. Regulation of all drivers with diabetes, or all drivers using insulin, ignores the diversity of people with diabetes and fails to focus on the subpopulation posing the greatest risk. Advances in diabetes care technology and understanding of safety consequences of diabetes have expanded techniques available to limit risks of driving with diabetes. New means of insulin administration and blood glucose monitoring offer greater ease of anticipating and preventing hypoglycemia, and thus, limit driving risk for persons with diabetes. So too do less sophisticated steps taken by people with diabetes and the health care professionals they consult. These include adoption and endorsement of safety-sensitive behaviors, such as testing before a drive and periodic testing on longer trips. Overall, and in most individual cases, driving risks for persons with diabetes are less than those routinely tolerated by our society. Examples include freedom to drive in dangerous conditions and lax regulation of drivers in age and medical cohorts with elevated overall rates of driving mishaps. Data linking specific diabetes symptoms or features with driving risk are quite uncertain. Hence, there is much to recommend: a focus on technological advances, human precautions, and identifying individuals with diabetes with a specific history of driving difficulty. By contrast, available evidence does not support unfocused regulation of all or most drivers with diabetes. PMID:23566992

Human Factors Throughout the Life Cycle: Lessons Learned from the Shuttle Program. [Human Factors in Ground Processing

NASA Technical Reports Server (NTRS)

Kanki, Barbara G.

2011-01-01

With the ending of the Space Shuttle Program, it is critical that we not forget the Human Factors lessons we have learned over the years. At every phase of the life cycle, from manufacturing, processing and integrating vehicle and payload, to launch, flight operations, mission control and landing, hundreds of teams have worked together to achieve mission success in one of the most complex, high-risk socio-technical enterprises ever designed. Just as there was great diversity in the types of operations performed at every stage, there was a myriad of human factors that could further complicate these human systems. A single mishap or close call could point to issues at the individual level (perceptual or workload limitations, training, fatigue, human error susceptibilities), the task level (design of tools, procedures and aspects of the workplace), as well as the organizational level (appropriate resources, safety policies, information access and communication channels). While we have often had to learn through human mistakes and technological failures, we have also begun to understand how to design human systems in which individuals can excel, where tasks and procedures are not only safe but efficient, and how organizations can foster a proactive approach to managing risk and supporting human enterprises. Panelists will talk about their experiences as they relate human factors to a particular phase of the shuttle life cycle. They will conclude with a framework for tying together human factors lessons-learned into system-level risk management strategies.

A Chief Engineer's View of the NASA X-43A Scramjet Flight Test

NASA Technical Reports Server (NTRS)

Marshall, Laurie A.; Corpening, Griffin P.; Sherrill, Robert

2005-01-01

This paper presents an overview of the preparation and execution of the first two flights of the NASA X-43A scramjet flight test project. The project consisted of three flights, two planned for Mach 7 and one for Mach 10. The first flight, conducted on June 2, 2001, was unsuccessful and resulted in a nine-month mishap investigation. A two-year return to flight effort ensued and concluded when the second Mach 7 flight was successfully conducted on March 27, 2004. The challenges faced by the project team as they prepared the first ever scramjet-powered airplane for flight are presented. Modifications made to the second flight vehicle as a result of the first flight failure and the return to flight activities are discussed. Flight results and lessons learned are also presented.

"It Can Bust at Any Seam": Lessons for Deep Space Flight from Mawson's 1911-1914 Australasian Antarctic Expedition

NASA Astrophysics Data System (ADS)

Wallace, Phillip Scott

2010-09-01

Lessons useful for manned space flight can be gained by looking at exploring expeditions of the past. An aviation-accident style investigation was conducted on two fatalities that occurred on an Antarctic expedition in 1912-13. The causal factors of the accidents were determined; and lessons for future missions beyond LEO gleaned from both the causal factors and from looking at the expedition as a whole. The investigation highlighted, among other things, that probabilistic hazards can eventually take a life and that factors of terrain can and will damage equipment and kill men; that consumables should be segregated such that one mishap does not reduce margins to below those needed for survival, and that manned missions need to be able to jury-rig equipment in the field.

KSC off-runway contingency operation - Mode 7

NASA Technical Reports Server (NTRS)

Maples, Arthur; Doerr, Donald

1991-01-01

The possibility of a mishap during a space shuttle landing at Kennedy Space Center (KSC) dictates the need for plans to rescue astronauts from areas other than the Shuttle Landing Facility (SLF). All shuttle landings are unpowered, gliding flight maneuvers, and a deviation from the planned flight profile could result in a shuttle landing or crashing somewhere other than the SLF runway. The geography of the Kennedy Space Center makes helicopter airlifting the only universal means of transportation for the rescue crew. This rescue crew is composed of KSC contractor fire-rescuemen who would ride to the crash scene on USAF HH-3 helicopters. These crews are provided with personal protective suits and training in shallow water, swamp, and dry land rescues. They aid the egress of the crew to a safe area for helicopter pickup and subsequent triage and medevac.

[Pigeon sport and animal rights].

PubMed

Warzecha, M

2007-03-01

To begin, a short overview of the organization and the realization of the racing pigeon sport. Some physiological facts, relevant to racing pigeons, will be touched on. Lastly, a focus on the flights, their completion and the problems involved with the, in some cases, high number of lost pigeons. The German Club of Pigeon Breeders, has made improvements but, it is certainly not enough. The topic of "City Pigeons" will be briefed. The final part deals with pertinent animal rights issues, causes of mishaps, and some rectifying possibilities, which are available to the government veterinarian. Special emphasis will be placed on the international uniformity of this issue. The lecture should prove that there is a need for every government veterinarian to become actively involved, because the described problematic has a major effect on a very large number of animals.

Automated vehicle for railway track fault detection

NASA Astrophysics Data System (ADS)

Bhushan, M.; Sujay, S.; Tushar, B.; Chitra, P.

2017-11-01

For the safety reasons, railroad tracks need to be inspected on a regular basis for detecting physical defects or design non compliances. Such track defects and non compliances, if not detected in a certain interval of time, may eventually lead to severe consequences such as train derailments. Inspection must happen twice weekly by a human inspector to maintain safety standards as there are hundreds and thousands of miles of railroad track. But in such type of manual inspection, there are many drawbacks that may result in the poor inspection of the track, due to which accidents may cause in future. So to avoid such errors and severe accidents, this automated system is designed.Such a concept would surely introduce automation in the field of inspection process of railway track and can help to avoid mishaps and severe accidents due to faults in the track.

How safe is deep sedation or general anesthesia while providing dental care?

PubMed

Bennett, Jeffrey D; Kramer, Kyle J; Bosack, Robert C

2015-09-01

Deep sedation and general anesthesia are administered daily in dental offices, most commonly by oral and maxillofacial surgeons and dentist anesthesiologists. The goal of deep sedation or general anesthesia is to establish a safe environment in which the patient is comfortable and cooperative. This requires meticulous care in which the practitioner balances the patient's depth of sedation and level of responsiveness while maintaining airway integrity, ventilation, and cardiovascular hemodynamics. Using the available data and informational reports, the authors estimate that the incidence of death and brain injury associated with deep sedation or general anesthesia administered by all dentists most likely exceeds 1 per month. Airway compromise is a significant contributing factor to anesthetic complications. The American Society of Anesthesiology closed claim analysis also concluded that human error contributed highly to anesthetic mishaps. The establishment of a patient safety database for anesthetic management in dentistry would allow for a more complete assessment of morbidity and mortality that could direct efforts to further increase safe anesthetic care. Deep sedation and general anesthesia can be safely administered in the dental office. Optimization of patient care requires appropriate patient selection, selection of appropriate anesthetic agents, utilization of appropriate monitoring, and a highly trained anesthetic team. Achieving a highly trained anesthetic team requires emergency management preparation that can foster decision making, leadership, communication, and task management. Copyright © 2015 American Dental Association. Published by Elsevier Inc. All rights reserved.

Burn hazards of the deployed environment in wartime: epidemiology of noncombat burns from ongoing United States military operations.

PubMed

Kauvar, David S; Wade, Charles E; Baer, David G

2009-10-01

Service in the deployed military environment carries risks for accidental (noncombat-related) burns. Examining these risks can assist in the development of military burn prevention measures. This study endeavored to examine noncombat burn epidemiology in the context of similar civilian data. We performed a retrospective cohort study of consecutive casualties evacuated from operational military theaters in Iraq and Afghanistan to the sole tertiary military burn center in the US. Military data were compared with database samples of the US population from the American Burn Association and the Centers for Disease Control and Prevention. The main causes of the 180 noncombat burns seen from March 2003 to June 2008 were waste burning, fuel mishaps, and unintentional ordinance detonations. Overall prevalence of noncombat burns was 19.5 burns/100,000 person-years lived. If causes specific to military operations are removed, military prevalence was 13.0/100,000. More than one-third of noncombat burns occurred in the first year of the study; a period of stability followed. A similar US population had an accidental burn prevalence of 7.1/100,000 from 2003 to 2007. Burn size, presence of inhalation injury, and burn center mortality were not different from those in a similar civilian cohort. Deployed service members have a greater risk of unintentional burns than a similar civilian cohort does. This is in part because of the specific dangers of military activities. More attention to deployed military burn prevention is needed, especially early in combat support operations.

Reduction and mitigation of thermal injuries: what can be done?

PubMed

Voisine, J J; Albano, J P

1996-01-01

Soon after the introduction of the crashworthy fuel system and Nomex flight apparel, morbidity and mortality rates from thermal injuries in aviation were reduced to zero. Although the incidence of aircraft mishaps involving postcrash fires have remained the same, there has been a recent increase in thermal injury morbidity. These case reports describe three different aircraft accidents in which fire was caused by factors other than the crashworthy fuel system. They also describe sustained thermal injuries and compare them to personal protection equipment. We found that the condition of the personal protective equipment and unauthorized use of unapproved apparel were responsible for the sustained injuries. We maintain that personal protection equipment is effective if worn in the manner for which it was designed. We believe that the lessons learned apply to all military operations where the risk of fire is high, not solely aviation. A proactive program focused on education would reduce the thermal injury morbidity.

Manual transmission enhances attention and driving performance of ADHD adolescent males: pilot study.

PubMed

Cox, Daniel J; Punja, Mohan; Powers, Katie; Merkel, R Lawrence; Burket, Roger; Moore, Melissa; Thorndike, Frances; Kovatchev, Boris

2006-11-01

Inattention is a major contributor to driving mishaps and is especially problematic among adolescent drivers with ADHD, possibly contributing to their 2 to 4 times higher incidence of collisions. Manual transmission has been demonstrated to be associated with greater arousal. This study tests the hypotheses that manual transmission, compared to automatic transmission, would be associated with better attention and performance on a driving simulator. Ten adolescent drivers with ADHD practice driving on the simulator in the manual and automatic mode. Employing a single-blind, cross-over design, participants drive the simulator at 19:30 and 22:30 hr for 30 min in both transmissions and rate their attention to driving. Subjectively, participants report being more attentive while driving in manual transmission mode. Objectively, participants drive safer in the manual transmission mode. Although in need of replication, this pilot study suggests a behavioral intervention to improve driving performance among ADHD adolescents.

Erratum: ``Localized Enhancements of Fe+10 Density in the Corona as Observed in Fe XI 789.2 nm during the 2006 March 29 Total Solar Eclipse'' (ApJ, 663, 598 [2007])

NASA Astrophysics Data System (ADS)

Habbal, Shadia Rifai; Morgan, Huw; Johnson, Judd; Arndt, Martina Belz; Daw, Adrian; Jaeggli, Sarah; Kuhn, Jeff; Mickey, Don

2007-12-01

The eclipse image of Figure 3 was provided to the authors by Jackob Strikis of the Elizabeth Observatory, Athens, who claimed authorship. However, shortly after publication the authors discovered that this eclipse image was in fact a preliminary version of an image belonging to Prof. Miloslav Druckmüller, taken during the 2006 total solar eclipse from Libya at 30°56.946' N, 24°14.301' E, and at an altitude of 158 m. This image can be found at ApJ, 663, 598 [2007]. We extend our gratitude to Prof. Druckmüller, from Brno University of Technology, Czech Republic, who brought this incident to our attention, and who has graciously accepted our apology for this unintentional mishap. A forthcoming article in collaboration with Prof. Druckmüller is in preparation.

Procedural mishaps with trephine-based intraosseous anesthesia.

PubMed

Small, Joel C; Witherspoon, David E; Regan, John D; Hall, Ellen

2011-01-01

Failure to achieve profound anesthesia during dental treatment can be a significant problem for dental clinicians, especially for endodontic procedures on teeth in the mandibular arch with irreversible pulpitis. A number of supplemental local anesthesia techniques exist, the most effective of which may be the intraosseous injection. Two cases are presented demonstrating the dangers associated with the use of the intraosseous anesthesia technique. While the technique can provide profound anesthesia in otherwise difficult to anesthetize cases, care must be taken during its administration. Both cases show the damage done to the root and overlying bone by the injudicious use of the trephine. It is incumbent on the clinician to fully consider the anatomy in the area prior to insertion of the trephine. Intraosseous anesthesia techniques are a valuable addition to the clinicians' armamentarium. However careless administration can result in problems of endodontic or periodontal nature that may be difficult to rectify.

[Intravenous Sedation and Repeated "the Same Day General Anesthesia" for a School-age Boy with Dandy-Walker Syndrome and Dentinogenesis].

PubMed

Hitosugi, Takashi; Tsukamoto, Masanori; Fujiwara, Shigeki; Yokoyama, Takeshi

2016-03-01

Dandy-Walker syndrome (DWS) is characterized by perfect or partial defect of the cerebellum vermis and cystic dilatation of the posterior fossa communicating with the fourth ventricle. Common clinical signs are mental retardation, cerebellar ataxia, and those of increased intracranial pressure (ICP). Associated congenital anomalies are craniofacial, cardiac, renal, and skeletal abnormalities. We experienced a case of intravenous sedation and six times of "the same day" general anesthesia for a school-aged boy (10-13 years old) with DWS and hypodentinogenesis. The patient underwent an examination and dental treatments. We had to pay attention to airway management tracheal tube selection and control of ICP. In addition, we should prevent tooth injuries through mishaps during tracheal intubations, since all-tooth-hypoplasia with fragile dental crowns was strongly suggested in this case. Detailed postoperative care is also required for general anesthesia afflicted with DWS.

To catch a child's imagination 2: Educational update on CAN-DO

NASA Technical Reports Server (NTRS)

Nicholson, James H.

1987-01-01

At the G.A.S. Symposium last year, the Charleston County Public School CAN DO Project outlined an ambitious educational program revolving around the photography of Comet Halley from the Shuttle using a GAS canister. The target flight was STS 61-E scheduled for a March, 1986, launch. Such strict time constraints and highly specific mission requirements made the CAN DO program even more risky than normal. In spite of this, almost all of the planned educational goals were achieved, even after the postponement of all Shuttle activities in January of 1986. This follow-up paper summarizes the effects of events on the program as proposed and the attempts to carry out as many of the activities as possible. It is hoped that this paper will suggest constructive ways in which to cope with the delays and mishaps that are the invariable lot of pioneers who break new ground and attempt the new and untried.

Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology

PubMed Central

Naik, Aanand Dinkar; Rao, Raghuram; Petersen, Laura Ann

2008-01-01

Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record. PMID:18373151

Patient safety: lessons learned.

PubMed

Bagian, James P

2006-04-01

The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report "To Err Is Human: Building a Safer Health System." However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence "shame and blame") to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.

Effects of prosocial video games on prosocial behavior.

PubMed

Greitemeyer, Tobias; Osswald, Silvia

2010-02-01

Previous research has documented that playing violent video games has various negative effects on social behavior in that it causes an increase in aggressive behavior and a decrease in prosocial behavior. In contrast, there has been much less evidence on the effects of prosocial video games. In the present research, 4 experiments examined the hypothesis that playing a prosocial (relative to a neutral) video game increases helping behavior. In fact, participants who had played a prosocial video game were more likely to help after a mishap, were more willing (and devoted more time) to assist in further experiments, and intervened more often in a harassment situation. Results further showed that exposure to prosocial video games activated the accessibility of prosocial thoughts, which in turn promoted prosocial behavior. Thus, depending on the content of the video game, playing video games not only has negative effects on social behavior but has positive effects as well. Copyright 2009 APA, all rights reserved

Managing medical mistakes: ideology, insularity and accountability among internists-in-training.

PubMed

Mizrahi, T

1984-01-01

By the end of graduate medical training, novice internists (collectively known as the housestaff) were initiated into the experience of either having done something to a patient which had a deleterious consequence or else having witnessed colleagues do the same. When these events occurred, the housestaff engaged in social-psychological processes, utilizing a variety of coping mechanisms and in-group practices to manage these mishaps. Three major mechanisms were utilized by the housestaff for defining and defending the various mishaps which frequently occurred: denial, discounting and distancing. Denial consisted of three components: the negation of the concept of error by defining the practice of medicine as an art with 'gray areas', the repression of actual mistakes by forgetting them and the redefinition of mistakes to non-mistakes. Discounting included those defenses which externalized the blame; namely mistakes which were due to circumstances beyond their control. These included: blaming the bureaucratic system outside of medicine; blaming superiors or subordinates within internal medicine; blaming the disease and blaming the patient. When they could not longer deny or discount a mistake because of its magnitude, they utilized distancing techniques. Not withstanding this shared elaborate repertoire of denial, discounting and distancing, it was found that profound doubts and even guilt remained for many housestaff. These troublesome feelings neither easily nor automatically resolved themselves. Interspersed among their defenses were fundamental questions of culpability and responsibility as they vacillated between self and other blame. For many 'the case was never closed', even as they terminated formal training, a point neglected in the medical and sociological literature. Little in their 3 year graduate program allowed them to work through the attendant vulnerability and ambiguity accompanying the managing of mistakes. Hence, there were maladaptive aspects of the collectively acquired defense mechanisms. The whole system of accountability during graduate medical specialty training was found to be a variable, and at times, contradictory process. The housestaff ultimately sees itself as the sole arbiter of mistakes and their adjudication. Housestaffers come to feel that nobody can judge them or their decisions, least of all their patients. As they progress through training even internal accountability cohorts--the Department of Medicine, teaching faculty and peers--are discounted to varying degrees. They have developed a strong ideology justifying their jealously guarded autonomy.(ABSTRACT TRUNCATED AT 400 WORDS)

Generalized seismic analysis

NASA Technical Reports Server (NTRS)

Butler, Thomas G.

1993-01-01

There is a constant need to be able to solve for enforced motion of structures. Spacecraft need to be qualified for acceleration inputs. Truck cargoes need to be safeguarded from road mishaps. Office buildings need to withstand earthquake shocks. Marine machinery needs to be able to withstand hull shocks. All of these kinds of enforced motions are being grouped together under the heading of seismic inputs. Attempts have been made to cope with this problem over the years and they usually have ended up with some limiting or compromise conditions. The crudest approach was to limit the problem to acceleration occurring only at a base of a structure, constrained to be rigid. The analyst would assign arbitrarily outsized masses to base points. He would then calculate the magnitude of force to apply to the base mass (or masses) in order to produce the specified acceleration. He would of necessity have to sacrifice the determination of stresses in the vicinity of the base, because of the artificial nature of the input forces. The author followed the lead of John M. Biggs by using relative coordinates for a rigid base in a 1975 paper, and again in a 1981 paper . This method of relative coordinates was extended and made operational as DMAP ALTER packets to rigid formats 9, 10, 11, and 12 under contract N60921-82-C-0128. This method was presented at the twelfth NASTRAN Colloquium. Another analyst in the field developed a method that computed the forces from enforced motion then applied them as a forcing to the remaining unknowns after the knowns were partitioned off. The method was translated into DMAP ALTER's but was never made operational. All of this activity jelled into the current effort. Much thought was invested in working out ways to unshakle the analysis of enforced motions from the limitations that persisted.

Generalized seismic analysis

NASA Astrophysics Data System (ADS)

Butler, Thomas G.

1993-09-01

There is a constant need to be able to solve for enforced motion of structures. Spacecraft need to be qualified for acceleration inputs. Truck cargoes need to be safeguarded from road mishaps. Office buildings need to withstand earthquake shocks. Marine machinery needs to be able to withstand hull shocks. All of these kinds of enforced motions are being grouped together under the heading of seismic inputs. Attempts have been made to cope with this problem over the years and they usually have ended up with some limiting or compromise conditions. The crudest approach was to limit the problem to acceleration occurring only at a base of a structure, constrained to be rigid. The analyst would assign arbitrarily outsized masses to base points. He would then calculate the magnitude of force to apply to the base mass (or masses) in order to produce the specified acceleration. He would of necessity have to sacrifice the determination of stresses in the vicinity of the base, because of the artificial nature of the input forces. The author followed the lead of John M. Biggs by using relative coordinates for a rigid base in a 1975 paper, and again in a 1981 paper . This method of relative coordinates was extended and made operational as DMAP ALTER packets to rigid formats 9, 10, 11, and 12 under contract N60921-82-C-0128. This method was presented at the twelfth NASTRAN Colloquium. Another analyst in the field developed a method that computed the forces from enforced motion then applied them as a forcing to the remaining unknowns after the knowns were partitioned off. The method was translated into DMAP ALTER's but was never made operational. All of this activity jelled into the current effort. Much thought was invested in working out ways to unshakle the analysis of enforced motions from the limitations that persisted.

Pilot perception and confidence of location during a simulated helicopter navigation task.

PubMed

Yang, Ji Hyun; Cowden, Bradley T; Kennedy, Quinn; Schramm, Harrison; Sullivan, Joseph

2013-09-01

This paper aims to provide insights into human perception, navigation performance, and confidence in helicopter overland navigation. Helicopter overland navigation is a challenging mission area because it is a complex cognitive task, and failing to recognize when the aircraft is off-course can lead to operational failures and mishaps. A human-in-the-loop experiment to investigate pilot perception during simulated overland navigation by analyzing actual navigation trajectory, pilots' perceived location, and corresponding confidence levels was designed. There were 15 military officers with prior overland navigation experience who completed 4 simulated low-level navigation routes, 2 of which entailed auto-navigation. This route was paused roughly every 30 s for the subject to mark their perceived location on the map and their confidence level using a customized program. Analysis shows that there is no correlation between perceived and actual location of the aircraft, nor between confidence level and actual location. There is, however, some evidence that there is a correlation (rho = -0.60 to approximately 0.65) between perceived location and intended route of flight, suggesting that there is a bias toward believing one is on the intended flight route. If aviation personnel can proactively identify the circumstances in which usual misperceptions occur in navigation, they may reduce mission failure and accident rate. Fleet squadrons and instructional commands can benefit from this study to improve operations that require low-level flight while also improving crew resource management.

Improving Patient Safety in Hospitals: Contributions of High-Reliability Theory and Normal Accident Theory

PubMed Central

Tamuz, Michal; Harrison, Michael I

2006-01-01

Objective To identify the distinctive contributions of high-reliability theory (HRT) and normal accident theory (NAT) as frameworks for examining five patient safety practices. Data Sources/Study Setting We reviewed and drew examples from studies of organization theory and health services research. Study Design After highlighting key differences between HRT and NAT, we applied the frames to five popular safety practices: double-checking medications, crew resource management (CRM), computerized physician order entry (CPOE), incident reporting, and root cause analysis (RCA). Principal Findings HRT highlights how double checking, which is designed to prevent errors, can undermine mindfulness of risk. NAT emphasizes that social redundancy can diffuse and reduce responsibility for locating mistakes. CRM promotes high reliability organizations by fostering deference to expertise, rather than rank. However, HRT also suggests that effective CRM depends on fundamental changes in organizational culture. NAT directs attention to an underinvestigated feature of CPOE: it tightens the coupling of the medication ordering process, and tight coupling increases the chances of a rapid and hard-to-contain spread of infrequent, but harmful errors. Conclusions Each frame can make a valuable contribution to improving patient safety. By applying the HRT and NAT frames, health care researchers and administrators can identify health care settings in which new and existing patient safety interventions are likely to be effective. Furthermore, they can learn how to improve patient safety, not only from analyzing mishaps, but also by studying the organizational consequences of implementing safety measures. PMID:16898984

The hazard of spatial disorientation during helicopter flight using night vision devices.

PubMed

Braithwaite, M G; Douglass, P K; Durnford, S J; Lucas, G

1998-11-01

Night Vision Devices (NVDs) provide an enormous advantage to the operational effectiveness of military helicopter flying by permitting flight throughout the night. However, compared with daytime flight, many of the depth perception and orientational cues are severely degraded. These degraded cues predispose aviators to spatial disorientation (SD), which is a serious drawback of these devices. As part of an overall analysis of Army helicopter accidents to assess the impact of SD on military flying, we scrutinized the class A-C mishap reports involving night-aided flight from 1987 to 1995. The accidents were classified according to the role of SD by three independent assessors, with the SD group further analyzed to determine associated factors and possible countermeasures. Almost 43% of all SD-related accidents in this series occurred during flight using NVDs, whereas only 13% of non-SD accidents involved NVDs. An examination of the SD accident rates per 100,000 flying hours revealed a significant difference between the rate for day flying and the rate for flight using NVDs (mean rate for daytime flight = 1.66, mean rate for NVD flight = 9.00, p < 0.001). The most important factors associated with these accidents were related to equipment limitations, distraction from the task, and training or procedural inadequacies. SD remains an important source of attrition of Army aircraft. The more than fivefold increase in risk associated with NVD flight is of serious concern. The associated factors and suggested countermeasures should be urgently addressed.

