Probabilistic analysis of Millstone Unit 3 ultimate containment failure probability given high pressure: Chapter 14

International Nuclear Information System (INIS)

Bickel, J.H.

1983-01-01

The quantification of the containment event trees in the Millstone Unit 3 Probabilistic Safety Study utilizes a conditional probability of failure given high pressure which is based on a new approach. The generation of this conditional probability was based on a weakest link failure mode model which considered contributions from a number of overlapping failure modes. This overlap effect was due to a number of failure modes whose mean failure pressures were clustered within a 5 psi range and which had uncertainties due to variances in material strengths and analytical uncertainties which were between 9 and 15 psi. Based on a review of possible probability laws to describe the failure probability of individual structural failure modes, it was determined that a Weibull probability law most adequately described the randomness in the physical process of interest. The resultant conditional probability of failure is found to have a median failure pressure of 132.4 psia. The corresponding 5-95 percentile values are 112 psia and 146.7 psia respectively. The skewed nature of the conditional probability of failure vs. pressure results in a lower overall containment failure probability for an appreciable number of the severe accident sequences of interest, but also probabilities which are more rigorously traceable from first principles

Failure modes of composite sandwich beams

Directory of Open Access Journals (Sweden)

Gdoutos E.

2008-01-01

Full Text Available A thorough investigation of failure behavior of composite sandwich beams under three-and four-point bending was undertaken. The beams were made of unidirectional carbon/epoxy facings and a PVC closed-cell foam core. The constituent materials were fully characterized and in the case of the foam core, failure envelopes were developed for general two-dimensional states of stress. Various failure modes including facing wrinkling, indentation failure and core failure were observed and compared with analytical predictions. The initiation, propagation and interaction of failure modes depend on the type of loading, constituent material properties and geometrical dimensions.

A streamlined failure mode and effects analysis

International Nuclear Information System (INIS)

Ford, Eric C.; Smith, Koren; Terezakis, Stephanie; Croog, Victoria; Gollamudi, Smitha; Gage, Irene; Keck, Jordie; DeWeese, Theodore; Sibley, Greg

2014-01-01

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

A streamlined failure mode and effects analysis.

Science.gov (United States)

Ford, Eric C; Smith, Koren; Terezakis, Stephanie; Croog, Victoria; Gollamudi, Smitha; Gage, Irene; Keck, Jordie; DeWeese, Theodore; Sibley, Greg

2014-06-01

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

A streamlined failure mode and effects analysis

Energy Technology Data Exchange (ETDEWEB)

Ford, Eric C., E-mail: eford@uw.edu; Smith, Koren; Terezakis, Stephanie; Croog, Victoria; Gollamudi, Smitha; Gage, Irene; Keck, Jordie; DeWeese, Theodore; Sibley, Greg [Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD 21287 (United States)

2014-06-15

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

Defense against common-mode failures in protection system design

International Nuclear Information System (INIS)

Wyman, R.H.; Johnson, G.L.

1998-01-01

The introduction of digital instrumentation and control into reactor safety systems creates a heightened concern about common-mode failure. This paper discusses the concern and methods of cope with the concern. Common-mode failures have been a 'fact-of-life' in existing systems. The informal introduction of defense-in-depth and diversity (D-in-D and D) - coupled with the fact that hardware common-mode failures are often distributed in time - has allowed systems to deal with past common-mode failures. However, identical software operating in identical redundant systems presents the potential for simultaneous failure. Consequently, the use of digital systems raises the concern about common-mode failure to a new level. A more methodical approach to mitigating common-mode failure is needed to address these concerns. Purposeful introduction of D-in-D and D has been used as a defense against common-mode failure in reactor protection systems. At least two diverse systems are provided to mitigate any potential initiating event. Additionally, diverse displays and controls are provided to allow the operator to monitor plant status and manually initiate engineered safety features. A special form of common-mode failure analysis called 'defense-in-depth and diversity analysis' has been developed to identify possible common-mode failure vulnerabilities in digital systems. An overview of this analysis technique is provided. (author)

Defense against common-mode failures in protection system design

International Nuclear Information System (INIS)

Wyman, R.H.; Johnson, G.L.

1997-01-01

The introduction of digital instrumentation and control into reactor safety systems creates a heightened concern about common-mode failure. This paper discusses the concern and methods to cope with the concern. Common-mode failures have been a ''fact-of-life'' in existing systems. The informal introduction of defense-in-depth and diversity (D-in-D ampersand D)-coupled with the fact that hardware common-mode failures are often distributed in time-has allowed systems to deal with past common-mode failures. However, identical software operating in identical redundant systems presents the potential for simultaneous failure. Consequently, the use of digital systems raises the concern about common-mode failure to a new level. A more methodical approach to mitigating common-mode failure is needed to address these concerns. Purposeful introduction of D-in-D ampersand D has been used as a defense against common-mode failure in reactor protection systems. At least two diverse systems are provided to mitigate any potential initiating event. Additionally, diverse displays and controls are provided to allow the operator to monitor plant status and manually initiate engineered safety features. A special form of conimon-mode failure analysis called ''defense-in-depth and diversity analysis'' has been developed to identify possible conimon-mode failure vulnerabilities in digital systems. An overview of this analysis technique is provided

Plan on test to failure of a prestressed concrete containment vessel model

International Nuclear Information System (INIS)

Takumi, K.; Nonaka, A.; Umeki, K.; Nagata, K.; Soejima, M.; Yamaura, Y.; Costello, J.F.; Riesemann, W.A. von.; Parks, M.B.; Horschel, D.S.

1992-01-01

A summary of the plans to test a prestressed concrete containment vessel (PCCV) model to failure is provided in this paper. The test will be conducted as a part of a joint research program between the Nuclear Power Engineering Corporation (NUPEC), the United States Nuclear Regulatory Commission (NRC), and Sandia National Laboratories (SNL). The containment model will be a scaled representation of a PCCV for a pressurized water reactor (PWR). During the test, the model will be slowly pressurized internally until failure of the containment pressure boundary occurs. The objectives of the test are to measure the failure pressure, to observe the mode of failure, and to record the containment structural response up to failure. Pre- and posttest analyses will be conducted to forecast and evaluate the test results. Based on these results, a validated method for evaluating the structural behavior of an actual PWR PCCV will be developed. The concepts to design the PCCV model are also described in the paper

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

Science.gov (United States)

Chen, Ying-Chu; Tsai, Pei-Yi

2017-06-01

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

An engineering approach to common mode failure analysis

International Nuclear Information System (INIS)

Gangloff, W.C.; Franke, T.H.

1975-01-01

Safety systems for nuclear reactors can be designed using standard reliability engineering techniques such that system failure due to random component faults is extremely unlikely. However, the common-mode failure where several components fail together from a common cause is not susceptible to prevention by the usual tactics. In systems where a high degree of redundancy has been employed, the actual reliability of the system in service may be limited by common-mode failures. A methodical and thorough procedure for evaluation of system vulnerability to common-mode failures is presented. This procedure was developed for use in nuclear reactor safety systems and has been applied specifically to reactor protection. The method offers a qualitative assessment of a system whereby weak points can be identified and the resistance to common-mode failure can be judged. It takes into account all factors influencing system performance including design, manufacturing, installation, operation, testing, and maintenance. It is not a guarantee or sure solution, but rather a practical tool which can provide good assurance that the probability of common-mode protection failure has been made acceptably low. (author)

Failure Mode Estimation of Wolsong Unit 1 Containment Building with respect to Severe Accident Condition

International Nuclear Information System (INIS)

Hahm, Dae Gi; Choi, In Kil

2009-01-01

The containment buildings in a nuclear power plant (NPP) are final barriers against the exposure of harmful radiation materials at severe accident condition. Since the accident at Three Mile Island nuclear plant in 1979, it has become necessary to evaluate the internal pressure capacity of the containment buildings for the assessment of the safety of nuclear power plants. According to this necessity, many researchers including Yonezawa et al. and Hu and Lin analyzed the ultimate capacity of prestressed concrete containments subjected to internal pressure which can be occurred at sever accident condition. Especially in Wolsong nuclear power plant, the Unit 1 containment structures were constructed in the late 1970 to early 1980, so that the end of its service life will be reached in near future. Since that the complete decommission and reconstruction of the NPP may cause a huge expenses, an extension of the service time can be a cost-effective alternative. To extend the service time of NPP, an overall safety evaluation of the containment building under severe accident condition should be performed. In this study, we assessed the pressure capacity of Wolsong Unit 1 containment building under severe accident, and estimated the responses at all of the probable critical areas. Based on those results, we found the significant failure modes of Wolsong Unit 1 containment building with respect to the severe accident condition. On the other hand, for the aged NPP, the degradation of their structural performance must also be explained in the procedure of the internal pressure capacity evaluation. Therefore, in this study, we performed a parametric study on the degradation effects and evaluated the internal pressure capacity of Wolsong Unit 1 containment building with considering aging and degradation effects

Some elementary mechanics of explosive and brittle failure modes in prestressed containments

International Nuclear Information System (INIS)

Murray, D.W.

1978-06-01

Fundamental concepts related to pneumatic pressurization and explosive behaviour of containment structures are reviewed. It is shown that explosive behaviour occurs whenever a pressure equal to the ultimate capacity of the structure is attained. The energy associated with hydraulic pressurization is bounded and shown to be orders of magnitude less than that associated with pneumatic pressurization. It is also shown that structural behaviour prior to attaining the ultimate load capacity is independent of the pressurized medium. The phenomenon of brittle fracture, as it relates to prestressed concrete containments, is explored. A theoretical technique of proportioning cross sections is developed to eliminate the possibility of catastrophic brittle tensile fractures. The possibility of brittle fractures being triggered by failure of some type of 'detail' is also examined. An attempt is made to identify the types of failures for which the state of the art may be inadequate to assess behaviour under overpressure conditions. (author)

Failure modes of composite sandwich beams

OpenAIRE

Gdoutos E.; Daniel I.M.

2008-01-01

A thorough investigation of failure behavior of composite sandwich beams under three-and four-point bending was undertaken. The beams were made of unidirectional carbon/epoxy facings and a PVC closed-cell foam core. The constituent materials were fully characterized and in the case of the foam core, failure envelopes were developed for general two-dimensional states of stress. Various failure modes including facing wrinkling, indentation failure and core failure were observed and compared wit...

Preliminary Failure Modes and Effects Analysis of the US DCLL Test Blanket Module

Energy Technology Data Exchange (ETDEWEB)

Lee C. Cadwallader

2010-06-01

This report presents the results of a preliminary failure modes and effects analysis (FMEA) of a small tritium-breeding test blanket module design for the International Thermonuclear Experimental Reactor. The FMEA was quantified with “generic” component failure rate data, and the failure events are binned into postulated initiating event families and frequency categories for safety assessment. An appendix to this report contains repair time data to support an occupational radiation exposure assessment for test blanket module maintenance.

Preliminary Failure Modes and Effects Analysis of the US DCLL Test Blanket Module

Energy Technology Data Exchange (ETDEWEB)

Lee C. Cadwallader

2007-08-01

This report presents the results of a preliminary failure modes and effects analysis (FMEA) of a small tritium-breeding test blanket module design for the International Thermonuclear Experimental Reactor. The FMEA was quantified with “generic” component failure rate data, and the failure events are binned into postulated initiating event families and frequency categories for safety assessment. An appendix to this report contains repair time data to support an occupational radiation exposure assessment for test blanket module maintenance.

Preliminary Failure Modes and Effects Analysis of the US DCLL Test Blanket Module

International Nuclear Information System (INIS)

Lee C. Cadwallader

2007-01-01

This report presents the results of a preliminary failure modes and effects analysis (FMEA) of a small tritium-breeding test blanket module design for the International Thermonuclear Experimental Reactor. The FMEA was quantified with 'generic' component failure rate data, and the failure events are binned into postulated initiating event families and frequency categories for safety assessment. An appendix to this report contains repair time data to support an occupational radiation exposure assessment for test blanket module maintenance

A study of common-mode failures

International Nuclear Information System (INIS)

Edwards, G.T.; Watson, I.A.

1979-07-01

The purpose of the report is to investigate problems of the identification of the common failure mode (CFM) the reliability models used and the data required for their solution, particularly with regard to automatic protection systems for nuclear reactors. The available literature which was surveyed during the study is quoted and used as a basis for the main work of the study. The type of redundancy system under consideration is initially described and the types of CFM to which these systems are prone are identified before a general definition of the term 'common mode failure' is proposed. The definition and proposed classification system for CMF are based on the common cause of failure, so identifying the primary events. Defences against CFM are included and proposals for an overall strategy and detailed recommendations for design and operation are made. Common mode failures in US nuclear reactor systems, aircraft systems, and other sources including chemical plant systems are surveyed. The data indicates the importance of the human error problem in the causes of CMF in design, maintenance and operation. From a study of the collected data a redundancy sub-system model for CMF is developed which identifies three main categories of failure, non-recurrent engineering design errors, maintenance and test errors, and random interest events. The model proposed allows for the improvement in sub-system reliability where appropriate defences are applied. (author)

Preliminary failure mode and effect analysis

International Nuclear Information System (INIS)

Addison, J.V.

1972-01-01

A preliminary Failure Mode and Effect Analysis (FMEA) was made on the overall 5 Kwe system. A general discussion of the system and failure effect is given in addition to the tabulated FMEA and a primary block diagram of the system. (U.S.)

Evaluation of common mode failure of safety functions for limiting fault events

International Nuclear Information System (INIS)

Rezendes, J.P.; Hyde, A.W.

2004-01-01

The draft U.S. Nuclear Regulatory Commission (NRC) policy on digital protection system software requires all Advanced Light Water Reactors (ALWRs) to be evaluated assuming a hypothetical common mode failure (CMF) which incapacitates the normal automatic initiation of safety functions. The System 80 + ALWR has been evaluated for such hypothetical conditions. The results show that the diverse automatic and manual protective systems in System 80 + provide ample safety performance margins relative to core coolability, offsite radiological releases. Reactor Coolant System (RCS) pressurization and containment integrity. This deterministic evaluation served to quantify the significant inherent safety margins in the System 80 + Standard Plant design even in the event of this extremely low probability scenario of a common mode failure. (author)

Common mode and coupled failure

International Nuclear Information System (INIS)

Taylor, J.R.

1975-10-01

Based on examples and data from Abnormal Occurence Reports for nuclear reactors, a classification of common mode or coupled failures is given, and some simple statistical models are investigated. (author)

Failure mode analysis in adrenal vein sampling: a single-center experience.

Science.gov (United States)

Trerotola, Scott O; Asmar, Melissa; Yan, Yan; Fraker, Douglas L; Cohen, Debbie L

2014-10-01

To analyze failure modes in a high-volume adrenal vein sampling (AVS) practice in an effort to identify preventable causes of nondiagnostic sampling. A retrospective database was constructed containing 343 AVS procedures performed over a 10-year period. Each nondiagnostic AVS procedure was reviewed for failure mode and correlated with results of any repeat AVS. Data collected included selectivity index, lateralization index, adrenalectomy outcomes if performed, and details of AVS procedure. All AVS procedures were performed after cosyntropin stimulation, using sequential technique. AVS was nondiagnostic in 12 of 343 (3.5%) primary procedures and 2 secondary procedures. Failure was right-sided in 8 (57%) procedures, left-sided in 4 (29%) procedures, bilateral in 1 procedure, and neither in 1 procedure (laboratory error). Failure modes included diluted sample from correctly identified vein (n = 7 [50%]; 3 right and 4 left), vessel misidentified as adrenal vein (n = 3 [21%]; all right), failure to locate an adrenal vein (n = 2 [14%]; both right), cosyntropin stimulation failure (n = 1 [7%]; diagnostic by nonstimulated criteria), and laboratory error (n = 1 [7%]; specimen loss). A second AVS procedure was diagnostic in three of five cases (60%), and a third AVS procedure was diagnostic in one of one case (100%). Among the eight patients in whom AVS ultimately was not diagnostic, four underwent adrenalectomy based on diluted AVS samples, and one underwent adrenalectomy based on imaging; all five experienced improvement in aldosteronism. A substantial percentage of AVS failures occur on the left, all related to dilution. Even when technically nondiagnostic per strict criteria, some "failed" AVS procedures may be sufficient to guide therapy. Repeat AVS has a good yield. Copyright © 2014 SIR. Published by Elsevier Inc. All rights reserved.

Circuit breaker operation and potential failure modes during an earthquake

International Nuclear Information System (INIS)

Lambert, H.E.; Budnitz, R.J.

1987-01-01

This study addresses the effect of a strong-motion earthquake on circuit breaker operation. It focuses on the loss of offsite power (LOSP) transient caused by a strong-motion earthquake at the Zion Nuclear Power Plant. This paper also describes the operator action necessary to prevent core melt if the above circuit breaker failure modes occur simultaneously on three 4.16 KV buses. Numerous circuit breakers important to plant safety, such as circuit breakers to diesel generators and engineered safety systems (ESS), must open and/or close during this transient while strong motion is occurring. Potential seismically-induced circuit-breaker failures modes were uncovered while the study was conducted. These failure modes include: circuit breaker fails to close; circuit breaker trips inadvertently; circuit breaker fails to reclose after trip. The causes of these failure modes include: Relay chatter causes the circuit breaker to trip; Relay chatter causes anti-pumping relays to seal-in which prevents automatic closure of circuit breakers; Load sequencer failures. The incorporation of these failure modes as well as other instrumentation and control failures into a limited scope seismic probabilistic risk assessment is also discussed in this paper

Failure mode transition in AHSS resistance spot welds. Part I. Controlling factors

International Nuclear Information System (INIS)

Pouranvari, M.; Marashi, S.P.H.

2011-01-01

Highlights: → Interfacial to pullout failure mode transition for AHSS RSWs is studied. → An analytical mode is proposed to predict failure mode of AHSS RSWs. → Hardness characteristics of RSWs plays key role in the failure mode transition. - Abstract: Failure mode of resistance spot welds is a qualitative indicator of weld performance. Two major types of spot weld failure are pull-out and interfacial fracture. Interfacial failure, which typically results in reduced energy absorption capability, is considered unsatisfactory and industry standards are often designed to avoid this occurrence. Advanced High Strength Steel (AHSS) spot welds exhibit high tendency to fail in interfacial failure mode. Sizing of spot welds based on the conventional recommendation of 4t 0.5 (t is sheet thickness) does not guarantee the pullout failure mode in many cases of AHSS spot welds. Therefore, a new weld quality criterion should be found for AHSS resistance spot welds to guarantee pull-out failure. The aim of this paper is to investigate and analyze the transition between interfacial and pull-out failure modes in AHSS resistance spot welds during the tensile-shear test by the use of analytical approach. In this work, in the light of failure mechanism, a simple analytical model is presented for estimating the critical fusion zone size to prevent interfacial fracture. According to this model, the hardness ratio of fusion zone to pull-out failure location and the volume fraction of voids in fusion zone are the key metallurgical factors governing type of failure mode of AHSS spot welds during the tensile-shear test. Low hardness ratio and high susceptibility to form shrinkage voids in the case of AHSS spot welds appear to be the two primary causes for their high tendency to fail in interfacial mode.

System reliability analysis using dominant failure modes identified by selective searching technique

International Nuclear Information System (INIS)

Kim, Dong-Seok; Ok, Seung-Yong; Song, Junho; Koh, Hyun-Moo

2013-01-01

The failure of a redundant structural system is often described by innumerable system failure modes such as combinations or sequences of local failures. An efficient approach is proposed to identify dominant failure modes in the space of random variables, and then perform system reliability analysis to compute the system failure probability. To identify dominant failure modes in the decreasing order of their contributions to the system failure probability, a new simulation-based selective searching technique is developed using a genetic algorithm. The system failure probability is computed by a multi-scale matrix-based system reliability (MSR) method. Lower-scale MSR analyses evaluate the probabilities of the identified failure modes and their statistical dependence. A higher-scale MSR analysis evaluates the system failure probability based on the results of the lower-scale analyses. Three illustrative examples demonstrate the efficiency and accuracy of the approach through comparison with existing methods and Monte Carlo simulations. The results show that the proposed method skillfully identifies the dominant failure modes, including those neglected by existing approaches. The multi-scale MSR method accurately evaluates the system failure probability with statistical dependence fully considered. The decoupling between the failure mode identification and the system reliability evaluation allows for effective applications to larger structural systems

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

Science.gov (United States)

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

2017-11-01

Gamma Knife radiosurgery is a highly precise and accurate treatment technique for treating brain diseases with low risk of serious error that nevertheless could potentially be reduced. We applied the AAPM Task Group 100 recommended failure modes and effects analysis (FMEA) tool to develop a risk-based quality management program for Gamma Knife radiosurgery. A team consisting of medical physicists, radiation oncologists, neurosurgeons, radiation safety officers, nurses, operating room technologists, and schedulers at our institution and an external physicist expert on Gamma Knife was formed for the FMEA study. A process tree and a failure mode table were created for the Gamma Knife radiosurgery procedures using the Leksell Gamma Knife Perfexion and 4C units. Three scores for the probability of occurrence (O), the severity (S), and the probability of no detection for failure mode (D) were assigned to each failure mode by 8 professionals on a scale from 1 to 10. An overall risk priority number (RPN) for each failure mode was then calculated from the averaged O, S, and D scores. The coefficient of variation for each O, S, or D score was also calculated. The failure modes identified were prioritized in terms of both the RPN scores and the severity scores. The established process tree for Gamma Knife radiosurgery consists of 10 subprocesses and 53 steps, including a subprocess for frame placement and 11 steps that are directly related to the frame-based nature of the Gamma Knife radiosurgery. Out of the 86 failure modes identified, 40 Gamma Knife specific failure modes were caused by the potential for inappropriate use of the radiosurgery head frame, the imaging fiducial boxes, the Gamma Knife helmets and plugs, the skull definition tools as well as other features of the GammaPlan treatment planning system. The other 46 failure modes are associated with the registration, imaging, image transfer, contouring processes that are common for all external beam radiation therapy

Accelerated Testing with Multiple Failure Modes under Several Temperature Conditions

OpenAIRE

Zongyue Yu; Zhiqian Ren; Junyong Tao; Xun Chen

2014-01-01

A complicated device may have multiple failure modes, and some of the failure modes are sensitive to low temperatures. To assess the reliability of a product with multiple failure modes, this paper presents an accelerated testing in which both of the high temperatures and the low temperatures are applied. Firstly, an acceleration model based on the Arrhenius model but accounting for the influence of both the high temperatures and low temperatures is proposed. Accordingly, an accelerated testi...

Failure Mode and Effect Analysis for Wind Turbine Systems in China

DEFF Research Database (Denmark)

Zhu, Jiangsheng; Ma, Kuichao; N. Soltani, Mohsen

2017-01-01

This paper discusses a cost based Failure Mode and Effect Analysis (FMEA) approch for the Wind Turbine (WT) with condition monitoring system in China. Normally, the traditional FMEA uses the Risk Priority Number (RPN) to rank failure modes. But the RPN can be changed with the Condition Monitoring...... Systems (CMS) due to change of the score of detection. The cost of failure mode should also be considered because faults can be detected at an incipient level, and condition-based maintenance can be scheduled. The results show that the proposed failure mode priorities considering their cost consequences...

Rubble Mound Breakwater Failure Modes

DEFF Research Database (Denmark)

Burcharth, H. F.; Z., Liu

1995-01-01

The RMBFM-Project (Rubble Mound Breakwater Failure Modes) is sponsored by the Directorate General XII of the Commission of the European Communities under the Contract MAS-CT92- 0042, with the objective of contributing to the development of rational methods for the design of rubble mound breakwate...

Accelerated Testing with Multiple Failure Modes under Several Temperature Conditions

Directory of Open Access Journals (Sweden)

Zongyue Yu

2014-01-01

Full Text Available A complicated device may have multiple failure modes, and some of the failure modes are sensitive to low temperatures. To assess the reliability of a product with multiple failure modes, this paper presents an accelerated testing in which both of the high temperatures and the low temperatures are applied. Firstly, an acceleration model based on the Arrhenius model but accounting for the influence of both the high temperatures and low temperatures is proposed. Accordingly, an accelerated testing plan including both the high temperatures and low temperatures is designed, and a statistical analysis method is developed. The reliability function of the product with multiple failure modes under variable working conditions is given by the proposed statistical analysis method. Finally, a numerical example is studied to illustrate the proposed accelerated testing. The results show that the proposed accelerated testing is rather efficient.

Potential seismic structural failure modes associated with the Zion Nuclear Plant. Seismic safety margins research program (Phase I). Project VI. Fragilities

International Nuclear Information System (INIS)

1979-10-01

The Zion 1 and 2 Nuclear Power Plant consists of a number of structures. The most important of these from the viewpoint of safety are the containment buildings, the auxiliary building, the turbine building, and the crib house (or intake structure). The evaluation of the potential seismic failure modes and determination of the ultimate seismic capacity of the structures is a complex undertaking which will require a large number of detailed calculations. As the first step in this evaluation, a number of potential modes of structural failure have been determined and are discussed. The report is principally directed towards seismically induced failure of structures. To some extent, modes involving soil foundation failures are discussed in so far as they affect the buildings. However, failure modes involving soil liquefaction, surface faulting, tsunamis, etc., are considered outside the scope of this evaluation

Letter report seismic shutdown system failure mode and effect analysis

International Nuclear Information System (INIS)

KECK, R.D.

1999-01-01

The Supply Ventilation System Seismic Shutdown ensures that the 234-52 building supply fans, the dry air process fans and vertical development calciner are shutdown following a seismic event. This evaluates the failure modes and determines the effects of the failure modes

Low-rise shear wall failure modes

International Nuclear Information System (INIS)

Farrar, C.R.; Hashimoto, P.S.; Reed, J.W.

1991-01-01

A summary of the data that are available concerning the structural response of low-rise shear walls is presented. This data will be used to address two failure modes associated with the shear wall structures. First, data concerning the seismic capacity of the shear walls with emphasis on excessive deformations that can cause equipment failure are examined. Second, data concerning the dynamic properties of shear walls (stiffness and damping) that are necessary to compute the seismic inputs to attached equipment are summarized. This case addresses the failure of equipment when the structure remains functional. 23 refs

Newly discovered failure mode in high energy density, energy storage capacitors

International Nuclear Information System (INIS)

Boicourt, G.P.; Kemp, E.L.

1978-07-01

High energy density pulse capacitors, typified by the 10-kV, 170-μF unit, have become widely used in recent years. These units primarily were designed for lower cost and higher energy per unit volume. The life characteristics of these units have never been determined fully, but they have already been shown capable of lives much longer than originally expected. The Los Alamos Scientific Laboratory is now conducting an extended program to determine the long-term capabilities of these capacitors. This program is aimed not only at finding the statistical parameters of the failure distribution but also at determining the physical failure modes characteristic of such units. Recently, a new failure mode was found. This failure mode has prevented test samples of polypropylene-paper-dioctyl phthalate units from actually reaching the true potential life of the insulation. In this report, the new failure mechanism is examined and suggestions are made that could eliminate the failure mode

Uncertainties in container failure time predictions

International Nuclear Information System (INIS)

Williford, R.E.

1990-01-01

Stochastic variations in the local chemical environment of a geologic waste repository can cause corresponding variations in container corrosion rates and failure times, and thus in radionuclide release rates. This paper addresses how well the future variations in repository chemistries must be known in order to predict container failure times that are bounded by a finite time period within the repository lifetime. Preliminary results indicate that a 5000 year scatter in predicted container failure times requires that repository chemistries be known to within ±10% over the repository lifetime. These are small uncertainties compared to current estimates. 9 refs., 3 figs

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

Science.gov (United States)

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

2013-09-01

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

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

Science.gov (United States)

Flores, Melissa; Malin, Jane T.

2013-01-01

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

Reliability model for common mode failures in redundant safety systems

International Nuclear Information System (INIS)

Fleming, K.N.

1974-12-01

A method is presented for computing the reliability of redundant safety systems, considering both independent and common mode type failures. The model developed for the computation is a simple extension of classical reliability theory. The feasibility of the method is demonstrated with the use of an example. The probability of failure of a typical diesel-generator emergency power system is computed based on data obtained from U. S. diesel-generator operating experience. The results are compared with reliability predictions based on the assumption that all failures are independent. The comparison shows a significant increase in the probability of redundant system failure, when common failure modes are considered. (U.S.)

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

Science.gov (United States)

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

2018-04-01

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

Failure modes of low-rise shear walls

International Nuclear Information System (INIS)

Farrar, C.R.; Reed, J.W.; Salmon, M.W.

1993-01-01

A summary of available data concerning the structural response of low-rise shear walls is presented. These data will be used to address two failure modes associated with shear wall structures. First, the data concerning the seismic capacity of the shear walls are examined, with emphasis on excessive deformations that can cause equipment failure. Second, the data concerning the dynamic properties of shear walls (stiffness and damping) that are necessary for computing the seismic inputs to attached equipment are summarized. This case addresses the failure of equipment when the structure remains functional

Comprehensive method of common-mode failure analysis for LMFBR safety systems

International Nuclear Information System (INIS)

Unione, A.J.; Ritzman, R.L.; Erdmann, R.C.

