Traffic safety facts 2009 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

2009-01-01

In this annual report, Traffic Safety Facts 2009: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System, the National Highway Traffic Safety Administration (NHTSA) presents descriptive ...

Viewpoint on ISA TR84.0.02--simplified methods and fault tree analysis.

PubMed

Summers, A E

2000-01-01

ANSI/ISA-S84.01-1996 and IEC 61508 require the establishment of a safety integrity level for any safety instrumented system or safety related system used to mitigate risk. Each stage of design, operation, maintenance, and testing is judged against this safety integrity level. Quantitative techniques can be used to verify whether the safety integrity level is met. ISA-dTR84.0.02 is a technical report under development by ISA, which discusses how to apply quantitative analysis techniques to safety instrumented systems. This paper discusses two of those techniques: (1) Simplified equations and (2) Fault tree analysis.

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

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

Not Available

1992-03-01

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

Systems Analysis of NASA Aviation Safety Program: Final Report

NASA Technical Reports Server (NTRS)

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

2013-01-01

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

System safety education focused on flight safety

NASA Technical Reports Server (NTRS)

Holt, E.

1971-01-01

The measures necessary for achieving higher levels of system safety are analyzed with an eye toward maintaining the combat capability of the Air Force. Several education courses were provided for personnel involved in safety management. Data include: (1) Flight Safety Officer Course, (2) Advanced Safety Program Management, (3) Fundamentals of System Safety, and (4) Quantitative Methods of Safety Analysis.

Why the Eurocontrol Safety Regulation Commission Policy on Safety Nets and Risk Assessment is Wrong

NASA Astrophysics Data System (ADS)

Brooker, Peter

2004-05-01

Current Eurocontrol Safety Regulation Commission (SRC) policy says that the Air Traffic Management (ATM) system (including safety minima) must be demonstrated through risk assessments to meet the Target Level of Safety (TLS) without needing to take safety nets (such as Short Term Conflict Alert) into account. This policy is wrong. The policy is invalid because it does not build rationally and consistently from ATM's firm foundations of TLS and hazard analysis. The policy is bad because it would tend to retard safety improvements. Safety net policy must rest on a clear and rational treatment of integrated ATM system safety defences. A new safety net policy, appropriate to safe ATM system improvements, is needed, which recognizes that safety nets are an integrated part of ATM system defences. The effects of safety nets in reducing deaths from mid-air collisions should be fully included in hazard analysis and safety audits in the context of the TLS for total system design.

A Synthetic Vision Preliminary Integrated Safety Analysis

NASA Technical Reports Server (NTRS)

Hemm, Robert; Houser, Scott

2001-01-01

This report documents efforts to analyze a sample of aviation safety programs, using the LMI-developed integrated safety analysis tool to determine the change in system risk resulting from Aviation Safety Program (AvSP) technology implementation. Specifically, we have worked to modify existing system safety tools to address the safety impact of synthetic vision (SV) technology. Safety metrics include reliability, availability, and resultant hazard. This analysis of SV technology is intended to be part of a larger effort to develop a model that is capable of "providing further support to the product design and development team as additional information becomes available". The reliability analysis portion of the effort is complete and is fully documented in this report. The simulation analysis is still underway; it will be documented in a subsequent report. The specific goal of this effort is to apply the integrated safety analysis to SV technology. This report also contains a brief discussion of data necessary to expand the human performance capability of the model, as well as a discussion of human behavior and its implications for system risk assessment in this modeling environment.

Analysis of Aviation Safety Reporting System Incident Data Associated With the Technical Challenges of the Vehicle Systems Safety Technology Project

NASA Technical Reports Server (NTRS)

Withrow, Colleen A.; Reveley, Mary S.

2014-01-01

This analysis was conducted to support the Vehicle Systems Safety Technology (VSST) Project of the Aviation Safety Program (AVsP) milestone VSST4.2.1.01, "Identification of VSST-Related Trends." In particular, this is a review of incident data from the NASA Aviation Safety Reporting System (ASRS). The following three VSST-related technical challenges (TCs) were the focus of the incidents searched in the ASRS database: (1) Vechicle health assurance, (2) Effective crew-system interactions and decisions in all conditions; and (3) Aircraft loss of control prevention, mitigation, and recovery.

14 CFR 417.221 - Time delay analysis.

Code of Federal Regulations, 2010 CFR

2010-01-01

... OF TRANSPORTATION LICENSING LAUNCH SAFETY Flight Safety Analysis § 417.221 Time delay analysis. (a) General. A flight safety analysis must include a time delay analysis that establishes the mean elapsed time between the violation of a flight termination rule and the time when the flight safety system is...

14 CFR 417.221 - Time delay analysis.

Code of Federal Regulations, 2011 CFR

2011-01-01

... OF TRANSPORTATION LICENSING LAUNCH SAFETY Flight Safety Analysis § 417.221 Time delay analysis. (a) General. A flight safety analysis must include a time delay analysis that establishes the mean elapsed time between the violation of a flight termination rule and the time when the flight safety system is...

System safety education focused on system management

NASA Technical Reports Server (NTRS)

Grose, V. L.

1971-01-01

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

Analysis of Aviation Safety Reporting System Incident Data Associated with the Technical Challenges of the System-Wide Safety and Assurance Technologies Project

NASA Technical Reports Server (NTRS)

Withrow, Colleen A.; Reveley, Mary S.

2015-01-01

The Aviation Safety Program (AvSP) System-Wide Safety and Assurance Technologies (SSAT) Project asked the AvSP Systems and Portfolio Analysis Team to identify SSAT-related trends. SSAT had four technical challenges: advance safety assurance to enable deployment of NextGen systems; automated discovery of precursors to aviation safety incidents; increasing safety of human-automation interaction by incorporating human performance, and prognostic algorithm design for safety assurance. This report reviews incident data from the NASA Aviation Safety Reporting System (ASRS) for system-component-failure- or-malfunction- (SCFM-) related and human-factor-related incidents for commercial or cargo air carriers (Part 121), commuter airlines (Part 135), and general aviation (Part 91). The data was analyzed by Federal Aviation Regulations (FAR) part, phase of flight, SCFM category, human factor category, and a variety of anomalies and results. There were 38 894 SCFM-related incidents and 83 478 human-factorrelated incidents analyzed between January 1993 and April 2011.

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

DOT National Transportation Integrated Search

1988-02-01

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

A Framework for Assessment of Aviation Safety Technology Portfolios

NASA Technical Reports Server (NTRS)

Jones, Sharon M.; Reveley, Mary S.

2014-01-01

The programs within NASA's Aeronautics Research Mission Directorate (ARMD) conduct research and development to improve the national air transportation system so that Americans can travel as safely as possible. NASA aviation safety systems analysis personnel support various levels of ARMD management in their fulfillment of system analysis and technology prioritization as defined in the agency's program and project requirements. This paper provides a framework for the assessment of aviation safety research and technology portfolios that includes metrics such as projected impact on current and future safety, technical development risk and implementation risk. The paper also contains methods for presenting portfolio analysis and aviation safety Bayesian Belief Network (BBN) output results to management using bubble charts and quantitative decision analysis techniques.

Combining System Safety and Reliability to Ensure NASA CoNNeCT's Success

NASA Technical Reports Server (NTRS)

Havenhill, Maria; Fernandez, Rene; Zampino, Edward

2012-01-01

Hazard Analysis, Failure Modes and Effects Analysis (FMEA), the Limited-Life Items List (LLIL), and the Single Point Failure (SPF) List were applied by System Safety and Reliability engineers on NASA's Communications, Navigation, and Networking reConfigurable Testbed (CoNNeCT) Project. The integrated approach involving cross reviews of these reports by System Safety, Reliability, and Design engineers resulted in the mitigation of all identified hazards. The outcome was that the system met all the safety requirements it was required to meet.

Model-Driven Safety Analysis of Closed-Loop Medical Systems

PubMed Central

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

2013-01-01

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

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

PubMed

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

2012-10-26

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

Archetypes for Organisational Safety

NASA Technical Reports Server (NTRS)

Marais, Karen; Leveson, Nancy G.

2003-01-01

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

Sociotechnical attributes of safe and unsafe work systems.

PubMed

Kleiner, Brian M; Hettinger, Lawrence J; DeJoy, David M; Huang, Yuang-Hsiang; Love, Peter E D

2015-01-01

Theoretical and practical approaches to safety based on sociotechnical systems principles place heavy emphasis on the intersections between social-organisational and technical-work process factors. Within this perspective, work system design emphasises factors such as the joint optimisation of social and technical processes, a focus on reliable human-system performance and safety metrics as design and analysis criteria, the maintenance of a realistic and consistent set of safety objectives and policies, and regular access to the expertise and input of workers. We discuss three current approaches to the analysis and design of complex sociotechnical systems: human-systems integration, macroergonomics and safety climate. Each approach emphasises key sociotechnical systems themes, and each prescribes a more holistic perspective on work systems than do traditional theories and methods. We contrast these perspectives with historical precedents such as system safety and traditional human factors and ergonomics, and describe potential future directions for their application in research and practice. The identification of factors that can reliably distinguish between safe and unsafe work systems is an important concern for ergonomists and other safety professionals. This paper presents a variety of sociotechnical systems perspectives on intersections between social--organisational and technology--work process factors as they impact work system analysis, design and operation.

Ares I Integrated Vehicle System Safety Team

NASA Technical Reports Server (NTRS)

Wetherholt, Jon; McNairy, Lisa; Shackelford, Carla

2009-01-01

Complex systems require integrated analysis teams which sometimes are divided into subsystem teams. Proper division of the analysis in to subsystem teams is important. Safety analysis is one of the most difficult aspects of integration.

Overview of Energy Systems' safety analysis report programs

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

Not Available

1992-03-01

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

Software Safety Analysis of a Flight Guidance System

NASA Technical Reports Server (NTRS)

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

2004-01-01

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

Enhancing Safety of Artificially Ventilated Patients Using Ambient Process Analysis.

PubMed

Lins, Christian; Gerka, Alexander; Lüpkes, Christian; Röhrig, Rainer; Hein, Andreas

2018-01-01

In this paper, we present an approach for enhancing the safety of artificially ventilated patients using ambient process analysis. We propose to use an analysis system consisting of low-cost ambient sensors such as power sensor, RGB-D sensor, passage detector, and matrix infrared temperature sensor to reduce risks for artificially ventilated patients in both home and clinical environments. We describe the system concept and our implementation and show how the system can contribute to patient safety.

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

PubMed

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

2017-02-01

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

14 CFR 415.204-415.400 - [Reserved

Code of Federal Regulations, 2011 CFR

2011-01-01

... Subsystem Design Information 10.4Flight Safety System Analyses 10.5Flight Termination System Environmental... Analysis 4.1.1Flight Safety Sub-Analyses, Methods, and Assumptions 4.1.2Sample Calculation and Products 4.1.3 Launch Specific Updates and Final Flight Safety Analysis Data 4.2Radionuclide Data (where...

14 CFR 415.204-415.400 - [Reserved

Code of Federal Regulations, 2012 CFR

2012-01-01

... Subsystem Design Information 10.4Flight Safety System Analyses 10.5Flight Termination System Environmental... Analysis 4.1.1Flight Safety Sub-Analyses, Methods, and Assumptions 4.1.2Sample Calculation and Products 4.1.3 Launch Specific Updates and Final Flight Safety Analysis Data 4.2Radionuclide Data (where...

14 CFR 415.204-415.400 - [Reserved

Code of Federal Regulations, 2010 CFR

2010-01-01

... Subsystem Design Information 10.4Flight Safety System Analyses 10.5Flight Termination System Environmental... Analysis 4.1.1Flight Safety Sub-Analyses, Methods, and Assumptions 4.1.2Sample Calculation and Products 4.1.3 Launch Specific Updates and Final Flight Safety Analysis Data 4.2Radionuclide Data (where...

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

DOT National Transportation Integrated Search

2014-01-24

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

Designing for auto safety

NASA Technical Reports Server (NTRS)

Driver, E. T.

1971-01-01

Safety design features in the motor vehicle and highway construction fields result from systems analysis approach to prevent or lessen death, injury, and property damage results. Systems analysis considers the prevention of crashes, increased survivability in crashes, and prompt medical attention to injuries as well as other postcrash salvage measures. The interface of these system elements with the driver, the vehicle, and the environment shows that action on the vehicle system produces the greatest safety payoff through design modifications. New and amended safety standards developed through hazard analysis technique improved accident statistics in the 70'; these regulations include driver qualifications and countermeasures to identify the chronic drunken driver who is involved in more than two-thirds of all auto deaths.

Modeling and Analysis of Mixed Synchronous/Asynchronous Systems

NASA Technical Reports Server (NTRS)

Driscoll, Kevin R.; Madl. Gabor; Hall, Brendan

2012-01-01

Practical safety-critical distributed systems must integrate safety critical and non-critical data in a common platform. Safety critical systems almost always consist of isochronous components that have synchronous or asynchronous interface with other components. Many of these systems also support a mix of synchronous and asynchronous interfaces. This report presents a study on the modeling and analysis of asynchronous, synchronous, and mixed synchronous/asynchronous systems. We build on the SAE Architecture Analysis and Design Language (AADL) to capture architectures for analysis. We present preliminary work targeted to capture mixed low- and high-criticality data, as well as real-time properties in a common Model of Computation (MoC). An abstract, but representative, test specimen system was created as the system to be modeled.

14 CFR 417.405 - Ground safety analysis.

Code of Federal Regulations, 2011 CFR

2011-01-01

... hazard from affecting the public. A launch operator must incorporate the launch site operator's systems... personnel who are knowledgeable of launch vehicle systems, launch processing, ground systems, operations...) Begin a ground safety analysis by identifying the systems and operations to be analyzed; (2) Define the...

14 CFR 417.405 - Ground safety analysis.

Code of Federal Regulations, 2010 CFR

2010-01-01

... hazard from affecting the public. A launch operator must incorporate the launch site operator's systems... personnel who are knowledgeable of launch vehicle systems, launch processing, ground systems, operations...) Begin a ground safety analysis by identifying the systems and operations to be analyzed; (2) Define the...

Applicability of the Common Safety Method for Risk Evaluation and Assessment (CSM-RA) to the Space Domain

NASA Astrophysics Data System (ADS)

Moreira, Francisco; Silva, Nuno

2016-08-01

Safety systems require accident avoidance. This is covered by application standards, processes, techniques and tools that support the identification, analysis, elimination or reduction to an acceptable level of system risks and hazards. Ideally, a safety system should be free of hazards. However, both industry and academia have been struggling to ensure appropriate risk and hazard analysis, especially in what concerns completeness of the hazards, formalization, and timely analysis in order to influence the specifications and the implementation. Such analysis is also important when considering a change to an existing system. The Common Safety Method for Risk Evaluation and Assessment (CSM- RA) is a mandatory procedure whenever any significant change is proposed to the railway system in a European Member State. This paper provides insights on the fundamentals of CSM-RA based and complemented with Hazard Analysis. When and how to apply them, and the relation and similarities of these processes with industry standards and the system life cycles is highlighted. Finally, the paper shows how CSM-RA can be the basis of a change management process, guiding the identification and management of the hazards helping ensuring the similar safety level as the initial system. This paper will show how the CSM-RA principles can be used in other domains particularly for space system evolution.

Sociotechnical attributes of safe and unsafe work systems

PubMed Central

Kleiner, Brian M.; Hettinger, Lawrence J.; DeJoy, David M.; Huang, Yuang-Hsiang; Love, Peter E.D.

2015-01-01

Theoretical and practical approaches to safety based on sociotechnical systems principles place heavy emphasis on the intersections between social–organisational and technical–work process factors. Within this perspective, work system design emphasises factors such as the joint optimisation of social and technical processes, a focus on reliable human–system performance and safety metrics as design and analysis criteria, the maintenance of a realistic and consistent set of safety objectives and policies, and regular access to the expertise and input of workers. We discuss three current approaches to the analysis and design of complex sociotechnical systems: human–systems integration, macroergonomics and safety climate. Each approach emphasises key sociotechnical systems themes, and each prescribes a more holistic perspective on work systems than do traditional theories and methods. We contrast these perspectives with historical precedents such as system safety and traditional human factors and ergonomics, and describe potential future directions for their application in research and practice. Practitioner Summary: The identification of factors that can reliably distinguish between safe and unsafe work systems is an important concern for ergonomists and other safety professionals. This paper presents a variety of sociotechnical systems perspectives on intersections between social–organisational and technology–work process factors as they impact work system analysis, design and operation. PMID:25909756

In-space propellant logistics. Volume 1: Executive summary

NASA Technical Reports Server (NTRS)

1972-01-01

The study addresses the systems and operational problems associated with the transport, transfer, and storage of cryogenic propellants in low earth orbits. The safety problems connected with in-space propellant logistics operations are also considered.Correlation between the two projects was maintained by including safety considerations, resulting from the system safety analysis, in the trade studies and evaluations of alternate operating concepts in the systems operations analysis.

14 CFR 417.233 - Analysis for an unguided suborbital launch vehicle flown with a wind weighting safety system.

Code of Federal Regulations, 2012 CFR

2012-01-01

... vehicle flown with a wind weighting safety system. 417.233 Section 417.233 Aeronautics and Space... with a wind weighting safety system. For each launch of an unguided suborbital launch vehicle flown with a wind weighting safety system, in addition to the other requirements in this subpart outlined in...

14 CFR 417.233 - Analysis for an unguided suborbital launch vehicle flown with a wind weighting safety system.

Code of Federal Regulations, 2013 CFR

2013-01-01

... vehicle flown with a wind weighting safety system. 417.233 Section 417.233 Aeronautics and Space... with a wind weighting safety system. For each launch of an unguided suborbital launch vehicle flown with a wind weighting safety system, in addition to the other requirements in this subpart outlined in...

14 CFR 417.233 - Analysis for an unguided suborbital launch vehicle flown with a wind weighting safety system.

Code of Federal Regulations, 2014 CFR

2014-01-01

... vehicle flown with a wind weighting safety system. 417.233 Section 417.233 Aeronautics and Space... with a wind weighting safety system. For each launch of an unguided suborbital launch vehicle flown with a wind weighting safety system, in addition to the other requirements in this subpart outlined in...

14 CFR 417.233 - Analysis for an unguided suborbital launch vehicle flown with a wind weighting safety system.

Code of Federal Regulations, 2011 CFR

2011-01-01

... vehicle flown with a wind weighting safety system. 417.233 Section 417.233 Aeronautics and Space... with a wind weighting safety system. For each launch of an unguided suborbital launch vehicle flown with a wind weighting safety system, in addition to the other requirements in this subpart outlined in...

14 CFR 417.233 - Analysis for an unguided suborbital launch vehicle flown with a wind weighting safety system.

Code of Federal Regulations, 2010 CFR

2010-01-01

... vehicle flown with a wind weighting safety system. 417.233 Section 417.233 Aeronautics and Space... with a wind weighting safety system. For each launch of an unguided suborbital launch vehicle flown with a wind weighting safety system, in addition to the other requirements in this subpart outlined in...

A method for identifying EMI critical circuits during development of a large C3

NASA Astrophysics Data System (ADS)

Barr, Douglas H.

The circuit analysis methods and process Boeing Aerospace used on a large, ground-based military command, control, and communications (C3) system are described. This analysis was designed to help identify electromagnetic interference (EMI) critical circuits. The methodology used the MIL-E-6051 equipment criticality categories as the basis for defining critical circuits, relational database technology to help sort through and account for all of the approximately 5000 system signal cables, and Macintosh Plus personal computers to predict critical circuits based on safety margin analysis. The EMI circuit analysis process systematically examined all system circuits to identify which ones were likely to be EMI critical. The process used two separate, sequential safety margin analyses to identify critical circuits (conservative safety margin analysis, and detailed safety margin analysis). These analyses used field-to-wire and wire-to-wire coupling models using both worst-case and detailed circuit parameters (physical and electrical) to predict circuit safety margins. This process identified the predicted critical circuits that could then be verified by test.

Galileo and Ulysses missions safety analysis and launch readiness status

NASA Technical Reports Server (NTRS)

Cork, M. Joseph; Turi, James A.

1989-01-01

The Galileo spacecraft, which will release probes to explore the Jupiter system, was launched in October, 1989 as the payload on STS-34, and the Ulysses spacecraft, which will fly by Jupiter en route to a polar orbit of the sun, is presently entering system-test activity in preparation for an October, 1990 launch. This paper reviews the Galileo and Ulysses mission objectives and design approaches and presents details of the missions' safety analysis. The processes used to develop the safety analysis are described and the results of safety tests are presented.

Integrated risk assessment and screening analysis of drinking water safety of a conventional water supply system.

PubMed

Sun, F; Chen, J; Tong, Q; Zeng, S

2007-01-01

Management of drinking water safety is changing towards an integrated risk assessment and risk management approach that includes all processes in a water supply system from catchment to consumers. However, given the large number of water supply systems in China and the cost of implementing such a risk assessment procedure, there is a necessity to first conduct a strategic screening analysis at a national level. An integrated methodology of risk assessment and screening analysis is thus proposed to evaluate drinking water safety of a conventional water supply system. The violation probability, indicating drinking water safety, is estimated at different locations of a water supply system in terms of permanganate index, ammonia nitrogen, turbidity, residual chlorine and trihalomethanes. Critical parameters with respect to drinking water safety are then identified, based on which an index system is developed to prioritize conventional water supply systems in implementing a detailed risk assessment procedure. The evaluation results are represented as graphic check matrices for the concerned hazards in drinking water, from which the vulnerability of a conventional water supply system is characterized.

ASIL determination for motorbike's Electronics Throttle Control System (ETCS) mulfunction

NASA Astrophysics Data System (ADS)

Zaman Rokhani, Fakhrul; Rahman, Muhammad Taqiuddin Abdul; Ain Kamsani, Noor; Sidek, Roslina Mohd; Saripan, M. Iqbal; Samsudin, Khairulmizam; Khair Hassan, Mohd

2017-11-01

Electronics Throttle Control System (ETCS) is the principal electronic unit in all fuel injection engine motorbike, augmenting the engine performance efficiency in comparison to the conventional carburetor based engine. ETCS is regarded as a safety-critical component, whereby ETCS malfunction can cause unintended acceleration or deceleration event, which can be hazardous to riders. In this study, Hazard Analysis and Risk Assessment, an ISO26262 functional safety standard analysis has been applied on motorbike's ETCS to determine the required automotive safety integrity level. Based on the analysis, the established automotive safety integrity level can help to derive technical and functional safety measures for ETCS development.

Experience of creating a multifunctional safety system at the coal mining enterprise

NASA Astrophysics Data System (ADS)

Reshetnikov, V. V.; Davkaev, K. S.; Korolkov, M. V.; Lyakhovets, M. V.

2018-05-01

The principles of creating multifunctional safety systems (MFSS) based on mathematical models with Markov properties are considered. The applicability of such models for the analysis of the safety of the created systems and their effectiveness is substantiated. The method of this analysis and the results of its testing are discussed. The variant of IFSB implementation in the conditions of the operating coal-mining enterprise is given. The functional scheme, data scheme and operating modes of the MFSS are given. The automated workplace of the industrial safety controller is described.

Identification of Crew-Systems Interactions and Decision Related Trends

NASA Technical Reports Server (NTRS)

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

2013-01-01

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

[Study of post marketing safety reevaluation of shenqi fuzheng injection].

PubMed

Ai, Qing-Hua; Li, Yuan-Yuan; Xie, Yan-Ming

2014-09-01

In order to promote the Shenqifuzheng injection (SQFZ) clinical medication safety, this study reevaluate on SQFZ post marketing safety study systematically. Including multi center large sample registration type safety monitoring research, the analysis based on national spontaneous reporting system data, the analysis based on the 20 national hospital information system data and literature research. Above the analysis, it suggests that SQFZ has good security. The more adverse drug reaction (ADR) as allergic reactions, mainly involved in the damage of skin, appendages and its systemic damage, serious person can appear allergic shock. ADR/E is more common in the elderly, may be related to medication (tumor) populations. Early warning analysis based on SRS data and literature research are of the view that "phlebitis" has a strong association with SQFZ used.

Flight deck party line issues : an Aviation Safety Reporting System analysis

DOT National Transportation Integrated Search

1995-06-01

This document describes an analysis of the Aviation Safety Reporting System : (ASRS) database with regards to human factors aspects concerning the : implementation of Data Link into the flightdeck. The ASRS database contains : thousands of reports co...

Sociotechnical systems as a framework for regulatory system design and evaluation: Using Work Domain Analysis to examine a new regulatory system.

PubMed

Carden, Tony; Goode, Natassia; Read, Gemma J M; Salmon, Paul M

2017-03-15

Like most work systems, the domain of adventure activities has seen a series of serious incidents and subsequent calls to improve regulation. Safety regulation systems aim to promote safety and reduce accidents. However, there is scant evidence they have led to improved safety outcomes. In fact there is some evidence that the poor integration of regulatory system components has led to adverse safety outcomes in some contexts. Despite this, there is an absence of methods for evaluating regulatory and compliance systems. This article argues that sociotechnical systems theory and methods provide a suitable framework for evaluating regulatory systems. This is demonstrated through an analysis of a recently introduced set of adventure activity regulations. Work Domain Analysis (WDA) was used to describe the regulatory system in terms of its functional purposes, values and priority measures, purpose-related functions, object-related processes and cognitive objects. This allowed judgement to be made on the nature of the new regulatory system and on the constraints that may impact its efficacy following implementation. Importantly, the analysis suggests that the new system's functional purpose of ensuring safe activities is not fully supported in terms of the functions and objects available to fulfil them. Potential improvements to the design of the system are discussed along with the implications for regulatory system design and evaluation across the safety critical domains generally. Copyright © 2017 Elsevier Ltd. All rights reserved.

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

PubMed

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

2014-01-01

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

Motorcoach and school bus fire safety analysis.

DOT National Transportation Integrated Search

2016-11-01

This report documents a motorcoach and school bus fire safety analysis performed by the John A. Volpe National Transportation Systems Center (Volpe) for the Federal Motor Carrier Safety Administration. This report aims to: 1) identify the causes, fre...

ANALYSIS OF SEQUENTIAL FAILURES FOR ASSESSMENT OF RELIABILITY AND SAFETY OF MANUFACTURING SYSTEMS. (R828541)

EPA Science Inventory

Assessment of reliability and safety of a manufacturing system with sequential failures is an important issue in industry, since the reliability and safety of the system depend not only on all failed states of system components, but also on the sequence of occurrences of those...

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

NASA Technical Reports Server (NTRS)

1972-01-01

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

Just Culture: A Foundation for Balanced Accountability and Patient Safety

PubMed Central

Boysen, Philip G.

2013-01-01

Background The framework of a just culture ensures balanced accountability for both individuals and the organization responsible for designing and improving systems in the workplace. Engineering principles and human factors analysis influence the design of these systems so they are safe and reliable. Methods Approaches for improving patient safety introduced here are (1) analysis of error, (2) specific tools to enhance safety, and (3) outcome engineering. Conclusion The just culture is a learning culture that is constantly improving and oriented toward patient safety. PMID:24052772

Manned space flight nuclear system safety. Volume 3: Reactor system preliminary nuclear safety analysis. Part 1: Reference Design Document (RDD)

NASA Technical Reports Server (NTRS)

1972-01-01

The Reference Design Document, of the Preliminary Safety Analysis Report (PSAR) - Reactor System provides the basic design and operations data used in the nuclear safety analysis of the Rector Power Module as applied to a Space Base program. A description of the power module systems, facilities, launch vehicle and mission operations, as defined in NASA Phase A Space Base studies is included. Each of two Zirconium Hydride Reactor Brayton power modules provides 50 kWe for the nominal 50 man Space Base. The INT-21 is the prime launch vehicle. Resupply to the 500 km orbit over the ten year mission is provided by the Space Shuttle. At the end of the power module lifetime (nominally five years), a reactor disposal system is deployed for boost into a 990 km high altitude (long decay time) earth orbit.

Integrated vehicle-based safety systems (IVBSS) : light vehicle platform field operational test data analysis plan.

DOT National Transportation Integrated Search

2009-12-22

This document presents the University of Michigan Transportation Research Institutes plan to : perform analysis of data collected from the light vehicle platform field operational test of the : Integrated Vehicle-Based Safety Systems (IVBSS) progr...

Integrated vehicle-based safety systems (IVBSS) : heavy truck platform field operational test data analysis plan.

DOT National Transportation Integrated Search

2009-11-23

This document presents the University of Michigan Transportation Research Institutes plan to perform : analysis of data collected from the heavy truck platform field operational test of the Integrated Vehicle- : Based Safety Systems (IVBSS) progra...

Accident analysis and control options in support of the sludge water system safety analysis

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

HEY, B.E.

A hazards analysis was initiated for the SWS in July 2001 (SNF-8626, K Basin Sludge and Water System Preliminary Hazard Analysis) and updated in December 2001 (SNF-10020 Rev. 0, Hazard Evaluation for KE Sludge and Water System - Project A16) based on conceptual design information for the Sludge Retrieval System (SRS) and 60% design information for the cask and container. SNF-10020 was again revised in September 2002 to incorporate new hazards identified from final design information and from a What-if/Checklist evaluation of operational steps. The process hazards, controls, and qualitative consequence and frequency estimates taken from these efforts have beenmore » incorporated into Revision 5 of HNF-3960, K Basins Hazards Analysis. The hazards identification process documented in the above referenced reports utilized standard industrial safety techniques (AIChE 1992, Guidelines for Hazard Evaluation Procedures) to systematically guide several interdisciplinary teams through the system using a pre-established set of process parameters (e.g., flow, temperature, pressure) and guide words (e.g., high, low, more, less). The teams generally included representation from the U.S. Department of Energy (DOE), K Basins Nuclear Safety, T Plant Nuclear Safety, K Basin Industrial Safety, fire protection, project engineering, operations, and facility engineering.« less

Safety analysis and review system (SARS) assessment report

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

Browne, E.T.

1981-03-01

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

Statewide crash analysis and forecasting.

DOT National Transportation Integrated Search

2008-11-20

There is a need for the development of safety analysis tools to allow Penn DOT to better assess the safety performance of road : segments in the Commonwealth. The project utilized a safety management system database at Penn DOT that integrates crash,...

System safety in Stirling engine development

NASA Technical Reports Server (NTRS)

Bankaitis, H.

1981-01-01

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

Safety leadership and systems thinking: application and evaluation of a Risk Management Framework in the mining industry.

PubMed

Donovan, Sarah-Louise; Salmon, Paul M; Lenné, Michael G; Horberry, Tim

2017-10-01

Safety leadership is an important factor in supporting safety in high-risk industries. This article contends that applying systems-thinking methods to examine safety leadership can support improved learning from incidents. A case study analysis was undertaken of a large-scale mining landslide incident in which no injuries or fatalities were incurred. A multi-method approach was adopted, in which the Critical Decision Method, Rasmussen's Risk Management Framework and Accimap method were applied to examine the safety leadership decisions and actions which enabled the safe outcome. The approach enabled Rasmussen's predictions regarding safety and performance to be examined in the safety leadership context, with findings demonstrating the distribution of safety leadership across leader and system levels, and the presence of vertical integration as key to supporting the successful safety outcome. In doing so, the findings also demonstrate the usefulness of applying systems-thinking methods to examine and learn from incidents in terms of what 'went right'. The implications, including future research directions, are discussed. Practitioner Summary: This paper presents a case study analysis, in which systems-thinking methods are applied to the examination of safety leadership decisions and actions during a large-scale mining landslide incident. The findings establish safety leadership as a systems phenomenon, and furthermore, demonstrate the usefulness of applying systems-thinking methods to learn from incidents in terms of what 'went right'. Implications, including future research directions, are discussed.

10 CFR 52.79 - Contents of applications; technical information in final safety analysis report.

Code of Federal Regulations, 2010 CFR

2010-01-01

... assurance program will be implemented; (26) The applicant's organizational structure, allocations or... presents a safety analysis of the structures, systems, and components of the facility as a whole. The final... contain an analysis and evaluation of the major structures, systems, and components of the facility that...

Implementation of GIS-based highway safety analyses : bridging the gap

DOT National Transportation Integrated Search

2001-01-01

In recent years, efforts have been made to expand the analytical features of the Highway Safety Information System (HSIS) by integrating Geographic Information System (GIS) capabilities. The original version of the GIS Safety Analysis Tools was relea...

Analysis of en route operational errors : probability of resolution and time-on-position.

DOT National Transportation Integrated Search

2012-02-01

The Federation Administrations Air Traffic Control Organization Safety Management System (SMS) is : designed to prevent the introduction of unacceptable safety risk into the National Airspace System. One of the : most important safety metrics used...

Formal Foundations for Hierarchical Safety Cases

NASA Technical Reports Server (NTRS)

Denney, Ewen; Pai, Ganesh; Whiteside, Iain

2015-01-01

Safety cases are increasingly being required in many safety-critical domains to assure, using structured argumentation and evidence, that a system is acceptably safe. However, comprehensive system-wide safety arguments present appreciable challenges to develop, understand, evaluate, and manage, partly due to the volume of information that they aggregate, such as the results of hazard analysis, requirements analysis, testing, formal verification, and other engineering activities. Previously, we have proposed hierarchical safety cases, hicases, to aid the comprehension of safety case argument structures. In this paper, we build on a formal notion of safety case to formalise the use of hierarchy as a structuring technique, and show that hicases satisfy several desirable properties. Our aim is to provide a formal, theoretical foundation for safety cases. In particular, we believe that tools for high assurance systems should be granted similar assurance to the systems to which they are applied. To this end, we formally specify and prove the correctness of key operations for constructing and managing hicases, which gives the specification for implementing hicases in AdvoCATE, our toolset for safety case automation. We motivate and explain the theory with the help of a simple running example, extracted from a real safety case and developed using AdvoCATE.

Integrated Safety Risk Reduction Approach to Enhancing Human-Rated Spaceflight Safety

NASA Astrophysics Data System (ADS)

Mikula, J. F. Kip

2005-12-01

This paper explores and defines the current accepted concept and philosophy of safety improvement based on a Reliability enhancement (called here Reliability Enhancement Based Safety Theory [REBST]). In this theory a Reliability calculation is used as a measure of the safety achieved on the program. This calculation may be based on a math model or a Fault Tree Analysis (FTA) of the system, or on an Event Tree Analysis (ETA) of the system's operational mission sequence. In each case, the numbers used in this calculation are hardware failure rates gleaned from past similar programs. As part of this paper, a fictional but representative case study is provided that helps to illustrate the problems and inaccuracies of this approach to safety determination. Then a safety determination and enhancement approach based on hazard, worst case analysis, and safety risk determination (called here Worst Case Based Safety Theory [WCBST]) is included. This approach is defined and detailed using the same example case study as shown in the REBST case study. In the end it is concluded that an approach combining the two theories works best to reduce Safety Risk.

Safety analysis report for packaging (onsite) steel drum

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

McCormick, W.A.

This Safety Analysis Report for Packaging (SARP) provides the analyses and evaluations necessary to demonstrate that the steel drum packaging system meets the transportation safety requirements of HNF-PRO-154, Responsibilities and Procedures for all Hazardous Material Shipments, for an onsite packaging containing Type B quantities of solid and liquid radioactive materials. The basic component of the steel drum packaging system is the 208 L (55-gal) steel drum.

Safety Verification of the Small Aircraft Transportation System Concept of Operations

NASA Technical Reports Server (NTRS)

Carreno, Victor; Munoz, Cesar

2005-01-01

A critical factor in the adoption of any new aeronautical technology or concept of operation is safety. Traditionally, safety is accomplished through a rigorous process that involves human factors, low and high fidelity simulations, and flight experiments. As this process is usually performed on final products or functional prototypes, concept modifications resulting from this process are very expensive to implement. This paper describe an approach to system safety that can take place at early stages of a concept design. It is based on a set of mathematical techniques and tools known as formal methods. In contrast to testing and simulation, formal methods provide the capability of exhaustive state exploration analysis. We present the safety analysis and verification performed for the Small Aircraft Transportation System (SATS) Concept of Operations (ConOps). The concept of operations is modeled using discrete and hybrid mathematical models. These models are then analyzed using formal methods. The objective of the analysis is to show, in a mathematical framework, that the concept of operation complies with a set of safety requirements. It is also shown that the ConOps has some desirable characteristic such as liveness and absence of dead-lock. The analysis and verification is performed in the Prototype Verification System (PVS), which is a computer based specification language and a theorem proving assistant.

Comparative analysis of zonal systems for macro-level crash modeling.

PubMed

Cai, Qing; Abdel-Aty, Mohamed; Lee, Jaeyoung; Eluru, Naveen

2017-06-01

Macro-level traffic safety analysis has been undertaken at different spatial configurations. However, clear guidelines for the appropriate zonal system selection for safety analysis are unavailable. In this study, a comparative analysis was conducted to determine the optimal zonal system for macroscopic crash modeling considering census tracts (CTs), state-wide traffic analysis zones (STAZs), and a newly developed traffic-related zone system labeled traffic analysis districts (TADs). Poisson lognormal models for three crash types (i.e., total, severe, and non-motorized mode crashes) are developed based on the three zonal systems without and with consideration of spatial autocorrelation. The study proposes a method to compare the modeling performance of the three types of geographic units at different spatial configurations through a grid based framework. Specifically, the study region is partitioned to grids of various sizes and the model prediction accuracy of the various macro models is considered within these grids of various sizes. These model comparison results for all crash types indicated that the models based on TADs consistently offer a better performance compared to the others. Besides, the models considering spatial autocorrelation outperform the ones that do not consider it. Based on the modeling results and motivation for developing the different zonal systems, it is recommended using CTs for socio-demographic data collection, employing TAZs for transportation demand forecasting, and adopting TADs for transportation safety planning. The findings from this study can help practitioners select appropriate zonal systems for traffic crash modeling, which leads to develop more efficient policies to enhance transportation safety. Copyright © 2017 Elsevier Ltd and National Safety Council. All rights reserved.

NASA System Safety Handbook. Volume 1; System Safety Framework and Concepts for Implementation

NASA Technical Reports Server (NTRS)

Dezfuli, Homayoon; Benjamin, Allan; Everett, Christopher; Smith, Curtis; Stamatelatos, Michael; Youngblood, Robert

2011-01-01

System safety assessment is defined in NPR 8715.3C, NASA General Safety Program Requirements as a disciplined, systematic approach to the analysis of risks resulting from hazards that can affect humans, the environment, and mission assets. Achievement of the highest practicable degree of system safety is one of NASA's highest priorities. Traditionally, system safety assessment at NASA and elsewhere has focused on the application of a set of safety analysis tools to identify safety risks and formulate effective controls.1 Familiar tools used for this purpose include various forms of hazard analyses, failure modes and effects analyses, and probabilistic safety assessment (commonly also referred to as probabilistic risk assessment (PRA)). In the past, it has been assumed that to show that a system is safe, it is sufficient to provide assurance that the process for identifying the hazards has been as comprehensive as possible and that each identified hazard has one or more associated controls. The NASA Aerospace Safety Advisory Panel (ASAP) has made several statements in its annual reports supporting a more holistic approach. In 2006, it recommended that "... a comprehensive risk assessment, communication and acceptance process be implemented to ensure that overall launch risk is considered in an integrated and consistent manner." In 2009, it advocated for "... a process for using a risk-informed design approach to produce a design that is optimally and sufficiently safe." As a rationale for the latter advocacy, it stated that "... the ASAP applauds switching to a performance-based approach because it emphasizes early risk identification to guide designs, thus enabling creative design approaches that might be more efficient, safer, or both." For purposes of this preface, it is worth mentioning three areas where the handbook emphasizes a more holistic type of thinking. First, the handbook takes the position that it is important to not just focus on risk on an individual basis but to consider measures of aggregate safety risk and to ensure wherever possible that there be quantitative measures for evaluating how effective the controls are in reducing these aggregate risks. The term aggregate risk, when used in this handbook, refers to the accumulation of risks from individual scenarios that lead to a shortfall in safety performance at a high level: e.g., an excessively high probability of loss of crew, loss of mission, planetary contamination, etc. Without aggregated quantitative measures such as these, it is not reasonable to expect that safety has been optimized with respect to other technical and programmatic objectives. At the same time, it is fully recognized that not all sources of risk are amenable to precise quantitative analysis and that the use of qualitative approaches and bounding estimates may be appropriate for those risk sources. Second, the handbook stresses the necessity of developing confidence that the controls derived for the purpose of achieving system safety not only handle risks that have been identified and properly characterized but also provide a general, more holistic means for protecting against unidentified or uncharacterized risks. For example, while it is not possible to be assured that all credible causes of risk have been identified, there are defenses that can provide protection against broad categories of risks and thereby increase the chances that individual causes are contained. Third, the handbook strives at all times to treat uncertainties as an integral aspect of risk and as a part of making decisions. The term "uncertainty" here does not refer to an actuarial type of data analysis, but rather to a characterization of our state of knowledge regarding results from logical and physical models that approximate reality. Uncertainty analysis finds how the output parameters of the models are related to plausible variations in the input parameters and in the modeling assumptions. The evaluation of unrtainties represents a method of probabilistic thinking wherein the analyst and decision makers recognize possible outcomes other than the outcome perceived to be "most likely." Without this type of analysis, it is not possible to determine the worth of an analysis product as a basis for making decisions related to safety and mission success. In line with these considerations the handbook does not take a hazard-analysis-centric approach to system safety. Hazard analysis remains a useful tool to facilitate brainstorming but does not substitute for a more holistic approach geared to a comprehensive identification and understanding of individual risk issues and their contributions to aggregate safety risks. The handbook strives to emphasize the importance of identifying the most critical scenarios that contribute to the risk of not meeting the agreed-upon safety objectives and requirements using all appropriate tools (including but not limited to hazard analysis). Thereafter, emphasis shifts to identifying the risk drivers that cause these scenarios to be critical and ensuring that there are controls directed toward preventing or mitigating the risk drivers. To address these and other areas, the handbook advocates a proactive, analytic-deliberative, risk-informed approach to system safety, enabling the integration of system safety activities with systems engineering and risk management processes. It emphasizes how one can systematically provide the necessary evidence to substantiate the claim that a system is safe to within an acceptable risk tolerance, and that safety has been achieved in a cost-effective manner. The methodology discussed in this handbook is part of a systems engineering process and is intended to be integral to the system safety practices being conducted by the NASA safety and mission assurance and systems engineering organizations. The handbook posits that to conclude that a system is adequately safe, it is necessary to consider a set of safety claims that derive from the safety objectives of the organization. The safety claims are developed from a hierarchy of safety objectives and are therefore hierarchical themselves. Assurance that all the claims are true within acceptable risk tolerance limits implies that all of the safety objectives have been satisfied, and therefore that the system is safe. The acceptable risk tolerance limits are provided by the authority who must make the decision whether or not to proceed to the next step in the life cycle. These tolerances are therefore referred to as the decision maker's risk tolerances. In general, the safety claims address two fundamental facets of safety: 1) whether required safety thresholds or goals have been achieved, and 2) whether the safety risk is as low as possible within reasonable impacts on cost, schedule, and performance. The latter facet includes consideration of controls that are collective in nature (i.e., apply generically to broad categories of risks) and thereby provide protection against unidentified or uncharacterized risks.