System safety management lessons learned from the US Army acquisition process

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

Piatt, J.A.

1989-05-01

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

Romanian experience on packaging testing

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

Vieru, G.

2007-07-01

With more than twenty years ago, the Institute for Nuclear Research Pitesti (INR), through its Reliability and Testing Laboratory, was licensed by the Romanian Nuclear Regulatory Body- CNCAN and to carry out qualification tests [1] for packages intended to be used for the transport and storage of radioactive materials. Radioactive materials, generated by Romanian nuclear facilities [2] are packaged in accordance with national [3] and the IAEA's Regulations [1,6] for a safe transport to the disposal center. Subjecting these packages to the normal and simulating test conditions accomplish the evaluation and certification in order to prove the package technical performances.more » The paper describes the qualification tests for type A and B packages used for transport and storage of radioactive materials, during a period of 20 years of experience. Testing is used to substantiate assumption in analytical models and to demonstrate package structural response. The Romanian test facilities [1,3,6] are used to simulate the required qualification tests and have been developed at INR Pitesti, the main supplier of type A packages used for transport and storage of low radioactive wastes in Romania. The testing programme will continue to be a strong option to support future package development, to perform a broad range of verification and certification tests on radioactive material packages or component sections, such as packages used for transport of radioactive sources to be used for industrial or medical purposes [2,8]. The paper describes and contain illustrations showing some of the various tests packages which have been performed during certain periods and how they relate to normal conditions and minor mishaps during transport. Quality assurance and quality controls measures taken in order to meet technical specification provided by the design there are also presented and commented. (authors)« less

Emotional/Mental Challenges Pre-, In-, and Post-Flight

NASA Technical Reports Server (NTRS)

Voss, Janice

2001-01-01

Dr. Voss has flown aboard the Space Shuttle five times. She knows well her inner concerns, emotions, and mental challenges attending such highly demanding and risky adventures. And she has shared those ideas with her colleagues. She notes that their busy training schedules and fully committed on orbit time allow little time for dwelling on most of these issues. However, they are nonetheless real and may not be ignored with impunity. She thinks that perhaps they are more striking for rookie space farers, but all spacecrew members share them and can profit by assuring proper support and unique solutions for their own specific situation, which could vary with the mission. In her own experience, she found notable benefit from sharing with close members of her family, both before flight and during. The latter has proved of great value to all crew persons in the form of their personal ground contact time with family and friends. In addition, how one arranges and what one provides in the on board personal space and time goes far toward keeping a confident and upbeat view of the big picture. The type and amount of off duty diversions (e.g., music, reading material) are important, as are how one participates in group time. And it is universally agreed that viewing time at the spacecraft windows offers great joy and calm. Dr. Voss conjectures that there could be a difference in how people deal with these matters on busy, short-duration (Shuttle type) missions versus those of longer ones, particularly out of low earth orbit, where the options in the advent of mishap are fewer. Her final opinion is one of optimism and assurance that the human person will do well in coping with this new environment.

Longitudinal Outcomes of U.S. Air Force Pilot Applicants With Waivered Astigmatism.

PubMed

Andrus, David E; Haynes, Jared T; Wright, Steven T

2017-03-01

Current U.S. Air Force medical standards allow applicants to enter pilot training with up to 1.50 D of astigmatism. However, waivers are considered for individuals with up to 3.00 D of astigmatism. Although typically a benign finding, higher levels of astigmatism may be progressive and can be associated with corneal ectasia (e.g., keratoconus or pellucid marginal degeneration) leading to reduced visual acuity with spectacles and/or soft contact lenses. The goal of this study was to evaluate the long-term outcomes of pilot applicants waivered into training with astigmatism exceeding the aeromedical standard. Subjects were identified on the basis of their enrollment in the Excessive Astigmatism Management Group maintained by the Aeromedical Consultation Service, Ophthalmology branch at Wright-Patterson Air Force Base, Ohio. Metrics evaluated included refractive status, visual acuity, aeromedical waiver status, safety data, and the development of corneal ectasia. Seventy-six subjects were tracked for up to 10 years, with an average follow-up period of 5.5 years. Mean astigmatism at initial examination was 1.91 D, although mean astigmatism on the basis of the most recent examination was 2.19 D. Subjects with excessive astigmatism who were waivered into pilot training showed an average increase in astigmatism of slightly less than 0.05 D annually, which equates to a total increase in astigmatism of approximately 0.25 D for the duration of the study. No subjects developed ectasia or were disqualified from flying for vision or refractive reasons. No mishaps were identified with vision being a causative or contributing factor. This study supports continuation of current Air Force waiver policy, although a longer follow-up period is required to consider modifying the aeromedical standard for astigmatism. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

Perceived Nurse-Physician Communication in Patient Care and Associated Factors in Public Hospitals of Jimma Zone, South West Ethiopia: Cross Sectional Study.

PubMed

Hailu, Fikadu Balcha; Kassahun, Chanyalew Worku; Kerie, Mirkuzie Woldie

2016-01-01

Nurse-physician communication has been shown to have a significant impact on the job satisfaction and retention of staff. In areas where it has been studied, communication failure between nurses and physicians was found to be one of the leading causes of preventable patient injuries, complications, death and medical malpractice claims. The objective of this study is to determine perception of nurses and physicians towards nurse-physician communication in patient care and associated factors in public hospitals of Jimma zone, southwest Ethiopia. Institution based cross-sectional survey was conducted from March 10 to April 16, 2014 among 341 nurses and 168 physicians working in public hospitals in Jimma zone. Data was collected using a pre-tested self-administered questionnaire; entered into EpiData version 3.1 and exported to Statistical Package for Social Sciences (SPSS) version 16.0 for analysis. Factor analysis was carried out. Descriptive statistics, independent sample t-test, linear regression and one way analysis of variance were used. Variables with P-value < 0.05 were considered as statistically significant. The response rate of the study was 91.55%. The mean perceived nurse-physician communication scores were 50.88±19.7% for perceived professional respect and satisfaction, and 48.52±19.7% for perceived openness and sharing of patient information on nurse-physician communication. Age, salary and organizational factors were statistically significant predictors for perceived respect and satisfaction. Whereas sex, working hospital, work attitude individual factors and organizational factors were significant predictors of perceived openness and sharing of patient information in nurse-physician communication during patient care. Perceived level of nurse-physician communication mean score was low among nurses than physicians and it is attention seeking gap. Hence, the finding of our study suggests the need for developing and implementing nurse-physician communication improvement strategies to solve communication mishaps in patient care.

Perceived Nurse—Physician Communication in Patient Care and Associated Factors in Public Hospitals of Jimma Zone, South West Ethiopia: Cross Sectional Study

PubMed Central

Hailu, Fikadu Balcha; Kassahun, Chanyalew Worku; Kerie, Mirkuzie Woldie

2016-01-01

Background Nurse–physician communication has been shown to have a significant impact on the job satisfaction and retention of staff. In areas where it has been studied, communication failure between nurses and physicians was found to be one of the leading causes of preventable patient injuries, complications, death and medical malpractice claims. Objective The objective of this study is to determine perception of nurses and physicians towards nurse-physician communication in patient care and associated factors in public hospitals of Jimma zone, southwest Ethiopia. Methods Institution based cross-sectional survey was conducted from March 10 to April 16, 2014 among 341 nurses and 168 physicians working in public hospitals in Jimma zone. Data was collected using a pre-tested self-administered questionnaire; entered into EpiData version 3.1 and exported to Statistical Package for Social Sciences (SPSS) version 16.0 for analysis. Factor analysis was carried out. Descriptive statistics, independent sample t-test, linear regression and one way analysis of variance were used. Variables with P-value < 0.05 were considered as statistically significant. Results The response rate of the study was 91.55%. The mean perceived nurse-physician communication scores were 50.88±19.7% for perceived professional respect and satisfaction, and 48.52±19.7% for perceived openness and sharing of patient information on nurse-physician communication. Age, salary and organizational factors were statistically significant predictors for perceived respect and satisfaction. Whereas sex, working hospital, work attitude individual factors and organizational factors were significant predictors of perceived openness and sharing of patient information in nurse-physician communication during patient care. Conclusion Perceived level of nurse-physician communication mean score was low among nurses than physicians and it is attention seeking gap. Hence, the finding of our study suggests the need for developing and implementing nurse-physician communication improvement strategies to solve communication mishaps in patient care. PMID:27632162

The Implications of Handling Qualities in Civil Helicopter Accidents Involving Hover and Low Speed Flight

NASA Technical Reports Server (NTRS)

Dugan, Daniel C.; Delamer, Kevin J.

2005-01-01

Because of increasing accident rates in Army helicopters in hover and low speed flight, a study was made in 1999 of accidents which could be attributed to inadequate stability augmentation. A study of civil helicopter accidents from 1993-2004 was then undertaken to pursue the issue of poor handling qualities in helicopters which, in almost all cases, had no stability augmentation. The vast majority of the mishaps studied occurred during daylight in visual meteorological condition, reducing the impact of degraded visual environments (DVE) on the results. Based on the Cooper-Harper Rating Scale, the handling qualities of many of the helicopters studied could be described as having from "very objectionable" to "major" deficiencies. These costly deficiencies have resulted in unnecessary loss of life, injury, and high dollar damage. Low cost and lightweight augmentation systems for helicopters have been developed in the past and are still being investigated. They offer the potential for significant reductions in the accident rate.

Lessons from the motorized migrations

USGS Publications Warehouse

Ellis, D.H.; Gee, G.F.; Clegg, K.R.; Duff, J.W.; Lishman, W.A.; Sladen, William J. L.

2001-01-01

Ten experiments have been conducted to determine if cranes can be led on migration and if those so trained will repeat migrations on their own. Results have been mixed as we have experienced the mishaps common to pilot studies. Nevertheless, we have learned many valuable lessons. Chief among these are that cranes can be led long distances behind motorized craft (air and ground), and those led over most or the entire route will return north come spring and south in fall to and from the general area of training. However, they will follow their own route. Groups transported south and flown at intervals along the route will migrate but often miss target termini. If certain protocol restrictions are followed, it is possible to make the trained cranes wild, however, the most practical way of so doing is to introduce them into a flock of wild cranes. We project that it is possible to create or restore wild migratory flocks of cranes by first leading small groups from chosen northern to southern termini.

Pilot ejection, parachute, and helicopter crash injuries.

PubMed

McBratney, Colleen M; Rush, Stephen; Kharod, Chetan U

2014-01-01

USAF Pararescuemen (PJs) respond to downed aircrew as a fundamental mission for personnel recovery (PR), one of the Air Force's core functions. In addition to responding to these in Military settings, the PJs from the 212 Rescue Squadron routinely respond to small plane crashes in remote regions of Alaska. While there is a paucity of information on the latter, there have been articles detailing injuries sustained from helicopter crashes and while ejecting or parachuting from fixed wing aircraft. The following represents a new chapter added to the Pararescue Medical Operations Handbook, Sixth Edition (2014, editors Matt Wolf, MD, and Stephen Rush, MD, in press). It was designed to be a quick reference for PJs and their Special Operations flight surgeons to help with understanding of mechanism of injury with regard to pilot ejection, parachute, and helicopter accident injuries. It outlines the nature of the injuries sustained in such mishaps and provides an epidemiologic framework from which to approach the problem. 2014.

Managing emergencies and abnormal situations in air traffic control (part II): teamwork strategies.

PubMed

Malakis, Stathis; Kontogiannis, Tom; Kirwan, Barry

2010-07-01

Team performance has been studied in many safety-critical organizations including aviation, nuclear power plant, offshore oil platforms and health organizations. This study looks into teamwork strategies that air traffic controllers employ to manage emergencies and abnormal situations. Two field studies were carried out in the form of observations of simulator training in emergency and unusual scenarios of novices and experienced controllers. Teamwork strategies covered aspects of team orientation and coordination, information exchange, change management and error handling. Several performance metrics were used to rate the efficiency of teamwork and test the construct validity of a prototype model of teamwork. This is a companion study to an earlier investigation of taskwork strategies in the same field (part I) and contributes to the development of a generic model for Taskwork and Teamwork strategies in Emergencies in Air traffic Management (T(2)EAM). Suggestions are made on how to use T(2)EAM to develop training programs, assess team performance and improve mishap investigations. Copyright 2010 Elsevier Ltd. All rights reserved.

Retrofits we`d rather forget

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

Hurrelbrinck, N.

1996-01-01

We all make mistakes, and the best of us make some of the biggest and best ones. An energy service company in New York installed light sensitive thermostats in a complex where the residents covered windows with heavy curtains to curtail air leakage. A crew in Chicago forgot to place a top plate in the top floor bathroom of a multifamily building; when they blew insulation into the roof, it filled the bathroom. A state official in the Midwest was inspecting the attic insulation in an FHA house when his foot slipped off the walk board and went through themore » ceiling drywall. And weatherization experts in Pittsburgh have discovered that a blower door can fill a house with decades` worth of accumulated soot. These mishaps could visit anyone. Much as those visited would rather bury them, we think they deserve an airing on the pages of Home Energy. In this issue, we present some cautionary tales from the elites of insulation.« less

The X-43A (Hyper-X) Flies Into the Record Books

NASA Technical Reports Server (NTRS)

Grindle, Laurie; Bahm, Catherine

2006-01-01

The goal of the Hyper-X research program, conducted jointly by the NASA Dryden Flight Research Center and the NASA Langley Research Center, was to demonstrate and validate the technology, experimental techniques, and computation methods and tools for design and performance predictions of a hypersonic aircraft with an airframe-integrated, scramjet propulsion system. Three X-43A airframe-integrated, scramjet research vehicles were designed and fabricated to achieve that goal by flight test: two test flights at Mach 7 and one test flight at Mach 10. The first flight, conducted on June 2, 2001, experienced a launch vehicle failure and resulted in a 9-month mishap investigation. A two-year return-to-flight effort ensued and concluded when the second Mach 7 flight was successful on March 27, 2004. Just eight months later, on November 16, the X-43A successfully completed the third and final flight. These two flights were the first flight demonstrations, at Mach 7 and Mach 10 respectively, of an airframe-integrated, scramjet-powered, hypersonic vehicle.

Clearing the Air: A Qualitative Investigation of Genetic Counselors' Experiences of Counselor-Focused Patient Anger.

PubMed

Schema, Lynn; McLaughlin, Michaela; Veach, Patricia McCarthy; LeRoy, Bonnie S

2015-10-01

Patient anger is challenging for healthcare professionals to manage, particularly when it is directed at them. This study comprises the first in-depth investigation of genetic counselors' experiences with patient anger. Using a brief survey and interview methods, this study explored prevalence and context of patient anger directed at the genetic counselor, how genetic counselors manage patient anger directed at them, and possible thematic differences due to genetic counseling experience. Individuals enrolled in the National Society of Genetic Counselors (NSGC) listserv were invited to participate in a study of their experiences with patient anger directed at them. A majority of survey respondents (95.7 %, 243/254) reported experiencing patient anger directed at them, and 19.4 % reported having feared for their safety because of patient anger. Twenty-two survey respondents were purposively selected to participate in individual interviews. Inductive and cross case analysis yielded prevalent themes concerning patient triggers for anger, including bad news, logistical mishaps, and perceived counselor characteristics. Interview results further suggest unaddressed patient anger negatively affected patient and counselor emotional well-being and hindered genetic counseling goals. Prevalent challenges included genetic counselor attempts to accurately recognize, understand, and effectively manage patient anger without taking it personally. Commonly recommended strategies for addressing anger were empathy (i.e., understanding origins of patient anger), anticipating and acknowledging anger, maintaining personal, professional and legal protection, and debriefing with colleagues. Themes were quite similar across counselor experience levels. The findings underscore the importance of training and continuing education regarding patient anger. Additional findings, practice implications, and research recommendations are presented.

British army air corps accidents, 1991-2010: a review of contrasting decades.

PubMed

Adams, Mark S; Curry, Ian P; Gaydos, Steven J

2014-08-01

Accident investigation and review are important not only to attribute failure modes, but also mitigate risk, improve safety, and enhance capability. It was hypothesized that an interesting perspective on British Army Air Corps (AAC) rotary-wing (RW) accidents may be garnered by contrasting data from the previous two decades with a general operational (OP) shift from European theaters of conflict to operations in Southwest Asia. AAC mishaps for the period from January 1991 through December 2010 were reviewed within an air safety management system. Accidents, defined by category 4 or 5 aircraft damage or death or major injury of personnel, were selected. Analysis was conducted jointly by a minimum of two specialists in aviation medicine. There were 37 accidents that occurred in 6 differing airframes at an average rate of 2.5 per 100,000 flying hours. From 1991-2000, 25 accidents (9 OP) occurred with a rate of 2.8 per 100,000 flying hours. From 2001-2010, 12 accidents (5 OP) occurred with a rate of 2.1 per 100,000 flying hours. Aircrew human factors (HF) errors represented 84% of attributable causation for both decades. Spatial disorientation (SD) represented a higher proportion of HF-related accidents for OP flying. Despite the perception of a more difficult OP theater for the latter decade, the overall rate and the proportion of OP accidents did not differ appreciably. Rather than theater-specific threats or challenges, it has been the longstanding and prominent player of HF error and specifically SD in OP flying that has remained entrenched in the causal chain.

Communicating food risks in an era of growing public distrust: three case studies.

PubMed

Lofstedt, Ragnar

2013-02-01

The communication and regulation of risk has changed significantly over the past 30 years in Europe and to a noticeable but lesser extent in the United States. In Europe, this is partly due to a series of regulatory mishaps, ranging from mad cow disease in the United Kingdom to contamination of the blood supply in France. In the United States, general public confidence in the American government has been gradually declining for more than three decades, driven by a mix of cultural and political conflicts like negative political advertising, a corrosive news media, and cuts in regulatory budgets. While the former approach is based on an objective assessment of the risk, the latter is driven more by the perception of the risk, consumer sentiment, political will, and sectoral advocacy. In this article, the author examines three U.S.-based food case studies (acrylamide, bisphenol A, and artificial food colorings) where regulations at the local and state levels are increasingly being based on perceived risk advocacy rather than on the most effective response to the risk, be it to food safety or public health, as defined by regulatory interpretation of existing data. In the final section, the author puts forward a series of recommendations for how U.S.-based regulators can best handle those situations where the perceived risk is markedly different from the fact-based risk, such as strengthening the communication departments of food regulatory agencies, training officials in risk communication, and working more proactively with neutral third-party experts. © 2011 Society for Risk Analysis.

Assessment of CFD-based Response Surface Model for Ares I Supersonic Ascent Aerodynamics

NASA Technical Reports Server (NTRS)

Hanke, Jeremy L.

2011-01-01

The Ascent Force and Moment Aerodynamic (AFMA) Databases (DBs) for the Ares I Crew Launch Vehicle (CLV) were typically based on wind tunnel (WT) data, with increments provided by computational fluid dynamics (CFD) simulations for aspects of the vehicle that could not be tested in the WT tests. During the Design Analysis Cycle 3 analysis for the outer mold line (OML) geometry designated A106, a major tunnel mishap delayed the WT test for supersonic Mach numbers (M) greater than 1.6 in the Unitary Plan Wind Tunnel at NASA Langley Research Center, and the test delay pushed the final delivery of the A106 AFMA DB back by several months. The aero team developed an interim database based entirely on the already completed CFD simulations to mitigate the impact of the delay. This CFD-based database used a response surface methodology based on radial basis functions to predict the aerodynamic coefficients for M > 1.6 based on only the CFD data from both WT and flight Reynolds number conditions. The aero team used extensive knowledge of the previous AFMA DB for the A103 OML to guide the development of the CFD-based A106 AFMA DB. This report details the development of the CFD-based A106 Supersonic AFMA DB, constructs a prediction of the database uncertainty using data available at the time of development, and assesses the overall quality of the CFD-based DB both qualitatively and quantitatively. This assessment confirms that a reasonable aerodynamic database can be constructed for launch vehicles at supersonic conditions using only CFD data if sufficient knowledge of the physics and expected behavior is available. This report also demonstrates the applicability of non-parametric response surface modeling using radial basis functions for development of aerodynamic databases that exhibit both linear and non-linear behavior throughout a large data space.

Close-Call Action Log Form

NASA Technical Reports Server (NTRS)

Spuler, Linda M.; Ford, Patricia K.; Skeete, Darren C.; Hershman, Scot; Raviprakash, Pushpa; Arnold, John W.; Tran, Victor; Haenze, Mary Alice

2005-01-01

"Close Call Action Log Form" ("CCALF") is the name of both a computer program and a Web-based service provided by the program for creating an enhanced database of close calls (in the colloquial sense of mishaps that were avoided by small margins) assigned to the Center Operations Directorate (COD) at Johnson Space Center. CCALF provides a single facility for on-line collaborative review of close calls. Through CCALF, managers can delegate responses to employees. CCALF utilizes a pre-existing e-mail system to notify managers that there are close calls to review, but eliminates the need for the prior practices of passing multiple e-mail messages around the COD, then collecting and consolidating them into final responses: CCALF now collects comments from all responders for incorporation into reports that it generates. Also, whereas it was previously necessary to manually calculate metrics (e.g., numbers of maintenance-work orders necessitated by close calls) for inclusion in the reports, CCALF now computes the metrics, summarizes them, and displays them in graphical form. The reports and all pertinent information used to generate the reports are logged, tracked, and retained by CCALF for historical purposes.

Detecting Driver Drowsiness Based on Sensors: A Review

PubMed Central

Sahayadhas, Arun; Sundaraj, Kenneth; Murugappan, Murugappan

2012-01-01

In recent years, driver drowsiness has been one of the major causes of road accidents and can lead to severe physical injuries, deaths and significant economic losses. Statistics indicate the need of a reliable driver drowsiness detection system which could alert the driver before a mishap happens. Researchers have attempted to determine driver drowsiness using the following measures: (1) vehicle-based measures; (2) behavioral measures and (3) physiological measures. A detailed review on these measures will provide insight on the present systems, issues associated with them and the enhancements that need to be done to make a robust system. In this paper, we review these three measures as to the sensors used and discuss the advantages and limitations of each. The various ways through which drowsiness has been experimentally manipulated is also discussed. We conclude that by designing a hybrid drowsiness detection system that combines non-intusive physiological measures with other measures one would accurately determine the drowsiness level of a driver. A number of road accidents might then be avoided if an alert is sent to a driver that is deemed drowsy. PMID:23223151

Secrecy as embodied practice: beyond the confessional imperative.

PubMed

Hardon, Anita; Posel, Deborah

2012-01-01

This introduction to this special issue of Culture, Health & Sexuality aims to intervene critically in debates in public health about sexual rights and ways of de-stigmatising HIV/AIDS, in which silence and secrets are seen to undermine well-being and perpetuate stigma. It presents key insights from collaborative studies on HIV/AIDS and youth sexual health, arguing that advocates of disclosure and sexual rights need to think more contextually and tactically in promoting truth-telling. The authors aim to enhance current thinking on secrecy, which examines it primarily as a social practice, by emphasising the centrality of the body and the experience of embodiment in the making and unmaking of secrets. To understand secrecy as embodied practice requires understanding how it simultaneously involves the body as subject - as the basis from which we experience the world - and the body as object - that can be actively manipulated, silenced and 'done'. The authors show how tensions emerge when bodies reveal reproductive mishaps and describe how the dissonances are resolved through a variety of silencing practices. The paper ends by discussing the implications of these insights for sexual-health programmes.

Reduced G tolerance associated with supplement use.

PubMed

Barker, Patrick D

2011-02-01

High G forces encountered in tactical military aviation and aerobatic flight produce a host of physiologic responses aimed at preserving cerebral perfusion. The military has instituted measures to augment the physiologic response in order to avoid G-induced loss of consciousness (G-LOC) because of its potential to cause a catastrophic mishap. The case presented here details a Naval Aviator who experienced reduced G tolerance over two successive flights with a temporal relationship of starting a new supplement. Two components of the supplement, coenzyme Q10 and niacin, are highlighted here for their hemodynamic effects. After stopping the supplement the aviator regained his normal G tolerance and had no further issues in flight. There are several factors that can reduce G tolerance and supplement use has to be considered here because of the potential for altering the normal physiological response to increased G force. Our discussion reviews the physiological effects of increased G force, the spectrum of signs of decompensation under the stress of G force, and the potential effects this supplement had on the normal physiological response to increased G force, thus reducing the aviator's G tolerance.

Rough-and-tumble play as a window on animal communication.