1976-01-01

A technique is demonstrated which allows the systematic treatment of common-mode failures of safety system performance. The technique uses log analysis in the form of fault and success trees to qualitatively assess the sources of common-mode failure and quantitatively estimate the contribution to the overall risk of system failure. The analysis is applied to the secondary control rod system of an early sized LMFBR

Development of IPRO-ZONE to Determine Component Failure Modes Affected by a Fire Event

International Nuclear Information System (INIS)

Kang, Dae Il; Han, Sang Hoon

2010-01-01

A Fire PSA requires a PSA analyst to select internal initiating events and to determine component failure modes for fire occurrence event of each fire compartment. The component failure modes caused by a fire depend on the several factors. These factors are whether components and their relating equipment and cables are located at fire initiation and propagation compartments or not, fire effects on control and power cables for components and their relating equipment, designed failure modes of component, success criteria in a PSA model, etc. Up to the present, a PSA analyst has been manually determining component failure modes based on criteria mentioned above. This task is one of the difficult works required for fire PSA expertise. In addition, since it requires much information, a fire PSA analyst may have difficulty in maintaining consistency for determining the component failure modes and documentation for them. After determining the component failure modes, internal PSA basic events corresponding to the component failure modes are selected and fire events are modeled for the selected basic events if required. KAERI has been developing the IPRO-ZONE (interface program for constructing zone effect table) to determine component failure modes affected by a fire, to select the internal PSA basic events, and to generate fire events to be modeled. In this paper, we introduce the overview of the IPRO-ZONE and approaches for determining component failure modes implemented in the IPRO-ZONE

Risk analysis of geothermal power plants using Failure Modes and Effects Analysis (FMEA) technique

International Nuclear Information System (INIS)

Feili, Hamid Reza; Akar, Navid; Lotfizadeh, Hossein; Bairampour, Mohammad; Nasiri, Sina

2013-01-01

Highlights: • Using Failure Modes and Effects Analysis (FMEA) to find potential failures in geothermal power plants. • We considered 5 major parts of geothermal power plants for risk analysis. • Risk Priority Number (RPN) is calculated for all failure modes. • Corrective actions are recommended to eliminate or decrease the risk of failure modes. - Abstract: Renewable energy plays a key role in the transition toward a low carbon economy and the provision of a secure supply of energy. Geothermal energy is a versatile source as a form of renewable energy that meets popular demand. Since some Geothermal Power Plants (GPPs) face various failures, the requirement of a technique for team engineering to eliminate or decrease potential failures is considerable. Because no specific published record of considering an FMEA applied to GPPs with common failure modes have been found already, in this paper, the utilization of Failure Modes and Effects Analysis (FMEA) as a convenient technique for determining, classifying and analyzing common failures in typical GPPs is considered. As a result, an appropriate risk scoring of occurrence, detection and severity of failure modes and computing the Risk Priority Number (RPN) for detecting high potential failures is achieved. In order to expedite accuracy and ability to analyze the process, XFMEA software is utilized. Moreover, 5 major parts of a GPP is studied to propose a suitable approach for developing GPPs and increasing reliability by recommending corrective actions for each failure mode

Failure mode and effects analysis: A community practice perspective.

Science.gov (United States)

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

2017-11-01

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

Failure mode and effects analysis of software-based automation systems

International Nuclear Information System (INIS)

Haapanen, P.; Helminen, A.

2002-08-01

Failure mode and effects analysis (FMEA) is one of the well-known analysis methods having an established position in the traditional reliability analysis. The purpose of FMEA is to identify possible failure modes of the system components, evaluate their influences on system behaviour and propose proper countermeasures to suppress these effects. The generic nature of FMEA has enabled its wide use in various branches of industry reaching from business management to the design of spaceships. The popularity and diverse use of the analysis method has led to multiple interpretations, practices and standards presenting the same analysis method. FMEA is well understood at the systems and hardware levels, where the potential failure modes usually are known and the task is to analyse their effects on system behaviour. Nowadays, more and more system functions are realised on software level, which has aroused the urge to apply the FMEA methodology also on software based systems. Software failure modes generally are unknown - 'software modules do not fail, they only display incorrect behaviour' - and depend on dynamic behaviour of the application. These facts set special requirements on the FMEA of software based systems and make it difficult to realise. In this report the failure mode and effects analysis is studied for the use of reliability analysis of software-based systems. More precisely, the target system of FMEA is defined to be a safety-critical software-based automation application in a nuclear power plant, implemented on an industrial automation system platform. Through a literature study the report tries to clarify the intriguing questions related to the practical use of software failure mode and effects analysis. The study is a part of the research project 'Programmable Automation System Safety Integrity assessment (PASSI)', belonging to the Finnish Nuclear Safety Research Programme (FINNUS, 1999-2002). In the project various safety assessment methods and tools for

Phenomenological uncertainty analysis of early containment failure at severe accident of nuclear power plant

Energy Technology Data Exchange (ETDEWEB)

Lee, Su Won

2011-02-15

The severe accident has inherently significant uncertainty due to wide range of conditions and performing experiments, validation and practical application are extremely difficult because of its high temperature and pressure. Although internal and external researches were put into practice, the reference used in Korean nuclear plants were foreign data of 1980s and safety analysis as the probabilistic safety assessment has not applied the newest methodology. Also, it is applied to containment pressure formed into point value as results of thermal hydraulic analysis to identify the probability of containment failure in level 2 PSA. In this paper, the uncertainty analysis methods for phenomena of severe accident influencing early containment failure were developed, the uncertainty analysis that apply Korean nuclear plants using the MELCOR code was performed and it is a point of view to present the distribution of containment pressure as a result of uncertainty analysis. Because early containment failure is important factor of Large Early Release Frequency(LERF) that is used as representative criteria of decision-making in nuclear power plants, it was selected in this paper among various modes of containment failure. Important phenomena of early containment failure at severe accident based on previous researches were comprehended and methodology of 7th steps to evaluate uncertainty was developed. The MELCOR input for analysis of the severe accident reflected natural circulation flow was developed and the accident scenario for station black out that was representative initial event of early containment failure was determined. By reviewing the internal model and correlation for MELCOR model relevant important phenomena of early containment failure, the uncertainty factors which could affect on the uncertainty were founded and the major factors were finally identified through the sensitivity analysis. In order to determine total number of MELCOR calculations which can

A quantitative method for Failure Mode and Effects Analysis

NARCIS (Netherlands)

Braaksma, Anne Johannes Jan; Meesters, A.J.; Klingenberg, W.; Hicks, C.

2012-01-01

Failure Mode and Effects Analysis (FMEA) is commonly used for designing maintenance routines by analysing potential failures, predicting their effect and facilitating preventive action. It is used to make decisions on operational and capital expenditure. The literature has reported that despite its

Process Equipment Failure Mode Analysis in a Chemical Industry

Directory of Open Access Journals (Sweden)

J. Nasl Seraji

2008-04-01

Full Text Available Background and aims   Prevention of potential accidents and safety promotion in chemical processes requires systematic safety management in them. The main objective of this study was analysis of important process equipment components failure modes and effects in H2S and CO2  isolation from extracted natural gas process.   Methods   This study was done in sweetening unit of an Iranian gas refinery. Failure Mode and Effect Analysis (FMEA used for identification of process equipments failures.   Results   Totally 30 failures identified and evaluated using FMEA. P-1 blower's blade breaking and sour gas pressure control valve bearing tight moving had maximum risk Priority number (RPN, P-1 body corrosion and increasing plug lower side angle of reach DEAlevel control valve  in tower - 1 were minimum calculated RPN.   Conclusion   By providing a reliable documentation system for equipment failures and  incidents recording, maintaining of basic information for later safety assessments would be  possible. Also, the probability of failures and effects could be minimized by conducting preventive maintenance.

A reassessment of the potential for an alpha-mode containment failure and a review of the current understanding of broader fuel-coolant interaction issues. Second steam explosion review group workshop

Energy Technology Data Exchange (ETDEWEB)

Basu, S. [Nuclear Regulatory Commission, Washington, DC (United States); Ginsberg, T. [Brookhaven National Lab., Upton, NY (United States)

1996-08-01

This report summarizes the review and evaluation by experts of the current understanding of the molten fuel-coolant interaction (FCI) issues covering the complete spectrum of interactions, i.e., from mild quenching to very energetic interactions including those that could lead to the alpha-mode containment failure. Of the eleven experts polled, all but two concluded that the alpha-mode failure issue was resolved from a risk perspective, meaning that this mode of failure is of very low probability, that it is of little or no significance to the overall risk from a nuclear power plant, and that any further reduction in residual uncertainties is not likely to change the probability in an appreciable manner. To a lesser degree, discussions also took place on the broader FCI issues such as mild quenching of core melt during non-explosive FCI, and shock loading of lower head and ex-vessel support structures arising from explosive localized FCIs. These latter issues are relevant with regard to determining the efficacy of certain accident management strategies for operating reactors as well as for advanced light water reactors. The experts reviewed the status of understanding of the FCI phenomena in the context of these broader issues, identified residual uncertainties in the understanding, and recommended future research (both experimental and analytical) to reduce the uncertainties.

A reassessment of the potential for an alpha-mode containment failure and a review of the current understanding of broader fuel-coolant interaction issues. Second steam explosion review group workshop

International Nuclear Information System (INIS)

Basu, S.; Ginsberg, T.

1996-08-01

This report summarizes the review and evaluation by experts of the current understanding of the molten fuel-coolant interaction (FCI) issues covering the complete spectrum of interactions, i.e., from mild quenching to very energetic interactions including those that could lead to the alpha-mode containment failure. Of the eleven experts polled, all but two concluded that the alpha-mode failure issue was resolved from a risk perspective, meaning that this mode of failure is of very low probability, that it is of little or no significance to the overall risk from a nuclear power plant, and that any further reduction in residual uncertainties is not likely to change the probability in an appreciable manner. To a lesser degree, discussions also took place on the broader FCI issues such as mild quenching of core melt during non-explosive FCI, and shock loading of lower head and ex-vessel support structures arising from explosive localized FCIs. These latter issues are relevant with regard to determining the efficacy of certain accident management strategies for operating reactors as well as for advanced light water reactors. The experts reviewed the status of understanding of the FCI phenomena in the context of these broader issues, identified residual uncertainties in the understanding, and recommended future research (both experimental and analytical) to reduce the uncertainties

New understandings of failure modes in SSL luminaires

Science.gov (United States)

Shepherd, Sarah D.; Mills, Karmann C.; Yaga, Robert; Johnson, Cortina; Davis, J. Lynn

2014-09-01

As SSL products are being rapidly introduced into the market, there is a need to develop standard screening and testing protocols that can be performed quickly and provide data surrounding product lifetime and performance. These protocols, derived from standard industry tests, are known as ALTs (accelerated life tests) and can be performed in a timeframe of weeks to months instead of years. Accelerated testing utilizes a combination of elevated temperature and humidity conditions as well as electrical power cycling to control aging of the luminaires. In this study, we report on the findings of failure modes for two different luminaire products exposed to temperature-humidity ALTs. LEDs are typically considered the determining component for the rate of lumen depreciation. However, this study has shown that each luminaire component can independently or jointly influence system performance and reliability. Material choices, luminaire designs, and driver designs all have significant impacts on the system reliability of a product. From recent data, it is evident that the most common failure modes are not within the LED, but instead occur within resistors, capacitors, and other electrical components of the driver. Insights into failure modes and rates as a result of ALTs are reported with emphasis on component influence on overall system reliability.

Review of the current understanding of the potential for containment failure from in-vessel steam explosions

International Nuclear Information System (INIS)

1985-06-01

A group of experts was convened to review the current understanding of the potential for containment failure from in-vessel steam explosions during core meltdown accidents in LWRs. The Steam Explosion Review Group (SERG) was requested to provide assessments of: (1) the conditional probability of containment failure due to a steam explosion, (2) a Sandia National Laboratory (SNL) report entitled ''An Uncertainty Study of PWR Steam Explosions,'' NUREG/CR-3369, (3) a SNL proposed steam explosion research program. This report summarizes the results of the deliberations of the review group. It also presents the detailed response of each individual member to each of the issues. The consensus of the SERG is that the occurrence of a steam explosion of sufficient energetics which could lead to alpha-mode containment failure has a low probability. The SERG members disagreed with the methodology used in NUREG/CR-3369 for the purpose of establishing the uncertainty in the probability of containment failure by a steam explosion. A consensus was reached among SERG members on the need for a continuing steam explosion research program which would improve our understanding of certain aspects of steam explosion phenomenology

The probability of containment failure by direct containment heating in surry

International Nuclear Information System (INIS)

Pilch, M.M.; Allen, M.D.; Bergeron, K.D.; Tadios, E.L.; Stamps, D.W.; Spencer, B.W.; Quick, K.S.; Knudson, D.L.

1995-05-01

In a light-water reactor core melt accident, if the reactor pressure vessel (RPV) fails while the reactor coolant system (RCS) at high pressure, the expulsion of molten core debris may pressurize the reactor containment building (RCB) beyond its failure pressure. A failure in the bottom head of the RPV, followed by melt expulsion and blowdown of the RCS, will entrain molten core debris in the high-velocity steam blowdown gas. This chain of events is called a high-pressure melt ejection (HPME). Four mechanisms may cause a rapid increase in pressure and temperature in the reactor containment: (1) blowdown of the RCS, (2) efficient debris-to-gas heat transfer, (3) exothermic metal-steam and metal-oxygen reactions, and (4) hydrogen combustion. These processes, which lead to increased loads on the containment building, are collectively referred to as direct containment heating (DCH). It is necessary to understand factors that enhance or mitigate DCH because the pressure load imposed on the RCB may lead to early failure of the containment

Failure modes and natural control time for distributed vibrating systems

International Nuclear Information System (INIS)

Reid, R.M.

1994-01-01

The eigenstructure of the Gram matrix of frequency exponentials is used to study linear vibrating systems of hyperbolic type with distributed control. Using control norm as a practical measure of controllability and the vibrating string as a prototype, it is demonstrated that hyperbolic systems have a natural control time, even when only finitely many modes are excited. For shorter control times there are identifiable control failure modes which can be steered to zero only with very high cost in control norm. Both natural control time and the associated failure modes are constructed for linear fluids, strings, and beams, making note of the essential algorithms and Mathematica code, and displaying results graphically

WE-G-BRA-08: Failure Modes and Effects Analysis (FMEA) for Gamma Knife Radiosurgery

International Nuclear Information System (INIS)

Xu, Y; Bhatnagar, J; Bednarz, G; Flickinger, J; Arai, Y; Huq, M Saiful; Vacsulka, J; Monaco, E; Niranjan, A; Lunsford, L Dade; Feng, W

2015-01-01

Purpose: To perform a failure modes and effects analysis (FMEA) study for Gamma Knife (GK) radiosurgery processes at our institution based on our experience with the treatment of more than 13,000 patients. Methods: A team consisting of medical physicists, nurses, radiation oncologists, neurosurgeons at the University of Pittsburgh Medical Center and an external physicist expert was formed for the FMEA study. A process tree and a failure mode table were created for the GK procedures using the Leksell GK Perfexion and 4C units. Three scores for the probability of occurrence (O), the severity (S), and the probability of no detection (D) for failure modes were assigned to each failure mode by each professional on a scale from 1 to 10. The risk priority number (RPN) for each failure mode was then calculated (RPN = OxSxD) as the average scores from all data sets collected. Results: The established process tree for GK radiosurgery consists of 10 sub-processes and 53 steps, including a sub-process for frame placement and 11 steps that are directly related to the frame-based nature of the GK radiosurgery. Out of the 86 failure modes identified, 40 failure modes are GK specific, caused by the potential for inappropriate use of the radiosurgery head frame, the imaging fiducial boxes, the GK helmets and plugs, and the GammaPlan treatment planning system. The other 46 failure modes are associated with the registration, imaging, image transfer, contouring processes that are common for all radiation therapy techniques. The failure modes with the highest hazard scores are related to imperfect frame adaptor attachment, bad fiducial box assembly, overlooked target areas, inaccurate previous treatment information and excessive patient movement during MRI scan. Conclusion: The implementation of the FMEA approach for Gamma Knife radiosurgery enabled deeper understanding of the overall process among all professionals involved in the care of the patient and helped identify potential

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

Science.gov (United States)

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

2016-08-01

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

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

Energy Technology Data Exchange (ETDEWEB)

Sawant, Amit; Dieterich, Sonja; Svatos, Michelle; Keall, Paul [Stanford University, Stanford, California 94394 (United States); Varian Medical Systems, Palo Alto, California 94304 (United States); Stanford University, Stanford, California 94394 (United States)

2010-12-15

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

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

Science.gov (United States)

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

2010-12-01

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

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

International Nuclear Information System (INIS)

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

2010-01-01

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

Failure Modes Taxonomy for Reliability Assessment of Digital Instrumentation and Control Systems for Probabilistic Risk Analysis - Failure modes taxonomy for reliability assessment of digital I and C systems for PRA

International Nuclear Information System (INIS)

Amri, A.; Blundell, N.; ); Authen, S.; Betancourt, L.; Coyne, K.; Halverson, D.; Li, M.; Taylor, G.; Bjoerkman, K.; Brinkman, H.; Postma, W.; Bruneliere, H.; Chirila, M.; Gheorge, R.; Chu, L.; Yue, M.; Delache, J.; Georgescu, G.; Deleuze, G.; Quatrain, R.; Thuy, N.; Holmberg, J.-E.; Kim, M.C.; Kondo, K.; Mancini, F.; Piljugin, E.; Stiller, J.; Sedlak, J.; Smidts, C.; Sopira, V.

2015-01-01

Digital protection and control systems appear as upgrades in older nuclear power plants (NPP), and are commonplace in new NPPs. To assess the risk of NPP operation and to determine the risk impact of digital systems, there is a need to quantitatively assess the reliability of the digital systems in a justifiable manner. Due to the many unique attributes of digital systems (e.g., functions are implemented by software, units of the system interact in a communication network, faults can be identified and handled online), a number of modelling and data collection challenges exist, and international consensus on the reliability modelling has not yet been reached. The objective of the task group called DIGREL has been to develop a taxonomy of failure modes of digital components for the purposes of probabilistic risk analysis (PRA). An activity focused on the development of a common taxonomy of failure modes is seen as an important step towards standardised digital instrumentation and control (I and C) reliability assessment techniques for PRA. Needs from PRA has guided the work, meaning, e.g., that the I and C system and its failures are studied from the point of view of their functional significance point of view. The taxonomy will be the basis of future modelling and quantification efforts. It will also help to define a structure for data collection and to review PRA studies. The proposed failure modes taxonomy has been developed by first collecting examples of taxonomies provided by the task group organisations. This material showed some variety in the handling of I and C hardware failure modes, depending on the context where the failure modes have been defined. Regarding the software part of I and C, failure modes defined in NPP PRAs have been simple - typically a software CCF failing identical processing units. The DIGREL task group has defined a new failure modes taxonomy based on a hierarchical definition of five levels of abstraction: 1. system level (complete

Failure mode analysis using state variables derived from fault trees with application

International Nuclear Information System (INIS)

Bartholomew, R.J.

1982-01-01

Fault Tree Analysis (FTA) is used extensively to assess both the qualitative and quantitative reliability of engineered nuclear power systems employing many subsystems and components. FTA is very useful, but the method is limited by its inability to account for failure mode rate-of-change interdependencies (coupling) of statistically independent failure modes. The state variable approach (using FTA-derived failure modes as states) overcomes these difficulties and is applied to the determination of the lifetime distribution function for a heat pipe-thermoelectric nuclear power subsystem. Analyses are made using both Monte Carlo and deterministic methods and compared with a Markov model of the same subsystem

Failure Mode and Effect Analysis using Soft Set Theory and COPRAS Method

Directory of Open Access Journals (Sweden)

Ze-Ling Wang

2017-01-01

Full Text Available Failure mode and effect analysis (FMEA is a risk management technique frequently applied to enhance the system performance and safety. In recent years, many researchers have shown an intense interest in improving FMEA due to inherent weaknesses associated with the classical risk priority number (RPN method. In this study, we develop a new risk ranking model for FMEA based on soft set theory and COPRAS method, which can deal with the limitations and enhance the performance of the conventional FMEA. First, trapezoidal fuzzy soft set is adopted to manage FMEA team membersr linguistic assessments on failure modes. Then, a modified COPRAS method is utilized for determining the ranking order of the failure modes recognized in FMEA. Especially, we treat the risk factors as interdependent and employ the Choquet integral to obtain the aggregate risk of failures in the new FMEA approach. Finally, a practical FMEA problem is analyzed via the proposed approach to demonstrate its applicability and effectiveness. The result shows that the FMEA model developed in this study outperforms the traditional RPN method and provides a more reasonable risk assessment of failure modes.

Failure mode and effects analysis in a dual-product microsphere brachytherapy environment.

Science.gov (United States)

Younge, Kelly Cooper; Lee, Choonik; Moran, Jean M; Feng, Mary; Novelli, Paula; Prisciandaro, Joann I

We performed a failure mode and effects analysis (FMEA) during the addition of a new microspheres product into our existing microsphere brachytherapy program to identify areas for safety improvements. A diverse group of team members from the microsphere program participated in the project to create a process map, identify and score failure modes, and discuss programmatic changes to address the highest ranking items. We developed custom severity ranking scales for staff- and institution-related failure modes to encompass possible risks that may exist outside of patient-based effects. Between both types of microsphere products, 173 failure mode/effect pairs were identified: 90 for patients, 35 for staff, and 48 for the institution. The SIR-Spheres program was ranked separately from the TheraSphere program because of significant differences in workflow during dose calculation, preparation, and delivery. High-ranking failure modes in each category were addressed with programmatic changes. The FMEA aided in identifying potential risk factors in our microsphere program and allowed a theoretically safer and more efficient design of the workflow and quality assurance for both our new SIR-Spheres program and our existing TheraSphere program. As new guidelines are made available, and our experience with the SIR-Spheres program increases, we will update the FMEA as an efficient starting point for future improvements. Copyright © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Application of failure mode and effects analysis in a clinical chemistry laboratory.

Science.gov (United States)

Jiang, Yuanyuan; Jiang, Hongmin; Ding, Siyi; Liu, Qin

2015-08-25

Timely delivery of correct results has long been considered as the goal of quality management in clinical laboratory. With increasing workload as well as complexities of laboratory testing and patient care, the traditional technical adopted like internal quality control (IQC) and external quality assessment (EQA) may not enough to cope with quality management problems for clinical laboratories. We applied failure mode and effects analysis (FMEA), a proactive tool, to reduce errors associated with the process beginning with sample collection and ending with a test report in a clinical chemistry laboratory. Our main objection was to investigate the feasibility of FMEA in a real-world situation, namely the working environment of hospital. A team of 8 people (3 laboratory workers, 2 couriers, 2 nurses, and 1 physician) from different departments who were involved in the testing process were recruited and trained. Their main responsibility was to analyze and score all possible clinical chemistry laboratory failures based on three aspects: the severity of the outcome (S), the likeliness of occurrence (O), and the probability of being detected (D). These three parameters were multiplied to calculate risk priority numbers (RPNs), which were used to prioritize remedial measures. Failure modes with RPN≥200 were deemed as high risk, meaning that they needed immediate corrective action. After modifications that were put, we compared the resulting RPN with the previous one. A total of 33 failure modes were identified. Many of the failure modes, including the one with the highest RPN (specimen hemolysis) appeared in the pre-analytic phase, whereas no high-risk failure modes (RPN≥200) were found during the analytic phase. High-priority risks were "sample hemolysis" (RPN, 336), "sample delivery delay" (RPN, 225), "sample volume error" (RPN, 210), "failure to release results in a timely manner" (RPN, 210), and "failure to identify or report critical results" (RPN, 200). The

Safety Management in an Oil Company through Failure Mode Effects and Critical Analysis

Directory of Open Access Journals (Sweden)

Benedictus Rahardjo

2016-06-01

Full Text Available This study attempts to apply Failure Mode Effects and Criticality Analysis (FMECA to improve the safety of a production system, specifically the production process of an oil company. Since food processing is a worldwide issue and self-management of a food company is more important than relying on government regulations, therefore this study focused on that matter. The initial step of this study is to identify and analyze the criticality of the potential failure modes of the production process. Furthermore, take corrective action to minimize the probability of repeating the same failure mode, followed by a re-analysis of its criticality. The results of corrective actions were compared with those before improvement conditions by testing the significance of the difference using two sample t-test. The final measured result is the Criticality Priority Number (CPN, which refers to the severity category of the failure mode and the probability of occurrence of the same failure mode. The recommended actions proposed by the FMECA significantly reduce the CPN compared with the value before improvement, with increases of 38.46% for the palm olein case study.

Effect of a certain class of potential common mode failures on the reliability of redundant systems

International Nuclear Information System (INIS)

Apostolakis, G.E.

1975-11-01

This is a theoretical investigation of the importance of common mode failures on the reliability of redundant systems. These failures are assumed to be the result of fatal shocks (e.g., from earthquakes, explosions, etc.) which occur at a constant rate. This formulation makes it possible to predict analytically results obtained in the past which showed that the probability of a common mode failure of the redundant channels of the protection system of a typical nuclear power plant was orders of magnitude larger than the probability of failure from chance failures alone. Furthermore, since most reliability analyses of redundant systems do not include potential common mode failures in the probabilistic calculations, criteria are established which can be used to decide either that the common-mode-failure effects are indeed insignificant or that such calculations are meaningless, and more sophisticated methods of analysis are required, because common mode failures cannot be ignored

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

Science.gov (United States)

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

2017-12-01

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

Risk assessment of the emergency processes: Healthcare failure mode and effect analysis.

Science.gov (United States)

Taleghani, Yasamin Molavi; Rezaei, Fatemeh; Sheikhbardsiri, Hojat

2016-01-01

Ensuring about the patient's safety is the first vital step in improving the quality of care and the emergency ward is known as a high-risk area in treatment health care. The present study was conducted to evaluate the selected risk processes of emergency surgery department of a treatment-educational Qaem center in Mashhad by using analysis method of the conditions and failure effects in health care. In this study, in combination (qualitative action research and quantitative cross-sectional), failure modes and effects of 5 high-risk procedures of the emergency surgery department were identified and analyzed according to Healthcare Failure Mode and Effects Analysis (HFMEA). To classify the failure modes from the "nursing errors in clinical management model (NECM)", the classification of the effective causes of error from "Eindhoven model" and determination of the strategies to improve from the "theory of solving problem by an inventive method" were used. To analyze the quantitative data of descriptive statistics (total points) and to analyze the qualitative data, content analysis and agreement of comments of the members were used. In 5 selected processes by "voting method using rating", 23 steps, 61 sub-processes and 217 potential failure modes were identified by HFMEA. 25 (11.5%) failure modes as the high risk errors were detected and transferred to the decision tree. The most and the least failure modes were placed in the categories of care errors (54.7%) and knowledge and skill (9.5%), respectively. Also, 29.4% of preventive measures were in the category of human resource management strategy. "Revision and re-engineering of processes", "continuous monitoring of the works", "preparation and revision of operating procedures and policies", "developing the criteria for evaluating the performance of the personnel", "designing a suitable educational content for needs of employee", "training patients", "reducing the workload and power shortage", "improving team

Observations on analysis, testing and failure of prestressed concrete containments

International Nuclear Information System (INIS)

Murray, D.W.

1984-01-01

The paper reviews the mechanics which indicate that a bursting failure with large energy release is the failure mechanism to be expected from ductile lined containment structures pressurized to failure. It reviews a study which shows that, because of leakage, this is not the case for unlined prestressed containments. It argues that current practice, since it does not specifically address the bursting failure problem for lined prestressed containments, is inadequate to ensure that this type of failure could not occur. It concludes that, in view of the inadequacy of the current state-of-the-art to predict leakage from lined structures, the logical remedy is to eliminate all possibility of bursting failure by making provision for venting of containments. (orig.)

Failure modes of safety-related components at fires on nuclear power plants

International Nuclear Information System (INIS)

Aaslund, A.