Hazard Analysis and Safety Requirements for Small Drone Operations: To What Extent Do Popular Drones Embed Safety?

PubMed

Plioutsias, Anastasios; Karanikas, Nektarios; Chatzimihailidou, Maria Mikela

2018-03-01

Currently, published risk analyses for drones refer mainly to commercial systems, use data from civil aviation, and are based on probabilistic approaches without suggesting an inclusive list of hazards and respective requirements. Within this context, this article presents: (1) a set of safety requirements generated from the application of the systems theoretic process analysis (STPA) technique on a generic small drone system; (2) a gap analysis between the set of safety requirements and the ones met by 19 popular drone models; (3) the extent of the differences between those models, their manufacturers, and the countries of origin; and (4) the association of drone prices with the extent they meet the requirements derived by STPA. The application of STPA resulted in 70 safety requirements distributed across the authority, manufacturer, end user, or drone automation levels. A gap analysis showed high dissimilarities regarding the extent to which the 19 drones meet the same safety requirements. Statistical results suggested a positive correlation between drone prices and the extent that the 19 drones studied herein met the safety requirements generated by STPA, and significant differences were identified among the manufacturers. This work complements the existing risk assessment frameworks for small drones, and contributes to the establishment of a commonly endorsed international risk analysis framework. Such a framework will support the development of a holistic and methodologically justified standardization scheme for small drone flights. © 2017 Society for Risk Analysis.

A Method for Evaluating the Safety Impacts of Air Traffic Automation

NASA Technical Reports Server (NTRS)

Kostiuk, Peter; Shapiro, Gerald; Hanson, Dave; Kolitz, Stephan; Leong, Frank; Rosch, Gene; Bonesteel, Charles

1998-01-01

This report describes a methodology for analyzing the safety and operational impacts of emerging air traffic technologies. The approach integrates traditional reliability models of the system infrastructure with models that analyze the environment within which the system operates, and models of how the system responds to different scenarios. Products of the analysis include safety measures such as predicted incident rates, predicted accident statistics, and false alarm rates; and operational availability data. The report demonstrates the methodology with an analysis of the operation of the Center-TRACON Automation System at Dallas-Fort Worth International Airport.

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

NASA Technical Reports Server (NTRS)

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

2015-01-01

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

Investment appraisal using quantitative risk analysis.

PubMed

Johansson, Henrik

2002-07-01

Investment appraisal concerned with investments in fire safety systems is discussed. Particular attention is directed at evaluating, in terms of the Bayesian decision theory, the risk reduction that investment in a fire safety system involves. It is shown how the monetary value of the change from a building design without any specific fire protection system to one including such a system can be estimated by use of quantitative risk analysis, the results of which are expressed in terms of a Risk-adjusted net present value. This represents the intrinsic monetary value of investing in the fire safety system. The method suggested is exemplified by a case study performed in an Avesta Sheffield factory.

Investigation of safety analysis methods using computer vision techniques

NASA Astrophysics Data System (ADS)

Shirazi, Mohammad Shokrolah; Morris, Brendan Tran

2017-09-01

This work investigates safety analysis methods using computer vision techniques. The vision-based tracking system is developed to provide the trajectory of road users including vehicles and pedestrians. Safety analysis methods are developed to estimate time to collision (TTC) and postencroachment time (PET) that are two important safety measurements. Corresponding algorithms are presented and their advantages and drawbacks are shown through their success in capturing the conflict events in real time. The performance of the tracking system is evaluated first, and probability density estimation of TTC and PET are shown for 1-h monitoring of a Las Vegas intersection. Finally, an idea of an intersection safety map is introduced, and TTC values of two different intersections are estimated for 1 day from 8:00 a.m. to 6:00 p.m.

Assessment of documentation requirements under DOE 5481. 1, Safety Analysis and Review System (SARS)

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

Browne, E.T.

1981-03-01

This report assesses the requirements of DOE Order 5481.1, Safety Analysis and Review System for DOE Operations (SARS) in regard to maintaining SARS documentation. Under SARS, all pertinent details of the entire safety analysis and review process for each DOE operation are to be traceable from the initial identification of a hazard. This report is intended to provide assistance in identifying the points in the SARS cycle at which documentation is required, what type of documentation is most appropriate, and where it ultimately should be maintained.

Bayesian Statistics and Uncertainty Quantification for Safety Boundary Analysis in Complex Systems

NASA Technical Reports Server (NTRS)

He, Yuning; Davies, Misty Dawn

2014-01-01

The analysis of a safety-critical system often requires detailed knowledge of safe regions and their highdimensional non-linear boundaries. We present a statistical approach to iteratively detect and characterize the boundaries, which are provided as parameterized shape candidates. Using methods from uncertainty quantification and active learning, we incrementally construct a statistical model from only few simulation runs and obtain statistically sound estimates of the shape parameters for safety boundaries.

Advanced uncertainty modelling for container port risk analysis.

PubMed

Alyami, Hani; Yang, Zaili; Riahi, Ramin; Bonsall, Stephen; Wang, Jin

2016-08-13

Globalization has led to a rapid increase of container movements in seaports. Risks in seaports need to be appropriately addressed to ensure economic wealth, operational efficiency, and personnel safety. As a result, the safety performance of a Container Terminal Operational System (CTOS) plays a growing role in improving the efficiency of international trade. This paper proposes a novel method to facilitate the application of Failure Mode and Effects Analysis (FMEA) in assessing the safety performance of CTOS. The new approach is developed through incorporating a Fuzzy Rule-Based Bayesian Network (FRBN) with Evidential Reasoning (ER) in a complementary manner. The former provides a realistic and flexible method to describe input failure information for risk estimates of individual hazardous events (HEs) at the bottom level of a risk analysis hierarchy. The latter is used to aggregate HEs safety estimates collectively, allowing dynamic risk-based decision support in CTOS from a systematic perspective. The novel feature of the proposed method, compared to those in traditional port risk analysis lies in a dynamic model capable of dealing with continually changing operational conditions in ports. More importantly, a new sensitivity analysis method is developed and carried out to rank the HEs by taking into account their specific risk estimations (locally) and their Risk Influence (RI) to a port's safety system (globally). Due to its generality, the new approach can be tailored for a wide range of applications in different safety and reliability engineering and management systems, particularly when real time risk ranking is required to measure, predict, and improve the associated system safety performance. Copyright © 2016 Elsevier Ltd. All rights reserved.

A Taxonomy of Fallacies in System Safety Arguments

NASA Technical Reports Server (NTRS)

Greenwell, William S.; Knight, John C.; Holloway, C. Michael; Pease, Jacob J.

2006-01-01

Safety cases are gaining acceptance as assurance vehicles for safety-related systems. A safety case documents the evidence and argument that a system is safe to operate; however, logical fallacies in the underlying argument may undermine a system s safety claims. Removing these fallacies is essential to reduce the risk of safety-related system failure. We present a taxonomy of common fallacies in safety arguments that is intended to assist safety professionals in avoiding and detecting fallacious reasoning in the arguments they develop and review. The taxonomy derives from a survey of general argument fallacies and a separate survey of fallacies in real-world safety arguments. Our taxonomy is specific to safety argumentation, and it is targeted at professionals who work with safety arguments but may lack formal training in logic or argumentation. We discuss the rationale for the selection and categorization of fallacies in the taxonomy. In addition to its applications to the development and review of safety cases, our taxonomy could also support the analysis of system failures and promote the development of more robust safety case patterns.

Infusing Reliability Techniques into Software Safety Analysis

NASA Technical Reports Server (NTRS)

Shi, Ying

2015-01-01

Software safety analysis for a large software intensive system is always a challenge. Software safety practitioners need to ensure that software related hazards are completely identified, controlled, and tracked. This paper discusses in detail how to incorporate the traditional reliability techniques into the entire software safety analysis process. In addition, this paper addresses how information can be effectively shared between the various practitioners involved in the software safety analyses. The author has successfully applied the approach to several aerospace applications. Examples are provided to illustrate the key steps of the proposed approach.

Safer Systems: A NextGen Aviation Safety Strategic Goal

NASA Technical Reports Server (NTRS)

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

2008-01-01

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

Research on public participant urban infrastructure safety monitoring system using smartphone

NASA Astrophysics Data System (ADS)

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

2017-04-01

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

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

NASA Technical Reports Server (NTRS)

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

1978-01-01

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

Medical students' perceptions of a novel institutional incident reporting system : A thematic analysis.

PubMed

Gordon, Morris; Parakh, Dillan

2017-10-01

Errors in healthcare are a major patient safety issue, with incident reporting a key solution. The incident reporting system has been integrated within a new medical curriculum, encouraging medical students to take part in this key safety process. The aim of this study was to describe the system and assess how students perceived the reporting system with regards to its role in enhancing safety. Employing a thematic analysis, this study used interviews with medical students at the end of the first year. Thematic indices were developed according to the information emerging from the data. Through open, axial and then selective stages of coding, an understanding of how the system was perceived was established. Analysis of the interview specified five core themes: (1) Aims of the incident reporting system; (2) internalized cognition of the system; (3) the impact of the reporting system; (4) threshold for reporting; (5) feedback on the systems operation. Selective analysis revealed three overriding findings: lack of error awareness and error wisdom as underpinned by key theoretical constructs, student support of the principle of safety, and perceptions of a blame culture. Students did not interpret reporting as a manner to support institutional learning and safety, rather many perceived it as a tool for a blame culture. The impact reporting had on students was unexpected and may give insight into how other undergraduates and early graduates interpret such a system. Future studies should aim to produce interventions that can support a reporting culture.

41 CFR 102-80.110 - What must an equivalent level of safety analysis indicate?

Code of Federal Regulations, 2014 CFR

2014-01-01

..., and reliability of all building systems impacting fire growth, occupant knowledge of the fire, and... Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION REAL PROPERTY 80-SAFETY AND ENVIRONMENTAL MANAGEMENT Accident and Fire Prevention Equivalent Level of Safety...

41 CFR 102-80.110 - What must an equivalent level of safety analysis indicate?

Code of Federal Regulations, 2013 CFR

2013-07-01

..., and reliability of all building systems impacting fire growth, occupant knowledge of the fire, and... Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION REAL PROPERTY 80-SAFETY AND ENVIRONMENTAL MANAGEMENT Accident and Fire Prevention Equivalent Level of Safety...

41 CFR 102-80.110 - What must an equivalent level of safety analysis indicate?

Code of Federal Regulations, 2011 CFR

2011-01-01

..., and reliability of all building systems impacting fire growth, occupant knowledge of the fire, and... Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION REAL PROPERTY 80-SAFETY AND ENVIRONMENTAL MANAGEMENT Accident and Fire Prevention Equivalent Level of Safety...

41 CFR 102-80.110 - What must an equivalent level of safety analysis indicate?

Code of Federal Regulations, 2012 CFR

2012-01-01

..., and reliability of all building systems impacting fire growth, occupant knowledge of the fire, and... Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION REAL PROPERTY 80-SAFETY AND ENVIRONMENTAL MANAGEMENT Accident and Fire Prevention Equivalent Level of Safety...

Development of the FHR advanced natural circulation analysis code and application to FHR safety analysis

DOE PAGES

Guo, Z.; Zweibaum, N.; Shao, M.; ...

2016-04-19

The University of California, Berkeley (UCB) is performing thermal hydraulics safety analysis to develop the technical basis for design and licensing of fluoride-salt-cooled, high-temperature reactors (FHRs). FHR designs investigated by UCB use natural circulation for emergency, passive decay heat removal when normal decay heat removal systems fail. The FHR advanced natural circulation analysis (FANCY) code has been developed for assessment of passive decay heat removal capability and safety analysis of these innovative system designs. The FANCY code uses a one-dimensional, semi-implicit scheme to solve for pressure-linked mass, momentum and energy conservation equations. Graph theory is used to automatically generate amore » staggered mesh for complicated pipe network systems. Heat structure models have been implemented for three types of boundary conditions (Dirichlet, Neumann and Robin boundary conditions). Heat structures can be composed of several layers of different materials, and are used for simulation of heat structure temperature distribution and heat transfer rate. Control models are used to simulate sequences of events or trips of safety systems. A proportional-integral controller is also used to automatically make thermal hydraulic systems reach desired steady state conditions. A point kinetics model is used to model reactor kinetics behavior with temperature reactivity feedback. The underlying large sparse linear systems in these models are efficiently solved by using direct and iterative solvers provided by the SuperLU code on high performance machines. Input interfaces are designed to increase the flexibility of simulation for complicated thermal hydraulic systems. In conclusion, this paper mainly focuses on the methodology used to develop the FANCY code, and safety analysis of the Mark 1 pebble-bed FHR under development at UCB is performed.« less

Safety Guided Design of Crew Return Vehicle in Concept Design Phase Using STAMP/STPA

NASA Astrophysics Data System (ADS)

Nakao, H.; Katahira, M.; Miyamoto, Y.; Leveson, N.

2012-01-01

In the concept development and design phase of a new space system, such as a Crew Vehicle, designers tend to focus on how to implement new technology. Designers also consider the difficulty of using the new technology and trade off several system design candidates. Then they choose an optimal design from the candidates. Safety should be a key aspect driving optimal concept design. However, in past concept design activities, safety analysis such as FTA has not used to drive the design because such analysis techniques focus on component failure and component failure cannot be considered in the concept design phase. The solution to these problems is to apply a new hazard analysis technique, called STAMP/STPA. STAMP/STPA defines safety as a control problem rather than a failure problem and identifies hazardous scenarios and their causes. Defining control flow is the essential in concept design phase. Therefore STAMP/STPA could be a useful tool to assess the safety of system candidates and to be part of the rationale for choosing a design as the baseline of the system. In this paper, we explain our case study of safety guided concept design using STPA, the new hazard analysis technique, and model-based specification technique on Crew Return Vehicle design and evaluate benefits of using STAMP/STPA in concept development phase.

Reliability Modeling Methodology for Independent Approaches on Parallel Runways Safety Analysis

NASA Technical Reports Server (NTRS)

Babcock, P.; Schor, A.; Rosch, G.

1998-01-01

This document is an adjunct to the final report An Integrated Safety Analysis Methodology for Emerging Air Transport Technologies. That report presents the results of our analysis of the problem of simultaneous but independent, approaches of two aircraft on parallel runways (independent approaches on parallel runways, or IAPR). This introductory chapter presents a brief overview and perspective of approaches and methodologies for performing safety analyses for complex systems. Ensuing chapter provide the technical details that underlie the approach that we have taken in performing the safety analysis for the IAPR concept.

Timing of Formal Phase Safety Reviews for Large-Scale Integrated Hazard Analysis

NASA Technical Reports Server (NTRS)

Massie, Michael J.; Morris, A. Terry

2010-01-01

Integrated hazard analysis (IHA) is a process used to identify and control unacceptable risk. As such, it does not occur in a vacuum. IHA approaches must be tailored to fit the system being analyzed. Physical, resource, organizational and temporal constraints on large-scale integrated systems impose additional direct or derived requirements on the IHA. The timing and interaction between engineering and safety organizations can provide either benefits or hindrances to the overall end product. The traditional approach for formal phase safety review timing and content, which generally works well for small- to moderate-scale systems, does not work well for very large-scale integrated systems. This paper proposes a modified approach to timing and content of formal phase safety reviews for IHA. Details of the tailoring process for IHA will describe how to avoid temporary disconnects in major milestone reviews and how to maintain a cohesive end-to-end integration story particularly for systems where the integrator inherently has little to no insight into lower level systems. The proposal has the advantage of allowing the hazard analysis development process to occur as technical data normally matures.

Technology Overview for Advanced Aircraft Armament System Program.

DTIC Science & Technology

1981-05-01

availability of methods or systems for improving stores and armament safety. Of particular importance are aspects of safety involving hazards analysis ...flutter virtually insensitive to inertia and center-of- gravity location of store - Simplifies and reduces analysis and testing required to flutter- clear...status. Nearly every existing reliability analysis and discipline that prom- ised a positive return on reliability performance was drawn out, dusted

10 CFR 52.157 - Contents of applications; technical information in final safety analysis report.

Code of Federal Regulations, 2010 CFR

2010-01-01

... analysis of the structures, systems, and components of the reactor to be manufactured, with emphasis upon... assumed for this evaluation should be based upon a major accident, hypothesized for purposes of site... structures, systems, and components with the objective of assessing the risk to public health and safety...

More than meets the eye: Using cognitive work analysis to identify design requirements for future rail level crossing systems.

PubMed

Salmon, Paul M; Lenné, Michael G; Read, Gemma J M; Mulvihill, Christine M; Cornelissen, Miranda; Walker, Guy H; Young, Kristie L; Stevens, Nicholas; Stanton, Neville A

2016-03-01

An increasing intensity of operations means that the longstanding safety issue of rail level crossings is likely to become worse in the transport systems of the future. It has been suggested that the failure to prevent collisions may be, in part, due to a lack of systems thinking during design, crash analysis, and countermeasure development. This paper presents a systems analysis of current active rail level crossing systems in Victoria, Australia that was undertaken to identify design requirements to improve safety in future rail level crossing environments. Cognitive work analysis was used to analyse rail level crossing systems using data derived from a range of activities. Overall the analysis identified a range of instances where modification or redesign in line with systems thinking could potentially improve behaviour and safety. A notable finding is that there are opportunities for redesign outside of the physical rail level crossing infrastructure, including improved data systems, in-vehicle warnings and modifications to design processes, standards and guidelines. The implications for future rail level crossing systems are discussed. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Quantifying and Addressing the DOE Material Reactivity Requirements with Analysis and Testing of Hydrogen Storage Materials & Systems

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

Khalil, Y. F.

2012-04-30

The objective of this project is to examine safety aspects of candidate hydrogen storage materials and systems being developed in the DOE Hydrogen Program. As a result of this effort, the general DOE safety target will be given useful meaning by establishing a link between the characteristics of new storage materials and the satisfaction of safety criteria. This will be accomplished through the development and application of formal risk analysis methods, standardized materials testing, chemical reactivity characterization, novel risk mitigation approaches and subscale system demonstration. The project also will collaborate with other DOE and international activities in materials based hydrogenmore » storage safety to provide a larger, highly coordinated effort.« less

Safety Guided Design Based on Stamp/STPA for Manned Vehicle in Concept Design Phase

NASA Astrophysics Data System (ADS)

Ujiie, Ryo; Katahira, Masafumi; Miyamoto, Yuko; Umeda, Hiroki; Leveson, Nancy; Hoshino, Nobuyuki

2013-09-01

In manned vehicles, such as the Soyuz and the Space Shuttle, the crew and computer system cooperate to succeed in returning to the earth. While computers increase the functionality of system, they also increase the complexity of the interaction between the controllers (human and computer) and the target dynamics. In some cases, the complexity can produce a serious accident. To prevent such losses, traditional hazard analysis such as FTA has been applied to system development, however it can be used after creating a detailed system because it focuses on detailed component failures. As a result, it's more difficult to eliminate hazard cause early in the process when it is most feasible.STAMP/STPA is a new hazard analysis that can be applied from the early development phase, with the analysis being refined as more detailed decisions are made. In essence, the analysis and design decisions are intertwined and go hand-in-hand. We have applied STAMP/STPA to a concept design of a new JAXA manned vehicle and tried safety guided design of the vehicle. As a result of this trial, it has been shown that STAMP/STPA can be accepted easily by system engineers and the design has been made more sophisticated from a safety viewpoint. The result also shows that the consequences of human errors on system safety can be analysed in the early development phase and the system designed to prevent them. Finally, the paper will discuss an effective way to harmonize this safety guided design approach with system engineering process based on the result of this experience in this project.

Automating the Generation of Heterogeneous Aviation Safety Cases

NASA Technical Reports Server (NTRS)

Denney, Ewen W.; Pai, Ganesh J.; Pohl, Josef M.

2012-01-01

A safety case is a structured argument, supported by a body of evidence, which provides a convincing and valid justification that a system is acceptably safe for a given application in a given operating environment. This report describes the development of a fragment of a preliminary safety case for the Swift Unmanned Aircraft System. The construction of the safety case fragment consists of two parts: a manually constructed system-level case, and an automatically constructed lower-level case, generated from formal proof of safety-relevant correctness properties. We provide a detailed discussion of the safety considerations for the target system, emphasizing the heterogeneity of sources of safety-relevant information, and use a hazard analysis to derive safety requirements, including formal requirements. We evaluate the safety case using three classes of metrics for measuring degrees of coverage, automation, and understandability. We then present our preliminary conclusions and make suggestions for future work.

Rail Safety/Equipment Crashworthiness : Volume 1. A Systems Analysis of Injury Minimization in Rail Systems

DOT National Transportation Integrated Search

1978-07-01

The Department of Transportation, Transportation Systems Center (TSC), is providing technical assistance to the Federal Railroad Administration (FRA) in a program to improve railroad safety and efficiency by providing a technological basis for improv...

Manned space flight nuclear system safety. Volume 3: Reactor system preliminary nuclear safety analysis. Part 3: Nuclear Safety Analysis Document (NSAD)

NASA Technical Reports Server (NTRS)

1972-01-01

Nuclear safety analysis as applied to a space base mission is presented. The nuclear safety analysis document summarizes the mission and the credible accidents/events which may lead to nuclear hazards to the general public. The radiological effects and associated consequences of the hazards are discussed in detail. The probability of occurrence is combined with the potential number of individuals exposed to or above guideline values to provide a measure of accident and total mission risk. The overall mission risk has been determined to be low with the potential exposure to or above 25 rem limited to less than 4 individuals per every 1000 missions performed. No radiological risk to the general public occurs during the prelaunch phase at KSC. The most significant risks occur from prolonged exposure to reactor debris following land impact generally associated with the disposal phase of the mission where fission product inventories can be high.

Probabilistic assessment of dynamic system performance. Part 3

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

Belhadj, Mohamed

1993-01-01

Accurate prediction of dynamic system failure behavior can be important for the reliability and risk analyses of nuclear power plants, as well as for their backfitting to satisfy given constraints on overall system reliability, or optimization of system performance. Global analysis of dynamic systems through investigating the variations in the structure of the attractors of the system and the domains of attraction of these attractors as a function of the system parameters is also important for nuclear technology in order to understand the fault-tolerance as well as the safety margins of the system under consideration and to insure a safemore » operation of nuclear reactors. Such a global analysis would be particularly relevant to future reactors with inherent or passive safety features that are expected to rely on natural phenomena rather than active components to achieve and maintain safe shutdown. Conventionally, failure and global analysis of dynamic systems necessitate the utilization of different methodologies which have computational limitations on the system size that can be handled. Using a Chapman-Kolmogorov interpretation of system dynamics, a theoretical basis is developed that unifies these methodologies as special cases and which can be used for a comprehensive safety and reliability analysis of dynamic systems.« less

Ergonomics, safety, and resilience in the helicopter offshore transportation system of Campos Basin.

PubMed

Gomes, José Orlando; Huber, Gilbert J; Borges, Marcos R S; de Carvalho, Paulo Victor R

2015-01-01

Air transportation of personnel to offshore oil platforms is one of the major hazards of this kind of endeavor. Pilot performance is a key factor in the safety of the transportation system. This study seeks to identify the ergonomic factors present in pilots' activities that may in some way compromise or enhance their performance, the constraints and affordances which they are subject to; and where possible to link these to their associated risk factors. Methodology adopted in this project studies work in its context. It is a merging of Activity Analysis (Guerin et al. 2001) of European tradition with Cognitive Task Analysis (CTA - www.ctaresource.com) articulated with the recent approaches to cognitive systems engineering developed by Professors David Woods and Erik Hollnagel. Fifty-five hours of field interviews provided the input for analysis. Sixteen ergonomic constraints were identified, some cognitive, some physical, all considered relevant by the research subjects and expert advisers. Although the safety record of the personnel transportation system studied is considered acceptable, there is low hanging fruit to be picked which can help improve the system's safety.

SCAP: a new methodology for safety management based on feedback from credible accident-probabilistic fault tree analysis system.

PubMed

Khan, F I; Iqbal, A; Ramesh, N; Abbasi, S A

2001-10-12

As it is conventionally done, strategies for incorporating accident--prevention measures in any hazardous chemical process industry are developed on the basis of input from risk assessment. However, the two steps-- risk assessment and hazard reduction (or safety) measures--are not linked interactively in the existing methodologies. This prevents a quantitative assessment of the impacts of safety measures on risk control. We have made an attempt to develop a methodology in which risk assessment steps are interactively linked with implementation of safety measures. The resultant system tells us the extent of reduction of risk by each successive safety measure. It also tells based on sophisticated maximum credible accident analysis (MCAA) and probabilistic fault tree analysis (PFTA) whether a given unit can ever be made 'safe'. The application of the methodology has been illustrated with a case study.

Topics on Test Methods for Space Systems and Operations Safety: Applicability of Experimental Data

NASA Technical Reports Server (NTRS)

Hirsch, David B.

2009-01-01

This viewgraph presentation reviews topics on test methods for space systems and operations safety through experimentation and analysis. The contents include: 1) Perception of reality through experimentation and analysis; 2) Measurements, methods, and correlations with real life; and 3) Correlating laboratory aerospace materials flammability data with data in spacecraft environments.

Reliability/safety analysis of a fly-by-wire system

NASA Technical Reports Server (NTRS)

Brock, L. D.; Goddman, H. A.

1980-01-01

An analysis technique has been developed to estimate the reliability of a very complex, safety-critical system by constructing a diagram of the reliability equations for the total system. This diagram has many of the characteristics of a fault-tree or success-path diagram, but is much easier to construct for complex redundant systems. The diagram provides insight into system failure characteristics and identifies the most likely failure modes. A computer program aids in the construction of the diagram and the computation of reliability. Analysis of the NASA F-8 Digital Fly-by-Wire Flight Control System is used to illustrate the technique.

Safety impact of an integrated crash warning system based on field test data.

DOT National Transportation Integrated Search

2011-06-13

This paper provides the results of an analysis : conducted to assess the safety impact of an integrated : vehicle-based crash warning system based on : naturalistic driving data collected from a field : operational test. The system incorporates four ...

A Study on Urban Road Traffic Safety Based on Matter Element Analysis

PubMed Central

Hu, Qizhou; Zhou, Zhuping; Sun, Xu

2014-01-01

This paper examines a new evaluation of urban road traffic safety based on a matter element analysis, avoiding the difficulties found in other traffic safety evaluations. The issue of urban road traffic safety has been investigated through the matter element analysis theory. The chief aim of the present work is to investigate the features of urban road traffic safety. Emphasis was placed on the construction of a criterion function by which traffic safety achieved a hierarchical system of objectives to be evaluated. The matter element analysis theory was used to create the comprehensive appraisal model of urban road traffic safety. The technique was used to employ a newly developed and versatile matter element analysis algorithm. The matter element matrix solves the uncertainty and incompatibility of the evaluated factors used to assess urban road traffic safety. The application results showed the superiority of the evaluation model and a didactic example was included to illustrate the computational procedure. PMID:25587267

10 CFR 63.112 - Requirements for preclosure safety analysis of the geologic repository operations area.

Code of Federal Regulations, 2014 CFR

2014-01-01

... emergency power to instruments, utility service systems, and operating systems important to safety if there... include: (a) A general description of the structures, systems, components, equipment, and process... of the performance of the structures, systems, and components to identify those that are important to...

10 CFR 63.112 - Requirements for preclosure safety analysis of the geologic repository operations area.

Code of Federal Regulations, 2013 CFR

2013-01-01

... emergency power to instruments, utility service systems, and operating systems important to safety if there... include: (a) A general description of the structures, systems, components, equipment, and process... of the performance of the structures, systems, and components to identify those that are important to...

10 CFR 63.112 - Requirements for preclosure safety analysis of the geologic repository operations area.

Code of Federal Regulations, 2012 CFR

2012-01-01

... emergency power to instruments, utility service systems, and operating systems important to safety if there... include: (a) A general description of the structures, systems, components, equipment, and process... of the performance of the structures, systems, and components to identify those that are important to...

10 CFR 63.112 - Requirements for preclosure safety analysis of the geologic repository operations area.

Code of Federal Regulations, 2011 CFR

2011-01-01

... emergency power to instruments, utility service systems, and operating systems important to safety if there... include: (a) A general description of the structures, systems, components, equipment, and process... of the performance of the structures, systems, and components to identify those that are important to...

Making safety an integral part of 5S in healthcare.

PubMed

Ikuma, Laura H; Nahmens, Isabelina

2014-01-01

Healthcare faces major challenges with provider safety and rising costs, and many organizations are using Lean to instigate change. One Lean tool, 5S, is becoming popular for improving efficiency of physical work environments, and it can also improve safety. This paper demonstrates that safety is an integral part of 5S by examining five specific 5S events in acute care facilities. We provide two arguments for how safety is linked to 5S:1. Safety is affected by 5S events, regardless of whether safety is a specific goal and 2. Safety can and should permeate all five S's as part of a comprehensive plan for system improvement. Reports of 5S events from five departments in one health system were used to evaluate how changes made at each step of the 5S impacted safety. Safety was affected positively in each step of the 5S through initial safety goals and side effects of other changes. The case studies show that 5S can be a mechanism for improving safety. Practitioners may reap additional safety benefits by incorporating safety into 5S events through a safety analysis before the 5S, safety goals and considerations during the 5S, and follow-up safety analysis.

Automated Pedestrian Detection, Count and Analysis System

DOT National Transportation Integrated Search

2015-04-15

Pedestrian and bicycle count data is necessary for transportation planning, implementing safety countermeasures, and traffic management. This data is critical when evaluating the pedestrian level of service of safety (LOSS) and pedestrian safety perf...

14 CFR Appendix A to Part 417 - Flight Safety Analysis Methodologies and Products for a Launch Vehicle Flown With a Flight Safety...

Code of Federal Regulations, 2013 CFR

2013-01-01

... approach provides an equivalent level of safety. If a Federal launch range performs the launch operator's... FAA will measure any proposed alternative analysis approach. This appendix also identifies the... control systems; (ix) Steering misalignment; and (x) Winds. (2) Each three-sigma trajectory must account...

14 CFR Appendix A to Part 417 - Flight Safety Analysis Methodologies and Products for a Launch Vehicle Flown With a Flight Safety...

Code of Federal Regulations, 2012 CFR

2012-01-01

... approach provides an equivalent level of safety. If a Federal launch range performs the launch operator's... FAA will measure any proposed alternative analysis approach. This appendix also identifies the... control systems; (ix) Steering misalignment; and (x) Winds. (2) Each three-sigma trajectory must account...

14 CFR Appendix A to Part 417 - Flight Safety Analysis Methodologies and Products for a Launch Vehicle Flown With a Flight Safety...

Code of Federal Regulations, 2010 CFR

2010-01-01

... approach provides an equivalent level of safety. If a Federal launch range performs the launch operator's... FAA will measure any proposed alternative analysis approach. This appendix also identifies the... control systems; (ix) Steering misalignment; and (x) Winds. (2) Each three-sigma trajectory must account...

14 CFR Appendix A to Part 417 - Flight Safety Analysis Methodologies and Products for a Launch Vehicle Flown With a Flight Safety...

Code of Federal Regulations, 2014 CFR

2014-01-01

... approach provides an equivalent level of safety. If a Federal launch range performs the launch operator's... FAA will measure any proposed alternative analysis approach. This appendix also identifies the... control systems; (ix) Steering misalignment; and (x) Winds. (2) Each three-sigma trajectory must account...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2012 CFR

2012-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2010 CFR

2010-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2013 CFR

2013-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2014 CFR

2014-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

14 CFR 417.309 - Flight safety system analysis.

Code of Federal Regulations, 2011 CFR

2011-01-01

... system anomaly occurring and all of its effects as determined by the single failure point analysis and... termination system. (c) Single failure point. A command control system must undergo an analysis that... fault tree analysis or a failure modes effects and criticality analysis; (2) Identify all possible...

COLD-SAT feasibility study safety analysis

NASA Technical Reports Server (NTRS)

Mchenry, Steven T.; Yost, James M.

1991-01-01

The Cryogenic On-orbit Liquid Depot-Storage, Acquisition, and Transfer (COLD-SAT) satellite presents some unique safety issues. The feasibility study conducted at NASA-Lewis desired a systems safety program that would be involved from the initial design in order to eliminate and/or control the inherent hazards. Because of this, a hazards analysis method was needed that: (1) identified issues that needed to be addressed for a feasibility assessment; and (2) identified all potential hazards that would need to be controlled and/or eliminated during the detailed design phases. The developed analysis method is presented as well as the results generated for the COLD-SAT system.

Local Food Systems Food Safety Concerns.

PubMed

Chapman, Benjamin; Gunter, Chris

2018-04-01

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

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

PubMed

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

2017-06-01

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

Human performance cognitive-behavioral modeling: a benefit for occupational safety.

PubMed

Gore, Brian F

2002-01-01

Human Performance Modeling (HPM) is a computer-aided job analysis software methodology used to generate predictions of complex human-automation integration and system flow patterns with the goal of improving operator and system safety. The use of HPM tools has recently been increasing due to reductions in computational cost, augmentations in the tools' fidelity, and usefulness in the generated output. An examination of an Air Man-machine Integration Design and Analysis System (Air MIDAS) model evaluating complex human-automation integration currently underway at NASA Ames Research Center will highlight the importance to occupational safety of considering both cognitive and physical aspects of performance when researching human error.

Human performance cognitive-behavioral modeling: a benefit for occupational safety

NASA Technical Reports Server (NTRS)

Gore, Brian F.

2002-01-01

Human Performance Modeling (HPM) is a computer-aided job analysis software methodology used to generate predictions of complex human-automation integration and system flow patterns with the goal of improving operator and system safety. The use of HPM tools has recently been increasing due to reductions in computational cost, augmentations in the tools' fidelity, and usefulness in the generated output. An examination of an Air Man-machine Integration Design and Analysis System (Air MIDAS) model evaluating complex human-automation integration currently underway at NASA Ames Research Center will highlight the importance to occupational safety of considering both cognitive and physical aspects of performance when researching human error.

On Building an Ontological Knowledge Base for Managing Patient Safety Events.

PubMed

Liang, Chen; Gong, Yang

2015-01-01

Over the past decade, improving healthcare quality and safety through patient safety event reporting systems has drawn much attention. Unfortunately, such systems are suffering from low data quality, inefficient data entry and ineffective information retrieval. For improving the systems, we develop a semantic web ontology based on the WHO International Classification for Patient Safety (ICPS) and AHRQ Common Formats for patient safety event reporting. The ontology holds potential in enhancing knowledge management and information retrieval, as well as providing flexible data entry and case analysis for both reporters and reviewers of patient safety events. In this paper, we detailed our efforts in data acquisition, transformation, implementation and initial evaluation of the ontology.

Safety management as a foundation for evidence-based aeromedical standards and reporting of medical events.

PubMed

Evans, Anthony D; Watson, Dougal B; Evans, Sally A; Hastings, John; Singh, Jarnail; Thibeault, Claude

2009-06-01

The different interpretations by States (countries) of the aeromedical standards established by the International Civil Aviation Organization has resulted in a variety of approaches to the development of national aeromedical policy, and consequently a relative lack of harmonization. However, in many areas of aviation, safety management systems have been recently introduced and may represent a way forward. A safety management system can be defined as "A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies, and procedures" (1). There are four main areas where, by applying safety management principles, it may be possible to better use aeromedical data to enhance flight safety. These are: 1) adjustment of the periodicity and content of routine medical examinations to more accurately reflect aeromedical risk; 2) improvement in reporting and analysis of routine medical examination data; 3) improvement in reporting and analysis of in-flight medical events; and 4) support for improved reporting of relevant aeromedical events through the promotion of an appropriate culture by companies and regulatory authorities. This paper explores how the principles of safety management may be applied to aeromedical systems to improve their contribution to safety.

Safety Management Information Statistics (SAMIS) - 1991 Annual Report

DOT National Transportation Integrated Search

1993-02-01

The Safety Management Information Statistics 1991 Annual Report is a compilation and analysis of mass transit accident and casualty statistics reported by transit systems in the United States during 1991, under FTA's Section 15 reporting system.

Estimation of potential safety benefits for pedestrian crash avoidance/mitigation systems.

DOT National Transportation Integrated Search

2017-04-01

This report presents and exercises a methodology to estimate the effectiveness and potential safety benefits of production pedestrian crash avoidance/mitigation systems. The analysis focuses on light vehicles moving forward and striking a pedestrian ...

Safety and fitness electronic records (SAFER) system : logical architecture document : working draft

DOT National Transportation Integrated Search

1997-01-31

This Logical Architecture Document includes the products developed during the functional analysis of the Safety and Fitness Electronic Records (SAFER) System. This document, along with the companion Operational Concept and Physical Architecture Docum...

Efficacy and safety of biologic therapies for systemic lupus erythematosus treatment: systematic review and meta-analysis.

PubMed

Borba, Helena Hiemisch Lobo; Wiens, Astrid; de Souza, Thais Teles; Correr, Cassyano Januário; Pontarolo, Roberto

2014-04-01

The objectives of this study were to evaluate the efficacy, safety, and tolerability of biologic drugs compared with placebo for systemic lupus erythematosus (SLE) treatment. A systematic review evaluating the efficacy and safety of biologic therapies compared with placebo in adult SLE patients treatment was performed. Data from studies performed before September 2013 were collected from several databases (MEDLINE, Cochrane Library, SCIELO, Scopus, and International Pharmaceutical Abstracts). Study eligibility criteria included randomized, double-blind, placebo-controlled trials; regarding treatment with biologic agents in SLE adult patients; and published in English, German, Portuguese, and Spanish. Extracted data were statistically analyzed in a meta-analysis using the Review Manager (RevMan) 5.1 software. Efficacy outcomes included the SELENA-SLEDAI (Safety of Estrogens in Lupus Erythematosus National Assessment version of the SLE Disease Activity Index) score, the SRI (Systemic Lupus Erythematosus Responder Index), normalization of low C3 (<90 mg/dL), anti-double-stranded DNA positive to negative, and no new BILAG (British Isles Lupus Assessment Group index) 1A or 2B flares. Data on safety profile included adverse events, serious and severe adverse events, death, malignancy, infections, and infusion reactions. We also evaluated withdrawals from treatment due to lack of efficacy or adverse events. Thirteen randomized placebo-controlled trials met the criteria for data extraction for systematic review. A meta-analysis regarding the efficacy and safety of belimumab compared with placebo involving four of these trials was undertaken and the remainder contributed to a meta-analysis of the safety of biologic agents. In addition, two trials allowed the performance of a meta-analysis regarding the efficacy and safety of rituximab compared with placebo. Belimumab was more effective than placebo in most evaluated outcomes. No significant differences in the safety and tolerability data were observed between the belimumab and placebo groups. No differences were observed between the rituximab and placebo groups for the efficacy outcomes or safety parameters. Extracted data from the 13 studies were pooled, allowing assessment of the safety of biologic drugs. The meta-analysis revealed a satisfactory safety profile of these agents when used for SLE treatment, as there were no significant differences between the two evaluated groups (biologic agents and placebo) for all outcomes analyzed. Belimumab exhibited a satisfactory profile regarding efficacy, safety, and tolerability. Rituximab showed no superiority over placebo in terms of efficacy, despite its suitable safety profile. Biologic agents exhibited a good safety profile for SLE treatment, indicating that these agents are promising therapies and should be further investigated.

Loss of Coolant Accident (LOCA) / Emergency Core Coolant System (ECCS Evaluation of Risk-Informed Margins Management Strategies for a Representative Pressurized Water Reactor (PWR)

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

Szilard, Ronaldo Henriques

A Risk Informed Safety Margin Characterization (RISMC) toolkit and methodology are proposed for investigating nuclear power plant core, fuels design and safety analysis, including postulated Loss-of-Coolant Accident (LOCA) analysis. This toolkit, under an integrated evaluation model framework, is name LOCA toolkit for the US (LOTUS). This demonstration includes coupled analysis of core design, fuel design, thermal hydraulics and systems analysis, using advanced risk analysis tools and methods to investigate a wide range of results.

Systemic Analysis Approaches for Air Transportation

NASA Technical Reports Server (NTRS)

Conway, Sheila

2005-01-01

Air transportation system designers have had only limited success using traditional operations research and parametric modeling approaches in their analyses of innovations. They need a systemic methodology for modeling of safety-critical infrastructure that is comprehensive, objective, and sufficiently concrete, yet simple enough to be used with reasonable investment. The methodology must also be amenable to quantitative analysis so issues of system safety and stability can be rigorously addressed. However, air transportation has proven itself an extensive, complex system whose behavior is difficult to describe, no less predict. There is a wide range of system analysis techniques available, but some are more appropriate for certain applications than others. Specifically in the area of complex system analysis, the literature suggests that both agent-based models and network analysis techniques may be useful. This paper discusses the theoretical basis for each approach in these applications, and explores their historic and potential further use for air transportation analysis.

75 FR 52587 - 2009 Fatality Analysis Reporting System (FARS)/National Automotive Sampling System General...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-26

... DEPARTMENT OF TRANSPORTATION National Highway Traffic Safety Administration [U.S. DOT Docket Number NHTSA-2010-0122] 2009 Fatality Analysis Reporting System (FARS)/National Automotive Sampling... Administration (NHTSA)--2009 Fatality Analysis Reporting System (FARS) & National Automotive Sampling System...

Assessment of Primary Production of Horticultural Safety Management Systems of Mushroom Farms in South Africa.

PubMed

Dzingirayi, Garikayi; Korsten, Lise

2016-07-01

Growing global consumer concern over food safety in the fresh produce industry requires producers to implement necessary quality assurance systems. Varying effectiveness has been noted in how countries and food companies interpret and implement food safety standards. A diagnostic instrument (DI) for global fresh produce industries was developed to measure the compliancy of companies with implemented food safety standards. The DI is made up of indicators and descriptive grids for context factors and control and assurance activities to measure food safety output. The instrument can be used in primary production to assess food safety performance. This study applied the DI to measure food safety standard compliancy of mushroom farming in South Africa. Ten farms representing almost half of the industry farms and more than 80% of production were independently assessed for their horticultural safety management system (HSMS) compliance via in-depth interviews with each farm's quality assurance personnel. The data were processed using Microsoft Office Excel 2010 and are represented in frequency tables. The diagnosis revealed that the mushroom farming industry had an average food safety output. The farms were implementing an average-toadvanced HSMS and operating in a medium-risk context. Insufficient performance areas in HSMSs included inadequate hazard analysis and analysis of control points, low specificity of pesticide assessment, and inadequate control of suppliers and incoming materials. Recommendations to the industry and current shortcomings are suggested for realization of an improved industry-wide food safety assurance system.