PubMed

Palagi, Elisabetta; Burghardt, Gordon M; Smuts, Barbara; Cordoni, Giada; Dall'Olio, Stefania; Fouts, Hillary N; Řeháková-Petrů, Milada; Siviy, Stephen M; Pellis, Sergio M

2016-05-01

Rough-and-tumble play (RT) is a widespread phenomenon in mammals. Since it involves competition, whereby one animal attempts to gain advantage over another, RT runs the risk of escalation to serious fighting. Competition is typically curtailed by some degree of cooperation and different signals help negotiate potential mishaps during RT. This review provides a framework for such signals, showing that they range along two dimensions: one from signals borrowed from other functional contexts to those that are unique to play, and the other from purely emotional expressions to highly cognitive (intentional) constructions. Some animal taxa have exaggerated the emotional and cognitive interplay aspects of play signals, yielding admixtures of communication that have led to complex forms of RT. This complexity has been further exaggerated in some lineages by the development of specific novel gestures that can be used to negotiate playful mood and entice reluctant partners. Play-derived gestures may provide new mechanisms by which more sophisticated communication forms can evolve. Therefore, RT and playful communication provide a window into the study of social cognition, emotional regulation and the evolution of communication systems. © 2015 Cambridge Philosophical Society.

Road safety in Poland: magnitude, causes and injuries.

PubMed

Goniewicz, Krzysztof; Goniewicz, Mariusz; Pawłowski, Witold; Fiedor, Piotr; Lasota, Dorota

2017-01-01

Road accidents are a serious problem of the modern world. They are one of the main causes of injuries and are the third most frequent cause of death. Every year, about one million people, adults and children, die on the roads and several millions get injured. Mortality rate due to injuries from road accidents amounts to 2.2% of all deaths in the world. The research presents epidemiology of road accidents in the period 2004-2015 with particular emphasis on the key issues of road safety in Poland, related to the dangerous behaviour of road users (disregard toward traffic rules). Between years 2004 and 2015 on Polish roads took place more than 508000 accidents with 53155 fatalities and more then 572000 casualties. Despite the various measures which are taken to improve safety on Polish roads, the number of dead and wounded in the vehicle mishap is still large, and losses borne by society are high. To improve safety on Polish roads, it is necessary to continue multi- action plan to systematically progress in the level of road safety.

Case Report of a Hypobaric Chamber Fitness to Fly Test in a Child With Severe Cystic Lung Disease.

PubMed

Loo, Sarah; Campbell, Andrew; Vyas, Julian; Pillarisetti, Naveen

2017-07-01

Patients with severe cystic lung disease are considered to be at risk for cyst rupture during air travel because of the possibility of increase in cyst size and impaired equilibration of pressure between the cysts and other parts of the lung. This may have clinically devastating consequences for the patient but may also result in significant costs for emergency alteration of flight schedule. We report the use of a hypobaric chamber to simulate cabin pressure changes encountered on a commercial flight to assess the safety to fly of a child with severe cystic lung disease secondary to Langerhans cell histiocytosis. The test did not result in an air leak, and the child subsequently undertook air travel without mishap. This is the first reported use of a hypobaric chamber test in a child with severe cystic lung disease. This test has the potential to be used as a fitness to fly test in children at risk for air leak syndromes who are being considered for air travel. Copyright © 2017 by the American Academy of Pediatrics.

Solid Xenon Project

NASA Astrophysics Data System (ADS)

Balakishiyeva, Durdana N.; Mahapatra, Rupak; Saab, Tarek; Yoo, Jonghee

2010-08-01

Crystals like Germanium and Silicon need to be grown in specialized facilities which is time and money costly. It takes many runs to test the detector once it's manufactured and mishaps are very probable. It is of a great challenge to grow big germanium crystals and that's why stacking them up in a tower is the only way at the moment to increase testing mass. Liquid Noble gas experiments experiencing contamination problems, their predicted energy resolution at 10 keV and lower energy range is not as good as predicted. Every experiment is targeting one specific purpose, looking for one thing. Why not to design an experiment that is diverse and build a detector that can search for Dark Matter, Solar Axions, Neutrinoless Double Beta decay, etc. Solid Xenon detector is such detector. We designed a simple Xenon crystal growing chamber that was put together at Fermi National Accelerator Laboratory. The first phase of this experiment was to demonstrate that a good, crack free Xenon crystal can be grown (regardless of many failed attempts by various groups) and our first goal, 1 kg crystal, was successful.

Fire hazard considerations for composites in vehicle design

NASA Technical Reports Server (NTRS)

Gordon, Rex B.

1994-01-01

Military ground vehicles fires are a significant cause of system loss, equipment damage, and crew injury in both combat and non-combat situations. During combat, the ability to successfully fight an internal fire, without losing fighting and mobility capabilities, is often the key to crew survival and mission success. In addition to enemy hits in combat, vehicle fires are initiated by electrical system failures, fuel line leaks, munitions mishaps and improper personnel actions. If not controlled, such fires can spread to other areas of the vehicle, causing extensive damage and the potential for personnel injury and death. The inherent fire safety characteristics (i.e. ignitability, compartments of these vehicles play a major roll in determining rather a newly started fire becomes a fizzle or a catastrophe. This paper addresses a systems approach to assuring optimum vehicle fire safety during the design phase of complex vehicle systems utilizing extensive uses of composites, plastic and related materials. It provides practical means for defining the potential fire hazard risks during a conceptual design phase, and criteria for the selection of composite materials based on its fire safety characteristics.

Mechanisms of DNA damage repair in adult stem cells and implications for cancer formation.

PubMed

Weeden, Clare E; Asselin-Labat, Marie-Liesse

2018-01-01

Maintenance of genomic integrity in tissue-specific stem cells is critical for tissue homeostasis and the prevention of deleterious diseases such as cancer. Stem cells are subject to DNA damage induced by endogenous replication mishaps or exposure to exogenous agents. The type of DNA lesion and the cell cycle stage will invoke different DNA repair mechanisms depending on the intrinsic DNA repair machinery of a cell. Inappropriate DNA repair in stem cells can lead to cell death, or to the formation and accumulation of genetic alterations that can be transmitted to daughter cells and so is linked to cancer formation. DNA mutational signatures that are associated with DNA repair deficiencies or exposure to carcinogenic agents have been described in cancer. Here we review the most recent findings on DNA repair pathways activated in epithelial tissue stem and progenitor cells and their implications for cancer mutational signatures. We discuss how deep knowledge of early molecular events leading to carcinogenesis provides insights into DNA repair mechanisms operating in tumours and how these could be exploited therapeutically. Copyright © 2017 Elsevier B.V. All rights reserved.

Did Vertigo Kill America's Forgotten Astronaut?

NASA Technical Reports Server (NTRS)

Bendrick, Gregg A.; Merlin, Peter W.

2007-01-01

On November 15, 1967, U.S. Air Force test pilot Major Michael J. Adams was killed while flying the X-15 rocket-propelled research vehicle in a parabolic spaceflight profile. This flight was part of a joint effort with NASA. An electrical short in one of the experiments aboard the vehicle caused electrical transients, resulting in excessive workload by the pilot. At altitude Major Adams inappropriately initiated a flat spin that led to a series of unusual aircraft attitudes upon atmospheric re-entry, ultimately causing structural failure of the airframe. Major Adams was known to experience vertigo (i.e. spatial disorientation) while flying the X-15, but all X-15 pilots most likely experienced vertigo (i.e. somatogravic, or "Pitch-Up", illusion) as a normal physiologic response to the accelerative forces involved. Major Adams probably experienced vertigo to a greater degree than did others, since prior aeromedical testing for astronaut selection at Brooks AFB revealed that he had an unusually high degree of labyrinthine sensitivity. Subsequent analysis reveals that after engine burnout, and through the zenith of the flight profile, he likely experienced the oculoagravic ("Elevator") illusion. Nonetheless, painstaking investigation after the mishap revealed that spatial disorientation (Type II, Recognized) was NOT the cause, but rather, a contributing factor. The cause was in fact the misinterpretation of a dual-use flight instrument (i.e. Loss of Mode Awareness), resulting in confusion between yaw and roll indications, with subsequent flight control input that was inappropriate. Because of the altitude achieved on this flight, Major Adams was awarded Astronaut wings posthumously. Understanding the potential for spatial disorientation, particularly the oculoagravic illusion, associated with parabolic spaceflight profiles, and understanding the importance of maintaining mode awareness in the context of automated cockpit design, are two lessons that have direct application to the commercial space industry today.

Young people and snowmobiling in northern Norway: accidents, injury prevention and safety strategies.

PubMed

Mehus, Grete; Mehus, Alf Gunnar; Germeten, Sidsel; Henriksen, Nils

2016-01-01

Snowmobiling among young people in Scandinavia frequently leads to accidents and injuries. Systematic studies of accidents exist, but few studies have addressed young drivers' experiences. The aim of this article is to reveal how young people experience and interpret accidents, and to outline a prevention strategy. Thirty-one girls and 50 boys aged 16-23 years from secondary schools in Northern Norway and on Svalbard, a Norwegian archipelago in the Arctic Ocean, participated in 17 focus groups segregated by gender. A content analysis identified themes addressing the research questions. Participants described risk as being inherent to snowmobiling, and claimed that accidents followed from poor risk assessment, careless driving or mishaps. Evaluation of accidents and recommendations for preventive measures varied. Girls acknowledged the risks and wanted knowledge about outdoor life, navigation and external risks. Boys underestimated or downplayed the risks, and wanted knowledge about safety precautions while freeriding. Both genders were aware of how and why accidents occurred, and took precautions. Boys tended to challenge norms in ways that contradict the promotion of safe driving behaviour. Stories of internal justice regarding driving under the influence of alcohol occurred. Adolescents are aware of how accidents occur and how to avoid them. Injury prevention strategies should include a general population strategy and a high-risk strategy targeted at extreme risk-seekers. Drivers, snowmobilers' organisations and the community should share local knowledge in an effort to define problem areas, set priorities and develop and implement preventive measures. Risk prevention should include preparation of safe tracks and focus on safety equipment and safe driving behaviour, but should also pay increased attention to the potential of strengthening normative regulation within peer groups regarding driving behaviour and mutual responsibility for preventing accidents.

A 10-Year Retrospective Review of Nephrolithiasis in the Navy and Navy Pilots.

PubMed

Masterson, James H; Phillips, Christopher J; Crum-Cianflone, Nancy F; Krause, Robert J; Sur, Roger L; L'Esperance, James O

2017-08-01

Little is known about the incidence of nephrolithiasis in the United States Navy. Navy pilots must be kidney stone-free and are often referred for treatment of small asymptomatic stones. The primary objectives of this study were to determine the incidence of nephrolithiasis and computerized tomography, proportion undergoing treatment and incidence of stone related mishaps in Navy pilots compared with other Navy personnel. We retrospectively studied the records of all Navy service members from 2002 to 2011 for nephrolithiasis based on ICD-9 stone codes to determine the mentioned rates. We also reviewed NSC (Naval Safety Center) data for a history of accidents associated with nephrolithiasis. Rates of disease were calculated using person-years of followup and inferential statistics were done using univariable and multivariable analyses. We evaluated 667,840 Navy personnel with a total of 3,238,331 person-years of followup. The annual incidence of nephrolithiasis was 240/100,000 person-years with a 5-year recurrence rate of 35.3%. On multivariable analysis pilots had nephrolithiasis incidence and treatment rates similar to those of the overall Navy population. Women had a higher incidence of nephrolithiasis compared with men (OR 1.17, p <0.0001). The rate of computerized tomography was lower in pilots than in the rest of the Navy (39 vs 66/10,000 person-years, p <0.0001). No recorded accidents were associated with kidney stones. Navy pilots had a similar incidence of nephrolithiasis and were no more likely to undergo a surgical procedure. Given that no accidents were associated with nephrolithiasis, this study suggests reconsidering current military policies necessitating pilots to be completely stone-free. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Probabilistic Survivability Versus Time Modeling

NASA Technical Reports Server (NTRS)

Joyner, James J., Sr.

2015-01-01

This technical paper documents Kennedy Space Centers Independent Assessment team work completed on three assessments for the Ground Systems Development and Operations (GSDO) Program to assist the Chief Safety and Mission Assurance Officer (CSO) and GSDO management during key programmatic reviews. The assessments provided the GSDO Program with an analysis of how egress time affects the likelihood of astronaut and worker survival during an emergency. For each assessment, the team developed probability distributions for hazard scenarios to address statistical uncertainty, resulting in survivability plots over time. The first assessment developed a mathematical model of probabilistic survivability versus time to reach a safe location using an ideal Emergency Egress System at Launch Complex 39B (LC-39B); the second used the first model to evaluate and compare various egress systems under consideration at LC-39B. The third used a modified LC-39B model to determine if a specific hazard decreased survivability more rapidly than other events during flight hardware processing in Kennedys Vehicle Assembly Building (VAB).Based on the composite survivability versus time graphs from the first two assessments, there was a soft knee in the Figure of Merit graphs at eight minutes (ten minutes after egress ordered). Thus, the graphs illustrated to the decision makers that the final emergency egress design selected should have the capability of transporting the flight crew from the top of LC 39B to a safe location in eight minutes or less. Results for the third assessment were dominated by hazards that were classified as instantaneous in nature (e.g. stacking mishaps) and therefore had no effect on survivability vs time to egress the VAB. VAB emergency scenarios that degraded over time (e.g. fire) produced survivability vs time graphs that were line with aerospace industry norms.

Prospective controlled trial comparing colostomy irrigation with "spontaneous-action" method.

PubMed

Williams, N S; Johnston, D

1980-07-12

Thirty randomly selected patients with permanent colostomies entered a prospective controlled trial comparing colostomy irrigation with spontaneous action. Each patient was interviewed and examined before irrigation was begun and again after the technique had been used for three months. Each then reverted to spontaneous action for a further three months and was then reassessed. Eight patients abandoned irrigation and 22 (73%) adhered to the protocol. Irrigation caused no mishaps or complications. The mean time spent managing the stoma was 45 +/- SEM 9 min/24 hours during spontaneous action and 53 +/- 9 min/24 hours during irrigation. This difference was not significant. The numbers of bowel actions weekly were 13 +/ SEM 2 during spontaneous action and 6 +/- 1 during irrigation (p < 0.01). Irrigation reduced odour and flatus in 20 patients and enabled 12 out of 18 to stop using drugs and seven to discard their appliance. Irrigation also improved the social life of 18 patients and the working conditions of eight out of 14. These finding show that some patients may not be suitable for irrigation but that for many it is better than the conventional British method of colostomy management. With modern apparatus the technique is safe.

Prospective controlled trial comparing colostomy irrigation with "spontaneous-action" method.

PubMed Central

Williams, N S; Johnston, D

1980-01-01

Thirty randomly selected patients with permanent colostomies entered a prospective controlled trial comparing colostomy irrigation with spontaneous action. Each patient was interviewed and examined before irrigation was begun and again after the technique had been used for three months. Each then reverted to spontaneous action for a further three months and was then reassessed. Eight patients abandoned irrigation and 22 (73%) adhered to the protocol. Irrigation caused no mishaps or complications. The mean time spent managing the stoma was 45 +/- SEM 9 min/24 hours during spontaneous action and 53 +/- 9 min/24 hours during irrigation. This difference was not significant. The numbers of bowel actions weekly were 13 +/ SEM 2 during spontaneous action and 6 +/- 1 during irrigation (p < 0.01). Irrigation reduced odour and flatus in 20 patients and enabled 12 out of 18 to stop using drugs and seven to discard their appliance. Irrigation also improved the social life of 18 patients and the working conditions of eight out of 14. These finding show that some patients may not be suitable for irrigation but that for many it is better than the conventional British method of colostomy management. With modern apparatus the technique is safe. PMID:7000249

Small UAV Automatic Ground Collision Avoidance System Design Considerations and Flight Test Results

NASA Technical Reports Server (NTRS)

Sorokowski, Paul; Skoog, Mark; Burrows, Scott; Thomas, SaraKatie

2015-01-01

The National Aeronautics and Space Administration (NASA) Armstrong Flight Research Center Small Unmanned Aerial Vehicle (SUAV) Automatic Ground Collision Avoidance System (Auto GCAS) project demonstrated several important collision avoidance technologies. First, the SUAV Auto GCAS design included capabilities to take advantage of terrain avoidance maneuvers flying turns to either side as well as straight over terrain. Second, the design also included innovative digital elevation model (DEM) scanning methods. The combination of multi-trajectory options and new scanning methods demonstrated the ability to reduce the nuisance potential of the SUAV while maintaining robust terrain avoidance. Third, the Auto GCAS algorithms were hosted on the processor inside a smartphone, providing a lightweight hardware configuration for use in either the ground control station or on board the test aircraft. Finally, compression of DEM data for the entire Earth and successful hosting of that data on the smartphone was demonstrated. The SUAV Auto GCAS project demonstrated that together these methods and technologies have the potential to dramatically reduce the number of controlled flight into terrain mishaps across a wide range of aviation platforms with similar capabilities including UAVs, general aviation aircraft, helicopters, and model aircraft.

Navy Safety Center data on the effects of fire protection systems on electrical equipment

NASA Astrophysics Data System (ADS)

Levine, Robert S.

1991-04-01

Records of the Navy Safety Center, Norfolk, VA were reviewed to find data relevant to inadvertant operation of installed fire extinguishing systems in civilian nuclear power plants. Navy data show the incidence of collateral fire or other damage by fresh water on operating electrical equipment in submarines and in shore facilities is about the same as the civilian experience, about 30 percent. Aboard surface ships, however, the collateral damage incidence in much lower, about 15 percent. With sea water, the collateral damage incidence is at least 75 percent. It is concluded that the fire extinguisher water has to be contaminated, as by rust in sprinkler systems or deposited salt spray, for most collateral damage to occur. Reasons for inadvertant operation (or advertant operation) of firex systems at shore facilities, submarines, and surface ships resemble those for nuclear power plants. Mechanical or electrical failures lead the list, followed by mishaps during maintenance. Detector and alarm system failures are significant problems at Navy shore facilities, and significant at nuclear power plants. Fixed halon and CO2 systems in shore facilities cause no collateral damage. Lists of individual Navy incidents with water and with halon and carbon dioxide are included as appendices.

NASA Tech Briefs, June 2007

NASA Technical Reports Server (NTRS)

2007-01-01

Topics covered include: High-Accuracy, High-Dynamic-Range Phase-Measurement System; Simple, Compact, Safe Impact Tester; Multi-Antenna Radar Systems for Doppler Rain Measurements; 600-GHz Electronically Tunable Vector Measurement System; Modular Architecture for the Measurement of Space Radiation; VLSI Design of a Turbo Decoder; Architecture of an Autonomous Radio Receiver; Improved On-Chip Measurement of Delay in an FPGA or ASIC; Resource Selection and Ranking; Accident/Mishap Investigation System; Simplified Identification of mRNA or DNA in Whole Cells; Printed Multi-Turn Loop Antennas for RF Biotelemetry; Making Ternary Quantum Dots From Single-Source Precursors; Improved Single-Source Precursors for Solar-Cell Absorbers; Spray CVD for Making Solar-Cell Absorber Layers; Glass/BNNT Composite for Sealing Solid Oxide Fuel Cells; A Method of Assembling Compact Coherent Fiber-Optic Bundles; Manufacturing Diamond Under Very High Pressure; Ring-Resonator/Sol-Gel Interferometric Immunosensor; Compact Fuel-Cell System Would Consume Neat Methanol; Algorithm Would Enable Robots to Solve Problems Creatively; Hypothetical Scenario Generator for Fault-Tolerant Diagnosis; Smart Data Node in the Sky; Pseudo-Waypoint Guidance for Proximity Spacecraft Maneuvers; Update on Controlling Herds of Cooperative Robots; and Simulation and Testing of Maneuvering of a Planetary Rover.

Preserving the pot and water: a traditional concept of reproductive health in a Yoruba community, Nigeria.

PubMed

Adetunji, J A

1996-12-01

Within the background of the outcome of the 1994 Cairo Conference, this paper describes a traditional conceptualization of prenatal care in a Nigerian community and draws their implication for effective delivery of reproductive health services in the area. The data used were from qualitative interviews during 2 field trips to the community in 1988-89 and 1991. The finding of the study highlights a local metaphor that likened the risks of pregnancy and child birth to a group of women that trekked to a local brook to fetch water with their earthen pots: some fell, broke their pots; some missed steps and spilt their water but kept their pots, and others returned without any mishap. The first group represented cases of maternal mortality; the second group were cases of miscarriage, still-births or infant deaths, and the third group represented successful outcomes for both pregnancy and the resultant baby. Various steps that were traditionally taken to ensure that the mother neither lost her pot nor spilled her water are described. The implications of these findings for policy and research are discussed in the paper.

Transcranial Doppler ultrasound and the etiology of neurologic decompression sickness during altitude decompression

NASA Technical Reports Server (NTRS)

Norfleet, W. T.; Powell, M. R.; Kumar, K. Vasantha; Waligora, J.

1993-01-01

The presence of gas bubbles in the arterial circulation can occur from iatrogenic mishaps, cardiopulmonary bypass devices, or following decompression, e.g., in deep-sea or SCUBA diving or in astronauts during extravehicular activities (EVA). We have examined the pathophysiology of neurological decompression sickness in human subjects who developed a large number of small gas bubbles in the right side of the heart as a result of hypobaric exposures. In one case, gas bubbles were detected in the middle cerebral artery (MCA) and the subject developed neurological symptoms; a 'resting' patent foramen ovalae (PFO) was found upon saline contrast echocardiography. A PFO was also detected in another individual who developed Spencer Grade 4 precordial Doppler ultrasound bubbles, but no evidence was seen of arterialization of bubbles upon insonation of either the MCA or common carotid artery. The reason for this difference in the behavior of intracardiac bubbles in these two individuals is not known. To date, we have not found evidence of right-to-left shunting of bubbles through pulmonary vasculature. The volume of gas bubbles present following decompression is examined and compared with the number arising from saline contrast injection. The estimates are comparable.

Hazard perception and the economic impact of internment on residential land values

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

Merz, J.F.

1983-04-01

The potential for large scale natural and man-made hazards exists in the form of hurricanes, earthquakes, volcanoes, floods, dams, accidents involving poisonous, explosive or radioactive materials, and severe pollution or waste disposal mishaps. Regions prone to natural hazards and areas located proximally to technological hazards may be subject to economic losses from low probability-high consequence events. Economic costs may be incurred in: evacuation and relocation of inhabitants; personal, industrial, agricultural, and tax revenue losses; decontamination; property damage or loss of value; and temporary or prolonged internment of land. The value of land in an area subjected to a low probability-highmore » consequence event may decrease, reflecting, a fortiori, a reluctance to continue living in the area or to repopulate a region which had required internment. The future value of such land may be described as a function of location, time, interdiction period (if applicable), and variables reflecting the magnitude of the perceived hazard. This paper presents a study of these variables and proposes a model for land value estimation. As an example, the application of the model to the Love Canal area in Niagara Falls, New York is presented.« less

Commission 31: Time

NASA Astrophysics Data System (ADS)

Matsakis, Demetrios; Defraigne, Pascale; Hosokawa, M.; Leschiutta, S.; Petit, G.; Zhai, Z.-C.

2007-03-01

The most intensely discussed and controversial issue in time keeping has been the proposal before the International Telecommunications Union (ITU) to redefine Coordinated Universal Time (UTC) so as to replace leap seconds by leap hours. Should this proposal be adopted, the practice of inserting leap seconds would cease after a specific date. Should the Earth's rotation continue to de-accelerate at its historical rate, the next discontinuity in UTC would be an hour inserted several centuries from now. Advocates of this proposal cite the need to synchronize satellite and other systems, such as GPS, Galileo, and GLONASS, which did not exist and were not envisioned when the current system was adopted. They note that leap second insertions can be and have been incorrectly implemented or accounted for. Such errors have to date had localized impact, but they could cause serious mishaps involving loss of life. For example, some GPS receivers have been known to fail simply because there was no leap second after a long enough interval, other GPS receivers failed because the leap second information was broadcast more than three months in advance, and some commercial software used for internet time-transfer Network Time Protocol (NTP) could either discard all data received after a leap second or interpret it as a frequency change. The ambiguity associated with the extra second could also disrupt financial accounting and certain forms of encryption. Those opposed to the proposal question the need for a change, and also point out the costs of adjusting to the proposed change and its inconvenience to amateur astronomers and others who rely upon astronomical calculations published in advance. Reports have been circulated that the cost of checking and correcting software to accommodate the new definition of UTC would be many millions of dollars for some systems. In October 2005 American Astronomical Society asked the ITU for a year's time to study the issue. This commission has supported the efforts of the IAU' s Committee on the Leap Second to make an informed recommendation, and anticipates considerable discussion at the IAU's 26th General Assembly in 2006.

Sleipner mishap jolts booming Norway

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

Not Available

1991-09-02

This paper reports on Norway's buoyant offshore industry that was stunned when the concrete substructure for Sleipner natural gas field's main production platform sank in the Grandsfjord off Stavanger late last month. The accident, a blow to Norway's gas sales program in Europe, came with offshore activity in the Norwegian North Sea moving into a new boom period. Currently, 10 oil and gas fields are under development, and several projects are on the drawing board. Aker Oil and Gas, a leading offshore firm, says the country's construction industry will be working at capacity for the next 4 years. Norwegian oilmore » production has been hovering just below 2 million b/d since the beginning of this year, making Norway the North Sea's largest producer, a position formerly held by the U.K. Gas production averages about 3 bcfd. With European gas demand sharply increasing, Norway is under pressure to increase output from new fields in the mid to late 1990s. The Sleipner setback forces state owned Den norske stats oljeselskap AS (Statoil) to cast around for supplies. Sleipner was to have begun deliveries to a consortium of continental gas companies in October 1993. Statoil believes it can fill the gap from existing fields in Norwegian waters.« less

Roller skating injuries in children.