2000-03-01

Probabilistic assessment methods can be used to identify specific plant vulnerabilities. Application of such methods can also facilitate selection among system design alternatives available for safety enhancements. The quality of assessment results is however strongly dependent on realistic and accurate input data for modelling of system component behaviour and failure modes during conditions to be assessed. Use of conservative input data may not lead to results providing guidance on safety upgrades. Adequate input data for probabilistic assessments seems to be lacking for at least failure modes of some electrical components when exposed to a fire. This report presents an attempt to improve the situation with respect to such input data. In order to take advantage of information in existing documentation of fire incident occurrences some of the lessons learned from the fire at Browns Ferry Nuclear Power Plant on March 22, 1975 are discussed in this report. Also a summary of results from different fire tests of electrical cables presented in a fire risk analysis report is a part of the references. The failure modes used to describe fire-induced damage are 'open circuit' and 'hot short' which seems to be commonly accepted terms within the branch. Definitions of the terms are included in the report. Effects of the failure modes when occurring in some of the channels of the reactor protection system are discussed with respect to the existing design of the reactor protection system at Ringhals 2 nuclear power unit. Experiences from the Browns Ferry fire and results from fire tests of electrical cables indicate that the dominating failure mode for electrical cables is 'open circuit'. An 'open circuit' failure leads to circuit disjunction and loss of continuity. The circuit can no longer transmit its signal or power. When affecting channels of the reactor protection system an 'open circuit' failure can cause extensive inadvertent actions of safety related equipment

Failure mode and effects analysis and fault tree analysis of surface image guided cranial radiosurgery.

Science.gov (United States)

Manger, Ryan P; Paxton, Adam B; Pawlicki, Todd; Kim, Gwe-Ya

2015-05-01

Surface image guided, Linac-based radiosurgery (SIG-RS) is a modern approach for delivering radiosurgery that utilizes optical stereoscopic imaging to monitor the surface of the patient during treatment in lieu of using a head frame for patient immobilization. Considering the novelty of the SIG-RS approach and the severity of errors associated with delivery of large doses per fraction, a risk assessment should be conducted to identify potential hazards, determine their causes, and formulate mitigation strategies. The purpose of this work is to investigate SIG-RS using the combined application of failure modes and effects analysis (FMEA) and fault tree analysis (FTA), report on the effort required to complete the analysis, and evaluate the use of FTA in conjunction with FMEA. A multidisciplinary team was assembled to conduct the FMEA on the SIG-RS process. A process map detailing the steps of the SIG-RS was created to guide the FMEA. Failure modes were determined for each step in the SIG-RS process, and risk priority numbers (RPNs) were estimated for each failure mode to facilitate risk stratification. The failure modes were ranked by RPN, and FTA was used to determine the root factors contributing to the riskiest failure modes. Using the FTA, mitigation strategies were formulated to address the root factors and reduce the risk of the process. The RPNs were re-estimated based on the mitigation strategies to determine the margin of risk reduction. The FMEA and FTAs for the top two failure modes required an effort of 36 person-hours (30 person-hours for the FMEA and 6 person-hours for two FTAs). The SIG-RS process consisted of 13 major subprocesses and 91 steps, which amounted to 167 failure modes. Of the 91 steps, 16 were directly related to surface imaging. Twenty-five failure modes resulted in a RPN of 100 or greater. Only one of these top 25 failure modes was specific to surface imaging. The riskiest surface imaging failure mode had an overall RPN-rank of eighth

Development of container failure models

International Nuclear Information System (INIS)

Garisto, N.C.

1990-01-01

In order to produce a complete performance assessment for a Canadian waste vault some prediction of container failure times is required. Data are limited; however, the effects of various possible failure scenarios on the rest of the vault model can be tested. For titanium and copper, the two materials considered in the Canadian program, data are available on the frequency of failures due to manufacturing defects; there is also an estimate on the expected size of such defects. It can be shown that the consequences of such small defects in terms of the dose to humans are acceptable. It is not clear, from a modelling point of view, whether titanium or copper are preferable

Metallized Film Capacitor Lifetime Evaluation and Failure Mode Analysis

CERN Document Server

Gallay, R.

2015-06-15

One of the main concerns for power electronic engineers regarding capacitors is to predict their remaining lifetime in order to anticipate costly failures or system unavailability. This may be achieved using a Weibull statistical law combined with acceleration factors for the temperature, the voltage, and the humidity. This paper discusses the different capacitor failure modes and their effects and consequences.

Failure Atlas for Rolling Bearings in Wind Turbines

Energy Technology Data Exchange (ETDEWEB)

Tallian, T. E.

2006-01-01

This Atlas is structured as a supplement to the book: T.E. Tallian: Failure Atlas for Hertz Contact Machine Elements, 2nd edition, ASME Press New York, (1999). The content of the atlas comprises plate pages from the book that contain bearing failure images, application data, and descriptions of failure mode, image, and suspected failure causes. Rolling bearings are a critical component of the mainshaft system, gearbox and generator in the rapidly developing technology of power generating wind turbines. The demands for long service life are stringent; the design load, speed and temperature regimes are demanding and the environmental conditions including weather, contamination, impediments to monitoring and maintenance are often unfavorable. As a result, experience has shown that the rolling bearings are prone to a variety of failure modes that may prevent achievement of design lives. Morphological failure diagnosis is extensively used in the failure analysis and improvement of bearing operation. Accumulated experience shows that the failure appearance and mode of failure causation in wind turbine bearings has many distinguishing features. The present Atlas is a first effort to collect an interpreted database of specifically wind turbine related rolling bearing failures and make it widely available. This Atlas is structured as a supplement to the book: T. E. Tallian: Failure Atlas for Hertz Contact Machine Elements, 2d edition, ASME Press New York, (1999). The main body of that book is a comprehensive collection of self-contained pages called Plates, containing failure images, bearing and application data, and three descriptions: failure mode, image and suspected failure causes. The Plates are sorted by main failure mode into chapters. Each chapter is preceded by a general technical discussion of the failure mode, its appearance and causes. The Plates part is supplemented by an introductory part, describing the appearance classification and failure classification

Characterising mechanical transmission wire ropes’ typical failure modes

Directory of Open Access Journals (Sweden)

Edgar Espejo

2007-01-01

Full Text Available The National University of Colombia’s Engineering School’s AFIS research group has helped several public and private institutions during the last five years in analysing the causes of failures presented in elevation and trans- port machinery leading to expensive consequences and even the loss of life. A group of typical wire rope failure modes have been identified, along with their common causes. These are presented in this work to offer help to our industry’s engineers and technicians, allowing them to identify possible risk situations in their routine work regarding the wire ropes which they use and approaches for carrying out wire rope failure analysis.

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

Science.gov (United States)

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

2016-01-01

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

Potentially damaging failure modes of high- and medium-voltage electrical equipment

International Nuclear Information System (INIS)

Hoy, H.C.

1983-07-01

The electrical equipment failures of both nuclear and nonnuclear public utilities were reviewed. Those failures that could pose an additional problem to surrounding and connected equipment were defined. The literature was searched; utilities, repair shops, and large electrical equipment users were contacted for failure information. The data were reviewed in detail, and failure modes were determined. Sample cascade failures are discussed. The failure rate of electrical equipment in utilities is historically quite low. Nuclear plants record too few failures to be statistically valid, but failures that have been recorded show that good design usually restricts the failure to a single piece of equipment

Tougher containment design goals

International Nuclear Information System (INIS)

O'Farrelly, C.

1978-01-01

Present day LWR containment design goals are reviewed, together with their potential failure modes. Rasmussen's estimates of failure probabilities are discussed and the concept of ''delayed failure'' is seen to be a valuable safety goal for hypothetical accidents. The paper investigates the inherent coremelt resistance capability of various containment designs and suggests improvements, with special emphasis on increasing the failure delay times. (author)

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

Science.gov (United States)

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

2010-01-01

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

Efficient surrogate models for reliability analysis of systems with multiple failure modes

International Nuclear Information System (INIS)

Bichon, Barron J.; McFarland, John M.; Mahadevan, Sankaran

2011-01-01

Despite many advances in the field of computational reliability analysis, the efficient estimation of the reliability of a system with multiple failure modes remains a persistent challenge. Various sampling and analytical methods are available, but they typically require accepting a tradeoff between accuracy and computational efficiency. In this work, a surrogate-based approach is presented that simultaneously addresses the issues of accuracy, efficiency, and unimportant failure modes. The method is based on the creation of Gaussian process surrogate models that are required to be locally accurate only in the regions of the component limit states that contribute to system failure. This approach to constructing surrogate models is demonstrated to be both an efficient and accurate method for system-level reliability analysis. - Highlights: → Extends efficient global reliability analysis to systems with multiple failure modes. → Constructs locally accurate Gaussian process models of each response. → Highly efficient and accurate method for assessing system reliability. → Effectiveness is demonstrated on several test problems from the literature.

Understanding aging in containment cooling systems

International Nuclear Information System (INIS)

Lofaro, R.J.

1993-01-01

A study has been performed to assess the effects of aging in nuclear power plant containment cooling systems. Failure records from national databases, as well as plant specific data were reviewed and analyzed to identify aging characteristics for this system. The predominant aging mechanisms were determined, along with the most frequently failed components and their associated failure modes. This paper discusses the aging mechanisms present in the containment spray system and the containment fan cooler system, which are two systems used to provide the containment cooling function. The failure modes, along with the relative frequency of each is also discussed

Evaluation of Safety in a Radiation Oncology Setting Using Failure Mode and Effects Analysis

International Nuclear Information System (INIS)

Ford, Eric C.; Gaudette, Ray; Myers, Lee; Vanderver, Bruce; Engineer, Lilly; Zellars, Richard; Song, Danny Y.; Wong, John; DeWeese, Theodore L.

2009-01-01

Purpose: Failure mode and effects analysis (FMEA) is a widely used tool for prospectively evaluating safety and reliability. We report our experiences in applying FMEA in the setting of radiation oncology. Methods and Materials: We performed an FMEA analysis for our external beam radiation therapy service, which consisted of the following tasks: (1) create a visual map of the process, (2) identify possible failure modes; assign risk probability numbers (RPN) to each failure mode based on tabulated scores for the severity, frequency of occurrence, and detectability, each on a scale of 1 to 10; and (3) identify improvements that are both feasible and effective. The RPN scores can span a range of 1 to 1000, with higher scores indicating the relative importance of a given failure mode. Results: Our process map consisted of 269 different nodes. We identified 127 possible failure modes with RPN scores ranging from 2 to 160. Fifteen of the top-ranked failure modes were considered for process improvements, representing RPN scores of 75 and more. These specific improvement suggestions were incorporated into our practice with a review and implementation by each department team responsible for the process. Conclusions: The FMEA technique provides a systematic method for finding vulnerabilities in a process before they result in an error. The FMEA framework can naturally incorporate further quantification and monitoring. A general-use system for incident and near miss reporting would be useful in this regard.

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

International Nuclear Information System (INIS)

Harry, T; Manger, R; Cervino, L; Pawlicki, T

2016-01-01

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

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

Energy Technology Data Exchange (ETDEWEB)

Harry, T [Oregon State University, Corvallis, OR (United States); University of California, San Diego, La Jolla, CA (United States); Manger, R; Cervino, L; Pawlicki, T [University of California, San Diego, La Jolla, CA (United States)

2016-06-15

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

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

Science.gov (United States)

Sawant, M.; Christou, A.

2012-12-01

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

Failure mode taxonomy for assessing the reliability of Field Programmable Gate Array based Instrumentation and Control systems

International Nuclear Information System (INIS)

McNelles, Phillip; Zeng, Zhao Chang; Renganathan, Guna; Chirila, Marius; Lu, Lixuan

2017-01-01

Highlights: • The use FPGAs in I&C systems in Nuclear Power Plants is an important issue (IAEA). • OECD-NEA published a failure mode taxonomy for software-based digital I&C systems. • This paper extends the OECD-NEA taxonomy to model FPGA-based systems. • FPGA failure modes, failure effects, uncovering methods are categorized/described. • Provides an example of modelling an FPGA-Based RTS/ESFAS using the FPGA taxonomy. - Abstract: Field Programmable Gate Arrays (FPGAs) are a form of programmable digital hardware configured to perform digital logic functions. This configuration (programming) is performed using Hardware Description Language (HDL), making FPGAs a form of HDL Programmed Device (HPD). In the nuclear field, FPGAs have seen use in upgrades and replacements of obsolete Instrumentation and Control (I&C) systems. This paper expands upon previous work that resulted in extensive FPGA failure mode data, to allow for the application of the OECD-NEA failure modes taxonomy. The OECD-NEA taxonomy presented a method to model digital (software-based) I&C systems, based on the hardware and software failure modes, failure uncovering effects and levels of abstraction, using a Reactor Trip System/Engineering Safety Feature Actuation System (RTS/ESFAS) as an example system. To create the FPGA taxonomy, this paper presents an additional “sub-component” level of abstraction, to demonstrate the effect of the FPGA failure modes and failure categories on an FPGA-based system. The proposed FPGA taxonomy is based on the FPGA failure modes, failure categories, failure effects and uncovering situations. The FPGA taxonomy is applied to the RTS/ESFAS test system, to demonstrate the effects of the anticipated FPGA failure modes on a digital I&C system, and to provide a modelling example for this proposed taxonomy.

WE-H-BRC-02: Failure Mode and Effect Analysis of Liver Stereotactic Body Radiotherapy

Energy Technology Data Exchange (ETDEWEB)

Rusu, I; Thomas, T; Roeske, J; Price, J; Perino, C; Surucu, M [Loyola University Chicago, Maywood, IL (United States); Mescioglu, I [Lewis University, Romeoville, IL (United States)

2016-06-15

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

WE-H-BRC-02: Failure Mode and Effect Analysis of Liver Stereotactic Body Radiotherapy

International Nuclear Information System (INIS)

Rusu, I; Thomas, T; Roeske, J; Price, J; Perino, C; Surucu, M; Mescioglu, I

2016-01-01

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

A multi-level maintenance policy for a multi-component and multifailure mode system with two independent failure modes

International Nuclear Information System (INIS)

Zhu, Wenjin; Fouladirad, Mitra; Bérenguer, Christophe

2016-01-01

This paper studies the maintenance modelling of a multi-component system with two independent failure modes with imperfect prediction signal in the context of a system of systems. Each individual system consists of multiple series components and the failure modes of all the components are divided into two classes due to their consequences: hard failure and soft failure, where the former causes system failure while the later results in inferior performance (production reduction) of system. Besides, the system is monitored and can be alerted by imperfect prediction signal before hard failure. Based on an illustration example of offshore wind farm, in this paper three maintenance strategies are considered: periodic routine, reactive and opportunistic maintenance. The periodic routine maintenance is scheduled at fixed period for each individual system in the perspective of system of systems. Between two successive routine maintenances, the reactive maintenance is instructed by the imperfect prediction signal according to two criterion proposed in this study for the system components. Due to the high setup cost and practical restraints of implementing maintenance activities, both routine and reactive maintenance can create the opportunities of maintenance for the other components of an individual system. The life cycle of the system and the cost of the proposed maintenance policies are analytically derived. Restrained by the complexity from both the system failure modelling and maintenance strategies, the performances and application scope of the proposed maintenance model are evaluated by numerical simulations. - Highlights: • We study the life behavior of a complex system with two failure modes. • We consider the imperfect prediction signal of potential failure by monitoring. • We propose an integrated maintenance policy with three levels based on wind turbine. • We derive the mathematical cost formulations for the proposed maintenance policy.

Failure mode, effect and criticality analysis (FMECA) on mechanical subsystems of diesel generator at NPP

International Nuclear Information System (INIS)

Kim, Tae Woon; Singh, Brijendra; Sung, Tae Yong; Park, Jin Hee; Lee, Yoon Hwan

1996-06-01

Largely, the RCM approach can be divided in three phases; (1) Functional failure analysis (FFA) on the selected system or subsystem, (2) Failure mode, effect and criticality analysis (FMECA) to identify the impact of failure to plant safety or economics, (3) Logical tree analysis (LTA) to select appropriate preventive maintenance and surveillance tasks. This report presents FMECA results for six mechanical subsystems of the diesel generators of nuclear power plants. The six mechanical subsystems are Starting air, Lub oil, Governor, Jacket water cooling, Fuel, and Engine subsystems. Generic and plant-specific failure and maintenance records are reviewed to identify critical components/failure modes. FMECA was performed for these critical component/failure modes. After reviewing current preventive maintenance activities of Wolsung unit 1, draft RCM recommendations are developed. 6 tabs., 16 refs. (Author)

Failure mode, effect and criticality analysis (FMECA) on mechanical subsystems of diesel generator at NPP

Energy Technology Data Exchange (ETDEWEB)

Kim, Tae Woon; Singh, Brijendra; Sung, Tae Yong; Park, Jin Hee; Lee, Yoon Hwan [Korea Atomic Energy Research Institute, Taejon (Korea, Republic of)

1996-06-01

Largely, the RCM approach can be divided in three phases; (1) Functional failure analysis (FFA) on the selected system or subsystem, (2) Failure mode, effect and criticality analysis (FMECA) to identify the impact of failure to plant safety or economics, (3) Logical tree analysis (LTA) to select appropriate preventive maintenance and surveillance tasks. This report presents FMECA results for six mechanical subsystems of the diesel generators of nuclear power plants. The six mechanical subsystems are Starting air, Lub oil, Governor, Jacket water cooling, Fuel, and Engine subsystems. Generic and plant-specific failure and maintenance records are reviewed to identify critical components/failure modes. FMECA was performed for these critical component/failure modes. After reviewing current preventive maintenance activities of Wolsung unit 1, draft RCM recommendations are developed. 6 tabs., 16 refs. (Author).

Utilizing foreign operating experience to derive reliability data - especially for common mode failures

International Nuclear Information System (INIS)

Bongartz, R.; Hennings, W.; Meessen, H.

1987-11-01

Failure rates for common mode failures of redundant components of the same design are derived from abnormal occurrences in safety systems of US nuclear power stations for use on a national level. The available raw data of interest for pumps and valves (processed Licensee Event Reports) are progressively re-evaluated and checked for transferability of German conditions. Most of the common mode failures (CMF) experienced affected only part of the redundancies; the homogeneous Marshall-Olkin model is therefore used to determine failure rates for both partial and total failures of redundant components. Some few results based on zero failure statistics and a small data base (four-train systems) seem to be too conservative. On the whole, however, the application of the data determined here does not provide any unrealistically high system unavailabilities. (orig.) [de

Determination of Component Failure Modes for a Fire PSA by Using Decision Trees

International Nuclear Information System (INIS)

Kang, Dae Il; Han, Sang Hoon; Lim, Jae Won

2007-01-01

KAERI developed the method, called a mapping technique, for the quantification of external events PSA models with one top model for an internal events PSA. The mapping technique can be implemented by the construction of mapping tables. The mapping tables include initiating events and transfer events of fire, and internal PSA basic events affected by a fire. This year, KAERI is making mapping tables for the one top model for Ulchin Unit 3 and 4 fire PSA with previously conducted Fire PSA results for Ulchin Unit 3 and 4. A Fire PSA requires a PSA analyst to determine component failure modes affected by a fire. The component failure modes caused by a fire depend on several factors. These several factors are whether components are located at fire initiation and propagation areas or not, fire effects on control and power cables for components, designed failure modes of components, success criteria in a PSA model, etc. Thus, it is not easy to manually determine component failure modes caused by a fire. In this paper, we propose the use of decision trees for the determination of component failure modes affected by a fire and the selection of internal PSA basic events. Section 2 presents the procedure for previously performed the Ulchin Unit 3 and 4 fire PSA and mapping technique. Section 3 presents the process for identification of basic events and decision trees. Section 4 presents the concluding remarks

Fuzzy logic prioritization of failures in a system failure mode, effects and criticality analysis

International Nuclear Information System (INIS)

Bowles, John B.; Pelaez, C.E.

1995-01-01

This paper describes a new technique, based on fuzzy logic, for prioritizing failures for corrective actions in a Failure Mode, Effects and Criticality Analysis (FMECA). As in a traditional criticality analysis, the assessment is based on the severity, frequency of occurrence, and detectability of an item failure. However, these parameters are here represented as members of a fuzzy set, combined by matching them against rules in a rule base, evaluated with min-max inferencing, and then defuzzified to assess the riskiness of the failure. This approach resolves some of the problems in traditional methods of evaluation and it has several advantages compared to strictly numerical methods: 1) it allows the analyst to evaluate the risk associated with item failure modes directly using the linguistic terms that are employed in making the criticality assessment; 2) ambiguous, qualitative, or imprecise information, as well as quantitative data, can be used in the assessment and they are handled in a consistent manner; and 3) it gives a more flexible structure for combining the severity, occurrence, and detectability parameters. Two fuzzy logic based approaches for assessing criticality are presented. The first is based on the numerical rankings used in a conventional Risk Priority Number (RPN) calculation and uses crisp inputs gathered from the user or extracted from a reliability analysis. The second, which can be used early in the design process when less detailed information is available, allows fuzzy inputs and also illustrates the direct use of the linguistic rankings defined for the RPN calculations

Common mode failures in redundancy systems

International Nuclear Information System (INIS)

Watson, I.A.; Edwards, G.T.

1978-01-01

Difficulties are experienced in assessing the impact of common mode failures on the reliability of safety systems. The paper first covers the investigation, definition and classification of CMF based on an extensive study of the nature of CMF. This is used as a basis for analysing data from nuclear reactor safety systems and aircraft systems. Design and maintenance errors are shown to be the prdominant cause of CMF. The analysis has laid the grounds for work on relating CMF modelling and defences. (author)

Failure mode and effects analysis applied to the administration of liquid medication by oral syringes

Directory of Open Access Journals (Sweden)

Eva María Guerra-Alia

2017-11-01

Full Text Available To carry out a Failure Mode and Effects Analysis (FMEA to the use of oral syringes. Methods: A multidisciplinary team was assembled within the Safety Committee. The stages of oral administration process of liquid medication were analysed, identifying the most critical and establishing the potential modes of failure that can cause errors. The impact associated with each mode of failure was calculated using the Risk Priority Number (RPN. Preventive actions were proposed. Results: Five failure modes were identified, all classified as high risk (RPN> 100. Seven of the eight preventive actions were implemented. Conclusions: The FMEA methodology was a useful tool. It has allowed to know the risks, analyse the causes that cause them, their effects on patient safety and the measures to reduce them

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

International Nuclear Information System (INIS)

Xie, J; Xiao, Y; Wang, J; Peng, J; Lu, S; Hu, W

2014-01-01

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

Failure modes and effects analysis of fusion magnet systems

International Nuclear Information System (INIS)

Zimmermann, M.; Kazimi, M.S.; Siu, N.O.; Thome, R.J.

1988-12-01

A failure modes and consequence analysis of fusion magnet system is an important contributor towards enhancing the design by improving the reliability and reducing the risk associated with the operation of magnet systems. In the first part of this study, a failure mode analysis of a superconducting magnet system is performed. Building on the functional breakdown and the fault tree analysis of the Toroidal Field (TF) coils of the Next European Torus (NET), several subsystem levels are added and an overview of potential sources of failures in a magnet system is provided. The failure analysis is extended to the Poloidal Field (PF) magnet system. Furthermore, an extensive analysis of interactions within the fusion device caused by the operation of the PF magnets is presented in the form of an Interaction Matrix. A number of these interactions may have significant consequences for the TF magnet system particularly interactions triggered by electrical failures in the PF magnet system. In the second part of this study, two basic categories of electrical failures in the PF magnet system are examined: short circuits between the terminals of external PF coils, and faults with a constant voltage applied at external PF coil terminals. An electromagnetic model of the Compact Ignition Tokamak (CIT) is used to examine the mechanical load conditions for the PF and the TF coils resulting from these fault scenarios. It is found that shorts do not pose large threats to the PF coils. Also, the type of plasma disruption has little impact on the net forces on the PF and the TF coils. 39 refs., 30 figs., 12 tabs

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

Energy Technology Data Exchange (ETDEWEB)

Huq, M. [University of Pittsburgh Medical Center (United States)

2015-06-15

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

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

International Nuclear Information System (INIS)

Huq, M.

2015-01-01

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

Preliminary failure modes and effects analysis on Korean HCCR TBS to be tested in ITER

International Nuclear Information System (INIS)

Ahn, Mu-Young; Cho, Seungyon; Jin, Hyung Gon; Lee, Dong Won; Park, Yi-Hyun; Lee, Youngmin

2015-01-01

Highlights: • Postulated initiating events are identified through failure modes and effects analysis on the current HCCR TBS design. • A set of postulated initiating events are selected for consideration of deterministic analysis. • Accident evolutions on the selected postualted initiating events are qualitatively described for deterministic analysis. - Abstract: Korean Helium cooled ceramic reflector (HCCR) Test blanket system (TBS), which comprises Test blanket module (TBM) and ancillary systems in various locations of ITER building, is operated at high temperature and pressure with decay heat. Therefore, safety is utmost concern in design process and it is required to demonstrate that the HCCR TBS is designed to comply with the safety requirements and guidelines of ITER. Due to complexity of the system with many interfaces with ITER, a systematic approach is necessary for safety analysis. This paper presents preliminary failure modes and effects analysis (FMEA) study performed for the HCCR TBS. FMEA is a systematic methodology in which failure modes for components in the system and their consequences are studied from the bottom-up. Over eighty failure modes have been investigated on the HCCR TBS. The failure modes that have similar consequences are grouped as postulated initiating events (PIEs) and total seven reference accident scenarios are derived from FMEA study for deterministic accident analysis. Failure modes not covered here due to evolving design of the HCCR TBS and uncertainty in maintenance procedures will be studied further in near future.

Preliminary failure modes and effects analysis on Korean HCCR TBS to be tested in ITER

Energy Technology Data Exchange (ETDEWEB)

Ahn, Mu-Young, E-mail: myahn74@nfri.re.kr [National Fusion Research Institute, Daejeon (Korea, Republic of); Cho, Seungyon [National Fusion Research Institute, Daejeon (Korea, Republic of); Jin, Hyung Gon; Lee, Dong Won [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of); Park, Yi-Hyun; Lee, Youngmin [National Fusion Research Institute, Daejeon (Korea, Republic of)

2015-10-15

Highlights: • Postulated initiating events are identified through failure modes and effects analysis on the current HCCR TBS design. • A set of postulated initiating events are selected for consideration of deterministic analysis. • Accident evolutions on the selected postualted initiating events are qualitatively described for deterministic analysis. - Abstract: Korean Helium cooled ceramic reflector (HCCR) Test blanket system (TBS), which comprises Test blanket module (TBM) and ancillary systems in various locations of ITER building, is operated at high temperature and pressure with decay heat. Therefore, safety is utmost concern in design process and it is required to demonstrate that the HCCR TBS is designed to comply with the safety requirements and guidelines of ITER. Due to complexity of the system with many interfaces with ITER, a systematic approach is necessary for safety analysis. This paper presents preliminary failure modes and effects analysis (FMEA) study performed for the HCCR TBS. FMEA is a systematic methodology in which failure modes for components in the system and their consequences are studied from the bottom-up. Over eighty failure modes have been investigated on the HCCR TBS. The failure modes that have similar consequences are grouped as postulated initiating events (PIEs) and total seven reference accident scenarios are derived from FMEA study for deterministic accident analysis. Failure modes not covered here due to evolving design of the HCCR TBS and uncertainty in maintenance procedures will be studied further in near future.

Development of a container failure function for copper

International Nuclear Information System (INIS)

King, F.; Litke, C.D.

1990-01-01

A simple approach to the modeling of failure rates for a copper container under Canadian waste disposal conditions is presented. Both uniform corrosion and pitting must be considered. Short-term failures due to fabrication defects must be taken into account. The model allows for short-term sorption of copper by the clay buffer material, and assumes a steady-state condition for uniform corrosion. Using worst-case assumptions, a container penetration time of 3300 years can be predicted

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

Science.gov (United States)

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

2011-01-01

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

FAILURE MODE AND EFFECT ANALYSIS (FMEA OF BUTTERFLY VALVE IN OIL AND GAS INDUSTRY

Directory of Open Access Journals (Sweden)

MUHAMMAD AMIRUL BIN YUSOF

2016-04-01

Full Text Available Butterfly valves are mostly used in various industries such as oil and gas plant. This valve operates with rotating motion using pneumatic system. Rotating actuator turns the disc either parallel or perpendicular to the flow. When the valve is fully open, the disc is rotated a quarter turn so that it allows free passage of the fluid and when fully closed, the disc rotated a quarter turns to block the fluid. The primary failure modes for valves are the valve leaks to environment through flanges, seals on the valve body, valve stem packing not properly protected, over tightened packing nuts, the valve cracks and leaks over the seat. To identify the failure of valve Failure Mode and Effects Analysis has been chosen. FMEA is the one of technique to perform failure analysis. It involves reviewing as many components to identify failure modes, and their causes and effects. For each component, the failure modes and their resulting effects on the rest of the system are recorded in a specific FMEA form. Risk priority number, severity, detection, occurrence are the factor determined in this studies. Risk priority number helps to find out the highest hazardous activities which need more attention than the other activity. The highest score of risk priority number in this research is seat. Action plan was proposed to reduce the risk priority number and so that potential failures also will be reduced.

Recent performance, lifetime, and failure modes of the 5045 klystron population at SLAC

International Nuclear Information System (INIS)

Koontz, R.F.; Lee, T.G.; Pearson, C.; Vlieks, A.E.