Random safety auditing, root cause analysis, failure mode and effects analysis.

PubMed

Ursprung, Robert; Gray, James

2010-03-01

Improving quality and safety in health care is a major concern for health care providers, the general public, and policy makers. Errors and quality issues are leading causes of morbidity and mortality across the health care industry. There is evidence that patients in the neonatal intensive care unit (NICU) are at high risk for serious medical errors. To facilitate compliance with safe practices, many institutions have established quality-assurance monitoring procedures. Three techniques that have been found useful in the health care setting are failure mode and effects analysis, root cause analysis, and random safety auditing. When used together, these techniques are effective tools for system analysis and redesign focused on providing safe delivery of care in the complex NICU system. Copyright 2010 Elsevier Inc. All rights reserved.

Traffic safety data : state data system quality varies and limited resources and coordination can inhibit further progress

DOT National Transportation Integrated Search

2010-04-01

GAOs analysis of traffic records assessmentsconducted for states by NHTSA technical teams or contractors at least every 5 yearsindicates that the quality of state traffic safety data systems varies across the six data systems maintained by s...

14 CFR 417.307 - Support systems.

Code of Federal Regulations, 2014 CFR

2014-01-01

... subsystem, component, and part that can affect the reliability of the support system must have written...) Data processing, display, and recording. A flight safety system must include one or more subsystems... accordance with the flight safety analysis required by subpart C of this part; (5) Display and record raw...

14 CFR 417.307 - Support systems.

Code of Federal Regulations, 2012 CFR

2012-01-01

... subsystem, component, and part that can affect the reliability of the support system must have written...) Data processing, display, and recording. A flight safety system must include one or more subsystems... accordance with the flight safety analysis required by subpart C of this part; (5) Display and record raw...

14 CFR 417.307 - Support systems.

Code of Federal Regulations, 2011 CFR

2011-01-01

... subsystem, component, and part that can affect the reliability of the support system must have written...) Data processing, display, and recording. A flight safety system must include one or more subsystems... accordance with the flight safety analysis required by subpart C of this part; (5) Display and record raw...

14 CFR 417.307 - Support systems.

Code of Federal Regulations, 2013 CFR

2013-01-01

... subsystem, component, and part that can affect the reliability of the support system must have written...) Data processing, display, and recording. A flight safety system must include one or more subsystems... accordance with the flight safety analysis required by subpart C of this part; (5) Display and record raw...

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

DOT National Transportation Integrated Search

1992-02-01

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

Early warning reporting categories analysis of recall and complaints data.

DOT National Transportation Integrated Search

2001-12-31

This analysis was performed to assist the National Highway Traffic Safety Administration (NHTSA) in identifying components and systems to be included in early warning reporting (EWR) categories that would be based upon historical safety-related recal...

14 CFR 33.75 - Safety analysis.

Code of Federal Regulations, 2011 CFR

2011-01-01

... Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION AIRCRAFT AIRWORTHINESS STANDARDS: AIRCRAFT ENGINES Design and Construction; Turbine Aircraft Engines § 33.75 Safety analysis. (a) (1) The applicant must analyze the engine, including the control system, to assess the likely...

Vortex Advisory System Safety Analysis : Volume III, Summary of Laser Data Collection and Analysis

DOT National Transportation Integrated Search

1979-08-01

A Laser-Doppler velocimeter (LDV) was used to monitor the wake vortices shed by 5300 landing aircraft at a point 10,000 feet from the runway threshold. The data were collected to verify the analysis in Volume I of the safety of decreasing interarriva...

Systems thinking applied to safety during manual handling tasks in the transport and storage industry.

PubMed

Goode, Natassia; Salmon, Paul M; Lenné, Michael G; Hillard, Peter

2014-07-01

Injuries resulting from manual handling tasks represent an on-going problem for the transport and storage industry. This article describes an application of a systems theory-based approach, Rasmussen's (1997. Safety Science 27, 183), risk management framework, to the analysis of the factors influencing safety during manual handling activities in a freight handling organisation. Observations of manual handling activities, cognitive decision method interviews with workers (n=27) and interviews with managers (n=35) were used to gather information about three manual handling activities. Hierarchical task analysis and thematic analysis were used to identify potential risk factors and performance shaping factors across the levels of Rasmussen's framework. These different data sources were then integrated using Rasmussen's Accimap technique to provide an overall analysis of the factors influencing safety during manual handling activities in this context. The findings demonstrate how a systems theory-based approach can be applied to this domain, and suggest that policy-orientated, rather than worker-orientated, changes are required to prevent future manual handling injuries. Copyright © 2013 Elsevier Ltd. All rights reserved.

[Road map for health and safety management systems in healthcare facilities, according to the OHSAS 18001:2007 standard].

PubMed

Pugliese, F; Albini, E; Serio, O; Apostoli, P

2011-01-01

The 81/2008 Act has defined a model of a health and safety management system that can contribute to prevent the occupational health and safety risks. We have developed the structure of a health and safety management system model and the necessary tools for its implementation in health care facilities. The realization of a model is structured in various phases: initial review, safety policy, planning, implementation, monitoring, management review and continuous improvement. Such a model, in continuous evolution, is based on the responsibilities of the different corporate characters and on an accurate analysis of risks and involved norms.

Safety Hazards During Intrahospital Transport: A Prospective Observational Study.

PubMed

Bergman, Lina M; Pettersson, Monica E; Chaboyer, Wendy P; Carlström, Eric D; Ringdal, Mona L

2017-10-01

To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. The study was undertaken at two ICUs in one university hospital. Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. None. Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4-10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety.

Software Dependability and Safety Evaluations ESA's Initiative

NASA Astrophysics Data System (ADS)

Hernek, M.

ESA has allocated funds for an initiative to evaluate Dependability and Safety methods of Software. The objectives of this initiative are; · More extensive validation of Safety and Dependability techniques for Software · Provide valuable results to improve the quality of the Software thus promoting the application of Dependability and Safety methods and techniques. ESA space systems are being developed according to defined PA requirement specifications. These requirements may be implemented through various design concepts, e.g. redundancy, diversity etc. varying from project to project. Analysis methods (FMECA. FTA, HA, etc) are frequently used during requirements analysis and design activities to assure the correct implementation of system PA requirements. The criticality level of failures, functions and systems is determined and by doing that the critical sub-systems are identified, on which dependability and safety techniques are to be applied during development. Proper performance of the software development requires the development of a technical specification for the products at the beginning of the life cycle. Such technical specification comprises both functional and non-functional requirements. These non-functional requirements address characteristics of the product such as quality, dependability, safety and maintainability. Software in space systems is more and more used in critical functions. Also the trend towards more frequent use of COTS and reusable components pose new difficulties in terms of assuring reliable and safe systems. Because of this, its dependability and safety must be carefully analysed. ESA identified and documented techniques, methods and procedures to ensure that software dependability and safety requirements are specified and taken into account during the design and development of a software system and to verify/validate that the implemented software systems comply with these requirements [R1].

Testing of Safety-Critical Software Embedded in an Artificial Heart

NASA Astrophysics Data System (ADS)

Cha, Sungdeok; Jeong, Sehun; Yoo, Junbeom; Kim, Young-Gab

Software is being used more frequently to control medical devices such as artificial heart or robotic surgery system. While much of software safety issues in such systems are similar to other safety-critical systems (e.g., nuclear power plants), domain-specific properties may warrant development of customized techniques to demonstrate fitness of the system on patients. In this paper, we report results of a preliminary analysis done on software controlling a Hybrid Ventricular Assist Device (H-VAD) developed by Korea Artificial Organ Centre (KAOC). It is a state-of-the-art artificial heart which completed animal testing phase. We performed software testing in in-vitro experiments and animal experiments. An abnormal behaviour, never detected during extensive in-vitro analysis and animal testing, was found.

Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems

PubMed Central

Hearns, S; Shirley, P J

2006-01-01

Retrieval and transfer of critically ill and injured patients is a high risk activity. Risk can be minimised with robust safety and clinical governance systems in place. This article describes the various governance systems that can be employed to optimise safety and efficiency in retrieval services. These include operating procedure development, equipment management, communications procedures, crew resource management, significant event analysis, audit and training. PMID:17130608

Incorporating organisational safety culture within ergonomics practice.

PubMed

Bentley, Tim; Tappin, David

2010-10-01

This paper conceptualises organisational safety culture and considers its relevance to ergonomics practice. Issues discussed in the paper include the modest contribution that ergonomists and ergonomics as a discipline have made to this burgeoning field of study and the significance of safety culture to a systems approach. The relevance of safety culture to ergonomics work with regard to the analysis, design, implementation and evaluation process, and implications for participatory ergonomics approaches, are also discussed. A potential user-friendly, qualitative approach to assessing safety culture as part of ergonomics work is presented, based on a recently published conceptual framework that recognises the dynamic and multi-dimensional nature of safety culture. The paper concludes by considering the use of such an approach, where an understanding of different aspects of safety culture within an organisation is seen as important to the success of ergonomics projects. STATEMENT OF RELEVANCE: The relevance of safety culture to ergonomics practice is a key focus of this paper, including its relationship with the systems approach, participatory ergonomics and the ergonomics analysis, design, implementation and evaluation process. An approach to assessing safety culture as part of ergonomics work is presented.

10 CFR 52.137 - Contents of applications; technical information.

Code of Federal Regulations, 2010 CFR

2010-01-01

... limits on its operation, and presents a safety analysis of the structures, systems, and components and of... products. The description shall be sufficient to permit understanding of the system designs and their relationship to the safety evaluations. Items such as the reactor core, reactor coolant system, instrumentation...

Evaluation of analytical methodology for hydrocarbons in high pressure air and nitrogen systems. [data aquisition

NASA Technical Reports Server (NTRS)

1977-01-01

Information regarding the safety limits of hydrocarbons in liquid and gaseous oxygen, the steps taken for hydrocarbon removal from liquified gases, and the analysis of the contaminants was searched and the results are presented. The safety of hydrocarbons in gaseous systems was studied, and the latest hydrocarbon test equipment and methodology is reviewed. A detailed sampling and analysis plan is proposed to evaluate high pressure GN2 and LOX systems.

Analysis of existing work-zone devices with MASH safety performance criteria.

DOT National Transportation Integrated Search

2009-02-01

Crashworthy, work-zone, portable sign support systems accepted under NCHRP Report No. 350 were analyzed to : predict their safety peformance according to the TL-3 MASH evaluation criteria. An analysis was conducted to determine : which hardware param...

Time Factor in the Theory of Anthropogenic Risk Prediction in Complex Dynamic Systems

NASA Astrophysics Data System (ADS)

Ostreikovsky, V. A.; Shevchenko, Ye N.; Yurkov, N. K.; Kochegarov, I. I.; Grishko, A. K.

2018-01-01

The article overviews the anthropogenic risk models that take into consideration the development of different factors in time that influence the complex system. Three classes of mathematical models have been analyzed for the use in assessing the anthropogenic risk of complex dynamic systems. These models take into consideration time factor in determining the prospect of safety change of critical systems. The originality of the study is in the analysis of five time postulates in the theory of anthropogenic risk and the safety of highly important objects. It has to be stressed that the given postulates are still rarely used in practical assessment of equipment service life of critically important systems. That is why, the results of study presented in the article can be used in safety engineering and analysis of critically important complex technical systems.

Final safety analysis report for the Ground Test Accelerator (GTA), Phase 2

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

NONE

1994-10-01

This document is the second volume of a 3 volume safety analysis report on the Ground Test Accelerator (GTA). The GTA program at the Los Alamos National Laboratory (LANL) is the major element of the national Neutral Particle Beam (NPB) program, which is supported by the Strategic Defense Initiative Office (SDIO). A principal goal of the national NPB program is to assess the feasibility of using hydrogen and deuterium neutral particle beams outside the Earth`s atmosphere. The main effort of the NPB program at Los Alamos concentrates on developing the GTA. The GTA is classified as a low-hazard facility, exceptmore » for the cryogenic-cooling system, which is classified as a moderate-hazard facility. This volume consists of failure modes and effects analysis; accident analysis; operational safety requirements; quality assurance program; ES&H management program; environmental, safety, and health systems critical to safety; summary of waste-management program; environmental monitoring program; facility expansion, decontamination, and decommissioning; summary of emergency response plan; summary plan for employee training; summary plan for operating procedures; glossary; and appendices A and B.« less

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

PubMed

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

2017-11-17

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

Implementation of a patient safety program at a tertiary health system: A longitudinal analysis of interventions and serious safety events.

PubMed

Cropper, Douglas P; Harb, Nidal H; Said, Patricia A; Lemke, Jon H; Shammas, Nicolas W

2018-04-01

We hypothesize that implementation of a safety program based on high reliability organization principles will reduce serious safety events (SSE). The safety program focused on 7 essential elements: (a) safety rounding, (b) safety oversight teams, (c) safety huddles, (d) safety coaches, (e) good catches/safety heroes, (f) safety education, and (g) red rule. An educational curriculum was implemented focusing on changing high-risk behaviors and implementing critical safety policies. All unusual occurrences were captured in the Midas system and investigated by risk specialists, the safety officer, and the chief medical officer. A multidepartmental committee evaluated these events, and a root cause analysis (RCA) was performed. Events were tabulated and serious safety event (SSE) recorded and plotted over time. Safety success stories (SSSs) were also evaluated over time. A steady drop in SSEs was seen over 9 years. Also a rise in SSSs was evident, reflecting on staff engagement in the program. The parallel change in SSEs, SSSs, and the implementation of various safety interventions highly suggest that the program was successful in achieving its goals. A safety program based on high-reliability organization principles and made a core value of the institution can have a significant positive impact on reducing SSEs. © 2018 American Society for Healthcare Risk Management of the American Hospital Association.

Portable Wireless LAN Device and Two-Way Radio Threat Assessment for Aircraft VHF Communication Radio Band

NASA Technical Reports Server (NTRS)

Nguyen, Truong X.; Koppen, Sandra V.; Ely, Jay J.; Williams, Reuben A.; Smith, Laura J.; Salud, Maria Theresa P.

2004-01-01

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

Influence of different safety shoes on gait and plantar pressure: a standardized examination of workers in the automotive industry

PubMed Central

Ochsmann, Elke; Noll, Ulrike; Ellegast, Rolf; Hermanns, Ingo; Kraus, Thomas

2016-01-01

Objective: Working conditions, such as walking and standing on hard surfaces, can increase the development of musculoskeletal complaints. At the interface between flooring and musculoskeletal system, safety shoes may play an important role in the well-being of employees. The aim of this study was to evaluate the effects of different safety shoes on gait and plantar pressure distributions on industrial flooring. Methods: Twenty automotive workers were individually fitted out with three different pairs of safety shoes ( "normal" shoes, cushioned shoes, and midfoot bearing shoes). They walked at a given speed of 1.5 m/s. The CUELA measuring system and shoe insoles were used for gait analysis and plantar pressure measurements, respectively. Statistical analysis was conducted by ANOVA analysis for repeated measures. Results: Walking with cushioned safety shoes or a midfoot bearing safety shoe led to a significant decrease of the average trunk inclination (p<0.005). Furthermore, the average hip flexion angle decreased for cushioned shoes as well as midfoot bearing shoes (p<0.002). The range of motion of the knee joint increased for cushioned shoes. As expected, plantar pressure distributions varied significantly between cushioned or midfoot bearing shoes and shoes without ergonomic components. Conclusion: The overall function of safety shoes is the avoidance of injury in case of an industrial accident, but in addition, safety shoes could be a long-term preventive instrument for maintaining health of the employees' musculoskeletal system, as they are able to affect gait parameters. Further research needs to focus on safety shoes in working situations. PMID:27488038

Influence of different safety shoes on gait and plantar pressure: a standardized examination of workers in the automotive industry.

PubMed

Ochsmann, Elke; Noll, Ulrike; Ellegast, Rolf; Hermanns, Ingo; Kraus, Thomas

2016-09-30

Working conditions, such as walking and standing on hard surfaces, can increase the development of musculoskeletal complaints. At the interface between flooring and musculoskeletal system, safety shoes may play an important role in the well-being of employees. The aim of this study was to evaluate the effects of different safety shoes on gait and plantar pressure distributions on industrial flooring. Twenty automotive workers were individually fitted out with three different pairs of safety shoes ( "normal" shoes, cushioned shoes, and midfoot bearing shoes). They walked at a given speed of 1.5 m/s. The CUELA measuring system and shoe insoles were used for gait analysis and plantar pressure measurements, respectively. Statistical analysis was conducted by ANOVA analysis for repeated measures. Walking with cushioned safety shoes or a midfoot bearing safety shoe led to a significant decrease of the average trunk inclination (p<0.005). Furthermore, the average hip flexion angle decreased for cushioned shoes as well as midfoot bearing shoes (p<0.002). The range of motion of the knee joint increased for cushioned shoes. As expected, plantar pressure distributions varied significantly between cushioned or midfoot bearing shoes and shoes without ergonomic components. The overall function of safety shoes is the avoidance of injury in case of an industrial accident, but in addition, safety shoes could be a long-term preventive instrument for maintaining health of the employees' musculoskeletal system, as they are able to affect gait parameters. Further research needs to focus on safety shoes in working situations.

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

PubMed

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

2015-01-01

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

2006 NASA Range Safety Annual Report

NASA Technical Reports Server (NTRS)

TenHaken, Ron; Daniels, B.; Becker, M.; Barnes, Zack; Donovan, Shawn; Manley, Brenda

2007-01-01

Throughout 2006, Range Safety was involved in a number of exciting and challenging activities and events, from developing, implementing, and supporting Range Safety policies and procedures-such as the Space Shuttle Launch and Landing Plans, the Range Safety Variance Process, and the Expendable Launch Vehicle Safety Program procedures-to evaluating new technologies. Range Safety training development is almost complete with the last course scheduled to go on line in mid-2007. Range Safety representatives took part in a number of panels and councils, including the newly formed Launch Constellation Range Safety Panel, the Range Commanders Council and its subgroups, the Space Shuttle Range Safety Panel, and the unmanned aircraft systems working group. Space based range safety demonstration and certification (formerly STARS) and the autonomous flight safety system were successfully tested. The enhanced flight termination system will be tested in early 2007 and the joint advanced range safety system mission analysis software tool is nearing operational status. New technologies being evaluated included a processor for real-time compensation in long range imaging, automated range surveillance using radio interferometry, and a space based range command and telemetry processor. Next year holds great promise as we continue ensuring safety while pursuing our quest beyond the Moon to Mars.

[Examination of safety improvement by failure record analysis that uses reliability engineering].

PubMed

Kato, Kyoichi; Sato, Hisaya; Abe, Yoshihisa; Ishimori, Yoshiyuki; Hirano, Hiroshi; Higashimura, Kyoji; Amauchi, Hiroshi; Yanakita, Takashi; Kikuchi, Kei; Nakazawa, Yasuo

2010-08-20

How the maintenance checks of the medical treatment system, including start of work check and the ending check, was effective for preventive maintenance and the safety improvement was verified. In this research, date on the failure of devices in multiple facilities was collected, and the data of the trouble repair record was analyzed by the technique of reliability engineering. An analysis of data on the system (8 general systems, 6 Angio systems, 11 CT systems, 8 MRI systems, 8 RI systems, and the radiation therapy system 9) used in eight hospitals was performed. The data collection period assumed nine months from April to December 2008. Seven items were analyzed. (1) Mean time between failures (MTBF) (2) Mean time to repair (MTTR) (3) Mean down time (MDT) (4) Number found by check in morning (5) Failure generation time according to modality. The classification of the breakdowns per device, the incidence, and the tendency could be understood by introducing reliability engineering. Analysis, evaluation, and feedback on the failure generation history are useful to keep downtime to a minimum and to ensure safety.

The MOD-OA 200 kilowatt wind turbine generator design and analysis report

NASA Astrophysics Data System (ADS)

Andersen, T. S.; Bodenschatz, C. A.; Eggers, A. G.; Hughes, P. S.; Lampe, R. F.; Lipner, M. H.; Schornhorst, J. R.

1980-08-01

The project requirements, approach, system description, design requirements, design, analysis, system tests, installation safety considerations, failure modes and effects analysis, data acquisition, and initial performance for the MOD-OA 200 kw wind turbine generator are discussed. The components, the rotor, driven train, nacelle equipment, yaw drive mechanism and brake, tower, foundation, electrical system, and control systems are presented. The rotor includes the blades, hub and pitch change mechanism. The drive train includes the low speed shaft, speed increaser, high speed shaft, and rotor brake. The electrical system includes the generator, switchgear, transformer, and utility connection. The control systems are the blade pitch, yaw, and generator control, and the safety system. Manual, automatic, and remote control and Dynamic loads and fatigue are analyzed.

The MOD-OA 200 kilowatt wind turbine generator design and analysis report

NASA Technical Reports Server (NTRS)

Andersen, T. S.; Bodenschatz, C. A.; Eggers, A. G.; Hughes, P. S.; Lampe, R. F.; Lipner, M. H.; Schornhorst, J. R.

1980-01-01

The project requirements, approach, system description, design requirements, design, analysis, system tests, installation safety considerations, failure modes and effects analysis, data acquisition, and initial performance for the MOD-OA 200 kw wind turbine generator are discussed. The components, the rotor, driven train, nacelle equipment, yaw drive mechanism and brake, tower, foundation, electrical system, and control systems are presented. The rotor includes the blades, hub and pitch change mechanism. The drive train includes the low speed shaft, speed increaser, high speed shaft, and rotor brake. The electrical system includes the generator, switchgear, transformer, and utility connection. The control systems are the blade pitch, yaw, and generator control, and the safety system. Manual, automatic, and remote control and Dynamic loads and fatigue are analyzed.

Safety evaluation methodology for advanced coal extraction systems

NASA Technical Reports Server (NTRS)

Zimmerman, W. F.

1981-01-01

Qualitative and quantitative evaluation methods for coal extraction systems were developed. The analysis examines the soundness of the design, whether or not the major hazards have been eliminated or reduced, and how the reduction would be accomplished. The quantitative methodology establishes the approximate impact of hazards on injury levels. The results are weighted by peculiar geological elements, specialized safety training, peculiar mine environmental aspects, and reductions in labor force. The outcome is compared with injury level requirements based on similar, safer industries to get a measure of the new system's success in reducing injuries. This approach provides a more detailed and comprehensive analysis of hazards and their effects than existing safety analyses.

Another Approach to Enhance Airline Safety: Using Management Safety Tools

NASA Technical Reports Server (NTRS)

Lu, Chien-tsug; Wetmore, Michael; Przetak, Robert

2006-01-01

The ultimate goal of conducting an accident investigation is to prevent similar accidents from happening again and to make operations safer system-wide. Based on the findings extracted from the investigation, the "lesson learned" becomes a genuine part of the safety database making risk management available to safety analysts. The airline industry is no exception. In the US, the FAA has advocated the usage of the System Safety concept in enhancing safety since 2000. Yet, in today s usage of System Safety, the airline industry mainly focuses on risk management, which is a reactive process of the System Safety discipline. In order to extend the merit of System Safety and to prevent accidents beforehand, a specific System Safety tool needs to be applied; so a model of hazard prediction can be formed. To do so, the authors initiated this study by reviewing 189 final accident reports from the National Transportation Safety Board (NTSB) covering FAR Part 121 scheduled operations. The discovered accident causes (direct hazards) were categorized into 10 groups Flight Operations, Ground Crew, Turbulence, Maintenance, Foreign Object Damage (FOD), Flight Attendant, Air Traffic Control, Manufacturer, Passenger, and Federal Aviation Administration. These direct hazards were associated with 36 root factors prepared for an error-elimination model using Fault Tree Analysis (FTA), a leading tool for System Safety experts. An FTA block-diagram model was created, followed by a probability simulation of accidents. Five case studies and reports were provided in order to fully demonstrate the usefulness of System Safety tools in promoting airline safety.

Design of agricultural product quality safety retrospective supervision system of Jiangsu province

NASA Astrophysics Data System (ADS)

Wang, Kun

2017-08-01

In store and supermarkets to consumers can trace back agricultural products through the electronic province card to query their origin, planting, processing, packaging, testing and other important information and found that the problems. Quality and safety issues can identify the responsibility of the problem. This paper designs a retroactive supervision system for the quality and safety of agricultural products in Jiangsu Province. Based on the analysis of agricultural production and business process, the goal of Jiangsu agricultural product quality safety traceability system construction is established, and the specific functional requirements and non-functioning requirements of the retroactive system are analyzed, and the target is specified for the specific construction of the retroactive system. The design of the quality and safety traceability system in Jiangsu province contains the design of the overall design, the trace code design and the system function module.

Laser Safety and Hazardous Analysis for the ARES (Big Sky) Laser System

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

AUGUSTONI, ARNOLD L.

A laser safety and hazard analysis was performed for the ARES laser system based on the 2000 version of the American National Standards Institute's (ANSI) Standard Z136.1,for Safe Use of Lasers and the 2000 version of the ANSI Standard Z136.6, for Safe Use of Lasers Outdoors. The ARES laser system is a Van/Truck based mobile platform, which is used to perform laser interaction experiments and tests at various national test sites.

Consumer product safety: A systems problem

NASA Technical Reports Server (NTRS)

Clark, C. C.

1971-01-01

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

Cross-modal work helps OMC improve the safety of commercial transportation

DOT National Transportation Integrated Search

1997-01-01

This article describes the Commercial Vehicle Information System (CVIS), designed to deploy a national safety program for the U.S. commercial trucking fleet. CVIS is built around a safety analysis algorithm called SafeStat which constructs a profile ...

Feedback from incident reporting: information and action to improve patient safety.

PubMed

Benn, J; Koutantji, M; Wallace, L; Spurgeon, P; Rejman, M; Healey, A; Vincent, C

2009-02-01

Effective feedback from incident reporting systems in healthcare is essential if organisations are to learn from failures in the delivery of care. Despite the wide-scale development and implementation of incident reporting in healthcare, studies in the UK suggest that information concerning system vulnerabilities could be better applied to improve operational safety within organisations. In this article, the findings and implications of research to identify forms of effective feedback from incident reporting are discussed, to promote best practices in this area. The research comprised a mixed methods review to investigate mechanisms of effective feedback for healthcare, drawing upon experience within established reporting programmes in high-risk industry and transport domains. Systematic searches of published literature were undertaken, and 23 case studies describing incident reporting programmes with feedback were identified for analysis from the international healthcare literature. Semistructured interviews were undertaken with 19 subject matter experts across a range of domains, including: civil aviation, maritime, energy, rail, offshore production and healthcare. In analysis, qualitative information from several sources was synthesised into practical requirements for developing effective feedback in healthcare. Both action and information feedback mechanisms were identified, serving safety awareness, improvement and motivational functions. The provision of actionable feedback that visibly improved systems was highlighted as important in promoting future reporting. Fifteen requirements for the design of effective feedback systems were identified, concerning: the role of leadership, the credibility and content of information, effective dissemination channels, the capacity for rapid action and the need for feedback at all levels of the organisation, among others. Above all, the safety-feedback cycle must be closed by ensuring that reporting, analysis and investigation result in timely corrective actions that effectively address vulnerabilities in existing work systems. Limited research evidence exists concerning the issue of effective forms of safety feedback within healthcare. Much valuable operational knowledge resides in safety management communities within high-risk industries. Multiple means of feeding back recommended actions and safety information may be usefully employed to promote safety awareness, improve clinical processes and promote future reporting. Further work is needed to establish best practices for feedback systems in healthcare that effectively close the safety loop.

Engineering Safety- and Security-Related Requirements for Software-Intensive Systems

DTIC Science & Technology

2010-04-27

Requirements Negative (shall not) Requirements Hardware Requirements equ remen s System / Documentation Requirements eve oper Requirements Operational ...Validation Actual / Proposed Defensibility C li Operational Vulnerability Analysis VulnerabilityVulnerability Safety Vulnerability performs System ...including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson

78 FR 41436 - Proposed Revision to Treatment of Non-Safety Systems for Passive Advanced Light Water Reactors

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-10

... Safety Analysis Reports for Nuclear Power Plants: LWR Edition,'' on a proposed new section to its... revised position on the treatment of the high winds external hazard for certain RTNSS structures, systems... winds external hazard for certain RTNSS structures, systems and components (SSCs). This position differs...

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

PubMed

2017-01-01

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

Potential safety benefits of intelligent cruise control systems.

PubMed

Chira-Chavala, T; Yoo, S M

1994-04-01

Potential safety impact of a hypothetical intelligent cruise control system (ICCS) is evaluated in terms of changes in traffic accidents and some traffic operation characteristics affecting safety. The analysis of changes in traffic accidents is accomplished by in-depth examinations of police accident reports for four major counties in California. The evaluation of changes in traffic operation characteristics affecting safety is accomplished by vehicle simulation. The accident analysis reveals that the use of the hypothetical ICCS could potentially reduce traffic accidents by up to 7.5%. Preliminary vehicle simulation results based on a 10-vehicle convoy indicate that the use of the hypothetical ICCS could reduce frequencies of hard acceleration and deceleration, enhance speed harmonization among vehicles, and reduce incidence of "less-safe" headway.

Effective vaccine safety systems in all countries: a challenge for more equitable access to immunization.

PubMed

Amarasinghe, Ananda; Black, Steve; Bonhoeffer, Jan; Carvalho, Sandra M Deotti; Dodoo, Alexander; Eskola, Juhani; Larson, Heidi; Shin, Sunheang; Olsson, Sten; Balakrishnan, Madhava Ram; Bellah, Ahmed; Lambach, Philipp; Maure, Christine; Wood, David; Zuber, Patrick; Akanmori, Bartholomew; Bravo, Pamela; Pombo, María; Langar, Houda; Pfeifer, Dina; Guichard, Stéphane; Diorditsa, Sergey; Hossain, Md Shafiqul; Sato, Yoshikuni

2013-04-18

Serious vaccine-associated adverse events are rare. To further minimize their occurrence and to provide adequate care to those affected, careful monitoring of immunization programs and case management is required. Unfounded vaccine safety concerns have the potential of seriously derailing effective immunization activities. To address these issues, vaccine pharmacovigilance systems have been developed in many industrialized countries. As new vaccine products become available to prevent new diseases in various parts of the world, the demand for effective pharmacovigilance systems in low- and middle-income countries (LMIC) is increasing. To help establish such systems in all countries, WHO developed the Global Vaccine Safety Blueprint in 2011. This strategic plan is based on an in-depth analysis of the vaccine safety landscape that involved many stakeholders. This analysis reviewed existing systems and international vaccine safety activities and assessed the financial resources required to operate them. The Blueprint sets three main strategic goals to optimize the safety of vaccines through effective use of pharmacovigilance principles and methods: to ensure minimal vaccine safety capacity in all countries; to provide enhanced capacity for specific circumstances; and to establish a global support network to assist national authorities with capacity building and crisis management. In early 2012, the Global Vaccine Safety Initiative (GVSI) was launched to bring together and explore synergies among on-going vaccine safety activities. The Global Vaccine Action Plan has identified the Blueprint as its vaccine safety strategy. There is an enormous opportunity to raise awareness for vaccine safety in LMIC and to garner support from a large number of stakeholders for the GVSI between now and 2020. Synergies and resource mobilization opportunities presented by the Decade of Vaccines can enhance monitoring and response to vaccine safety issues, thereby leading to more equitable delivery of vaccines worldwide. Copyright © 2012 Elsevier Ltd. All rights reserved.

High Reliability and the Evaluation of ATC System Configuration by Communizing Resources

NASA Astrophysics Data System (ADS)

Yamamoto, Masanori

Automatic Train Control (ATC) in the railway signalling system is required high safety, high availability, reduction of unit, energy saving and cost reduction. This paper described the resources communization redundancy of the ATC system that shared the redundant units in preparation for common use units in order to accommodate with this issue by keeping safety and availability in the same level of conventional ATC. It was evaluated on N+2 redundant system which established 2 spares for the common use system N piece in transmission division. It was done the safety evaluation of the N+2 redundant system by way of hazard analysis of FTA method and safety issue was confirmed by FMEA. The new redundant system concludes that 19% of downsizing and 36% of the energy saving are surely possible.

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

NASA Technical Reports Server (NTRS)

Pelouch, J. J., Jr.

1974-01-01

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

Preliminary Results Obtained in Integrated Safety Analysis of NASA Aviation Safety Program Technologies

NASA Technical Reports Server (NTRS)

Reveley, Mary S.

2003-01-01

The goal of the NASA Aviation Safety Program (AvSP) is to develop and demonstrate technologies that contribute to a reduction in the aviation fatal accident rate by a factor of 5 by the year 2007 and by a factor of 10 by the year 2022. Integrated safety analysis of day-to-day operations and risks within those operations will provide an understanding of the Aviation Safety Program portfolio. Safety benefits analyses are currently being conducted. Preliminary results for the Synthetic Vision Systems (SVS) and Weather Accident Prevention (WxAP) projects of the AvSP have been completed by the Logistics Management Institute under a contract with the NASA Glenn Research Center. These analyses include both a reliability analysis and a computer simulation model. The integrated safety analysis method comprises two principal components: a reliability model and a simulation model. In the reliability model, the results indicate how different technologies and systems will perform in normal, degraded, and failed modes of operation. In the simulation, an operational scenario is modeled. The primary purpose of the SVS project is to improve safety by providing visual-flightlike situation awareness during instrument conditions. The current analyses are an estimate of the benefits of SVS in avoiding controlled flight into terrain. The scenario modeled has an aircraft flying directly toward a terrain feature. When the flight crew determines that the aircraft is headed toward an obstruction, the aircraft executes a level turn at speed. The simulation is ended when the aircraft completes the turn.

Application of Microprocessor-Based Equipment in Nuclear Power Plants - Technical Basis for a Qualification Methodology

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

Korsah, K.

This document (1) summarizes the most significant findings of the ''Qualification of Advanced Instrumentation and Control (I&C) Systems'' program initiated by the Nuclear Regulatory Commission (NRC); (2) documents a comparative analysis of U.S. and European qualification standards; and (3) provides recommendations for enhancing regulatory guidance for environmental qualification of microprocessor-based safety-related systems. Safety-related I&C system upgrades of present-day nuclear power plants, as well as I&C systems of Advanced Light-Water Reactors (ALWRs), are expected to make increasing use of microprocessor-based technology. The Nuclear Regulatory Commission (NRC) recognized that the use of such technology may pose environmental qualification challenges different from current,more » analog-based I&C systems. Hence, it initiated the ''Qualification of Advanced Instrumentation and Control Systems'' program. The objectives of this confirmatory research project are to (1) identify any unique environmental-stress-related failure modes posed by digital technologies and their potential impact on the safety systems and (2) develop the technical basis for regulatory guidance using these findings. Previous findings from this study have been documented in several technical reports. This final report in the series documents a comparative analysis of two environmental qualification standards--Institute of Electrical and Electronics Engineers (IEEE) Std 323-1983 and International Electrotechnical Commission (IEC) 60780 (1998)--and provides recommendations for environmental qualification of microprocessor-based systems based on this analysis as well as on the findings documented in the previous reports. The two standards were chosen for this analysis because IEEE 323 is the standard used in the U.S. for the qualification of safety-related equipment in nuclear power plants, and IEC 60780 is its European counterpart. In addition, the IEC document was published in 1998, and should reflect any new qualification concerns, from the European perspective, with regard to the use of microprocessor-based safety systems in power plants.« less

Pilot-controller communication errors : an analysis of Aviation Safety Reporting System (ASRS) reports

DOT National Transportation Integrated Search

1998-08-01

The purpose of this study was to identify the factors that contribute to pilot-controller communication errors. Resports submitted to the Aviation Safety Reporting System (ASRS) offer detailed accounts of specific types of errors and a great deal of ...

Loss-of-flow-without-scram tests in Experimental Breeder Reactor-II and comparison with pretest predictions

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

Chang, L.K.; Mohr, D.; Planchon, H.P.

This article discusses a series of successful loss-of-flow-without-scram tests conducted in Experimental Breeder Reactor-II (EBR-II), a metal-fueled, sodium-cooled fast reactor. These May 1985 tests demonstrated the capability of the EBR to reduce reactor power passively during a loss of flow and to maintain reactor temperatures within bounds without any reliance on an active safety system. The tests were run from reduced power to ensure that temperatures could be maintained well below the fuel-clad eutectic temperature. Good agreement was found between selected test data and pretest predictions made with the EBR-II system analysis code NATDEMO and the hot channel analysis codemore » HOTCHAN. The article also discusses safety assessments of the tests as well as modifications required on the EBR-II reactor safety system for conducting required on the EBR-II reactor safety system for the conducting the tests.« less

Modeling and Hazard Analysis Using STPA

NASA Astrophysics Data System (ADS)

Ishimatsu, Takuto; Leveson, Nancy; Thomas, John; Katahira, Masa; Miyamoto, Yuko; Nakao, Haruka

2010-09-01

A joint research project between MIT and JAXA/JAMSS is investigating the application of a new hazard analysis to the system and software in the HTV. Traditional hazard analysis focuses on component failures but software does not fail in this way. Software most often contributes to accidents by commanding the spacecraft into an unsafe state(e.g., turning off the descent engines prematurely) or by not issuing required commands. That makes the standard hazard analysis techniques of limited usefulness on software-intensive systems, which describes most spacecraft built today. STPA is a new hazard analysis technique based on systems theory rather than reliability theory. It treats safety as a control problem rather than a failure problem. The goal of STPA, which is to create a set of scenarios that can lead to a hazard, is the same as FTA but STPA includes a broader set of potential scenarios including those in which no failures occur but the problems arise due to unsafe and unintended interactions among the system components. STPA also provides more guidance to the analysts that traditional fault tree analysis. Functional control diagrams are used to guide the analysis. In addition, JAXA uses a model-based system engineering development environment(created originally by Leveson and called SpecTRM) which also assists in the hazard analysis. One of the advantages of STPA is that it can be applied early in the system engineering and development process in a safety-driven design process where hazard analysis drives the design decisions rather than waiting until reviews identify problems that are then costly or difficult to fix. It can also be applied in an after-the-fact analysis and hazard assessment, which is what we did in this case study. This paper describes the experimental application of STPA to the JAXA HTV in order to determine the feasibility and usefulness of the new hazard analysis technique. Because the HTV was originally developed using fault tree analysis and following the NASA standards for safety-critical systems, the results of our experimental application of STPA can be compared with these more traditional safety engineering approaches in terms of the problems identified and the resources required to use it.

Analyzing system safety in lithium-ion grid energy storage

NASA Astrophysics Data System (ADS)

Rosewater, David; Williams, Adam

2015-12-01

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

Sophisticated Calculation of the 1oo4-architecture for Safety-related Systems Conforming to IEC61508

NASA Astrophysics Data System (ADS)

Hayek, A.; Bokhaiti, M. Al; Schwarz, M. H.; Boercsoek, J.

2012-05-01

With the publication and enforcement of the standard IEC 61508 of safety related systems, recent system architectures have been presented and evaluated. Among a number of techniques and measures to the evaluation of safety integrity level (SIL) for safety-related systems, several measures such as reliability block diagrams and Markov models are used to analyze the probability of failure on demand (PFD) and mean time to failure (MTTF) which conform to IEC 61508. The current paper deals with the quantitative analysis of the novel 1oo4-architecture (one out of four) presented in recent work. Therefore sophisticated calculations for the required parameters are introduced. The provided 1oo4-architecture represents an advanced safety architecture based on on-chip redundancy, which is 3-failure safe. This means that at least one of the four channels have to work correctly in order to trigger the safety function.

Identification of Vehicle Health Assurance Related Trends

NASA Technical Reports Server (NTRS)

Phojanamongkolkij, Nipa; Evans, Joni K.; Barr, Lawrence C.; Leone, Karen M.; Reveley, Mary S.

2014-01-01

Trend analysis in aviation as related to vehicle health management (VHM) was performed by reviewing the most current statistical and prognostics data available from the National Transportation Safety Board (NTSB) accident, the Federal Aviation Administration (FAA) incident, and the NASA Aviation Safety Reporting System (ASRS) incident datasets. In addition, future directions in aviation technology related to VHM research areas were assessed through the Commercial Aviation Safety Team (CAST) Safety Enhancements Reserved for Future Implementations (SERFIs), the National Transportation Safety Board (NTSB) Most-Wanted List and recent open safety recommendations, the National Research Council (NRC) Decadal Survey of Civil Aeronautics, and the Future Aviation Safety Team (FAST) areas of change. Future research direction in the VHM research areas is evidently strong as seen from recent research solicitations from the Naval Air Systems Command (NAVAIR), and VHM-related technologies actively being developed by aviation industry leaders, including GE, Boeing, Airbus, and UTC Aerospace Systems. Given the highly complex VHM systems, modifications can be made in the future so that the Vehicle Systems Safety Technology Project (VSST) technical challenges address inadequate maintenance crew's trainings and skills, and the certification methods of such systems as recommended by the NTSB, NRC, and FAST areas of change.

Analyzing and strengthening the vaccine safety program in Manitoba.

PubMed

Montalban, J M; Ogbuneke, C; Hilderman, T

2014-12-04

The emergence of a novel influenza A virus in 2009 and the rapid introduction of new pandemic vaccines prompted an analysis of the current state of the adverse events following immunization (AEFI) surveillance response in several provinces. To highlight aspects of the situational analysis of the Manitoba Health, Healthy Living and Seniors (MHHLS's) AEFI surveillance system and to demonstrate how common business techniques could be usefully applied to a provincial vaccine safety monitoring program. Situational analysis of the AEFI surveillance system in Manitoba was developed through a strengths-weaknesses-opportunities-threats (SWOT) analysis and informed by the National Immunization Strategy vaccine safety priorities. Strategy formulation was developed by applying the threats-opportunities-weaknesses-strengths (TOWS) matrix. Thirteen strategies were formulated that use strengths to either take advantage of opportunities or avoid threats, that exploit opportunities to overcome weaknesses, or that rectify weaknesses to circumvent threats. These strategies entailed the development of various tools and resources, most of which are either actively underway or completed. The SWOT analysis and the TOWS matrix enabled MHHLS to enhance the capacity of its vaccine safety program.