PubMed

Inkelis, S H; Stroberg, A J; Keller, E L; Christenson, P D

1988-06-01

Many children who roller skate sustain injuries. To determine the type and severity of these mishaps, the medical records of 76 children less than 16 years of age with roller skating injuries presenting to two pediatric emergency departments were reviewed. Seventy-five percent were girls, and 25% were boys. The upper extremity was the most common body part injured (74%) (P less than 0.0001). Lower extremity injuries occurred in 12%, head and face injuries in 10%, and chest injuries in 4%. The most common type of injury was a fracture (69%), with the wrist and forearm being most frequently fractured (53%). Hospitalization and long-term sequelae were infrequent. Younger children (less than or equal to 9) had an increased frequency of fracture injury (P less than 0.02). This is most likely because maturation of lower and upper extremity speed, strength, agility, coordination, balance, and reaction time and morphologically stronger bones combine to afford relative protection to the older child. Physicians and parents need to be aware of a child's skill level before the child is encouraged to roller skate. Measures which may decrease the likelihood of injury include protective gear, instruction in roller skating technique, learning to skate in an uncongested area on level, familiar terrain, and learning to fall properly.

Stress training improves performance during a stressful flight.

PubMed

McClernon, Christopher K; McCauley, Michael E; O'Connor, Paul E; Warm, Joel S

2011-06-01

This study investigated whether stress training introduced during the acquisition of simulator-based flight skills enhances pilot performance during subsequent stressful flight operations in an actual aircraft. Despite knowledge that preconditions to aircraft accidents can be strongly influenced by pilot stress, little is known about the effectiveness of stress training and how it transfers to operational flight settings. For this study, 30 participants with no flying experience were assigned at random to a stress-trained treatment group or a control group. Stress training consisted of systematic pairing of skill acquisition in a flight simulator with stress coping mechanisms in the presence of a cold pressor. Control participants received identical flight skill acquisition training but without stress training. Participants then performed a stressful flying task in a Piper Archer aircraft. Stress-trained research participants flew the aircraft more smoothly, as recorded by aircraft telemetry data, and generally better, as recorded by flight instructor evaluations, than did control participants. Introducing stress coping mechanisms during flight training improved performance in a stressful flying task. The results of this study indicate that stress training during the acquisition of flight skills may serve to enhance pilot performance in stressful operational flight and, therefore, might mitigate the contribution of pilot stress to aircraft mishaps.

A Review of Modern Control Strategies for Clinical Evaluation of Propofol Anesthesia Administration Employing Hypnosis Level Regulation.

PubMed

Ilyas, Muhammad; Butt, Muhammad Fasih Uddin; Bilal, Muhammad; Mahmood, Khalid; Khaqan, Ali; Ali Riaz, Raja

2017-01-01

Regulating the depth of hypnosis during surgery is one of the major objectives of an anesthesia infusion system. Continuous administration of Propofol infusion during surgical procedures is essential but it unduly increases the load of an anesthetist working in a multitasking scenario in the operation theatre. Manual and target controlled infusion systems are not appropriate to handle instabilities like blood pressure and heart rate changes arising due to interpatient and intrapatient variability. Patient safety, large interindividual variability, and less postoperative effects are the main factors motivating automation in anesthesia administration. The idea of automated system for Propofol infusion excites control engineers to come up with more sophisticated systems that can handle optimum delivery of anesthetic drugs during surgery and avoid postoperative effects. A linear control technique is applied initially using three compartmental pharmacokinetic and pharmacodynamic models. Later on, sliding mode control and model predicative control achieve considerable results with nonlinear sigmoid model. Chattering and uncertainties are further improved by employing adaptive fuzzy control and H ∞ control. The proposed sliding mode control scheme can easily handle the nonlinearities and achieve an optimum hypnosis level as compared to linear control schemes, hence preventing mishaps such as underdosing and overdosing of anesthesia.

The X-43 Fin Actuation System Problem - Reliability in Shades of Gray

NASA Technical Reports Server (NTRS)

Peebles, Curtis

2006-01-01

Following the loss of the first X-43 during launch, the mishap investigation board indicated the Fin Actuator System (FAS) needed to have a larger torque margin. To supply this added torque, a second actuator was added. The consequences of what seemed to be a simple modification would trouble the X-43 program. Because of the second actuator, a new computer board was required. This proved to be subject to electronic noise. This resulted in the actuator latch up in ground tests of the FAS for the second launch. Such a latch up would cause the Pegasus booster to fail, as the FAS was a single string system. The problem was corrected and the second flight was successful. The same modifications were added to the FAS for flight three. When the FAS underwent ground tests, it also latched up. The failure indicated that each computer board had a different tolerance to electronic noise. The problem with the FAS was corrected. Subsequently, another failure occurred, raising questions about the design, and the probability of failure for the X-43 Mach 10 flight. This was not simply a technical issue, but illuminated the difficulties facing both managers and engineers in assessing risk, design requirements, and probabilities in cutting edge aerospace projects.

A Match Made in Space

NASA Technical Reports Server (NTRS)

2006-01-01

Just before the space shuttle reaches orbit, its three main engines shut down so that it can achieve separation from the massive external tank that provided the fuel required for liftoff and ascent. In jettisoning the external tank, which is completely devoid of fuel at this point in the flight, the space shuttle fires a series of thrusters, separate from its main engines, that gives the orbiter the maneuvering ability necessary to safely steer clear of the descending tank and maintain its intended flight path. These thrusters make up the space shuttle s Reaction Control System. While the space shuttle s main engines only provide thrust in one direction (albeit a very powerful thrust), the Reaction Control System engines allow the vehicle to maneuver in any desired direction (via small amounts of thrust). The resulting rotational maneuvers are known as pitch, roll, and yaw, and are very important in ensuring that the shuttle docks properly when it arrives at the International Space Station and safely reenters the Earth s atmosphere upon leaving. To prevent the highly complex Reaction Control System from malfunctioning during space shuttle flights, and to provide a diagnosis if such a mishap were to occur, NASA turned to a method of artificial intelligence that truly defied the traditional laws of computer science.

How to Build a Vacuum Spring-transport Package for Spinning Rotor Gauges

PubMed Central

Fedchak, James A.; Scherschligt, Julia; Sefa, Makfir

2016-01-01

The spinning rotor gauge (SRG) is a high-vacuum gauge often used as a secondary or transfer standard for vacuum pressures in the range of 1.0 x 10-4 Pa to 1.0 Pa. In this application, the SRGs are frequently transported to laboratories for calibration. Events can occur during transportation that change the rotor surface conditions, thus changing the calibration factor. To assure calibration stability, a spring-transport mechanism is often used to immobilize the rotor and keep it under vacuum during transport. It is also important to transport the spring-transport mechanism using packaging designed to minimize the risk of damage during shipping. In this manuscript, a detailed description is given on how to build a robust spring-transport mechanism and shipping container. Together these form a spring-transport package. The spring-transport package design was tested using drop-tests and the performance was found to be excellent. The present spring-transport mechanism design keeps the rotor immobilized when experiencing shocks of several hundred g (g = 9.8 m/sec2 and is the acceleration due to gravity), while the shipping container assures that the mechanism will not experience shocks greater than about 100 g during common shipping mishaps (as defined by industry standards). PMID:27078575

A Review of General Aviation Safety (1984-2017).

PubMed

Boyd, Douglas D

2017-07-01

General aviation includes all civilian aviation apart from operations involving paid passenger transport. Unfortunately, this category of aviation holds a lackluster safety record, accounting for 94% of civil aviation fatalities. In 2014, of 1143 general aviation accidents, 20% were fatal compared with 0 of 29 airline mishaps in the United States. Herein, research findings over the past 30 yr will be reviewed. Accident risk factors (e.g., adverse weather, geographical region, post-impact fire, gender differences) will be discussed. The review will also summarize the development and implementation of stringent crashworthiness designs with multi-axis dynamic testing and head-injury protection and its impact on mitigating occupant injury severity. The benefits and drawbacks of new technology and human factor considerations associated with increased general aviation automation will be debated. Data on the safety of the aging general aviation population and increased drug usage will also be described. Finally, areas in which general aviation occupant survival could be improved and injury severity mitigated will be discussed with the view of equipping aircraft with 1) crash-resistant fuel tanks to reduce post-impact conflagration; 2) after-market ballistic parachutes for older aircraft; and 3) current generation electronic locator beacons to hasten site access by first responders.Boyd DD. A review of general aviation safety (1984-2017). Aerosp Med Hum Perform. 2017; 88(7):657-664.

Multi-actuators vehicle collision avoidance system - Experimental validation

NASA Astrophysics Data System (ADS)

Hamid, Umar Zakir Abdul; Zakuan, Fakhrul Razi Ahmad; Akmal Zulkepli, Khairul; Zulfaqar Azmi, Muhammad; Zamzuri, Hairi; Rahman, Mohd Azizi Abdul; Aizzat Zakaria, Muhammad

2018-04-01

The Insurance Institute for Highway Safety (IIHS) of the United States of America in their reports has mentioned that a significant amount of the road mishaps would be preventable if more automated active safety applications are adopted into the vehicle. This includes the incorporation of collision avoidance system. The autonomous intervention by the active steering and braking systems in the hazardous scenario can aid the driver in mitigating the collisions. In this work, a real-time platform of a multi-actuators vehicle collision avoidance system is developed. It is a continuous research scheme to develop a fully autonomous vehicle in Malaysia. The vehicle is a modular platform which can be utilized for different research purposes and is denominated as Intelligent Drive Project (iDrive). The vehicle collision avoidance proposed design is validated in a controlled environment, where the coupled longitudinal and lateral motion control system is expected to provide desired braking and steering actuation in the occurrence of a frontal static obstacle. Results indicate the ability of the platform to yield multi-actuators collision avoidance navigation in the hazardous scenario, thus avoiding the obstacle. The findings of this work are beneficial for the development of a more complex and nonlinear real-time collision avoidance work in the future.

A Review of Modern Control Strategies for Clinical Evaluation of Propofol Anesthesia Administration Employing Hypnosis Level Regulation

PubMed Central

Ilyas, Muhammad; Bilal, Muhammad; Mahmood, Khalid; Ali Riaz, Raja

2017-01-01

Regulating the depth of hypnosis during surgery is one of the major objectives of an anesthesia infusion system. Continuous administration of Propofol infusion during surgical procedures is essential but it unduly increases the load of an anesthetist working in a multitasking scenario in the operation theatre. Manual and target controlled infusion systems are not appropriate to handle instabilities like blood pressure and heart rate changes arising due to interpatient and intrapatient variability. Patient safety, large interindividual variability, and less postoperative effects are the main factors motivating automation in anesthesia administration. The idea of automated system for Propofol infusion excites control engineers to come up with more sophisticated systems that can handle optimum delivery of anesthetic drugs during surgery and avoid postoperative effects. A linear control technique is applied initially using three compartmental pharmacokinetic and pharmacodynamic models. Later on, sliding mode control and model predicative control achieve considerable results with nonlinear sigmoid model. Chattering and uncertainties are further improved by employing adaptive fuzzy control and H∞ control. The proposed sliding mode control scheme can easily handle the nonlinearities and achieve an optimum hypnosis level as compared to linear control schemes, hence preventing mishaps such as underdosing and overdosing of anesthesia. PMID:28466018

Family Medicine in Ethiopia: Lessons from a Global Collaboration.

PubMed

Evensen, Ann; Wondimagegn, Dawit; Zemenfes Ashebir, Daniel; Rouleau, Katherine; Haq, Cynthia; Ghavam-Rassoul, Abbas; Janakiram, Praseedha; Kvach, Elizabeth; Busse, Heidi; Conniff, James; Cornelson, Brian

2017-01-01

Building the capacity of local health systems to provide high-quality, self-sustaining medical education and health care is the central purpose for many global health partnerships (GHPs). Since 2001, our global partner consortium collaborated to establish Family Medicine in Ethiopia; the first Ethiopian family physicians graduated in February 2016. The authors, representing the primary Ethiopian, Canadian, and American partners in the GHP, identified obstacles, accomplishments, opportunities, errors, and observations from the years preceding residency launch and the first 3 years of the residency. Common themes were identified through personal reflection and presented as lessons to guide future GHPs. LESSON 1: Promote Family Medicine as a distinct specialty. LESSON 2: Avoid gaps, conflict, and redundancy in partner priorities and activities. LESSON 3: Building relationships takes time and shared experiences. LESSON 4: Communicate frequently to create opportunities for success. LESSON 5: Engage local leaders to build sustainable, long-lasting programs from the beginning of the partnership. GHPs can benefit individual participants, their organizations, and their communities served. Engaging with numerous partners may also result in challenges-conflicting expectations, misinterpretations, and duplication or gaps in efforts. The lessons discussed in this article may be used to inform GHP planning and interactions to maximize benefits and minimize mishaps. © Copyright 2017 by the American Board of Family Medicine.

Modeling Increased Complexity and the Reliance on Automation: FLightdeck Automation Problems (FLAP) Model

NASA Technical Reports Server (NTRS)

Ancel, Ersin; Shih, Ann T.

2014-01-01

This paper highlights the development of a model that is focused on the safety issue of increasing complexity and reliance on automation systems in transport category aircraft. Recent statistics show an increase in mishaps related to manual handling and automation errors due to pilot complacency and over-reliance on automation, loss of situational awareness, automation system failures and/or pilot deficiencies. Consequently, the aircraft can enter a state outside the flight envelope and/or air traffic safety margins which potentially can lead to loss-of-control (LOC), controlled-flight-into-terrain (CFIT), or runway excursion/confusion accidents, etc. The goal of this modeling effort is to provide NASA's Aviation Safety Program (AvSP) with a platform capable of assessing the impacts of AvSP technologies and products towards reducing the relative risk of automation related accidents and incidents. In order to do so, a generic framework, capable of mapping both latent and active causal factors leading to automation errors, is developed. Next, the framework is converted into a Bayesian Belief Network model and populated with data gathered from Subject Matter Experts (SMEs). With the insertion of technologies and products, the model provides individual and collective risk reduction acquired by technologies and methodologies developed within AvSP.

THE SLEEP OF LONG-HAUL TRUCK DRIVERS

PubMed Central

Mitler, Merrill M.; Miller, James C.; Lipsitz, Jeffrey J.; Walsh, James K.; Wylie, C. Dennis

2008-01-01

Background Fatigue and sleep deprivation are important safety issues for long-haul truck drivers. Methods We conducted round-the-clock electrophysiologic and performance monitoring of four groups of 20 male truck drivers who were carrying revenue-producing loads. We compared four driving schedules, two in the United States (five 10-hour trips of day driving beginning about the same time each day or of night driving beginning about 2 hours earlier each day) and two in Canada (four 13-hour trips of late-night-to-morning driving beginning at about the same time each evening or of afternoon-to-night driving beginning 1 hour later each day). Results Drivers averaged 5.18 hours in bed per day and 4.78 hours of electrophysiologically verified sleep per day over the five-day study (range, 3.83 hours of sleep for those on the steady 13-hour night schedule to 5.38 hours of sleep for those on the steady 10-hour day schedule). These values compared with a mean (±SD) self-reported ideal amount of sleep of 7.1±1 hours a day. For 35 drivers (44 percent), naps augmented the sleep obtained by an average of 0.45±0.31 hour. No crashes or other vehicle mishaps occurred. Two drivers had undiagnosed sleep apnea, as detected by polysomnography. Two other drivers had one episode each of stage 1 sleep while driving, as detected by electroencephalography. Forty-five drivers (56 percent) had at least 1 six-minute interval of drowsiness while driving, as judged by analysis of video recordings of their faces; 1067 of the 1989 six-minute segments (54 percent) showing drowsy drivers involved just eight drivers. Conclusions Long-haul truck drivers in this study obtained less sleep than is required for alertness on the job. The greatest vulnerability to sleep or sleep-like states is in the late night and early morning. PMID:9287232

Simulator-induced spatial disorientation: effects of age, sleep deprivation, and type of conflict.

PubMed

Previc, Fred H; Ercoline, William R; Evans, Richard H; Dillon, Nathan; Lopez, Nadia; Daluz, Christina M; Workman, Andrew

2007-05-01

Spatial disorientation mishaps are greater at night and with greater time on task, and sleep deprivation is known to decrease cognitive and overall flight performance. However, the ability to perceive and to be influenced by physiologically appropriate simulated SD conflicts has not previously been studied in an automated simulator flight profile. A set of 10 flight profiles were flown by 10 U.S. Air Force (USAF) pilots over a period of 28 h in a specially designed flight simulator for spatial disorientation research and training. Of the 10 flights, 4 had a total of 7 spatial disorientation (SD) conflicts inserted into each of them, 5 simulating motion illusions and 2 involving visual illusions. The percentage of conflict reports was measured along with the effects of four conflicts on flight performance. The results showed that, with one exception, all motion conflicts were reported over 60% of the time, whereas the two visual illusions were reported on average only 25% of the time, although they both significantly affected flight performance. Pilots older than 35 yr of age were more likely to report conflicts than were those under 30 yr of age (63% vs. 38%), whereas fatigue had little effect overall on either recognized or unrecognized SD. The overall effects of these conflicts on perception and performance were generally not altered by sleep deprivation, despite clear indications of fatigue in our pilots.

Synthesis of Metal Oxide Nanomaterials for Chemical Sensors by Molecular Beam Epitaxy

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

Nandasiri, Manjula I.; Kuchibhatla, Satyanarayana V N T; Thevuthasan, Suntharampillai

2013-12-01

Since the industrial revolution, detection and monitoring of toxic matter, chemical wastes, and air pollutants has become an important environmental issue. Thus, it leads to the development of chemical sensors for various environmental applications. The recent disastrous oil spills over the near-surface of ocean due to the offshore drilling emphasize the use of chemical sensors for prevention and monitoring of the processes that might lead to these mishaps.1, 2 Chemical sensors operated on a simple principle that the sensing platform undergoes a detectable change when exposed to the target substance to be sensed. Among all the types of chemical sensors,more » solid state gas sensors have attracted a great deal of attention due to their advantages such as high sensitivity, greater selectivity, portability, high stability and low cost.3, 4 Especially, semiconducting metal oxides such as SnO2, TiO2, and WO3 have been widely used as the active sensing platforms in solid state gas sensors.5 For the enhanced properties of solid state gas sensors, finding new sensing materials or development of existing materials will be needed. Thus, nanostructured materials such as nanotubes,6-8 nanowires,9-11 nanorods,12-15 nanobelts,16, 17 and nano-scale thin films18-23 have been synthesized and studied for chemical sensing applications.« less

The pattern of acute poisoning in a teaching hospital, north-west Ethiopia.

PubMed

Abula, Teferra; Wondmikun, Yared

2006-04-01

Poisoning by means of hazardous chemicals through ignorance, mishap or intentionally is becoming a serious health problem worldwide. Epidemiological data on this important health issue are, however, scarce in Ethiopia. The purpose of this study is to assess the pattern of acute poisonings and determine the approaches employed for the management of poisoning. The medical records of patients with acute poisonings presented to the Gondar University hospital between July 2001 and June 2004 were reviewed retrospectively. One hundred and two patients presenting to the emergency department of the hospital were due to acute poisoning; accounting for about 0.45% of emergency room admissions. Organophosphates, rat poison and alcohol were the commonly encountered poisoning agents (in about 70% of cases) mainly in adults possibly with suicidal or para-suicidal intention. The approaches employed in the management of poisoning mainly involved gastrointestinal decontamination procedures. Specific antidotes were used in a substantial number of patients. The fatality rate was 2.4%. Poisoning with suicidal intention is becoming a serious health problem particularly in adults. Pesticides are commonly used toxicants. The approaches in the management of poisoning are justifiable in some cases. However, much is to be done to improve the recording of patient-related information and record-keeping processes. Further large scale studies are required to investigate national trends of poisoning and factors associated with poisoning.

Effects of lightning on operations of aerospace vehicles

NASA Technical Reports Server (NTRS)

Fisher, Bruce D.

1989-01-01

Traditionally, aircraft lightning strikes were a major aviation safety issue. However, the increasing use of composite materials and the use of digital avionics for flight critical systems will require that more specific lightning protection measures be incorporated in the design of such aircraft in order to maintain the excellent lightning safety record presently enjoyed by transport aircraft. In addition, several recent lightning mishaps, most notably the loss of the Atlas/Centaur-67 vehicle at Cape Canaveral Air Force Station, Florida in March 1987, have shown the susceptibility of aircraft and launch vehicles to the phenomenon of vehicle-triggered lightning. The recent findings of the NASA Storm Hazards Program were reviewed as they pertain to the atmospheric conditions conducive to aircraft lightning strikes. These data are then compared to recent summaries of lightning strikes to operational aircraft fleets. Finally, the new launch commit criteria for triggered lightning being used by NASA and the U.S. Defense Department are summarized. The NASA Research data show that the greatest probability of a direct strike in a thunderstorm occurs at ambient temperatures of about -40 C. Relative precipitation and turbulence levels were characterized as negligible to light for these conditions. However, operational fleet data have shown that most aircraft lightning strikes in routine operations occur at temperatures near the freezing level in non-cumulonimbus clouds. The non-thunderstorm environment was not the subject of dedicated airborne lightning research.

Communication skills of anesthesiologists: An Indian perspective.

PubMed

Kumar, Mritunjay; Dash, Hari Har; Chawla, Rajiv

2013-07-01

Communication failure is a risk factor for mishaps and complaints, which can be reduced by effective communication between operating room team members and patients. To conduct a survey among anesthesiologists regarding communications skills and related issues like stress in case of communication failure, need for training, music in operation theater, and language barrier at their work place. We conducted a survey among anesthesiologists coming for a neuroanesthesia conference in India (n = 110) in February 2011 by questionnaire sent by e-mail to them. The response rate was 61.8% (68/110). Majority (95.5%) of the respondents agreed that good verbal communication leads to better patient outcome, better handling of crisis and is important between surgeons and anesthesiologists (98.5%). A total of 86% of the anesthesiologists felt that failure of communication caused stress to them. The idea of communication by e-mail or phone text messages instead of verbal communications was discouraged by 65.2%. A total of 82% of respondents felt that training of communication skills should be mandatory for all medical personnel and 77.6% were interested in participating in such course. Language barrier at work place was seen as hurdle by 62.7% of the respondents. A total of 80% of respondents felt that playing music in operating theater is appropriate. Results of the survey highlight the need for effective communication in the operating room between team members and need for formal training to improve it.

Innovation as Road Safety Felicitator

NASA Astrophysics Data System (ADS)

Sahoo, S.; Mitra, A.; Kumar, J.; Sahoo, B.

2018-03-01

Transportation via Roads should only be used for safely commuting from one place to another. In 2015, when 1.5 Million people, across the Globe started out on a journey, it was meant to be their last. The Global Status Report on Road Safety, 2015, reflected this data from 180 countries as road traffic deaths, worldwide. In India, more than 1.37 Lakh[4] people were victims of road accidents in 2013 alone. That number is more than the number of Indians killed in all the wars put together. With these disturbing facts in mind, we found out some key ambiguities in the Indian Road Traffic Management systems like the non-adaptive nature to fluctuating traffic, pedestrians and motor vehicles not adhering to the traffic norms strictly, to name a few. Introduction of simple systems would greatly erase the effects of this silent epidemic and our Project aims to achieve the same. It would introduce a pair of Barricade systems to cautiously separate the pedestrians and motor vehicles to minimise road mishaps to the extent possible. Exceptional situations like that of an Ambulance or any emergency vehicles will be taken care off by the use of RFID tags to monitor the movement of the Barricades. The varied traffic scenario can be guided properly by using the ADS-B (Automatic Detection System-Broadcast) for monitoring traffic density according to the time and place.

Developmental trajectory from early responses to transgressions to future antisocial behavior: Evidence for the role of the parent-child relationship from two longitudinal studies

PubMed Central

Kim, Sanghag; Kochanska, Grazyna; Boldt, Lea J.; Nordling, Jamie Koenig; O’Bleness, Jessica J.

2014-01-01

Parent-child relationships are critical in development, but much remains to be learned about mechanisms of their impact. We examined early parent-child relationship as a moderator of the developmental trajectory from children’s affective and behavioral responses to transgressions to future antisocial, externalizing behavior problems in Family Study (102 community mothers, fathers, and infants, followed through age 8) and Play Study (186 low-income, diverse mothers and toddlers, followed for 10 months). The relationship quality was indexed by attachment security in Family Study and maternal responsiveness in Play Study. Responses to transgressions (tense discomfort and reparation) were observed in laboratory mishaps that led children to believe they had damaged a valued object. Antisocial outcomes were rated by parents. In both studies, early relationship moderated the future developmental trajectory: Children’s attenuated tense discomfort predicted more antisocial outcomes, but only in insecure or unresponsive relationships. That risk was defused in secure or responsive relationships. Moderated mediation analyses in Family Study indicated that the links between low tense discomfort and future antisocial behavior in insecure parent-child dyads were mediated by parental stronger discipline pressure. By influencing indirectly future developmental sequelae, early relationship may increase or decrease the probability that the parent-child dyad will embark on a path toward antisocial outcomes. PMID:24280347

The contribution of attention in virtual moped riding training of teenagers.