1992-08-01

The 65 MW S-Band klystrons (5045) used to power SLC have been in service for over seven years. Currently, 244 of these tubes are in place on the accelerator, operating full power at 120 pulses per second. Enough tubes have now reached end of life, or experienced other failures to allow a good analysis of failure modes, and to project average lifetime for this type of tube. This paper describes the various modes of failure seen in klystrons rammed from SLC service, and provides data on expected lifetime from current production based on accumulated SLC operating experience

Recent performance, lifetime, and failure modes or the 5045 klystron population at SLAC

International Nuclear Information System (INIS)

Koontz, R.F.; Lee, T.G.; Pearson, C.; Vlieks, A.E.

1992-01-01

The 65 MW S-Band klystrons (5045) used to power SLC have been in service for over seven years. Currently, 244 of these tubes are in place on the accelerator, operating full power at 120 pulses per second. Enough tubes have now reached cathode end of life, or experienced other failures to allow a good analysis of failure modes, and to project average lifetime for this type of tube. This paper describes the various modes of failure seen in klystrons returned from SLC service, and provides data on expected lifetime from current production based on accumulated SLC operating experience. 3 refs., 6 figs

Modes of failures: primary and secondary stresses

International Nuclear Information System (INIS)

Roche, R.L.

1987-07-01

The paper begins with a reminder that the purpose of stress classification is to ensure suitable margins with respect to failure modes. The distinction between primary stresses and secondary stresses is then examined and a method is given for assessing the degree of elastic follow up in the elastic plastic field. The importance of elastic follow up is then highlighted by an examination of the effect of primary and secondary stresses on crack behavior

Failure internal pressure of spherical steel containments

International Nuclear Information System (INIS)

Sanchez Sarmiento, G.

1985-01-01

An application of the British CEGB's R6 Failure Assessment Approach to the determination of failure internal pressure of nuclear power plant spherical steel containments is presented. The presence of hypothetical cracks both in the base metal and in the welding material of the containment, with geometrical idealizations according to the ASME Boiler and Pressure Vessel Code (Section XI), was taken into account in order to analyze the sensitivity of the failure assessment with the values of the material fracture properties. Calculations of the elastoplastic collapse load have been performed by means of the Finite Element System SAMCEF. The clean axisymmetric shell (neglecting the influence of nozzles and minor irregularities) and two major penetrations (personnel and emergency locks) have been taken separately into account. Large-strain elastoplastic behaviour of the material was considered in the Code, using lower bounds of true stress-true strain relations obtained by testing a collection of tensile specimens. Assuming the presence of cracks in non-perturbed regions, the reserve factor for test pressure and the failure internal pressure have been determined as a function of the flaw depth. (orig.)

The common mode failures analysis of the redundent system with dependent human error

International Nuclear Information System (INIS)

Kim, M.K.; Chang, S.H.

1983-01-01

Common mode failures (CMFs) have been a serious concern in the nuclear power plant. Thereis a broad category of the failure mechanisms that can cause common mode failures. This paper is a theoretical investigation of the CMFs on the unavailability of the redundent system. It is assumed that the total CMFs consist of the potential CMFs and the dependent human error CMFs. As the human error dependency is higher, the total CMFs are more effected by the dependent human error. If the human error dependence is lower, the system unavailability strongly depends on the potential CMFs, rather than the mechanical failure or the dependent human error. And it is shown that the total CMFs are dominant factor to the unavailability of the redundent system. (Author)

Evaluation of failure modes of computerized planning phase of interstitial implants with high dose rate brachytherapy using HFMEA

International Nuclear Information System (INIS)

Biazotto, Bruna; Tokarski, Marcio

2014-01-01

This paper evaluates the failure modes of the computerized planning step in interstitial implants with high dose rate brachytherapy. The prospective tool of risk management Health Care Failure Mode and Effects Analysis (HFMEA) was used. Twelve subprocesses were identified, and 33 failure modes of which 21 justified new safety actions, and 9 of them were intolerable risks. The method proved itself useful in identifying failure modes, but laborious and subjective in their assessment. The main risks were due to human factors, which require training and commitment of management to their mitigation. (author)

Practical Implementation of Failure Mode and Effects Analysis for Safety and Efficiency in Stereotactic Radiosurgery

International Nuclear Information System (INIS)

Younge, Kelly Cooper; Wang, Yizhen; Thompson, John; Giovinazzo, Julia; Finlay, Marisa; Sankreacha, Raxa

2015-01-01

Purpose: To improve the safety and efficiency of a new stereotactic radiosurgery program with the application of failure mode and effects analysis (FMEA) performed by a multidisciplinary team of health care professionals. Methods and Materials: Representatives included physicists, therapists, dosimetrists, oncologists, and administrators. A detailed process tree was created from an initial high-level process tree to facilitate the identification of possible failure modes. Group members were asked to determine failure modes that they considered to be the highest risk before scoring failure modes. Risk priority numbers (RPNs) were determined by each group member individually and then averaged. Results: A total of 99 failure modes were identified. The 5 failure modes with an RPN above 150 were further analyzed to attempt to reduce these RPNs. Only 1 of the initial items that the group presumed to be high-risk (magnetic resonance imaging laterality reversed) was ranked in these top 5 items. New process controls were put in place to reduce the severity, occurrence, and detectability scores for all of the top 5 failure modes. Conclusions: FMEA is a valuable team activity that can assist in the creation or restructuring of a quality assurance program with the aim of improved safety, quality, and efficiency. Performing the FMEA helped group members to see how they fit into the bigger picture of the program, and it served to reduce biases and preconceived notions about which elements of the program were the riskiest

Practical Implementation of Failure Mode and Effects Analysis for Safety and Efficiency in Stereotactic Radiosurgery

Energy Technology Data Exchange (ETDEWEB)

Younge, Kelly Cooper, E-mail: kyounge@med.umich.edu [Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan (United States); Wang, Yizhen [Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan (United States); Thompson, John; Giovinazzo, Julia; Finlay, Marisa [Department of Radiation Oncology, Trillium Health Partners - Credit Valley Hospital Site, Mississauga Halton/Central West Regional Cancer Program, Mississauga, ON (Canada); Sankreacha, Raxa [Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan (United States)

2015-04-01

Purpose: To improve the safety and efficiency of a new stereotactic radiosurgery program with the application of failure mode and effects analysis (FMEA) performed by a multidisciplinary team of health care professionals. Methods and Materials: Representatives included physicists, therapists, dosimetrists, oncologists, and administrators. A detailed process tree was created from an initial high-level process tree to facilitate the identification of possible failure modes. Group members were asked to determine failure modes that they considered to be the highest risk before scoring failure modes. Risk priority numbers (RPNs) were determined by each group member individually and then averaged. Results: A total of 99 failure modes were identified. The 5 failure modes with an RPN above 150 were further analyzed to attempt to reduce these RPNs. Only 1 of the initial items that the group presumed to be high-risk (magnetic resonance imaging laterality reversed) was ranked in these top 5 items. New process controls were put in place to reduce the severity, occurrence, and detectability scores for all of the top 5 failure modes. Conclusions: FMEA is a valuable team activity that can assist in the creation or restructuring of a quality assurance program with the aim of improved safety, quality, and efficiency. Performing the FMEA helped group members to see how they fit into the bigger picture of the program, and it served to reduce biases and preconceived notions about which elements of the program were the riskiest.

Analysis of functional failure mode of commercial deep sub-micron SRAM induced by total dose irradiation

International Nuclear Information System (INIS)

Zheng Qi-Wen; Cui Jiang-Wei; Zhou Hang; Yu De-Zhao; Yu Xue-Feng; Lu Wu; Guo Qi; Ren Di-Yuan

2015-01-01

Functional failure mode of commercial deep sub-micron static random access memory (SRAM) induced by total dose irradiation is experimentally analyzed and verified by circuit simulation. We extensively characterize the functional failure mode of the device by testing its electrical parameters and function with test patterns covering different functional failure modes. Experimental results reveal that the functional failure mode of the device is a temporary function interruption caused by peripheral circuits being sensitive to the standby current rising. By including radiation-induced threshold shift and off-state leakage current in memory cell transistors, we simulate the influence of radiation on the functionality of the memory cell. Simulation results reveal that the memory cell is tolerant to irradiation due to its high stability, which agrees with our experimental result. (paper)

Modelling the failure modes in geobag revetments.

Science.gov (United States)

Akter, A; Crapper, M; Pender, G; Wright, G; Wong, W S

2012-01-01

In recent years, sand filled geotextile bags (geobags) have been used as a means of long-term riverbank revetment stabilization. However, despite their deployment in a significant number of locations, the failure modes of such structures are not well understood. Three interactions influence the geobag performance, i.e. geobag-geobag, geobag-water flow and geobag-water flow-river bank. The aim of the research reported here is to develop a detailed understanding of the failure mechanisms in a geobag revetment using a discrete element model (DEM) validated by laboratory data. The laboratory measured velocity data were used for preparing a mapped velocity field for a coupled DEM simulation of geobag revetment failure. The validated DEM model could identify well the critical bag location in varying water depths. Toe scour, one of the major instability factors in revetments, and its influence on the bottom-most layer of the bags were also reasonably represented in this DEM model. It is envisaged that the use of a DEM model will provide more details on geobag revetment performance in riverbanks.

Influence of crosshead speed on failure load and failure mode of restored maxillary premolars

Directory of Open Access Journals (Sweden)

Lucas Zago NAVES

2016-01-01

Full Text Available We analyzed the effect of the crosshead speed of an applied load on failure load and failure mode of restored human premolars. Fifty intact, noncarious human premolars were selected. Class II mesio-occlusodistal preparations were made with a water-cooled high-speed preparation machine, and the teeth were restored with composite resin. The specimens were divided into five groups (n = 10 each and tested individually in a mechanical testing machine, in which a 6.0-mm-diameter steel cylinder was mounted to vary the crosshead speed: v0.5: 0.5 mm/min; v1: 1.0 mm/min; v2.5: 2.5 mm/min; v5: 5.0 mm/min; and v10: 10.0 mm/min. The cylinder contacted the facial and lingual ridges beyond the margins of the restorations. Peak load to fracture was measured for each specimen (N. The means were calculated and analyzed with one-way analysis of variance followed by Tukey's test (a = 0.05. The mean load at failure values were (N as follows: v0.5, 769.4 ± 174.8; v1, 645.2 ± 115.7; v5, 614.3 ± 126.0; v2.5, 609.2 ± 208.1; and v10, 432.5 ± 136.9. The fracture modes were recorded on the basis of the degree of the tooth structural and restorative damage: (I fracture of the restoration involving a small portion of the tooth; (II fractures involving the coronal portion of the tooth with cohesive failure of the composite resin; (III oblique tooth and restoration fracture with periodontal involvement; and (IV vertical root and coronal fracture. Varying crosshead speeds of 0.5–5.0 mm/min did not influence the failure load of restored maxillary premolars; however, increasing the crosshead speed to 10 mm/min decreased the failure load values and the degree of tooth structural damage.

Failure modes of prestressed CFRP rods in a wedge anchored set-up

DEFF Research Database (Denmark)

Bennitz, Anders; Schmidt, Jacob Wittrup; Täljsten, Björn

2009-01-01

: soft slip, power slip, cutting of fibres, crushing of rod, bending of fibres, frontal overload and intermediate rupture. In this paper the failure modes are discussed further. The failures are documented with explanatory figures and their backgrounds are found in the theory. Suggestions are given...

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

Science.gov (United States)

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

2015-10-01

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

Reprioritization of failures in a system failure mode and effects analysis by decision making trial and evaluation laboratory technique

International Nuclear Information System (INIS)

Seyed-Hosseini, S.M.; Safaei, N.; Asgharpour, M.J.

2006-01-01

In this paper an effective methodology related to decision making field has been developed for reprioritization of failure modes in a system Failure Mode and Effects Analysis (FMEA) for corrective actions. The proposed methodology can cover some of inherently shortcomings of conventional Risk Priority Number (RPN) method and like. The current prioritization methods have two main deficiencies as: they have not considered indirect relations between components and are deficient for systems with many subsystems or components. The proposed method called Decision Making Trial and Evaluation Laboratory (DEMATEL) is an effective approach for analyzing relation between components of a system in respect to its type (direct/indirect) and severity. The main advantages of DEMATEL are involving indirect relations in analyze, allocating as possible as unique ranks to alternatives and clustering alternatives in large systems. The demonstrated results have shown that DEMATEL method can be an efficient, complementary and confident approach for reprioritization of failure modes in a FMEA. For verification of proposed methodology, two illustrative practical examples are solved and obtained outcomes are reported

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

Science.gov (United States)

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

2008-07-01

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

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

Science.gov (United States)

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

2015-11-01

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

An analysis of molten-corium-induced failure of drain pipes in BWR Mark 2 containments

International Nuclear Information System (INIS)

Taleyarkhan, R.P.; Podowski, M.Z.

1991-01-01

This study has focused on mechanistic simulation and analysis of potential failure modes for inpedestal drywell drain pipes in the Limerick boiling water reactor (BWR) Mark 2 containment. Physical phenomena related to surface tension breakdown, heatup, melting, ablation, crust formation and failure, and core material relocation into drain pipes with simultaneous melting of pipe walls were modeled and analyzed. The results of analysis have been used to assess the possibility of drain pipe failure and the resultant loss of pressure-suppression capability. Estimates have been made for the timing and amount of molten corium released to the wetwell. The study has revealed that significantly different melt progression sequences can result depending upon the failure characteristics of the frozen metallic crust which forms over the drain cover during the initial stages of debris pour. Another important result is that it can take several days for the molten fuel to ablate the frozen metallic debris layer -- if the frozen layer has cooled below 1100 K before fuel attack. 10 refs., 3 figs., 4 tabs

Advanced approaches to failure mode and effect analysis (FMEA applications

Directory of Open Access Journals (Sweden)

D. Vykydal

2015-10-01

Full Text Available The present paper explores advanced approaches to the FMEA method (Failure Mode and Effect Analysis which take into account the costs associated with occurrence of failures during the manufacture of a product. Different approaches are demonstrated using an example FMEA application to production of drawn wire. Their purpose is to determine risk levels, while taking account of the above-mentioned costs. Finally, the resulting priority levels are compared for developing actions mitigating the risks.

Potentially damaging failure modes of high- and medium-voltage electrical equipment

International Nuclear Information System (INIS)

Hoy, H.C.

1984-01-01

The high- and medium-voltage electrical equipment failures of both nuclear and nonnuclear electric utilities have been reviewed for possible disruptive failure modes that would be of special concern in a nuclear power plant. The resulting emphasis was on the electrical faults of transformers, switchgear (circuit breakers), lightning (surge) arrestors, high-voltage cabling and buswork, control boards, and other electrical equipment that, through failure, can be the initiating event that may expand the original fault to nearby or associated equipment. Many failures of such equipment were found and documented, although the failure rate of electrical equipment in utilities is historically quite low. Nuclear plants record too few failures to be statistically valid, but failures that have been recorded show that good design usually restricts the failure to a single piece of equipment. Conclusions and recommendations pertaining to the design, maintenance, and operation of the affected electrical equipment are presented

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

Science.gov (United States)

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

2018-06-01

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

Matrix Failure Modes and Effects Analysis as a Knowledge Base for a Real Time Automated Diagnosis Expert System

Science.gov (United States)

Herrin, Stephanie; Iverson, David; Spukovska, Lilly; Souza, Kenneth A. (Technical Monitor)

1994-01-01

Failure Modes and Effects Analysis contain a wealth of information that can be used to create the knowledge base required for building automated diagnostic Expert systems. A real time monitoring and diagnosis expert system based on an actual NASA project's matrix failure modes and effects analysis was developed. This Expert system Was developed at NASA Ames Research Center. This system was first used as a case study to monitor the Research Animal Holding Facility (RAHF), a Space Shuttle payload that is used to house and monitor animals in orbit so the effects of space flight and microgravity can be studied. The techniques developed for the RAHF monitoring and diagnosis Expert system are general enough to be used for monitoring and diagnosis of a variety of other systems that undergo a Matrix FMEA. This automated diagnosis system was successfully used on-line and validated on the Space Shuttle flight STS-58, mission SLS-2 in October 1993.

MEMS Reliability: Infrastructure, Test Structures, Experiments, and Failure Modes

Energy Technology Data Exchange (ETDEWEB)

TANNER,DANELLE M.; SMITH,NORMAN F.; IRWIN,LLOYD W.; EATON,WILLIAM P.; HELGESEN,KAREN SUE; CLEMENT,J. JOSEPH; MILLER,WILLIAM M.; MILLER,SAMUEL L.; DUGGER,MICHAEL T.; WALRAVEN,JEREMY A.; PETERSON,KENNETH A.

2000-01-01

The burgeoning new technology of Micro-Electro-Mechanical Systems (MEMS) shows great promise in the weapons arena. We can now conceive of micro-gyros, micro-surety systems, and micro-navigators that are extremely small and inexpensive. Do we want to use this new technology in critical applications such as nuclear weapons? This question drove us to understand the reliability and failure mechanisms of silicon surface-micromachined MEMS. Development of a testing infrastructure was a crucial step to perform reliability experiments on MEMS devices and will be reported here. In addition, reliability test structures have been designed and characterized. Many experiments were performed to investigate failure modes and specifically those in different environments (humidity, temperature, shock, vibration, and storage). A predictive reliability model for wear of rubbing surfaces in microengines was developed. The root causes of failure for operating and non-operating MEMS are discussed. The major failure mechanism for operating MEMS was wear of the polysilicon rubbing surfaces. Reliability design rules for future MEMS devices are established.

The probability of containment failure by direct containment heating in Zion

International Nuclear Information System (INIS)

Pilch, M.M.; Yan, H.; Theofanous, T.G.

1994-12-01

This report is the first step in the resolution of the Direct Containment Heating (DCH) issue for the Zion Nuclear Power Plant using the Risk Oriented Accident Analysis Methodology (ROAAM). This report includes the definition of a probabilistic framework that decomposes the DCH problem into three probability density functions that reflect the most uncertain initial conditions (UO 2 mass, zirconium oxidation fraction, and steel mass). Uncertainties in the initial conditions are significant, but our quantification approach is based on establishing reasonable bounds that are not unnecessarily conservative. To this end, we also make use of the ROAAM ideas of enveloping scenarios and ''splintering.'' Two causal relations (CRs) are used in this framework: CR1 is a model that calculates the peak pressure in the containment as a function of the initial conditions, and CR2 is a model that returns the frequency of containment failure as a function of pressure within the containment. Uncertainty in CR1 is accounted for by the use of two independently developed phenomenological models, the Convection Limited Containment Heating (CLCH) model and the Two-Cell Equilibrium (TCE) model, and by probabilistically distributing the key parameter in both, which is the ratio of the melt entrainment time to the system blowdown time constant. The two phenomenological models have been compared with an extensive database including recent integral simulations at two different physical scales. The containment load distributions do not intersect the containment strength (fragility) curve in any significant way, resulting in containment failure probabilities less than 10 -3 for all scenarios considered. Sensitivity analyses did not show any areas of large sensitivity

Pressure Load Analysis during Severe Accidents for the Evaluation of Late Containment Failure in OPR-1000

Energy Technology Data Exchange (ETDEWEB)

Park, S. Y.; Ahn, K. I. [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2014-05-15

The MAAP code is a system level computer code capable of performing integral analyses of potential severe accident progressions in nuclear power plants, whose main purpose is to support a level 2 probabilistic safety assessment or severe accident management strategy developments. The code employs lots of user-options for supporting a sensitivity and uncertainty analysis. The present application is mainly focused on determining an estimate of the containment building pressure load caused by severe accident sequences. Key modeling parameters and phenomenological models employed for the present uncertainty analysis are closely related to in-vessel hydrogen generation, gas combustion in the containment, corium distribution in the containment after a reactor vessel failure, corium coolability in the reactor cavity, and molten-corium interaction with concrete. The phenomenology of severe accidents is extremely complex. In this paper, a sampling-based phenomenological uncertainty analysis was performed to statistically quantify uncertainties associated with the pressure load of a containment building for a late containment failure evaluation, based on the key modeling parameters employed in the MAAP code and random samples for those parameters. Phenomenological issues surrounding the late containment failure mode are highly complex. Included are the pressurization owing to steam generation in the cavity, molten corium-concrete interaction, late hydrogen burn in the containment, and the secondary heat removal availability. The methodology and calculation results can be applied for the optimum assessment of a late containment failure model. The accident sequences considered were a loss of coolant accidents and loss of offsite accidents expected in the OPR-1000 plant. As a result, uncertainties addressed in the pressure load of the containment building were quantified as a function of time. A realistic evaluation of the mean and variance estimates provides a more complete

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

Science.gov (United States)

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

2016-01-01

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

Quantification of human error and common-mode failures in man-machine systems

International Nuclear Information System (INIS)

Lisboa, J.J.

1988-01-01

Quantification of human performance, particularly the determination of human error, is essential for realistic assessment of overall system performance of man-machine systems. This paper presents an analysis of human errors in nuclear power plant systems when measured against common-mode failures (CMF). Human errors evaluated are improper testing, inadequate maintenance strategy, and miscalibration. The methodology presented in the paper represents a positive contribution to power plant systems availability by identifying sources of common-mode failure when operational functions are involved. It is also applicable to other complex systems such as chemical plants, aircraft and motor industries; in fact, any large man-created, man-machine system could be included

Microstructural Study of IF-WS2 Failure Modes

Directory of Open Access Journals (Sweden)

Jamie Cook

2014-07-01

Full Text Available This manuscript summarizes the failure mechanisms found in inorganic fullerene-type tungsten disulfide (IF-WS2 nanoparticles treated with diverse pressure loading methods. The approaches utilized to induce failure included: the use of an ultrasonic horn, the buildup of high pressures inside a shock tube which created a shock wave that propagated and impinged in the sample, and impact with military rounds. After treatment, samples were characterized using electron microscopy, powder X-ray diffraction, energy dispersive X-ray spectroscopy, and surface area analysis. The microstructural changes observed in the IF-WS2 particulates as a consequence of the treatments could be categorized in two distinct fracture modes. The most commonly observed was the formation of a crack at the particles surface followed by a phase transformation from the 3D cage-like structures into the 2D layered polymorphs, with subsequent agglomeration of the plate-like sheets to produce larger particle sizes. The secondary mechanism identified was the incipient delamination of IF-WS2. We encountered evidence that the IF-WS2 structure collapse initiated in all cases at the edges and vertices of the polyhedral particles, which acted as stress concentrators, independent of the load application mode or its duration.

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

Science.gov (United States)

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

2017-04-18

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

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

Energy Technology Data Exchange (ETDEWEB)

Schubert, L; Westerly, D; Vinogradskiy, Y; Fisher, C; Liu, A [University of Colorado Denver, Aurora, CO (United States); Aldridge, J [University of Colorado Hospital, Aurora, CO (United States)

2016-06-15

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

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

International Nuclear Information System (INIS)

Schubert, L; Westerly, D; Vinogradskiy, Y; Fisher, C; Liu, A; Aldridge, J

2016-01-01

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

The probability of containment failure by direct containment heating in zion

International Nuclear Information System (INIS)

Pilch, M.M.; Yan, H.; Theofanous, T.G.

1994-01-01

This report is the first step in the resolution of the Direct Containment Heating (DCH) issue for the Zion Nuclear Power Plant using the Risk Oriented Accident Analysis Methodology (ROAAM). This report includes the definition of a probabilistic framework that decomposes the DCH problem into three probability density functions that reflect the most uncertain initial conditions (UO 2 mass, zirconium oxidation fraction, and steel mass). Uncertainties in the initial conditions are significant, but the quantification approach is based on establishing reasonable bounds that are not unnecessarily conservative. To this end, the authors also make use of the ROAAM ideas of enveloping scenarios and open-quotes splinteringclose quotes. Two casual relations (CRs) are used in this framework: CR1 is a model that calculates the peak pressure in the containment as a function of the initial conditions, and CR2 is a model that returns the frequency of containment failure as a function of pressure within the containment. Uncertainty in CR1 is accounted for by the use of two independently developed phenomenological models, the Convection Limited Containment Heating (CLCH) model and the Two-Cell Equilibrium (TCE) model, and by probabilistically distributing the key parameter in both, which is the ratio of the melt entrainment time to the system blowdown time constant. The two phenomenological models have been compared with an extensive data base including recent integral simulations at two different physical scales (1/10th scale in the Surtsey facility at Sandia National Laboratories and 1/40th scale in the COREXIT facility at Argonne National Laboratory). The loads predicted by these models were significantly lower than those from previous parametric calculations. The containment load distributions do not intersect the containment strength curve in any significant way, resulting in containment failure probabilities less than 10 -3 for all scenarios considered

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

Science.gov (United States)

Mirzaei Rafsanjani, H.; Rezaei Nasab, A.

2012-05-01

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

Study of behavior on bonding and failure mode of pressurized and doped BWR fuel rod

International Nuclear Information System (INIS)

Yanagisawa, Kazuaki

1992-03-01

The study of transient behavior on the bonding and the failure mode was made using the pressurized/doped 8 x 8 BWR type fuel rod. The dopant was mullite minerals consisted mainly of silicon and aluminum up to 1.5 w/o. Pressurization of the fuel rod with pure helium was made to the magnitude about 0.6 MPa. As a reference, the non-pressurized/non-doped 8 x 8 BWR fuel rod and the pressurized/7 x 7 BWR fuel rod up to 0.6 MPa were prepared. Magnitude of energy deposition given to the tested fuel rods was 248, 253, and 269 cal/g·fuel, respectively. Obtained results from the pulse irradiation in NSRR are as follows. (1) It was found from the experiment that alternation of the fuel design by the adoption of pressurization up to 0.6 MPa and the use of wider gap up to 0.38 mm could avoid the dopant BWR fuel from the overall bonding. The failure mode of the present dopant fuel was revealed to be the melt combined with rupture. (2) The time of fuel failure of the pressurized/doped 8 x 8 BWR fuel defected by the melt/rupture mode is of order of two times shorter than that of the pressurized/ 7 x 7 BWR defected by the rupture mode. Failure threshold of the pressurized/doped 8 x 8 BWR BWR tended to be lower than that of non-pressurized/non-doped 8 x 8 BWR one. Cracked area of the pressurized/doped 8 x 8 BWR was more wider and magnitude of oxidation at the place is relatively larger than the other tested fuels. (3) Failure mode of the non-pressurized/ 8 x 8 BWR fuel rod was the melt/brittle accompanied with a significant bonding at failed location. While, failure mode of the pressurized/ 7 x 7 BWR fuel rod was the cladding rupture accompanied with a large ballooning. No bonding at failed location of the latter was observed. (author)

Risk management for outsourcing biomedical waste disposal – Using the failure mode and effects analysis

International Nuclear Information System (INIS)

Liao, Ching-Jong; Ho, Chao Chung

2014-01-01

Highlights: • This study is based on a real case in hospital in Taiwan. • We use Failure Mode and Effects Analysis (FMEA) as the evaluation method. • We successfully identify the evaluation factors of bio-medical waste disposal risk. - Abstract: Using the failure mode and effects analysis, this study examined biomedical waste companies through risk assessment. Moreover, it evaluated the supervisors of biomedical waste units in hospitals, and factors relating to the outsourcing risk assessment of biomedical waste in hospitals by referring to waste disposal acts. An expert questionnaire survey was conducted on the personnel involved in waste disposal units in hospitals, in order to identify important factors relating to the outsourcing risk of biomedical waste in hospitals. This study calculated the risk priority number (RPN) and selected items with an RPN value higher than 80 for improvement. These items included “availability of freezing devices”, “availability of containers for sharp items”, “disposal frequency”, “disposal volume”, “disposal method”, “vehicles meeting the regulations”, and “declaration of three lists”. This study also aimed to identify important selection factors of biomedical waste disposal companies by hospitals in terms of risk. These findings can serve as references for hospitals in the selection of outsourcing companies for biomedical waste disposal

Risk management for outsourcing biomedical waste disposal – Using the failure mode and effects analysis

Energy Technology Data Exchange (ETDEWEB)

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

2014-07-15

Highlights: • This study is based on a real case in hospital in Taiwan. • We use Failure Mode and Effects Analysis (FMEA) as the evaluation method. • We successfully identify the evaluation factors of bio-medical waste disposal risk. - Abstract: Using the failure mode and effects analysis, this study examined biomedical waste companies through risk assessment. Moreover, it evaluated the supervisors of biomedical waste units in hospitals, and factors relating to the outsourcing risk assessment of biomedical waste in hospitals by referring to waste disposal acts. An expert questionnaire survey was conducted on the personnel involved in waste disposal units in hospitals, in order to identify important factors relating to the outsourcing risk of biomedical waste in hospitals. This study calculated the risk priority number (RPN) and selected items with an RPN value higher than 80 for improvement. These items included “availability of freezing devices”, “availability of containers for sharp items”, “disposal frequency”, “disposal volume”, “disposal method”, “vehicles meeting the regulations”, and “declaration of three lists”. This study also aimed to identify important selection factors of biomedical waste disposal companies by hospitals in terms of risk. These findings can serve as references for hospitals in the selection of outsourcing companies for biomedical waste disposal.