Analyzing and strengthening the vaccine safety program in Manitoba

PubMed Central

Montalban, JM; Ogbuneke, C; Hilderman, T

2014-01-01

Background: The emergence of a novel influenza A virus in 2009 and the rapid introduction of new pandemic vaccines prompted an analysis of the current state of the adverse events following immunization (AEFI) surveillance response in several provinces. Objectives To highlight aspects of the situational analysis of the Manitoba Health, Healthy Living and Seniors (MHHLS’s) AEFI surveillance system and to demonstrate how common business techniques could be usefully applied to a provincial vaccine safety monitoring program. Method Situational analysis of the AEFI surveillance system in Manitoba was developed through a strengths-weaknesses-opportunities-threats (SWOT) analysis and informed by the National Immunization Strategy vaccine safety priorities. Strategy formulation was developed by applying the threats-opportunities-weaknesses-strengths (TOWS) matrix. Results Thirteen strategies were formulated that use strengths to either take advantage of opportunities or avoid threats, that exploit opportunities to overcome weaknesses, or that rectify weaknesses to circumvent threats. These strategies entailed the development of various tools and resources, most of which are either actively underway or completed. Conclusion The SWOT analysis and the TOWS matrix enabled MHHLS to enhance the capacity of its vaccine safety program. PMID:29769910

FY2017 Updates to the SAS4A/SASSYS-1 Safety Analysis Code

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

Fanning, T. H.

The SAS4A/SASSYS-1 safety analysis software is used to perform deterministic analysis of anticipated events as well as design-basis and beyond-design-basis accidents for advanced fast reactors. It plays a central role in the analysis of U.S. DOE conceptual designs, proposed test and demonstration reactors, and in domestic and international collaborations. This report summarizes the code development activities that have taken place during FY2017. Extensions to the void and cladding reactivity feedback models have been implemented, and Control System capabilities have been improved through a new virtual data acquisition system for plant state variables and an additional Block Signal for a variablemore » lag compensator to represent reactivity feedback for novel shutdown devices. Current code development and maintenance needs are also summarized in three key areas: software quality assurance, modeling improvements, and maintenance of related tools. With ongoing support, SAS4A/SASSYS-1 can continue to fulfill its growing role in fast reactor safety analysis and help solidify DOE’s leadership role in fast reactor safety both domestically and in international collaborations.« less

9 CFR 417.4 - Validation, Verification, Reassessment.

Code of Federal Regulations, 2012 CFR

2012-01-01

... not have a HACCP plan because a hazard analysis has revealed no food safety hazards that are.... 417.4 Section 417.4 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF... ACT HAZARD ANALYSIS AND CRITICAL CONTROL POINT (HACCP) SYSTEMS § 417.4 Validation, Verification...

9 CFR 417.4 - Validation, Verification, Reassessment.

Code of Federal Regulations, 2010 CFR

2010-01-01

... not have a HACCP plan because a hazard analysis has revealed no food safety hazards that are.... 417.4 Section 417.4 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF... ACT HAZARD ANALYSIS AND CRITICAL CONTROL POINT (HACCP) SYSTEMS § 417.4 Validation, Verification...

9 CFR 417.4 - Validation, Verification, Reassessment.

Code of Federal Regulations, 2011 CFR

2011-01-01

... not have a HACCP plan because a hazard analysis has revealed no food safety hazards that are.... 417.4 Section 417.4 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF... ACT HAZARD ANALYSIS AND CRITICAL CONTROL POINT (HACCP) SYSTEMS § 417.4 Validation, Verification...

NASA Range Safety Annual Report 2007

NASA Technical Reports Server (NTRS)

Dumont, Alan G.

2007-01-01

As always, Range Safety has been involved in a number of exciting and challenging activities and events. Throughout the year, we have strived to meet our goal of protecting the public, the workforce, and property during range operations. During the past year, Range Safety was involved in the development, implementation, and support of range safety policy. Range Safety training curriculum development was completed this year and several courses were presented. Tailoring exercises concerning the Constellation Program were undertaken with representatives from the Constellation Program, the 45th Space Wing, and the Launch Constellation Range Safety Panel. Range Safety actively supported the Range Commanders Council and it subgroups and remained involved in updating policy related to flight safety systems and flight safety analysis. In addition, Range Safety supported the Space Shuttle Range Safety Panel and addressed policy concerning unmanned aircraft systems. Launch operations at Kennedy Space Center, the Eastern and Western ranges, Dryden Flight Research Center, and Wallops Flight Facility were addressed. Range Safety was also involved in the evaluation of a number of research and development efforts, including the space-based range (formerly STARS), the autonomous flight safety system, the enhanced flight termination system, and the joint advanced range safety system. Flight safety system challenges were evaluated. Range Safety's role in the Space Florida Customer Assistance Service Program for the Eastern Range was covered along with our support for the Space Florida Educational Balloon Release Program. We hope you have found the web-based format both accessible and easy to use. Anyone having questions or wishing to have an article included in the 2008 Range Safety Annual Report should contact Alan Dumont, the NASA Range Safety Program Manager located at the Kennedy Space Center, or Michael Dook at NASA Headquarters.

The Range Safety Debris Catalog Analysis in Preparation for the Pad Abort One Flight Test

NASA Technical Reports Server (NTRS)

Kutty, Prasad M.; Pratt, William D.

2010-01-01

The Pad Abort One flight test of the Orion Abort Flight Test Program is currently under development with the goal of demonstrating the capability of the Launch Abort System. In the event of a launch failure, this system will propel the Crew Exploration Vehicle to safety. An essential component of this flight test is range safety, which ensures the security of range assets and personnel. A debris catalog analysis was done as part of a range safety data package delivered to the White Sands Missile Range in New Mexico where the test will be conducted. The analysis discusses the consequences of an overpressurization of the Abort Motor. The resulting structural failure was assumed to create a debris field of vehicle fragments that could potentially pose a hazard to the range. A statistical model was used to assemble the debris catalog of potential propellant fragments. Then, a thermodynamic, energy balance model was applied to the system in order to determine the imparted velocity to these propellant fragments. This analysis was conducted at four points along the flight trajectory to better understand the failure consequences over the entire flight. The methods used to perform this analysis are outlined in detail and the corresponding results are presented and discussed.

NASA Accident Precursor Analysis Handbook, Version 1.0

NASA Technical Reports Server (NTRS)

Groen, Frank; Everett, Chris; Hall, Anthony; Insley, Scott

2011-01-01

Catastrophic accidents are usually preceded by precursory events that, although observable, are not recognized as harbingers of a tragedy until after the fact. In the nuclear industry, the Three Mile Island accident was preceded by at least two events portending the potential for severe consequences from an underappreciated causal mechanism. Anomalies whose failure mechanisms were integral to the losses of Space Transportation Systems (STS) Challenger and Columbia had been occurring within the STS fleet prior to those accidents. Both the Rogers Commission Report and the Columbia Accident Investigation Board report found that processes in place at the time did not respond to the prior anomalies in a way that shed light on their true risk implications. This includes the concern that, in the words of the NASA Aerospace Safety Advisory Panel (ASAP), "no process addresses the need to update a hazard analysis when anomalies occur" At a broader level, the ASAP noted in 2007 that NASA "could better gauge the likelihood of losses by developing leading indicators, rather than continue to depend on lagging indicators". These observations suggest a need to revalidate prior assumptions and conclusions of existing safety (and reliability) analyses, as well as to consider the potential for previously unrecognized accident scenarios, when unexpected or otherwise undesired behaviors of the system are observed. This need is also discussed in NASA's system safety handbook, which advocates a view of safety assurance as driving a program to take steps that are necessary to establish and maintain a valid and credible argument for the safety of its missions. It is the premise of this handbook that making cases for safety more experience-based allows NASA to be better informed about the safety performance of its systems, and will ultimately help it to manage safety in a more effective manner. The APA process described in this handbook provides a systematic means of analyzing candidate accident precursors by evaluating anomaly occurrences for their system safety implications and, through both analytical and deliberative methods used to project to other circumstances, identifying those that portend more serious consequences to come if effective corrective action is not taken. APA builds upon existing safety analysis processes currently in practice within NASA, leveraging their results to provide an improved understanding of overall system risk. As such, APA represents an important dimension of safety evaluation; as operational experience is acquired, precursor information is generated such that it can be fed back into system safety analyses to risk-inform safety improvements. Importantly, APA utilizes anomaly data to predict risk whereas standard reliability and PRA approaches utilize failure data which often is limited and rare.

Software system safety

NASA Technical Reports Server (NTRS)

Uber, James G.

1988-01-01

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

Implementing Software Safety in the NASA Environment

NASA Technical Reports Server (NTRS)

Wetherholt, Martha S.; Radley, Charles F.

1994-01-01

Until recently, NASA did not consider allowing computers total control of flight systems. Human operators, via hardware, have constituted the ultimate safety control. In an attempt to reduce costs, NASA has come to rely more and more heavily on computers and software to control space missions. (For example. software is now planned to control most of the operational functions of the International Space Station.) Thus the need for systematic software safety programs has become crucial for mission success. Concurrent engineering principles dictate that safety should be designed into software up front, not tested into the software after the fact. 'Cost of Quality' studies have statistics and metrics to prove the value of building quality and safety into the development cycle. Unfortunately, most software engineers are not familiar with designing for safety, and most safety engineers are not software experts. Software written to specifications which have not been safety analyzed is a major source of computer related accidents. Safer software is achieved step by step throughout the system and software life cycle. It is a process that includes requirements definition, hazard analyses, formal software inspections, safety analyses, testing, and maintenance. The greatest emphasis is placed on clearly and completely defining system and software requirements, including safety and reliability requirements. Unfortunately, development and review of requirements are the weakest link in the process. While some of the more academic methods, e.g. mathematical models, may help bring about safer software, this paper proposes the use of currently approved software methodologies, and sound software and assurance practices to show how, to a large degree, safety can be designed into software from the start. NASA's approach today is to first conduct a preliminary system hazard analysis (PHA) during the concept and planning phase of a project. This determines the overall hazard potential of the system to be built. Shortly thereafter, as the system requirements are being defined, the second iteration of hazard analyses takes place, the systems hazard analysis (SHA). During the systems requirements phase, decisions are made as to what functions of the system will be the responsibility of software. This is the most critical time to affect the safety of the software. From this point, software safety analyses as well as software engineering practices are the main focus for assuring safe software. While many of the steps proposed in this paper seem like just sound engineering practices, they are the best technical and most cost effective means to assure safe software within a safe system.

MOD-0A 200 kW wind turbine generator design and analysis report

NASA Astrophysics Data System (ADS)

Anderson, T. S.; Bodenschatz, C. A.; Eggers, A. G.; Hughes, P. S.; Lampe, R. F.; Lipner, M. H.; Schornhorst, J. R.

1980-08-01

The design, analysis, and initial performance of the MOD-OA 200 kW wind turbine generator at Clayton, NM is documented. The MOD-OA was designed and built to obtain operation and performance data and experience in utility environments. The project requirements, approach, system description, design requirements, design, analysis, system tests, installation, safety considerations, failure modes and effects analysis, data acquisition, and initial performance for the wind turbine are discussed. The design and analysis of the rotor, drive train, nacelle equipment, yaw drive mechanism and brake, tower, foundation, electricl system, and control systems are presented. The rotor includes the blades, hub, and pitch change mechanism. The drive train includes the low speed shaft, speed increaser, high speed shaft, and rotor brake. The electrical system includes the generator, switchgear, transformer, and utility connection. The control systems are the blade pitch, yaw, and generator control, and the safety system. Manual, automatic, and remote control are discussed. Systems analyses on dynamic loads and fatigue are presented.

MOD-0A 200 kW wind turbine generator design and analysis report

NASA Technical Reports Server (NTRS)

Anderson, T. S.; Bodenschatz, C. A.; Eggers, A. G.; Hughes, P. S.; Lampe, R. F.; Lipner, M. H.; Schornhorst, J. R.

1980-01-01

The design, analysis, and initial performance of the MOD-OA 200 kW wind turbine generator at Clayton, NM is documented. The MOD-OA was designed and built to obtain operation and performance data and experience in utility environments. The project requirements, approach, system description, design requirements, design, analysis, system tests, installation, safety considerations, failure modes and effects analysis, data acquisition, and initial performance for the wind turbine are discussed. The design and analysis of the rotor, drive train, nacelle equipment, yaw drive mechanism and brake, tower, foundation, electricl system, and control systems are presented. The rotor includes the blades, hub, and pitch change mechanism. The drive train includes the low speed shaft, speed increaser, high speed shaft, and rotor brake. The electrical system includes the generator, switchgear, transformer, and utility connection. The control systems are the blade pitch, yaw, and generator control, and the safety system. Manual, automatic, and remote control are discussed. Systems analyses on dynamic loads and fatigue are presented.

Circuit board accident--organizational dimension hidden by prescribed safety.

PubMed

de Almeida, Ildeberto Muniz; Buoso, Eduardo; do Amaral Dias, Maria Dionísia; Vilela, Rodolfo Andrade Gouveia

2012-01-01

This study analyzes an accident in which two maintenance workers suffered severe burns while replacing a circuit breaker panel in a steel mill, following model of analysis and prevention of accidents (MAPA) developed with the objective of enlarging the perimeter of interventions and contributing to deconstruction of blame attribution practices. The study was based on materials produced by a health service team in an in-depth analysis of the accident. The analysis shows that decisions related to system modernization were taken without considering their implications in maintenance scheduling and creating conflicts of priorities and of interests between production and safety; and also reveals that the lack of a systemic perspective in safety management was its principal failure. To explain the accident as merely non-fulfillment of idealized formal safety rules feeds practices of blame attribution supported by alibi norms and inhibits possible prevention. In contrast, accident analyses undertaken in worker health surveillance services show potential to reveal origins of these events incubated in the history of the system ignored in practices guided by the traditional paradigm.

48 CFR 252.246-7003 - Notification of Potential Safety Issues.

Code of Federal Regulations, 2013 CFR

2013-10-01

.... Critical safety item means a part, subassembly, assembly, subsystem, installation equipment, or support... impact for systems, or subsystems, assemblies, subassemblies, or parts integral to a system, acquired by... the extent known at the time of notification; (iv) A point of contact to coordinate problem analysis...

48 CFR 252.246-7003 - Notification of Potential Safety Issues.

Code of Federal Regulations, 2010 CFR

2010-10-01

.... Critical safety item means a part, subassembly, assembly, subsystem, installation equipment, or support... impact for systems, or subsystems, assemblies, subassemblies, or parts integral to a system, acquired by... the extent known at the time of notification; (iv) A point of contact to coordinate problem analysis...

48 CFR 252.246-7003 - Notification of Potential Safety Issues.

Code of Federal Regulations, 2011 CFR

2011-10-01

.... Critical safety item means a part, subassembly, assembly, subsystem, installation equipment, or support... impact for systems, or subsystems, assemblies, subassemblies, or parts integral to a system, acquired by... the extent known at the time of notification; (iv) A point of contact to coordinate problem analysis...

48 CFR 252.246-7003 - Notification of Potential Safety Issues.

Code of Federal Regulations, 2012 CFR

2012-10-01

.... Critical safety item means a part, subassembly, assembly, subsystem, installation equipment, or support... impact for systems, or subsystems, assemblies, subassemblies, or parts integral to a system, acquired by... the extent known at the time of notification; (iv) A point of contact to coordinate problem analysis...

48 CFR 252.246-7003 - Notification of Potential Safety Issues.

Code of Federal Regulations, 2014 CFR

2014-10-01

.... Critical safety item means a part, subassembly, assembly, subsystem, installation equipment, or support... impact for systems, or subsystems, assemblies, subassemblies, or parts integral to a system, acquired by... the extent known at the time of notification; (iv) A point of contact to coordinate problem analysis...

Evaluation of the comfort and convenience of safety belt systems in 1980 and 1981 model vehicles

DOT National Transportation Integrated Search

1981-03-01

An analysis was conducted of both user and vehicle characteristics that influence the user perceptions of safety belt system comfort and convenience. A research design was developed involving various passenger cars, vans, and pickups, and a set of dr...

System analysis of vehicle active safety problem

NASA Astrophysics Data System (ADS)

Buznikov, S. E.

2018-02-01

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

Safety analysis report for packaging, onsite, long-length contaminated equipment transport system

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

McCormick, W.A.

1997-05-09

This safety analysis report for packaging describes the components of the long-length contaminated equipment (LLCE) transport system (TS) and provides the analyses, evaluations, and associated operational controls necessary for the safe use of the LLCE TS on the Hanford Site. The LLCE TS will provide a standardized, comprehensive approach for the disposal of approximately 98% of LLCE scheduled to be removed from the 200 Area waste tanks.

SCALE Code System

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

Rearden, Bradley T.; Jessee, Matthew Anderson

The SCALE Code System is a widely-used modeling and simulation suite for nuclear safety analysis and design that is developed, maintained, tested, and managed by the Reactor and Nuclear Systems Division (RNSD) of Oak Ridge National Laboratory (ORNL). SCALE provides a comprehensive, verified and validated, user-friendly tool set for criticality safety, reactor and lattice physics, radiation shielding, spent fuel and radioactive source term characterization, and sensitivity and uncertainty analysis. Since 1980, regulators, licensees, and research institutions around the world have used SCALE for safety analysis and design. SCALE provides an integrated framework with dozens of computational modules including three deterministicmore » and three Monte Carlo radiation transport solvers that are selected based on the desired solution strategy. SCALE includes current nuclear data libraries and problem-dependent processing tools for continuous-energy (CE) and multigroup (MG) neutronics and coupled neutron-gamma calculations, as well as activation, depletion, and decay calculations. SCALE includes unique capabilities for automated variance reduction for shielding calculations, as well as sensitivity and uncertainty analysis. SCALE’s graphical user interfaces assist with accurate system modeling, visualization of nuclear data, and convenient access to desired results.« less

SCALE Code System 6.2.1

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

Rearden, Bradley T.; Jessee, Matthew Anderson

The SCALE Code System is a widely-used modeling and simulation suite for nuclear safety analysis and design that is developed, maintained, tested, and managed by the Reactor and Nuclear Systems Division (RNSD) of Oak Ridge National Laboratory (ORNL). SCALE provides a comprehensive, verified and validated, user-friendly tool set for criticality safety, reactor and lattice physics, radiation shielding, spent fuel and radioactive source term characterization, and sensitivity and uncertainty analysis. Since 1980, regulators, licensees, and research institutions around the world have used SCALE for safety analysis and design. SCALE provides an integrated framework with dozens of computational modules including three deterministicmore » and three Monte Carlo radiation transport solvers that are selected based on the desired solution strategy. SCALE includes current nuclear data libraries and problem-dependent processing tools for continuous-energy (CE) and multigroup (MG) neutronics and coupled neutron-gamma calculations, as well as activation, depletion, and decay calculations. SCALE includes unique capabilities for automated variance reduction for shielding calculations, as well as sensitivity and uncertainty analysis. SCALE’s graphical user interfaces assist with accurate system modeling, visualization of nuclear data, and convenient access to desired results.« less

The Role of Probabilistic Design Analysis Methods in Safety and Affordability

NASA Technical Reports Server (NTRS)

Safie, Fayssal M.

2016-01-01

For the last several years, NASA and its contractors have been working together to build space launch systems to commercialize space. Developing commercial affordable and safe launch systems becomes very important and requires a paradigm shift. This paradigm shift enforces the need for an integrated systems engineering environment where cost, safety, reliability, and performance need to be considered to optimize the launch system design. In such an environment, rule based and deterministic engineering design practices alone may not be sufficient to optimize margins and fault tolerance to reduce cost. As a result, introduction of Probabilistic Design Analysis (PDA) methods to support the current deterministic engineering design practices becomes a necessity to reduce cost without compromising reliability and safety. This paper discusses the importance of PDA methods in NASA's new commercial environment, their applications, and the key role they can play in designing reliable, safe, and affordable launch systems. More specifically, this paper discusses: 1) The involvement of NASA in PDA 2) Why PDA is needed 3) A PDA model structure 4) A PDA example application 5) PDA link to safety and affordability.

Software safety - A user's practical perspective

NASA Technical Reports Server (NTRS)

Dunn, William R.; Corliss, Lloyd D.

1990-01-01

Software safety assurance philosophy and practices at the NASA Ames are discussed. It is shown that, to be safe, software must be error-free. Software developments on two digital flight control systems and two ground facility systems are examined, including the overall system and software organization and function, the software-safety issues, and their resolution. The effectiveness of safety assurance methods is discussed, including conventional life-cycle practices, verification and validation testing, software safety analysis, and formal design methods. It is concluded (1) that a practical software safety technology does not yet exist, (2) that it is unlikely that a set of general-purpose analytical techniques can be developed for proving that software is safe, and (3) that successful software safety-assurance practices will have to take into account the detailed design processes employed and show that the software will execute correctly under all possible conditions.

Try Fault Tree Analysis, a Step-by-Step Way to Improve Organization Development.

ERIC Educational Resources Information Center

Spitzer, Dean

1980-01-01

Fault Tree Analysis, a systems safety engineering technology used to analyze organizational systems, is described. Explains the use of logic gates to represent the relationship between failure events, qualitative analysis, quantitative analysis, and effective use of Fault Tree Analysis. (CT)

The arrangement of deformation monitoring project and analysis of monitoring data of a hydropower engineering safety monitoring system

NASA Astrophysics Data System (ADS)

Wang, Wanshun; Chen, Zhuo; Li, Xiuwen

2018-03-01

The safety monitoring is very important in the operation and management of water resources and hydropower projects. It is the important means to understand the dam running status, to ensure the dam safety, to safeguard people’s life and property security, and to make full use of engineering benefits. This paper introduces the arrangement of engineering safety monitoring system based on the example of a water resource control project. The monitoring results of each monitoring project are analyzed intensively to show the operating status of the monitoring system and to provide useful reference for similar projects.

Deep Borehole Disposal Safety Analysis.

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

Freeze, Geoffrey A.; Stein, Emily; Price, Laura L.

This report presents a preliminary safety analysis for the deep borehole disposal (DBD) concept, using a safety case framework. A safety case is an integrated collection of qualitative and quantitative arguments, evidence, and analyses that substantiate the safety, and the level of confidence in the safety, of a geologic repository. This safety case framework for DBD follows the outline of the elements of a safety case, and identifies the types of information that will be required to satisfy these elements. At this very preliminary phase of development, the DBD safety case focuses on the generic feasibility of the DBD concept.more » It is based on potential system designs, waste forms, engineering, and geologic conditions; however, no specific site or regulatory framework exists. It will progress to a site-specific safety case as the DBD concept advances into a site-specific phase, progressing through consent-based site selection and site investigation and characterization.« less

NASA-Langley Research Center's Aircraft Condition Analysis and Management System Implementation

NASA Technical Reports Server (NTRS)

Frye, Mark W.; Bailey, Roger M.; Jessup, Artie D.

2004-01-01

This document describes the hardware implementation design and architecture of Aeronautical Radio Incorporated (ARINC)'s Aircraft Condition Analysis and Management System (ACAMS), which was developed at NASA-Langley Research Center (LaRC) for use in its Airborne Research Integrated Experiments System (ARIES) Laboratory. This activity is part of NASA's Aviation Safety Program (AvSP), the Single Aircraft Accident Prevention (SAAP) project to develop safety-enabling technologies for aircraft and airborne systems. The fundamental intent of these technologies is to allow timely intervention or remediation to improve unsafe conditions before they become life threatening.

Rasmussen's legacy: A paradigm change in engineering for safety.

PubMed

Leveson, Nancy G

2017-03-01

This paper describes three applications of Rasmussen's idea to systems engineering practice. The first is the application of the abstraction hierarchy to engineering specifications, particularly requirements specification. The second is the use of Rasmussen's ideas in safety modeling and analysis to create a new, more powerful type of accident causation model that extends traditional models to better handle human-operated, software-intensive, sociotechnical systems. Because this new model has a formal, mathematical foundation built on systems theory (as was Rasmussen's original model), new modeling and analysis tools become possible. The third application is to engineering hazard analysis. Engineers have traditionally either omitted human from consideration in system hazard analysis or have treated them rather superficially, for example, that they behave randomly. Applying Rasmussen's model of human error to a powerful new hazard analysis technique allows human behavior to be included in engineering hazard analysis. Copyright © 2016 Elsevier Ltd. All rights reserved.

Systems, methods and apparatus for quiesence of autonomic safety devices with self action

NASA Technical Reports Server (NTRS)

Hinchey, Michael G. (Inventor); Sterritt, Roy (Inventor)

2011-01-01

Systems, methods and apparatus are provided through which in some embodiments an autonomic environmental safety device may be quiesced. In at least one embodiment, a method for managing an autonomic safety device, such as a smoke detector, based on functioning state and operating status of the autonomic safety device includes processing received signals from the autonomic safety device to obtain an analysis of the condition of the autonomic safety device, generating one or more stay-awake signals based on the functioning status and the operating state of the autonomic safety device, transmitting the stay-awake signal, transmitting self health/urgency data, and transmitting environment health/urgency data. A quiesce component of an autonomic safety device can render the autonomic safety device inactive for a specific amount of time or until a challenging situation has passed.

The use of experimental data in an MTR-type nuclear reactor safety analysis

NASA Astrophysics Data System (ADS)

Day, Simon E.

Reactivity initiated accidents (RIAs) are a category of events required for research reactor safety analysis. A subset of this is unprotected RIAs in which mechanical systems or human intervention are not credited in the response of the system. Light-water cooled and moderated MTR-type ( i.e., aluminum-clad uranium plate fuel) reactors are self-limiting up to some reactivity insertion limit beyond which fuel damage occurs. This characteristic was studied in the Borax and Spert reactor tests of the 1950s and 1960s in the USA. This thesis considers the use of this experimental data in generic MTR-type reactor safety analysis. The approach presented herein is based on fundamental phenomenological understanding and uses correlations in the reactor test data with suitable account taken for differences in important system parameters. Specifically, a semi-empirical approach is used to quantify the relationship between the power, energy and temperature rise response of the system as well as parametric dependencies on void coefficient and the degree of subcooling. Secondary effects including the dependence on coolant flow are also examined. A rigorous curve fitting approach and error assessment is used to quantify the trends in the experimental data. In addition to the initial power burst stage of an unprotected transient, the longer term stability of the system is considered with a stylized treatment of characteristic power/temperature oscillations (chugging). A bridge from the HEU-based experimental data to the LEU fuel cycle is assessed and outlined based on existing simulation results presented in the literature. A cell-model based parametric study is included. The results are used to construct a practical safety analysis methodology for determining reactivity insertion safety limits for a light-water moderated and cooled MTR-type core.

78 FR 70398 - Proposed Agency Information Collection Activities; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-25

... System Evaluation-Related Interview Data Collection. OMB Control Number: 2130-0574. Type of Request... approaches to improving safety, FRA has instituted the Confidential Close Call Reporting System (C\\3\\RS). The... reporting component, and a problem analysis/solution component. C\\3\\RS is expected to affect safety in two...

Human factors in airport surface incidents : an analysis of pilot reports submitted to the Aviation Safety Reporting System (ASRS)

DOT National Transportation Integrated Search

2006-12-01

The purpose of this study was to examine human factors involved in airport surface incidents as reported by pilots. Reports submitted to the : Aviation Safety Reporting System (ASRS) are a good source of information regarding the human performance is...

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

DTIC Science & Technology

2016-06-01

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

Evaluation of the safety performance of highway alignments based on fault tree analysis and safety boundaries.

PubMed

Chen, Yikai; Wang, Kai; Xu, Chengcheng; Shi, Qin; He, Jie; Li, Peiqing; Shi, Ting

2018-05-19

To overcome the limitations of previous highway alignment safety evaluation methods, this article presents a highway alignment safety evaluation method based on fault tree analysis (FTA) and the characteristics of vehicle safety boundaries, within the framework of dynamic modeling of the driver-vehicle-road system. Approaches for categorizing the vehicle failure modes while driving on highways and the corresponding safety boundaries were comprehensively investigated based on vehicle system dynamics theory. Then, an overall crash probability model was formulated based on FTA considering the risks of 3 failure modes: losing steering capability, losing track-holding capability, and rear-end collision. The proposed method was implemented on a highway segment between Bengbu and Nanjing in China. A driver-vehicle-road multibody dynamics model was developed based on the 3D alignments of the Bengbu to Nanjing section of Ning-Luo expressway using Carsim, and the dynamics indices, such as sideslip angle and, yaw rate were obtained. Then, the average crash probability of each road section was calculated with a fixed-length method. Finally, the average crash probability was validated against the crash frequency per kilometer to demonstrate the accuracy of the proposed method. The results of the regression analysis and correlation analysis indicated good consistency between the results of the safety evaluation and the crash data and that it outperformed the safety evaluation methods used in previous studies. The proposed method has the potential to be used in practical engineering applications to identify crash-prone locations and alignment deficiencies on highways in the planning and design phases, as well as those in service.

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

PubMed

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

2016-11-01

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

Development and Present Situation Analysis of Power Transformer State Maintenance

NASA Astrophysics Data System (ADS)

Lv, Sen; Li, Biao; Li, Huan

2018-02-01

The pivotal status of power transformer in the power system is one of the most important equipment. The safety and reliability of its operation is directly related to the safety and stability of power system. Based on the analysis of the present situation of power transformer state maintenance in home and abroad. The paper points out the deficiency of the current method and provides a theoretical basis for further research, which has a certain guiding significance.

Do not blame the driver: a systems analysis of the causes of road freight crashes.

PubMed

Newnam, Sharon; Goode, Natassia

2015-03-01

Although many have advocated a systems approach in road transportation, this view has not meaningfully penetrated road safety research, practice or policy. In this study, a systems theory-based approach, Rasmussens's (1997) risk management framework and associated Accimap technique, is applied to the analysis of road freight transportation crashes. Twenty-seven highway crash investigation reports were downloaded from the National Transport Safety Bureau website. Thematic analysis was used to identify the complex system of contributory factors, and relationships, identified within the reports. The Accimap technique was then used to represent the linkages and dependencies within and across system levels in the road freight transportation industry and to identify common factors and interactions across multiple crashes. The results demonstrate how a systems approach can increase knowledge in this safety critical domain, while the findings can be used to guide prevention efforts and the development of system-based investigation processes for the heavy vehicle industry. A research agenda for developing an investigation technique to better support the application of the Accimap technique by practitioners in road freight transportation industry is proposed. Copyright © 2015 Elsevier Ltd. All rights reserved.

Model-based safety analysis of human-robot interactions: the MIRAS walking assistance robot.

PubMed

Guiochet, Jérémie; Hoang, Quynh Anh Do; Kaaniche, Mohamed; Powell, David

2013-06-01

Robotic systems have to cope with various execution environments while guaranteeing safety, and in particular when they interact with humans during rehabilitation tasks. These systems are often critical since their failure can lead to human injury or even death. However, such systems are difficult to validate due to their high complexity and the fact that they operate within complex, variable and uncertain environments (including users), in which it is difficult to foresee all possible system behaviors. Because of the complexity of human-robot interactions, rigorous and systematic approaches are needed to assist the developers in the identification of significant threats and the implementation of efficient protection mechanisms, and in the elaboration of a sound argumentation to justify the level of safety that can be achieved by the system. For threat identification, we propose a method called HAZOP-UML based on a risk analysis technique adapted to system description models, focusing on human-robot interaction models. The output of this step is then injected in a structured safety argumentation using the GSN graphical notation. Those approaches have been successfully applied to the development of a walking assistant robot which is now in clinical validation.

Comparison of a Traditional Probabilistic Risk Assessment Approach with Advanced Safety Analysis

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

Smith, Curtis L; Mandelli, Diego; Zhegang Ma

2014-11-01

As part of the Light Water Sustainability Program (LWRS) [1], the purpose of the Risk Informed Safety Margin Characterization (RISMC) [2] Pathway research and development (R&D) is to support plant decisions for risk-informed margin management with the aim to improve economics, reliability, and sustain safety of current NPPs. In this paper, we describe the RISMC analysis process illustrating how mechanistic and probabilistic approaches are combined in order to estimate a safety margin. We use the scenario of a “station blackout” (SBO) wherein offsite power and onsite power is lost, thereby causing a challenge to plant safety systems. We describe themore » RISMC approach, illustrate the station blackout modeling, and contrast this with traditional risk analysis modeling for this type of accident scenario. We also describe our approach we are using to represent advanced flooding analysis.« less

41 CFR 102-80.110 - What must an equivalent level of safety analysis indicate?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 41 Public Contracts and Property Management 3 2010-07-01 2010-07-01 false What must an equivalent... Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION REAL PROPERTY 80-SAFETY AND ENVIRONMENTAL MANAGEMENT Accident and Fire Prevention Equivalent Level of Safety...

Driver performance measurement and analysis system (DPMAS). Volume 1, Description and operations manual

DOT National Transportation Integrated Search

1976-08-01

A prototype driver performance measurement and analysis system (DPMAS) has been developed for the National Highway Traffic Safety Administration (NHTSA). This system includes a completely instrumented 1974 Chevrolet Impala capable of digitally record...

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

MITCHELL,GERRY W.; LONGLEY,SUSAN W.; PHILBIN,JEFFREY S.

This Safety Analysis Report (SAR) is prepared in compliance with the requirements of DOE Order 5480.23, Nuclear Safety Analysis Reports, and has been written to the format and content guide of DOE-STD-3009-94 Preparation Guide for U. S. Department of Energy Nonreactor Nuclear Safety Analysis Reports. The Hot Cell Facility is a Hazard Category 2 nonreactor nuclear facility, and is operated by Sandia National Laboratories for the Department of Energy. This SAR provides a description of the HCF and its operations, an assessment of the hazards and potential accidents which may occur in the facility. The potential consequences and likelihood ofmore » these accidents are analyzed and described. Using the process and criteria described in DOE-STD-3009-94, safety-related structures, systems and components are identified, and the important safety functions of each SSC are described. Additionally, information which describes the safety management programs at SNL are described in ancillary chapters of the SAR.« less

Analysis of general aviation single-pilot IFR incident data obtained from the NASA aviation safety reporting system

NASA Technical Reports Server (NTRS)

Bergeron, H. P.

1980-01-01

Data obtained from the NASA Aviation Safety Reporting System (ASRS) data base were used to determine problems in general aviation single pilot IFR operations. The data examined consisted of incident reports involving flight safety in the National Aviation System. Only those incidents involving general aviation fixed wing aircraft flying under IFR in instrument meteorological conditions were analyzed. The data were cataloged into one of five major problem areas: (1) controller judgement and response problems; (2) pilot judgement and response problems; (3) air traffic control intrafacility and interfacility conflicts; (4) ATC and pilot communications problems; and (5) IFR-VFR conflicts. The significance of the related problems, and the various underlying elements associated with each are discussed. Previous ASRS reports covering several areas of analysis are reviewed.

Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database.

PubMed

Cooper, Jennifer; Edwards, Adrian; Williams, Huw; Sheikh, Aziz; Parry, Gareth; Hibbert, Peter; Butlin, Amy; Donaldson, Liam; Carson-Stevens, Andrew

2017-09-01

A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent of blame attribution in safety incident reports, which may reflect the underlying safety culture of health care systems, is unknown. This study set out to explore the nature of blame in family practice safety incident reports. We characterized a random sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System. Reports were analyzed according to prespecified classification systems to describe the incident type, contributory factors, outcomes, and severity of harm. We developed a taxonomy of blame attribution, and we then used descriptive statistical analyses to identify the proportions of blame types and to explore associations between incident characteristics and one type of blame. Health care professionals making family practice incident reports attributed blame to a person in 45% of cases (n = 975 of 2,148; 95% CI, 43%-47%). In 36% of cases, those who reported the incidents attributed fault to another person, whereas 2% of those reporting acknowledged personal responsibility. Blame was commonly associated with incidents where a complaint was anticipated. The high frequency of blame in these safety, incident reports may reflect a health care culture that leads to blame and retribution, rather than to identifying areas for learning and improvement, and a failure to appreciate the contribution of system factors in others' behavior. Successful improvement in patient safety through the analysis of incident reports is unlikely without achieving a blame-free culture. © 2017 Annals of Family Medicine, Inc.

Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database

PubMed Central

Cooper, Jennifer; Edwards, Adrian; Williams, Huw; Sheikh, Aziz; Parry, Gareth; Hibbert, Peter; Butlin, Amy; Donaldson, Liam; Carson-Stevens, Andrew

2017-01-01

PURPOSE A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent of blame attribution in safety incident reports, which may reflect the underlying safety culture of health care systems, is unknown. This study set out to explore the nature of blame in family practice safety incident reports. METHODS We characterized a random sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System. Reports were analyzed according to prespecified classification systems to describe the incident type, contributory factors, outcomes, and severity of harm. We developed a taxonomy of blame attribution, and we then used descriptive statistical analyses to identify the proportions of blame types and to explore associations between incident characteristics and one type of blame. RESULTS Health care professionals making family practice incident reports attributed blame to a person in 45% of cases (n = 975 of 2,148; 95% CI, 43%–47%). In 36% of cases, those who reported the incidents attributed fault to another person, whereas 2% of those reporting acknowledged personal responsibility. Blame was commonly associated with incidents where a complaint was anticipated. CONCLUSIONS The high frequency of blame in these safety, incident reports may reflect a health care culture that leads to blame and retribution, rather than to identifying areas for learning and improvement, and a failure to appreciate the contribution of system factors in others’ behavior. Successful improvement in patient safety through the analysis of incident reports is unlikely without achieving a blame-free culture. PMID:28893816

AADL Fault Modeling and Analysis Within an ARP4761 Safety Assessment

DTIC Science & Technology

2014-10-01

Analysis Generator 27 3.2.3 Mapping to OpenFTA Format File 27 3.2.4 Mapping to Generic XML Format 28 3.2.5 AADL and FTA Mapping Rules 28 3.2.6 Issues...PSSA), System Safety Assessment (SSA), Common Cause Analysis (CCA), Fault Tree Analysis ( FTA ), Failure Modes and Effects Analysis (FMEA), Failure...Modes and Effects Summary, Mar - kov Analysis (MA), and Dependence Diagrams (DDs), also referred to as Reliability Block Dia- grams (RBDs). The

Analyzing system safety in lithium-ion grid energy storage

DOE PAGES

Rosewater, David; Williams, Adam

2015-10-08

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

Probabilistic Risk Assessment Procedures Guide for NASA Managers and Practitioners (Second Edition)

NASA Technical Reports Server (NTRS)

Stamatelatos,Michael; Dezfuli, Homayoon; Apostolakis, George; Everline, Chester; Guarro, Sergio; Mathias, Donovan; Mosleh, Ali; Paulos, Todd; Riha, David; Smith, Curtis;

Automated Mixed Traffic Vehicle (AMTV) technology and safety study

NASA Technical Reports Server (NTRS)

Johnston, A. R.; Peng, T. K. C.; Vivian, H. C.; Wang, P. K.

1978-01-01

Technology and safety related to the implementation of an Automated Mixed Traffic Vehicle (AMTV) system are discussed. System concepts and technology status were reviewed and areas where further development is needed are identified. Failure and hazard modes were also analyzed and methods for prevention were suggested. The results presented are intended as a guide for further efforts in AMTV system design and technology development for both near term and long term applications. The AMTV systems discussed include a low speed system, and a hybrid system consisting of low speed sections and high speed sections operating in a semi-guideway. The safety analysis identified hazards that may arise in a properly functioning AMTV system, as well as hardware failure modes. Safety related failure modes were emphasized. A risk assessment was performed in order to create a priority order and significant hazards and failure modes were summarized. Corrective measures were proposed for each hazard.

The Aviation System Monitoring and Modeling (ASMM) Project: A Documentation of its History and Accomplishments: 1999-2005

NASA Technical Reports Server (NTRS)

Statler, Irving C. (Editor)

2007-01-01

The Aviation System Monitoring and Modeling (ASMM) Project was one of the projects within NASA s Aviation Safety Program from 1999 through 2005. The objective of the ASMM Project was to develop the technologies to enable the aviation industry to undertake a proactive approach to the management of its system-wide safety risks. The ASMM Project entailed four interdependent elements: (1) Data Analysis Tools Development - develop tools to convert numerical and textual data into information; (2) Intramural Monitoring - test and evaluate the data analysis tools in operational environments; (3) Extramural Monitoring - gain insight into the aviation system performance by surveying its front-line operators; and (4) Modeling and Simulations - provide reliable predictions of the system-wide hazards, their causal factors, and their operational risks that may result from the introduction of new technologies, new procedures, or new operational concepts. This report is a documentation of the history of this highly successful project and of its many accomplishments and contributions to improved safety of the aviation system.

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

NASA Astrophysics Data System (ADS)

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

2016-07-01

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

Fault Tree Analysis Application for Safety and Reliability

NASA Technical Reports Server (NTRS)

Wallace, Dolores R.

2003-01-01

Many commercial software tools exist for fault tree analysis (FTA), an accepted method for mitigating risk in systems. The method embedded in the tools identifies a root as use in system components, but when software is identified as a root cause, it does not build trees into the software component. No commercial software tools have been built specifically for development and analysis of software fault trees. Research indicates that the methods of FTA could be applied to software, but the method is not practical without automated tool support. With appropriate automated tool support, software fault tree analysis (SFTA) may be a practical technique for identifying the underlying cause of software faults that may lead to critical system failures. We strive to demonstrate that existing commercial tools for FTA can be adapted for use with SFTA, and that applied to a safety-critical system, SFTA can be used to identify serious potential problems long before integrator and system testing.

Mission safety evaluation report for STS-35: Postflight edition

NASA Technical Reports Server (NTRS)

Hill, William C.; Finkel, Seymour I.

1991-01-01

Space Transportation System 35 (STS-35) safety risk factors that represent a change from previous flights that had an impact on this flight, and factors that were unique to this flight are discussed. While some changes to the safety risk baseline since the previous flight are included to highlight their significance in risk level change, the primary purpose is to insure that changes which were too late too include in formal changes through the Failure Modes and Effects Analysis/Critical Items List (FMEA/CIL) and Hazard Analysis process are documented along with the safety position, which includes the acceptance rationale.

Safety Management Information Statistics (SAMIS) - 1995 Annual Report

DOT National Transportation Integrated Search

1997-04-01

The Safety Management Information Statistics 1995 Annual Report is a compilation and analysis of transit accident, casualty and crime statistics reported under the Federal Transit Administration's National Transit Database Reporting by transit system...

Injuries Associated With Hazards Involving Motor Vehicle Power Windows

DOT National Transportation Integrated Search

1997-05-01

National Highway Traffic Safety Administration's (NHTSA) National Center for : Statistics and Analysis (NCSA) recently completed a study of data from the : Consumer Product Safety Commission's (CPSC) National Electronic Injury : Surveillance System (...

Management system of health and safety work (SMK3) with job safety analysis (JSA) in PT. Nira Murni construction

NASA Astrophysics Data System (ADS)

Melliana, Armen, Yusrizal, Akmal, Syarifah

2017-11-01

PT Nira Murni construction is a contractor of PT Chevron Pacific Indonesia which engaged in contractor, fabrication, maintenance construction suppliers, and labor services. The high of accident rate in this company is caused the lack of awareness of workplace safety. Therefore, it requires an effort to reduce the accident rate on the company so that the financial losses can be minimized. In this study, Safe T-Score method is used to analyze the accident rate by measuring the level of frequency. Analysis is continued using risk management methods which identify hazards, risk measurement and risk management. The last analysis uses Job safety analysis (JSA) which will identify the effect of accidents. From the result of this study can be concluded that Job Safety Analysis (JSA) methods has not been implemented properly. Therefore, JSA method needs to follow-up in the next study, so that can be well applied as prevention of occupational accidents.