PubMed

Tagliabue, Mariaelena; Da Pos, Osvaldo; Spoto, Andrea; Vidotto, Giulio

2013-08-01

Riding a moped, like many other everyday activities, is a complex behavior in which attention plays a crucial role. This study aims to investigate the role of attention in enhancing the skills required to ride a moped simulator. Two experiments were conducted with 207 and 60 students (14-15 years old), respectively, using a moped simulator to ride on 12 different tracks. The assignment was to ride safely and avoid hazards. In experiment 1, we divided the hazard scenes of the tracks on the basis of the fact that a shift in attention was required to escape the danger. We showed that during the riding training, when no attentional shift was required, the ability to avoid hazards was constantly higher. In experiment 2, participants were asked to cope with the same basic experimental setting but with an additional attentive task. The results showed that they performed in such a way that not only did the attentive task not impair their performance, but it also produced an improvement in the ability to shift attentional focus, preserving performance efficiency. On the basis of these data, it can be claimed that, primarily, attentional shift plays a prominent role in accounting for accident circumstances. Secondarily, it can be claimed that attentional training contributes to improved processing efficiency so as to prevent mishaps. Copyright © 2013 Elsevier Ltd. All rights reserved.

Fatalities due to intoxicated arrestees jumping out of moving police vehicles.

PubMed

Jacobs, Werner

2006-12-01

Fatalities resulting from emergency vehicle crashes are relatively rare. Mortality, particularly in the case of unbelted occupants, is relatively high. Data on drunken (handcuffed) arrestees jumping out of a moving police vehicle or the circumstances of such events have not been published. Two cases of such fatalities are described in this paper. Since these cases should be considered as "death in custody," may give rise to significant covering and speculation in the media, and may raise liability questions, they require an in-depth medicolegal investigation, including investigation of the crime scene, complete medicolegal autopsy/toxicology, and reconstruction of the event in the presence of an experienced forensic pathologist. From the 2 cases described in this paper, it appears that mechanical malfunctioning of the locking device of the door of the police vehicle and lack of controlling the actual lock-tied closing of the vehicle door (instead just assuming that it happened) may precipitate such cases. Auditory control by the police officers of the arrestee tampering with or manipulating the car door may be hampered by the background noise of the police vehicle, the on-board radio, and the use of a siren. Regular visual control and adequate control of the actual locking of the vehicle door are of paramount importance to prevent such mishaps. Reconstruction of the event in the presence of the forensic experts is mandatory to test the different hypotheses of the fatal event.

Developmental trajectory from early responses to transgressions to future antisocial behavior: evidence for the role of the parent-child relationship from two longitudinal studies.

PubMed

Kim, Sanghag; Kochanska, Grazyna; Boldt, Lea J; Nordling, Jamie Koenig; O'Bleness, Jessica J

2014-02-01

Parent-child relationships are critical in development, but much remains to be learned about the mechanisms of their impact. We examined the early parent-child relationship as a moderator of the developmental trajectory from children's affective and behavioral responses to transgressions to future antisocial, externalizing behavior problems in the Family Study (102 community mothers, fathers, and infants, followed through age 8) and the Play Study (186 low-income, diverse mothers and toddlers, followed for 10 months). The relationship quality was indexed by attachment security in the Family Study and maternal responsiveness in the Play Study. Responses to transgressions (tense discomfort and reparation) were observed in laboratory mishaps wherein children believed they had damaged a valued object. Antisocial outcomes were rated by parents. In both studies, early relationships moderated the future developmental trajectory: diminished tense discomfort predicted more antisocial outcomes, but only in insecure or unresponsive relationships. That risk was defused in secure or responsive relationships. Moderated mediation analyses in the Family Study indicated that the links between diminished tense discomfort and future antisocial behavior in insecure parent-child dyads were mediated by stronger discipline pressure from parents. By indirectly influencing future developmental sequelae, early relationships may increase or decrease the probability that the parent-child dyad will embark on a path toward antisocial outcomes.

An evaluation of legislative measures on electrical and electronic waste in the People's Republic of China

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

Chung, Shan-Shan, E-mail: sschung@hkbu.edu.hk; Zhang Chan, E-mail: abigailchanzhang@gmail.com

2011-12-15

Graphical abstract: Highlights: > The most recent specific WEEE laws of China are reviewed and evaluated. > Take-back requirement is vaguely defined. > The 'environmental expiry date' requirement is redundant. > Use of a 'multiple enforcement body' approach has hampered enforcement. - Abstract: With the increasing number of recycling mishaps in connection with waste electronic and electrical equipment (WEEE) in the People's Republic of China, it is imperative that the handling and recycling of WEEE be sufficiently regulated in China. Regulations covering three major issues, namely, take-back issues, controls on hazardous substances in WEEE and the assurance of good environmentalmore » management in WEEE plants, were promulgated between 2006 and 2008. The evaluation in this country report shows that few of these regulatory measures have performed satisfactorily in terms of enforcement, of public acceptance and of environmental concerns. In brief, the take-back requirements and the associated financial responsibilities are only vaguely defined; the control on hazardous substances and the so-called 'environmental expiry date' requirements cannot be properly enforced, and the resources needed to ensure the satisfactory enforcement of the environmental abatement and pollution control requirements in WEEE plants are overwhelming. In addition, the use of a 'multiple enforcement body' approach to the control of hazardous substances in WEEE is an indication that the Chinese government lacks the determination to properly enforce the relevant legal requirements.« less

An in vitro study of mesiobuccal root thickness of maxillary first molars.

PubMed

Mohammadzadeh Akhlaghi, Nahid; Ravandoust, Yasaman; Najafi, Mohammad; Dadresanfar, Bahareh

2012-01-01

Understanding the internal anatomy of root canal system can significantly influence outcomes of root canal treatment. The aim of this in vitro study was to measure the thickness of mesiobuccal root at different levels in maxillary first molars. In this cross-sectional study, forty extracted human maxillary first molars were radiographed; accordingly, the mesial and distal root thicknesses of mesiobuccal (MB) roots were measured at four parallel horizontal levels. The samples were sectioned at the measured levels and then sections were scanned and saved in the computer. Buccal (B), Palatal (P), Mesial (M) and Distal (D) aspects of root thicknesses in single-canalled roots were measured. In two-canalled mesiobuccal roots, Distobuccal (DB) and Distopalatal (DP) aspects were evaluated alongside other measurements. Average radicular thickness in each aspect and each level was compared using ANOVA and t-test. A total of 25 had two canals and 15 had one canal in MB root. In single-canalled roots M and D aspects were the thinnest whereas in two-canalled samples, the thicknesses of DP and DB aspects were significantly less than others (P<0.001). The B and P had the greatest thicknesses in all the samples. The results showed that special attention should be paid to "danger zone" areas of mesiobuccal maxillary first molar roots in order to avoid technical mishaps.

United States Air Force Computer-Aided Acquisition and Logistics Support (CALS). Logistics Support Analysis Current Environment. Volume 2

DOT National Transportation Integrated Search

1988-10-01

An analysis of the current environment within the Acquisition stage of the Weapon System Life Cycle Pertaining to the Logistics Support Analysis (LSA) process, the Logistics Support Analysis Record (LSAR), and other Logistics Support data was underta...

United States Air Force Computer-Aided Acquisition and Logistics Support (CALS). Logistics Support Analysis Current Environment. Volume 1

DOT National Transportation Integrated Search

1988-10-01

An analysis of the current environment within the Acquisition stage of the Weapon System Life Cycle Pertaining to the Logistics Support Analysis (LSA) process, the Logistics Support Analysis Record (LSAR), and other Logistics Support data was underta...

Thallium-201 for cardiac stress tests: residual radioactivity worries patients and security.

PubMed

Geraci, Matthew J; Brown, Norman; Murray, David

2012-12-01

A 47-year-old man presented to the Emergency Department (ED) in duress and stated he was "highly radioactive." There were no reports of nuclear disasters, spills, or mishaps in the local area. This report discusses the potential for thallium-201 (Tl-201) patients to activate passive radiation alarms days to weeks after nuclear stress tests, even while shielded inside industrial vehicles away from sensors. Characteristics of Tl-201, as used for medical imaging, are described. This patient was twice detained by Homeland Security Agents and searched after he activated radiation detectors at a seaport security checkpoint. Security agents deemed him not to be a threat, but they expressed concern regarding his health and level of personal radioactivity. The patient was subsequently barred from his job and sent to the hospital. Tl-201 is a widely used radioisotope for medical imaging. The radioactive half-life of Tl-201 is 73.1h, however, reported periods of extended personal radiation have been seen as far out as 61 days post-administration. This case describes an anxious, but otherwise asymptomatic patient presenting to the ED with detection of low-level personal radiation. Documentation should be provided to and carried by individuals receiving radionuclides for a minimum of five to six half-lives of the longest-lasting isotope provided. Patients receiving Tl-201 should understand the potential for security issues; reducing probable tense moments, confusion, and anxiety to themselves, their employers, security officials, and ED staff. Copyright © 2012 Elsevier Inc. All rights reserved.

Occupant Injury Severity and Accident Causes in Helicopter Emergency Medical Services (1983-2014).

PubMed

Boyd, Douglas D; Macchiarella, Nickolas D

2016-01-01

Helicopter emergency medical services (HEMS) transport critically ill patients to/between emergency care facilities and operate in a hazardous environment: the destination site is often encumbered with obstacles, difficult to visualize at night, and lack instrument approaches for degraded visibility. The study objectives were to determine 1) HEMS accident rates and causes; 2) occupant injury severity profiles; and 3) whether accident aircraft were certified to the more stringent crashworthiness standards implemented two decades ago. The National Transportation Safety Board (NTSB) aviation accident database was used to identify HEMS mishaps for the years spanning 1983-2014. Contingency tables (Pearson Chi-square or Fisher's exact test) were used to determine differences in proportions. A generalized linear model (Poisson distribution) was used to determine if accident rates differed over time. While the HEMS accident rate decreased by 71% across the study period, the fraction of fatal accidents (36-50%) and the injury severity profiles were unchanged. None of the accident aircraft fully satisfied the current crashworthiness standards. Failure to clear obstacles and visual-to-instrument flight, the most frequent accident causes (37 and 26%, respectively), showed a downward trend, whereas accidents ascribed to aircraft malfunction showed an upward trend over time. HEMS operators should consider updating their fleet to the current, more stringent crashworthiness standards in an attempt to reduce injury severity. Additionally, toward further mitigating accidents ascribed to inadvertent visual-to-instrument conditions, HEMS aircraft should be avionics-equipped for instrument flight rules flight.

Mechanisms of slow-pitch softball injuries reported to the HQ Air Force Safety Center a 10-year descriptive study, 1993-2002.

PubMed

Burnham, Bruce R; Copley, G Bruce; Shim, Matthew J; Kemp, Philip A; Jones, Bruce H

2010-01-01

Softball is a popular sport in civilian and military populations and results in a large number of lost-workday injuries. The purpose of this study is to describe the mechanisms associated with softball injuries occurring among active duty U.S. Air Force (USAF) personnel to better identify potentially effective countermeasures. Data derived from safety reports were obtained from the USAF Ground Safety Automated System in 2003. Softball injuries for the years 1993-2002 that resulted in at least one lost workday were included in the study. Narrative data were systematically reviewed and coded in order to categorize and summarize mechanisms associated with these injuries. This report documents a total of 1181 softball-related mishap reports, involving 1171 active duty USAF members who sustained one lost-workday injury while playing softball. Eight independent mechanisms were identified. Three specific scenarios (sliding, being hit by a ball, and colliding with a player) accounted for 60% of reported softball injuries. Mechanisms of injury for activities such as playing softball, necessary for prevention planning, can be identified using the detailed information found in safety reports. This information should also be used to develop better sports injury coding systems. Within the USAF and U.S. softball community, interventions to reduce injuries related to the most common mechanisms (sliding, being hit by a ball, and colliding with a player) should be developed, implemented, and evaluated. Published by Elsevier Inc.

[Nursing practice in maternity intensive care units. Severe pre-eclampsia in a primigravida].

PubMed

Carmona-Guirado, A J; Escaño-Cardona, V; García-Cañedo, F J

2015-01-01

39 year old woman, pregnant for 31+5 weeks, who came to our intensive care unit (ICU) referred from the emergency department of the hospital, having swollen ankles, headache and fatigue at moderate effort. We proceeded to take blood pressure (158/96 mmHg) and assess lower limb edema. The fetal heart rate monitoring was normal. Knowledgeable and user of healthy guidelines during her pregnancy, she did not follow any treatment. Single mother, she worried about her fetus (achieved through in vitro fertilization), her mother offered to help for any mishap. We developed an Individualized Care Plan. For data collection we used: Rating 14 Virginia Henderson Needs and diagnostic taxonomy NANDA, NOC, NIC. Nursing diagnoses of "fluid volume excess" and "risk of impaired maternal-fetal dyad" were detected, as well as potential complications such as eclampsia and fetal prematurity. Our overall objectives (NOC) were to integrate the woman in the process she faced and that she knew how to recognize the risk factors inherent in her illness. Nursing interventions (NIC) contemplated the awareness and treatment of her illness and the creation of new healthy habits. The work of nursing Maternal ICU allowed women to help maintain maximum maternal and fetal well-being by satisfying any of her needs. Mishandling of the situation leads into a framework of high morbidity and mortality in our units. Copyright © 2014 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

Lessons Learned and Technical Standards: A Logical Marriage

NASA Technical Reports Server (NTRS)

Gill, Paul; Vaughan, William W.; Garcia, Danny; Gill, Maninderpal S. (Technical Monitor)

2001-01-01

A comprehensive database of lessons learned that corresponds with relevant technical standards would be a boon to technical personnel and standards developers. The authors discuss the emergence of one such database within NASA, and show how and why the incorporation of lessons learned into technical standards databases can be an indispensable tool for government and industry. Passed down from parent to child, teacher to pupil, and from senior to junior employees, lessons learned have been the basis for our accomplishments throughout the ages. Government and industry, too, have long recognized the need to systematically document And utilize the knowledge gained from past experiences in order to avoid the repetition of failures and mishaps. The use of lessons learned is a principle component of any organizational culture committed to continuous improvement. They have formed the foundation for discoveries, inventions, improvements, textbooks, and technical standards. Technical standards are a very logical way to communicate these lessons. Using the time-honored tradition of passing on lessons learned while utilizing the newest in information technology, the National Aeronautics and Space Administration (NASA) has launched an intensive effort to link lessons learned with specific technical standards through various Internet databases. This article will discuss the importance of lessons learned to engineers, the difficulty in finding relevant lessons learned while engaged in an engineering project, and the new NASA project that can help alleviate this difficulty. The article will conclude with recommendations for more expanded cross-sectoral uses of lessons learned with reference to technical standards.

Learning from Past Experiences

NASA Technical Reports Server (NTRS)

Hulet, Michael W.

2007-01-01

Space flight is a risky business. This truism has been bandied about since the earliest days of the space program. When asked by the young daughter of a coworker, one of the Mercury astronauts likened launching into space to "riding a Roman candle" -- it was both exciting and dangerous. Even in these more technologically advanced days, the solid rocket boosters and external tanks of the space shuttle provide a no less exciting, or dangerous, ride into space. However much the phrase "risk mitigation" is bandied about within the U.S. space program, there is still the history of the Apollo 1 fire during a ground test at Cape Canaveral, Fla., the loss of the shuttle Challenger during liftoff, and the loss of the shuttle Columbia when returning to Earth to remind us that while we give lip-service to risk management, we have not learned to manage risk as well as we ought. Moreover, there are many more less dramatic, but equally critical, incidents that have occurred in association with the space program that also highlight our inability to accurately gauge and manage risk. Why do we seem caught in a senseless spiral in which we focus most on risk only after a tragedy? Why do we repeat serious mishaps and not learn from our mistakes? This paper reviews some possible explanations for our risk-taking behavior and provides examples of interest to the NASA centers, while also discussing inter center and intra-center opportunities for sharing information to mitigate risk.

Modeling Types of Pedal Applications Using a Driving Simulator.

PubMed

Wu, Yuqing; Boyle, Linda Ng; McGehee, Daniel; Roe, Cheryl A; Ebe, Kazutoshi; Foley, James

2015-11-01

The aim of this study was to examine variations in drivers' foot behavior and identify factors associated with pedal misapplications. Few studies have focused on the foot behavior while in the vehicle and the mishaps that a driver can encounter during a potentially hazardous situation. A driving simulation study was used to understand how drivers move their right foot toward the pedals. The study included data from 43 drivers as they responded to a series of rapid traffic signal phase changes. Pedal application types were classified as (a) direct hit, (b) hesitated, (c) corrected trajectory, and (d) pedal errors (incorrect trajectories, misses, slips, or pressed both pedals). A mixed-effects multinomial logit model was used to predict the likelihood of one of these pedal applications, and linear mixed models with repeated measures were used to examine the response time and pedal duration given the various experimental conditions (stimuli color and location). Younger drivers had higher probabilities of direct hits when compared to other age groups. Participants tended to have more pedal errors when responding to a red signal or when the signal appeared to be closer. Traffic signal phases and locations were associated with pedal response time and duration. The response time and pedal duration affected the likelihood of being in one of the four pedal application types. Findings from this study suggest that age-related and situational factors may play a role in pedal errors, and the stimuli locations could affect the type of pedal application. © 2015, Human Factors and Ergonomics Society.

NASA Materials Related Lessons Learned

NASA Technical Reports Server (NTRS)

Garcia, Danny; Gill, Paul S.; Vaughan, William W.

2003-01-01

Lessons Learned have been the basis for our accomplishments throughout the ages. They have been passed down from father to son, mother to daughter, teacher to pupil, and older to younger worker. Lessons Learned have also been the basis for the nation s accomplishments for more than 200 years. Both government and industry have long recognized the need to systematically document and utilize the knowledge gained from past experiences in order to avoid the repetition of failures and mishaps. Through the knowledge captured and recorded in Lessons Learned from more than 80 years of flight in the Earth s atmosphere, NASA s materials researchers are constantly working to develop stronger, lighter, and more durable materials that can withstand the challenges of space. The Agency s talented materials engineers and scientists continue to build on that rich tradition by using the knowledge and wisdom gained from past experiences to create futuristic materials and technologies that will be used in the next generation of advanced spacecraft and satellites that may one day enable mankind to land men on another planet or explore our nearest star. These same materials may also have application here on Earth to make commercial aircraft more economical to build and fly. With the explosion in technical accomplishments over the last decade, the ability to capture knowledge and have the capability to rapidly communicate this knowledge at lightning speed throughout an organization like NASA has become critical. Use of Lessons Learned is a principal component of an organizational culture committed to continuous improvement.

NASA Materials Related Lessons Learned

NASA Technical Reports Server (NTRS)

Garcia, Danny; Gill, Paul S.; Vaughan, William W.; Parker, Nelson C. (Technical Monitor)

2002-01-01

Lessons Learned have been the basis for our accomplishments throughout the ages. They have been passed down from father to son, mother to daughter, teacher to pupil, and older to younger worker. Lessons Learned have also been the basis for the nation's accomplishments for more than 200 years. Both government and industry have long recognized the need to systematically document and utilize the knowledge gained from past experiences in order to avoid the repetition of failures and mishaps. Through the knowledge captured and recorded in Lessons Learned from more than 80 years of flight in the Earth's atmosphere, NASA's materials researchers are constantly working to develop stronger, lighter, and more durable materials that can withstand the challenges of space. The Agency's talented materials engineers and scientists continue to build on that rich tradition by using the knowledge and wisdom gained from past experiences to create futurist materials and technologies that will be used in the next generation of advanced spacecraft and satellites that may one day enable mankind to land men on another planet or explore our nearest star. These same materials may also have application here on Earth to make commercial aircraft more economical to build and fly. With the explosion in technical accomplishments over the last decade, the ability to capture knowledge and have the capability to rapidly communicate this knowledge at lightning speed throughout an organization like NASA has become critical. Use of Lessons Learned is a principal component of an organizational culture committed to continuous improvement.

X-43A Final Flight Observations

NASA Technical Reports Server (NTRS)

Grindle, Laurie

2011-01-01

The presentation will provide an overview of the final flight of the NASA X-43A project. The project consisted of three flights, two planned for Mach 7 and one for Mach 10. The first flight, conducted on June 2, 2001, was unsuccessful and resulted in a nine-month mishap investigation. A two-year return to flight effort ensued and concluded when the second Mach 7 flight was successfully conducted on March 27, 2004. The third and final flight, which occurred on November 16, 2004, was the first Mach 10 flight demonstration of an airframe-integrated, scramjet-powered, hypersonic vehicle. As such, the final flight presented first time technical challenges in addition to final flight project closeout concerns. The goals and objectives for the third flight as well as those for the project will be presented. The configuration of the Hyper-X stack including the X-43A, Hyper-X launch vehicle, and Hyper-X research vehicle adapter wil also be presented. Mission differences, vehicle modifications and lessons learned from the first and second flights as they applied to the third flight will also be discussed. Although X-43A flight 3 was always planned to be the final flight of the X-43A project, the X-43 program had two other vehicles and corresponding flight phases in X-43C and X-43B. Those other projects never manifested under the X-43 banner and X-43A flight 3 also became the final flight of X-43 program.

Transferring Aviation Practices into Clinical Medicine for the Promotion of High Reliability.

PubMed

Powell-Dunford, Nicole; McPherson, Mark K; Pina, Joseph S; Gaydos, Steven J

2017-05-01

Aviation is a classic example of a high reliability organization (HRO)-an organization in which catastrophic events are expected to occur without control measures. As health care systems transition toward high reliability, aviation practices are increasingly transferred for clinical implementation. A PubMed search using the terms aviation, crew resource management, and patient safety was undertaken. Manuscripts authored by physician pilots and accident investigation regulations were analyzed. Subject matter experts involved in adoption of aviation practices into the medical field were interviewed. A PubMed search yielded 621 results with 22 relevant for inclusion. Improved clinical outcomes were noted in five research trials in which aviation practices were adopted, particularly with regard to checklist usage and crew resource-management training. Effectiveness of interventions was influenced by intensity of application, leadership involvement, and provision of staff training. The usefulness of incorporating mishap investigation techniques has not been established. Whereas aviation accident investigation is highly standardized, the investigation of medical error is characterized by variation. The adoption of aviation practices into clinical medicine facilitates an evolution toward high reliability. Evidence for the efficacy of the checklist and crew resource-management training is robust. Transference of aviation accident investigation practices is preliminary. A standardized, independent investigation process could facilitate the development of a safety culture commensurate with that achieved in the aviation industry.Powell-Dunford N, McPherson MK, Pina JS, Gaydos SJ. Transferring aviation practices into clinical medicine for the promotion of high reliability. Aerosp Med Hum Perform. 2017; 88(5):487-491.

Laser-heating and Radiance Spectrometry for the Study of Nuclear Materials in Conditions Simulating a Nuclear Power Plant Accident.

PubMed

Manara, Dario; Soldi, Luca; Mastromarino, Sara; Boboridis, Kostantinos; Robba, Davide; Vlahovic, Luka; Konings, Rudy

2017-12-14

Major and severe accidents have occurred three times in nuclear power plants (NPPs), at Three Mile Island (USA, 1979), Chernobyl (former USSR, 1986) and Fukushima (Japan, 2011). Research on the causes, dynamics, and consequences of these mishaps has been performed in a few laboratories worldwide in the last three decades. Common goals of such research activities are: the prevention of these kinds of accidents, both in existing and potential new nuclear power plants; the minimization of their eventual consequences; and ultimately, a full understanding of the real risks connected with NPPs. At the European Commission Joint Research Centre's Institute for Transuranium Elements, a laser-heating and fast radiance spectro-pyrometry facility is used for the laboratory simulation, on a small scale, of NPP core meltdown, the most common type of severe accident (SA) that can occur in a nuclear reactor as a consequence of a failure of the cooling system. This simulation tool permits fast and effective high-temperature measurements on real nuclear materials, such as plutonium and minor actinide-containing fission fuel samples. In this respect, and in its capability to produce large amount of data concerning materials under extreme conditions, the current experimental approach is certainly unique. For current and future concepts of NPP, example results are presented on the melting behavior of some different types of nuclear fuels: uranium-plutonium oxides, carbides, and nitrides. Results on the high-temperature interaction of oxide fuels with containment materials are also briefly shown.

Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research.

PubMed

Fingerhut, A; Hay, J M; Elhadad, A; Lacaine, F; Flamant, Y

1995-09-01

Although used widely for supraperitoneal anastomoses, circular stapled anastomoses have never been proved better than hand-sewn anastomoses. In the one prospective controlled trial that studied these anastomoses specifically, the only significant difference found was that there were more clinically obvious leakages with the circular stapled variety, but not in the overall clinical and roentgenologic leakage rates. One hundred fifty-nine consecutive patients (88 men and 71 women, mean age 65.8 +/- 12.1 years) were randomized to undergo hand-sewn (n = 74) or circular stapled (n = 85) supraperitoneal colorectal anastomosis after left colectomy. Patient demographics were similar in both groups. Overall mortality was 1.3% (2 of 159; one in each group). No statistically significant difference (NS) was found in the rate of early complications, including anastomotic leakage (4 of 74 versus 6 of 85) in the hand-sewn and stapled anastomoses, respectively). Mishaps (n = 10) and hemorrhage (n = 5) occurred in the stapled group only. Stapled anastomoses took an average of 8 minutes less to perform (p < 0.001), but this time gain did not significantly influence the overall duration of operation (identical median times). The median duration of hospitalization was 13 and 14 days, respectively (NS). At 8 months there were 2 of 74 strictures in the hand-sewn group and 4 of 85 strictures in the stapled group (NS). According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.