Steel containment buckling

International Nuclear Information System (INIS)

Bennett, J.G.; Fly, G.W.; Baker, W.E.

1984-01-01

The Steel Containment Buckling program is in its fourth phase of work directed at the evaluation of the effects of the structural failure mode of steel containments when the membrane stresses are compressive. The structural failure mode for this state of stress is instability or buckling. The program to date has investigated: (1) the effect on overall buckling capacity of the ASME area replacement method for reinforcing around circular penetrations; (2) a set of benchmark experiments on ring-stiffened shells having reinforced and framed penetrations; (3) large and small scale experiments on knuckle region buckling from internal pressure and post-buckling behavior to failure for vessel heads having torispherical geometries; and (4) buckling under time-dependent loadings (dynamic buckling). The first two investigations are complete, the knuckle buckling experimental efforts are complete with data analysis and reporting in progress, and the dynamic buckling experimental and analytical work is in progress

Structural failure modes in vertical tanks: reinforcement evaluation and solutions

International Nuclear Information System (INIS)

Alcantud Abellan, M.; Orden Martinez, A.

1995-01-01

Vertical storage tanks are essential components in the safety of nuclear plant systems. It has been shown that the traditional method of analysing seismic loads is not conservative, as it does not take account of the interaction between fluid and tank structure. This paper identifies different possible structural failure modes in tanks due to seismic load, and methods devised by various authors to evaluate tank structure capacity under different failure modes. These methods are based on experimental data relating to the structural behaviour of tanks during actual seismic events, tests, and theoretical analyses. The paper describes the problems of these structures under seismic loads in nuclear plants. It proposes solutions to the main structural problem, tank anchorage, for which the re-evaluation of the anchorage capacity is required, using methods (finite element) less conservative than those proposed by other authors. Also proposed is the local reinforcement of anchorages to increase their capacity. (Author) 4 refs

Actions to reduce radioactive emissions: prevention of containment failure by flooding Containment and Reactor Cavity

International Nuclear Information System (INIS)

Fornos Herrando, J.

2013-01-01

The reactor cavity of Asco and Vandellos II is dry type, thus a severe accident leading to vessel failure might potentially end up resulting in the loss of containment integrity, depending on the viability to cool the molten core. Therefore, significant radioactive emissions could be released to outside. In the framework of Fukushima Stress Tests, ANAV has analyzed the convenience of carrying out different actions to prevent failure of the containment integrity in order to reduce radioactive emissions. The aim of this paper is to present and describe the main phenomenological aspects associated with two of these actions: containment flooding and reactor cavity flooding.

Behaviour of concrete nuclear containment structures upto ultimate failure with special reference to MAPP-1 containment

International Nuclear Information System (INIS)

Appa Rao, T.V.S.R.

1975-01-01

Theoretical and experimental methods for investigating the behaviour of concrete secondary containment structures subjected to loads upto their ultimate failure have been discussed in the paper. Need for inelastic nonlinear analysis of containments has been emphasized. Different contitutive models of concrete that can be employed in the nonlinear analysis of concrete structures were briefly reviewed. Based on the experimental results obtained in a 1:12 scale model test conducted at the Structural Engineering Research (Regional) Centre, Madras, behaviour of the MAPP-1 containment to internal pressure loading upto its ultimate failure has been discussed. (author)

Change of the mode of failure by interface friction and width-to-height ratio of coal specimens

Directory of Open Access Journals (Sweden)

Gamal Rashed

2015-06-01

Full Text Available Bumps in coal mines have been recognized as a major hazard for many years. These sudden and violent failures around mine openings have compromised safety, ventilation and access to mine workings. Previous studies showed that the violence of coal specimen failure depends on both the interface friction and width-to-height (W/H ratio of coal specimen. The mode of failure for a uniaxially loaded coal specimen or a coal pillar is a combination of both shear failure along the interface and compressive failure in the coal. The shear failure along the interface triggered the compressive failure in coal. The compressive failure of a coal specimen or a coal pillar can be controlled by changing its W/H ratio. As the W/H ratio increases, the ultimate strength increases. Hence, with a proper combination of interface friction and the W/H ratio of pillar or coal specimen, the mode of failure will change from sudden violent failure which is brittle failure to non-violent failure which is ductile failure. The main objective of this paper is to determine at what W/H ratio and interface friction the mode of failure changes from violent to non-violent. In this research, coal specimens of W/H ratio ranging from 1 to 10 were uniaxially tested under two interface frictions of 0.1 and 0.25, and the results are presented and discussed.

Application of Failure Mode Effect and Criticality Analysis (FMECA to a Computer Integrated Manufacturing (CIM Conveyor Belt

Directory of Open Access Journals (Sweden)

I. Elbadawi

2018-06-01

Full Text Available Fault finding and failure predicting techniques in manufacturing and production systems often involve forecasting failures, their effects, and occurrences. The majority of these techniques predict failures that may appear during the regular system production time. However, they do not estimate the failure modes and they require extensive source code instrumentation. In this study, we suggest an approach for predicting failure occurrences and modes during system production time intervals at the University of Hail (UoH. The aim of this project is to implement failure mode effect and criticality analysis (FMECA on computer integrated manufacturing (CIM conveyors to determine the effect of various failures on the CIM conveyor belt by ranking and prioritizing each failure according to its risk priority number (RPN. We incorporated the results of FMECA in the development of formal specifications of fail-safe CIM conveyor belt systems. The results show that the highest RPN values are for motor over current failure (450, conveyor chase of vibration (400, belt run off at the head pulley (200, accumulated dirt (180, and Bowed belt (150. The study concludes that performing FMECA is highly effective in improving CIM conveyor belt reliability and safety in the mechanical engineering workshop at UoH.

A multi-component and multi-failure mode inspection model based on the delay time concept

International Nuclear Information System (INIS)

Wang Wenbin; Banjevic, Dragan; Pecht, Michael

2010-01-01

The delay time concept and the techniques developed for modelling and optimising plant inspection practices have been reported in many papers and case studies. For a system comprised of many components and subject to many different failure modes, one of the most convenient ways to model the inspection and failure processes is to use a stochastic point process for defect arrivals and a common delay time distribution for the duration between defect the arrival and failure of all defects. This is an approximation, but has been proven to be valid when the number of components is large. However, for a system with just a few key components and subject to few major failure modes, the approximation may be poor. In this paper, a model is developed to address this situation, where each component and failure mode is modelled individually and then pooled together to form the system inspection model. Since inspections are usually scheduled for the whole system rather than individual components, we then formulate the inspection model when the time to the next inspection from the point of a component failure renewal is random. This imposes some complication to the model, and an asymptotic solution was found. Simulation algorithms have also been proposed as a comparison to the analytical results. A numerical example is presented to demonstrate the model.

Seismic failure modes and seismic safety of Hardfill dam

Directory of Open Access Journals (Sweden)

Kun Xiong

2013-04-01

Full Text Available Based on microscopic damage theory and the finite element method, and using the Weibull distribution to characterize the random distribution of the mechanical properties of materials, the seismic response of a typical Hardfill dam was analyzed through numerical simulation during the earthquakes with intensities of 8 degrees and even greater. The seismic failure modes and failure mechanism of the dam were explored as well. Numerical results show that the Hardfill dam remains at a low stress level and undamaged or slightly damaged during an earthquake with an intensity of 8 degrees. During overload earthquakes, tensile cracks occur at the dam surfaces and extend to inside the dam body, and the upstream dam body experiences more serious damage than the downstream dam body. Therefore, under the seismic conditions, the failure pattern of the Hardfill dam is the tensile fracture of the upstream regions and the dam toe. Compared with traditional gravity dams, Hardfill dams have better seismic performance and greater seismic safety.

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

Science.gov (United States)

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

2014-06-01

The aim of this study was to determine whether biomarkers of myocardial stress and fibrosis improve prediction of the mode of death in patients with chronic heart failure. The 2 most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of the mode of death may facilitate treatment decisions. The relationship between amino-terminal pro-brain natriuretic peptide (NT-proBNP), galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown. HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) was a randomized controlled trial of exercise training versus usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox proportional hazards modeling, and interaction testing was used to measure differential associations between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP. After a median follow-up period of 2.5 years, there were 155 deaths: 49 from pump failure, 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk for both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death, but this relationship was attenuated after adjustment for clinical risk factors. Clinical

Contained modes in mirrors with sheared rotation

International Nuclear Information System (INIS)

Fetterman, Abraham J.; Fisch, Nathaniel J.

2010-01-01

In mirrors with ExB rotation, a fixed azimuthal perturbation in the laboratory frame can appear as a wave in the rotating frame. If the rotation frequency varies with radius, the plasma-frame wave frequency will also vary radially due to the Doppler shift. A wave that propagates in the high rotation plasma region might therefore be evanescent at the plasma edge. This can lead to radially localized Alfven eigenmodes with high azimuthal mode numbers. Contained Alfven modes are found both for peaked and nonpeaked rotation profiles. These modes might be useful for alpha channeling or ion heating, as the high azimuthal wave number allows the plasma wave frequency in the rotating frame to exceed the ion cyclotron frequency.

Probabilistic evaluation of multiple failures for steam generators tubes by common mode

International Nuclear Information System (INIS)

Bloch, M.; Pierrey, J.L.; Dussarte, D.

1987-11-01

The reactor safety can be affected when systems or components are subject to phenomena conducting at a wear nontake in account in the conception. This paper presents a methodology which takes in account the non simultaneous failures resulting of this situation. To illustrate this purpose, we give an evaluation of risk of multiple failures for steam generators tubes by common mode (stress corrosion) when the reactor is in normal operation [fr

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

Directory of Open Access Journals (Sweden)

Magnezi R

2016-12-01

Full Text Available Racheli Magnezi,1 Asaf Hemi,1 Rina Hemi2 1Department of Management, Public Health and Health Systems Management Program, Bar Ilan University, Ramat Gan, 2Endocrine Service Unit, Sheba Medical Center, Tel Aviv, Israel Background: Risk management in health care systems applies to all hospital employees and directors as they deal with human life and emergency routines. There is a constant need to decrease risk and increase patient safety in the hospital environment. The purpose of this article is to review the laboratory testing procedures for parathyroid hormone and adrenocorticotropic hormone (which are characterized by short half-lives and to track failure modes and risks, and offer solutions to prevent them. During a routine quality improvement review at the Endocrine Laboratory in Tel Hashomer Hospital, we discovered these tests are frequently repeated unnecessarily due to multiple failures. The repetition of the tests inconveniences patients and leads to extra work for the laboratory and logistics personnel as well as the nurses and doctors who have to perform many tasks with limited resources.Methods: A team of eight staff members accompanied by the Head of the Endocrine Laboratory formed the team for analysis. The failure mode and effects analysis model (FMEA was used to analyze the laboratory testing procedure and was designed to simplify the process steps and indicate and rank possible failures.Results: A total of 23 failure modes were found within the process, 19 of which were ranked by level of severity. The FMEA model prioritizes failures by their risk priority number (RPN. For example, the most serious failure was the delay after the samples were collected from the department (RPN =226.1.Conclusion: This model helped us to visualize the process in a simple way. After analyzing the information, solutions were proposed to prevent failures, and a method to completely avoid the top four problems was also developed. Keywords: failure mode

The failure mode of natural silk epoxy triggered composite tubes

International Nuclear Information System (INIS)

Eshkour, R A; Ariffin, A K; Zulkifli, R; Sulong, A B; Azhari, C H

2012-01-01

In this study the quasi static compression test over natural silk epoxy triggered composite tubes has been carried out, the natural silk epoxy composite tubes consist of 24 layer of woven natural silk as reinforcement and thermoset epoxy resin as matrix which both of them i e natural silk and epoxy have excellent mechanical properties More over the natural silk have better moisture resistance in comparison with other natural reinforcements, the length of tubes are 50, 80 and 120 mm The natural silk epoxy composite tubes are associated with an external trigger which includes 4 steel pieces welded on downside flat plate fixture The hand lay up fabrication method has been used to make the natural silk epoxy composite tubes Instron universal testing machine with 250 KN load capacity has been employed to accomplish this investigation The failure modes of natural silk epoxy triggered composite tubes has been investigated by representative photographs which has been taken by a high resolution camera(12 2 Mp) during the quasi static compression test, from the photographs is observed the failure modes is progressive local buckling

Quantitative Approach to Failure Mode and Effect Analysis for Linear Accelerator Quality Assurance

Energy Technology Data Exchange (ETDEWEB)

O' Daniel, Jennifer C., E-mail: jennifer.odaniel@duke.edu; Yin, Fang-Fang

2017-05-01

Purpose: To determine clinic-specific linear accelerator quality assurance (QA) TG-142 test frequencies, to maximize physicist time efficiency and patient treatment quality. Methods and Materials: A novel quantitative approach to failure mode and effect analysis is proposed. Nine linear accelerator-years of QA records provided data on failure occurrence rates. The severity of test failure was modeled by introducing corresponding errors into head and neck intensity modulated radiation therapy treatment plans. The relative risk of daily linear accelerator QA was calculated as a function of frequency of test performance. Results: Although the failure severity was greatest for daily imaging QA (imaging vs treatment isocenter and imaging positioning/repositioning), the failure occurrence rate was greatest for output and laser testing. The composite ranking results suggest that performing output and lasers tests daily, imaging versus treatment isocenter and imaging positioning/repositioning tests weekly, and optical distance indicator and jaws versus light field tests biweekly would be acceptable for non-stereotactic radiosurgery/stereotactic body radiation therapy linear accelerators. Conclusions: Failure mode and effect analysis is a useful tool to determine the relative importance of QA tests from TG-142. Because there are practical time limitations on how many QA tests can be performed, this analysis highlights which tests are the most important and suggests the frequency of testing based on each test's risk priority number.

Quantitative Approach to Failure Mode and Effect Analysis for Linear Accelerator Quality Assurance.

Science.gov (United States)

O'Daniel, Jennifer C; Yin, Fang-Fang

2017-05-01

To determine clinic-specific linear accelerator quality assurance (QA) TG-142 test frequencies, to maximize physicist time efficiency and patient treatment quality. A novel quantitative approach to failure mode and effect analysis is proposed. Nine linear accelerator-years of QA records provided data on failure occurrence rates. The severity of test failure was modeled by introducing corresponding errors into head and neck intensity modulated radiation therapy treatment plans. The relative risk of daily linear accelerator QA was calculated as a function of frequency of test performance. Although the failure severity was greatest for daily imaging QA (imaging vs treatment isocenter and imaging positioning/repositioning), the failure occurrence rate was greatest for output and laser testing. The composite ranking results suggest that performing output and lasers tests daily, imaging versus treatment isocenter and imaging positioning/repositioning tests weekly, and optical distance indicator and jaws versus light field tests biweekly would be acceptable for non-stereotactic radiosurgery/stereotactic body radiation therapy linear accelerators. Failure mode and effect analysis is a useful tool to determine the relative importance of QA tests from TG-142. Because there are practical time limitations on how many QA tests can be performed, this analysis highlights which tests are the most important and suggests the frequency of testing based on each test's risk priority number. Copyright © 2017 Elsevier Inc. All rights reserved.

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

International Nuclear Information System (INIS)

Younge, K C; Lee, C I; Feng, M; Novelli, P; Moran, J M; Prisciandaro, J I

2015-01-01

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

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

Energy Technology Data Exchange (ETDEWEB)

Younge, K C; Lee, C I; Feng, M; Novelli, P; Moran, J M; Prisciandaro, J I [Univ Michigan Medical Center, Ann Arbor, MI (United States)

2015-06-15

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

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

Science.gov (United States)

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

2013-09-06

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

Failure mode and effects analysis based risk profile assessment for stereotactic radiosurgery programs at three cancer centers in Brazil

Energy Technology Data Exchange (ETDEWEB)

Teixeira, Flavia C., E-mail: flavitiz@gmail.com [CNEN—Comissao Nacional de Energia Nuclear, Rio de Janeiro, RJ 22290-901, Brazil and LCR/UERJ—Laboratorio de Ciencias Radiologicas/Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ 20550-013 (Brazil); Almeida, Carlos E. de [LCR/UERJ—Laboratorio de Ciencias Radiologicas/Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ 20550-013 (Brazil); Saiful Huq, M. [Department of Radiation Oncology, University of Pittsburgh Cancer Institute and UPMC Cancer Center, Pittsburgh, Pennsylvania 15232 (United States)

2016-01-15

Purpose: The goal of this study was to evaluate the safety and quality management program for stereotactic radiosurgery (SRS) treatment processes at three radiotherapy centers in Brazil by using three industrial engineering tools (1) process mapping, (2) failure modes and effects analysis (FMEA), and (3) fault tree analysis. Methods: The recommendations of Task Group 100 of American Association of Physicists in Medicine were followed to apply the three tools described above to create a process tree for SRS procedure for each radiotherapy center and then FMEA was performed. Failure modes were identified for all process steps and values of risk priority number (RPN) were calculated from O, S, and D (RPN = O × S × D) values assigned by a professional team responsible for patient care. Results: The subprocess treatment planning was presented with the highest number of failure modes for all centers. The total number of failure modes were 135, 104, and 131 for centers I, II, and III, respectively. The highest RPN value for each center is as follows: center I (204), center II (372), and center III (370). Failure modes with RPN ≥ 100: center I (22), center II (115), and center III (110). Failure modes characterized by S ≥ 7, represented 68% of the failure modes for center III, 62% for center II, and 45% for center I. Failure modes with RPNs values ≥100 and S ≥ 7, D ≥ 5, and O ≥ 5 were considered as high priority in this study. Conclusions: The results of the present study show that the safety risk profiles for the same stereotactic radiotherapy process are different at three radiotherapy centers in Brazil. Although this is the same treatment process, this present study showed that the risk priority is different and it will lead to implementation of different safety interventions among the centers. Therefore, the current practice of applying universal device-centric QA is not adequate to address all possible failures in clinical processes at different

Failure mode and effects analysis based risk profile assessment for stereotactic radiosurgery programs at three cancer centers in Brazil

International Nuclear Information System (INIS)

Teixeira, Flavia C.; Almeida, Carlos E. de; Saiful Huq, M.

2016-01-01

Purpose: The goal of this study was to evaluate the safety and quality management program for stereotactic radiosurgery (SRS) treatment processes at three radiotherapy centers in Brazil by using three industrial engineering tools (1) process mapping, (2) failure modes and effects analysis (FMEA), and (3) fault tree analysis. Methods: The recommendations of Task Group 100 of American Association of Physicists in Medicine were followed to apply the three tools described above to create a process tree for SRS procedure for each radiotherapy center and then FMEA was performed. Failure modes were identified for all process steps and values of risk priority number (RPN) were calculated from O, S, and D (RPN = O × S × D) values assigned by a professional team responsible for patient care. Results: The subprocess treatment planning was presented with the highest number of failure modes for all centers. The total number of failure modes were 135, 104, and 131 for centers I, II, and III, respectively. The highest RPN value for each center is as follows: center I (204), center II (372), and center III (370). Failure modes with RPN ≥ 100: center I (22), center II (115), and center III (110). Failure modes characterized by S ≥ 7, represented 68% of the failure modes for center III, 62% for center II, and 45% for center I. Failure modes with RPNs values ≥100 and S ≥ 7, D ≥ 5, and O ≥ 5 were considered as high priority in this study. Conclusions: The results of the present study show that the safety risk profiles for the same stereotactic radiotherapy process are different at three radiotherapy centers in Brazil. Although this is the same treatment process, this present study showed that the risk priority is different and it will lead to implementation of different safety interventions among the centers. Therefore, the current practice of applying universal device-centric QA is not adequate to address all possible failures in clinical processes at different

No significant fuel failures (NSFF)

International Nuclear Information System (INIS)

Domaratzki, Z.

1979-01-01

It has long been recognized that no emergency core cooling system (ECCS) could be absolutely guaranteed to prevent fuel failures. In 1976 the Atomic Energy Control Board decided that the objective for an ECCS should be to prevent fuel failures, but if the objective could not be met it should be shown that the consequences are acceptable for dual failures comprising any LOCA combined with an assumed impairment of containment. Out of the review of the Bruce A plant came the definition of 'no significant fuel failures': for any postulated LOCA combined with any one mode of containment impairment the resultant dose to a person at the edge of the exclusion zone is less than the reference dose limits for dual failures

Predicting the Lifetimes of Nuclear Waste Containers

Science.gov (United States)

King, Fraser

2014-03-01

As for many aspects of the disposal of nuclear waste, the greatest challenge we have in the study of container materials is the prediction of the long-term performance over periods of tens to hundreds of thousands of years. Various methods have been used for predicting the lifetime of containers for the disposal of high-level waste or spent fuel in deep geological repositories. Both mechanical and corrosion-related failure mechanisms need to be considered, although until recently the interactions of mechanical and corrosion degradation modes have not been considered in detail. Failure from mechanical degradation modes has tended to be treated through suitable container design. In comparison, the inevitable loss of container integrity due to corrosion has been treated by developing specific corrosion models. The most important aspect, however, is to be able to justify the long-term predictions by demonstrating a mechanistic understanding of the various degradation modes.

Evaluation of crack growth behavior and probabilistic S–N characteristics of carburized Cr–Mn–Si steel with multiple failure modes

International Nuclear Information System (INIS)

Li, Wei; Sun, Zhenduo; Zhang, Zhenyu; Deng, Hailong; Sakai, Tatsuo

2014-01-01

Highlights: • The stepwise S–N characteristics only for interior induced failure was observed. • The interior crack growth behavior with threshold conditions in different stages was clarified. • The distribution characteristics of test data in transition failure region was evaluated. • A model for evaluating the probabilistic S–N curve with multiple failure modes was developed. - Abstract: The unexpected failures of case-hardened steels in long life regime have been a critical issue in modern engineering design. In this study, the failure behavior of a carburized Cr–Mn–Si steel under very high cycle fatigue (VHCF) was investigated, and a model for evaluating the probabilistic S–N curve associated with multiple failure modes was developed. Results show that the carburized Cr–Mn–Si steel exhibits three failure modes including the surface flaw-induced failure, the interior inclusion-induced failure without the fine granular area (FGA) and the interior inclusion-induced failure with the FGA. As the predominant failure mode in the VHCF regime, the interior failure process can be divided into four stages: (i) the small crack growth around the inclusion, (ii) the stable macroscopic crack growth outside the FGA, (iii) the unstable crack growth outside the fish-eye and (iv) the momentary fracture outside the final crack growth zone. The threshold values are successively evaluated to be 2.33 MPa m 1/2 , 4.13 MPa m 1/2 , 18.51 MPa m 1/2 and 29.26 MPa m 1/2 . The distribution characteristics of the test data in transition failure region can be well characterized by the mixed two-parameter Weibull distribution function. The developed probabilistic S–N curve model is in good agreement with the test data with multiple failure modes. Although the result is somewhat conservative in the VHCF regime, it is acceptable for safety considerations

Contained Modes In Mirrors With Sheared Rotation

International Nuclear Information System (INIS)

Fetterman, Abraham J.; Fisch, Nathaniel J.

2010-01-01

In mirrors with E x B rotation, a fixed azimuthal perturbation in the lab frame can appear as a wave in the rotating frame. If the rotation frequency varies with radius, the plasma-frame wave frequency will also vary radially due to the Doppler shift. A wave that propagates in the high rotation plasma region might therefore be evanescent at the plasma edge. This can lead to radially localized Alfven eigenmodes with high azimuthal mode numbers. Contained Alfven modes are found both for peaked and non-peaked rotation profiles. These modes might be useful for alpha channeling or ion heating, as the high azimuthal wave number allows the plasma wave frequency in the rotating frame to exceed the ion cyclotron frequency.

Contained Modes In Mirrors With Sheared Rotation

Energy Technology Data Exchange (ETDEWEB)

Abraham J. Fetterman and Nathaniel J. Fisch

2010-10-08

In mirrors with E × B rotation, a fixed azimuthal perturbation in the lab frame can appear as a wave in the rotating frame. If the rotation frequency varies with radius, the plasma-frame wave frequency will also vary radially due to the Doppler shift. A wave that propagates in the high rotation plasma region might therefore be evanescent at the plasma edge. This can lead to radially localized Alfven eigenmodes with high azimuthal mode numbers. Contained Alfven modes are found both for peaked and non-peaked rotation profiles. These modes might be useful for alpha channeling or ion heating, as the high azimuthal wave number allows the plasma wave frequency in the rotating frame to exceed the ion cyclotron frequency. __________________________________________________

Tensile and compressive failure modes of laminated composites loaded by fatigue with different mean stress

Science.gov (United States)

Rotem, Assa

1990-01-01

Laminated composite materials tend to fail differently under tensile or compressive load. Under tension, the material accumulates cracks and fiber fractures, while under compression, the material delaminates and buckles. Tensile-compressive fatigue may cause either of these failure modes depending on the specific damage occurring in the laminate. This damage depends on the stress ratio of the fatigue loading. Analysis of the fatigue behavior of the composite laminate under tension-tension, compression-compression, and tension-compression had led to the development of a fatigue envelope presentation of the failure behavior. This envelope indicates the specific failure mode for any stress ratio and number of loading cycles. The construction of the fatigue envelope is based on the applied stress-cycles to failure (S-N) curves of both tensile-tensile and compressive-compressive fatigue. Test results are presented to verify the theoretical analysis.

SU-E-T-421: Failure Mode and Effects Analysis (FMEA) of Xoft Electronic Brachytherapy for the Treatment of Superficial Skin Cancers

International Nuclear Information System (INIS)

Hoisak, J; Manger, R; Dragojevic, I

2015-01-01

Purpose: To perform a failure mode and effects analysis (FMEA) of the process for treating superficial skin cancers with the Xoft Axxent electronic brachytherapy (eBx) system, given the recent introduction of expanded quality control (QC) initiatives at our institution. Methods: A process map was developed listing all steps in superficial treatments with Xoft eBx, from the initial patient consult to the completion of the treatment course. The process map guided the FMEA to identify the failure modes for each step in the treatment workflow and assign Risk Priority Numbers (RPN), calculated as the product of the failure mode’s probability of occurrence (O), severity (S) and lack of detectability (D). FMEA was done with and without the inclusion of recent QC initiatives such as increased staffing, physics oversight, standardized source calibration, treatment planning and documentation. The failure modes with the highest RPNs were identified and contrasted before and after introduction of the QC initiatives. Results: Based on the FMEA, the failure modes with the highest RPN were related to source calibration, treatment planning, and patient setup/treatment delivery (Fig. 1). The introduction of additional physics oversight, standardized planning and safety initiatives such as checklists and time-outs reduced the RPNs of these failure modes. High-risk failure modes that could be mitigated with improved hardware and software interlocks were identified. Conclusion: The FMEA analysis identified the steps in the treatment process presenting the highest risk. The introduction of enhanced QC initiatives mitigated the risk of some of these failure modes by decreasing their probability of occurrence and increasing their detectability. This analysis demonstrates the importance of well-designed QC policies, procedures and oversight in a Xoft eBx programme for treatment of superficial skin cancers. Unresolved high risk failure modes highlight the need for non-procedural quality

Extending Failure Modes and Effects Analysis Approach for Reliability Analysis at the Software Architecture Design Level

NARCIS (Netherlands)

Sözer, Hasan; Tekinerdogan, B.; Aksit, Mehmet; de Lemos, Rogerio; Gacek, Cristina

2007-01-01

Several reliability engineering approaches have been proposed to identify and recover from failures. A well-known and mature approach is the Failure Mode and Effect Analysis (FMEA) method that is usually utilized together with Fault Tree Analysis (FTA) to analyze and diagnose the causes of failures.

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

Energy Technology Data Exchange (ETDEWEB)

Howe, J [Associates In Medical Physics, Louisville, KY (United States)

2015-06-15

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

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

International Nuclear Information System (INIS)

Howe, J

2015-01-01

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

Comparison of Failure Modes in 2-D and 3-D Woven Carbon Phenolic Systems

Science.gov (United States)

Rossman, Grant A.; Stackpoole, Mairead; Feldman, Jay; Venkatapathy, Ethiraj; Braun, Robert D.

2013-01-01

NASA Ames Research Center is developing Woven Thermal Protection System (WTPS) materials as a new class of heatshields for entry vehicles (Stackpoole). Currently, there are few options for ablative entry heatshield materials, none of which is ideally suited to the planetary probe missions currently of interest to NASA. While carbon phenolic was successfully used for the missions Pioneer Venus and Galileo (to Jupiter), the heritage constituents are no longer available. An alternate carbon phenolic would need to be qualified for probe missions, which is most efficient at heat fluxes greater than those currently of interest. Additional TPS materials such as Avcoat and PICA are not sufficiently robust for the heat fluxes required. As a result, there is a large TPS gap between the materials efficient at very high conditions (carbon phenolic) and those that are effective at low-moderate conditions (all others). Development of 3D Woven TPS is intended to fill this gap, targeting mid-density weaves that could with withstand mid-range heat fluxes between 1100 W/sq cm and 8000 W/sq cm (Venkatapathy (2012). Preliminary experimental studies have been performed to show the feasibility of WTPS as a future mid-range TPS material. One study performed in the mARC Jet Facility at NASA Ames Research Center characterized the performance of a 3D Woven TPS sample and compared it to 2D carbon phenolic samples at ply angles of 0deg, 23.5deg, and 90deg. Each sample contained similar compositions of phenolic and carbon fiber volume fractions for experimental consistency. The goal of this study was to compare the performance of the TPS materials by evaluating resulting recession and failure modes. After exposing both samples to similar heat flux and pressure conditions, the 2D carbon phenolic laminate was shown to experience significant delamination between layers and further pocketing underneath separated layers. The 3D Woven TPS sample did not experience the delamination or pocketing

Potential failure mode and effects analysis for the ITER NB injector

International Nuclear Information System (INIS)

Boldrin, M.; De Lorenzi, A.; Fiorentin, A.; Grando, L.; Marcuzzi, D.; Peruzzo, S.; Pomaro, N.; Rigato, W.; Serianni, G.