Traffic safety facts 1996 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

1997-12-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

Safety of High Speed Guided Ground Transportation Systems - Magnetic and Electric Field Testing of the Massachusetts Bay Transportation Authority (MBTA) Urban Transit System: Volume I - Analysis

DOT National Transportation Integrated Search

1993-06-01

The safety of magnetlcally levitated (maglev) and high speed rail (HSR) trains proposed for application in the : United States is the responsibility of the Federal Railroad Administratlon (FRA). Plans for near future US applications : include maglev ...

Safety of High Speed Guided Ground Transportation Systems : Magnetic and Electric Field Testing of the Washington Metropolitan Area Transit Authority Metrorail System. v. 1. Analysis.

DOT National Transportation Integrated Search

1993-06-01

The safety of magnetically levitated (maglev) and high speed rail (HSR) trains proposed for application in the United States is the responsibility of the Federal Railroad Administration (FRA). Plans for near future US applications include maglev tech...

14 CFR 415.129 - Flight safety system test data.

Code of Federal Regulations, 2012 CFR

2012-01-01

..., acceptance, age surveillance, and preflight testing of a flight safety system and its subsystems and..., subsystem, and component testing requirements of part 417 of this chapter and appendix E to part 417 of this... demonstrate similarity by performing the analysis required by appendix E of part 417 of this chapter. The...

14 CFR 415.129 - Flight safety system test data.

Code of Federal Regulations, 2011 CFR

2011-01-01

..., acceptance, age surveillance, and preflight testing of a flight safety system and its subsystems and..., subsystem, and component testing requirements of part 417 of this chapter and appendix E to part 417 of this... demonstrate similarity by performing the analysis required by appendix E of part 417 of this chapter. The...

14 CFR 415.129 - Flight safety system test data.

Code of Federal Regulations, 2013 CFR

2013-01-01

..., acceptance, age surveillance, and preflight testing of a flight safety system and its subsystems and..., subsystem, and component testing requirements of part 417 of this chapter and appendix E to part 417 of this... demonstrate similarity by performing the analysis required by appendix E of part 417 of this chapter. The...

14 CFR 415.129 - Flight safety system test data.

Code of Federal Regulations, 2010 CFR

2010-01-01

..., acceptance, age surveillance, and preflight testing of a flight safety system and its subsystems and..., subsystem, and component testing requirements of part 417 of this chapter and appendix E to part 417 of this... demonstrate similarity by performing the analysis required by appendix E of part 417 of this chapter. The...

14 CFR 415.129 - Flight safety system test data.

Code of Federal Regulations, 2014 CFR

2014-01-01

..., acceptance, age surveillance, and preflight testing of a flight safety system and its subsystems and..., subsystem, and component testing requirements of part 417 of this chapter and appendix E to part 417 of this... demonstrate similarity by performing the analysis required by appendix E of part 417 of this chapter. The...

Traffic safety facts 2005 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

2006-01-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

Traffic safety facts 2006 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

2007-01-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

A 1064 nm dispersive Raman spectral imaging system for food safety and quality evaluation

USDA-ARS?s Scientific Manuscript database

Raman spectral imaging is an effective method to analyze and evaluate chemical composition and structure of a sample, and has many applications for food safety and quality research. This study developed a 1064 nm Raman spectral imaging system for surface and subsurface analysis of food samples. A 10...

Traffic safety facts 2000 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

2001-12-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

Traffic safety facts 2001 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

2002-12-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

Traffic safety facts 1998 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

1999-10-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

Traffic safety facts 2002 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

2004-01-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

Traffic safety facts 2003 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

2005-01-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

Traffic safety facts 1999 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

2000-12-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

Traffic safety facts 1994 : a compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system

DOT National Transportation Integrated Search

1995-08-01

This annual report presents descriptive statistics about traffic crashes of all severities, from those that result in property damage to those that result in the loss of human life. Information from two of the National Highway Traffic Safety Administ...

RPP-PRT-58489, Revision 1, One Systems Consistent Safety Analysis Methodologies Report. 24590-WTP-RPT-MGT-15-014

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

Gupta, Mukesh; Niemi, Belinda; Paik, Ingle

2015-09-02

In 2012, One System Nuclear Safety performed a comparison of the safety bases for the Tank Farms Operations Contractor (TOC) and Hanford Tank Waste Treatment and Immobilization Plant (WTP) (RPP-RPT-53222 / 24590-WTP-RPT-MGT-12-018, “One System Report of Comparative Evaluation of Safety Bases for Hanford Waste Treatment and Immobilization Plant Project and Tank Operations Contract”), and identified 25 recommendations that required further evaluation for consensus disposition. This report documents ten NSSC approved consistent methodologies and guides and the results of the additional evaluation process using a new set of evaluation criteria developed for the evaluation of the new methodologies.

Establishing a culture for patient safety - the role of education.

PubMed

Milligan, Frank J

2007-02-01

This paper argues that the process of making significant moves towards a patient safety culture requires changes in healthcare education. Improvements in patient safety are a shared international priority as too many errors and other forms of unnecessary harm are currently occurring in the process of caring for and treating patients. A description of the patient safety agenda is given followed by a brief analysis of human factors theory and its use in other safety critical industries, most notably aviation. The all too common problem of drug administration errors is used to illustrate the relevance of human factors theory to healthcare education with specific mention made of the Human Factors Analysis and Classification System (HFACS).

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

Guo, Z.; Zweibaum, N.; Shao, M.

The University of California, Berkeley (UCB) is performing thermal hydraulics safety analysis to develop the technical basis for design and licensing of fluoride-salt-cooled, high-temperature reactors (FHRs). FHR designs investigated by UCB use natural circulation for emergency, passive decay heat removal when normal decay heat removal systems fail. The FHR advanced natural circulation analysis (FANCY) code has been developed for assessment of passive decay heat removal capability and safety analysis of these innovative system designs. The FANCY code uses a one-dimensional, semi-implicit scheme to solve for pressure-linked mass, momentum and energy conservation equations. Graph theory is used to automatically generate amore » staggered mesh for complicated pipe network systems. Heat structure models have been implemented for three types of boundary conditions (Dirichlet, Neumann and Robin boundary conditions). Heat structures can be composed of several layers of different materials, and are used for simulation of heat structure temperature distribution and heat transfer rate. Control models are used to simulate sequences of events or trips of safety systems. A proportional-integral controller is also used to automatically make thermal hydraulic systems reach desired steady state conditions. A point kinetics model is used to model reactor kinetics behavior with temperature reactivity feedback. The underlying large sparse linear systems in these models are efficiently solved by using direct and iterative solvers provided by the SuperLU code on high performance machines. Input interfaces are designed to increase the flexibility of simulation for complicated thermal hydraulic systems. In conclusion, this paper mainly focuses on the methodology used to develop the FANCY code, and safety analysis of the Mark 1 pebble-bed FHR under development at UCB is performed.« less

A Smartphone-Based Driver Safety Monitoring System Using Data Fusion

PubMed Central

Lee, Boon-Giin; Chung, Wan-Young

2012-01-01

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

A Microbial Assessment Scheme to measure microbial performance of Food Safety Management Systems.

PubMed

Jacxsens, L; Kussaga, J; Luning, P A; Van der Spiegel, M; Devlieghere, F; Uyttendaele, M

2009-08-31

A Food Safety Management System (FSMS) implemented in a food processing industry is based on Good Hygienic Practices (GHP), Hazard Analysis Critical Control Point (HACCP) principles and should address both food safety control and assurance activities in order to guarantee food safety. One of the most emerging challenges is to assess the performance of a present FSMS. The objective of this work is to explain the development of a Microbial Assessment Scheme (MAS) as a tool for a systematic analysis of microbial counts in order to assess the current microbial performance of an implemented FSMS. It is assumed that low numbers of microorganisms and small variations in microbial counts indicate an effective FSMS. The MAS is a procedure that defines the identification of critical sampling locations, the selection of microbiological parameters, the assessment of sampling frequency, the selection of sampling method and method of analysis, and finally data processing and interpretation. Based on the MAS assessment, microbial safety level profiles can be derived, indicating which microorganisms and to what extent they contribute to food safety for a specific food processing company. The MAS concept is illustrated with a case study in the pork processing industry, where ready-to-eat meat products are produced (cured, cooked ham and cured, dried bacon).

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

PubMed

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

2002-12-01

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

Defining attributes of patient safety through a concept analysis.

PubMed

Kim, Linda; Lyder, Courtney H; McNeese-Smith, Donna; Leach, Linda Searle; Needleman, Jack

2015-11-01

The aim of this study was to report an analysis of the concept of patient safety. Despite recent increase in the number of work being done to clarify the concept and standardize measurement of patient safety, there are still huge variations in how the term is conceptualized and how to measure patient safety data across various healthcare settings and in research. Concept analysis. A literature search was conducted through PubMed and Cumulative Index to Nursing and Allied Health Literature, Plus using the terms 'patient safety' in the title and 'concept analysis,' 'attributes' or 'definition' in the title and or abstract. All English language literature published between 2002-2014 were considered for the review. Walker and Avant's method guided this analysis. The defining attributes of patient safety include prevention of medical errors and avoidable adverse events, protection of patients from harm or injury and collaborative efforts by individual healthcare providers and a strong, well-integrated healthcare system. The application of Collaborative Alliance of Nursing Outcomes indicators as empirical referents would facilitate the measurement of patient safety. With the knowledge gained from this analysis, nurses may improve patient surveillance efforts that identify potential hazards before they become adverse events and have a stronger voice in health policy decision-making that influence implementation efforts aimed at promoting patient safety, worldwide. Further studies are needed on development of a conceptual model and framework that can aid with collection and measurement of standardized patient safety data. © 2015 John Wiley & Sons Ltd.

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

NASA Astrophysics Data System (ADS)

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

1980-07-01

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

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

NASA Technical Reports Server (NTRS)

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

1980-01-01

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

Analysis of Material Handling Safety in Construction Sites and Countermeasures for Effective Enhancement

PubMed Central

Anil Kumar, C. N.; Sakthivel, M.; Elangovan, R. K.; Arularasu, M.

2015-01-01

One of many hazardous workplaces includes the construction sites as they involve several dangerous tasks. Many studies have revealed that material handling equipment is a major cause of accidents at these sites. Though safety measures are being followed and monitored continuously, accident rates are still high as either workers are unaware of hazards or the safety regulations are not being strictly followed. This paper analyses the safety management systems at construction sites through means of questionnaire surveys with employees, specifically referring to safety of material handling equipment. Based on results of the questionnaire surveys, two construction sites were selected for a safety education program targeting worker safety related to material handling equipment. Knowledge levels of the workers were gathered before and after the program and results obtained were subjected to a t-test analysis to mark significance level of the conducted safety education program. PMID:26446572

Minutes of the Explosives Safety Seminar (20th) Held at OMNI international Hotel, Norfolk, Virginia on 24-26 August 1982. Volume I

DTIC Science & Technology

1982-08-01

between one that provides for total protection of life and property and one that per- mits operators to conduct activities in a " laisse - faire " manner...Workers. AD-PO00 456 General Risk Analysis Methodological Implications to Explosives Risk Management Systems. AD-PO0O 457 Risk Analysis for Explosives...THE EFFECTS OF THE HEALTH AND SAFETY AT WORK ACT, 1974, ON MILITARY EXPLOSIVES SAFETY MANAGEMENT IN THE UNITED KINGDOM ........................ 7 Air

14 CFR 417.113 - Launch safety rules.

Code of Federal Regulations, 2010 CFR

2010-01-01

... flight safety analysis of subpart C of this part. These must include criteria for: (i) Surveillance of... criteria for ensuring that: (i) The flight safety system is operating to ensure the launch vehicle will... source at all times from lift-off to orbit insertion for an orbital launch, to the end of powered flight...

14 CFR 417.113 - Launch safety rules.

Code of Federal Regulations, 2014 CFR

2014-01-01

... flight safety analysis of subpart C of this part. These must include criteria for: (i) Surveillance of... criteria for ensuring that: (i) The flight safety system is operating to ensure the launch vehicle will... source at all times from lift-off to orbit insertion for an orbital launch, to the end of powered flight...

14 CFR 417.113 - Launch safety rules.

Code of Federal Regulations, 2011 CFR

2011-01-01

... flight safety analysis of subpart C of this part. These must include criteria for: (i) Surveillance of... criteria for ensuring that: (i) The flight safety system is operating to ensure the launch vehicle will... source at all times from lift-off to orbit insertion for an orbital launch, to the end of powered flight...

14 CFR 417.113 - Launch safety rules.

Code of Federal Regulations, 2013 CFR

2013-01-01

... flight safety analysis of subpart C of this part. These must include criteria for: (i) Surveillance of... criteria for ensuring that: (i) The flight safety system is operating to ensure the launch vehicle will... source at all times from lift-off to orbit insertion for an orbital launch, to the end of powered flight...

14 CFR 417.113 - Launch safety rules.

Code of Federal Regulations, 2012 CFR

2012-01-01

... flight safety analysis of subpart C of this part. These must include criteria for: (i) Surveillance of... criteria for ensuring that: (i) The flight safety system is operating to ensure the launch vehicle will... source at all times from lift-off to orbit insertion for an orbital launch, to the end of powered flight...

Updated laser safety & hazard analysis for the ARES laser system based on the 2007 ANSI Z136.1 standard.

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

Augustoni, Arnold L.

A laser safety and hazard analysis was performed for the temperature stabilized Big Sky Laser Technology (BSLT) laser central to the ARES system based on the 2007 version of the American National Standards Institutes (ANSI) Standard Z136.1, for Safe Use of Lasers and the 2005 version of the ANSI Standard Z136.6, for Safe Use of Lasers Outdoors. The ARES laser system is a Van/Truck based mobile platform, which is used to perform laser interaction experiments and tests at various national test sites.

Introduction: Aims and Requirements of Future Aerospace Vehicles. Chapter 1

NASA Technical Reports Server (NTRS)

Rodriguez, Pedro I.; Smeltzer, Stanley S., III; McConnaughey, Paul (Technical Monitor)

2001-01-01

The goals and system-level requirements for the next generation aerospace vehicles emphasize safety, reliability, low-cost, and robustness rather than performance. Technologies, including new materials, design and analysis approaches, manufacturing and testing methods, operations and maintenance, and multidisciplinary systems-level vehicle development are key to increasing the safety and reducing the cost of aerospace launch systems. This chapter identifies the goals and needs of the next generation or advanced aerospace vehicle systems.

Drug safety assurance through clinical genotyping: near-term considerations for a system-wide implementation of personalized medicine.

PubMed

Kane, Michael D; Springer, John A; Sprague, Jon E

2008-07-01

The rationale and overall system-wide behavior of a clinical genotyping information system (both DNA analysis and data management) requires a near-term, scalable approach, which is emerging in the focused implementation of pharmacogenomics and drug safety assurance. The challenges to implementing a successful clinical genotyping system are described, as are how the benefits of a focused, near-term system for drug safety assessment and assurance overcome the logistical and operational challenges that perpetually hinder the development of a societal-scale clinical genotyping system. This rationale is based on the premise that a focused application domain for clinical genotyping, specifically drug safety assurance, provides a transition paradigm for both professionals and consumers of healthcare, thereby facilitating the movement of genotyping from bench to bedside and paving the way for the adoption of prognostic and diagnostic applications in clinical genomics.

Comparing international crash statistics

DOT National Transportation Integrated Search

1999-12-01

In order to examine national developments in traffic safety, crash statistics from several of the more safety, crash statistics from several of the more United States. Data obtained from the Fatality Analysis Reporting System (FARS) and the Internati...

How Safe Is Control Software

NASA Technical Reports Server (NTRS)

Dunn, William R.; Corliss, Lloyd D.

1991-01-01

Paper examines issue of software safety. Presents four case histories of software-safety analysis. Concludes that, to be safe, software, for all practical purposes, must be free of errors. Backup systems still needed to prevent catastrophic software failures.

Risk analysis based CWR track buckling safety evaluations

DOT National Transportation Integrated Search

2001-01-01

As part of the Federal Railroad Administrations (FRA) track systems research program, the US DOTS Volpe Center is conducting analytic and experimental investigations to evaluate track lateral strength and stability limits for improved safety an...

Wheelchair User Injuries and Deaths Associated with Motor Vehicle Related Incidents

DOT National Transportation Integrated Search

1997-09-01

National Highway Traffic Safety Administration's National Center for Statistics : and Analysis (NCSA) recently completed a study of data from the Consumer Product : Safety Commission's (CPSC) National Electronic Injury Surveillance System : (NEISS) o...

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

PubMed

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

2017-04-01

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

Changing conversations: teaching safety and quality in residency training.

PubMed

Voss, John D; May, Natalie B; Schorling, John B; Lyman, Jason A; Schectman, Joel M; Wolf, Andrew M D; Nadkarni, Mohan M; Plews-Ogan, Margaret

2008-11-01

Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Dynamic analysis methods for detecting anomalies in asynchronously interacting systems

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

Kumar, Akshat; Solis, John Hector; Matschke, Benjamin

2014-01-01

Detecting modifications to digital system designs, whether malicious or benign, is problematic due to the complexity of the systems being analyzed. Moreover, static analysis techniques and tools can only be used during the initial design and implementation phases to verify safety and liveness properties. It is computationally intractable to guarantee that any previously verified properties still hold after a system, or even a single component, has been produced by a third-party manufacturer. In this paper we explore new approaches for creating a robust system design by investigating highly-structured computational models that simplify verification and analysis. Our approach avoids the needmore » to fully reconstruct the implemented system by incorporating a small verification component that dynamically detects for deviations from the design specification at run-time. The first approach encodes information extracted from the original system design algebraically into a verification component. During run-time this component randomly queries the implementation for trace information and verifies that no design-level properties have been violated. If any deviation is detected then a pre-specified fail-safe or notification behavior is triggered. Our second approach utilizes a partitioning methodology to view liveness and safety properties as a distributed decision task and the implementation as a proposed protocol that solves this task. Thus the problem of verifying safety and liveness properties is translated to that of verifying that the implementation solves the associated decision task. We develop upon results from distributed systems and algebraic topology to construct a learning mechanism for verifying safety and liveness properties from samples of run-time executions.« less

Structural analysis of a rehabilitative training system based on a ceiling rail for safety of hemiplegia patients.

PubMed

Kim, Kyong; Song, Won Kyung; Chong, Woo Suk; Yu, Chang Ho

2018-04-17

The body-weight support (BWS) function, which helps to decrease load stresses on a user, is an effective tool for gait and balance rehabilitation training for elderly people with weakened lower-extremity muscular strength, hemiplegic patients, etc. This study conducts structural analysis to secure user safety in order to develop a rail-type gait and balance rehabilitation training system (RRTS). The RRTS comprises a rail, trolley, and brain-machine interface. The rail (platform) is connected to the ceiling structure, bearing the loads of the RRTS and of the user and allowing locomobility. The trolley consists of a smart drive unit (SDU) that assists the user with forward and backward mobility and a body-weight support (BWS) unit that helps the user to control his/her body-weight load, depending on the severity of his/her hemiplegia. The brain-machine interface estimates and measures on a real-time basis the body-weight (load) of the user and the intended direction of his/her movement. Considering the weight of the system and the user, the mechanical safety performance of the system frame under an applied 250-kg static load is verified through structural analysis using ABAQUS (6.14-3) software. The maximum stresses applied on the rail and trolley under the given gravity load of 250 kg, respectively, are 18.52 MPa and 48.44 MPa. The respective safety factors are computed to be 7.83 and 5.26, confirming the RRTS's mechanical safety. An RRTS with verified structural safety could be utilized for gait movement and balance rehabilitation and training for patients with hemiplegia.

Manned space flight nuclear system safety. Volume 3: Reactor system preliminary nuclear safety analysis. Part 2: Accident Model Document (AMD)

NASA Technical Reports Server (NTRS)

1972-01-01

The Accident Model Document is one of three documents of the Preliminary Safety Analysis Report (PSAR) - Reactor System as applied to a Space Base Program. Potential terrestrial nuclear hazards involving the zirconium hydride reactor-Brayton power module are identified for all phases of the Space Base program. The accidents/events that give rise to the hazards are defined and abort sequence trees are developed to determine the sequence of events leading to the hazard and the associated probabilities of occurence. Source terms are calculated to determine the magnitude of the hazards. The above data is used in the mission accident analysis to determine the most probable and significant accidents/events in each mission phase. The only significant hazards during the prelaunch and launch ascent phases of the mission are those which arise form criticality accidents. Fission product inventories during this time period were found to be very low due to very limited low power acceptance testing.

Integrated Response Time Evaluation Methodology for the Nuclear Safety Instrumentation System

NASA Astrophysics Data System (ADS)

Lee, Chang Jae; Yun, Jae Hee

2017-06-01

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

A Framework for Reliability and Safety Analysis of Complex Space Missions

NASA Technical Reports Server (NTRS)

Evans, John W.; Groen, Frank; Wang, Lui; Austin, Rebekah; Witulski, Art; Mahadevan, Nagabhushan; Cornford, Steven L.; Feather, Martin S.; Lindsey, Nancy

2017-01-01

Long duration and complex mission scenarios are characteristics of NASA's human exploration of Mars, and will provide unprecedented challenges. Systems reliability and safety will become increasingly demanding and management of uncertainty will be increasingly important. NASA's current pioneering strategy recognizes and relies upon assurance of crew and asset safety. In this regard, flexibility to develop and innovate in the emergence of new design environments and methodologies, encompassing modeling of complex systems, is essential to meet the challenges.

Determination of UAV pre-flight Checklist for flight test purpose using qualitative failure analysis

NASA Astrophysics Data System (ADS)

Hendarko; Indriyanto, T.; Syardianto; Maulana, F. A.

2018-05-01

Safety aspects are of paramount importance in flight, especially in flight test phase. Before performing any flight tests of either manned or unmanned aircraft, one should include pre-flight checklists as a required safety document in the flight test plan. This paper reports on the development of a new approach for determination of pre-flight checklists for UAV flight test based on aircraft’s failure analysis. The Lapan’s LSA (Light Surveillance Aircraft) is used as a study case, assuming this aircraft has been transformed into the unmanned version. Failure analysis is performed on LSA using fault tree analysis (FTA) method. Analysis is focused on propulsion system and flight control system, which fail of these systems will lead to catastrophic events. Pre-flight checklist of the UAV is then constructed based on the basic causes obtained from failure analysis.

The Role and Quality of Software Safety in the NASA Constellation Program

NASA Technical Reports Server (NTRS)

Layman, Lucas; Basili, Victor R.; Zelkowitz, Marvin V.

2010-01-01

In this study, we examine software safety risk in the early design phase of the NASA Constellation spaceflight program. Obtaining an accurate, program-wide picture of software safety risk is difficult across multiple, independently-developing systems. We leverage one source of safety information, hazard analysis, to provide NASA quality assurance managers with information regarding the ongoing state of software safety across the program. The goal of this research is two-fold: 1) to quantify the relative importance of software with respect to system safety; and 2) to quantify the level of risk presented by software in the hazard analysis. We examined 154 hazard reports created during the preliminary design phase of three major flight hardware systems within the Constellation program. To quantify the importance of software, we collected metrics based on the number of software-related causes and controls of hazardous conditions. To quantify the level of risk presented by software, we created a metric scheme to measure the specificity of these software causes. We found that from 49-70% of hazardous conditions in the three systems could be caused by software or software was involved in the prevention of the hazardous condition. We also found that 12-17% of the 2013 hazard causes involved software, and that 23-29% of all causes had a software control. Furthermore, 10-12% of all controls were software-based. There is potential for inaccuracy in these counts, however, as software causes are not consistently scoped, and the presence of software in a cause or control is not always clear. The application of our software specificity metrics also identified risks in the hazard reporting process. In particular, we found a number of traceability risks in the hazard reports may impede verification of software and system safety.

Mindful Application of Aviation Practices in Healthcare.

PubMed

Powell-Dunford, Nicole; Brennan, Peter A; Peerally, Mohammad Farhad; Kapur, Narinder; Hynes, Jonny M; Hodkinson, Peter D

2017-12-01

Evidence supports the efficacy of incorporating select recognized aviation practices and procedures into healthcare. Incident analysis, debrief, safety brief, and crew resource management (CRM) have all been assessed for implementation within the UK healthcare system, a world leader in aviation-based patient safety initiatives. Mindful application, in which aviation practices are specifically tailored to the unique healthcare setting, show promise in terms of acceptance and long-term sustainment. In order to establish British healthcare applications of aviation practices, a PubMed search of UK authored manuscripts published between 2005-2016 was undertaken using search terms 'aviation,' 'healthcare,' 'checklist,' and 'CRM.' A convenience sample of UK-authored aviation medical conference presentations and UK-authored patient safety manuscripts were also reviewed. A total of 11 of 94 papers with UK academic affiliations published between 2005-2016 and relevant to aviation modeled healthcare delivery were found. The debrief process, incident analysis, and CRM are the primary practices incorporated into UK healthcare, with success dependent on cultural acceptance and mindful application. CRM training has gained significant acceptance in UK healthcare environments. Aviation modeled incident analysis, debrief, safety brief, and CRM training are increasingly undertaken within the UK healthcare system. Nuanced application, in which the unique aspects of the healthcare setting are addressed as part of a comprehensive safety approach, shows promise for long-term success. The patient safety brief and aviation modeled incident analysis are in earlier phases of implementation, and warrant further analysis.Powell-Dunford N, Brennan PA, Peerally MF, Kapur N, Hynes JM, Hodkinson PD. Mindful application of aviation practices in healthcare. Aerosp Med Hum Perform. 2017; 88(12):1107-1116.

An Analysis of the Food Safety Educational Processes in the Cooperative Extension System of the North Central Region of the United States

ERIC Educational Resources Information Center

Koundinya, Vikram Swaroop Chandra

2010-01-01

Literature suggests that food safety is a serious concern all over the world, and lack of it has huge health and economic implications to different stakeholders. The situation in the U.S. is also no different with most of the American public not much knowledgeable about agriculture and food safety. Therefore, food safety education assumes…

Safety assessment for EPS electron-proton spectrometer

NASA Technical Reports Server (NTRS)

Gleeson, P.

1971-01-01

A safety analysis was conducted to identify the efforts required to assure relatively hazard free operation of the EPS and to meet the safety requirements of the program. Safety engineering criteria, principles, and techniques in applicable disciplines are stressed in the performance of the system and subsystem studies; in test planning; in the design, development, test, evaluation, and checkout of the equipment; and the operating procedures for the EPS program.

Risk analysis based CWR track buckling safety evaluations

DOT National Transportation Integrated Search

1999-12-01

As part of the Federal Railroad Administration's (FRA) track systems research program, the US DOT'S Volpe Center is conducting analytic and experimental investigations to evaluate track lateral strength and stability limits for improved safety and pe...

Safety Management Information Statistics (SAMIS) - 1994 Annual Report

DOT National Transportation Integrated Search

1996-07-01

The Safety Management Information Statistics 1994 Annual Report is a compilation and analysis of mass transit accident and casualty statistics reported by transit systems in the United States during 1994, reported under the Federal Transit Administra...

Implementation plan and cost analysis for Oregon's online crash reporting system.

DOT National Transportation Integrated Search

2011-07-01

Federal, state and local transportation agencies, law enforcement, the legislature, consulting firms, safety advocates and the : public use crash data to quantify emerging traffic safety issues and problems, determine priorities, support decision-mak...

Sociotechnical approaches to workplace safety: Research needs and opportunities.

PubMed

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

2015-01-01

The sociotechnical systems perspective offers intriguing and potentially valuable insights into problems associated with workplace safety. While formal sociotechnical systems thinking originated in the 1950s, its application to the analysis and design of sustainable, safe working environments has not been fully developed. To that end, a Hopkinton Conference was organised to review and summarise the state of knowledge in the area and to identify research priorities. A group of 26 international experts produced collaborative articles for this special issue of Ergonomics, and each focused on examining a key conceptual, methodological and/or theoretical issue associated with sociotechnical systems and safety. In this concluding paper, we describe the major conference themes and recommendations. These are organised into six topic areas: (1) Concepts, definitions and frameworks, (2) defining research methodologies, (3) modelling and simulation, (4) communications and decision-making, (5) sociotechnical attributes of safe and unsafe systems and (6) potential future research directions for sociotechnical systems research. Sociotechnical complexity, a characteristic of many contemporary work environments, presents potential safety risks that traditional approaches to workplace safety may not adequately address. In this paper, we summarise the investigations of a group of international researchers into questions associated with the application of sociotechnical systems thinking to improve worker safety.

Ending on a positive: Examining the role of safety leadership decisions, behaviours and actions in a safety critical situation.

PubMed

Donovan, Sarah-Louise; Salmon, Paul M; Horberry, Timothy; Lenné, Michael G

2018-01-01

Safety leadership is an important factor in supporting safe performance in the workplace. The present case study examined the role of safety leadership during the Bingham Canyon Mine high-wall failure, a significant mining incident in which no fatalities or injuries were incurred. The Critical Decision Method (CDM) was used in conjunction with a self-reporting approach to examine safety leadership in terms of decisions, behaviours and actions that contributed to the incidents' safe outcome. Mapping the analysis onto Rasmussen's Risk Management Framework (Rasmussen, 1997), the findings demonstrate clear links between safety leadership decisions, and emergent behaviours and actions across the work system. Communication and engagement based decisions featured most prominently, and were linked to different leadership practices across the work system. Further, a core sub-set of CDM decision elements were linked to the open flow and exchange of information across the work system, which was critical to supporting the safe outcome. The findings provide practical implications for the development of safety leadership capability to support safety within the mining industry. Copyright © 2017 Elsevier Ltd. All rights reserved.

Intelligent Hardware-Enabled Sensor and Software Safety and Health Management for Autonomous UAS

NASA Technical Reports Server (NTRS)

Rozier, Kristin Y.; Schumann, Johann; Ippolito, Corey

2015-01-01

Unmanned Aerial Systems (UAS) can only be deployed if they can effectively complete their mission and respond to failures and uncertain environmental conditions while maintaining safety with respect to other aircraft as well as humans and property on the ground. We propose to design a real-time, onboard system health management (SHM) capability to continuously monitor essential system components such as sensors, software, and hardware systems for detection and diagnosis of failures and violations of safety or performance rules during the ight of a UAS. Our approach to SHM is three-pronged, providing: (1) real-time monitoring of sensor and software signals; (2) signal analysis, preprocessing, and advanced on-the- y temporal and Bayesian probabilistic fault diagnosis; (3) an unobtrusive, lightweight, read-only, low-power hardware realization using Field Programmable Gate Arrays (FPGAs) in order to avoid overburdening limited computing resources or costly re-certi cation of ight software due to instrumentation. No currently available SHM capabilities (or combinations of currently existing SHM capabilities) come anywhere close to satisfying these three criteria yet NASA will require such intelligent, hardwareenabled sensor and software safety and health management for introducing autonomous UAS into the National Airspace System (NAS). We propose a novel approach of creating modular building blocks for combining responsive runtime monitoring of temporal logic system safety requirements with model-based diagnosis and Bayesian network-based probabilistic analysis. Our proposed research program includes both developing this novel approach and demonstrating its capabilities using the NASA Swift UAS as a demonstration platform.

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.

Laser safety and hazard analysis for the temperature stabilized BSLT ARES laser system.

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

Augustoni, Arnold L.

A laser safety and hazard analysis was performed for the temperature stabilized Big Sky Laser Technology (BSLT) laser central to the ARES system based on the 2000 version of the American National Standards Institute's (ANSI) Standard Z136.1, for Safe Use of Lasers and the 2000 version of the ANSI Standard Z136.6, for Safe Use of Lasers Outdoors. As a result of temperature stabilization of the BSLT laser the operating parameters of the laser had changed requiring a hazard analysis based on the new operating conditions. The ARES laser system is a Van/Truck based mobile platform, which is used to performmore » laser interaction experiments and tests at various national test sites.« less

Fault trees for decision making in systems analysis

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

Lambert, Howard E.

1975-10-09

The application of fault tree analysis (FTA) to system safety and reliability is presented within the framework of system safety analysis. The concepts and techniques involved in manual and automated fault tree construction are described and their differences noted. The theory of mathematical reliability pertinent to FTA is presented with emphasis on engineering applications. An outline of the quantitative reliability techniques of the Reactor Safety Study is given. Concepts of probabilistic importance are presented within the fault tree framework and applied to the areas of system design, diagnosis and simulation. The computer code IMPORTANCE ranks basic events and cut setsmore » according to a sensitivity analysis. A useful feature of the IMPORTANCE code is that it can accept relative failure data as input. The output of the IMPORTANCE code can assist an analyst in finding weaknesses in system design and operation, suggest the most optimal course of system upgrade, and determine the optimal location of sensors within a system. A general simulation model of system failure in terms of fault tree logic is described. The model is intended for efficient diagnosis of the causes of system failure in the event of a system breakdown. It can also be used to assist an operator in making decisions under a time constraint regarding the future course of operations. The model is well suited for computer implementation. New results incorporated in the simulation model include an algorithm to generate repair checklists on the basis of fault tree logic and a one-step-ahead optimization procedure that minimizes the expected time to diagnose system failure.« less

Patient safety principles in family medicine residency accreditation standards and curriculum objectives

PubMed Central

Kassam, Aliya; Sharma, Nishan; Harvie, Margot; O’Beirne, Maeve; Topps, Maureen

2016-01-01

Abstract Objective To conduct a thematic analysis of the College of Family Physicians of Canada’s (CFPC’s) Red Book accreditation standards and the Triple C Competency-based Curriculum objectives with respect to patient safety principles. Design Thematic content analysis of the CFPC’s Red Book accreditation standards and the Triple C curriculum. Setting Canada. Main outcome measures Coding frequency of the patient safety principles (ie, patient engagement; respectful, transparent relationships; complex systems; a just and trusting culture; responsibility and accountability for actions; and continuous learning and improvement) found in the analyzed CFPC documents. Results Within the analyzed CFPC documents, the most commonly found patient safety principle was patient engagement (n = 51 coding references); the least commonly found patient safety principles were a just and trusting culture (n = 5 coding references) and complex systems (n = 5 coding references). Other patient safety principles that were uncommon included responsibility and accountability for actions (n = 7 coding references) and continuous learning and improvement (n = 12 coding references). Conclusion Explicit inclusion of patient safety content such as the use of patient safety principles is needed for residency training programs across Canada to ensure the full spectrum of care is addressed, from community-based care to acute hospital-based care. This will ensure a patient safety culture can be cultivated from residency and sustained into primary care practice. PMID:27965349

Who is in control of road safety? A STAMP control structure analysis of the road transport system in Queensland, Australia.

PubMed

Salmon, Paul M; Read, Gemma J M; Stevens, Nicholas J

2016-11-01

Despite significant progress, road trauma continues to represent a global safety issue. In Queensland (Qld), Australia, there is currently a focus on preventing the 'fatal five' behaviours underpinning road trauma (drug and drink driving, distraction, seat belt wearing, speeding, and fatigue), along with an emphasis on a shared responsibility for road safety that spans road users, vehicle manufacturers, designers, policy makers etc. The aim of this article is to clarify who shares the responsibility for road safety in Qld and to determine what control measures are enacted to prevent the fatal five behaviours. This is achieved through the presentation of a control structure model that depicts the actors and organisations within the Qld road transport system along with the control and feedback relationships that exist between them. Validated through a Delphi study, the model shows a diverse set of actors and organisations who share the responsibility for road safety that goes beyond those discussed in road safety policies and strategies. The analysis also shows that, compared to other safety critical domains, there are less formal control structures in road transport and that opportunities exist to add new controls and strengthen existing ones. Relationships that influence rather than control are also prominent. Finally, when compared to other safety critical domains, the strength of road safety controls is brought into question. Copyright © 2016 Elsevier Ltd. All rights reserved.

Development of Safety Analysis Code System of Beam Transport and Core for Accelerator Driven System

NASA Astrophysics Data System (ADS)

Aizawa, Naoto; Iwasaki, Tomohiko

2014-06-01

Safety analysis code system of beam transport and core for accelerator driven system (ADS) is developed for the analyses of beam transients such as the change of the shape and position of incident beam. The code system consists of the beam transport analysis part and the core analysis part. TRACE 3-D is employed in the beam transport analysis part, and the shape and incident position of beam at the target are calculated. In the core analysis part, the neutronics, thermo-hydraulics and cladding failure analyses are performed by the use of ADS dynamic calculation code ADSE on the basis of the external source database calculated by PHITS and the cross section database calculated by SRAC, and the programs of the cladding failure analysis for thermoelastic and creep. By the use of the code system, beam transient analyses are performed for the ADS proposed by Japan Atomic Energy Agency. As a result, the rapid increase of the cladding temperature happens and the plastic deformation is caused in several seconds. In addition, the cladding is evaluated to be failed by creep within a hundred seconds. These results have shown that the beam transients have caused a cladding failure.

Fire safety in transit systems fault tree analysis

DOT National Transportation Integrated Search

1981-09-01

Fire safety countermeasures applicable to transit vehicles are identified and evaluated. This document contains fault trees which illustrate the sequences of events which may lead to a transit-fire related casualty. A description of the basis for the...

Target crashes and safety benefits estimation methodology for pedestrian crash avoidance/mitigation systems

DOT National Transportation Integrated Search

2014-04-01

Through the analysis of national crash databases from the National Highway Traffic Safety Administration, pre-crash scenarios are identified, prioritized, and described for the development of objective tests for pedestrian crash avoidance/mitigation ...

Integration of Active and Passive Safety Technologies--A Method to Study and Estimate Field Capability.

PubMed

Hu, Jingwen; Flannagan, Carol A; Bao, Shan; McCoy, Robert W; Siasoco, Kevin M; Barbat, Saeed

2015-11-01

The objective of this study is to develop a method that uses a combination of field data analysis, naturalistic driving data analysis, and computational simulations to explore the potential injury reduction capabilities of integrating passive and active safety systems in frontal impact conditions. For the purposes of this study, the active safety system is actually a driver assist (DA) feature that has the potential to reduce delta-V prior to a crash, in frontal or other crash scenarios. A field data analysis was first conducted to estimate the delta-V distribution change based on an assumption of 20% crash avoidance resulting from a pre-crash braking DA feature. Analysis of changes in driver head location during 470 hard braking events in a naturalistic driving study found that drivers' head positions were mostly in the center position before the braking onset, while the percentage of time drivers leaning forward or backward increased significantly after the braking onset. Parametric studies with a total of 4800 MADYMO simulations showed that both delta-V and occupant pre-crash posture had pronounced effects on occupant injury risks and on the optimal restraint designs. By combining the results for the delta-V and head position distribution changes, a weighted average of injury risk reduction of 17% and 48% was predicted by the 50th percentile Anthropomorphic Test Device (ATD) model and human body model, respectively, with the assumption that the restraint system can adapt to the specific delta-V and pre-crash posture. This study demonstrated the potential for further reducing occupant injury risk in frontal crashes by the integration of a passive safety system with a DA feature. Future analyses considering more vehicle models, various crash conditions, and variations of occupant characteristics, such as age, gender, weight, and height, are necessary to further investigate the potential capability of integrating passive and DA or active safety systems.

System Safety and the Unintended Consequence

NASA Technical Reports Server (NTRS)

Watson, Clifford

2012-01-01

The analysis and identification of risks often result in design changes or modification of operational steps. This paper identifies the potential of unintended consequences as an over-looked result of these changes. Examples of societal changes such as prohibition, regulatory changes including mandating lifeboats on passenger ships, and engineering proposals or design changes to automobiles and spaceflight hardware are used to demonstrate that the System Safety Engineer must be cognizant of the potential for unintended consequences as a result of an analysis. Conclusions of the report indicate the need for additional foresight and consideration of the potential effects of analysis-driven design, processing changes, and/or operational modifications.

A Framework to Guide the Assessment of Human-Machine Systems.

PubMed

Stowers, Kimberly; Oglesby, James; Sonesh, Shirley; Leyva, Kevin; Iwig, Chelsea; Salas, Eduardo

2017-03-01

We have developed a framework for guiding measurement in human-machine systems. The assessment of safety and performance in human-machine systems often relies on direct measurement, such as tracking reaction time and accidents. However, safety and performance emerge from the combination of several variables. The assessment of precursors to safety and performance are thus an important part of predicting and improving outcomes in human-machine systems. As part of an in-depth literature analysis involving peer-reviewed, empirical articles, we located and classified variables important to human-machine systems, giving a snapshot of the state of science on human-machine system safety and performance. Using this information, we created a framework of safety and performance in human-machine systems. This framework details several inputs and processes that collectively influence safety and performance. Inputs are divided according to human, machine, and environmental inputs. Processes are divided into attitudes, behaviors, and cognitive variables. Each class of inputs influences the processes and, subsequently, outcomes that emerge in human-machine systems. This framework offers a useful starting point for understanding the current state of the science and measuring many of the complex variables relating to safety and performance in human-machine systems. This framework can be applied to the design, development, and implementation of automated machines in spaceflight, military, and health care settings. We present a hypothetical example in our write-up of how it can be used to aid in project success.

The Analysis of the Contribution of Human Factors to the In-Flight Loss of Control Accidents

NASA Technical Reports Server (NTRS)

Ancel, Ersin; Shih, Ann T.

2012-01-01

In-flight loss of control (LOC) is currently the leading cause of fatal accidents based on various commercial aircraft accident statistics. As the Next Generation Air Transportation System (NextGen) emerges, new contributing factors leading to LOC are anticipated. The NASA Aviation Safety Program (AvSP), along with other aviation agencies and communities are actively developing safety products to mitigate the LOC risk. This paper discusses the approach used to construct a generic integrated LOC accident framework (LOCAF) model based on a detailed review of LOC accidents over the past two decades. The LOCAF model is comprised of causal factors from the domain of human factors, aircraft system component failures, and atmospheric environment. The multiple interdependent causal factors are expressed in an Object-Oriented Bayesian belief network. In addition to predicting the likelihood of LOC accident occurrence, the system-level integrated LOCAF model is able to evaluate the impact of new safety technology products developed in AvSP. This provides valuable information to decision makers in strategizing NASA's aviation safety technology portfolio. The focus of this paper is on the analysis of human causal factors in the model, including the contributions from flight crew and maintenance workers. The Human Factors Analysis and Classification System (HFACS) taxonomy was used to develop human related causal factors. The preliminary results from the baseline LOCAF model are also presented.

Safety culture: analysis of the causal relationships between its key dimensions.