Rapid identification of oil-contaminated soils using visible near-infrared diffuse reflectance spectroscopy.

PubMed

Chakraborty, Somsubhra; Weindorf, David C; Morgan, Cristine L S; Ge, Yufeng; Galbraith, John M; Li, Bin; Kahlon, Charanjit S

2010-01-01

In the United States, petroleum extraction, refinement, and transportation present countless opportunities for spillage mishaps. A method for rapid field appraisal and mapping of petroleum hydrocarbon-contaminated soils for environmental cleanup purposes would be useful. Visible near-infrared (VisNIR, 350-2500 nm) diffuse reflectance spectroscopy (DRS) is a rapid, nondestructive, proximal-sensing technique that has proven adept at quantifying soil properties in situ. The objective of this study was to determine the prediction accuracy of VisNIR DRS in quantifying petroleum hydrocarbons in contaminated soils. Forty-six soil samples (including both contaminated and reference samples) were collected from six different parishes in Louisiana. Each soil sample was scanned using VisNIR DRS at three combinations of moisture content and pretreatment: (i) field-moist intact aggregates, (ii) air-dried intact aggregates, (iii) and air-dried ground soil (sieved through a 2-mm sieve). The VisNIR spectra of soil samples were used to predict total petroleum hydrocarbon (TPH) content in the soil using partial least squares (PLS) regression and boosted regression tree (BRT) models. Each model was validated with 30% of the samples that were randomly selected and not used in the calibration model. The field-moist intact scan proved best for predicting TPH content with a validation r2 of 0.64 and relative percent difference (RPD) of 1.70. Because VisNIR DRS was promising for rapidly predicting soil petroleum hydrocarbon content, future research is warranted to evaluate the methodology for identifying petroleum contaminated soils.

Exhaustive Thresholds and Resistance Checkpoints

NASA Technical Reports Server (NTRS)

Easton, Charles; Khuzadi, Mbuyi

2008-01-01

Once deployed, all intricate systems that operate for a long time (such as an airplane or chemical processing plant) experience degraded performance during operational lifetime. These can result from losses of integrity in subsystems and parts that generally do not materially impact the operation of the vehicle (e.g., the light behind the button that opens the sliding door of the minivan). Or it can result from loss of more critical parts or subsystems. Such losses need to be handled quickly in order to avoid loss of personnel, mission, or part of the system itself. In order to manage degraded systems, knowledge of its potential problem areas and the means by which these problems are detected should be developed during the initial development of the system. Once determined, a web of sensors is employed and their outputs are monitored with other system parameters while the system is in preparation or operation. Just gathering the data is only part of the story. The interpretation of the data itself and the response of the system must be carefully developed as well to avoid a mishap. Typically, systems use a test-threshold-response paradigm to process potential system faults. However, such processing sub-systems can suffer from errors and oversights of a consistent type, causing system aberrant behavior instead of expected system and recovery operations. In our study, we developed a complete checklist for determining the completeness of a fault system and its robustness to common processing and response difficulties.

75 FR 69140 - NUREG-1953, Confirmatory Thermal-Hydraulic Analysis To Support Specific Success Criteria in the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-10

... To Support Specific Success Criteria in the Standardized Plant Analysis Risk Models--Surry and Peach... INFORMATION: NUREG-1953, ``Confirmatory Thermal-Hydraulic Analysis to Support Specific Success Criteria in the... document entitled: NUREG-1953, ``Confirmatory Thermal- Hydraulic Analysis to Support Specific Success...

18 CFR 300.12 - Analysis of supporting data.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 18 Conservation of Power and Water Resources 1 2011-04-01 2011-04-01 false Analysis of supporting... APPROVAL OF THE RATES OF FEDERAL POWER MARKETING ADMINISTRATIONS Filing Requirements § 300.12 Analysis of supporting data. (a) An analysis of the data provided under § 300.11 must be supported by an appropriate...

18 CFR 300.12 - Analysis of supporting data.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 18 Conservation of Power and Water Resources 1 2010-04-01 2010-04-01 false Analysis of supporting... APPROVAL OF THE RATES OF FEDERAL POWER MARKETING ADMINISTRATIONS Filing Requirements § 300.12 Analysis of supporting data. (a) An analysis of the data provided under § 300.11 must be supported by an appropriate...

Moving Forward: Positive Behavior Support and Applied Behavior Analysis

ERIC Educational Resources Information Center

Tincani, Matt

2007-01-01

A controversy has emerged about the relationship between positive behavior support and applied behavior analysis. Some behavior analysts suggest that positive behavior support and applied behavior analysis are the same (e.g., Carr & Sidener, 2002). Others argue that positive behavior support is harmful to applied behavior analysis (e.g., Johnston,…

75 FR 80544 - NUREG-1953, Confirmatory Thermal-Hydraulic Analysis To Support Specific Success Criteria in the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-22

... To Support Specific Success Criteria in the Standardized Plant Analysis Risk Models--Surry and Peach... Specific Success Criteria in the Standardized Plant Analysis Risk Models--Surry and Peach Bottom, Draft..., ``Confirmatory Thermal-Hydraulic Analysis to Support Specific Success Criteria in the Standardized Plant Analysis...

48 CFR 2815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Information to support proposal analysis. All requests for field pricing support shall be made by the... 48 Federal Acquisition Regulations System 6 2010-10-01 2010-10-01 true Information to support proposal analysis. 2815.404-2 Section 2815.404-2 Federal Acquisition Regulations System DEPARTMENT OF...

48 CFR 2815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Information to support proposal analysis. All requests for field pricing support shall be made by the... 48 Federal Acquisition Regulations System 6 2013-10-01 2013-10-01 false Information to support proposal analysis. 2815.404-2 Section 2815.404-2 Federal Acquisition Regulations System DEPARTMENT OF...

48 CFR 2815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2014 CFR

2014-10-01

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48 CFR 2815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Information to support proposal analysis. All requests for field pricing support shall be made by the... 48 Federal Acquisition Regulations System 6 2012-10-01 2012-10-01 false Information to support proposal analysis. 2815.404-2 Section 2815.404-2 Federal Acquisition Regulations System DEPARTMENT OF...

48 CFR 2815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2011 CFR

2011-10-01

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PREFACE: Soft Magnetic Materials 8

NASA Astrophysics Data System (ADS)

Pfützner, H.

1988-01-01

The Conference "Soft Magnetic Materials 8" was held from 1 to 4 September 1987 at the Congress Centre Badgastein, Austria. It was organized by the Division of Bioelectricity and Magnetism and by the Institute of Applied and Technical Physics of the University of Technology, Vienna. The Conference was the eighth in the bi-annual series which commenced in Turin, Italy. It was attended by about 130 scientists from universities and industrial companies from 19 countries. The theme of the Conference was the recent progress in industrial applications and developments of soft magnetic alloys including magnetic measurements and field computation problems as well as fundamental aspects. In five sessions, 13 invited papers were presented in oral form. In addition, the program of poster sessions included 122 contributed papers. Regrettably, some of them were not presented when authors (especially from Eastern European countries as well as from China) were unable to be present. A clear emphasis of papers was laid on characteristics and applications of amorphous materials. As confirmed by the delegates, the spacious Congress Centre—well aerated by the near-by waterfall—provided an effective environment for informal discussions. The Conference Dinner as well as the Mountain Lodge Evening were utilized for general communications in an intensive form. However, a slight mishap of this Conference should not be concealed: Due to a thunder storm, one delegate spent a long frosty night on a rock peak of Badgasteins mountains. Still, next day he presented his excellent paper in top condition. The next Conference, SMM9, is planned to be held in El Escorial, Spain, in 1989.

Old Journey, New Heights

NASA Technical Reports Server (NTRS)

DelFrate, John

2005-01-01

If you could see the road ahead, you might pass up a fantastic opportunity because you're blinded by the potential pitfalls. In my case, I was testing the project management waters at the NASA Dryden Flight Research Center after ten years of being a research engineer. I was an eager (but ignorant) rookie project manager (PM) and I was willing to engage in just about any project without knowing what it would entail. The assignment I accepted was to help NASA's Environment Research Aircraft and Sensor Technology (ERAST) Project, a partnership with a fledgling Uninhabited Aerial Vehicle (UAV) industry, to tackle stratospheric flight. I remember one of our industrial partners querying me about whether or not I understood what 1 was getting into. Like one of those bobble-head toys that have become quite popular, I nodded. But in reality, I didn't have a clue. His response was, "Hang on, it's going to be a wild ride." He was right. In retrospect, if I had clearly understood the ten years of pitfalls that were coming, I might not have "hung on." Now I can look back and say that I would not trade the experience for anything. The lows included the destruction of a number of UAVs on my watch. Later someone told me that we should not be surprised if we lost one UAV for every ten flights. We wrote many chapters in the book on what can go wrong with UAVs-and we are still writing. As you can imagine, each mishap was accompanied by an investigation. What an education!

Patient injuries from anesthesia gas delivery equipment: a closed claims update.

PubMed

Mehta, Sonya P; Eisenkraft, James B; Posner, Karen L; Domino, Karen B

2013-10-01

Improvements in anesthesia gas delivery equipment and provider training may increase patient safety. The authors analyzed patient injuries related to gas delivery equipment claims from the American Society of Anesthesiologists Closed Claims Project database over the decades from 1970s to the 2000s. After the Institutional Review Board approval, the authors reviewed the Closed Claims Project database of 9,806 total claims. Inclusion criteria were general anesthesia for surgical or obstetric anesthesia care (n = 6,022). Anesthesia gas delivery equipment was defined as any device used to convey gas to or from (but not involving) the airway management device. Claims related to anesthesia gas delivery equipment were compared between time periods by chi-square test, Fisher exact test, and Mann-Whitney U test. Anesthesia gas delivery claims decreased over the decades (P < 0.001) to 1% of claims in the 2000s. Outcomes in claims from 1990 to 2011 (n = 40) were less severe, with a greater proportion of awareness (n = 9, 23%; P = 0.003) and pneumothorax (n = 7, 18%; P = 0.047). Severe injuries (death/permanent brain damage) occurred in supplemental oxygen supply events outside the operating room, breathing circuit events, or ventilator mishaps. The majority (85%) of claims involved provider error with (n = 7) or without (n = 27) equipment failure. Thirty-five percent of claims were judged as preventable by preanesthesia machine check. Gas delivery equipment claims in the Closed Claims Project database decreased in 1990-2011 compared with earlier decades. Provider error contributed to severe injury, especially with inadequate alarms, improvised oxygen delivery systems, and misdiagnosis or treatment of breathing circuit events.

Experimental heat treatment of silcrete implies analogical reasoning in the Middle Stone Age.

PubMed

Wadley, Lyn; Prinsloo, Linda C

2014-05-01

Siliceous rocks that were not heated to high temperatures during their geological formation display improved knapping qualities when they are subjected to controlled heating. Experimental heat treatment of South African silcrete, using open fires of the kind used during the Middle Stone Age, shows that the process needed careful management, notwithstanding recent arguments to the contrary. Silcrete blocks fractured when heated on the surface of open fires or on coal beds, but were heated without mishap when buried in sand below a fire. Three silcrete samples, a control, a block heated underground with maximum temperature between 400 and 500 °C and a block heated in an open fire with maximum temperature between 700 and 800 °C, were analysed with X-ray powder diffraction (XRD), X-ray fluorescence (XRF), optical microscopy, and both Fourier transform infrared (FTIR) and Raman spectroscopy. The results show that the volume expansion during the thermally induced α- to β-quartz phase transformation and the volume contraction during cooling play a major role in the heat treatment of silcrete. Rapid heating or cooling through the phase transformation at 573 °C will cause fracture of the silcrete. Successful heat treatment requires controlling surface fire temperatures in order to obtain the appropriate underground temperatures to stay below the quartz inversion temperature. Heat treatment of rocks is a transformative technology that requires skilled use of fire. This process involves analogical reasoning, which is an attribute of complex cognition. Copyright © 2014 Elsevier Ltd. All rights reserved.

Quality aspects of ex vivo root canal treatments done by undergraduate dental students using four different endodontic treatment systems.

PubMed

Jungnickel, Luise; Kruse, Casper; Vaeth, Michael; Kirkevang, Lise-Lotte

2018-04-01

To evaluate factors associated with treatment quality of ex vivo root canal treatments performed by undergraduate dental students using different endodontic treatment systems. Four students performed root canal treatment on 80 extracted human teeth using four endodontic treatment systems in designated treatment order following a Latin square design. Lateral seal and length of root canal fillings was radiographically assessed; for lateral seal, a graded visual scale was used. Treatment time was measured separately for access preparation, biomechanical root canal preparation, obturation and for the total procedure. Mishaps were registered. An ANOVA mirroring the Latin square design was performed. Use of machine-driven nickel-titanium systems resulted in overall better quality scores for lateral seal than use of the manual stainless-steel system. Among systems with machine-driven files, scores did not significantly differ. Use of machine-driven instruments resulted in shorter treatment time than manual instrumentation. Machine-driven systems with few files achieved shorter treatment times. With increasing number of treatments, root canal-filling quality increased, treatment time decreased; a learning curve was plotted. No root canal shaping file separated. The use of endodontic treatment systems with machine-driven files led to higher quality lateral seal compared to the manual system. The three contemporary machine-driven systems delivered comparable results regarding quality of root canal fillings; they were safe to use and provided a more efficient workflow than the manual technique. Increasing experience had a positive impact on the quality of root canal fillings while treatment time decreased.

Laser-heating and Radiance Spectrometry for the Study of Nuclear Materials in Conditions Simulating a Nuclear Power Plant Accident

PubMed Central

Manara, Dario; Soldi, Luca; Mastromarino, Sara; Boboridis, Kostantinos; Robba, Davide; Vlahovic, Luka; Konings, Rudy

2017-01-01

Major and severe accidents have occurred three times in nuclear power plants (NPPs), at Three Mile Island (USA, 1979), Chernobyl (former USSR, 1986) and Fukushima (Japan, 2011). Research on the causes, dynamics, and consequences of these mishaps has been performed in a few laboratories worldwide in the last three decades. Common goals of such research activities are: the prevention of these kinds of accidents, both in existing and potential new nuclear power plants; the minimization of their eventual consequences; and ultimately, a full understanding of the real risks connected with NPPs. At the European Commission Joint Research Centre's Institute for Transuranium Elements, a laser-heating and fast radiance spectro-pyrometry facility is used for the laboratory simulation, on a small scale, of NPP core meltdown, the most common type of severe accident (SA) that can occur in a nuclear reactor as a consequence of a failure of the cooling system. This simulation tool permits fast and effective high-temperature measurements on real nuclear materials, such as plutonium and minor actinide-containing fission fuel samples. In this respect, and in its capability to produce large amount of data concerning materials under extreme conditions, the current experimental approach is certainly unique. For current and future concepts of NPP, example results are presented on the melting behavior of some different types of nuclear fuels: uranium-plutonium oxides, carbides, and nitrides. Results on the high-temperature interaction of oxide fuels with containment materials are also briefly shown. PMID:29286382

Flight Dynamics Analysis Branch End of Fiscal Year 1999 Report

NASA Technical Reports Server (NTRS)

Stengle, Thomas; Flores-Amaya, Felipe

1999-01-01

This document summarizes the major activities and accomplishments carried out by the Goddard Space Flight Center (GSFC)'s Flight Dynamics Analysis Branch (FDAB), Code 572, in support of flight projects and technology development initiatives in Fiscal Year (FY) 1999. The document is intended to serve as both an introduction to the type of support carried out by the FDAB (Flight Dynamics Analysis Branch), as well as a concise reference summarizing key analysis results and mission experience derived from the various mission support roles assumed over the past year. The major accomplishments in the FDAB in FY99 were: 1) Provided flight dynamics support to the Lunar Prospector and TRIANA missions among a variety of spacecraft missions; 2) Sponsored the Flight Mechanics Symposium; 3) Supported the Consultative Committee for Space Data Systems (CCSDS) workshops; 4) Performed numerous analyses and studies for future missions; 5) Started the Flight Dynamics Analysis Branch Lab for in-house mission analysis and support; and 6) Complied with all requirements in support of GSFC IS09000 certification.

Cognitive Task Analysis and Work-Centered Support System Recommendations for a Deployed Network Operations Support Center (NOSC-D)

DTIC Science & Technology

2001-08-01

This report presents the results of a preliminary Cognitive Task Analysis (CTA) of the deployed Network Operations Support Center (NOSC-D), and the...conducted Cognitive Task Analysis interviews with four (4) NOSC-D personnel. Because of the preliminary nature of the finding, the analysis is

Analysis, modeling, and simulation (AMS) testbed development and evaluation to support dynamic mobility applications (DMA) and active transportation and demand management (ATDM) programs : Dallas testbed analysis plan. [supporting datasets - Dallas Testbed

DOT National Transportation Integrated Search

2017-07-26

The datasets in this zip file are in support of Intelligent Transportation Systems Joint Program Office (ITS JPO) report FHWA-JPO-16-385, "Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applica...

Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applications (DMA) and Active Transportation and Demand Management (ATDM) Programs - San Mateo Testbed Analysis Plan [supporting datasets - San Mateo Testbed

DOT National Transportation Integrated Search

2017-06-26

This zip file contains files of data to support FHWA-JPO-16-370, Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applications (DMA) and Active Transportation and Demand Management (ATDM) Program...

Software Tools Streamline Project Management

NASA Technical Reports Server (NTRS)

2009-01-01

Three innovative software inventions from Ames Research Center (NETMARK, Program Management Tool, and Query-Based Document Management) are finding their way into NASA missions as well as industry applications. The first, NETMARK, is a program that enables integrated searching of data stored in a variety of databases and documents, meaning that users no longer have to look in several places for related information. NETMARK allows users to search and query information across all of these sources in one step. This cross-cutting capability in information analysis has exponentially reduced the amount of time needed to mine data from days or weeks to mere seconds. NETMARK has been used widely throughout NASA, enabling this automatic integration of information across many documents and databases. NASA projects that use NETMARK include the internal reporting system and project performance dashboard, Erasmus, NASA s enterprise management tool, which enhances organizational collaboration and information sharing through document routing and review; the Integrated Financial Management Program; International Space Station Knowledge Management; Mishap and Anomaly Information Reporting System; and management of the Mars Exploration Rovers. Approximately $1 billion worth of NASA s projects are currently managed using Program Management Tool (PMT), which is based on NETMARK. PMT is a comprehensive, Web-enabled application tool used to assist program and project managers within NASA enterprises in monitoring, disseminating, and tracking the progress of program and project milestones and other relevant resources. The PMT consists of an integrated knowledge repository built upon advanced enterprise-wide database integration techniques and the latest Web-enabled technologies. The current system is in a pilot operational mode allowing users to automatically manage, track, define, update, and view customizable milestone objectives and goals. The third software invention, Query-Based Document Management (QBDM) is a tool that enables content or context searches, either simple or hierarchical, across a variety of databases. The system enables users to specify notification subscriptions where they associate "contexts of interest" and "events of interest" to one or more documents or collection(s) of documents. Based on these subscriptions, users receive notification when the events of interest occur within the contexts of interest for associated document or collection(s) of documents. Users can also associate at least one notification time as part of the notification subscription, with at least one option for the time period of notifications.

NASA Supportability Engineering Implementation Utilizing DoD Practices and Processes

NASA Technical Reports Server (NTRS)

Smith, David A.; Smith, John V.

2010-01-01

The Ares I design and development program made the determination early in the System Design Review Phase to utilize DoD ILS and LSA approach for supportability engineering as an integral part of the system engineering process. This paper is to provide a review of the overall approach to design Ares-I with an emphasis on a more affordable, supportable, and sustainable launch vehicle. Discussions will include the requirements development, design influence, support concept alternatives, ILS and LSA planning, Logistics support analyses/trades performed, LSA tailoring for NASA Ares Program, support system infrastructure identification, ILS Design Review documentation, Working Group coordination, and overall ILS implementation. At the outset, the Ares I Project initiated the development of the Integrated Logistics Support Plan (ILSP) and a Logistics Support Analysis process to provide a path forward for the management of the Ares-I ILS program and supportability analysis activities. The ILSP provide the initial planning and coordination between the Ares-I Project Elements and Ground Operation Project. The LSA process provided a system engineering approach in the development of the Ares-I supportability requirements; influence the design for supportability and development of alternative support concepts that satisfies the program operability requirements. The LSA planning and analysis results are documented in the Logistics Support Analysis Report. This document was required during the Ares-I System Design Review (SDR) and Preliminary Design Review (PDR) review cycles. To help coordinate the LSA process across the Ares-I project and between programs, the LSA Report is updated and released quarterly. A System Requirement Analysis was performed to determine the supportability requirements and technical performance measurements (TPMs). Two working groups were established to provide support in the management and implement the Ares-I ILS program, the Integrated Logistics Support Working Group (ILSWG) and the Logistics Support Analysis Record Working Group (LSARWG). The Ares I ILSWG is established to assess the requirements and conduct, evaluate analyses and trade studies associated with acquisition logistic and supportability processes and to resolve Ares I integrated logistics and supportability issues. It established a strategic collaborative alliance for coordination of Logistics Support Analysis activates in support of the integrated Ares I vehicle design and development of logistics support infrastructure. A Joint Ares I - Orion LSAR Working Group was established to: 1) Guide the development of Ares-I and Orion LSAR data and serve as a model for future Constellation programs, 2) Develop rules and assumptions that will apply across the Constellation program with regards to the program's LSAR development, and 3) Maintain the Constellation LSAR Style Guide.

Product Support Manager Guidebook

DTIC Science & Technology

2011-04-01

package is being developed using supportability analysis concepts such as Failure Mode, Effects and Criticality Analysis (FMECA), Fault Tree Analysis ( FTA ...Analysis (LORA) Condition Based Maintenance + (CBM+) Fault Tree Analysis ( FTA ) Failure Mode, Effects, and Criticality Analysis (FMECA) Maintenance Task...Reporting and Corrective Action System (FRACAS), Fault Tree Analysis ( FTA ), Level of Repair Analysis (LORA), Maintenance Task Analysis (MTA

48 CFR 815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2013 CFR

2013-10-01

...-2 Information to support proposal analysis. In evaluating start-up and other non-recurring costs... 48 Federal Acquisition Regulations System 5 2013-10-01 2013-10-01 false Information to support proposal analysis. 815.404-2 Section 815.404-2 Federal Acquisition Regulations System DEPARTMENT OF...

48 CFR 815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2010 CFR

2010-10-01

...-2 Information to support proposal analysis. In evaluating start-up and other non-recurring costs... 48 Federal Acquisition Regulations System 5 2010-10-01 2010-10-01 false Information to support proposal analysis. 815.404-2 Section 815.404-2 Federal Acquisition Regulations System DEPARTMENT OF...

48 CFR 315.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Information to support proposal analysis. (a)(2) When some or all information sufficient to determine the... 48 Federal Acquisition Regulations System 4 2011-10-01 2011-10-01 false Information to support proposal analysis. 315.404-2 Section 315.404-2 Federal Acquisition Regulations System HEALTH AND HUMAN...

48 CFR 215.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Contract Pricing 215.404-2 Information to support proposal analysis. See PGI 215.404-2 for guidance on... 48 Federal Acquisition Regulations System 3 2010-10-01 2010-10-01 false Information to support proposal analysis. 215.404-2 Section 215.404-2 Federal Acquisition Regulations System DEFENSE ACQUISITION...

48 CFR 315.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Information to support proposal analysis. (a)(2) When some or all information sufficient to determine the... 48 Federal Acquisition Regulations System 4 2013-10-01 2013-10-01 false Information to support proposal analysis. 315.404-2 Section 315.404-2 Federal Acquisition Regulations System HEALTH AND HUMAN...

48 CFR 815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2014 CFR

2014-10-01

...-2 Information to support proposal analysis. In evaluating start-up and other non-recurring costs... 48 Federal Acquisition Regulations System 5 2014-10-01 2014-10-01 false Information to support proposal analysis. 815.404-2 Section 815.404-2 Federal Acquisition Regulations System DEPARTMENT OF...

48 CFR 315.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Information to support proposal analysis. (a)(2) When some or all information sufficient to determine the... 48 Federal Acquisition Regulations System 4 2012-10-01 2012-10-01 false Information to support proposal analysis. 315.404-2 Section 315.404-2 Federal Acquisition Regulations System HEALTH AND HUMAN...

48 CFR 315.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Information to support proposal analysis. (a)(2) When some or all information sufficient to determine the... 48 Federal Acquisition Regulations System 4 2014-10-01 2014-10-01 false Information to support proposal analysis. 315.404-2 Section 315.404-2 Federal Acquisition Regulations System HEALTH AND HUMAN...