2009-01-01

The failure mode and effects analysis (FMEA) is a widely used analytical technique that helps in identifying and reducing the risks of failure in a system, component or process. The application of a systematic method like the FMEA was deemed necessary and adequate to support the design process of the ITER NBI (neutral beam injector). The approach adopted was to develop a FMEA at a general 'system level', focusing the study on the main functions of the system and ensuring that all the interfaces and interactions are covered among the various subsystems. The FMEA was extended to the whole NBI system taking into account the present design status. The FMEA procedure will be then applied to the detailed design phase at the component level, in particular to identify (or define) the ITER Class of Risk. Several important failure modes were evidenced, and estimates of subsystems and components reliability are now available. FMEA procedure resulted essential to identify and confirm the diagnostic systems required for protection and control, and the outcome of this analysis will represent the baseline document for the design of the NBI and NBTF integrated protection system. In the paper, rationale and background of the FMEA for ITER NBI are presented, methods employed are described and most interesting results are reported and discussed.

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

International Nuclear Information System (INIS)

Ciocca, Mario; Cantone, Marie-Claire; Veronese, Ivan; Cattani, Federica; Pedroli, Guido; Molinelli, Silvia; Vitolo, Viviana; Orecchia, Roberto

2012-01-01

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

Robust adaptive multivariable higher-order sliding mode flight control for air-breathing hypersonic vehicle with actuator failures

Directory of Open Access Journals (Sweden)

Peng Li

2016-10-01

Full Text Available This article proposes an adaptive multivariable higher-order sliding mode control for the longitudinal model of an air-breathing vehicle under system uncertainties and actuator failures. Firstly, a fast finite-time control law is designed for a chain of integrators. Secondly, based on the input/output feedback linearization technique, the system uncertainty and external disturbances are modeled as additive certainty and the actuator failures are modeled as multiplicative uncertainty. By using the proposed fast finite-time control law, a robust multivariable higher-order sliding mode control is designed for the air-breathing hypersonic vehicle with actuator failures. Finally, adaptive laws are proposed for the adaptation of the parameters in the robust multivariable higher-order sliding mode control. Thus, the bounds of the uncertainties are not needed in the control system design. Simulation results show the effectiveness of the proposed robust adaptive multivariable higher-order sliding mode control.

Concepts for measuring maintenance performance and methods for analysing competing failure modes

DEFF Research Database (Denmark)

Cooke, R.; Paulsen, J.L.

1997-01-01

competing failure modes. This article examines ways to assess maintenance performance without introducing statistical assumptions, then introduces a plausible statistical model for describing the interaction of preventive and corrective maintenance, and finally illustrates these with examples from...

Long-term lumen depreciation behavior and failure modes of multi-die array LEDs

Science.gov (United States)

Jayawardena, Asiri; Marcus, Daniel; Prugue, Ximena; Narendran, Nadarajah

2013-09-01

One of the main advantages of multi-die array light-emitting diodes (LEDs) is their high flux density. However, a challenge for using such a product in lighting fixture applications is the heat density and the need for thermal management to keep the junction temperatures of all the dies low for long-term reliable performance. Ten multi-die LED array samples for each product from four different manufacturers were subjected to lumen maintenance testing (as described in IES-LM-80-08), and their resulting lumen depreciation and failure modes were studied. The products were tested at the maximum case (or pin) temperature reported by the respective manufacturer by appropriately powering the LEDs. In addition, three samples for each product from two different manufacturers were subjected to rapid thermal cycling, and the resulting lumen depreciation and failure modes were studied. The results showed that the exponential lumen decay model using long-term lumen maintenance data as recommended in IES TM-21 does not fit for all package types. The failure of a string of dies and single die failure in a string were observed in some of the packages.

Using failure mode and effect analysis in identification of components sensitive to ageing

International Nuclear Information System (INIS)

Nitoi, Mirela; Turcu, Ilie; Apostol, Minodora; Farcasiu, Mita; Popa, Adrian; Florescu, Gheorghe; Pavelescu, Margarit

2008-01-01

Ageing represents a phenomenon of concern since any degradation that may occur in time could lower a component performance and so reduce its reliability. If the phenomenon is left unchecked and unmitigated, the ageing could increase the risk associated with the facility operation. To understand the ageing degradation of a component, it is first necessary to identify and understand the ageing processes. Since these processes involve constituent materials, parts and the service conditions of components, it is necessary to know the design, materials, service conditions, performance requirements, operating experience (operation, surveillance and maintenance histories) and relevant research results for the component of interest. The purpose of the Ageing Failure Mode and Effect Analysis (AFMEA) is to study the results or effects of item failure caused by ageing, on system operation and to classify each potential failure according to its severity The paper will present the advantages of using AFMEA in identification of most sensitive to ageing components, as the results obtained for a particular case. For each component analyzed, the stressors will be established, the corresponding ageing mechanisms will be identified, as the failure modes induced by the ageing mechanisms. (authors)

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

Science.gov (United States)

Jain, Khushboo

2017-03-13

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

Failure Mode and Effect Analysis for remote handling transfer systems of ITER

International Nuclear Information System (INIS)

Pinna, T.; Caporali, R.; Tesini, A.

2008-01-01

A Failure Mode and Effect Analysis (FMEA) at component level was done to study safety-relevant implications arising from possible failures in performing remote handling (RH) operations at ITER facility . Autonomous air cushion transporter, pallet, sealed casks and tractor movers needed for port plug mounting/dismantling operation were analysed. For each sub-system, the breakdown of significant components was outlined and, for each component, possible failure modes have been investigated pointing out possible causes, possible actions to prevent the causes, consequences and actions to prevent or mitigate consequences. Off-normal events which may result in hazardous consequences to the public and the environment have been defined as Postulated Initiating Events (PIEs). Two safety-relevant PIEs have been defined by assessing elementary failures related to the analysed system. Each PIE has been discussed in order to qualitatively identify accident sequences arising from each of them. As an output of this FMEA study, possible incidental scenarios, where the intervention of rescue RH equipments is required to overcome critical situations determined by fault of RH components, were defined as well. Being rescue scenarios of main concern for ITER remote handling activities, such families could be helpful in defining the design requirements of port handling systems in general and on RH transfer system in particular. Furthermore, they could be useful in defining casks and vehicles to be used for rescue activities

Experimental study on the EMP failure mode of DC solid state relay

International Nuclear Information System (INIS)

Sun Beiyun; Chen Xiangyue; Zhai Aibin; Mao Congguang

2009-01-01

DC solid state relay is a new type switch device without touch point, and is extensive used by aviation and spaceflight technique. In this paper, the EMP failure modes of solid state relays were obtained by current injection method. (authors)

A novel approach for evaluating the risk of health care failure modes.

Science.gov (United States)

Chang, Dong Shang; Chung, Jenq Hann; Sun, Kuo Lung; Yang, Fu Chiang

2012-12-01

Failure mode and effects analysis (FMEA) can be employed to reduce medical errors by identifying the risk ranking of the health care failure modes and taking priority action for safety improvement. The purpose of this paper is to propose a novel approach of data analysis. The approach is to integrate FMEA and a mathematical tool-Data envelopment analysis (DEA) with "slack-based measure" (SBM), in the field of data analysis. The risk indexes (severity, occurrence, and detection) of FMEA are viewed as multiple inputs of DEA. The practicality and usefulness of the proposed approach is illustrated by one case of health care. Being a systematic approach for improving the service quality of health care, the approach can offer quantitative corrective information of risk indexes that thereafter reduce failure possibility. For safety improvement, these new targets of the risk indexes could be used for management by objectives. But FMEA cannot provide quantitative corrective information of risk indexes. The novel approach can surely overcome this chief shortcoming of FMEA. After combining DEA SBM model with FMEA, the two goals-increase of patient safety, medical cost reduction-can be together achieved.

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

Science.gov (United States)

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

2017-11-10

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

Analysis on the effect of risk from containment failure by over-pressurization during the operation of containment filtered venting system

International Nuclear Information System (INIS)

Ham, Jaehyun; Kang, Hyun Gook; Chang, Soon Heung

2015-01-01

Passive safety systems which are operated without power source are suggested as a solution SBO. For containment protection system, Containment Filtered Venting System (CFVS) is suggested. CFVS controls the containment pressure by releasing the containment gas through filter passively without any power source. But because still small amount of radioactive material have no choice but to release to the environment, starting time and operation method of CFVS have to be determined carefully. Later starting time brings not only lower release but also higher risk from containment failure by over-pressurization, so it is a problem. In this research, the effect of risk from containment failure by over-pressurization during the operation of containment filtered venting system was analyzed. In this research, optimized values for variables of the CFVS operation method are found as 0.67 MPa, 9 cm, 0.1 MPa each for open pressure, pressure interval, and vent pipe diameter when DF as a function of time and risk from containment over-pressurization failure are considered. Generally in this research, release without risk get lower values in higher pressure, and lower vent pipe diameter. Release with risk get sharply high values when the containment pressure exceeds the design pressure because of the effect of risk from containment failure by over-pressurization. In conclusion, highest pressure, and lowest vent pipe diameter which are not influenced by risk is the optimized values for CFVS operation method because amount of risk is much larger than release through the CFVS

Review on experiments relating to primary containment vessel failure

International Nuclear Information System (INIS)

Suzuki, Hiroyuki; Okada, Hidetoshi; Uchida, Sunsuke; Naitoh, Masanori

2015-01-01

Experiments regarding failures of primary containment vessels (PCVs) are reviewed and remained issues to be investigated in the future are discussed. Experiments are categorized as those relating to criteria of PCV failures and to FP releases through breaches on PCV boundaries. In the experiments categorized as those relating to criteria of PCV failures, experiments with full-scale, scale models, and compounds used for sealing are surveyed. Experiments relating to an amount of radioactive fission products (FPs) trapped at breaches on PCV boundaries are also reviewed. As remained issues to be investigated in the future, two items are pointed out: Evaluating degradation behavior of PCV boundaries exposed to temperature and pressure from the failure onset criteria to far above them, and evaluating an amount of FPs trapped at breaches on PCV boundaries. (author)

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

Energy Technology Data Exchange (ETDEWEB)

Zheng, Yuanshui, E-mail: yuanshui.zheng@okc.procure.com [ProCure Proton Therapy Center, 5901 W Memorial Road, Oklahoma City, Oklahoma 73142 and Department of Physics, Oklahoma State University, Stillwater, Oklahoma 74078-3072 (United States); Johnson, Randall; Larson, Gary [ProCure Proton Therapy Center, 5901 W Memorial Road, Oklahoma City, Oklahoma 73142 (United States)

2016-06-15

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

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

International Nuclear Information System (INIS)

Zheng, Yuanshui; Johnson, Randall; Larson, Gary

2016-01-01

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

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

Directory of Open Access Journals (Sweden)

Qing Ye

2015-01-01

Full Text Available This research proposes a novel framework of final drive simultaneous failure diagnosis containing feature extraction, training paired diagnostic models, generating decision threshold, and recognizing simultaneous failure modes. In feature extraction module, adopt wavelet package transform and fuzzy entropy to reduce noise interference and extract representative features of failure mode. Use single failure sample to construct probability classifiers based on paired sparse Bayesian extreme learning machine which is trained only by single failure modes and have high generalization and sparsity of sparse Bayesian learning approach. To generate optimal decision threshold which can convert probability output obtained from classifiers into final simultaneous failure modes, this research proposes using samples containing both single and simultaneous failure modes and Grid search method which is superior to traditional techniques in global optimization. Compared with other frequently used diagnostic approaches based on support vector machine and probability neural networks, experiment results based on F1-measure value verify that the diagnostic accuracy and efficiency of the proposed framework which are crucial for simultaneous failure diagnosis are superior to the existing approach.

Recent Advances In Structural Vibration And Failure Mode Control In Mainland China: Theory, Experiments And Applications

International Nuclear Information System (INIS)

Li Hui; Ou Jinping

2008-01-01

A number of researchers have been focused on structural vibration control in the past three decades over the world and fruit achievements have been made. This paper introduces the recent advances in structural vibration control including passive, active and semiactive control in mainland China. Additionally, the co-author extends the structural vibration control to failure mode control. The research on the failure mode control is also involved in this paper. For passive control, this paper introduces full scale tests of buckling-restrained braces conducted to investigate the performance of the dampers and the second-editor of the Code of Seismic Design for Buildings. For active control, this paper introduces the HMD system for wind-induced vibration control of the Guangzhou TV tower. For semiactive control, the smart damping devices, algorithms for semi-active control, design methods and applications of semi-active control for structures are introduced in this paper. The failure mode control for bridges is also introduced

Analytical criteria for fuel failure modes observed in reactivity initiated accidents

International Nuclear Information System (INIS)

Luxat, J.C.

2005-01-01

The behaviour of nuclear fuel subjected to a short duration power pulse is of relevance to LWR and CANDU reactor safety. A Reactivity Initiated Accident (RIA) in an LWR would subject fuel to a short duration power pulse of large amplitude, whereas in CANDU a large break Loss of Coolant Accident (LOCA) would subject fuel to a longer duration, lower amplitude power excursion. The energy generated in the fuel during the power pulse is a key parameter governing the fuel response. This paper reviews the various power pulse tests that have been conducted in research reactors over the past three decades and summarizes the fuel failure modes that that have been observed in these tests. A simple analytical model is developed to characterize fuel behaviour under power pulse conditions and the model is applied to assess the experimental data from the power pulse tests. It is shown that the simple model provides a good basis for establishing criteria that demarcate the observed fuel failure modes for the various fuel designs that have been used in these tests. (author)

The probability of containment failure by direct containment heating in Zion. Supplement 1

International Nuclear Information System (INIS)

Pilch, M.M.; Allen, M.D.; Stamps, D.W.; Tadios, E.L.; Knudson, D.L.

1994-12-01

Supplement 1 of NUREG/CR-6075 brings to closure the DCH issue for the Zion plant. It includes the documentation of the peer review process for NUREG/CR-6075, the assessments of four new splinter scenarios defined in working group meetings, and modeling enhancements recommended by the working groups. In the four new scenarios, consistency of the initial conditions has been implemented by using insights from systems-level codes. SCDAP/RELAP5 was used to analyze three short-term station blackout cases with Different lead rates. In all three case, the hot leg or surge line failed well before the lower head and thus the primary system depressurized to a point where DCH was no longer considered a threat. However, these calculations were continued to lower head failure in order to gain insights that were useful in establishing the initial and boundary conditions. The most useful insights are that the RCS pressure is-low at vessel breach metallic blockages in the core region do not melt and relocate into the lower plenum, and melting of upper plenum steel is correlated with hot leg failure. THE SCDAP/RELAP output was used as input to CONTAIN to assess the containment conditions at vessel breach. The containment-side conditions predicted by CONTAIN are similar to those originally specified in NUREG/CR-6075

Review of constitutive models and failure criteria for concrete

Energy Technology Data Exchange (ETDEWEB)

Seo, Jeong Moon; Choun, Young Sun [Korea Atomic Energy Research Institute, Taejeon (Korea)

2000-03-01

The general behavior, constitutive models, and failure criteria of concrete are reviewed. The current constitutive models for concrete cannot satisfy all of mechanical behavior of concrete. Among several constitutive models, damage models are recommended to describe properly the structural behavior of concrete containment buildings, because failure modes and post-failure behavior are important in containment buildings. A constitutive model which can describe the concrete behavior in tension is required because the containment buildings will reach failure state due to ultimate internal pressure. Therefore, a thorough study on the behavior and models under tension stress state in concrete and reinforced concrete has to be performed. There are two types of failure criteria in containment buildings: structural failure criteria and leakage failure criteria. For reinforced or prestressed concrete containment buildings, concrete cracking does not mean the structural failure of containment building because the reinforcement or post-tensioning system is able to resist tensile stress up to yield stress. Therefore leakage failure criteria will be prior to structural failure criteria, and a strain failure criterion for concrete has to be established. 120 refs., 59 figs., 1 tabs. (Author)

Fracture Resistance and Mode of Failure of Ceramic versus Titanium Implant Abutments and Single Implant-Supported Restorations.

Science.gov (United States)

Sghaireen, Mohd G

2015-06-01

The material of choice for implant-supported restorations is affected by esthetic requirements and type of abutment. This study compares the fracture resistance of different types of implant abutments and implant-supported restorations and their mode of failure. Forty-five Oraltronics Pitt-Easy implants (Oraltronics Dental Implant Technology GmbH, Bremen, Germany) (4 mm diameter, 10 mm length) were embedded in clear autopolymerizing acrylic resin. The implants were randomly divided into three groups, A, B and C, of 15 implants each. In group A, titanium abutments and metal-ceramic crowns were used. In group B, zirconia ceramic abutments and In-Ceram Alumina crowns were used. In group C, zirconia ceramic abutments and IPS Empress Esthetic crowns were used. Specimens were tested to failure by applying load at 130° from horizontal plane using an Instron Universal Testing Machine. Subsequently, the mode of failure of each specimen was identified. Fracture resistance was significantly different between groups (p Empress crowns supported by zirconia abutments had the lowest fracture loads (p = .000). Fracture modes of metal-ceramic crowns supported by titanium abutments included screw fracture and screw bending. Fracture of both crown and abutment was the dominant mode of failure of In-Ceram/IPS Empress crowns supported by zirconia abutments. Metal-ceramic crowns supported by titanium abutments were more resistant to fracture than In-Ceram crowns supported by zirconia abutments, which in turn were more resistant to fracture than IPS Empress crowns supported by zirconia abutments. In addition, failure modes of restorations supported by zirconia abutments were more catastrophic than those for restorations supported by titanium abutments. © 2013 Wiley Periodicals, Inc.

Evaluation of containment failure and cleanup time for Pu shots on the Z machine.

Energy Technology Data Exchange (ETDEWEB)

Darby, John L.

2010-02-01

Between November 30 and December 11, 2009 an evaluation was performed of the probability of containment failure and the time for cleanup of contamination of the Z machine given failure, for plutonium (Pu) experiments on the Z machine at Sandia National Laboratories (SNL). Due to the unique nature of the problem, there is little quantitative information available for the likelihood of failure of containment components or for the time to cleanup. Information for the evaluation was obtained from Subject Matter Experts (SMEs) at the Z machine facility. The SMEs provided the State of Knowledge (SOK) for the evaluation. There is significant epistemic- or state of knowledge- uncertainty associated with the events that comprise both failure of containment and cleanup. To capture epistemic uncertainty and to allow the SMEs to reason at the fidelity of the SOK, we used the belief/plausibility measure of uncertainty for this evaluation. We quantified two variables: the probability that the Pu containment system fails given a shot on the Z machine, and the time to cleanup Pu contamination in the Z machine given failure of containment. We identified dominant contributors for both the time to cleanup and the probability of containment failure. These results will be used by SNL management to decide the course of action for conducting the Pu experiments on the Z machine.

Failure mode analysis of a PCRV. Influence of some hypothesis

International Nuclear Information System (INIS)

Zimmermann, T.; Saugy, B.; Rebora, B.

1975-01-01

This paper is concerned with the most recent developments and results obtained using a mathematical model for the non-linear analysis of massive reinforced and prestressed concrete strucures developed by the IPEN at the Swiss Federal Institute of Technology, in Lausanne. The method is based on three-dimensional isoparametric finite elements. A linear solution is adapted step by step to the idealized behavior laws of the materials up to the failure of the structure. The laws proposed here for the non-linear behavior of concrete and steel have been described elsewhere but a simple extension to the time-dependent behavior is presented. A numerical algorithm for the superposition of creep deformations is also proposed, the basic creep law being supposed to satisfy a power expression. Time-dependent failure is discussed. The calculus of a PCRV of a helium cooled fast reactor is then performed and the influence of the liner on the failure mode is analyzed. The failure analysis under increasing internal pressure is run at the present time and the influence of an eventual pressure in the cracks is being investigated. The paper aims mainly to demonstrate the accuracy of a failure analysis by three-dimensional finite-elements and to compare it with a model test, in particular when complete deformation and failure tests of the materials are available. The proposed model has already been extensively tested on simple structures and has proved to be useful for the analysis of different simplifying hypotheses

UAV Swarm Behavior Modeling for Early Exposure of Failure Modes

Science.gov (United States)

2016-09-01

have felt like an absentee husband and father, through the rigor and struggles of completing this thesis, they not only continuously provided support...to understand their specific 12 product , they must now have a firm understanding of how their product fits into a plethora of other systems...mission in Monterey Phoenix (MP) proved to provide valuable insight into identifying failure modes and failsafe behaviors. A product of this research

Parametric and Wavelet Analyses of Acoustic Emission Signals for the Identification of Failure Modes in CFRP Composites Using PZT and PVDF Sensors

Energy Technology Data Exchange (ETDEWEB)

Prasopchaichana, Kritsada; Kwon, Oh Yang [Inha University, Incheon (Korea, Republic of)

2007-12-15

Combination of the parametric and the wavelet analyses of acoustic emission (AE) signals was applied to identify the failure modes in carbon fiber reinforced plastic (CFRP) composite laminates during tensile testing. AE signals detected by surface mounted lead-zirconate-titanate (PZT) and polyvinylidene fluoride (PVDF) sensors were analyzed by parametric analysis based on the time of occurrence which classifies AE signals corresponding to failure modes. The frequency band level-energy analysis can distinguish the dominant frequency band for each failure mode. It was observed that the same type of failure mechanism produced signals with different characteristics depending on the stacking sequences and the type of sensors. This indicates that the proposed method can identify the failure modes of the signals if the stacking sequences and the sensors used are known

Failure Mode and Effect Analysis in Increasing the Revenue of Emergency Department

Directory of Open Access Journals (Sweden)

Farhad Rahmati

2015-02-01

Full Text Available Introduction: Successful performance of emergency department(ED is one of the important indications of increasing the satisfaction among referees. The insurance of such successful performance is fiscal discipline and avoiding from non-beneficial activities in this department. Therefore, the increasing revenue of emergency department is one of the interested goals of hospital management system. According to above-mentioned, the researchers assessed problems lead to loss the revenue of ED and eliminate them by using failure mode and effects analysis (FMEA.Methods: This was the prospective cohort study performed during 18 months, set in 6 phases. In the first phase, the failures were determined and some solutions suggested to eliminate them. During 2-5 phases, based on the prioritizing the problems, solutions were performed. In the sixth phase, final assessment of the study was done. Finally, the feedback of system’s revenue was evaluated and data analyzed using repeated measure ANOVA.Results: Lack of recording the consuming instrument and attribution of separate codes for emergency services of hospitalized patients were the most important failures that lead to decrease the revenue of ED. Such elimination caused to 75.9% increase in revenue within a month (df = 1.6; F = 84.0; p<0.0001.  Totally, 18 months following the eliminating of failures caused to 328.2% increase in the revenue of ED (df = 15.9; F = 215; p<0.0001.Conclusion: The findings of the present study shows that failure mode and effect analysis, can be used as a safe and effected method to reduce the expenses of ED and increase its revenue.

Investigation and Classification of Short-Circuit Failure Modes Based on Three-Dimensional Safe Operating Area for High-Power IGBT Modules

DEFF Research Database (Denmark)

Chen, Yuxiang; Li, Wuhua; Iannuzzo, Francesco

2018-01-01

is implemented to motivate advanced contributions in future dependence research of device short-circuit failure modes on temperature. Consequently, a comprehensive and thoughtful review of where the development of short-circuit failure mode research works of IGBT stands and is heading is provided....

Periodic imperfect preventive maintenance with two categories of competing failure modes

Energy Technology Data Exchange (ETDEWEB)

Zequeira, R.I. [ISTIT FRE CNRS 2732-Equipe LM2S, Universite de Technologie de Troyes, 12 rue Marie Curie, BP 2060, 10010 Troyes (France)]. E-mail: romulo.zequeira@utt.fr; Berenguer, C. [ISTIT FRE CNRS 2732-Equipe LM2S, Universite de Technologie de Troyes, 12 rue Marie Curie, BP 2060, 10010 Troyes (France)]. E-mail: christophe.berenguer@utt.fr

2006-04-15

A maintenance policy is studied for a system with two types of failure modes: maintainable and non-maintainable. The quality of maintenance actions is modelled by its effect on the system failure rate. Preventive maintenance actions restore the system to a condition between as good as new and as bad as immediately before the maintenance action. The model presented permits to study the equipment condition improvement (improvement factor) as a function of the time of the preventive maintenance action. The determination of the maintenance policy, which minimizes the cost rate for an infinite time span, is examined. Conditions are given under which a unique optimal policy exists.

Periodic imperfect preventive maintenance with two categories of competing failure modes

International Nuclear Information System (INIS)

Zequeira, R.I.; Berenguer, C.

2006-01-01

A maintenance policy is studied for a system with two types of failure modes: maintainable and non-maintainable. The quality of maintenance actions is modelled by its effect on the system failure rate. Preventive maintenance actions restore the system to a condition between as good as new and as bad as immediately before the maintenance action. The model presented permits to study the equipment condition improvement (improvement factor) as a function of the time of the preventive maintenance action. The determination of the maintenance policy, which minimizes the cost rate for an infinite time span, is examined. Conditions are given under which a unique optimal policy exists

A probability model for the failure of pressure containing parts

International Nuclear Information System (INIS)

Thomas, H.M.

1978-01-01

The model provides a method of estimating the order of magnitude of the leakage failure probability of pressure containing parts. It is a fatigue based model which makes use of the statistics available for both specimens and vessels. Some novel concepts are introduced but essentially the model simply quantifies the obvious i.e. that failure probability increases with increases in stress levels, number of cycles, volume of material and volume of weld metal. A further model based on fracture mechanics estimates the catastrophic fraction of leakage failures. (author)

Failure modes observed on worn surfaces of W-C-Co sputtered coatings

International Nuclear Information System (INIS)

Ramalho, A.; Cavaleiro, A.; Miranda, A.S.; Vieira, M.T.

1993-01-01

During scratch testing, the indenter gives rise to a distribution of stresses similar to that observed in tribocontacts. In this work, r.f.-sputtered W-C-Co coatings deposited from sintered WC + Co (6, 10 and 15 wt.% Co) at various substrate biases were scratched and tested tribologically and the morphology of the damaged surfaces was analysed. The cobalt content of the coatings is the main factor determining their tribological characteristics. The failure modes observed on the worn pin-on-disc tested surfaces are explained and compared with those obtained by scratch testing. In spite of it not being possible to establish quantitative results for the wear resistance of W-C-Co coatings from scratch testing, an estimation can be performed based on the observation of the failure modes in the scratch track. Thus scratch testing can be used to predict the tribological behaviour of coated surfaces. This possibility can reduce the number and cost of tribological tests. (orig.)

Accident management to prevent containment failure and reduce fission product release

International Nuclear Information System (INIS)

Lehner, J.R.; Lin, C.C.; Luckas, W.J.; Pratt, W.T.

1991-01-01

Brookhaven National Laboratory, under the auspices of the US Nuclear Regulatory Commission, is investigating accident management strategies which could help preserve containment integrity or minimize releases during a severe accident. The strategies considered make use of existing plant systems and equipment in innovative ways to reduce the likelihood of containment failure or to mitigate the release of fission products to the environment if failure cannot be prevented. Many of these strategies would be implemented during the later stages of a severe accident, i.e. after vessel breach, and sizable uncertainties exist regarding some of the phenomena involved. The identification and assessment process for containment and release strategies is described, and some insights derived from its application to specific containment types are presented. 2 refs., 5 figs., 2 tabs

Failure Mode and Effect Analysis (FMEA for confectionery manufacturing in developing countries: Turkish delight production as a case study

Directory of Open Access Journals (Sweden)

Sibel Ozilgen

2012-09-01

Full Text Available The Failure Mode and Effect Analysis (FMEA was applied for risk assessment of confectionary manufacturing, in whichthe traditional methods and equipment were intensively used in the production. Potential failure modes and effects as well as their possible causes were identified in the process flow. Processing stages that involve intensive handling of food by workers had the highest risk priority numbers (RPN = 216 and 189, followed by chemical contamination risks in different stages of the process. The application of corrective actions substantially reduced the RPN (risk priority number values. Therefore, the implementation of FMEA (The Failure Mode and Effect Analysis model in confectionary manufacturing improved the safety and quality of the final products.