PubMed

Fernández-Muñiz, Beatriz; Montes-Peón, José Manuel; Vázquez-Ordás, Camilo José

2007-01-01

Several fields are showing increasing interest in safety culture as a means of reducing accidents in the workplace. The literature shows that safety culture is a multidimensional concept. However, considerable confusion surrounds this concept, about which little consensus has been reached. This study proposes a model for a positive safety culture and tests this on a sample of 455 Spanish companies, using the structural equation modeling statistical technique. Results show the important role of managers in the promotion of employees' safe behavior, both directly, through their attitudes and behaviors, and indirectly, by developing a safety management system. This paper identifies the key dimensions of safety culture. In addition, a measurement scale for the safety management system is validated. This will assist organizations in defining areas where they need to progress if they wish to improve their safety. Also, we stress that managers need to be wholly committed to and personally involved in safety activities, thereby conveying the importance the firm attaches to these issues.

Posttest analysis of the FFTF inherent safety tests

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

Padilla, A. Jr.; Claybrook, S.W.

Inherent safety tests were performed during 1986 in the 400-MW (thermal) Fast Flux Test Facility (FFTF) reactor to demonstrate the effectiveness of an inherent shutdown device called the gas expansion module (GEM). The GEM device provided a strong negative reactivity feedback during loss-of-flow conditions by increasing the neutron leakage as a result of an expanding gas bubble. The best-estimate pretest calculations for these tests were performed using the IANUS plant analysis code (Westinghouse Electric Corporation proprietary code) and the MELT/SIEX3 core analysis code. These two codes were also used to perform the required operational safety analyses for the FFTF reactormore » and plant. Although it was intended to also use the SASSYS systems (core and plant) analysis code, the calibration of the SASSYS code for FFTF core and plant analysis was not completed in time to perform pretest analyses. The purpose of this paper is to present the results of the posttest analysis of the 1986 FFTF inherent safety tests using the SASSYS code.« less

Urban transport safety assessment in akure based on corresponding performance indicators

NASA Astrophysics Data System (ADS)

Oye, Adedamola; Aderinlewo, Olufikayo; Croope, Silvana

2013-03-01

The level of safety of the transportation system in Akure, Nigeria was assessed by identifying the associated road safety problems and developing the corresponding safety performance indicators. These indicators were analysed with respect to accidents that occurred within the city from the year 2005 to 2009 based on the corresponding attributable risk measures. The results of the analysis showed the state of existing safety programs in Akure town. Six safety performance indicators were identified namely alcohol and drug use, excessive speeds, protection system (use of seat belts and helmets), use of day time running lights, state of vehicles (passive safety) and road condition. These indicators were used to determine the percentage of injury accidents as follows: 83.33% and 86.36% for years 2005 and 2006 respectively, 81.46% for year 2007 while years 2008 and 2009 had 82.86% and 78.12% injury accidents respectively.

An Online Risk Monitor System (ORMS) to Increase Safety and Security Levels in Industry

NASA Astrophysics Data System (ADS)

Zubair, M.; Rahman, Khalil Ur; Hassan, Mehmood Ul

2013-12-01

The main idea of this research is to develop an Online Risk Monitor System (ORMS) based on Living Probabilistic Safety Assessment (LPSA). The article highlights the essential features and functions of ORMS. The basic models and modules such as, Reliability Data Update Model (RDUM), running time update, redundant system unavailability update, Engineered Safety Features (ESF) unavailability update and general system update have been described in this study. ORMS not only provides quantitative analysis but also highlights qualitative aspects of risk measures. ORMS is capable of automatically updating the online risk models and reliability parameters of equipment. ORMS can support in the decision making process of operators and managers in Nuclear Power Plants.

Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare.

PubMed

Van Spall, Harriette; Kassam, Alisha; Tollefson, Travis T

2015-08-01

Near-miss investigations in high reliability organizations (HROs) aim to mitigate risk and improve system safety. Healthcare settings have a higher rate of near-misses and subsequent adverse events than most high-risk industries, but near-misses are not systematically reported or analyzed. In this review, we will describe the strategies for near-miss analysis that have facilitated a culture of safety and continuous quality improvement in HROs. Near-miss analysis is routine and systematic in HROs such as aviation. Strategies implemented in aviation include the Commercial Aviation Safety Team, which undertakes systematic analyses of near-misses, so that findings can be incorporated into Standard Operating Procedures (SOPs). Other strategies resulting from incident analyses include Crew Resource Management (CRM) for enhanced communication, situational awareness training, adoption of checklists during operations, and built-in redundancy within systems. Health care organizations should consider near-misses as opportunities for quality improvement. The systematic reporting and analysis of near-misses, commonplace in HROs, can be adapted to health care settings to prevent adverse events and improve clinical outcomes.

ESSAA: Embedded system safety analysis assistant

NASA Technical Reports Server (NTRS)

Wallace, Peter; Holzer, Joseph; Guarro, Sergio; Hyatt, Larry

1987-01-01

The Embedded System Safety Analysis Assistant (ESSAA) is a knowledge-based tool that can assist in identifying disaster scenarios. Imbedded software issues hazardous control commands to the surrounding hardware. ESSAA is intended to work from outputs to inputs, as a complement to simulation and verification methods. Rather than treating the software in isolation, it examines the context in which the software is to be deployed. Given a specified disasterous outcome, ESSAA works from a qualitative, abstract model of the complete system to infer sets of environmental conditions and/or failures that could cause a disasterous outcome. The scenarios can then be examined in depth for plausibility using existing techniques.

Design and application of a tool for structuring, capitalizing and making more accessible information and lessons learned from accidents involving machinery.

PubMed

Sadeghi, Samira; Sadeghi, Leyla; Tricot, Nicolas; Mathieu, Luc

2017-12-01

Accident reports are published in order to communicate the information and lessons learned from accidents. An efficient accident recording and analysis system is a necessary step towards improvement of safety. However, currently there is a shortage of efficient tools to support such recording and analysis. In this study we introduce a flexible and customizable tool that allows structuring and analysis of this information. This tool has been implemented under TEEXMA®. We named our prototype TEEXMA®SAFETY. This tool provides an information management system to facilitate data collection, organization, query, analysis and reporting of accidents. A predefined information retrieval module provides ready access to data which allows the user to quickly identify the possible hazards for specific machines and provides information on the source of hazards. The main target audience for this tool includes safety personnel, accident reporters and designers. The proposed data model has been developed by analyzing different accident reports.

A System for Integrated Reliability and Safety Analyses

NASA Technical Reports Server (NTRS)

Kostiuk, Peter; Shapiro, Gerald; Hanson, Dave; Kolitz, Stephan; Leong, Frank; Rosch, Gene; Coumeri, Marc; Scheidler, Peter, Jr.; Bonesteel, Charles

1999-01-01

We present an integrated reliability and aviation safety analysis tool. The reliability models for selected infrastructure components of the air traffic control system are described. The results of this model are used to evaluate the likelihood of seeing outcomes predicted by simulations with failures injected. We discuss the design of the simulation model, and the user interface to the integrated toolset.

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

West, W.S.

Progress during the period includes completion of the SNAP 7C system tests, completion of safety analysis for the SNAP 7A and C systems, assembly and initial testing of SNAP 7A, assembly of a modified reliability model, and assembly of a 10-W generator. Other activities include completion of thermal and safety analyses for SNAP 7B and D generators and fuel processing for these generators. (J.R.D.)

Learning from Taiwan patient-safety reporting system.

PubMed

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

2012-12-01

The aim of this study is to create a national database to record incidents that endanger patient safety. We try to identify systemic problems in hospitals in order to avoid safety incidents in the future and improve the quality of healthcare. The Taiwan Patient Safety Reporting System employs a voluntary notification model. We define 13 types of patient safety incidents, and the reports of different types of incidents are recorded using common terminology. Statistical analysis is used to identify the incident type, time of occurrence, location, person who reported the incident, and possible reasons for frequently occurring incidents. There were 340 hospitals that joined this program from 2005 to 2010. Over 128,271 incident events were reported and analyzed. The three most common incidents were drug-related incidents, falls, and endo tube related incidents. By analyzing the time of occurrence of incidents, we found that drug-related incidents usually occurred between 8 and 10 am. Falls and endo tube incidents usually occurred between 4 and 6 am. The most common location was wards (57.6%), followed by intensive care areas (13.5%), and pharmacies (9.1%). Among hospital staff, nurses reported the highest number of incidents (68.9%), followed by pharmacists (14.5%) and administrative staff (5.5%). The number of incidents reported by doctors was much lower (1.2%). Most staff members who reported incidents had been working for less than five years (58.1%). The unified reporting system was found to improve the recording and analysis of patient safety incidents. To encourage hospital staff to report incidents, hospitals need to be assisted in establishing an internal report and management system for safety incidents. Hospitals also need a protection mechanism to allow staff members to report incidents without the fear of punishment. By identifying the root causes of safety incidents and sharing the lessons learned across hospitals is the only way such incidents can be stopped from happening again. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

The Necessity of Functional Analysis for Space Exploration Programs

NASA Technical Reports Server (NTRS)

Morris, A. Terry; Breidenthal, Julian C.

2011-01-01

As NASA moves toward expanded commercial spaceflight within its human exploration capability, there is increased emphasis on how to allocate responsibilities between government and commercial organizations to achieve coordinated program objectives. The practice of program-level functional analysis offers an opportunity for improved understanding of collaborative functions among heterogeneous partners. Functional analysis is contrasted with the physical analysis more commonly done at the program level, and is shown to provide theoretical performance, risk, and safety advantages beneficial to a government-commercial partnership. Performance advantages include faster convergence to acceptable system solutions; discovery of superior solutions with higher commonality, greater simplicity and greater parallelism by substituting functional for physical redundancy to achieve robustness and safety goals; and greater organizational cohesion around program objectives. Risk advantages include avoidance of rework by revelation of some kinds of architectural and contractual mismatches before systems are specified, designed, constructed, or integrated; avoidance of cost and schedule growth by more complete and precise specifications of cost and schedule estimates; and higher likelihood of successful integration on the first try. Safety advantages include effective delineation of must-work and must-not-work functions for integrated hazard analysis, the ability to formally demonstrate completeness of safety analyses, and provably correct logic for certification of flight readiness. The key mechanism for realizing these benefits is the development of an inter-functional architecture at the program level, which reveals relationships between top-level system requirements that would otherwise be invisible using only a physical architecture. This paper describes the advantages and pitfalls of functional analysis as a means of coordinating the actions of large heterogeneous organizations for space exploration programs.

Remote Safety Monitoring for Elderly Persons Based on Omni-Vision Analysis

PubMed Central

Xiang, Yun; Tang, Yi-ping; Ma, Bao-qing; Yan, Hang-chen; Jiang, Jun; Tian, Xu-yuan

2015-01-01

Remote monitoring service for elderly persons is important as the aged populations in most developed countries continue growing. To monitor the safety and health of the elderly population, we propose a novel omni-directional vision sensor based system, which can detect and track object motion, recognize human posture, and analyze human behavior automatically. In this work, we have made the following contributions: (1) we develop a remote safety monitoring system which can provide real-time and automatic health care for the elderly persons and (2) we design a novel motion history or energy images based algorithm for motion object tracking. Our system can accurately and efficiently collect, analyze, and transfer elderly activity information and provide health care in real-time. Experimental results show that our technique can improve the data analysis efficiency by 58.5% for object tracking. Moreover, for the human posture recognition application, the success rate can reach 98.6% on average. PMID:25978761

Safety and Security Interface Technology Initiative

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

Dr. Michael A. Lehto; Kevin J. Carroll; Dr. Robert Lowrie

Safety and Security Interface Technology Initiative Mr. Kevin J. Carroll Dr. Robert Lowrie, Dr. Micheal Lehto BWXT Y12 NSC Oak Ridge, TN 37831 865-576-2289/865-241-2772 carrollkj@y12.doe.gov Work Objective. Earlier this year, the Energy Facility Contractors Group (EFCOG) was asked to assist in developing options related to acceleration deployment of new security-related technologies to assist meeting design base threat (DBT) needs while also addressing the requirements of 10 CFR 830. NNSA NA-70, one of the working group participants, designated this effort the Safety and Security Interface Technology Initiative (SSIT). Relationship to Workshop Theme. “Supporting Excellence in Operations Through Safety Analysis,” (workshop theme)more » includes security and safety personnel working together to ensure effective and efficient operations. One of the specific workshop elements listed in the call for papers is “Safeguards/Security Integration with Safety.” This paper speaks directly to this theme. Description of Work. The EFCOG Safety Analysis Working Group (SAWG) and the EFCOG Security Working Group formed a core team to develop an integrated process involving both safety basis and security needs allowing achievement of the DBT objectives while ensuring safety is appropriately considered. This effort garnered significant interest, starting with a two day breakout session of 30 experts at the 2006 Safety Basis Workshop. A core team was formed, and a series of meetings were held to develop that process, including safety and security professionals, both contractor and federal personnel. A pilot exercise held at Idaho National Laboratory (INL) in mid-July 2006 was conducted as a feasibility of concept review. Work Results. The SSIT efforts resulted in a topical report transmitted from EFCOG to DOE/NNSA in August 2006. Elements of the report included: Drivers and Endstate, Control Selections Alternative Analysis Process, Terminology Crosswalk, Safety Basis/Security Documentation Integration, Configuration Control, and development of a shared ‘tool box’ of information/successes. Specific Benefits. The expectation or end state resulting from the topical report and associated implementation plan includes: (1) A recommended process for handling the documentation of the security and safety disciplines, including an appropriate change control process and participation by all stakeholders. (2) A means to package security systems with sufficient information to help expedite the flow of that system through the process. In addition, a means to share successes among sites, to include information and safety basis to the extent such information is transportable. (3) Identification of key security systems and associated essential security elements being installed and an arrangement for the sites installing these systems to host an appropriate team to review a specific system and determine what information is exportable. (4) Identification of the security systems’ essential elements and appropriate controls required for testing of these essential elements in the facility. (5) The ability to help refine and improve an agreed to control set at the manufacture stage.« less

Aviation Data Integration System

NASA Technical Reports Server (NTRS)

Kulkarni, Deepak; Wang, Yao; Windrem, May; Patel, Hemil; Keller, Richard

2003-01-01

During the analysis of flight data and safety reports done in ASAP and FOQA programs, airline personnel are not able to access relevant aviation data for a variety of reasons. We have developed the Aviation Data Integration System (ADIS), a software system that provides integrated heterogeneous data to support safety analysis. Types of data available in ADIS include weather, D-ATIS, RVR, radar data, and Jeppesen charts, and flight data. We developed three versions of ADIS to support airlines. The first version has been developed to support ASAP teams. A second version supports FOQA teams, and it integrates aviation data with flight data while keeping identification information inaccessible. Finally, we developed a prototype that demonstrates the integration of aviation data into flight data analysis programs. The initial feedback from airlines is that ADIS is very useful in FOQA and ASAP analysis.

Analysis of general aviation single-pilot IFR incident data obtained from the NASA Aviation Safety Reporting System

NASA Technical Reports Server (NTRS)

Bergeron, H. P.

1983-01-01

An analysis of incident data obtained from the NASA Aviation Safety Reporting System (ASRS) has been made to determine the problem areas in general aviation single-pilot IFR (SPIFR) operations. The Aviation Safety Reporting System data base is a compilation of voluntary reports of incidents from any person who has observed or been involved in an occurrence which was believed to have posed a threat to flight safety. This paper examines only those reported incidents specifically related to general aviation single-pilot IFR operations. The frequency of occurrence of factors related to the incidents was the criterion used to define significant problem areas and, hence, to suggest where research is needed. The data was cataloged into one of five major problem areas: (1) controller judgment and response problems, (2) pilot judgment and response problems, (3) air traffic control (ATC) intrafacility and interfacility conflicts, (4) ATC and pilot communication problems, and (5) IFR-VFR conflicts. In addition, several points common to all or most of the problems were observed and reported. These included human error, communications, procedures and rules, and work load.

[Introduction of hazard analysis and critical control points (HACCP) principles at the flight catering food production plant].

PubMed

Popova, A Yu; Trukhina, G M; Mikailova, O M

In the article there is considered the quality control and safety system implemented in the one of the largest flight catering food production plant for airline passengers and flying squad. The system for the control was based on the Hazard Analysis And Critical Control Points (HACCP) principles and developed hygienic and antiepidemic measures. There is considered the identification of hazard factors at stages of the technical process. There are presented results of the analysis data of monitoring for 6 critical control points over the five-year period. The quality control and safety system permit to decline food contamination risk during acceptance, preparation and supplying of in-flight meal. There was proved the efficiency of the implemented system. There are determined further ways of harmonization and implementation for HACCP principles in the plant.

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

PubMed

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

2016-05-01

In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of events reported in each database were related to the purpose of the database and the source of the reports, resulting in significant differences in reported event categories across the 3 systems, and (3) a public-private collaboration for investigating ventilator-related adverse events under the P5S model is feasible. Copyright © 2016 by Daedalus Enterprises.

Probabilistic safety analysis of earth retaining structures during earthquakes

NASA Astrophysics Data System (ADS)

Grivas, D. A.; Souflis, C.

1982-07-01

A procedure is presented for determining the probability of failure of Earth retaining structures under static or seismic conditions. Four possible modes of failure (overturning, base sliding, bearing capacity, and overall sliding) are examined and their combined effect is evaluated with the aid of combinatorial analysis. The probability of failure is shown to be a more adequate measure of safety than the customary factor of safety. As Earth retaining structures may fail in four distinct modes, a system analysis can provide a single estimate for the possibility of failure. A Bayesian formulation of the safety retaining walls is found to provide an improved measure for the predicted probability of failure under seismic loading. The presented Bayesian analysis can account for the damage incurred to a retaining wall during an earthquake to provide an improved estimate for its probability of failure during future seismic events.

Reliability, Safety and Error Recovery for Advanced Control Software

NASA Technical Reports Server (NTRS)

Malin, Jane T.

2003-01-01

For long-duration automated operation of regenerative life support systems in space environments, there is a need for advanced integration and control systems that are significantly more reliable and safe, and that support error recovery and minimization of operational failures. This presentation outlines some challenges of hazardous space environments and complex system interactions that can lead to system accidents. It discusses approaches to hazard analysis and error recovery for control software and challenges of supporting effective intervention by safety software and the crew.

Software for occupational health and safety risk analysis based on a fuzzy model.

PubMed

Stefanovic, Miladin; Tadic, Danijela; Djapan, Marko; Macuzic, Ivan

2012-01-01

Risk and safety management are very important issues in healthcare systems. Those are complex systems with many entities, hazards and uncertainties. In such an environment, it is very hard to introduce a system for evaluating and simulating significant hazards. In this paper, we analyzed different types of hazards in healthcare systems and we introduced a new fuzzy model for evaluating and ranking hazards. Finally, we presented a developed software solution, based on the suggested fuzzy model for evaluating and monitoring risk.

Spaceborne power systems preference analyses. Volume 1: Summary

NASA Technical Reports Server (NTRS)

Smith, J. H.; Feinberg, A.; Miles, R. F., Jr.

1985-01-01

Sixteen alternative spaceborne nuclear power system concepts were ranked using multiattribute decision analysis to identify promising concepts for further technology development. Four groups interviewed were: safety, systems definition and design, technology assessment, and mission analysis. The ranking results were consistent from group and for different utility function models for individuals.

14 CFR 35.15 - Safety analysis.

Code of Federal Regulations, 2011 CFR

2011-01-01

..., maintenance checks, and other similar equipment or procedures. If items of the safety system are outside the... Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION AIRCRAFT AIRWORTHINESS.... (1) Maintenance actions being carried out at stated intervals. This includes verifying that items...

ASAP Aerospace Safety Advisory Panel

NASA Technical Reports Server (NTRS)

2004-01-01

This is the First Quarterly Report for the newly reconstituted Aerospace Safety Advisory Panel (ASAP). The NASA Administrator rechartered the Panel on November 18,2003, to provide an independent, vigilant, and long-term oversight of NASA's safety policies and programs well beyond Return to Flight of the Space Shuttle. The charter was revised to be consistent with the original intent of Congress in enacting the statute establishing ASAP in 1967 to focus on NASA's safety and quality systems, including industrial and systems safety, risk-management and trend analysis, and the management of these activities.The charter also was revised to provide more timely feedback to NASA by requiring quarterly rather than annual reports, and by requiring ASAP to perform special assessments with immediate feedback to NASA. ASAP was positioned to help institutionalize the safety culture of NASA in the post- Stafford-Covey Return to Flight environment.

SCALE Code System 6.2.2

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

Rearden, Bradley T.; Jessee, Matthew Anderson

The SCALE Code System is a widely used modeling and simulation suite for nuclear safety analysis and design that is developed, maintained, tested, and managed by the Reactor and Nuclear Systems Division (RNSD) of Oak Ridge National Laboratory (ORNL). SCALE provides a comprehensive, verified and validated, user-friendly tool set for criticality safety, reactor physics, radiation shielding, radioactive source term characterization, and sensitivity and uncertainty analysis. Since 1980, regulators, licensees, and research institutions around the world have used SCALE for safety analysis and design. SCALE provides an integrated framework with dozens of computational modules including 3 deterministic and 3 Monte Carlomore » radiation transport solvers that are selected based on the desired solution strategy. SCALE includes current nuclear data libraries and problem-dependent processing tools for continuous-energy (CE) and multigroup (MG) neutronics and coupled neutron-gamma calculations, as well as activation, depletion, and decay calculations. SCALE includes unique capabilities for automated variance reduction for shielding calculations, as well as sensitivity and uncertainty analysis. SCALE’s graphical user interfaces assist with accurate system modeling, visualization of nuclear data, and convenient access to desired results. SCALE 6.2 represents one of the most comprehensive revisions in the history of SCALE, providing several new capabilities and significant improvements in many existing features.« less

Preliminary design review report - sludge offload system

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

Mcwethy, L.M. Westinghouse Hanford

1996-06-05

This report documents the conceptual design review of the sludge offload system for the Spent Nuclear Fuel Project. The design description, drawings, available analysis, and safety analysis were reviewed by a peer group. The design review comments and resolutions are documented.

[Experience feedback committee: a method for patient safety improvement].

PubMed

François, P; Sellier, E; Imburchia, F; Mallaret, M-R

2013-04-01

An experience feedback committee (CREX, Comité de Retour d'EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties. We performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results. The CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a "pilot" responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety. Safety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Safety Sufficiency for NextGen: Assessment of Selected Existing Safety Methods, Tools, Processes, and Regulations

NASA Technical Reports Server (NTRS)

Xu, Xidong; Ulrey, Mike L.; Brown, John A.; Mast, James; Lapis, Mary B.

2013-01-01

NextGen is a complex socio-technical system and, in many ways, it is expected to be more complex than the current system. It is vital to assess the safety impact of the NextGen elements (technologies, systems, and procedures) in a rigorous and systematic way and to ensure that they do not compromise safety. In this study, the NextGen elements in the form of Operational Improvements (OIs), Enablers, Research Activities, Development Activities, and Policy Issues were identified. The overall hazard situation in NextGen was outlined; a high-level hazard analysis was conducted with respect to multiple elements in a representative NextGen OI known as OI-0349 (Automation Support for Separation Management); and the hazards resulting from the highly dynamic complexity involved in an OI-0349 scenario were illustrated. A selected but representative set of the existing safety methods, tools, processes, and regulations was then reviewed and analyzed regarding whether they are sufficient to assess safety in the elements of that OI and ensure that safety will not be compromised and whether they might incur intolerably high costs.

Development of a generalized perturbation theory method for sensitivity analysis using continuous-energy Monte Carlo methods

DOE PAGES

Perfetti, Christopher M.; Rearden, Bradley T.

2016-03-01

The sensitivity and uncertainty analysis tools of the ORNL SCALE nuclear modeling and simulation code system that have been developed over the last decade have proven indispensable for numerous application and design studies for nuclear criticality safety and reactor physics. SCALE contains tools for analyzing the uncertainty in the eigenvalue of critical systems, but cannot quantify uncertainty in important neutronic parameters such as multigroup cross sections, fuel fission rates, activation rates, and neutron fluence rates with realistic three-dimensional Monte Carlo simulations. A more complete understanding of the sources of uncertainty in these design-limiting parameters could lead to improvements in processmore » optimization, reactor safety, and help inform regulators when setting operational safety margins. A novel approach for calculating eigenvalue sensitivity coefficients, known as the CLUTCH method, was recently explored as academic research and has been found to accurately and rapidly calculate sensitivity coefficients in criticality safety applications. The work presented here describes a new method, known as the GEAR-MC method, which extends the CLUTCH theory for calculating eigenvalue sensitivity coefficients to enable sensitivity coefficient calculations and uncertainty analysis for a generalized set of neutronic responses using high-fidelity continuous-energy Monte Carlo calculations. Here, several criticality safety systems were examined to demonstrate proof of principle for the GEAR-MC method, and GEAR-MC was seen to produce response sensitivity coefficients that agreed well with reference direct perturbation sensitivity coefficients.« less

Evaluating oversight systems for emerging technologies: a case study of genetically engineered organisms.

PubMed

Kuzma, Jennifer; Najmaie, Pouya; Larson, Joel

2009-01-01

The U.S. oversight system for genetically engineered organisms (GEOs) was evaluated to develop hypotheses and derive lessons for oversight of other emerging technologies, such as nanotechnology. Evaluation was based upon quantitative expert elicitation, semi-standardized interviews, and historical literature analysis. Through an interdisciplinary policy analysis approach, blending legal, ethical, risk analysis, and policy sciences viewpoints, criteria were used to identify strengths and weaknesses of GEOs oversight and explore correlations among its attributes and outcomes. From the three sources of data, hypotheses and broader conclusions for oversight were developed. Our analysis suggests several lessons for oversight of emerging technologies: the importance of reducing complexity and uncertainty in oversight for minimizing financial burdens on small product developers; consolidating multi-agency jurisdictions to avoid gaps and redundancies in safety reviews; consumer benefits for advancing acceptance of GEO products; rigorous and independent pre- and post-market assessment for environmental safety; early public input and transparency for ensuring public confidence; and the positive role of public input in system development, informed consent, capacity, compliance, incentives, and data requirements and stringency in promoting health and environmental safety outcomes, as well as the equitable distribution of health impacts. Our integrated approach is instructive for more comprehensive analyses of oversight systems, developing hypotheses for how features of oversight systems affect outcomes, and formulating policy options for oversight of future technological products, especially nanotechnology products.

An analysis of electronic health record-related patient safety concerns

PubMed Central

Meeks, Derek W; Smith, Michael W; Taylor, Lesley; Sittig, Dean F; Scott, Jean M; Singh, Hardeep

2014-01-01

Objective A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system. Methods The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports. Results We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or ‘hidden dependencies’ within the EHR. Discussion EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’ and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA. Conclusions Because EHR-related safety concerns have complex sociotechnical origins, institutions with long-standing as well as recent EHR implementations should build a robust infrastructure to monitor and learn from them. PMID:24951796

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

NASA Technical Reports Server (NTRS)

Withrow, Colleen A.; Reveley, Mary S.

2014-01-01

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

Certification of highly complex safety-related systems.

PubMed

Reinert, D; Schaefer, M

1999-01-01

The BIA has now 15 years of experience with the certification of complex electronic systems for safety-related applications in the machinery sector. Using the example of machining centres this presentation will show the systematic procedure for verifying and validating control systems using Application Specific Integrated Circuits (ASICs) and microcomputers for safety functions. One section will describe the control structure of machining centres with control systems using "integrated safety." A diverse redundant architecture combined with crossmonitoring and forced dynamization is explained. In the main section the steps of the systematic certification procedure are explained showing some results of the certification of drilling machines. Specification reviews, design reviews with test case specification, statistical analysis, and walk-throughs are the analytical measures in the testing process. Systematic tests based on the test case specification, Electro Magnetic Interference (EMI), and environmental testing, and site acceptance tests on the machines are the testing measures for validation. A complex software driven system is always undergoing modification. Most of the changes are not safety-relevant but this has to be proven. A systematic procedure for certifying software modifications is presented in the last section of the paper.

Selected considerations of implementation of the GNSS

NASA Astrophysics Data System (ADS)

Cwiklak, Janusz; Fellner, Andrzej; Fellner, Radoslaw; Jafernik, Henryk; Sledzinski, Janusz

2014-05-01

The article describes analysis of the safety and risk for the implementation of precise approach procedures (Localizer Performance and Vertical Guidance - LPV) with GNSS sensor at airports in Warsaw and Katowice. There were used some techniques of the identification of threats (inducing controlled flight into terrain, landing accident, mid-air collision) and evaluations methods based on Fault Tree Analysis, probability of the risk, safety risk evaluation matrix and Functional Hazard Assesment. Also safety goals were determined. Research led to determine probabilities of appearing of threats, as well as allow compare them with regard to the ILS. As a result of conducting the Preliminary System Safety Assessment (PSSA), there were defined requirements essential to reach the required level of the safety. It is worth to underline, that quantitative requirements were defined using FTA.

Providing Nuclear Criticality Safety Analysis Education through Benchmark Experiment Evaluation

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

John D. Bess; J. Blair Briggs; David W. Nigg

2009-11-01

One of the challenges that today's new workforce of nuclear criticality safety engineers face is the opportunity to provide assessment of nuclear systems and establish safety guidelines without having received significant experience or hands-on training prior to graduation. Participation in the International Criticality Safety Benchmark Evaluation Project (ICSBEP) and/or the International Reactor Physics Experiment Evaluation Project (IRPhEP) provides students and young professionals the opportunity to gain experience and enhance critical engineering skills.

An approach to evaluating reactive airborne wind shear systems

NASA Technical Reports Server (NTRS)

Gibson, Joseph P., Jr.

1992-01-01

An approach to evaluating reactive airborne windshear detection systems was developed to support a deployment study for future FAA ground-based windshear detection systems. The deployment study methodology assesses potential future safety enhancements beyond planned capabilities. The reactive airborne systems will be an integral part of planned windshear safety enhancements. The approach to evaluating reactive airborne systems involves separate analyses for both landing and take-off scenario. The analysis estimates the probability of effective warning considering several factors including NASA energy height loss characteristics, reactive alert timing, and a probability distribution for microburst strength.

Formal Modeling and Analysis of a Preliminary Small Aircraft Transportation System (SATS)Concept

NASA Technical Reports Server (NTRS)

Carrreno, Victor A.; Gottliebsen, Hanne; Butler, Ricky; Kalvala, Sara

2004-01-01

New concepts for automating air traffic management functions at small non-towered airports raise serious safety issues associated with the software implementations and their underlying key algorithms. The criticality of such software systems necessitates that strong guarantees of the safety be developed for them. In this paper we present a formal method for modeling and verifying such systems using the PVS theorem proving system. The method is demonstrated on a preliminary concept of operation for the Small Aircraft Transportation System (SATS) project at NASA Langley.

Sociotechnical approaches to workplace safety: Research needs and opportunities

PubMed Central

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

2015-01-01

The sociotechnical systems perspective offers intriguing and potentially valuable insights into problems associated with workplace safety. While formal sociotechnical systems thinking originated in the 1950s, its application to the analysis and design of sustainable, safe working environments has not been fully developed. To that end, a Hopkinton Conference was organised to review and summarise the state of knowledge in the area and to identify research priorities. A group of 26 international experts produced collaborative articles for this special issue of Ergonomics, and each focused on examining a key conceptual, methodological and/or theoretical issue associated with sociotechnical systems and safety. In this concluding paper, we describe the major conference themes and recommendations. These are organised into six topic areas: (1) Concepts, definitions and frameworks, (2) defining research methodologies, (3) modelling and simulation, (4) communications and decision-making, (5) sociotechnical attributes of safe and unsafe systems and (6) potential future research directions for sociotechnical systems research. Practitioner Summary: Sociotechnical complexity, a characteristic of many contemporary work environments, presents potential safety risks that traditional approaches to workplace safety may not adequately address. In this paper, we summarise the investigations of a group of international researchers into questions associated with the application of sociotechnical systems thinking to improve worker safety. PMID:25728246

Integrated Safety Analysis Teams

NASA Technical Reports Server (NTRS)

Wetherholt, Jonathan C.

2008-01-01

Today's complex systems require understanding beyond one person s capability to comprehend. Each system requires a team to divide the system into understandable subsystems which can then be analyzed with an Integrated Hazard Analysis. The team must have both specific experiences and diversity of experience. Safety experience and system understanding are not always manifested in one individual. Group dynamics make the difference between success and failure as well as the difference between a difficult task and a rewarding experience. There are examples in the news which demonstrate the need to connect the pieces of a system into a complete picture. The Columbia disaster is now a standard example of a low consequence hazard in one part of the system; the External Tank is a catastrophic hazard cause for a companion subsystem, the Space Shuttle Orbiter. The interaction between the hardware, the manufacturing process, the handling, and the operations contributed to the problem. Each of these had analysis performed, but who constituted the team which integrated this analysis together? This paper will explore some of the methods used for dividing up a complex system; and how one integration team has analyzed the parts. How this analysis has been documented in one particular launch space vehicle case will also be discussed.

Using Meta Analysis Techniques to Assess the Safety Effect of Red Light Running Cameras

DOT National Transportation Integrated Search

2002-02-01

Automated enforcement programs, including automated systems that are used to enforce red light running violations, have recently come under scrutiny regarding their value in terms of improving safety, their primary purpose. One of the major hurdles t...

Further Analysis of Motorcycle Helmet Effectiveness Using CODES Linked Data

DOT National Transportation Integrated Search

1998-01-01

Linked data from the Crash Outcome Data Evaluation System (CODES) in seven : states was used by the National Highway Traffic Safety Administration as the : basis of a 1996 Report to Congress on the Benefits of Safety Belts and : Motorcycle Helmets (D...

Monte Carlo capabilities of the SCALE code system

DOE PAGES

Rearden, Bradley T.; Petrie, Jr., Lester M.; Peplow, Douglas E.; ...

2014-09-12

SCALE is a broadly used suite of tools for nuclear systems modeling and simulation that provides comprehensive, verified and validated, user-friendly capabilities for criticality safety, reactor physics, radiation shielding, and sensitivity and uncertainty analysis. For more than 30 years, regulators, licensees, and research institutions around the world have used SCALE for nuclear safety analysis and design. SCALE provides a “plug-and-play” framework that includes three deterministic and three Monte Carlo radiation transport solvers that can be selected based on the desired solution, including hybrid deterministic/Monte Carlo simulations. SCALE includes the latest nuclear data libraries for continuous-energy and multigroup radiation transport asmore » well as activation, depletion, and decay calculations. SCALE’s graphical user interfaces assist with accurate system modeling, visualization, and convenient access to desired results. SCALE 6.2 will provide several new capabilities and significant improvements in many existing features, especially with expanded continuous-energy Monte Carlo capabilities for criticality safety, shielding, depletion, and sensitivity and uncertainty analysis. Finally, an overview of the Monte Carlo capabilities of SCALE is provided here, with emphasis on new features for SCALE 6.2.« less

[Analysis of foreign experience of usage of automation systems of medication distribution in prevention and treatment facilities].

PubMed

Miroshnichenko, Iu V; Umarov, S Z

2012-12-01

One of the ways of increase of effectiveness and safety of patients medication supplement is the use of automated systems of distribution, through which substantially increases the efficiency and safety of patients' medication supplement, achieves significant economy of material and financial resources for medication assistance and possibility of systematical improvement of its accessibility and quality.

Electrical deaths in the US construction: an analysis of fatality investigations.

PubMed

Zhao, Dong; Thabet, Walid; McCoy, Andrew; Kleiner, Brian

2014-01-01

Electrocution is among the 'fatal four' in US construction according to the Occupational Safety and Health Administration. Learning from failures is believed to be an effective path to success, with deaths being the most serious system failures. This paper examined the failures in electrical safety by analysing all electrical fatality investigations (N = 132) occurring between 1989 and 2010 from the Fatality Assessment and Control Evaluation programme that is completed by the National Institute of Occupational Safety and Health. Results reveal the features of the electrical fatalities in construction and disclose the most common electrical safety challenges on construction sites. This research also suggests the sociotechnical system breakdowns and the less effectiveness of current safety training programmes may significantly contribute to worker's unsafe behaviours and electrical fatality occurrences.

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.

49 CFR Appendix D to Part 172 - Rail Risk Analysis Factors

Code of Federal Regulations, 2012 CFR

2012-10-01

... nature of the rail system, each carrier must select and document the analysis method/model used and identify the routes to be analyzed. D. The safety and security risk analysis must consider current data and... curvature; 7. Presence or absence of signals and train control systems along the route (“dark” versus...

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

NASA Astrophysics Data System (ADS)

Klicker, M.; Putzer, H.

2012-01-01

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

Integrated deterministic and probabilistic safety analysis for safety assessment of nuclear power plants

DOE PAGES

Di Maio, Francesco; Zio, Enrico; Smith, Curtis; ...

2015-07-06

The present special issue contains an overview of the research in the field of Integrated Deterministic and Probabilistic Safety Assessment (IDPSA) of Nuclear Power Plants (NPPs). Traditionally, safety regulation for NPPs design and operation has been based on Deterministic Safety Assessment (DSA) methods to verify criteria that assure plant safety in a number of postulated Design Basis Accident (DBA) scenarios. Referring to such criteria, it is also possible to identify those plant Structures, Systems, and Components (SSCs) and activities that are most important for safety within those postulated scenarios. Then, the design, operation, and maintenance of these “safety-related” SSCs andmore » activities are controlled through regulatory requirements and supported by Probabilistic Safety Assessment (PSA).« less

Space Shuttle Range Safety Command Destruct System Analysis and Verification. Phase 1. Destruct System Analysis and Verification

DTIC Science & Technology

1981-03-01

overcome the shortcomings of this system. A phase III study develops the breakup model of the Space Shuttle clus’ter at various times into flight. The...2-1 ROCKET MODEL ..................................................... 2-5 COMBUSTION CHAMBER OPERATION ................................... 2-5...2-19 RESULTS .......................................................... 2-22 ROCKET MODEL

Applications of Tutoring Systems in Specialized Subject Areas: An Analysis of Skills, Methodologies, and Results.

ERIC Educational Resources Information Center

Heron, Timothy E.; Welsch, Richard G.; Goddard, Yvonne L.

2003-01-01

This article reviews how tutoring systems have been applied across specialized subject areas (e.g., music, horticulture, health and safety, social interactions). It summarizes findings, provides an analysis of skills learned within each tutoring system, identifies the respective methodologies, and reports relevant findings, implications, and…

Visit from JAXA to NASA MSFC: The Engines Element & Ideas for Collaboration

NASA Technical Reports Server (NTRS)

Greene, William D.

2013-01-01

System Design, Development, and Fabrication: Design, develop, and fabricate or procure MB-60 component hardware compliant with the imposed technical requirements and in sufficient quantities to fulfill the overall MB-60 development effort. System Development, Assembly, and Test: Manage the scope of the development, assembly, and test-related activities for MB-60 development. This scope includes engine-level development planning, engine assembly and disassembly, test planning, engine testing, inspection, anomaly resolution, and development of necessary ground support equipment and special test equipment. System Integration: Provide coordinated integration in the realms of engineering, safety, quality, and manufacturing disciplines across the scope of the MB-60 design and associated products development Safety and Mission Assurance, structural design, fracture control, materials and processes, thermal analysis. Systems Engineering and Analysis: Manage and perform Systems Engineering and Analysis to provide rigor and structure to the overall design and development effort for the MB-60. Milestone reviews, requirements management, system analysis, program management support Program Management: Manage, plan, and coordinate the activities across all portions of the MB-60 work scope by providing direction for program administration, business management, and supplier management.

Statechart Analysis with Symbolic PathFinder

NASA Technical Reports Server (NTRS)

Pasareanu, Corina S.

2012-01-01

We report here on our on-going work that addresses the automated analysis and test case generation for software systems modeled using multiple Statechart formalisms. The work is motivated by large programs such as NASA Exploration, that involve multiple systems that interact via safety-critical protocols and are designed with different Statechart variants. To verify these safety-critical systems, we have developed Polyglot, a framework for modeling and analysis of model-based software written using different Statechart formalisms. Polyglot uses a common intermediate representation with customizable Statechart semantics and leverages the analysis and test generation capabilities of the Symbolic PathFinder tool. Polyglot is used as follows: First, the structure of the Statechart model (expressed in Matlab Stateflow or Rational Rhapsody) is translated into a common intermediate representation (IR). The IR is then translated into Java code that represents the structure of the model. The semantics are provided as "pluggable" modules.

Shared Information Framework and Technology (SHIFT) Handbook

DTIC Science & Technology

2009-02-01

field. Such a patchwork of separate systems neither improves information sharing nor guarantees the safety and security of communities and personnel in...analysis. In many organizations, security may not necessarily be the expertise of people working in the field, or security and safety issues may be...the safety and security of all crisis management personnel in crisis areas. Functioning information sharing between organisations improves situational

Combining Systems and Teamwork Approaches to Enhance the Effectiveness of Safety Improvement Interventions in Surgery: The Safer Delivery of Surgical Services (S3) Program.

PubMed

McCulloch, Peter; Morgan, Lauren; New, Steve; Catchpole, Ken; Roberston, Eleanor; Hadi, Mohammed; Pickering, Sharon; Collins, Gary; Griffin, Damian

2017-01-01

Patient safety improvement interventions usually address either work systems or team culture. We do not know which is more effective, or whether combining approaches is beneficial. To compare improvement in surgical team performance after interventions addressing teamwork culture, work systems, or both. Suite of 5 identical controlled before-after intervention studies, with preplanned analysis of pooled data for indirect comparisons of strategies. Operating theatres in 5 UK hospitals performing elective orthopedic, plastic, or vascular surgery PARTICIPANTS:: All operating theatres staff, including surgeons, nurses, anaesthetists, and others INTERVENTIONS:: 4-month safety improvement interventions, using teamwork training (TT), systems redesign and standardization (SOP), Lean quality improvement, SOP + TT combination, or Lean + TT combination. Team technical and nontechnical performance and World Health Organization (WHO) checklist compliance, measured for 3 months before and after intervention using validated scales. Pooled data analysis of before-after change in active and control groups, comparing combined versus single and systems versus teamwork interventions, using 2-way ANOVA. We studied 453 operations, (255 intervention, 198 control). TT improved nontechnical skills and WHO compliance (P < 0.001), but not technical performance; systems interventions (Lean & SOP, 2 & 3) improved nontechnical skills and technical performance (P < 0.001) but improved WHO compliance less. Combined interventions (4 & 5) improved all performance measures except WHO time-out attempts, whereas single approaches (1 & 2 & 3) improved WHO compliance less (P < 0.001) and failed to improve technical performance. Safety interventions combining teamwork training and systems rationalization are more effective than those adopting either approach alone. This has important implications for safety improvement strategies in hospitals.

A flooding induced station blackout analysis for a pressurized water reactor using the RISMC toolkit

DOE PAGES

Mandelli, Diego; Prescott, Steven; Smith, Curtis; ...