48 CFR 815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2012 CFR

2012-10-01

...-2 Information to support proposal analysis. In evaluating start-up and other non-recurring costs... 48 Federal Acquisition Regulations System 5 2012-10-01 2012-10-01 false Information to support proposal analysis. 815.404-2 Section 815.404-2 Federal Acquisition Regulations System DEPARTMENT OF...

48 CFR 215.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Contract Pricing 215.404-2 Information to support proposal analysis. See PGI 215.404-2 for guidance on... 48 Federal Acquisition Regulations System 3 2011-10-01 2011-10-01 false Information to support proposal analysis. 215.404-2 Section 215.404-2 Federal Acquisition Regulations System DEFENSE ACQUISITION...

48 CFR 315.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Information to support proposal analysis. (a)(2) When some or all information sufficient to determine the... 48 Federal Acquisition Regulations System 4 2010-10-01 2010-10-01 false Information to support proposal analysis. 315.404-2 Section 315.404-2 Federal Acquisition Regulations System HEALTH AND HUMAN...

48 CFR 215.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Contract Pricing 215.404-2 Information to support proposal analysis. See PGI 215.404-2 for guidance on... 48 Federal Acquisition Regulations System 3 2012-10-01 2012-10-01 false Information to support proposal analysis. 215.404-2 Section 215.404-2 Federal Acquisition Regulations System DEFENSE ACQUISITION...

48 CFR 815.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2011 CFR

2011-10-01

...-2 Information to support proposal analysis. In evaluating start-up and other non-recurring costs... 48 Federal Acquisition Regulations System 5 2011-10-01 2011-10-01 false Information to support proposal analysis. 815.404-2 Section 815.404-2 Federal Acquisition Regulations System DEPARTMENT OF...

Understanding the Support Needs of People with Intellectual and Related Developmental Disabilities through Cluster Analysis and Factor Analysis of Statewide Data

ERIC Educational Resources Information Center

Viriyangkura, Yuwadee

2014-01-01

Through a secondary analysis of statewide data from Colorado, people with intellectual and related developmental disabilities (ID/DD) were classified into five clusters based on their support needs characteristics using cluster analysis techniques. Prior latent factor models of support needs in the field of ID/DD were examined to investigate the…

A Quantitative Analysis of the Extrinsic and Intrinsic Turnover Factors of Relational Database Support Professionals

ERIC Educational Resources Information Center

Takusi, Gabriel Samuto

2010-01-01

This quantitative analysis explored the intrinsic and extrinsic turnover factors of relational database support specialists. Two hundred and nine relational database support specialists were surveyed for this research. The research was conducted based on Hackman and Oldham's (1980) Job Diagnostic Survey. Regression analysis and a univariate ANOVA…

40 CFR 300.430 - Remedial investigation/feasibility study and selection of remedy.

Code of Federal Regulations, 2014 CFR

2014-07-01

..., to provide additional data for the detailed analysis and to support engineering design of remedial... threat to human health or the environment or to support the analysis and design of potential response... timely manner and no later than the early stages of the comparative analysis. The lead and support...

40 CFR 300.430 - Remedial investigation/feasibility study and selection of remedy.

Code of Federal Regulations, 2012 CFR

2012-07-01

..., to provide additional data for the detailed analysis and to support engineering design of remedial... threat to human health or the environment or to support the analysis and design of potential response... timely manner and no later than the early stages of the comparative analysis. The lead and support...

40 CFR 300.430 - Remedial investigation/feasibility study and selection of remedy.

Code of Federal Regulations, 2010 CFR

2010-07-01

..., to provide additional data for the detailed analysis and to support engineering design of remedial... threat to human health or the environment or to support the analysis and design of potential response... timely manner and no later than the early stages of the comparative analysis. The lead and support...

40 CFR 300.430 - Remedial investigation/feasibility study and selection of remedy.

Code of Federal Regulations, 2011 CFR

2011-07-01

..., to provide additional data for the detailed analysis and to support engineering design of remedial... threat to human health or the environment or to support the analysis and design of potential response... timely manner and no later than the early stages of the comparative analysis. The lead and support...

40 CFR 300.430 - Remedial investigation/feasibility study and selection of remedy.

Code of Federal Regulations, 2013 CFR

2013-07-01

..., to provide additional data for the detailed analysis and to support engineering design of remedial... threat to human health or the environment or to support the analysis and design of potential response... timely manner and no later than the early stages of the comparative analysis. The lead and support...

40 CFR 412.31 - Effluent limitations attainable by the application of the best practicable control technology...

Code of Federal Regulations, 2010 CFR

2010-07-01

... supporting technical analysis and any other relevant information and data that would support such site... event. The technical analysis of the discharge of pollutants must include: (A) All daily inputs to the... the supporting technical analysis, including inspection of the CAFO. (3) The CAFO shall attain the...

48 CFR 15.404-2 - Data to support proposal analysis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 1 2010-10-01 2010-10-01 false Data to support proposal analysis. 15.404-2 Section 15.404-2 Federal Acquisition Regulations System FEDERAL ACQUISITION REGULATION CONTRACTING METHODS AND CONTRACT TYPES CONTRACTING BY NEGOTIATION Contract Pricing 15.404-2 Data to support proposal analysis. (a) Field pricing...

40 CFR 412.31 - Effluent limitations attainable by the application of the best practicable control technology...

Code of Federal Regulations, 2011 CFR

2011-07-01

... supporting technical analysis and any other relevant information and data that would support such site... event. The technical analysis of the discharge of pollutants must include: (A) All daily inputs to the... the supporting technical analysis, including inspection of the CAFO. (3) The CAFO shall attain the...

48 CFR 1415.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Information to support proposal analysis. The CO shall initiate an audit by sending a completed form DI-1902... 48 Federal Acquisition Regulations System 5 2012-10-01 2012-10-01 false Information to support proposal analysis. 1415.404-2 Section 1415.404-2 Federal Acquisition Regulations System DEPARTMENT OF THE...

48 CFR 1415.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Information to support proposal analysis. The CO shall initiate an audit by sending a completed form DI-1902... 48 Federal Acquisition Regulations System 5 2010-10-01 2010-10-01 false Information to support proposal analysis. 1415.404-2 Section 1415.404-2 Federal Acquisition Regulations System DEPARTMENT OF THE...

48 CFR 1415.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Information to support proposal analysis. The CO shall initiate an audit by sending a completed form DI-1902... 48 Federal Acquisition Regulations System 5 2013-10-01 2013-10-01 false Information to support proposal analysis. 1415.404-2 Section 1415.404-2 Federal Acquisition Regulations System DEPARTMENT OF THE...

48 CFR 1415.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Information to support proposal analysis. The CO shall initiate an audit by sending a completed form DI-1902... 48 Federal Acquisition Regulations System 5 2014-10-01 2014-10-01 false Information to support proposal analysis. 1415.404-2 Section 1415.404-2 Federal Acquisition Regulations System DEPARTMENT OF THE...

48 CFR 1415.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Information to support proposal analysis. The CO shall initiate an audit by sending a completed form DI-1902... 48 Federal Acquisition Regulations System 5 2011-10-01 2011-10-01 false Information to support proposal analysis. 1415.404-2 Section 1415.404-2 Federal Acquisition Regulations System DEPARTMENT OF THE...

Performance and Safety Characteristics of Sanyo NiCd Cells

NASA Technical Reports Server (NTRS)

Deng, Yi; Jeevarajan, Judith; Bragg, Bobby; Zhang, Wenlin

2002-01-01

NiCd batteries are widely used for high drain applications like power tools and also in other portable equipment like cameras, PCs, etc. NASA and Dreamtime Holdings, Inc. worked together to have the capability of a High Definition TV (HDTV) on the ISS and Space Shuttle. The Sanyo HD camcorder was used on the STS 105 fight in July, 2001 . The camcorder used two versions of a NiCd battery. One was a cOlnmercial off-the-shelf Sony BP90 battery pack that had Sanyo NiCd D cells. The other was a modified battery (FBP-90) made by Frezzi Energy, which also had the same Sanyo NiCd D cells. The battery has 10 NiCd D cells in series to form a 12 V pack with 5.0 Ah capacity. Our current study involved the perforn1ance and abuse tests on the Sanyo NiCd 5.0 Ah D cells. The best combination of charge/discharge current rate is 0.3C for charge and 1/2e for discharge within 200 cycles. No significant changes in capacity were observed in 200 cycles. The cell also showed capability of 5C (25.0A) high rate discharge. In overcharge and overdischarge tests, all tested cells passed the tests without venting. In imbalance tests, the battery pack could be charged and discharged only at relatively low current. At charge current of 1.0A or less, the imbalanced cells in the battery pack displayed relatively high temperatures during charge or discharge. The cells functioned normally during internal short and no mishap occurred during external short. Cells passed exposure tests at 80 C and no leakage till 150 C during heat-tovent tests.

Pediatric trauma: enabling factors, social situations, and outcome.

PubMed

Hartzog, T H; Timerding, B L; Alson, R L

1996-03-01

1) To determine, for severely injured pediatric patients, which enabling factors and social situations are associated with the most severe and costly injuries; 2) to determine which subsets of patients are affected by particular enabling factors; and 3) to determine which enabling factors are associated with death. Retrospective chart review of patients included in a pediatric trauma registry at a level I trauma center, plus review of medical examiner reports for deaths declared at the scene for one year. Abstracted data included age, gender, enabling factors (e.g., abuse/assault, neglect, endangerment, and nonuse of safety measures), mechanisms of injury, Injury Severity Scale (ISS) score, length of stay, need for intensive care unit (ICU) care, and expense. Records were reviewed for 336 identified children. There was a 2:1 male-to-female ratio; 9.5% died, 3.5% at the scene. Active endangerment or neglect was associated with death (p = 0.0004). However, the nonuse of safety devices was more common and resulted in a higher absolute number of deaths. Similarly, while inadvertent gunshot wounds, intentional injury, and environmental mishaps were more commonly lethal, motor vehicle crashes (MVCs) were more common and claimed the most lives. Cost was highest for the patients aged 14-16 years, in part reflecting the larger number of MVCs. The severity of pediatric trauma is largely influenced by the mechanism of injury. Our data highlight the importance of enabling factors for such injuries overall and as a function of age group (reflecting developmental status). While injury prevention education for caregivers is necessary, the incorporation of passive safety measures also is vital for decreasing injuries and their severity.

How to make experience your company's best teacher.

PubMed

Kleiner, A; Roth, G

1997-01-01

In our personal life, experience is often the best teacher. Not so in corporate life. After a major event--a product failure, a downsizing crisis, or a merger--many companies stumble along, oblivious to the lessons of the past. Mistakes get repeated, but smart decisions do not. Most important, the old ways of thinking are never discussed, so they are still in place to spawn new mishaps. Individuals will often tell you that they understand what went wrong (or right). Yet their insights are rarely shared openly. And they are analyzed and internalized by the company even less frequently. Why? Because managers have few tools with which to capture institutional experience, disseminate its lessons, and translate them into effective action. In an effort to solve this problem, a group of social scientists, business managers, and journalists at MIT have developed and tested a tool called the learning history. It is a written narrative of a company's recent critical event, nearly all of it presented in two columns. In one column, relevant episodes are described by the people who took part in them, were affected by them, or observed them. In the other, learning historians--trained outsiders and knowledgeable insiders--identify recurrent themes in the narrative, pose questions, and raise "undiscussable" issues. The learning history forms the basis for group discussions, both for those involved in the event and for others who also might learn from it. The authors believe that this tool--based on the ancient practice of community storytelling--can build trust, raise important issues, transfer knowledge from one part of a company to another, and help build a body of generalizable knowledge about management.

Peri-operative deaths in Singapore: a forensic perspective in a study of 132 cases.

PubMed

Lau, G

1994-05-01

A study of 132, largely non-traumatic, peri-operative deaths out of 6605 Coroner's autopsies, conducted over a three-year period from 1989 to 1991, showed a preponderance of males (M:F ratio = 1.36), with almost half (46.3%) being middle-aged subjects between 40 to 59 years, while infants (< one year old) made up about a tenth of the cases. A total of 51 cases (38.6%) were related to cardiothoracic surgery, which also accounted for the majority of deaths that had occurred intra-operatively (11/21 or 8.3% in all) and within the first postoperative day (16/36 or 12.1% in all). The vast majority of cases (81.8%) were pathologically natural deaths, with 15.2% attributable to complications or mishaps of surgery and invasive diagnostic or therapeutic procedures. There were three anaesthetic deaths which accounted for 2.3% of the cases. Out of 124 completed Coroner's inquiries as at the end of June 1993, verdicts of death from natural causes were recorded in 110 (83.3%) cases. General surgery accounted for the highest proportion of unnatural deaths (6.1%), which was twice that for cardiothoracic surgery (3.0%). While there was close agreement between a finding of a pathologically natural death and a similar Coroner's verdict (107/110 or 97.3%), only a total of ten out of 23 pathologically unnatural deaths received verdicts of misadventure at the time of writing. Although a verdict of misadventure usually pertained to an iatrogenic death, this was not invariably the case. Thus far, no findings of medical negligence was made in any of the Coroner's inquiries into these cases.(ABSTRACT TRUNCATED AT 250 WORDS)

SOHO Mission Interruption Joint NASA/ESA Investigation Board

NASA Technical Reports Server (NTRS)

1998-01-01

Contact with the SOlar Heliospheric Observatory (SOHO) spacecraft was lost in the early morning hours of June 25, 1998, Eastern Daylight Time (EDT), during a planned period of calibrations, maneuvers, and spacecraft reconfigurations. Prior to this the SOHO operations team had concluded two years of extremely successful science operations. A joint European Space Agency (ESA)/National Aeronautics and Space Administration (NASA) engineering team has been planning and executing recovery efforts since loss of contact with some success to date. ESA and NASA management established the SOHO Mission Interruption Joint Investigation Board to determine the actual or probable cause(s) of the SOHO spacecraft mishap. The Board has concluded that there were no anomalies on-board the SOHO spacecraft but that a number of ground errors led to the major loss of attitude experienced by the spacecraft. The Board finds that the loss of the SOHO spacecraft was a direct result of operational errors, a failure to adequately monitor spacecraft status, and an erroneous decision which disabled part of the on-board autonomous failure detection. Further, following the occurrence of the emergency situation, the Board finds that insufficient time was taken by the operations team to fully assess the spacecraft status prior to initiating recovery operations. The Board discovered that a number of factors contributed to the circumstances that allowed the direct causes to occur. The Board strongly recommends that the two Agencies proceed immediately with a comprehensive review of SOHO operations addressing issues in the ground procedures, procedure implementation, management structure and process, and ground systems. This review process should be completed and process improvements initiated prior to the resumption of SOHO normal operations.

General aviation accidents related to exceedance of airplane weight/center of gravity limits.

PubMed

Boyd, Douglas D

2016-06-01

Obesity, affects a third of the US population and its corollary occupant weight adversely impacts safe flight operations. Increased aircraft weight results in longer takeoff/landing distances, degraded climb gradients and airframe failure may occur in turbulence. In this study, the rate, temporal changes, and lethality of accidents in piston-powered, general aviation aircraft related to exceeding the maximum aircraft weight/center of gravity (CG) limits were determined. Nation-wide person body mass were from the National Health and Nutrition Examination Survey. The NTSB database was used to identify accidents related to operation of aircraft outside of their weight/CG envelope. Statistical analyses employed T-tests, proportion tests and a Poisson distribution. While the average body mass climbed steadily (p<0.001) between 1999 and 2014 the rate of accidents related to exceedance of the weight/CG limits did not change (p=0.072). However, 57% were fatal, higher (p<0.001) than the 21% for mishaps attributed to other causes/factors. The majority (77%) of accidents were due to an overloaded aircraft operating within its CG limits. As to the phase of flight, accidents during takeoff and those occurring enroute carried the lowest (50%) and highest (85%) proportion of fatal accidents respectively. While the rate of general aviation accidents related to operating an aircraft outside of its weight/CG envelope has not increased over the past 15 years, these types of accidents carry a high risk of fatality. Airmen should be educated as to such risks and to dispel the notion held by some that flights may be safely conducted with an overloaded aircraft within its CG limits. Copyright © 2016 Elsevier Ltd. All rights reserved.

Dynamics of the G-excess illusion

NASA Technical Reports Server (NTRS)

Baylor, K. A.; Reschke, M.; Guedry, F. E.; Mcgrath, B. J.; Rupert, A. H.

1992-01-01

The G-excess illusion is increasingly recognized as a cause of aviation mishaps especially when pilots perform high-speed, steeply banked turns at low altitudes. Centrifuge studies of this illusion have examined the perception of subject orientation and/or target displacement during maintained hypergravity with the subject's head held stationary. The transient illusory perceptions produced by moving the head in hypergravity are difficult to study onboard centrifuges because the high angular velocity ensures the presence of strong Coriolis cross-coupled semicircular canal effects that mask immediate transient otolith-organ effects. The present study reports perceptions following head movements in hypergravity produced by high-speed aircraft maintaining a banked attitude with low angular velocity to minimize cross-coupled effects. Methods: Fourteen subjects flew on the NASA KC-135 and were exposed to resultant gravity forces of 1.3, 1.5, and 1.8 G for 3 minute periods. On command, seated subjects made controlled head movements in roll, pitch, and yaw at 30 second intervals both in the dark and with faint targets at a distance of 5 feet. Results: head movement produced transient perception of target displacement and velocity at levels as low as 1.3 G. Reports of target velocity without appropriate corresponding displacement were common. At 1.8 G when yaw head movements were made from a face down position, 4 subjects reported oscillatory rotational target displacement with fast and slow alternating components suggestive of torsional nystagmus. Head movements evoked symptoms of nausea in most subjects, with 2 subjects and 1 observer vomiting. Conclusions: The transient percepts present conflicting signals, which introduced confusion in target and subject orientation. Repeated head movements in hypergravity generate nausea by mechanisms distinct from cross-coupled Coriolis effects.

Honey yield of different commercial apiaries treated with Lactobacillus salivarius A3iob, a new bee-probiotic strain.

PubMed

Fanciotti, M Novicov; Tejerina, M; Benítez-Ahrendts, M R; Audisio, M C

2018-02-27

The main objective of this study was to determine the impact of Lactobacillus salivarius A3iob, a honey bee gut-associated strain (GenBank code access KX198010), on honey yield. Independent assays were conducted from May to September 2014 and 2015, in three commercial apiaries: Tilquiza, El Carmen and Yala, all located in north-western Argentina. Local Apis mellifera L. bees were kept in standard Langstroth hives; treated hives were fed once a month with 1×10 5 cfu/ml viable Lactobacillus cells, administered to the bees through a Doolittle-type feeder in 125 g/l sucrose syrup. Control hives were only given the syrup mixed with MRS sterile broth. The main honey harvest was done in December in all groups and we found that there was an overall increase in honey yield from the treated hives. In 2014, all treated hives produced between 2.3 to 6.5 times more honey than the controls. However, in 2015, higher honey average yields in the treated hives at El Carmen and Yala were obtained, yet not at Tilquiza, because of a slight mishap. They experienced the swarming of several bee colonies due to a higher number of bees without appropriate management, which caused the control group to yield more honey compared to the hives fed with Lactobacillus. Interestingly, at El Carmen, two honey harvests were recorded: one in winter and another in summer (July and December 2015, respectively). This unexpected result arose from the particular flora of the region, mainly Tithonia tubaeformis, which blooms in winter. L. salivarius A3iob cells prove to be a natural alternative that will positively impact the beekeepers' economy by providing a higher honey yield.

Early morning awakening and nonrestorative sleep are associated with increased minor non-fatal accidents during work and leisure time.

PubMed

Chiu, Hsiao-Yean; Wang, Mei-Yeh; Chang, Cheng-Kuei; Chen, Ching-Min; Chou, Kuei-Ru; Tsai, Jen-Chen; Tsai, Pei-Shan

2014-10-01

The relationship between a composite measure of insomnia and occupational or fatal accidents has been investigated previously; however, little is known regarding the effect of various insomnia symptoms on minor non-fatal accidents during work and leisure time. We investigated the predicting role of insomnia symptoms on minor non-fatal accidents during work and leisure time. Data from the 2005 Taiwan Social Development Trend Survey of 36,473 Taiwanese aged ≥18 years were analyzed in 2013. Insomnia symptoms, including difficulty in initiating sleep (DIS), difficulty in maintaining sleep (DMS), early morning awakening (EMA), and nonrestorative sleep (NRS) were investigated. A minor non-fatal accident was defined as any mishap such as forgetting to turn off the gas or faucets, accidental falls, and abrasions or cuts occurring during work and leisure time in the past month that do not require immediate medical attention. Multivariable logistic regression was performed to assess the odds ratios (ORs) and associated 95% confidence interval (CI) of minor non-fatal accidents (as a binary variable) for each insomnia symptom compared with those of people presenting no symptoms, while controlling for possible confounders. EMA and NRS increased the odds of minor non-fatal accidents occurring during work and leisure time (adjusted OR=1.19, 95% CI=1.08-1.32 and adjusted OR=1.27, 95% CI=1.17-1.37, respectively). EMA and NRS are two symptoms that are significantly associated with an increased likelihood of minor non-fatal accidents during work and leisure time after adjusting for of a range of covariates. Copyright © 2014 Elsevier Ltd. All rights reserved.

Fatigue on the flight deck: the consequences of sleep loss and the benefits of napping.

PubMed

Hartzler, Beth M

2014-01-01

The detrimental effects of fatigue in aviation are well established, as evidenced by both the number of fatigue-related mishaps and numerous studies which have found that most pilots experience a deterioration in cognitive performance as well as increased stress during the course of a flight. Further, due to the nature of the average pilot's work schedule, with frequent changes in duty schedule, early morning starts, and extended duty periods, fatigue may be impossible to avoid. Thus, it is critical that fatigue countermeasures be available which can help to combat the often overwhelming effects of sleep loss or sleep disruption. While stimulants such as caffeine are typically effective at maintaining alertness and performance, such countermeasures do nothing to address the actual source of fatigue - insufficient sleep. Consequently, strategic naps are considered an efficacious means of maintaining performance while also reducing the individual's sleep debt. These types of naps have been advocated for pilots in particular, as opportunities to sleep either in the designated rest facilities or on the flight deck may be beneficial in reducing both the performance and alertness impairments associated with fatigue, as well as the subjective feelings of sleepiness. Evidence suggests that strategic naps can reduce subjective feelings of fatigue and improve performance and alertness. Despite some contraindications to implementing strategic naps while on duty, such as sleep inertia experienced upon awakening, both researchers and pilots agree that the benefits associated with these naps far outweigh the potential risks. This article is a literature review detailing both the health and safety concerns of fatigue among commercial pilots as well as benefits and risks associated with strategic napping to alleviate this fatigue. Published by Elsevier Ltd.

SUPERFUND REMOTE SENSING SUPPORT

EPA Science Inventory

This task provides remote sensing technical support to the Superfund program. Support includes the collection, processing, and analysis of remote sensing data to characterize hazardous waste disposal sites and their history. Image analysis reports, aerial photographs, and assoc...

1991 NASA Life Support Systems Analysis workshop

NASA Technical Reports Server (NTRS)

Evanich, Peggy L.; Crabb, Thomas M.; Gartrell, Charles F.

1992-01-01

The 1991 Life Support Systems Analysis Workshop was sponsored by NASA Headquarters' Office of Aeronautics and Space Technology (OAST) to foster communication among NASA, industrial, and academic specialists, and to integrate their inputs and disseminate information to them. The overall objective of systems analysis within the Life Support Technology Program of OAST is to identify, guide the development of, and verify designs which will increase the performance of the life support systems on component, subsystem, and system levels for future human space missions. The specific goals of this workshop were to report on the status of systems analysis capabilities, to integrate the chemical processing industry technologies, and to integrate recommendations for future technology developments related to systems analysis for life support systems. The workshop included technical presentations, discussions, and interactive planning, with time allocated for discussion of both technology status and time-phased technology development recommendations. Key personnel from NASA, industry, and academia delivered inputs and presentations on the status and priorities of current and future systems analysis methods and requirements.

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.

40 CFR 52.1490 - Original identification of plan.

Code of Federal Regulations, 2012 CFR

2012-07-01

... measures. (ii) A modeling analysis indicating 1982 attainment. (iii) Documentation of the modeling analysis... agencies, (ii) Additional supporting documentation for the 1982 attainment modeling analysis which included... factors for the model. (iii) A revised 1982 attainment modeling analysis and supporting documentation...

40 CFR 52.1490 - Original identification of plan.

Code of Federal Regulations, 2013 CFR

2013-07-01

... measures. (ii) A modeling analysis indicating 1982 attainment. (iii) Documentation of the modeling analysis... agencies, (ii) Additional supporting documentation for the 1982 attainment modeling analysis which included... factors for the model. (iii) A revised 1982 attainment modeling analysis and supporting documentation...

40 CFR 52.1490 - Original identification of plan.

Code of Federal Regulations, 2014 CFR

2014-07-01

... measures. (ii) A modeling analysis indicating 1982 attainment. (iii) Documentation of the modeling analysis... agencies, (ii) Additional supporting documentation for the 1982 attainment modeling analysis which included... factors for the model. (iii) A revised 1982 attainment modeling analysis and supporting documentation...