Failure mode and effects analysis outputs: are they valid?

Science.gov (United States)

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

2012-06-10

Failure Mode and Effects Analysis (FMEA) is a prospective risk assessment tool that has been widely used within the aerospace and automotive industries and has been utilised within healthcare since the early 1990s. The aim of this study was to explore the validity of FMEA outputs within a hospital setting in the United Kingdom. Two multidisciplinary teams each conducted an FMEA for the use of vancomycin and gentamicin. Four different validity tests were conducted: Face validity: by comparing the FMEA participants' mapped processes with observational work. Content validity: by presenting the FMEA findings to other healthcare professionals. Criterion validity: by comparing the FMEA findings with data reported on the trust's incident report database. Construct validity: by exploring the relevant mathematical theories involved in calculating the FMEA risk priority number. Face validity was positive as the researcher documented the same processes of care as mapped by the FMEA participants. However, other healthcare professionals identified potential failures missed by the FMEA teams. Furthermore, the FMEA groups failed to include failures related to omitted doses; yet these were the failures most commonly reported in the trust's incident database. Calculating the RPN by multiplying severity, probability and detectability scores was deemed invalid because it is based on calculations that breach the mathematical properties of the scales used. There are significant methodological challenges in validating FMEA. It is a useful tool to aid multidisciplinary groups in mapping and understanding a process of care; however, the results of our study cast doubt on its validity. FMEA teams are likely to need different sources of information, besides their personal experience and knowledge, to identify potential failures. As for FMEA's methodology for scoring failures, there were discrepancies between the teams' estimates and similar incidents reported on the trust's incident

Cracking and Failure in Rock Specimen Containing Combined Flaw and Hole under Uniaxial Compression

Directory of Open Access Journals (Sweden)

Xiang Fan

2018-01-01

Full Text Available Flaw is a key factor influencing failure behavior of a fractured specimen. In the present study, rectangular-flawed specimens were prepared using sandstone to investigate the effect of flaw on failure behavior of rock. Open flaw and cylindrical hole were simultaneously precut within rock specimens using high-pressure water jet cutting technology. Five series of specimens including intact, single-hole-alone, two-hole-alone, single-hole and two-flaw, and two-hole and single-flaw blocks were prepared. Uniaxial compressive tests using a rigid servo control instrument were carried out to investigate the fracture processes of these flawed specimens. It is observed that during loading, internal stress always intensively distributed at both sidewalls of open hole, especially at midpoint of sidewalls, so rock crumb flaking was firstly observed among all sandstone specimens containing single hole or two holes. Cracking around open hole is associated with the flaw inclination angle which was observed in Series III and V. Crack easily initiated at the tips of flaw with inclination angles of 0°, 30°, and 60° but hard for 90° in Series III and V. Rock burst was the major failure mode among most tested specimens, which generally induced new cracks and finally created crater shape. Additionally, due to extrusion between blocks, new shear or tensile cracks were generated and the rock specimen surface spalled. Eventually, four typical failure processes including rock crumb flaking, crack initiation and propagation, rock burst, and second rupture, were summarized.

Failure mode and effects analysis on typical reactor trip system

International Nuclear Information System (INIS)

Eisawy, E.A.

2010-01-01

An updated failure mode and effects analysis, FMEA , has been performed on a typical reactor trip system. This upgrade helps to avoid system damage and ,as a result, extends the system service life. It also provides for simplified maintenance and surveillance testing. The operating conditions under which the system is to carry out its function and the operational profile expected for the system have been determined. The results of the FMEA have been given in terms of operating states of the subsystem.The results are given in form of table which is set up such that for a given failure one can read across it and determine which items remain operating in the system. From this data one can identify the number of components operating in the system for monitors pressure exceeds the setpoint pressure.

Reliability analysis for the creep rupture mode of failure

International Nuclear Information System (INIS)

Vaidyanathan, S.

1975-01-01

An analytical study has been carried out to relate the factors of safety employed in the design of a component to the probability of failure in the thermal creep rupture mode. The analysis considers the statistical variations in the operating temperature, stress and rupture time, and applies the life fraction damage criterion as the indicator of failure. Typical results for solution annealed type 304-stainless steel material for the temperature and stress variations expected in an LMFBR environment have been obtained. The analytical problem was solved by considering the joint distribution of the independent variables and deriving the distribution for the function associated with the probability of failure by integrating over proper regions as dictated by the deterministic design rule. This leads to a triple integral for the final probability of failure where the coefficients of variation associated with the temperature, stress and rupture time distributions can be specified by the user. The derivation is general, and can be used for time varying stress histories and the case of irradiated material where the rupture time varies with accumulated fluence. Example calculations applied to solution annealed type 304 stainless steel material have been carried out for an assumed coefficient of variation of 2% for temperature and 6% for stress. The results show that the probability of failure associated with dependent stress intensity limits specified in the ASME Boiler and Pressure Vessel Section III Code Case 1592 is less than 5x10 -8 . Rupture under thermal creep conditions is a highly complicated phenomenon. It is believed that the present study will help in quantizing the reliability to be expected with deterministic design factors of safety

WE-H-BRC-03: Failure Mode and Effects Analysis in the First Clinical Implementation of a Novel Stereotactic Breast Radiotherapy Device: GammaPod™

Energy Technology Data Exchange (ETDEWEB)

Mossahebi, S; Feigenberg, S; Nichols, E; Becker, S; Prado, K; Yi, B; Mutaf, Y [University of Maryland School of Medicine, Baltimore, MD (United States); Niu, Y [Xcision Medical Systems, Rockville, MD (United States); Yu, C [University of Maryland School of Medicine, Baltimore, MD (United States); Xcision Medical Systems, Rockville, MD (United States)

2016-06-15

Purpose: GammaPod™, the first stereotactic radiotherapy device for early stage breast cancer treatment, has been recently installed and commissioned at our institution. A multidisciplinary working group applied the failure mode and effects analysis (FMEA) approach to perform a risk analysis. Methods: FMEA was applied to the GammaPod™ treatment process by: 1) generating process maps for each stage of treatment; 2) identifying potential failure modes and outlining their causes and effects; 3) scoring the potential failure modes using the risk priority number (RPN) system based on the product of severity, frequency of occurrence, and detectability (ranging 1–10). An RPN of higher than 150 was set as the threshold for minimal concern of risk. For these high-risk failure modes, potential quality assurance procedures and risk control techniques have been proposed. A new set of severity, occurrence, and detectability values were re-assessed in presence of the suggested mitigation strategies. Results: In the single-day image-and-treat workflow, 19, 22, and 27 sub-processes were identified for the stages of simulation, treatment planning, and delivery processes, respectively. During the simulation stage, 38 potential failure modes were found and scored, in terms of RPN, in the range of 9-392. 34 potential failure modes were analyzed in treatment planning with a score range of 16-200. For the treatment delivery stage, 47 potential failure modes were found with an RPN score range of 16-392. The most critical failure modes consisted of breast-cup pressure loss and incorrect target localization due to patient upper-body alignment inaccuracies. The final RPN score of these failure modes based on recommended actions were assessed to be below 150. Conclusion: FMEA risk analysis technique was applied to the treatment process of GammaPod™, a new stereotactic radiotherapy technology. Application of systematic risk analysis methods is projected to lead to improved quality of

Failure Mode and Effect Analysis of Subsea Multiphase Pump Equipment

Directory of Open Access Journals (Sweden)

Oluwatoyin Shobowale Kafayat

2014-07-01

Full Text Available Finding oil and gas reserves in deep/harsh environment with challenging reservoir and field conditions, subsea multiphase pumping benefits has found its way to provide solutions to these issues. Challenges such as failure issues that are still surging the industry and with the current practice of information hiding, this issues becomes even more difficult to tackle. Although, there are some joint industry projects which are only accessible to its members, still there is a need to have a clear understanding of these equipment groups so as to know which issues to focus attention on. A failure mode and effect analysis (FMEA is a potential first aid in understanding this equipment groups. A survey questionnaire/interview was conducted with the oil and gas operating company and equipment manufacturer based on the literature review. The results indicates that these equipment’s group are similar with its onshore counterpart, but the difference is the robustness built into the equipment internal subsystems for subsea applications. The results from the manufacturer perspectives indicates that Helico-axial multiphase pump have a mean time to failure of more than 10 years, twin-screw and electrical submersible pumps are still struggling with a mean time to failure of less than 5 years.

Comparison Study of Electromagnet and Permanent Magnet Systems for an Accelerator Using Cost-Based Failure Modes and Effects Analysis

International Nuclear Information System (INIS)

Spencer, C

2004-01-01

The next generation of particle accelerators will be one-of-a-kind facilities, and to meet their luminosity goals they must have guaranteed availability over their several decade lifetimes. The Next Linear Collider (NLC) is one viable option for a 1 TeV electron-positron linear collider, it has an 85% overall availability goal. We previously showed how a traditional Failure Modes and Effects Analysis (FMEA) of a SLAC electromagnet leads to reliability-enhancing design changes. Traditional FMEA identifies failure modes with high risk but does not consider the consequences in terms of cost, which could lead to unnecessarily expensive components. We have used a new methodology, ''Life Cost-Based FMEA'', which measures risk of failure in terms of cost, in order to evaluate and compare two different technologies that might be used for the 8653 NLC magnets: electromagnets or permanent magnets. The availabilities for the two different types of magnet systems have been estimated using empirical data from SLAC's accelerator failure database plus expert opinion on permanent magnet failure modes and industry standard failure data. Labor and material costs to repair magnet failures are predicted using a Monte Carlo simulation of all possible magnet failures over a 30-year lifetime. Our goal is to maximize up-time of the NLC through magnet design improvements and the optimal combination of electromagnets and permanent magnets, while reducing magnet system lifecycle costs

Predicting the creep life and failure mode of low-alloy steel weldments

Energy Technology Data Exchange (ETDEWEB)

Brear, J M; Middleton, C J; Aplin, P F [ERA Technology Ltd., Leatherhead (United Kingdom)

1999-12-31

This presentation reviews and consolidates experience gained through a number of research projects and practical plant assessments in predicting both the life and the likely failure mode and location in low alloy steel weldments. The approach adopted begins with the recognition that the relative strength difference between the microstructural regions is a key factor controlling both life and failure location. Practical methods based on hardness measurement and adaptable to differing weld geometries are presented and evidence for correlations between hardness ratio, damage accumulation and strain development is discussed. Predictor diagrams relating weld life and failure location to the service conditions and the hardness of the individual microstructural constituents are suggested and comments are given on the implications for identifying the circumstances in which Type IV cracking is to be expected. (orig.) 6 refs.

Predicting the creep life and failure mode of low-alloy steel weldments

Energy Technology Data Exchange (ETDEWEB)

Brear, J.M.; Middleton, C.J.; Aplin, P.F. [ERA Technology Ltd., Leatherhead (United Kingdom)

1998-12-31

This presentation reviews and consolidates experience gained through a number of research projects and practical plant assessments in predicting both the life and the likely failure mode and location in low alloy steel weldments. The approach adopted begins with the recognition that the relative strength difference between the microstructural regions is a key factor controlling both life and failure location. Practical methods based on hardness measurement and adaptable to differing weld geometries are presented and evidence for correlations between hardness ratio, damage accumulation and strain development is discussed. Predictor diagrams relating weld life and failure location to the service conditions and the hardness of the individual microstructural constituents are suggested and comments are given on the implications for identifying the circumstances in which Type IV cracking is to be expected. (orig.) 6 refs.

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

Science.gov (United States)

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

2012-01-01

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

Effect on localized waste-container failure on radionuclide transport from an underground nuclear waste vault

International Nuclear Information System (INIS)

Cheung, S.C.H.; Chan, T.

1983-07-01

In the geological disposal of nuclear fuel waste, one option is to emplace the waste container in a borehole drilled into the floor of the underground vault. In the borehole, the waste container is surrounded by a compacted soil material known as the buffer. A finite-element simulation has been performed to study the effect of localized partial failure of the waste container on the steady-state radionuclide transport by diffusion from the container through the buffer to the surrounding rock and/or backfill. In this study, the radionuclide concentration at the buffer-backfill interface is assumed to be zero. Two cases are considered at the interface between the buffer and the rock. In case 1, a no-flux boundary condition is used to simulate intact rock. In case 2, a constant radionuclide concentration condition is used to simulate fractured rock with groundwater flow. The results show that the effect of localized partial failure of the waste container on the total flux is dependent on the boundary condition at the buffer-rock interface. For the intact rock condition, the total flux is mainly dependent on the location of the failure. The total flux increases as the location changes from the bottom to the top of the emplaced waste container. For a given localized failure of the waste container, the total flux remains unaffected by the area of failed surface below the top of the failure. For fractured rock, the total flux is directly proportional to the failed surface area of the waste container regardless of the failure location

DELPHI expert panel evaluation of Hanford high level waste tank failure modes and release quantities

Energy Technology Data Exchange (ETDEWEB)

Dunford, G.L.; Han, F.C.

1996-09-30

The Failure Modes and Release Quantities of the Hanford High Level Waste Tanks due to postulated accident loads were established by a DELPHI Expert Panel consisting of both on-site and off-site experts in the field of Structure and Release. The Report presents the evaluation process, accident loads, tank structural failure conclusion reached by the panel during the two-day meeting.

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

Science.gov (United States)

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

2015-01-01

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

Reliability and failure modes of implant-supported zirconium-oxide fixed dental prostheses related to veneering techniques

Science.gov (United States)

Baldassarri, Marta; Zhang, Yu; Thompson, Van P.; Rekow, Elizabeth D.; Stappert, Christian F. J.

2011-01-01

Summary Objectives To compare fatigue failure modes and reliability of hand-veneered and over-pressed implant-supported three-unit zirconium-oxide fixed-dental-prostheses(FDPs). Methods Sixty-four custom-made zirconium-oxide abutments (n=32/group) and thirty-two zirconium-oxide FDP-frameworks were CAD/CAM manufactured. Frameworks were veneered with hand-built up or over-pressed porcelain (n=16/group). Step-stress-accelerated-life-testing (SSALT) was performed in water applying a distributed contact load at the buccal cusp-pontic-area. Post failure examinations were carried out using optical (polarized-reflected-light) and scanning electron microscopy (SEM) to visualize crack propagation and failure modes. Reliability was compared using cumulative-damage step-stress analysis (Alta-7-Pro, Reliasoft). Results Crack propagation was observed in the veneering porcelain during fatigue. The majority of zirconium-oxide FDPs demonstrated porcelain chipping as the dominant failure mode. Nevertheless, fracture of the zirconium-oxide frameworks was also observed. Over-pressed FDPs failed earlier at a mean failure load of 696 ± 149 N relative to hand-veneered at 882 ± 61 N (profile I). Weibull-stress-number of cycles-unreliability-curves were generated. The reliability (2-sided at 90% confidence bounds) for a 400N load at 100K cycles indicated values of 0.84 (0.98-0.24) for the hand-veneered FDPs and 0.50 (0.82-0.09) for their over-pressed counterparts. Conclusions Both zirconium-oxide FDP systems were resistant under accelerated-life-time-testing. Over-pressed specimens were more susceptible to fatigue loading with earlier veneer chipping. PMID:21557985

A risk-based evaluation of LMFBR containment response under core disruptive accident conditions

International Nuclear Information System (INIS)

Hartung, J.; Berk, S.

1978-01-01

Probabilistic risk methodology is utilized to evaluate the failure modes and effects of LMFBR containment systems under Core Disruptive Accident (CDA) conditions. First, the potential causes of LMFBR containment failure under CDA conditions are discussed and categorized. Then, a simple scoping-type risk assessment of a reference design is presented to help place these potential causes of failure in perspective. The highest risk containment failure modes are identified for the reference design, and several design and research and development options which appear capable of reducing these risks are discussed. The degree to which large LMFBR containment systems must mitigate the consequences of CDA's to achieve a level of risk (for LMFBR's) comparable to the already very low risk of contemporary LWR's is explored. Based on the results of this evaluation, several suggestions are offered concerning CDA-related design goals and research and development priorities for large LMFBR's. (author)

The study of Influencing Maintenance Factors on Failures of Two gypsum Kilns by Failure Modes and Effects Analysis (FMEA

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Iraj Alimohammadi

2014-06-01

Full Text Available Developing technology and using equipment in Iranian industries caused that maintenance system would be more important to use. Using proper management techniques not only increase the performance of production system but also reduce the failures and costs. The aim of this study was to determine the quality of maintenance system and the effects of its components on failures of kilns in two gypsum production companies using Failure Modes and Effects Analysis (FMEA. Furthermore the costs of failures were studied. After the study of gypsum production steps in the factories, FMEA was conducted by the determination of analysis insight, information gathering, making list of kilns’ component and filling up the FMEA’s tables. The effects of failures on production, how to fail, failure rate, failure severity, and control measures were studied. The evaluation of maintenance system was studied by a check list including questions related to system components. The costs of failures were determined by refer in accounting notebooks and interview with the head of accounting department. It was found the total qualities of maintenance system in NO.1 was more than NO.2 but because of lower quality of NO.1’s kiln design, number of failures and their costs were more. In addition it was determined that repair costs in NO.2’s kiln were about one third of NO.1’s. The low severity failures caused the most costs in comparison to the moderate and low ones. The technical characteristics of kilns were appeared to be the most important factors in reducing of failures and costs.

Failure mode and effects analysis outputs: are they valid?

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Shebl Nada

2012-06-01

Full Text Available Abstract Background Failure Mode and Effects Analysis (FMEA is a prospective risk assessment tool that has been widely used within the aerospace and automotive industries and has been utilised within healthcare since the early 1990s. The aim of this study was to explore the validity of FMEA outputs within a hospital setting in the United Kingdom. Methods Two multidisciplinary teams each conducted an FMEA for the use of vancomycin and gentamicin. Four different validity tests were conducted: · Face validity: by comparing the FMEA participants’ mapped processes with observational work. · Content validity: by presenting the FMEA findings to other healthcare professionals. · Criterion validity: by comparing the FMEA findings with data reported on the trust’s incident report database. · Construct validity: by exploring the relevant mathematical theories involved in calculating the FMEA risk priority number. Results Face validity was positive as the researcher documented the same processes of care as mapped by the FMEA participants. However, other healthcare professionals identified potential failures missed by the FMEA teams. Furthermore, the FMEA groups failed to include failures related to omitted doses; yet these were the failures most commonly reported in the trust’s incident database. Calculating the RPN by multiplying severity, probability and detectability scores was deemed invalid because it is based on calculations that breach the mathematical properties of the scales used. Conclusion There are significant methodological challenges in validating FMEA. It is a useful tool to aid multidisciplinary groups in mapping and understanding a process of care; however, the results of our study cast doubt on its validity. FMEA teams are likely to need different sources of information, besides their personal experience and knowledge, to identify potential failures. As for FMEA’s methodology for scoring failures, there were discrepancies

Failure Modes and Effects Analysis (FMEA) of the Residual Heat Removal System

International Nuclear Information System (INIS)

Eggleston, F.T.

1976-01-01

The Residual Heat Removal System (RHRS) transfer heat from the Reactor Coolant System (RCS) to the reactor plant Component Cooling System (CCS) to reduce the temperature of the RCS at a controlled rate during the second part of normal plant cooldown and maintains the desired temperature until the plant is restarted. By the use of an analytic tool, the Failure Modes and Effects Analysis, it is shown that the RHRS, because of its redundant two train design, is able to accommodate any credible component single failure with the only effect being an extension in the required cooldown time, thus demonstrating the reliability of the RHRS to perform its intended function

Strain-based failure criteria for steel containments

International Nuclear Information System (INIS)

Fanous, F.; Greimann, L.F.

1989-01-01

The Containment Integrity Division of the Sandia National Laboratories (Sandia) has been conducting a program to evaluate the performance of containment buildings with internal pressure. Sandia has suggested that in the absence of leakage past penetrations, containment buildings will fail by rupturing after large plastic strains are developed up to ultimate strain of the material. This paper represents a portion of work conducted at Ames Laboratory for Sandia, the objective of which was to identify fabrication details that may affect the performance of a containment building. Construction drawings for nine steel containment buildings were surveyed, and several significant strain concentration regions were identified by using recommendations from Sandia and Section NE-3217 of the ASME Boiler and Pressure Vessel Code. These following regions were identified as: eccentricities in stiffener patterns around penetrations, eccentricities in containment shell middle surface, flat plate covers used on spare penetrations, containment base connection details, and containment heads. Examples of each of these regions were analyzed by the finite-element method, by simplified equations or both. In the case of middle surface eccentricities, the strains were found to be self-limiting. Even though flat plates have primary strains, they are typically designed so as not to control. Bolts in the base connection have primary strains and may control. The circumferential compressive strains introduced at the knuckle during buckling of the containment head grow as the pressure increases, but are somewhat restricted by the meridional tension. Finally, three analysis techniques and their associated failure criteria for the analysis of containment strength are introduced. (orig.)

Practical Aspects of the Use of Healthcare Failure Mode and Effects Analysis Tool in The Risk Management of Pediatric Emergency Department: The Scrutiny in Iran

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Yasamin Molavi-Taleghani

2018-03-01

Full Text Available Aim: The Emergency Department is one of the most challenging wards of the hospital for studying patient safety and the prevention of treatment errors is the basic rule in the quality of health care. The present study was conducted to evaluate the selected risk processes of Pediatric Emergency of Qaem Educational Hospital in Mashhad by the Healthcare Failure Mode and Effects Analysis (HFMEA methodology. Materials and Methods: A mixed method was used to analyze failure modes and their effects with HFMEA. Five high-risk processes of the Pediatric Emergency were identified and analyzed. To classify failure modes, nursing errors in clinical management model; for classifying factors affecting error, the approved model by the United Kingdom National Health System; and for determining solutions for improvement, Theory of Inventive Problem Solving was used. Results: In 5 selected processes, 28 steps, 80 sub-processes and 254 potential failure modes were identified with HFMEA. Thirty-seven (14.5% failure modes as high-risk errors were detected and transferred to the decision tree. The most and the least failure modes were placed in the categories of care errors as 62.3%, and knowledge and skill as 8.1% respectively. Also, 23.6% of preventive measures were in the category of human resource management strategy. Conclusion: Using the proactive method of HFMEA for identifying the possible failure of treatment procedures, determining the effective cause on each failure mode and proposing the improvement strategies, has high efficiency and effectiveness.

Review and evaluation of the Millstone Unit 3 probabilistic safety study. Containment failure modes, radiological source - terms and offsite consequences

International Nuclear Information System (INIS)

Khatib-Rahbar, M.; Pratt, W.; Ludewig, H.

1985-09-01

A technical review and evaluation of the Millstone Unit 3 probabilistic safety study has been performed. It was determined that; (1) long-term damage indices (latent fatalities, person-rem, etc.) are dominated by late failure of the containment, (2) short-term damage indices (early fatalities, etc.) are dominated by bypass sequences for internally initiated events, while severe seismic sequences can also contribute significantly to early damage indices. These overall estimates of severe accident risk are extremely low compared with other societal sources of risk. Furthermore, the risks for Millstone-3 are comparable to risks from other nuclear plants at high population sites. Seismically induced accidents dominate the severe accident risks at Millstone-3. Potential mitigative features were shown not to be cost-effective for internal events. Value-impact analysis for seismic events showed that a manually actuated containment spray system might be cost-effective

Augmenting health care failure modes and effects analysis with simulation

DEFF Research Database (Denmark)

Staub-Nielsen, Ditte Emilie; Dieckmann, Peter; Mohr, Marlene

2014-01-01

This study explores whether simulation plays a role in health care failure mode and effects analysis (HFMEA); it does this by evaluating whether additional data are found when a traditional HFMEA is augmented with simulation. Two multidisciplinary teams identified vulnerabilities in a process...... by brainstorming, followed by simulation. Two means of adding simulation were investigated as follows: just simulating the process and interrupting the simulation between substeps of the process. By adding simulation to a traditional HFMEA, both multidisciplinary teams identified additional data that were relevant...

Numerical Analysis on Failure Modes and Mechanisms of Mine Pillars under Shear Loading

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Tianhui Ma

2016-01-01

Full Text Available Severe damage occurs frequently in mine pillars subjected to shear stresses. The empirical design charts or formulas for mine pillars are not applicable to orebodies under shear. In this paper, the failure process of pillars under shear stresses was investigated by numerical simulations using the rock failure process analysis (RFPA 2D software. The numerical simulation results indicate that the strength of mine pillars and the corresponding failure mode vary with different width-to-height ratios and dip angles. With increasing dip angle, stress concentration first occurs at the intersection between the pillar and the roof, leading to formation of microcracks. Damage gradually develops from the surface to the core of the pillar. The damage process is tracked with acoustic emission monitoring. The study in this paper can provide an effective means for understanding the failure mechanism, planning, and design of mine pillars.

PENERAPAN FUZZY ANALYTIC HIERARCHY PROCESS DALAM METODE MULTI ATTRIBUTE FAILURE MODE ANALYSIS UNTUK MENGIDENTIFIKASI PENYEBAB KEGAGALAN POTENSIAL PADA PROSES PRODUKSI

OpenAIRE

Dorina Hetharia

2012-01-01

Banyak metode dalam Total Quality Management (TQM) yang dapat digunakan untuk melakukan perbaikan kualitas produk dan jasa. Salah satunya adalah Multi Attribute Failure Mode Analysis (MAFMA), yang dapat digunakan untuk mengeliminasi atau mengurangi kemungkinan terjadinya kegagalan bila dilihat dari faktor penyebabnya, sehingga dapat mencegah terulang kembali kegagalan tersebut. MAFMA merupakan pengembangan dari Failure Mode and Effect Analysis (FMEA), yang mengintegrasikan atribut severity, o...

Aortic regurgitation after valve-sparing aortic root replacement: modes of failure.

Science.gov (United States)

Oka, Takanori; Okita, Yutaka; Matsumori, Masamichi; Okada, Kenji; Minami, Hitoshi; Munakata, Hiroshi; Inoue, Takeshi; Tanaka, Akiko; Sakamoto, Toshihito; Omura, Atsushi; Nomura, Takuo

2011-11-01

Despite the positive clinical results of valve-sparing aortic root replacement, little is known about the causes of reoperations and the modes of failure. From October 1999 to June 2010, 101 patients underwent valve-sparing aortic root replacement using the David reimplantation technique. The definition of aortic root repair failure included the following: (1) intraoperative conversion to the Bentall procedure; (2) reoperation performed because of aortic regurgitation; and (3) aortic regurgitation equal to or greater than a moderate degree at the follow-up. Sixteen patients were considered to have repair failure. Three patients required intraoperative conversion to valve replacement, 3 required reoperation within 3 months, and another 8 required reoperation during postoperative follow-up. At initial surgery 5 patients had moderate to severe aortic regurgitation, 6 patients had acute aortic dissections, 3 had Marfan syndrome, 2 had status post Ross operations, 3 had bicuspid aortic valves, and 1 had aortitis. Five patients had undergone cusp repair, including Arantius plication in 3 and plication at the commissure in 2. The causes of early failure in 6 patients included cusp perforation (3), cusp prolapse (3), and severe hemolysis (1). The causes of late failure in 10 patients included cusp prolapse (4), commissure dehiscence (3), torn cusp (2), and cusp retraction (1). Patients had valve replacements at a mean of 23 ± 20.9 months after reimplantation and survived. Causes of early failure after valve-sparing root replacement included technical failure, cusp lesions, and steep learning curve. Late failure was caused by aortic root wall degeneration due to gelatin-resorcin-formalin glue, cusp degeneration, or progression of cusp prolapse. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Failure Mode and Effect Analysis (FMEA) for confectionery manufacturing in developing countries: Turkish delight production as a case study

OpenAIRE

Ozilgen,Sibel

2012-01-01

The Failure Mode and Effect Analysis (FMEA) was applied for risk assessment of confectionary manufacturing, in whichthe traditional methods and equipment were intensively used in the production. Potential failure modes and effects as well as their possible causes were identified in the process flow. Processing stages that involve intensive handling of food by workers had the highest risk priority numbers (RPN = 216 and 189), followed by chemical contamination risks in different stages of the ...

Fuzzy Risk Evaluation in Failure Mode and Effects Analysis Using a D Numbers Based Multi-Sensor Information Fusion Method.

Science.gov (United States)

Deng, Xinyang; Jiang, Wen

2017-09-12

Failure mode and effect analysis (FMEA) is a useful tool to define, identify, and eliminate potential failures or errors so as to improve the reliability of systems, designs, and products. Risk evaluation is an important issue in FMEA to determine the risk priorities of failure modes. There are some shortcomings in the traditional risk priority number (RPN) approach for risk evaluation in FMEA, and fuzzy risk evaluation has become an important research direction that attracts increasing attention. In this paper, the fuzzy risk evaluation in FMEA is studied from a perspective of multi-sensor information fusion. By considering the non-exclusiveness between the evaluations of fuzzy linguistic variables to failure modes, a novel model called D numbers is used to model the non-exclusive fuzzy evaluations. A D numbers based multi-sensor information fusion method is proposed to establish a new model for fuzzy risk evaluation in FMEA. An illustrative example is provided and examined using the proposed model and other existing method to show the effectiveness of the proposed model.