2015-05-17

In this paper we evaluate the impact of a power uprate on a pressurized water reactor (PWR) for a tsunami-induced flooding test case. This analysis is performed using the RISMC toolkit: the RELAP-7 and RAVEN codes. RELAP-7 is the new generation of system analysis codes that is responsible for simulating the thermal-hydraulic dynamics of PWR and boiling water reactor systems. RAVEN has two capabilities: to act as a controller of the RELAP-7 simulation (e.g., component/system activation) and to perform statistical analyses. In our case, the simulation of the flooding is performed by using an advanced smooth particle hydrodynamics code calledmore » NEUTRINO. The obtained results allow the user to investigate and quantify the impact of timing and sequencing of events on system safety. The impact of power uprate is determined in terms of both core damage probability and safety margins.« less

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

PubMed

Wagar, Elizabeth A; Tamashiro, Lorraine; Yasin, Bushra; Hilborne, Lee; Bruckner, David A

2006-11-01

Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.

Effectiveness of maritime safety control in different navigation zones using a spatial sequential DEA model: Yangtze River case.

PubMed

Wu, Bing; Wang, Yang; Zhang, Jinfen; Savan, Emanuel Emil; Yan, Xinping

2015-08-01

This paper aims to analyze the effectiveness of maritime safety control from the perspective of safety level along the Yangtze River with special considerations for navigational environments. The influencing variables of maritime safety are reviewed, including ship condition, maritime regulatory system, human reliability and navigational environment. Because the former three variables are generally assumed to be of the same level of safety, this paper focuses on studying the impact of navigational environments on the level of safety in different waterways. An improved data envelopment analysis (DEA) model is proposed by treating the navigational environment factors as inputs and ship accident data as outputs. Moreover, because the traditional DEA model cannot provide an overall ranking of different decision making units (DMUs), the spatial sequential frontiers and grey relational analysis are incorporated into the DEA model to facilitate a refined assessment. Based on the empirical study results, the proposed model is able to solve the problem of information missing in the prior models and evaluate the level of safety with a better accuracy. The results of the proposed DEA model are further compared with an evidential reasoning (ER) method, which has been widely used for level of safety evaluations. A sensitivity analysis is also conducted to better understand the relationship between the variation of navigational environments and level of safety. The sensitivity analysis shows that the level of safety varies in terms of traffic flow. It indicates that appropriate traffic control measures should be adopted for different waterways to improve their safety. This paper presents a practical method of conducting maritime level of safety assessments under dynamic navigational environment. Copyright © 2015 Elsevier Ltd. All rights reserved.

Selecting an Architecture for a Safety-Critical Distributed Computer System with Power, Weight and Cost Considerations

NASA Technical Reports Server (NTRS)

Torres-Pomales, Wilfredo

2014-01-01

This report presents an example of the application of multi-criteria decision analysis to the selection of an architecture for a safety-critical distributed computer system. The design problem includes constraints on minimum system availability and integrity, and the decision is based on the optimal balance of power, weight and cost. The analysis process includes the generation of alternative architectures, evaluation of individual decision criteria, and the selection of an alternative based on overall value. In this example presented here, iterative application of the quantitative evaluation process made it possible to deliberately generate an alternative architecture that is superior to all others regardless of the relative importance of cost.

How to reduce your inventory: a real world case study.

PubMed

Mack, J A; Jordan, H H

1994-08-01

This case study describes the use of a performance analysis system at the Safety Products Division of Mine Safety Appliances Company, which contributed to the reduction of excess inventories by more than $8,000,000 during the first two years of implementation.

Safety of High Speed Magnetic Levitation Transportation Systems : Thermal Effects and Related Safety Issues of Typical Maglev Steel Guideways

DOT National Transportation Integrated Search

1994-09-01

This report presents a theoretical analysis predicting the temperature distribution, thermal deflections, and thermal stresses that may occur in typical steel Maglev guideways under the proposed Orlando FL thermal environment. Transient, finite eleme...

Implementation of Recommendations from the One System Comparative Evaluation of the Hanford Tank Farms and Waste Treatment Plant Safety Bases

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

Garrett, Richard L.; Niemi, Belinda J.; Paik, Ingle K.

2013-11-07

A Comparative Evaluation was conducted for One System Integrated Project Team to compare the safety bases for the Hanford Waste Treatment and Immobilization Plant Project (WTP) and Tank Operations Contract (TOC) (i.e., Tank Farms) by an Expert Review Team. The evaluation had an overarching purpose to facilitate effective integration between WTP and TOC safety bases. It was to provide One System management with an objective evaluation of identified differences in safety basis process requirements, guidance, direction, procedures, and products (including safety controls, key safety basis inputs and assumptions, and consequence calculation methodologies) between WTP and TOC. The evaluation identified 25more » recommendations (Opportunities for Integration). The resolution of these recommendations resulted in 16 implementation plans. The completion of these implementation plans will help ensure consistent safety bases for WTP and TOC along with consistent safety basis processes. procedures, and analyses. and should increase the likelihood of a successful startup of the WTP. This early integration will result in long-term cost savings and significant operational improvements. In addition, the implementation plans lead to the development of eight new safety analysis methodologies that can be used at other U.S. Department of Energy (US DOE) complex sites where URS Corporation is involved.« less

Innovative Forms Supporting Safe Methods of Work in Safety Engineering for the Development of Intelligent Specializations

NASA Astrophysics Data System (ADS)

Gembalska-Kwiecień, Anna

2016-12-01

The article discusses innovative forms of participation of employees in the work safety system. It also presents the advantages of these forms of employees' involvement. The aim of empirical studies was the analysis of their behavior and attitude towards health and safety at work. The issues considered in the article have a significant impact on the improvement of methods of prevention related to work safety and aided the creation of a healthy society.

Analysis of the medication-use process in North American hospital systems: underlining key points for adoption to improve patient safety in French hospitals.

PubMed

Brouard, Agnes; Fagon, Jean Yves; Daniels, Charles E

2011-01-01

This project was designed to underline any actions relative to medication error prevention and patient safety improvement setting up in North American hospitals which could be implemented in French Parisian hospitals. A literature research and analysis of medication-use process in the North American hospitals and a validation survey of hospital pharmacist managers in the San Diego area was performed to assess main points of hospital medication-use process. Literature analysis, survey analysis of respondents highlighted main differences between the two countries at three levels: nationwide, hospital level and pharmaceutical service level. According to this, proposal development to optimize medication-use process in the French system includes the following topics: implementation of an expanded use of information technology and robotics; increase pharmaceutical human resources allowing expansion of clinical pharmacy activities; focus on high-risk medications and high-risk patient populations; develop a collective sense of responsibility for medication error prevention in hospital settings, involving medical, pharmaceutical and administrative teams. Along with a strong emphasis that should be put on the identified topics to improve the quality and safety of hospital care in France, consideration of patient safety as a priority at a nationwide level needs to be reinforced.

9 CFR 417.8 - Agency verification.

Code of Federal Regulations, 2014 CFR

2014-01-01

....8 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF AGRICULTURE... ANALYSIS AND CRITICAL CONTROL POINT (HACCP) SYSTEMS § 417.8 Agency verification. FSIS will verify the... plan or system; (f) Direct observation or measurement at a CCP; (g) Sample collection and analysis to...

9 CFR 417.8 - Agency verification.

Code of Federal Regulations, 2012 CFR

2012-01-01

....8 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF AGRICULTURE... ANALYSIS AND CRITICAL CONTROL POINT (HACCP) SYSTEMS § 417.8 Agency verification. FSIS will verify the... plan or system; (f) Direct observation or measurement at a CCP; (g) Sample collection and analysis to...

9 CFR 417.8 - Agency verification.

Code of Federal Regulations, 2013 CFR

2013-01-01

....8 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF AGRICULTURE... ANALYSIS AND CRITICAL CONTROL POINT (HACCP) SYSTEMS § 417.8 Agency verification. FSIS will verify the... plan or system; (f) Direct observation or measurement at a CCP; (g) Sample collection and analysis to...

9 CFR 417.8 - Agency verification.

Code of Federal Regulations, 2010 CFR

2010-01-01

....8 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF AGRICULTURE... ANALYSIS AND CRITICAL CONTROL POINT (HACCP) SYSTEMS § 417.8 Agency verification. FSIS will verify the... plan or system; (f) Direct observation or measurement at a CCP; (g) Sample collection and analysis to...

9 CFR 417.8 - Agency verification.

Code of Federal Regulations, 2011 CFR

2011-01-01

....8 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF AGRICULTURE... ANALYSIS AND CRITICAL CONTROL POINT (HACCP) SYSTEMS § 417.8 Agency verification. FSIS will verify the... plan or system; (f) Direct observation or measurement at a CCP; (g) Sample collection and analysis to...

Hazard Analysis Guidelines for Transit Projects

DOT National Transportation Integrated Search

2000-01-01

These hazard analysis guidelines discuss safety critical systems and subsystems, types of hazard analyses, when hazard analyses should be performed, and the hazard analysis philosophy. These guidelines are published by FTA to assist the transit indus...

A Simplified Approach to Risk Assessment Based on System Dynamics: An Industrial Case Study.

PubMed

Garbolino, Emmanuel; Chery, Jean-Pierre; Guarnieri, Franck

2016-01-01

Seveso plants are complex sociotechnical systems, which makes it appropriate to support any risk assessment with a model of the system. However, more often than not, this step is only partially addressed, simplified, or avoided in safety reports. At the same time, investigations have shown that the complexity of industrial systems is frequently a factor in accidents, due to interactions between their technical, human, and organizational dimensions. In order to handle both this complexity and changes in the system over time, this article proposes an original and simplified qualitative risk evaluation method based on the system dynamics theory developed by Forrester in the early 1960s. The methodology supports the development of a dynamic risk assessment framework dedicated to industrial activities. It consists of 10 complementary steps grouped into two main activities: system dynamics modeling of the sociotechnical system and risk analysis. This system dynamics risk analysis is applied to a case study of a chemical plant and provides a way to assess the technological and organizational components of safety. © 2016 Society for Risk Analysis.

Diagnosis of poor safety culture as a major shortcoming in OHSAS 18001-certified companies.

PubMed

Ghahramani, Abolfazl

2017-04-07

The evaluation of safety performance in occupational health and safety assessment series (OHSAS) 18001-certified companies provides useful information about the quality of the management system. A certified organization should employ an adequate level of safety management and a positive safety culture to achieve a satisfactory safety performance. The present study conducted in six manufacturing companies: three OHSAS 18001-certified, and three non-certified to assess occupational health and safety (OHS) as well as OHSAS 18001 practices. The certified companies had a better OHS practices compared with the non-certified companies. The certified companies slightly differed in OHS and OHSAS 18001 practices and one of the certified companies had the highest activity rates for both practices. The results indicated that the implemented management systems have not developed and been maintained appropriately in the certified companies. The in-depth analysis of the collected evidence revealed shortcomings in safety culture improvement in the certified companies. This study highlights the importance of safety culture to continuously improve the quality of OHSAS 18001 and to properly perform OHS/OHSAS 18001 practices in the certified companies.

Diagnosis of poor safety culture as a major shortcoming in OHSAS 18001-certified companies

PubMed Central

GHAHRAMANI, Abolfazl

2016-01-01

The evaluation of safety performance in occupational health and safety assessment series (OHSAS) 18001-certified companies provides useful information about the quality of the management system. A certified organization should employ an adequate level of safety management and a positive safety culture to achieve a satisfactory safety performance. The present study conducted in six manufacturing companies: three OHSAS 18001-certified, and three non-certified to assess occupational health and safety (OHS) as well as OHSAS 18001 practices. The certified companies had a better OHS practices compared with the non-certified companies. The certified companies slightly differed in OHS and OHSAS 18001 practices and one of the certified companies had the highest activity rates for both practices. The results indicated that the implemented management systems have not developed and been maintained appropriately in the certified companies. The in-depth analysis of the collected evidence revealed shortcomings in safety culture improvement in the certified companies. This study highlights the importance of safety culture to continuously improve the quality of OHSAS 18001 and to properly perform OHS/OHSAS 18001 practices in the certified companies. PMID:28025422

Station Blackout: A case study in the interaction of mechanistic and probabilistic safety analysis

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

Curtis Smith; Diego Mandelli; Cristian Rabiti

2013-11-01

The ability to better characterize and quantify safety margins is important to improved decision making about nuclear power plant design, operation, and plant life extension. As research and development (R&D) in the light-water reactor (LWR) Sustainability (LWRS) Program and other collaborative efforts yield new data, sensors, and improved scientific understanding of physical processes that govern the aging and degradation of plant SSCs needs and opportunities to better optimize plant safety and performance will become known. The purpose of the Risk Informed Safety Margin Characterization (RISMC) Pathway R&D is to support plant decisions for risk-informed margin management with the aim tomore » improve economics, reliability, and sustain safety of current NPPs. In this paper, we describe the RISMC analysis process illustrating how mechanistic and probabilistic approaches are combined in order to estimate a safety margin. We use the scenario of a “station blackout” wherein offsite power and onsite power is lost, thereby causing a challenge to plant safety systems. We describe the RISMC approach, illustrate the station blackout modeling, and contrast this with traditional risk analysis modeling for this type of accident scenario.« less

[Preliminary studies on critical control point of traceability system in wolfberry].

PubMed

Liu, Sai; Xu, Chang-Qing; Li, Jian-Ling; Lin, Chen; Xu, Rong; Qiao, Hai-Li; Guo, Kun; Chen, Jun

2016-07-01

As a traditional Chinese medicine, wolfberry (Lycium barbarum) has a long cultivation history and a good industrial development foundation. With the development of wolfberry production, the expansion of cultivation area and the increased attention of governments and consumers on food safety, the quality and safety requirement of wolfberry is higher demanded. The quality tracing and traceability system of production entire processes is the important technology tools to protect the wolfberry safety, and to maintain sustained and healthy development of the wolfberry industry. Thus, this article analyzed the wolfberry quality management from the actual situation, the safety hazard sources were discussed according to the HACCP (hazard analysis and critical control point) and GAP (good agricultural practice for Chinese crude drugs), and to provide a reference for the traceability system of wolfberry. Copyright© by the Chinese Pharmaceutical Association.

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

PubMed

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

2013-01-01

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

Resilient Practices in Maintaining Safety of Health Information Technologies

PubMed Central

Ash, Joan S.; Sittig, Dean F.; Singh, Hardeep

2014-01-01

Electronic health record systems (EHRs) can improve safety and reliability of health care, but they can also introduce new vulnerabilities by failing to accommodate changes within a dynamic EHR-enabled health care system. Continuous assessment and improvement is thus essential for achieving resilience in EHR-enabled health care systems. Given the rapid adoption of EHRs by many organizations that are still early in their experiences with EHR safety, it is important to understand practices for maintaining resilience used by organizations with a track record of success in EHR use. We conducted interviews about safety practices with 56 key informants (including information technology managers, chief medical information officers, physicians, and patient safety officers) at two large health care systems recognized as leaders in EHR use. We identified 156 references to resilience-related practices from 41 informants. Framework analysis generated five categories of resilient practices: (a) sensitivity to dynamics and interdependencies affecting risks, (b) basic monitoring and responding practices, (c) management of practices and resources for monitoring and responding, (d) sensitivity to risks beyond the horizon, and (e) reflecting on risks with the safety and quality control process itself. The categories reflect three functions that facilitate resilience: reflection, transcending boundaries, and involving sharp-end practitioners in safety management. PMID:25866492

Railway safety climate: a study on organizational development.

PubMed

Cheng, Yung-Hsiang

2017-09-07

The safety climate of an organization is considered a leading indicator of potential risk for railway organizations. This study adopts the perceptual measurement-individual attribute approach to investigate the safety climate of a railway organization. The railway safety climate attributes are evaluated from the perspective of railway system staff. We identify four safety climate dimensions from exploratory factor analysis, namely safety communication, safety training, safety management and subjectively evaluated safety performance. Analytical results indicate that the safety climate differs at vertical and horizontal organizational levels. This study contributes to the literature by providing empirical evidence of the multilevel safety climate in a railway organization, presents possible causes of the differences under various cultural contexts and differentiates between safety climate scales for diverse workgroups within the railway organization. This information can be used to improve the safety sustainability of railway organizations and to conduct safety supervisions for the government.

The Decision Making Trial and Evaluation Laboratory (Dematel) and Analytic Network Process (ANP) for Safety Management System Evaluation Performance

NASA Astrophysics Data System (ADS)

Rolita, Lisa; Surarso, Bayu; Gernowo, Rahmat

2018-02-01

In order to improve airport safety management system (SMS) performance, an evaluation system is required to improve on current shortcomings and maximize safety. This study suggests the integration of the DEMATEL and ANP methods in decision making processes by analyzing causal relations between the relevant criteria and taking effective analysis-based decision. The DEMATEL method builds on the ANP method in identifying the interdependencies between criteria. The input data consists of questionnaire data obtained online and then stored in an online database. Furthermore, the questionnaire data is processed using DEMATEL and ANP methods to obtain the results of determining the relationship between criteria and criteria that need to be evaluated. The study cases on this evaluation system were Adi Sutjipto International Airport, Yogyakarta (JOG); Ahmad Yani International Airport, Semarang (SRG); and Adi Sumarmo International Airport, Surakarta (SOC). The integration grades SMS performance criterion weights in a descending order as follow: safety and destination policy, safety risk management, healthcare, and safety awareness. Sturges' formula classified the results into nine grades. JOG and SMG airports were in grade 8, while SOG airport was in grade 7.

Model Transformation for a System of Systems Dependability Safety Case

NASA Technical Reports Server (NTRS)

Murphy, Judy; Driskell, Stephen B.

2010-01-01

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

Waste Isolation Safety Assessment Program. Technical progress report for FY-1978

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

Brandstetter, A.; Harwell, M.A.; Howes, B.W.

1979-07-01

Associated with commercial nuclear power production in the United States is the generation of potentially hazardous radioactive wastes. The Department of Energy (DOE) is seeking to develop nuclear waste isolation systems in geologic formations that will preclude contact with the biosphere of waste radionuclides in concentrations which are sufficient to cause deleterious impact on humans or their environments. Comprehensive analyses of specific isolation systems are needed to assess the expectations of meeting that objective. The Waste Isolation Safety Assessment Program (WISAP) has been established at the Pacific Northwest Laboratory (operated by Battelle Memorial Institute) for developing the capability of makingmore » those analyses. Progress on the following tasks is reported: release scenario analysis, waste form release rate analysis, release consequence analysis, sorption-desorption analysis, and societal acceptance analysis. (DC)« less

Safety, tolerability, efficacy and pharmacodynamics of the selective JAK1 inhibitor GSK2586184 in patients with systemic lupus erythematosus.

PubMed

Kahl, L; Patel, J; Layton, M; Binks, M; Hicks, K; Leon, G; Hachulla, E; Machado, D; Staumont-Sallé, D; Dickson, M; Condreay, L; Schifano, L; Zamuner, S; van Vollenhoven, R F

2016-11-01

We aimed to evaluate the pharmacodynamics, efficacy, safety and tolerability of the JAK1 inhibitor GSK2586184 in adults with systemic lupus erythematosus (SLE). In this adaptive, randomized, double-blind, placebo-controlled study, patients received oral GSK2586184 50-400 mg, or placebo twice daily for 12 weeks. Primary endpoints included interferon-mediated messenger RNA transcription over time, changes in Safety of Estrogen in Lupus National Assessment-SLE Disease Activity Index score, and number/severity of adverse events. A pre-specified interim analysis was performed when ≥ 5 patients per group completed 2 weeks of treatment. In total, 84-92% of patients were high baseline expressors of the interferon transcriptional biomarkers evaluated. At interim analysis, GSK2586184 showed no significant effect on mean interferon transcriptional biomarker expression (all panels). The study was declared futile and recruitment was halted at 50 patients. Shortly thereafter, significant safety data were identified, including elevated liver enzymes in six patients (one confirmed and one suspected case of Drug Reaction with Eosinophilia and Systemic Symptoms), leading to immediate dosing cessation. Safety of Estrogen in Lupus National Assessment-SLE Disease Activity Index scores were not analysed due to the small number of patients completing the study. The study futility and safety data described for GSK2586184 do not support further evaluation in patients with SLE. Study identifiers: GSK Study JAK115919; ClinicalTrials.gov identifier: NCT01777256.

Safety I-II, resilience and antifragility engineering: a debate explained through an accident occurring on a mobile elevating work platform.

PubMed

Martinetti, Alberto; Chatzimichailidou, Maria Mikela; Maida, Luisa; van Dongen, Leo

2018-04-24

Occupational health and safety (OHS) represents an important field of exploration for the research community: in spite of the growth of technological innovations, the increasing complexity of systems involves critical issues in terms of degradation of the safety levels. In such a situation, new safety management approaches are now mandatory in order to face the safety implications of the current technological evolutions. Along these lines, performing risk-based analysis alone seems not to be enough anymore. The evaluation of robustness, antifragility and resilience of a socio-technical system is now indispensable in order to face unforeseen events. This article will briefly introduce the topics of Safety I and Safety II, resilience engineering and antifragility engineering, explaining correlations, overlapping aspects and synergies. Secondly, the article will discuss the applications of those paradigms to a real accident, highlighting how they can challenge, stimulate and inspire research for improving OHS conditions.

Evolution of Safety Analysis to Support New Exploration Missions

NASA Technical Reports Server (NTRS)

Thrasher, Chard W.

2008-01-01

NASA is currently developing the Ares I launch vehicle as a key component of the Constellation program which will provide safe and reliable transportation to the International Space Station, back to the moon, and later to Mars. The risks and costs of the Ares I must be significantly lowered, as compared to other manned launch vehicles, to enable the continuation of space exploration. It is essential that safety be significantly improved, and cost-effectively incorporated into the design process. This paper justifies early and effective safety analysis of complex space systems. Interactions and dependences between design, logistics, modeling, reliability, and safety engineers will be discussed to illustrate methods to lower cost, reduce design cycles and lessen the likelihood of catastrophic events.

Patient-reported experiences of patient safety incidents need to be utilized more systematically in promoting safe care.

PubMed

Sahlström, Merja; Partanen, Pirjo; Turunen, Hannele

2018-04-16

To analyze patient safety incidents (PSIs) reported by patients and their use in Finnish healthcare organizations. Cross-sectional study. About 15 Finnish healthcare organizations ranging from specialized hospital care to home care, outpatient and inpatient clinics, and geographically diverse areas of Finland. The study population included all Finnish patients who had voluntarily reported PSI via web-based system in 2009-15. Quantitative analysis of patients' safety reports, inductive content analysis of patients' suggestions to prevent the reoccurrence incidents and how those suggestions were used in healthcare organizations. Patients reported 656 PSIs, most of which were classified by the healthcare organizations' analysts as problems associated with information flow (32.6%) and medications (18%). Most of the incidents (65%) did not cause any harm to patients. About 76% of the reports suggested ways to prevent reoccurrence of PSIs, most of which were feasible, system-based amendments of processes for reviewing or administering treatment, anticipating risks or improving diligence in patient care. However, only 6% had led to practical implementation of corrective actions in the healthcare organizations. The results indicate that patients report diverse PSIs and suggest practical systems-based solutions to prevent their reoccurrence. However, patients' reports rarely lead to corrective actions documented in the registering system, indicating that there is substantial scope to improve utilization of patients' reports. There is also a need for strong patient safety management, including willingness and commitment of HCPs and leaders to learn from safety incidents.

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

NASA Technical Reports Server (NTRS)

1972-01-01

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

Fuzzy-logic-based network for complex systems risk assessment: application to ship performance analysis.

PubMed

Abou, Seraphin C

2012-03-01

In this paper, a new interpretation of intuitionistic fuzzy sets in the advanced framework of the Dempster-Shafer theory of evidence is extended to monitor safety-critical systems' performance. Not only is the proposed approach more effective, but it also takes into account the fuzzy rules that deal with imperfect knowledge/information and, therefore, is different from the classical Takagi-Sugeno fuzzy system, which assumes that the rule (the knowledge) is perfect. We provide an analytical solution to the practical and important problem of the conceptual probabilistic approach for formal ship safety assessment using the fuzzy set theory that involves uncertainties associated with the reliability input data. Thus, the overall safety of the ship engine is investigated as an object of risk analysis using the fuzzy mapping structure, which considers uncertainty and partial truth in the input-output mapping. The proposed method integrates direct evidence of the frame of discernment and is demonstrated through references to examples where fuzzy set models are informative. These simple applications illustrate how to assess the conflict of sensor information fusion for a sufficient cooling power system of vessels under extreme operation conditions. It was found that propulsion engine safety systems are not only a function of many environmental and operation profiles but are also dynamic and complex. Copyright © 2011 Elsevier Ltd. All rights reserved.

Generalized implementation of software safety policies

NASA Technical Reports Server (NTRS)

Knight, John C.; Wika, Kevin G.

1994-01-01

As part of a research program in the engineering of software for safety-critical systems, we are performing two case studies. The first case study, which is well underway, is a safety-critical medical application. The second, which is just starting, is a digital control system for a nuclear research reactor. Our goal is to use these case studies to permit us to obtain a better understanding of the issues facing developers of safety-critical systems, and to provide a vehicle for the assessment of research ideas. The case studies are not based on the analysis of existing software development by others. Instead, we are attempting to create software for new and novel systems in a process that ultimately will involve all phases of the software lifecycle. In this abstract, we summarize our results to date in a small part of this project, namely the determination and classification of policies related to software safety that must be enforced to ensure safe operation. We hypothesize that this classification will permit a general approach to the implementation of a policy enforcement mechanism.

How shall we design the future vehicle for Chinese market.

PubMed

Chen, Fang; Wang, Minjuan; Zhu, Xi Chan; Li, Jiaqi

2012-01-01

Surface transportation system is developing very fast in China and the number of vehicles is increasing quickly as well. This development creates a lot of problems on traffic safety and the number of accident is also increasing. In this paper, we made deep analysis of different possible causes of safety problems through three aspects: the traffic environment and infrastructure, in-vehicle information system design and the characteristics of drivers. There are many factors in each aspects may contribute to the transportation safety problems. Problems with infrastructure design and traffic design contribute over 50% of the traffic accident. Another important factor is that people has very little traffic safety concept and very weak on understanding the important of right behavior on the road. This paper has pointed the urgent needs to study the human factors in road and transportation system and vehicle HMI design, as there are very few such studies available in literature based on Chinese situation. The paper also proposed the needs to develop proactive educational system that can promote driver's understanding of traffic safety and to take the right action during drive.

A Concept Analysis of Systems Thinking.

PubMed

Stalter, Ann M; Phillips, Janet M; Ruggiero, Jeanne S; Scardaville, Debra L; Merriam, Deborah; Dolansky, Mary A; Goldschmidt, Karen A; Wiggs, Carol M; Winegardner, Sherri

2017-10-01

This concept analysis, written by the National Quality and Safety Education for Nurses (QSEN) RN-BSN Task Force, defines systems thinking in relation to healthcare delivery. A review of the literature was conducted using five databases with the keywords "systems thinking" as well as "nursing education," "nursing curriculum," "online," "capstone," "practicum," "RN-BSN/RN to BSN," "healthcare organizations," "hospitals," and "clinical agencies." Only articles that focused on systems thinking in health care were used. The authors identified defining attributes, antecedents, consequences, and empirical referents of systems thinking. Systems thinking was defined as a process applied to individuals, teams, and organizations to impact cause and effect where solutions to complex problems are accomplished through collaborative effort according to personal ability with respect to improving components and the greater whole. Four primary attributes characterized systems thinking: dynamic system, holistic perspective, pattern identification, and transformation. Using the platform provided in this concept analysis, interprofessional practice has the ability to embrace planned efforts to improve critically needed quality and safety initiatives across patients' lifespans and all healthcare settings. © 2016 Wiley Periodicals, Inc.

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

NASA Astrophysics Data System (ADS)

Malyshev, Mikhail; Kreimer, Johannes

2013-09-01

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

Safety Analysis of Soybean Processing for Advanced Life Support

NASA Technical Reports Server (NTRS)

Hentges, Dawn L.

1999-01-01

Soybeans (cv. Hoyt) is one of the crops planned for food production within the Advanced Life Support System Integration Testbed (ALSSIT), a proposed habitat simulation for long duration lunar/Mars missions. Soybeans may be processed into a variety of food products, including soymilk, tofu, and tempeh. Due to the closed environmental system and importance of crew health maintenance, food safety is a primary concern on long duration space missions. Identification of the food safety hazards and critical control points associated with the closed ALSSIT system is essential for the development of safe food processing techniques and equipment. A Hazard Analysis Critical Control Point (HACCP) model was developed to reflect proposed production and processing protocols for ALSSIT soybeans. Soybean processing was placed in the type III risk category. During the processing of ALSSIT-grown soybeans, critical control points were identified to control microbiological hazards, particularly mycotoxins, and chemical hazards from antinutrients. Critical limits were suggested at each CCP. Food safety recommendations regarding the hazards and risks associated with growing, harvesting, and processing soybeans; biomass management; and use of multifunctional equipment were made in consideration of the limitations and restraints of the closed ALSSIT.

Usability Methods for Ensuring Health Information Technology Safety: Evidence-Based Approaches. Contribution of the IMIA Working Group Health Informatics for Patient Safety.

PubMed

Borycki, E; Kushniruk, A; Nohr, C; Takeda, H; Kuwata, S; Carvalho, C; Bainbridge, M; Kannry, J

2013-01-01

Issues related to lack of system usability and potential safety hazards continue to be reported in the health information technology (HIT) literature. Usability engineering methods are increasingly used to ensure improved system usability and they are also beginning to be applied more widely for ensuring the safety of HIT applications. These methods are being used in the design and implementation of many HIT systems. In this paper we describe evidence-based approaches to applying usability engineering methods. A multi-phased approach to ensuring system usability and safety in healthcare is described. Usability inspection methods are first described including the development of evidence-based safety heuristics for HIT. Laboratory-based usability testing is then conducted under artificial conditions to test if a system has any base level usability problems that need to be corrected. Usability problems that are detected are corrected and then a new phase is initiated where the system is tested under more realistic conditions using clinical simulations. This phase may involve testing the system with simulated patients. Finally, an additional phase may be conducted, involving a naturalistic study of system use under real-world clinical conditions. The methods described have been employed in the analysis of the usability and safety of a wide range of HIT applications, including electronic health record systems, decision support systems and consumer health applications. It has been found that at least usability inspection and usability testing should be applied prior to the widespread release of HIT. However, wherever possible, additional layers of testing involving clinical simulations and a naturalistic evaluation will likely detect usability and safety issues that may not otherwise be detected prior to widespread system release. The framework presented in the paper can be applied in order to develop more usable and safer HIT, based on multiple layers of evidence.

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

PubMed

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

2000-12-05

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

A systems-based food safety evaluation: an experimental approach.

PubMed

Higgins, Charles L; Hartfield, Barry S

2004-11-01

Food establishments are complex systems with inputs, subsystems, underlying forces that affect the system, outputs, and feedback. Building on past exploration of the hazard analysis critical control point concept and Ludwig von Bertalanffy General Systems Theory, the National Park Service (NPS) is attempting to translate these ideas into a realistic field assessment of food service establishments and to use information gathered by these methods in efforts to improve food safety. Over the course of the last two years, an experimental systems-based methodology has been drafted, developed, and tested by the NPS Public Health Program. This methodology is described in this paper.

Space safety and rescue 1979-1981: Worldwide disaster response, rescue and safety employing space-borne systems

NASA Technical Reports Server (NTRS)

Brown, J. W. (Editor)

1983-01-01

Selected papers from the 1979, 1980, and 1981 IAA symposia on space safety and rescue and on worldwide disaster response, safety, and rescue employing spaceborne systems are presented. Available papers published elsewhere and those presented at the 1976, 1977, and 1978 symposia are presented in abstract form. Subjects discussed include man-made space debris, nuclear-waste disposal in space, space-station safety design, psychological training, the introduction of female crewmembers, analysis of the November 23, 1980 earthquake as a design basis for satellite emergency communication, disaster warning using the GOES satellite, and satellite communications for disaster relief operations. Three reviews of the application of space technology to emergency and disaster relief and prevention, given at other symposia in 1981, are presented in an appendix. No individual items are abstracted in this volume

A COMPARATIVE ANALYSIS BETWEEN FRANCE AND JAPAN ON LOCAL GOVERNMENTS' INVOLVEMENT IN NUCLEAR SAFETY GOVERNANCE

NASA Astrophysics Data System (ADS)

Sugawara, Shin-Etsu; Shiroyama, Hideaki

This paper shows a comparative analysis between France and Japan on the way of the local governments' involvement in nuclear safety governance through some interviews. In France, a law came into force that requires related local governments to establish "Commision Locale d'Information" (CLI), which means the local governments officially involve in nuclear regulatory activity. Meanwhile, in Japan, related local governments substantially involve in the operation of nuclear facilities through the "safety agreements" in spite of the lack of legal authority. As a result of comparative analysis, we can point out some institutional input from French cases as follows: to clarify the local governments' roles in the nuclear regulation system, to establish the official channels of communication among nuclear utilities, national regulatory authorities and local governments, and to stipulate explicitly the transparency as a purpose of safety regulation.

Health and safety evaluation of a modified tunnel borer design for application to single entry coal mine development

NASA Technical Reports Server (NTRS)

Zimmerman, W. F.

1982-01-01

A health and safety analysis of a single entry coal tunnel borer system is given. The results of the health analysis indicated that while the tunnel borer design offered improvements in dust control through the use of water sprays, a higher face ventilation rule, and the application of spalling rather than the conventional grinding process, it interjected an additional mutagen and toxic compound into the environment through the use of shotcrete. The tunnel borer system easily conformed with the prescribed fatality limit, but exceeded the required limits for disabling and overall injuries. It also exhibited projected disabling and overall injury rates considerably higher than existing continuous mining injury rates. Consequently, the tunnel borer system was not considered an advanced system.

Integrating Data From the UK National Reporting and Learning System With Work Domain Analysis to Understand Patient Safety Incidents in Community Pharmacy.

PubMed

Phipps, Denham L; Tam, W Vanessa; Ashcroft, Darren M

2017-03-01

To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting. A retrospective review was conducted of incidents reported to the UK National Reporting and Learning System (NRLS) that involved community pharmacy between April 2005 and August 2010. A work domain analysis of community pharmacy was constructed using observational data from 5 community pharmacies, technical documentation, and a focus group with 6 pharmacists. Reports from the NRLS were mapped onto the model generated by the work domain analysis. Approximately 14,709 incident reports meeting the selection criteria were retrieved from the NRLS. Descriptive statistical analysis of these reports found that almost all of the incidents involved medication and that the most frequently occurring error types were dose/strength errors, incorrect medication, and incorrect formulation. The work domain analysis identified 4 overall purposes for community pharmacy: business viability, health promotion and clinical services, provision of medication, and use of medication. These purposes were served by lower-order characteristics of the work system (such as the functions, processes and objects). The tasks most frequently implicated in the incident reports were those involving medication storage, assembly, or patient medication records. Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.

An Assessment of Civil Tiltrotor Concept of Operations in the Next Generation Air Transportation System

NASA Technical Reports Server (NTRS)

Chung, William W.; Salvano, Dan; Rinehart, David; Young, Ray; Cheng, Victor; Lindsey, James

2012-01-01

Based on a previous Civil Tiltrotor (CTR) National Airspace System (NAS) performance analysis study, CTR operations were evaluated over selected routes and terminal airspace configurations assuming noninterference operations (NIO) and runway-independent operations (RIO). This assessment aims to further identify issues associated with these concepts of operations (ConOps), and their dependency on the airspace configuration and interaction with conventional fixed-wing traffic. Safety analysis following a traditional Safety Management System (SMS) methodology was applied to CTR-unique departure and arrival failures in the selected airspace to identify any operational and certification issues. Additional CTR operational cases were then developed to get a broader understanding of issues and gaps that will need to be addressed in future CTR operational studies. Finally, needed enhancements to National Airspace System performance analysis tools were reviewed, and recommendations were made on improvements in these tools that are likely to be required to support future progress toward CTR fleet operations in the Next Generation Air Transportation System (NextGen).

The influence of authentic leadership on safety climate in nursing.

PubMed

Dirik, Hasan Fehmi; Seren Intepeler, Seyda

2017-07-01

This study analysed nurses' perceptions of authentic leadership and safety climate and examined the contribution of authentic leadership to the safety climate. It has been suggested and emphasised that authentic leadership should be used as a guidance to ensure quality care and the safety of patients and health-care personnel. This predictive study was conducted with 350 nurses in three Turkish hospitals. The data were collected using the Authentic Leadership Questionnaire and the Safety Climate Survey and analysed using hierarchical regression analysis. The mean authentic leadership perception and the safety climate scores of the nurses were 2.92 and 3.50, respectively. The percentage of problematic responses was found to be less than 10% for only four safety climate items. Hierarchical regression analysis revealed that authentic leadership significantly predicted the safety climate. Procedural and political improvements are required in terms of the safety climate in institutions, where the study was conducted, and authentic leadership increases positive perceptions of safety climate. Exhibiting the characteristics of authentic leadership, or improving them and reflecting them on to personnel can enhance the safety climate. Planning information sharing meetings to raise the personnel's awareness of safety climate and systemic improvements can contribute to creating safe care climates. © 2017 John Wiley & Sons Ltd.

Sources of Safety Data and Statistical Strategies for Design and Analysis: Postmarket Surveillance.

PubMed

Izem, Rima; Sanchez-Kam, Matilde; Ma, Haijun; Zink, Richard; Zhao, Yueqin

2018-03-01

Safety data are continuously evaluated throughout the life cycle of a medical product to accurately assess and characterize the risks associated with the product. The knowledge about a medical product's safety profile continually evolves as safety data accumulate. This paper discusses data sources and analysis considerations for safety signal detection after a medical product is approved for marketing. This manuscript is the second in a series of papers from the American Statistical Association Biopharmaceutical Section Safety Working Group. We share our recommendations for the statistical and graphical methodologies necessary to appropriately analyze, report, and interpret safety outcomes, and we discuss the advantages and disadvantages of safety data obtained from passive postmarketing surveillance systems compared to other sources. Signal detection has traditionally relied on spontaneous reporting databases that have been available worldwide for decades. However, current regulatory guidelines and ease of reporting have increased the size of these databases exponentially over the last few years. With such large databases, data-mining tools using disproportionality analysis and helpful graphics are often used to detect potential signals. Although the data sources have many limitations, analyses of these data have been successful at identifying safety signals postmarketing. Experience analyzing these dynamic data is useful in understanding the potential and limitations of analyses with new data sources such as social media, claims, or electronic medical records data.

Integrating natural language processing expertise with patient safety event review committees to improve the analysis of medication events.

PubMed

Fong, Allan; Harriott, Nicole; Walters, Donna M; Foley, Hanan; Morrissey, Richard; Ratwani, Raj R

2017-08-01

Many healthcare providers have implemented patient safety event reporting systems to better understand and improve patient safety. Reviewing and analyzing these reports is often time consuming and resource intensive because of both the quantity of reports and length of free-text descriptions in the reports. Natural language processing (NLP) experts collaborated with clinical experts on a patient safety committee to assist in the identification and analysis of medication related patient safety events. Different NLP algorithmic approaches were developed to identify four types of medication related patient safety events and the models were compared. Well performing NLP models were generated to categorize medication related events into pharmacy delivery delays, dispensing errors, Pyxis discrepancies, and prescriber errors with receiver operating characteristic areas under the curve of 0.96, 0.87, 0.96, and 0.81 respectively. We also found that modeling the brief without the resolution text generally improved model performance. These models were integrated into a dashboard visualization to support the patient safety committee review process. We demonstrate the capabilities of various NLP models and the use of two text inclusion strategies at categorizing medication related patient safety events. The NLP models and visualization could be used to improve the efficiency of patient safety event data review and analysis. Copyright © 2017 Elsevier B.V. All rights reserved.

An Examination of Safety Management Systems and Aviation Technologies in the Helicopter Emergency Medical Services Industry

NASA Astrophysics Data System (ADS)

Buckner, Steven A.

The Helicopter Emergency Medical Service (HEMS) industry has a significant role in the transportation of injured patients, but has experienced more accidents than all other segments of the aviation industry combined. With the objective of addressing this discrepancy, this study assesses the effect of safety management systems implementation and aviation technologies utilization on the reduction of HEMS accident rates. Participating were 147 pilots from Federal Aviation Regulations Part 135 HEMS operators, who completed a survey questionnaire based on the Safety Culture and Safety Management System Survey (SCSMSS). The study assessed the predictor value of SMS implementation and aviation technologies to the frequency of HEMS accident rates with correlation and multiple linear regression. The correlation analysis identified three significant positive relationships. HEMS years of experience had a high significant positive relationship with accident rate (r=.90; p<.05); SMS had a moderate significant positive relationship to Night Vision Goggles (NVG) (r=.38; p<.05); and SMS had a slight significant positive relationship with Terrain Avoidance Warning System (TAWS) (r=.234; p<.05). Multiple regression analysis suggested that when combined with NVG, TAWS, and SMS, HEMS years of experience explained 81.4% of the variance in accident rate scores (p<.05), and HEMS years of experience was found to be a significant predictor of accident rates (p<.05). Additional quantitative regression analysis was recommended to replicate the results of this study and to consider the influence of these variables for continued reduction of HEMS accidents, and to induce execution of SMS and aviation technologies from a systems engineering application. Recommendations for practice included the adoption of existing regulatory guidance for a SMS program. A qualitative analysis was also recommended for future study SMS implementation and HEMS accident rate from the pilot's perspective. A quantitative longitudinal study would further explore inferential relationships between the study variables. Current strategies should include the increased utilization of available aviation technology resources as this proactive stance may be beneficial for the establishment of an effective safety culture within the HEMS industry.

Seniors managing multiple medications: using mixed methods to view the home care safety lens.