Dimensions of professional labor support for intrapartum practice.

PubMed

Sauls, Donna J

2006-01-01

To define and describe the dimensions of Professional Labor Support (PLS). A factor-analytic study was conducted with a random sample of 146 intrapartum nurses in Texas. Nurses' responses to the Labor Support Questionnaire (LSQ) were subjected to principal components analysis and descriptive analysis. A six-factor solution indicated the dimensions of PLS: Tangible Support, Advocacy, Emotional Support-Reassurance, Emotional Support-Creating Control, Security and Comfort, Emotional Support-Nurse Caring Behavior, and Informational Support. Although the presence of four dimensions was theorized, six dimensions were found. The emotional support dimension was identified by nurses as being an important component of labor support as indicated by the identification of three separate emotional support dimensions.

Classification of Support Needs for Elderly Outpatients with Diabetes Who Live Alone.

PubMed

Miyawaki, Yoshiko; Shimizu, Yasuko; Seto, Natsuko

2016-02-01

To investigate the support needs of elderly patients with diabetes and to classify elderly patients with diabetes living alone on the basis of support needs. Support needs were derived from a literature review of relevant journals and interviews of outpatients as well as expert nurses in the field of diabetes to prepare a 45-item questionnaire. Each item was analyzed on a 4-point Likert scale. The study included 634 elderly patients with diabetes who were recruited from 3 hospitals in Japan. Exploratory factor analysis was performed to determine the underlying structure of support needs, followed by hierarchical cluster analysis to clarify the characteristics of patients living alone (n=104) who had common support needs. Exploratory factor analysis suggested a 5-factor solution with 23 items: (1) hope for class and gatherings, (2) hope for personal advice including emergency response, (3) supportlessness and hopelessness, (4) barriers to food preparation, (5) hope of safe medical therapy. The hierarchical cluster analysis of subjects yielded 7 clusters, including a no special-support needs group, a collective support group, a self-care support group, a personal-support focus group, a life-support group, a food-preparation support group and a healthcare-environment support group. The support needs of elderly patients with diabetes who live alone can be divided into 2 categories: life and self-care support. Implementation of these categories in outpatient-management programs in which contact time with patients is limited is important in the overall management of elderly patients with diabetes who are living alone. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Advanced support systems development and supporting technologies for Controlled Ecological Life Support Systems (CELSS)

NASA Technical Reports Server (NTRS)

Simon, William E.; Li, Ku-Yen; Yaws, Carl L.; Mei, Harry T.; Nguyen, Vinh D.; Chu, Hsing-Wei

1994-01-01

A methyl acetate reactor was developed to perform a subscale kinetic investigation in the design and optimization of a full-scale metabolic simulator for long term testing of life support systems. Other tasks in support of the closed ecological life support system test program included: (1) heating, ventilation and air conditioning analysis of a variable pressure growth chamber, (2) experimental design for statistical analysis of plant crops, (3) resource recovery for closed life support systems, and (4) development of data acquisition software for automating an environmental growth chamber.

Canister Storage Building (CSB) Design Basis Accident Analysis Documentation

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

CROWE, R.D.; PIEPHO, M.G.

2000-03-23

This document provided the detailed accident analysis to support HNF-3553, Spent Nuclear Fuel Project Final Safety Analysis Report, Annex A, ''Canister Storage Building Final Safety Analysis Report''. All assumptions, parameters, and models used to provide the analysis of the design basis accidents are documented to support the conclusions in the Canister Storage Building Final Safety Analysis Report.

The State as a Support System: What Should Women in Academe Expect? A Global Perspective.

ERIC Educational Resources Information Center

NtiAsare, Nancy Sharp

A comparative analysis of family policy in various nations looks at state financial support for families and in particular how professional women in academia fare internationally with respect to state support for their families. The analysis includes a review of the general development of family support through the industrial revolution and the…

FY 2018 Grant Announcement: FY2018 Support for Geospatial Analysis Support

EPA Pesticide Factsheets

The U.S. Environmental Protection Agency’s (EPA) Chesapeake Bay Program Office (CBPO) is announcing a Request for Proposals (RFP) for applicants to provide the Chesapeake Bay Program (CBP) partners with a proposal for providing geospatial analysis support

Operational modes, health, and status monitoring

NASA Astrophysics Data System (ADS)

Taljaard, Corrie

2016-08-01

System Engineers must fully understand the system, its support system and operational environment to optimise the design. Operations and Support Managers must also identify the correct metrics to measure the performance and to manage the operations and support organisation. Reliability Engineering and Support Analysis provide methods to design a Support System and to optimise the Availability of a complex system. Availability modelling and Failure Analysis during the design is intended to influence the design and to develop an optimum maintenance plan for a system. The remote site locations of the SKA Telescopes place emphasis on availability, failure identification and fault isolation. This paper discusses the use of Failure Analysis and a Support Database to design a Support and Maintenance plan for the SKA Telescopes. It also describes the use of modelling to develop an availability dashboard and performance metrics.

The correlation of social support with mental health: A meta-analysis.

PubMed

Harandi, Tayebeh Fasihi; Taghinasab, Maryam Mohammad; Nayeri, Tayebeh Dehghan

2017-09-01

Social support is an important factor that can affect mental health. In recent decades, many studies have been done on the impact of social support on mental health. The purpose of the present study is to investigate the effect size of the relationship between social support and mental health in studies in Iran. This meta-analysis was carried out in studies that were performed from 1996 through 2015. Databases included SID and Magiran, the comprehensive portal of human sciences, Noor specialized magazine databases, IRANDOC, Proquest, PubMed, Scopus, ERIC, Iranmedex and Google Scholar. The keywords used to search these websites included "mental health or general health," and "Iran" and "social support." In total, 64 studies had inclusion criteria meta-analysis. In order to collect data used from a meta-analysis worksheet that was made by the researcher and for data analysis software, CMA-2 was used. The mean of effect size of the 64 studies in the fixed-effect model and random-effect model was obtained respectively as 0.356 and 0.330, which indicated the moderate effect size of social support on mental health. The studies did not have publication bias, and enjoyed a heterogeneous effect size. The target population and social support questionnaire were moderator variables, but sex, sampling method, and mental health questionnaire were not moderator variables. Regarding relatively high effect size of the correlation between social support and mental health, it is necessary to predispose higher social support, especially for women, the elderly, patients, workers, and students.

Generalized Full-Information Item Bifactor Analysis

ERIC Educational Resources Information Center

Cai, Li; Yang, Ji Seung; Hansen, Mark

2011-01-01

Full-information item bifactor analysis is an important statistical method in psychological and educational measurement. Current methods are limited to single-group analysis and inflexible in the types of item response models supported. We propose a flexible multiple-group item bifactor analysis framework that supports a variety of…

Test Analysis Guidelines

NASA Technical Reports Server (NTRS)

Jeng, Frank F.

2007-01-01

Development of analysis guidelines for Exploration Life Support (ELS) technology tests was completed. The guidelines were developed based on analysis experiences gained from supporting Environmental Control and Life Support System (ECLSS) technology development in air revitalization systems and water recovery systems. Analyses are vital during all three phases of the ELS technology test: pre-test, during test and post test. Pre-test analyses of a test system help define hardware components, predict system and component performances, required test duration, sampling frequencies of operation parameters, etc. Analyses conducted during tests could verify the consistency of all the measurements and the performance of the test system. Post test analyses are an essential part of the test task. Results of post test analyses are an important factor in judging whether the technology development is a successful one. In addition, development of a rigorous model for a test system is an important objective of any new technology development. Test data analyses, especially post test data analyses, serve to verify the model. Test analyses have supported development of many ECLSS technologies. Some test analysis tasks in ECLSS technology development are listed in the Appendix. To have effective analysis support for ECLSS technology tests, analysis guidelines would be a useful tool. These test guidelines were developed based on experiences gained through previous analysis support of various ECLSS technology tests. A comment on analysis from an experienced NASA ECLSS manager (1) follows: "Bad analysis was one that bent the test to prove that the analysis was right to begin with. Good analysis was one that directed where the testing should go and also bridged the gap between the reality of the test facility and what was expected on orbit."

Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applications (DMA) and Active Transportation and Demand Management (ATDM) Programs - calibration Report for Phoenix Testbed : Final Report. [supporting datasets - Phoenix Testbed

DOT National Transportation Integrated Search

2017-07-26

The datasets in this zip file are in support of FHWA-JPO-16-379, Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applications (DMA) and Active Transportation and Demand Management (ATDM) Program...

Analysis, modeling, and simulation (AMS) testbed development and evaluation to support dynamic mobility applications (DMA) and active transportation and demand management (ATDM) programs — summary report for the Chicago testbed. [supporting datasets - Chicago Testbed

DOT National Transportation Integrated Search

2017-04-01

The datasets in this zip file are in support of Intelligent Transportation Systems Joint Program Office (ITS JPO) report FHWA-JPO-16-385, "Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applica...

Computer-aided operations engineering with integrated models of systems and operations

NASA Technical Reports Server (NTRS)

Malin, Jane T.; Ryan, Dan; Fleming, Land

1994-01-01

CONFIG 3 is a prototype software tool that supports integrated conceptual design evaluation from early in the product life cycle, by supporting isolated or integrated modeling, simulation, and analysis of the function, structure, behavior, failures and operation of system designs. Integration and reuse of models is supported in an object-oriented environment providing capabilities for graph analysis and discrete event simulation. Integration is supported among diverse modeling approaches (component view, configuration or flow path view, and procedure view) and diverse simulation and analysis approaches. Support is provided for integrated engineering in diverse design domains, including mechanical and electro-mechanical systems, distributed computer systems, and chemical processing and transport systems. CONFIG supports abstracted qualitative and symbolic modeling, for early conceptual design. System models are component structure models with operating modes, with embedded time-related behavior models. CONFIG supports failure modeling and modeling of state or configuration changes that result in dynamic changes in dependencies among components. Operations and procedure models are activity structure models that interact with system models. CONFIG is designed to support evaluation of system operability, diagnosability and fault tolerance, and analysis of the development of system effects of problems over time, including faults, failures, and procedural or environmental difficulties.

Mental health and psychosocial support in humanitarian settings: linking practice and research

PubMed Central

Tol, Wietse A; Barbui, Corrado; Galappatti, Ananda; Silove, Derrick; Betancourt, Theresa S; Souza, Renato; Golaz, Anne; van Ommeren, Mark

2014-01-01

This review links practice, funding, and evidence for interventions for mental health and psychosocial wellbeing in humanitarian settings. We studied practice by reviewing reports of mental health and psychosocial support activities (2007–10); funding by analysis of the financial tracking service and the creditor reporting system (2007–09); and interventions by systematic review and meta-analysis. In 160 reports, the five most commonly reported activities were basic counselling for individuals (39%); facilitation of community support of vulnerable individuals (23%); provision of child-friendly spaces (21%); support of community-initiated social support (21%); and basic counselling for groups and families (20%). Most interventions took place and were funded outside national mental health and protection systems. 32 controlled studies of interventions were identified, 13 of which were randomised controlled trials (RCTs) that met the criteria for meta-analysis. Two studies showed promising effects for strengthening community and family supports. Psychosocial wellbeing was not included as an outcome in the meta-analysis, because its definition varied across studies. In adults with symptoms of post-traumatic stress disorder (PTSD), meta-analysis of seven RCTs showed beneficial effects for several interventions (psychotherapy and psychosocial supports) compared with usual care or waiting list (standardised mean difference [SMD] −0.38, 95% CI −0.55 to −0.20). In children, meta-analysis of four RCTs failed to show an effect for symptoms of PTSD (−0.36, −0.83 to 0.10), but showed a beneficial effect of interventions (group psychotherapy, school-based support, and other psychosocial support) for internalising symptoms (six RCTs; SMD −0.24, −0.40 to −0.09). Overall, research and evidence focuses on interventions that are infrequently implemented, whereas the most commonly used interventions have had little rigorous scrutiny. PMID:22008428

Capability of the Gas Analysis and Testing Laboratory at the NASA Johnson Space Center

NASA Technical Reports Server (NTRS)

Broerman, Craig; Jimenez, Javier; Sweterlitsch, Jeff

2012-01-01

The Gas Analysis and Testing Laboratory is an integral part of the testing performed at the NASA Johnson Space Center. The Gas Analysis and Testing Laboratory is a high performance laboratory providing real time analytical instruments to support manned and unmanned testing. The lab utilizes precision gas chromatographs, gas analyzers and spectrophotometers to support the technology development programs within the NASA community. The Gas Analysis and Testing Laboratory works with a wide variety of customers and provides engineering support for user-specified applications in compressed gas, chemical analysis, general and research laboratory.

Capability of the Gas Analysis and Testing Laboratory at the NASA Johnson Space Center

NASA Technical Reports Server (NTRS)

Broerman, Craig; Jimenez, Javier; Sweterlitsch, Jeff

2011-01-01

The Gas Analysis and Testing Laboratory is an integral part of the testing performed at the NASA Johnson Space Center. The Gas Analysis and Testing Laboratory is a high performance laboratory providing real time analytical instruments to support manned and unmanned testing. The lab utilizes precision gas chromatographs, gas analyzers and spectrophotometers to support the technology development programs within the NASA community. The Gas Analysis and Testing Laboratory works with a wide variety of customers and provides engineering support for user-specified applications in compressed gas, chemical analysis, general and research laboratory

A method comparison of photovoice and content analysis: research examining challenges and supports of family caregivers.

PubMed

Faucher, Mary Ann; Garner, Shelby L

2015-11-01

The purpose of this manuscript is to compare methods and thematic representations of the challenges and supports of family caregivers identified with photovoice methodology contrasted with content analysis, a more traditional qualitative approach. Results from a photovoice study utilizing a participatory action research framework was compared to an analysis of the audio-transcripts from that study utilizing content analysis methodology. Major similarities between the results are identified with some notable differences. Content analysis provides a more in-depth and abstract elucidation of the nature of the challenges and supports of the family caregiver. The comparison provides evidence to support the trustworthiness of photovoice methodology with limitations identified. The enhanced elaboration of theme and categories with content analysis may have some advantages relevant to the utilization of this knowledge by health care professionals. Copyright © 2015 Elsevier Inc. All rights reserved.

Risk Analysis of Return Support Material on Gas Compressor Platform Project

NASA Astrophysics Data System (ADS)

Silvianita; Aulia, B. U.; Khakim, M. L. N.; Rosyid, Daniel M.

2017-07-01

On a fixed platforms project are not only carried out by a contractor, but two or more contractors. Cooperation in the construction of fixed platforms is often not according to plan, it is caused by several factors. It takes a good synergy between the contractor to avoid miss communication may cause problems on the project. For the example is about support material (sea fastening, skid shoe and shipping support) used in the process of sending a jacket structure to operation place often does not return to the contractor. It needs a systematic method to overcome the problem of support material. This paper analyses the causes and effects of GAS Compressor Platform that support material is not return, using Fault Tree Analysis (FTA) and Event Tree Analysis (ETA). From fault tree analysis, the probability of top event is 0.7783. From event tree analysis diagram, the contractors lose Rp.350.000.000, - to Rp.10.000.000.000, -.

CONFIG: Integrated engineering of systems and their operation

NASA Technical Reports Server (NTRS)

Malin, Jane T.; Ryan, Dan; Fleming, Land

1994-01-01

This article discusses CONFIG 3, a prototype software tool that supports integrated conceptual design evaluation from early in the product life cycle, by supporting isolated or integrated modeling, simulation, and analysis of the function, structure, behavior, failures and operations of system designs. Integration and reuse of models is supported in an object-oriented environment providing capabilities for graph analysis and discrete event simulation. CONFIG supports integration among diverse modeling approaches (component view, configuration or flow path view, and procedure view) and diverse simulation and analysis approaches. CONFIG is designed to support integrated engineering in diverse design domains, including mechanical and electro-mechanical systems, distributed computer systems, and chemical processing and transport systems.

An Energy Analysis of the Pseudo Wigner-Ville Distribution in Support of Machinery Monitoring and Diagnostics

DTIC Science & Technology

1992-06-01

AD-A256 202 NAVAL POSTGRADUATE SCHOOL Monterey, California THESIS - _ ’. AN ENERGY ANALYSIS OF THE PSEUDO WIGNER - VILLE DISTRIBUTION IN SUPPORT OF...NO 11 TITLE (Include Security Classification) AN ENERGY ANALYSIS OF THE PSEUDO WIGNER - VILLE DISTRIBUTION IN SUPPORT OF MACHINERY MONITORING AND...block number) FIELD GROUP SUB-GROUP machinery monitoring, transient, pseudo wigner - ville distribution , machinery diagnostics 19 ABSTRACT (Continue on

Electronic clinical safety reporting system: a benefits evaluation.

PubMed

Elliott, Pamela; Martin, Desmond; Neville, Doreen

2014-06-11

Eastern Health, a large health care organization in Newfoundland and Labrador (NL), started a staged implementation of an electronic occurrence reporting system (used interchangeably with "clinical safety reporting system") in 2008, completing Phase One in 2009. The electronic clinical safety reporting system (CSRS) was designed to replace a paper-based system. The CSRS involves reporting on occurrences such as falls, safety/security issues, medication errors, treatment and procedural mishaps, medical equipment malfunctions, and close calls. The electronic system was purchased from a vendor in the United Kingdom that had implemented the system in the United Kingdom and other places, such as British Columbia. The main objective of the new system was to improve the reporting process with the goal of improving clinical safety. The project was funded jointly by Eastern Health and Canada Health Infoway. The objectives of the evaluation were to: (1) assess the CSRS on achieving its stated objectives (particularly, the benefits realized and lessons learned), and (2) identify contributions, if any, that can be made to the emerging field of electronic clinical safety reporting. The evaluation involved mixed methods, including extensive stakeholder participation, pre/post comparative study design, and triangulation of data where possible. The data were collected from several sources, such as project documentation, occurrence reporting records, stakeholder workshops, surveys, focus groups, and key informant interviews. The findings provided evidence that frontline staff and managers support the CSRS, identifying both benefits and areas for improvement. Many benefits were realized, such as increases in the number of occurrences reported, in occurrences reported within 48 hours, in occurrences reported by staff other than registered nurses, in close calls reported, and improved timelines for notification. There was also user satisfaction with the tool regarding ease of use, accessibility, and consistency. The implementation process encountered challenges related to customizing the software and the development of the classification system for coding occurrences. This impacted on the ability of the managers to close-out files in a timely fashion. The issues that were identified, and suggestions for improvements to the form itself, were shared with the Project Team as soon as they were noted. Changes were made to the system before the rollout. There were many benefits realized from the new system that can contribute to improved clinical safety. The participants preferred the electronic system over the paper-based system. The lessons learned during the implementation process resulted in recommendations that informed the rollout of the system in Eastern Health, and in other health care organizations in the province of Newfoundland and Labrador. This study also informed the evaluation of other health organizations in the province, which was completed in 2013.

Development of a decision support system for analysis and solutions of prolonged standing in the workplace.

PubMed

Halim, Isa; Arep, Hambali; Kamat, Seri Rahayu; Abdullah, Rohana; Omar, Abdul Rahman; Ismail, Ahmad Rasdan

2014-06-01

Prolonged standing has been hypothesized as a vital contributor to discomfort and muscle fatigue in the workplace. The objective of this study was to develop a decision support system that could provide systematic analysis and solutions to minimize the discomfort and muscle fatigue associated with prolonged standing. The integration of object-oriented programming and a Model Oriented Simultaneous Engineering System were used to design the architecture of the decision support system. Validation of the decision support system was carried out in two manufacturing companies. The validation process showed that the decision support system produced reliable results. The decision support system is a reliable advisory tool for providing analysis and solutions to problems related to the discomfort and muscle fatigue associated with prolonged standing. Further testing of the decision support system is suggested before it is used commercially.

Development of a Decision Support System for Analysis and Solutions of Prolonged Standing in the Workplace

PubMed Central

Halim, Isa; Arep, Hambali; Kamat, Seri Rahayu; Abdullah, Rohana; Omar, Abdul Rahman; Ismail, Ahmad Rasdan

2014-01-01

Background Prolonged standing has been hypothesized as a vital contributor to discomfort and muscle fatigue in the workplace. The objective of this study was to develop a decision support system that could provide systematic analysis and solutions to minimize the discomfort and muscle fatigue associated with prolonged standing. Methods The integration of object-oriented programming and a Model Oriented Simultaneous Engineering System were used to design the architecture of the decision support system. Results Validation of the decision support system was carried out in two manufacturing companies. The validation process showed that the decision support system produced reliable results. Conclusion The decision support system is a reliable advisory tool for providing analysis and solutions to problems related to the discomfort and muscle fatigue associated with prolonged standing. Further testing of the decision support system is suggested before it is used commercially. PMID:25180141

Donor Behavior and Voluntary Support for Higher Education Institutions.

ERIC Educational Resources Information Center

Leslie, Larry L.; Ramey, Garey

Voluntary support of higher education in America is investigated through regression analysis of institutional characteristics at two points in time. The assumption of donor rationality together with explicit consideration of interorganizational relationships offers a coherent framework for the analysis of voluntary support by the major…

Space-Based Space Surveillance Logistics Case Study: A Qualitative Product Support Element Analysis

DTIC Science & Technology

2017-12-01

Facilities and Infrastructure. Product Support Management and Design Interface are also covered, but only in a general manner. Conclusions from the study...core analysis, with the overarching two elements ( Design Interface and Product Support Management) mentioned briefly. G. THESIS STATEMENT This...were implemented. The two overarching elements of Product Support Management and Design Interface will be discussed briefly in the findings section

Analysis, modeling, and simulation (AMS) testbed development and evaluation to support dynamic mobility applications (DMA) and active transportation and demand management (ATDM) programs — evaluation report for ATDM program. [supporting datasets - Pasadena Testbed

DOT National Transportation Integrated Search

2017-07-26

This zip file contains POSTDATA.ATT (.ATT); Print to File (.PRN); Portable Document Format (.PDF); and document (.DOCX) files of data to support FHWA-JPO-16-385, Analysis, modeling, and simulation (AMS) testbed development and evaluation to support d...

Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applications (DMA) and Active Transportation and Demand Management (ATDM) Programs : Evaluation Report for the San Diego Testbed : Draft Report. [supporting datasets - San Diego

DOT National Transportation Integrated Search

2016-06-26

The datasets in this zip file are in support of Intelligent Transportation Systems Joint Program Office (ITS JPO) report FHWA-JPO-16-385, "Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applica...

Structured Analysis of the Logistic Support Analysis (LSA) Task, and Integrated Logistic Support (ILS) Element, LSA Subtask 301.2.4.2, Reliability Centered Maintenance (RCM)

DTIC Science & Technology

1988-06-01

Di’Lt. ibu601’. I j I o; DTIC Qt.ALTTY I ,2,1 4 AMERICAN POWER JET COMPANY RIDGEFIELD, NJ FALLS CHURCH...The logic is applied to each reparable item in the system/equipment. When the components have been analyzed, an overall system/equipment analysis is...in the AMSDL as applicable to the referenced DIDs of interest. 5. Apply staff experience in logistics support analysis to assure that the intent of the

ARL Support and Analysis to the Army Public Health Command Kabul Air Quality Data Collection (Spring 2014)

DTIC Science & Technology

2016-05-01

ARL-TR-7692•MAY 2016 US Army Research Laboratory ARL Support and Analysis to the Army Public Health Command Kabul Air Quality Data Collection (Spring...return it to the originator. ARL-TR-7692•MAY 2016 US Army Research Laboratory ARL Support and Analysis to the Army Public Health Command Kabul Air Quality ...and Analysis to the Army Public Health Command Kabul Air Quality Data Collection (Spring 2014) Alan Wetmore and Thomas DeFelice ARL-TR-7692 Approved

Support Air and Space Expeditionary Forces. Analysis of Combat Support Basing Options

DTIC Science & Technology

2004-01-01

Mahyar A . Amouzegar, Robert S. Tripp, Ronald G. McGarve Edward W Chan C. Robert Roll, Jr. _77 Ap L_ L; Reý PROJECT AIR FORCE - Supporting Air and Space...Expeditionary Forces Analysis of Combat Support Basing Options Mahyar A . Amouzegar Robert S. Tripp Ronald G. McGarvey Edward W. Chan C. Robert Roll...support basing options / Mahyar A . Amouzegar ... [et al. p. cm. "’MG-261." Indudes bibliographical references. ISBN 0-8330-3675-0 (pbk.) 1. Air bases

Comparative Analysis of Enrollment and Financial Strength of Private Institutions. AIR 1989 Annual Forum Paper.

ERIC Educational Resources Information Center

Glover, Robert H.; Mills, Michael R.

A research design, decision support system, and results of a comparative analysis of enrollment and financial strength (of private institutions granting masters and doctoral degrees) are presented. Cluster analysis, discriminant analysis, multiple regression, and an interactive decision support system are used to compare the enrollment and…

48 CFR 915.404-2 - Information to support proposal analysis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... for the auditor's review. (ii) Copies of technical analysis reports prepared by DOE technical or other... proposal analysis. 915.404-2 Section 915.404-2 Federal Acquisition Regulations System DEPARTMENT OF ENERGY... support proposal analysis. (a)(1) Field pricing assistance as discussed in FAR 15.404-2(a) is not required...