PubMed

Lang, Ariella; Macdonald, Marilyn; Marck, Patricia; Toon, Lynn; Griffin, Melissa; Easty, Tony; Fraser, Kimberly; MacKinnon, Neil; Mitchell, Jonathan; Lang, Eddy; Goodwin, Sharon

2015-12-12

Patient safety is a national and international priority with medication safety earmarked as both a prevalent and high-risk area of concern. To date, medication safety research has focused overwhelmingly on institutional based care provided by paid healthcare professionals, which often has little applicability to the home care setting. This critical gap in our current understanding of medication safety in the home care sector is particularly evident with the elderly who often manage more than one chronic illness and a complex palette of medications, along with other care needs. This study addresses the medication management issues faced by seniors with chronic illnesses, their family, caregivers, and paid providers within Canadian publicly funded home care programs in Alberta (AB), Ontario (ON), Quebec (QC) and Nova Scotia (NS). Informed by a socio-ecological perspective, this study utilized Interpretive Description (ID) methodology and participatory photographic methods to capture and analyze a range of visual and textual data. Three successive phases of data collection and analysis were conducted in a concurrent, iterative fashion in eight urban and/or rural households in each province. A total of 94 participants (i.e., seniors receiving home care services, their family/caregivers, and paid providers) were interviewed individually. In addition, 69 providers took part in focus groups. Analysis was iterative and concurrent with data collection in that each interview was compared with subsequent interviews for converging as well as diverging patterns. Six patterns were identified that provide a rich portrayal of the complexity of medication management safety in home care: vulnerabilities that impact the safe management and storage of medication, sustaining adequate supports, degrees of shared accountability for care, systems of variable effectiveness, poly-literacy required to navigate the system, and systemic challenges to maintaining medication safety in the home. There is a need for policy makers, health system leaders, care providers, researchers, and educators to work with home care clients and caregivers on three key messages for improvement: adapt care delivery models to the home care landscape; develop a palette of user-centered tools to support medication safety in the home; and strengthen health systems integration.

System Guidelines for EMC Safety-Critical Circuits: Design, Selection, and Margin Demonstration

NASA Technical Reports Server (NTRS)

Lawton, R. M.

1996-01-01

Demonstration of required safety margins on critical electrical/electronic circuits in large complex systems has become an implementation and cost problem. These margins are the difference between the activation level of the circuit and the electrical noise on the circuit in the actual operating environment. This document discusses the origin of the requirement and gives a detailed process flow for the identification of the system electromagnetic compatibility (EMC) critical circuit list. The process flow discusses the roles of engineering disciplines such as systems engineering, safety, and EMC. Design and analysis guidelines are provided to assist the designer in assuring the system design has a high probability of meeting the margin requirements. Examples of approaches used on actual programs (Skylab and Space Shuttle Solid Rocket Booster) are provided to show how variations of the approach can be used successfully.

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

PubMed

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

2017-08-01

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

Real-Time Safety Risk Assessment Based on a Real-Time Location System for Hydropower Construction Sites

PubMed Central

Fan, Qixiang; Qiang, Maoshan

2014-01-01

The concern for workers' safety in construction industry is reflected in many studies focusing on static safety risk identification and assessment. However, studies on real-time safety risk assessment aimed at reducing uncertainty and supporting quick response are rare. A method for real-time safety risk assessment (RTSRA) to implement a dynamic evaluation of worker safety states on construction site has been proposed in this paper. The method provides construction managers who are in charge of safety with more abundant information to reduce the uncertainty of the site. A quantitative calculation formula, integrating the influence of static and dynamic hazards and that of safety supervisors, is established to link the safety risk of workers with the locations of on-site assets. By employing the hidden Markov model (HMM), the RTSRA provides a mechanism for processing location data provided by the real-time location system (RTLS) and analyzing the probability distributions of different states in terms of false positives and negatives. Simulation analysis demonstrated the logic of the proposed method and how it works. Application case shows that the proposed RTSRA is both feasible and effective in managing construction project safety concerns. PMID:25114958

Real-time safety risk assessment based on a real-time location system for hydropower construction sites.

PubMed

Jiang, Hanchen; Lin, Peng; Fan, Qixiang; Qiang, Maoshan

2014-01-01

The concern for workers' safety in construction industry is reflected in many studies focusing on static safety risk identification and assessment. However, studies on real-time safety risk assessment aimed at reducing uncertainty and supporting quick response are rare. A method for real-time safety risk assessment (RTSRA) to implement a dynamic evaluation of worker safety states on construction site has been proposed in this paper. The method provides construction managers who are in charge of safety with more abundant information to reduce the uncertainty of the site. A quantitative calculation formula, integrating the influence of static and dynamic hazards and that of safety supervisors, is established to link the safety risk of workers with the locations of on-site assets. By employing the hidden Markov model (HMM), the RTSRA provides a mechanism for processing location data provided by the real-time location system (RTLS) and analyzing the probability distributions of different states in terms of false positives and negatives. Simulation analysis demonstrated the logic of the proposed method and how it works. Application case shows that the proposed RTSRA is both feasible and effective in managing construction project safety concerns.

Safety of High Speed Magnetic Levitation Transportation Systems : Magnetic Field Testing of TR-07 Maglev Vehicle. Volume 1. Analysis.

DOT National Transportation Integrated Search

1992-04-01

The safety of various magnetically levitated (maglev) and high speed rail (HSR) trains proposed for application in the United States is of direct concern to the Federal Railroad Administration (FRA). This report catalogs and documents detailed magnet...

10 CFR Appendix A to Part 851 - Worker Safety and Health Functional Areas

Code of Federal Regulations, 2013 CFR

2013-01-01

... Information Technology. (1) Employee medical, psychological, and employee assistance program (EAP) records... site information (e.g., site characterization data, as-built drawings) provided by the construction... systems; (5) A safety analysis approved by the Head of DOE Field Element must be developed for the...

Partial least squares models for hyperspectral contaminant detection

USDA-ARS?s Scientific Manuscript database

The United States of America food supply is one of the safest in the world. However, it is not free of pathogens. For the poultry industry, the Food Safety Inspection Service (FSIS) has regulatory responsiblity for food safety and has established a hazard analysis, critical control point system (HAC...

Food Safety, Farm to Fork.

ERIC Educational Resources Information Center

Jones, Rebecca

1998-01-01

In response to growing threat of food-borne illness, the federal government launched the Food Safety Initiative. A key element is the Hazard Analysis Critical Control Points system (HACCP), designed to make everyone in the food-delivery chain responsible for ensuring a safe food supply. The Food and Drug Administration also announced a beef…

41 CFR 102-80.105 - What information must be included in an equivalent level of safety analysis?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 41 Public Contracts and Property Management 3 2010-07-01 2010-07-01 false What information must be... Property Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION REAL PROPERTY 80-SAFETY AND ENVIRONMENTAL MANAGEMENT Accident and Fire Prevention Equivalent Level...

Demonstration of fully coupled simplified extended station black-out accident simulation with RELAP-7

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

Zhao, Haihua; Zhang, Hongbin; Zou, Ling

2014-10-01

The RELAP-7 code is the next generation nuclear reactor system safety analysis code being developed at the Idaho National Laboratory (INL). The RELAP-7 code develop-ment effort started in October of 2011 and by the end of the second development year, a number of physical components with simplified two phase flow capability have been de-veloped to support the simplified boiling water reactor (BWR) extended station blackout (SBO) analyses. The demonstration case includes the major components for the primary system of a BWR, as well as the safety system components for the safety relief valve (SRV), the reactor core isolation cooling (RCIC)more » system, and the wet well. Three scenar-ios for the SBO simulations have been considered. Since RELAP-7 is not a severe acci-dent analysis code, the simulation stops when fuel clad temperature reaches damage point. Scenario I represents an extreme station blackout accident without any external cooling and cooling water injection. The system pressure is controlled by automatically releasing steam through SRVs. Scenario II includes the RCIC system but without SRV. The RCIC system is fully coupled with the reactor primary system and all the major components are dynamically simulated. The third scenario includes both the RCIC system and the SRV to provide a more realistic simulation. This paper will describe the major models and dis-cuss the results for the three scenarios. The RELAP-7 simulations for the three simplified SBO scenarios show the importance of dynamically simulating the SRVs, the RCIC sys-tem, and the wet well system to the reactor safety during extended SBO accidents.« less

Identification of crew-systems interactions and decision related trends

DOT National Transportation Integrated Search

2013-05-01

National Aeronautics and Space Administration (NASA) Vehicle System Safety Technology (VSST) project management uses systems analysis to identify key issues and maintain a portfolio of research leading to potential solutions to its three identified t...

Crash data collection and analysis system

DOT National Transportation Integrated Search

2006-02-01

The Arizona Department of Transportation (ADOT) is responsible for ensuring the safety and operational : efficiency of Arizonas state highways. Fulfilling that responsibility requires extensive data collection and : analysis, which are very labor-...

29 CFR 1910.119 - Process safety management of highly hazardous chemicals.

Code of Federal Regulations, 2011 CFR

2011-07-01

... complexity of the process will influence the decision as to the appropriate PHA methodology to use. All PHA... process hazard analysis in sufficient detail to support the analysis. (3) Information pertaining to the...) Relief system design and design basis; (E) Ventilation system design; (F) Design codes and standards...

29 CFR 1910.119 - Process safety management of highly hazardous chemicals.

Code of Federal Regulations, 2010 CFR

2010-07-01

... complexity of the process will influence the decision as to the appropriate PHA methodology to use. All PHA... process hazard analysis in sufficient detail to support the analysis. (3) Information pertaining to the...) Relief system design and design basis; (E) Ventilation system design; (F) Design codes and standards...

[Medication error management climate and perception for system use according to construction of medication error prevention system].

PubMed

Kim, Myoung Soo

2012-08-01

The purpose of this cross-sectional study was to examine current status of IT-based medication error prevention system construction and the relationships among system construction, medication error management climate and perception for system use. The participants were 124 patient safety chief managers working for 124 hospitals with over 300 beds in Korea. The characteristics of the participants, construction status and perception of systems (electric pharmacopoeia, electric drug dosage calculation system, computer-based patient safety reporting and bar-code system) and medication error management climate were measured in this study. The data were collected between June and August 2011. Descriptive statistics, partial Pearson correlation and MANCOVA were used for data analysis. Electric pharmacopoeia were constructed in 67.7% of participating hospitals, computer-based patient safety reporting systems were constructed in 50.8%, electric drug dosage calculation systems were in use in 32.3%. Bar-code systems showed up the lowest construction rate at 16.1% of Korean hospitals. Higher rates of construction of IT-based medication error prevention systems resulted in greater safety and a more positive error management climate prevailed. The supportive strategies for improving perception for use of IT-based systems would add to system construction, and positive error management climate would be more easily promoted.

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

PubMed

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

2012-07-01

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

Integrated Safety Analysis Tiers

NASA Technical Reports Server (NTRS)

Shackelford, Carla; McNairy, Lisa; Wetherholt, Jon

2009-01-01

Commercial partnerships and organizational constraints, combined with complex systems, may lead to division of hazard analysis across organizations. This division could cause important hazards to be overlooked, causes to be missed, controls for a hazard to be incomplete, or verifications to be inefficient. Each organization s team must understand at least one level beyond the interface sufficiently enough to comprehend integrated hazards. This paper will discuss various ways to properly divide analysis among organizations. The Ares I launch vehicle integrated safety analyses effort will be utilized to illustrate an approach that addresses the key issues and concerns arising from multiple analysis responsibilities.

Enabling Medical Device Interoperability for the Integrated Clinical Environment

DTIC Science & Technology

2016-02-01

Pajic M, Mangharam R, Sokolsky O, Arney D, Goldman JM, Lee I. Model-Driven Safety Analysis of Closed - Loop Medical Systems. IEEE Transactions on...Manigel J, Osborn D, Roellike T, Weininger S, Westenskow D, “Development of a Standard for Physiologic Closed Loop Controllers in Medical Devices...3 2010. 27. Arney D, Pajic M, Goldman JM, Lee I, Mangharam R, Sokolsky O, “Toward Patient Safety in Closed - Loop Medical Device Systems,” In

The implementation of a Hazard Analysis and Critical Control Point management system in a peanut butter ice cream plant.

PubMed

Hung, Yu-Ting; Liu, Chi-Te; Peng, I-Chen; Hsu, Chin; Yu, Roch-Chui; Cheng, Kuan-Chen

2015-09-01

To ensure the safety of the peanut butter ice cream manufacture, a Hazard Analysis and Critical Control Point (HACCP) plan has been designed and applied to the production process. Potential biological, chemical, and physical hazards in each manufacturing procedure were identified. Critical control points for the peanut butter ice cream were then determined as the pasteurization and freezing process. The establishment of a monitoring system, corrective actions, verification procedures, and documentation and record keeping were followed to complete the HACCP program. The results of this study indicate that implementing the HACCP system in food industries can effectively enhance food safety and quality while improving the production management. Copyright © 2015. Published by Elsevier B.V.

Improving patient safety by instructional systems design

PubMed Central

Battles, J B

2006-01-01

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

Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

PubMed

Kuo, Calvin C; Robb, William J

2013-06-01

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

[Development and validation of the Korean patient safety culture scale for nursing homes].

PubMed

Yoon, Sook Hee; Kim, Byungsoo; Kim, Se Young

2013-06-01

The purpose of this study was to develop a tool to evaluate patient safety culture in nursing homes and to test its validity and reliability. A preliminary tool was developed through interviews with focus group, content validity tests, and a pilot study. A nationwide survey was conducted from February to April, 2011, using self-report questionnaires. Participants were 982 employees in nursing homes. Data were analyzed using Cronbach's alpha, item analysis, factor analysis, and multitrait/multi-Item analysis. From the results of the analysis, 27 final items were selected from 49 items on the preliminary tool. Items with low correlation with total scale were excluded. The 4 factors sorted by factor analysis contributed 63.4% of the variance in the total scale. The factors were labeled as leadership, organizational system, working attitude, management practice. Cronbach's alpha for internal consistency was .95 and the range for the 4 factors was from .86 to .93. The results of this study indicate that the Korean Patient Safety Culture Scale has reliability and validity and is suitable for evaluation of patient safety culture in Korean nursing homes.

14 CFR 417.409 - System hazard controls.

Code of Federal Regulations, 2012 CFR

2012-01-01

... hazard as identified by the ground safety analysis and satisfy the requirements of this section. A launch... electrical power and signal circuits that interface with hazardous subsystems. (e) Propulsion systems. A...

14 CFR 417.409 - System hazard controls.

Code of Federal Regulations, 2013 CFR

2013-01-01

... hazard as identified by the ground safety analysis and satisfy the requirements of this section. A launch... electrical power and signal circuits that interface with hazardous subsystems. (e) Propulsion systems. A...

14 CFR 417.409 - System hazard controls.

Code of Federal Regulations, 2014 CFR

2014-01-01

... hazard as identified by the ground safety analysis and satisfy the requirements of this section. A launch... electrical power and signal circuits that interface with hazardous subsystems. (e) Propulsion systems. A...

14 CFR 417.409 - System hazard controls.

Code of Federal Regulations, 2011 CFR

2011-01-01

... hazard as identified by the ground safety analysis and satisfy the requirements of this section. A launch... electrical power and signal circuits that interface with hazardous subsystems. (e) Propulsion systems. A...

[Patient safety culture based on a non-punitive response to error and freedom of expression of healthcare professionals].

PubMed

Mahjoub, Mohamed; Bouafia, Nabiha; Cheikh, Asma Ben; Ezzi, Olfa; Njah, Mansour

2016-11-25

This study provided an overview of healthcare professionals’ perception of patient safety based on analysis of the concept of freedom of expression and non-punitive response in order to identify and correct errors in our health system. This concept is a cornerstone of the patient safety culture among healthcare professionals and plays a central role in the quality improvement strategy..

RELEASE OF DRIED RADIOACTIVE WASTE MATERIALS TECHNICAL BASIS DOCUMENT

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

KOZLOWSKI, S.D.

2007-05-30

This technical basis document was developed to support RPP-23429, Preliminary Documented Safety Analysis for the Demonstration Bulk Vitrification System (PDSA) and RPP-23479, Preliminary Documented Safety Analysis for the Contact-Handled Transuranic Mixed (CH-TRUM) Waste Facility. The main document describes the risk binning process and the technical basis for assigning risk bins to the representative accidents involving the release of dried radioactive waste materials from the Demonstration Bulk Vitrification System (DBVS) and to the associated represented hazardous conditions. Appendices D through F provide the technical basis for assigning risk bins to the representative dried waste release accident and associated represented hazardous conditionsmore » for the Contact-Handled Transuranic Mixed (CH-TRUM) Waste Packaging Unit (WPU). The risk binning process uses an evaluation of the frequency and consequence of a given representative accident or represented hazardous condition to determine the need for safety structures, systems, and components (SSC) and technical safety requirement (TSR)-level controls. A representative accident or a represented hazardous condition is assigned to a risk bin based on the potential radiological and toxicological consequences to the public and the collocated worker. Note that the risk binning process is not applied to facility workers because credible hazardous conditions with the potential for significant facility worker consequences are considered for safety-significant SSCs and/or TSR-level controls regardless of their estimated frequency. The controls for protection of the facility workers are described in RPP-23429 and RPP-23479. Determination of the need for safety-class SSCs was performed in accordance with DOE-STD-3009-94, Preparation Guide for US. Department of Energy Nonreactor Nuclear Facility Documented Safety Analyses, as described below.« less

Correlated Topics in a Scalable Multidimensional Text Cube: Algorithms and Aviation Safety Case Study

NASA Technical Reports Server (NTRS)

Zhao, Bo; Lin, Cindy X.; Srivastava, Ashok N.; Oza, Nikunj C.; Han, Jiawei

2010-01-01

As world-wide air traffic continues to grow even at a modest pace, the overall complexity of the system will increase significantly. This increased complexity can lead to a larger number of fatalities per year even if the extremely low fatality rate that we currently enjoy is maintained. One important source of information about the safety of the aviation system is in Aviation Safety Text Reports which are written by members of the flight crew, air traffic controllers, and other parties involved with the aviation system. These anonymized narrative reports contain fixed-field contextual information about the flight but also contain free-form narratives that describe, in the author s own words, the nature of the safety incident and, in many cases, the contributing factors that led to the safety incident. Several thousand such reports are filed each month, each of which is read and analyzed by highly trained experts. However, it is possible that there are emerging safety issues due to the fact that they may be reported very infrequently and in different contexts with different descriptions. The goal of this research paper is to develop correlated topic models which uncover correlations in the subspaces defined by the intersection of numerous fixed fields and discovered correlated topics. This task requires the discovery of latent topics in the text reports and the creation of a topic cube. Furthermore, because the number of potential cells in the topic cube is very large, we discuss novel methods of pruning the search space in the topic cells, thereby making the analysis feasible. We demonstrate the new algorithms on an analysis of pilot fatigue and its contributing factors, as well as the safety incidents that are correlated with this phenomenon.

An Innovative Hybrid Loop-Pool SFR Design and Safety Analysis Methods: Today and Tomorrow

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

Hongbin Zhang; Haihua Zhao; Vincent Mousseau

2008-04-01

Investment in commercial sodium cooled fast reactor (SFR) power plants will become possible only if SFRs achieve economic competitiveness as compared to light water reactors and other Generation IV reactors. Toward that end, we have launched efforts to improve the economics and safety of SFRs from the thermal design and safety analyses perspectives at Idaho National Laboratory. From the thermal design perspective, an innovative hybrid loop-pool SFR design has been proposed. This design takes advantage of the inherent safety of a pool design and the compactness of a loop design to further improve economics and safety. From the safety analysesmore » perspective, we have initiated an effort to develop a high fidelity reactor system safety code.« less

Modelling runway incursion severity.

PubMed

Wilke, Sabine; Majumdar, Arnab; Ochieng, Washington Y

2015-06-01

Analysis of the causes underlying runway incursions is fundamental for the development of effective mitigation measures. However, there are significant weaknesses in the current methods to model these factors. This paper proposes a structured framework for modelling causal factors and their relationship to severity, which includes a description of the airport surface system architecture, establishment of terminological definitions, the determination and collection of appropriate data, the analysis of occurrences for severity and causes, and the execution of a statistical analysis framework. It is implemented in the context of U.S. airports, enabling the identification of a number of priority interventions, including the need for better investigation and causal factor capture, recommendations for airfield design, operating scenarios and technologies, and better training for human operators in the system. The framework is recommended for the analysis of runway incursions to support safety improvements and the methodology is transferable to other areas of aviation safety risk analysis. Copyright © 2015 Elsevier Ltd. All rights reserved.

Determining the causal relationships among balanced scorecard perspectives on school safety performance: case of Saudi Arabia.

PubMed

Alolah, Turki; Stewart, Rodney A; Panuwatwanich, Kriengsak; Mohamed, Sherif

2014-07-01

In the public schools of many developing countries, numerous accidents and incidents occur because of poor safety regulations and management systems. To improve the educational environment in Saudi Arabia, the Ministry of Education seeks novel approaches to measure school safety performance in order to decrease incidents and accidents. The main objective of this research was to develop a systematic approach for measuring Saudi school safety performance using the balanced scorecard framework philosophy. The evolved third generation balanced scorecard framework is considered to be a suitable and robust framework that captures the system-wide leading and lagging indicators of business performance. The balanced scorecard architecture is ideal for adaptation to complex areas such as safety management where a holistic system evaluation is more effective than traditional compartmentalised approaches. In developing the safety performance balanced scorecard for Saudi schools, the conceptual framework was first developed and peer-reviewed by eighteen Saudi education experts. Next, 200 participants, including teachers, school executives, and Ministry of Education officers, were recruited to rate both the importance and the performance of 79 measurement items used in the framework. Exploratory factor analysis, followed by the confirmatory partial least squares method, was then conducted in order to operationalise the safety performance balanced scorecard, which encapsulates the following five salient perspectives: safety management and leadership; safety learning and training; safety policy, procedures and processes; workforce safety culture; and safety performance. Partial least squares based structural equation modelling was then conducted to reveal five significant relationships between perspectives, namely, safety management and leadership had a significant effect on safety learning and training and safety policy, procedures and processes, both safety learning and training and safety policy, procedures and processes had significant effects on workforce safety culture, and workforce safety culture had a significant effect on safety performance. Copyright © 2014 Elsevier Ltd. All rights reserved.

Lessons learned from the Galileo and Ulysses flight safety review experience

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

Bennett, Gary L.

In preparation for the launches of the Galileo and Ulysses spacecraft, a very comprehensive aerospace nuclear safety program and flight safety review were conducted. A review of this work has highlighted a number of important lessons which should be considered in the safety analysis and review of future space nuclear systems. These lessons have been grouped into six general categories: (1) establishment of the purpose, objectives and scope of the safety process; (2) establishment of charters defining the roles of the various participants; (3) provision of adequate resources; (4) provision of timely peer-reviewed information to support the safety program; (5)more » establishment of general ground rules for the safety review; and (6) agreement on the kinds of information to be provided from the safety review process.« less

Analysis of crashes involving 15-passenger vans

DOT National Transportation Integrated Search

2004-05-01

This study explores the relationship between vehicle occupancy and several other variables in the National Highway Traffic Safety Administration's (NHTSA's) Fatality Analysis Reporting System (FARS) database and a 15-passenger van's risk of rollover....

[A systemic risk analysis of hospital management processes by medical employees--an effective basis for improving patient safety].

PubMed

Sobottka, Stephan B; Eberlein-Gonska, Maria; Schackert, Gabriele; Töpfer, Armin

2009-01-01

Due to the knowledge gap that exists between patients and health care staff the quality of medical treatment usually cannot be assessed securely by patients. For an optimization of safety in treatment-related processes of medical care, the medical staff needs to be actively involved in preventive and proactive quality management. Using voluntary, confidential and non-punitive systematic employee surveys, vulnerable topics and areas in patient care revealing preventable risks can be identified at an early stage. Preventive measures to continuously optimize treatment quality can be defined by creating a risk portfolio and a priority list of vulnerable topics. Whereas critical incident reporting systems are suitable for continuous risk assessment by detecting safety-relevant single events, employee surveys permit to conduct a systematic risk analysis of all treatment-related processes of patient care at any given point in time.

Engineering risk reduction in satellite programs

NASA Technical Reports Server (NTRS)

Dean, E. S., Jr.

1979-01-01

Methods developed in planning and executing system safety engineering programs for Lockheed satellite integration contracts are presented. These procedures establish the applicable safety design criteria, document design compliance and assess the residual risks where non-compliant design is proposed, and provide for hazard analysis of system level test, handling and launch preparations. Operations hazard analysis identifies product protection and product liability hazards prior to the preparation of operational procedures and provides safety requirements for inclusion in them. The method developed for documenting all residual hazards for the attention of program management assures an acceptable minimum level of risk prior to program deployment. The results are significant for persons responsible for managing or engineering the deployment and production of complex high cost equipment under current product liability law and cost/time constraints, have a responsibility to minimize the possibility of an accident, and should have documentation to provide a defense in a product liability suit.

A hybrid simulation approach for integrating safety behavior into construction planning: An earthmoving case study.

PubMed

Goh, Yang Miang; Askar Ali, Mohamed Jawad

2016-08-01

One of the key challenges in improving construction safety and health is the management of safety behavior. From a system point of view, workers work unsafely due to system level issues such as poor safety culture, excessive production pressure, inadequate allocation of resources and time and lack of training. These systemic issues should be eradicated or minimized during planning. However, there is a lack of detailed planning tools to help managers assess the impact of their upstream decisions on worker safety behavior. Even though simulation had been used in construction planning, the review conducted in this study showed that construction safety management research had not been exploiting the potential of simulation techniques. Thus, a hybrid simulation framework is proposed to facilitate integration of safety management considerations into construction activity simulation. The hybrid framework consists of discrete event simulation (DES) as the core, but heterogeneous, interactive and intelligent (able to make decisions) agents replace traditional entities and resources. In addition, some of the cognitive processes and physiological aspects of agents are captured using system dynamics (SD) approach. The combination of DES, agent-based simulation (ABS) and SD allows a more "natural" representation of the complex dynamics in construction activities. The proposed hybrid framework was demonstrated using a hypothetical case study. In addition, due to the lack of application of factorial experiment approach in safety management simulation, the case study demonstrated sensitivity analysis and factorial experiment to guide future research. Copyright © 2015 Elsevier Ltd. All rights reserved.

Can Disproportionality Analysis of Post-marketing Case Reports be Used for Comparison of Drug Safety Profiles?

PubMed

Michel, Christiane; Scosyrev, Emil; Petrin, Michael; Schmouder, Robert

2017-05-01

Clinical trials usually do not have the power to detect rare adverse drug reactions. Spontaneous adverse reaction reports as for example available in post-marketing safety databases such as the FDA Adverse Event Reporting System (FAERS) are therefore a valuable source of information to detect new safety signals early. To screen such large data-volumes for safety signals, data-mining algorithms based on the concept of disproportionality have been developed. Because disproportionality analysis is based on spontaneous reports submitted for a large number of drugs and adverse event types, one might consider using these data to compare safety profiles across drugs. In fact, recent publications have promoted this practice, claiming to provide guidance on treatment decisions to healthcare decision makers. In this article we investigate the validity of this approach. We argue that disproportionality cannot be used for comparative drug safety analysis beyond basic hypothesis generation because measures of disproportionality are: (1) missing the incidence denominators, (2) subject to severe reporting bias, and (3) not adjusted for confounding. Hypotheses generated by disproportionality analyses must be investigated by more robust methods before they can be allowed to influence clinical decisions.

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

LaSalle, F.R.; Golbeg, P.R.; Chenault, D.M.

For reactor and nuclear facilities, both Title 10, Code of Federal Regulations, Part 50, and US Department of Energy Order 6430.1A require assessments of the interaction of non-Safety Class 1 piping and equipment with Safety Class 1 piping and equipment during a seismic event to maintain the safety function. The safety class systems of nuclear reactors or nuclear facilities are designed to the applicable American Society of Mechanical Engineers standards and Seismic Category 1 criteria that require rigorous analysis, construction, and quality assurance. Because non-safety class systems are generally designed to lesser standards and seismic criteria, they may become missilesmore » during a safe shutdown earthquake. The resistance of piping, tubing, and equipment to seismically generated missiles is addressed in the paper. Gross plastic and local penetration failures are considered with applicable test verification. Missile types and seismic zones of influence are discussed. Field qualification data are also developed for missile evaluation.« less

Design for Reliability and Safety Approach for the NASA New Launch Vehicle

NASA Technical Reports Server (NTRS)

Safie, Fayssal, M.; Weldon, Danny M.

2007-01-01

The United States National Aeronautics and Space Administration (NASA) is in the midst of a space exploration program intended for sending crew and cargo to the international Space Station (ISS), to the moon, and beyond. This program is called Constellation. As part of the Constellation program, NASA is developing new launch vehicles aimed at significantly increase safety and reliability, reduce the cost of accessing space, and provide a growth path for manned space exploration. Achieving these goals requires a rigorous process that addresses reliability, safety, and cost upfront and throughout all the phases of the life cycle of the program. This paper discusses the "Design for Reliability and Safety" approach for the NASA new crew launch vehicle called ARES I. The ARES I is being developed by NASA Marshall Space Flight Center (MSFC) in support of the Constellation program. The ARES I consists of three major Elements: A solid First Stage (FS), an Upper Stage (US), and liquid Upper Stage Engine (USE). Stacked on top of the ARES I is the Crew exploration vehicle (CEV). The CEV consists of a Launch Abort System (LAS), Crew Module (CM), Service Module (SM), and a Spacecraft Adapter (SA). The CEV development is being led by NASA Johnson Space Center (JSC). Designing for high reliability and safety require a good integrated working environment and a sound technical design approach. The "Design for Reliability and Safety" approach addressed in this paper discusses both the environment and the technical process put in place to support the ARES I design. To address the integrated working environment, the ARES I project office has established a risk based design group called "Operability Design and Analysis" (OD&A) group. This group is an integrated group intended to bring together the engineering, design, and safety organizations together to optimize the system design for safety, reliability, and cost. On the technical side, the ARES I project has, through the OD&A environment, implemented a probabilistic approach to analyze and evaluate design uncertainties and understand their impact on safety, reliability, and cost. This paper focuses on the use of the various probabilistic approaches that have been pursued by the ARES I project. Specifically, the paper discusses an integrated functional probabilistic analysis approach that addresses upffont some key areas to support the ARES I Design Analysis Cycle (DAC) pre Preliminary Design (PD) Phase. This functional approach is a probabilistic physics based approach that combines failure probabilities with system dynamics and engineering failure impact models to identify key system risk drivers and potential system design requirements. The paper also discusses other probabilistic risk assessment approaches planned by the ARES I project to support the PD phase and beyond.

The adaptive safety analysis and monitoring system

NASA Astrophysics Data System (ADS)

Tu, Haiying; Allanach, Jeffrey; Singh, Satnam; Pattipati, Krishna R.; Willett, Peter

2004-09-01

The Adaptive Safety Analysis and Monitoring (ASAM) system is a hybrid model-based software tool for assisting intelligence analysts to identify terrorist threats, to predict possible evolution of the terrorist activities, and to suggest strategies for countering terrorism. The ASAM system provides a distributed processing structure for gathering, sharing, understanding, and using information to assess and predict terrorist network states. In combination with counter-terrorist network models, it can also suggest feasible actions to inhibit potential terrorist threats. In this paper, we will introduce the architecture of the ASAM system, and discuss the hybrid modeling approach embedded in it, viz., Hidden Markov Models (HMMs) to detect and provide soft evidence on the states of terrorist network nodes based on partial and imperfect observations, and Bayesian networks (BNs) to integrate soft evidence from multiple HMMs. The functionality of the ASAM system is illustrated by way of application to the Indian Airlines Hijacking, as modeled from open sources.

Conceptual design study of Fusion Experimental Reactor (FY86 FER): Safety

NASA Astrophysics Data System (ADS)

Seki, Yasushi; Iida, Hiromasa; Honda, Tsutomu

1987-08-01

This report describes the study on safety for FER (Fusion Experimental Reactor) which has been designed as a next step machine to the JT-60. Though the final purpose of this study is to have an image of design base accident, maximum credible accident and to assess their risk or probability, etc., as FER plant system, the emphasis of this years study is placed on fuel-gas circulation system where the tritium inventory is maximum. The report consists of two chapters. The first chapter summarizes the FER system and describes FMEA (Failure Mode and Effect Analysis) and related accident progression sequence for FER plant system as a whole. The second chapter of this report is focused on fuel-gas circulation system including purification, isotope separation and storage. Probability of risk is assessed by the probabilistic risk analysis (PRA) procedure based on FMEA, ETA and FTA.

Translating Health Services Research into Practice in the Safety Net.

PubMed

Moore, Susan L; Fischer, Ilana; Havranek, Edward P

2016-02-01

To summarize research relating to health services research translation in the safety net through analysis of the literature and case study of a safety net system. Literature review and key informant interviews at an integrated safety net hospital. This paper describes the results of a comprehensive literature review of translational science literature as applied to health care paired with qualitative analysis of five key informant interviews conducted with senior-level management at Denver Health and Hospital Authority. Results from the literature suggest that implementing innovation may be more difficult in the safety net due to multiple factors, including financial and organizational constraints. Results from key informant interviews confirmed the reality of financial barriers to innovation implementation but also implied that factors, including institutional respect for data, organizational attitudes, and leadership support, could compensate for disadvantages. Translating research into practice is of critical importance to safety net providers, which are under increased pressure to improve patient care and satisfaction. Results suggest that translational research done in the safety net can better illuminate the special challenges of this setting; more such research is needed. © Health Research and Educational Trust.

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

PubMed

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

2017-03-01

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

Automation for System Safety Analysis

NASA Technical Reports Server (NTRS)

Malin, Jane T.; Fleming, Land; Throop, David; Thronesbery, Carroll; Flores, Joshua; Bennett, Ted; Wennberg, Paul

2009-01-01

This presentation 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 and simulation to identify and evaluate possible paths from hazard sources to vulnerable entities and functions, in nominal and anomalous system-software configurations and scenarios; and 4) identify resulting candidate scenarios for software integration testing. There has been significant technical progress in model extraction from Orion program text sources, architecture model derivation (components and connections) and documentation of extraction sources. Models have been derived from Internal Interface Requirements Documents (IIRDs) and FMEA documents. Linguistic text processing is used to extract model parts and relationships, and the Aerospace Ontology also aids automated model development from the extracted information. Visualizations of these models assist analysts in requirements overview and in checking consistency and completeness.

Safety Study: The Performance and use of Child Restraint Systems, Seatbelts, and Air Bags for Children in Passenger Vehicles. Volume 1:Analysis

DOT National Transportation Integrated Search

1996-01-01

Despite the effectiveness of child restraints and lap/shoulder belts to reduce the likelihood of severe and fatal injuries, accidents continue to occur in which restrained children are being injured and killed. The Safety Board conducted this study t...

Safety assessment on pedestrian crossing environments using MLS data.

PubMed

Soilán, Mario; Riveiro, Belén; Sánchez-Rodríguez, Ana; Arias, Pedro

2018-02-01

In the framework of infrastructure analysis and maintenance in an urban environment, it is important to address the safety of every road user. This paper presents a methodology for the evaluation of several safety indicators on pedestrian crossing environments using geometric and radiometric information extracted from 3D point clouds collected by a Mobile Mapping System (MMS). The methodology is divided in four main modules which analyze the accessibility of the crossing area, the presence of traffic lights and traffic signs, and the visibility between a driver and a pedestrian on the proximities of a pedestrian crossing. The outputs of the analysis are exported to a Geographic Information System (GIS) where they are visualized and can be further processed in the context of city management. The methodology has been tested on approximately 30 pedestrian crossings in cluttered urban environments of two different cities. Results show that MMS are a valid mean to assess the safety of a specific urban environment, regarding its geometric conditions. Remarkable results are presented on traffic light classification, with a global F-score close to 95%. Copyright © 2017 Elsevier Ltd. All rights reserved.

Spaceflight Ground Support Equipment Reliability & System Safety Data

NASA Technical Reports Server (NTRS)

Fernandez, Rene; Riddlebaugh, Jeffrey; Brinkman, John; Wilkinson, Myron

2012-01-01

Presented were Reliability Analysis, consisting primarily of Failure Modes and Effects Analysis (FMEA), and System Safety Analysis, consisting of Preliminary Hazards Analysis (PHA), performed to ensure that the CoNNeCT (Communications, Navigation, and Networking re- Configurable Testbed) Flight System was safely and reliably operated during its Assembly, Integration and Test (AI&T) phase. A tailored approach to the NASA Ground Support Equipment (GSE) standard, NASA-STD-5005C, involving the application of the appropriate Requirements, S&MA discipline expertise, and a Configuration Management system (to retain a record of the analysis and documentation) were presented. Presented were System Block Diagrams of selected GSE and the corresponding FMEA, as well as the PHAs. Also discussed are the specific examples of the FMEAs and PHAs being used during the AI&T phase to drive modifications to the GSE (via "redlining" of test procedures, and the placement of warning stickers to protect the flight hardware) before being interfaced to the Flight System. These modifications were necessary because failure modes and hazards were identified during the analysis that had not been properly mitigated. Strict Configuration Management was applied to changes (whether due to upgrades or expired calibrations) in the GSE by revisiting the FMEAs and PHAs to reflect the latest System Block Diagrams and Bill Of Material. The CoNNeCT flight system has been successfully assembled, integrated, tested, and shipped to the launch site without incident. This demonstrates that the steps taken to safeguard the flight system when it was interfaced to the various GSE were successful.

European perspectives of food safety.

PubMed

Bánáti, Diána

2014-08-01

Food safety has been a growing concern among European Union (EU) citizens over the last decades. Despite the fact that food has never been safer, consumers are considerably uncertain and increasingly critical about the safety of their food. The introduction of new principles, such as the primary responsibility of producers, traceability, risk analysis, the separation of risk assessment and risk management provided a more transparent, science-based system in Europe, which can help to restore consumers' lost confidence. The present EU integrated approach to food safety 'from farm to fork' aims to assure a high level of food safety within the EU. © 2014 Society of Chemical Industry.

A hierarchical factor analysis of a safety culture survey.

PubMed

Frazier, Christopher B; Ludwig, Timothy D; Whitaker, Brian; Roberts, D Steve

2013-06-01

Recent reviews of safety culture measures have revealed a host of potential factors that could make up a safety culture (Flin, Mearns, O'Connor, & Bryden, 2000; Guldenmund, 2000). However, there is still little consensus regarding what the core factors of safety culture are. The purpose of the current research was to determine the core factors, as well as the structure of those factors that make up a safety culture, and establish which factors add meaningful value by factor analyzing a widely used safety culture survey. A 92-item survey was constructed by subject matter experts and was administered to 25,574 workers across five multi-national organizations in five different industries. Exploratory and hierarchical confirmatory factor analyses were conducted revealing four second-order factors of a Safety Culture consisting of Management Concern, Personal Responsibility for Safety, Peer Support for Safety, and Safety Management Systems. Additionally, a total of 12 first-order factors were found: three on Management Concern, three on Personal Responsibility, two on Peer Support, and four on Safety Management Systems. The resulting safety culture model addresses gaps in the literature by indentifying the core constructs which make up a safety culture. This clarification of the major factors emerging in the measurement of safety cultures should impact the industry through a more accurate description, measurement, and tracking of safety cultures to reduce loss due to injury. Copyright © 2013 National Safety Council and Elsevier Ltd. All rights reserved.

Effectiveness of Direct Safety Regulations on Manufacturers and Users of Industrial Machines: Its Implications on Industrial Safety Policies in Republic of Korea.

PubMed

Choi, Gi Heung

2017-03-01

Despite considerable efforts made in recent years, the industrial accident rate and the fatality rate in the Republic of Korea are much higher than those in most developed countries in Europe and North America. Industrial safety policies and safety regulations are also known to be ineffective and inefficient in some cases. This study focuses on the quantitative evaluation of the effectiveness of direct safety regulations such as safety certification, self-declaration of conformity, and safety inspection of industrial machines in the Republic of Korea. Implications on safety policies to restructure the industrial safety system associated with industrial machines are also explored. Analysis of causes in industrial accidents associated with industrial machines confirms that technical causes need to be resolved to reduce both the frequency and the severity of such industrial accidents. Statistical analysis also confirms that the indirect effects of safety device regulation on users are limited for a variety of reasons. Safety device regulation needs to be shifted to complement safety certification and self-declaration of conformity for more balanced direct regulations on manufacturers and users. An example of cost-benefit analysis on conveyor justifies such a transition. Industrial safety policies and regulations associated with industrial machines must be directed towards eliminating the sources of danger at the stage of danger creation, thereby securing the safe industrial machines. Safety inspection further secures the safety of workers at the stage of danger use. The overall balance between such safety regulations is achieved by proper distribution of industrial machines subject to such regulations and the intensity of each regulation. Rearrangement of industrial machines subject to safety certification and self-declaration of conformity to include more movable industrial machines and other industrial machines with a high level of danger is also suggested.

Pressure control and analysis report: Hydrogen Thermal Test Article (HTTA)

NASA Technical Reports Server (NTRS)

1971-01-01

Tasks accomplished during the HTTA Program study period included: (1) performance of a literature review to provide system guidelines; (2) development of analytical procedures needed to predict system performance; (3) design and analysis of the HTTA pressurization system considering (a) future utilization of results in the design of a spacecraft maneuvering system propellant package, (b) ease of control and operation, (c) system safety, and (d) hardware cost; and (4) making conclusions and recommendations for systems design.

APT Blanket System Loss-of-Coolant Accident (LOCA) Analysis Based on Initial Conceptual Design - Case 3: External HR Break at Pump Outlet without Pump Trip

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

Hamm, L.L.

1998-10-07

This report is one of a series of reports that document normal operation and accident simulations for the Accelerator Production of Tritium (APT) blanket heat removal (HR) system. These simulations were performed for the Preliminary Safety Analysis Report.

Summary Report: Uniform Traffic Control And Warning Messages For Portable Changeable Message Signs

DOT National Transportation Integrated Search

2000-03-01

The California database incorporated in the Highway Safety Information System (HSIS) is derived from the California TASAS (Traffic Accident Surveillance and Analysis System). The system, maintained by the Traffic Operations Office of Caltrans, is a m...

Analysis of the Influence of Construction Insulation Systems on Public Safety in China

PubMed Central

Zhang, Guowei; Zhu, Guoqing; Zhao, Guoxiang

2016-01-01

With the Government of China’s proposed Energy Efficiency Regulations (GB40411-2007), the implementation of external insulation systems will be mandatory in China. The frequent external insulation system fires cause huge numbers of casualties and extensive property damage and have rapidly become a new hot issue in construction evacuation safety in China. This study attempts to reconstruct an actual fire scene and propose a quantitative risk assessment method for upward insulation system fires using thermal analysis tests and large eddy simulations (using the Fire Dynamics Simulator (FDS) software). Firstly, the pyrolysis and combustion characteristics of Extruded polystyrene board (XPS panel), such as ignition temperature, combustion heat, limiting oxygen index, thermogravimetric analysis and thermal radiation analysis were studied experimentally. Based on these experimental data, large eddy simulation was then applied to reconstruct insulation system fires. The results show that upward insulation system fires could be accurately reconstructed by using thermal analysis test and large eddy simulation. The spread of insulation material system fires in the vertical direction is faster than that in the horizontal direction. Moreover, we also find that there is a possibility of flashover in enclosures caused by insulation system fires as the smoke temperature exceeds 600 °C. The simulation methods and experimental results obtained in this paper could provide valuable references for fire evacuation, hazard assessment and fire resistant construction design studies. PMID:27589774