Loads on EPR containment after RPV failure at high pressure

International Nuclear Information System (INIS)

Jacobs, G.

1995-01-01

As regards the desgin of the EPR, the general strategy is to eliminate, the vessel failure at high pressure by preventive and mitigative measures. The design proposals involved trust in the reliability of dedicated devices (relief valves) for rapid depressurization. The aim is to attain a lower pressure level at the moment of vessel failure, so that the containment is capable to cope with the blowdown impact on the pit walls and the vessel supporting structures. Nevertheless, the potential of a high-pressure failure of the vessel must be kept in mind, whatever well thought-out and reliable preventive depressurization measures might be. Therefore, the reactor pressure blowdown has been studied in order to quantify the ultimate containment load, which might support future design requirements. The calculations were performed with the LWR transient analysis thermal-hydraulics computer code REALAP5/MOD3. In previous analyses, the nodalization of the problem was based on the geometrical conditions of a typical German 1300 MW(e) NPP. In the present analysis a new input model has been used, which was based on the EPR conditions. (orig./HP)

Development of an Automated Technique for Failure Modes and Effect Analysis

DEFF Research Database (Denmark)

Blanke, M.; Borch, Ole; Allasia, G.

1999-01-01

Advances in automation have provided integration of monitoring and control functions to enhance the operator's overview and ability to take remedy actions when faults occur. Automation in plant supervision is technically possible with integrated automation systems as platforms, but new design...... methods are needed to cope efficiently with the complexity and to ensure that the functionality of a supervisor is correct and consistent. In particular these methods are expected to significantly improve fault tolerance of the designed systems. The purpose of this work is to develop a software module...... implementing an automated technique for Failure Modes and Effects Analysis (FMEA). This technique is based on the matrix formulation of FMEA for the investigation of failure propagation through a system. As main result, this technique will provide the design engineer with decision tables for fault handling...

Development of an automated technique for failure modes and effect analysis

DEFF Research Database (Denmark)

Blanke, Mogens; Borch, Ole; Bagnoli, F.

1999-01-01

Advances in automation have provided integration of monitoring and control functions to enhance the operator's overview and ability to take remedy actions when faults occur. Automation in plant supervision is technically possible with integrated automation systems as platforms, but new design...... methods are needed to cope efficiently with the complexity and to ensure that the functionality of a supervisor is correct and consistent. In particular these methods are expected to significantly improve fault tolerance of the designed systems. The purpose of this work is to develop a software module...... implementing an automated technique for Failure Modes and Effects Analysis (FMEA). This technique is based on the matrix formulation of FMEA for the investigation of failure propagation through a system. As main result, this technique will provide the design engineer with decision tables for fault handling...

Classification and calculation of primary failure modes in bread production line

International Nuclear Information System (INIS)

Tsarouhas, Panagiotis H.

2009-01-01

In this study, we describe the classification methodology over a 2-year period of the primary failure modes in categories based on failure data of bread production line. We estimate the probabilities of these categories applying the chi-square goodness of fit test, and we calculate their joint probabilities of mass function at workstation and line level. Then, we present numerical examples in order to predict the causes and frequencies of breakdowns for workstations and for the entire bread production line that will occur in the future. The methodology is meant to guide bread and bakery product manufacturers, improving the operation of the production lines. It can also be a useful tool to maintenance engineers, who wish to analyze and improve the reliability and efficiency of the manufacturing systems

ANALISA MODA DAN EFEK KEGAGALAN (FAILURE MODE AND EFFECTS ANALYSIS / FMEA PADA PRODUK KURSI LIPAT CHITOSE YAMATO HAA

Directory of Open Access Journals (Sweden)

Denny Nurkertamanda

2012-02-01

up tp 59% from all of the products manufactured. CHitose Yamato HAA foldable chair is one of the tools to sit down included with a back seat according to the vertebra of the human body and its is foldable to simplify its storage.  Furthermore, the H form of its feet structure allows it to be used in flat or hilly surface. The material used on the structure of Chitose Yamato HAA foldable chair is isotropic structure element, which has similar characteristic and material (stress,strain, mechanic, etc. On Failure Mode Analysis we identify potensial failure modes, severity that occurs, and the frequency of failure mode. With the failure mode analysis, the goal is to increase product quality and can be used according to its function. RPN is the critical indicator to determine the correction actions according to Failure modes. RPN is used in many FMEA procedures to approximate risks using three criterias that consists o:LSeverity(S, Occurrence(O, Detection(D. RPN priority number is the multiplying results from severity rating, occurrence, and detection. This number only shows ranks or sequence of the system design deficiency. Keywords: Failure mode, Failure effects, Failure causes, Detection, Severity, RPN (Risk Priority Number

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

Science.gov (United States)

Li, Xixi; He, Mei; Wang, Haiyan

2017-12-01

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

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

Science.gov (United States)

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

2012-07-01

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

Failure Mode of the Water-filled Fractures under Hydraulic Pressure in Karst Tunnels

Directory of Open Access Journals (Sweden)

Dong Xin

2017-06-01

Full Text Available Water-filled fractures continue to grow after the excavation of karst tunnels, and the hydraulic pressure in these fractures changes along with such growth. This paper simplifies the fractures in the surrounding rock as flat ellipses and then identifies the critical hydraulic pressure values required for the occurrence of tensile-shear and compression-shear failures in water-filled fractures in the case of plane stress. The occurrence of tensile-shear fracture requires a larger critical hydraulic pressure than compression-shear failure in the same fracture. This paper examines the effects of fracture strike and lateral pressure coefficient on critical hydraulic pressure, and identifies compression-shear failure as the main failure mode of water-filled fractures. This paper also analyses the hydraulic pressure distribution in fractures with different extensions, and reveals that hydraulic pressure decreases along with the continuous growth of fractures and cannot completely fill a newly formed fracture with water. Fracture growth may be interrupted under the effect of hydraulic tensile shear.

Steam explosions-induced containment failure studies for Swiss nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Zuchuat, O.; Schmocker, U. [Swiss Federal Nuclear Safety Inspectorate, Villigen (Switzerland); Esmaili, H.; Khatib-Rahbar, M.

1998-01-01

The assessment of the consequences of both in-vessel and ex-vessel energetic fuel-coolant interaction for Beznau (a Westinghouse pressurized water reactor with a large, dry containment), Goesgen (a Siemens/KWU pressurized water reactor with a large, dry containment) and Leibstadt (a General Electric boiling water reactor-6 with a free standing steel, MARK-III containment) nuclear power plants is presented in this paper. The Conditional Containment Failure Probability of the steel containment of these Swiss nuclear power plants is determined based on different probabilistic approaches. (author)

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

Science.gov (United States)

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

2018-02-01

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

Acute renal failure secondary to ingestion of ayurvedic medicine containing mercury

Directory of Open Access Journals (Sweden)

K Sathe

2013-01-01

Full Text Available Several traditional medicines contain potentially toxic heavy metals. Heavy metal poisoning is not an uncommon cause of renal damage, although the diagnosis can be easily missed. We report a case of chronic ingestion of an ayurvedic medicine containing mercury in a 2-year-old girl, resulting in anuric renal failure due to acute interstitial nephritis.

Usage of Failure Mode & EffectAnalysis Method (FMEA forsafety assessment in a drug manufacture

Directory of Open Access Journals (Sweden)

Y Nazari

2006-04-01

Full Text Available Background and Aims: This study was hold in purpose of recognizing and controlling workplacehazards in production units of a drag ManufactureMethod:So for recognition and assessment of hazards, FMEA Method was used. FMEASystematically investigates the effects of equipment and system failures leading often toequipment design improvements. At first the level of the study defined as system. Then accordingto observations, accident statistic, and interview with managers, supervisory, and workers highrisk system were determiner. So the boundaries of the system established and informationregarding the relevant Components, their function and interactions gathered. To preventConfusion between Similar pieces of equipment, a unique system identifier developed. After thatall failure modes and their causes for each equipment or system listed, the immediate effects ofeach failure mode and interactive effect on other equipment or system was described too. Riskpriority number was determined according to global and local criteriaResults: After all some actions and solution proposed to reduce the likelihood and severity offailures and raise their delectability.Conclusion :This study illustrated that although of the first step drug manufacture may seem safe,but there are still many hazardous condition that could cause serious accidents, The result proposedit is necessary: (1 to develop comprehensive manual for periodical and regular inspection ofinstruments of workplaces in purpose of recognize unknown failures and their causes, (2 developa comprehensive program for systems maintenance and repair, and (3 conduct worker training.

Relationship Between Unusual High-Temperature Fatigue Crack Growth Threshold Behavior in Superalloys and Sudden Failure Mode Transitions

Science.gov (United States)

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

2017-01-01

An investigation of high temperature cyclic fatigue crack growth (FCG) threshold behavior of two advanced nickel disk alloys was conducted. The focus of the study was the unusual crossover effect in the near-threshold region of these type of alloys where conditions which produce higher crack growth rates in the Paris regime, produce higher resistance to crack growth in the near threshold regime. It was shown that this crossover effect is associated with a sudden change in the fatigue failure mode from a predominant transgranular mode in the Paris regime to fully intergranular mode in the threshold fatigue crack growth region. This type of a sudden change in the fracture mechanisms has not been previously reported and is surprising considering that intergranular failure is typically associated with faster crack growth rates and not the slow FCG rates of the near-threshold regime. By characterizing this behavior as a function of test temperature, environment and cyclic frequency, it was determined that both the crossover effect and the onset of intergranular failure are caused by environmentally driven mechanisms which have not as yet been fully identified. A plausible explanation for the observed behavior is proposed.

Influence of platform diameter in the reliability and failure mode of extra-short dental implants.

Science.gov (United States)

Bordin, Dimorvan; Bergamo, Edmara T P; Bonfante, Estevam A; Fardin, Vinicius P; Coelho, Paulo G

2018-01-01

To evaluate the influence of implant diameter in the reliability and failure mode of extra-short dental implants. Sixty-three extra-short implants (5mm-length) were allocated into three groups according to platform diameter: Ø4.0-mm, Ø5.0-mm, and Ø6.0-mm (21 per group). Identical abutments were torqued to the implants and standardized crowns cemented. Three samples of each group were subjected to single-load to failure (SLF) to allow the design of the step-stress profiles, and the remaining 18 were subjected to step-stress accelerated life-testing (SSALT) in water. The use level probability Weibull curves, and the reliability (probability of survival) for a mission of 100,000 cycles at 100MPa, 200MPa, and 300MPa were calculated. Failed samples were characterized in scanning electron microscopy for fractographic inspection. No significant difference was observed for reliability regarding implant diameter for all loading missions. At 100MPa load, all groups showed reliability higher than 99%. A significant decreased reliability was observed for all groups when 200 and 300MPa missions were simulated, regardless of implant diameter. At 300MPa load, the reliability was 0%, 0%, and 5.24%, for Ø4.0mm, Ø5.0mm, and Ø6.0mm, respectively. The mean beta (β) values were lower than 0.55 indicating that failures were most likely influenced by materials strength, rather than damage accumulation. The Ø6.0mm implant showed significantly higher characteristic stress (η = 1,100.91MPa) than Ø4.0mm (1,030.25MPa) and Ø5.0mm implant (η = 1,012.97MPa). Weibull modulus for Ø6.0-mm implant was m = 7.41, m = 14.65 for Ø4.0mm, and m = 11.64 for Ø5.0mm. The chief failure mode was abutment fracture in all groups. The implant diameter did not influence the reliability and failure mode of 5mm extra-short implants. Copyright © 2017 Elsevier Ltd. All rights reserved.

Interim report on the state-of-the-art of solid-state motor controllers. Part 4. Failure-rate and failure-mode data

International Nuclear Information System (INIS)

Jaross, R.A.

1983-09-01

An assessment of the reliability of solid-state motor controllers for nuclear power plants is made. Available data on failure-rate and failure-mode data for solid-state motor controllers based on industrial operating experience is meager; the data are augmented by data on other solid-state power electronic devices that are shown to have components similar to those found in solid-state motor controllers. In addition to large nonnuclear solid-state adjustable-speed motor drives, the reliability of nuclear plant inverter systems and high-voltage solid-state dc transmission-line converters is assessed. Licensee Event Report analyses from several sources, the open literature, and personal communications are used to determine the realiability of solid-state devices typical of those expected to be used in nuclear power plants in terms of failures per hour

SU-F-P-07: Applying Failure Modes and Effects Analysis to Treatment Planning System QA

International Nuclear Information System (INIS)

Mathew, D; Alaei, P

2016-01-01

Purpose: A small-scale implementation of Failure Modes and Effects Analysis (FMEA) for treatment planning system QA by utilizing methodology of AAPM TG-100 report. Methods: FMEA requires numerical values for severity (S), occurrence (O) and detectability (D) of each mode of failure. The product of these three values gives a risk priority number (RPN). We have implemented FMEA for the treatment planning system (TPS) QA for two clinics which use Pinnacle and Eclipse TPS. Quantitative monthly QA data dating back to 4 years for Pinnacle and 1 year for Eclipse have been used to determine values for severity (deviations from predetermined doses at points or volumes), and occurrence of such deviations. The TPS QA protocol includes a phantom containing solid water and lung- and bone-equivalent heterogeneities. Photon and electron plans have been evaluated in both systems. The dose values at multiple distinct points of interest (POI) within the solid water, lung, and bone-equivalent slabs, as well as mean doses to several volumes of interest (VOI), have been re-calculated monthly using the available algorithms. Results: The computed doses vary slightly month-over-month. There have been more significant deviations following software upgrades, especially if the upgrade involved re-modeling of the beams. TG-100 guidance and the data presented here suggest an occurrence (O) of 2 depending on the frequency of re-commissioning the beams, severity (S) of 3, and detectability (D) of 2, giving an RPN of 12. Conclusion: Computerized treatment planning systems could pose a risk due to dosimetric errors and suboptimal treatment plans. The FMEA analysis presented here suggests that TPS QA should immediately follow software upgrades, but does not need to be performed every month.

SU-F-P-07: Applying Failure Modes and Effects Analysis to Treatment Planning System QA

Energy Technology Data Exchange (ETDEWEB)

Mathew, D; Alaei, P [University Minnesota, Minneapolis, MN (United States)

2016-06-15

Purpose: A small-scale implementation of Failure Modes and Effects Analysis (FMEA) for treatment planning system QA by utilizing methodology of AAPM TG-100 report. Methods: FMEA requires numerical values for severity (S), occurrence (O) and detectability (D) of each mode of failure. The product of these three values gives a risk priority number (RPN). We have implemented FMEA for the treatment planning system (TPS) QA for two clinics which use Pinnacle and Eclipse TPS. Quantitative monthly QA data dating back to 4 years for Pinnacle and 1 year for Eclipse have been used to determine values for severity (deviations from predetermined doses at points or volumes), and occurrence of such deviations. The TPS QA protocol includes a phantom containing solid water and lung- and bone-equivalent heterogeneities. Photon and electron plans have been evaluated in both systems. The dose values at multiple distinct points of interest (POI) within the solid water, lung, and bone-equivalent slabs, as well as mean doses to several volumes of interest (VOI), have been re-calculated monthly using the available algorithms. Results: The computed doses vary slightly month-over-month. There have been more significant deviations following software upgrades, especially if the upgrade involved re-modeling of the beams. TG-100 guidance and the data presented here suggest an occurrence (O) of 2 depending on the frequency of re-commissioning the beams, severity (S) of 3, and detectability (D) of 2, giving an RPN of 12. Conclusion: Computerized treatment planning systems could pose a risk due to dosimetric errors and suboptimal treatment plans. The FMEA analysis presented here suggests that TPS QA should immediately follow software upgrades, but does not need to be performed every month.

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

Science.gov (United States)

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

2015-06-13

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

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

Energy Technology Data Exchange (ETDEWEB)

Gray, J; Lukose, R; Bronson, J; Chandler, B; Merchant, T; Farr, J [St. Jude Children’s Research Hospital, Memphis, TN (United States)

2015-06-15

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

Mode I Failure of Armor Ceramics: Experiments and Modeling

Science.gov (United States)

Meredith, Christopher; Leavy, Brian

2017-06-01

The pre-notched edge on impact (EOI) experiment is a technique for benchmarking the damage and fracture of ceramics subjected to projectile impact. A cylindrical projectile impacts the edge of a thin rectangular plate with a pre-notch on the opposite edge. Tension is generated at the notch tip resulting in the initiation and propagation of a mode I crack back toward the impact edge. The crack can be quantitatively measured using an optical method called Digital Gradient Sensing, which measures the crack-tip deformation by simultaneously quantifying two orthogonal surface slopes via measuring small deflections of light rays from a specularly reflective surface around the crack. The deflections in ceramics are small so the high speed camera needs to have a very high pixel count. This work reports on the results from pre-crack EOI experiments of SiC and B4 C plates. The experimental data are quantitatively compared to impact simulations using an advanced continuum damage model. The Kayenta ceramic model in Alegra will be used to compare fracture propagation speeds, bifurcations and inhomogeneous initiation of failure will be compared. This will provide insight into the driving mechanisms required for the macroscale failure modeling of ceramics.

Evaluation of Pad 18 Spent Mercury Gold Trap Stainless Steel Container Failure

International Nuclear Information System (INIS)

Skidmore, E.

2016-01-01

Failure of the Pad 18 spent mercury gold trap stainless steel waste container is principally attributed to corrosion induced by degradation of plasticized polyvinyl chloride (pPVC) waste packaging material. Dehydrochlorination of pPVC polymer by thermal and/or radiolytic degradation is well-known to evolve HCl gas, which is highly corrosive to stainless steel and other metals in the presence of moisture. Degradation of the pPVC packaging material was likely caused by radiolysis in the presence of tritium gas within the waste container, though other degradation mechanisms (aging, thermo-oxidation, plasticizer migration) over 30 years storage may have contributed. Corrosion was also likely enhanced by the crevice in the container weld design, and may have been enhanced by the presence of tritiated water. Similar non-failed spent mercury gold trap waste containers did not show radiographic evidence of plastic packaging or trapped free liquid within the container. Therefore, those containers are not expected to exhibit similar failures. Halogenated polymers such as pPVC subject to degradation can evolve halide gases such as HCl, which is corrosive in the presence of moisture and can generate pressure in sealed systems.

Evaluation of Pad 18 Spent Mercury Gold Trap Stainless Steel Container Failure

Energy Technology Data Exchange (ETDEWEB)

Skidmore, E. [Savannah River Site (SRS), Aiken, SC (United States). Savannah River National Lab. (SRNL)

2016-08-03

Failure of the Pad 18 spent mercury gold trap stainless steel waste container is principally attributed to corrosion induced by degradation of plasticized polyvinyl chloride (pPVC) waste packaging material. Dehydrochlorination of pPVC polymer by thermal and/or radiolytic degradation is well-known to evolve HCl gas, which is highly corrosive to stainless steel and other metals in the presence of moisture. Degradation of the pPVC packaging material was likely caused by radiolysis in the presence of tritium gas within the waste container, though other degradation mechanisms (aging, thermo-oxidation, plasticizer migration) over 30 years storage may have contributed. Corrosion was also likely enhanced by the crevice in the container weld design, and may have been enhanced by the presence of tritiated water. Similar non-failed spent mercury gold trap waste containers did not show radiographic evidence of plastic packaging or trapped free liquid within the container. Therefore, those containers are not expected to exhibit similar failures. Halogenated polymers such as pPVC subject to degradation can evolve halide gases such as HCl, which is corrosive in the presence of moisture and can generate pressure in sealed systems.

A Study of Energy Management Systems and its Failure Modes in Smart Grid Power Distribution

Science.gov (United States)

Musani, Aatif

The subject of this thesis is distribution level load management using a pricing signal in a smart grid infrastructure. The project relates to energy management in a spe-cialized distribution system known as the Future Renewable Electric Energy Delivery and Management (FREEDM) system. Energy management through demand response is one of the key applications of smart grid. Demand response today is envisioned as a method in which the price could be communicated to the consumers and they may shift their loads from high price periods to the low price periods. The development and deployment of the FREEDM system necessitates controls of energy and power at the point of end use. In this thesis, the main objective is to develop the control model of the Energy Management System (EMS). The energy and power management in the FREEDM system is digitally controlled therefore all signals containing system states are discrete. The EMS is modeled as a discrete closed loop transfer function in the z-domain. A breakdown of power and energy control devices such as EMS components may result in energy con-sumption error. This leads to one of the main focuses of the thesis which is to identify and study component failures of the designed control system. Moreover, H-infinity ro-bust control method is applied to ensure effectiveness of the control architecture. A focus of the study is cyber security attack, specifically bad data detection in price. Test cases are used to illustrate the performance of the EMS control design, the effect of failure modes and the application of robust control technique. The EMS was represented by a linear z-domain model. The transfer function be-tween the pricing signal and the demand response was designed and used as a test bed. EMS potential failure modes were identified and studied. Three bad data detection meth-odologies were implemented and a voting policy was used to declare bad data. The run-ning mean and standard deviation analysis method proves to be

Loading capacities and failure modes of various reinforced concrete slabs subjected to high-speed loading

International Nuclear Information System (INIS)

Saito, H.; Imamura, A.; Takeuchi, M.; Okamoto, S.; Kasai, Y.; Tsubota, H.; Yoshimura, M.

1993-01-01

The objective of this study was to clarify experimentally and analytically the loading capacities, deformations and failure modes of various types of reinforced concrete structures subjected to loads applied at various loading rates. Flat slabs, slabs with beams and cylindrical walls were tested under static, low-speed and high-speed loading. Analysis was applied to estimate the test results by the finite element method using a layered shell element. The analysis closely simulated the experimental results until punching shear failure occurred. (author)

Rayleigh-Taylor instability and resulting failure modes of ablatively imploded inertial fusion targets

International Nuclear Information System (INIS)

Montierth, L.; Morse, R.

1984-01-01

This chapter discusses small amplitude growth of the outside surface instability and modes of failure resulting from nonlinear development of the inside surface instability. It is demonstrated that pellets with initial pellet aspect ratio, A /SUB p/ >5 may have difficulty with Rayleigh-Taylor instability and that shells with A /SUB p/ greater than or equal to10 will probably demand stringent smoothness specification in order not to experience failure in the final implosion. The linear amplification of the outside surface instability can easily exceed 10 3 for A /SUB p/ and resulting A values in the range of programmatic interest. Amplifications of this order, starting from attainable surface finishes, can then penetrate to the inside shell surface, producing perturbations there which approach the nonlinear development amplitude and at the start of the final deceleration. It is shown that such inside surface perturbations can be amplified to large amplitude by the inside instability and cause failure through reduction of the maximum fuel temperature achieved. Insight into the scaling of failure mechanisms is offered

Selection of transverse modes in laser cavities containing waveguides and open parts

International Nuclear Information System (INIS)

Gurin, O V; Degtyarev, A V; Maslov, Vyacheslav A; Svich, V A; Tkachenko, V M; Topkov, A N

2001-01-01

The transverse modes of a submillimetre laser cavity that contains waveguides and open parts were studied theoretically and experimentally with the purpose of finding methods for mode selection. Two methods based on the filtering of the Fourier spectra of the waveguide modes and the use of their interference were substantiated numerically and realised in experiment. Special attention was paid to the mode selection in tunable lasers. Scaling laws allowing one to use the obtained results in a wide range of the cavity parameters and wavelengths are presented. (laser applications and other topics in quantum electronics)

Fault tree and failure mode and effects analysis of a digital safety function

International Nuclear Information System (INIS)

Maskuniitty, M.; Pulkkinen, U.

1995-01-01

The principles of fault tree and failure mode and effects analysis (FMEA) for the analysis of digital safety functions of nuclear power plants are discussed. Based on experiences from a case study, a proposal for a full scale analysis is presented. The feasibility and applicability the above mentioned reliability engineering methods are discussed. (author). 13 refs, 1 fig., 2 tabs

SU-G-TeP4-05: An Evaluation of a Low Dose Rate (LDR) Prostate Brachytherapy Procedure Using a Failure Modes and Effects Analysis (FMEA)

International Nuclear Information System (INIS)

Cheong, S-K; Kim, J

2016-01-01

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

SU-G-TeP4-05: An Evaluation of a Low Dose Rate (LDR) Prostate Brachytherapy Procedure Using a Failure Modes and Effects Analysis (FMEA)

Energy Technology Data Exchange (ETDEWEB)

Cheong, S-K; Kim, J [University of Pittsburgh Medical Center, Pittsburgh, PA (United States)

2016-06-15

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

Bonded Joints with “Nano-Stitches”: Effect of Carbon Nanotubes on Load Capacity and Failure Modes

Directory of Open Access Journals (Sweden)

Henrique N. P. Oliva

Full Text Available Abstract Carbon nanotubes were employed as adhesive reinforcement/nano-stitches to aluminum bonded joints. The CNT addition to an epoxy adhesive not only lead to an increase on load capacity but it is also the most probable cause of the mixed failure mode (adhesive/cohesive. The damage evolution was described as the stiffness decrease and the failure mixed modes were related to the load capacity. Although the presence of CNT cluster were observed, in small concentrations (< 1.0 wt. %, these clusters acted as crack stoppers and lead to an increase on lap joint shear strength. The addition of 2.0 wt. % carbon nanotubes lead to an increase on load capacity of approximately 116.2 % when the results were compared against the single lap joints without carbon nanotubes.

Container Materials, Fabrication And Robustness

International Nuclear Information System (INIS)

Dunn, K.; Louthan, M.; Rawls, G.; Sindelar, R.; Zapp, P.; Mcclard, J.

2009-01-01

The multi-barrier 3013 container used to package plutonium-bearing materials is robust and thereby highly resistant to identified degradation modes that might cause failure. The only viable degradation mechanisms identified by a panel of technical experts were pressurization within and corrosion of the containers. Evaluations of the container materials and the fabrication processes and resulting residual stresses suggest that the multi-layered containers will mitigate the potential for degradation of the outer container and prevent the release of the container contents to the environment. Additionally, the ongoing surveillance programs and laboratory studies should detect any incipient degradation of containers in the 3013 storage inventory before an outer container is compromised.

Risk management for outsourcing biomedical waste disposal - using the failure mode and effects analysis.

Science.gov (United States)

Liao, Ching-Jong; Ho, Chao Chung

2014-07-01

Using the failure mode and effects analysis, this study examined biomedical waste companies through risk assessment. Moreover, it evaluated the supervisors of biomedical waste units in hospitals, and factors relating to the outsourcing risk assessment of biomedical waste in hospitals by referring to waste disposal acts. An expert questionnaire survey was conducted on the personnel involved in waste disposal units in hospitals, in order to identify important factors relating to the outsourcing risk of biomedical waste in hospitals. This study calculated the risk priority number (RPN) and selected items with an RPN value higher than 80 for improvement. These items included "availability of freezing devices", "availability of containers for sharp items", "disposal frequency", "disposal volume", "disposal method", "vehicles meeting the regulations", and "declaration of three lists". This study also aimed to identify important selection factors of biomedical waste disposal companies by hospitals in terms of risk. These findings can serve as references for hospitals in the selection of outsourcing companies for biomedical waste disposal. Copyright © 2014 Elsevier Ltd. All rights reserved.

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

International Nuclear Information System (INIS)

Xie, J; Wang, J; P, J; Chen, J; Hu, W

2016-01-01

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

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

Energy Technology Data Exchange (ETDEWEB)

Xie, J; Wang, J; P, J; Chen, J; Hu, W [Fudan University Shanghai Cancer Center, Shanghai, Shanghai (China)

2016-06-15

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

Failure detection system risk reduction assessment

Science.gov (United States)

Aguilar, Robert B. (Inventor); Huang, Zhaofeng (Inventor)

2012-01-01

A process includes determining a probability of a failure mode of a system being analyzed reaching a failure limit as a function of time to failure limit, determining a probability of a mitigation of the failure mode as a function of a time to failure limit, and quantifying a risk reduction based on the probability of the failure mode reaching the failure limit and the probability of the mitigation.

CE/Bechtel design containment response to severe accident phenomenology: A comparison among several combustion engineering plants

International Nuclear Information System (INIS)

Khalil, Y.F.; Schneider, R.E.

1995-01-01

The objectives of this paper are to: (1) discuss the types of severe accident phenomena that drive containment failure modes in CE plants and (2) contribute to the current state of knowledge of CE/Bechtel-design containment response to severe accident phenomenology. The second objective is addressed by providing a comparative study of containment response to severe accidents among several CE plants including Millstone Unit 2 (MP2), Palisades (Consumers Power), Calvert Cliffs (Baltimore Gas and Electric Company), Palo Verde (Arizona Public Service), and SONGS Units 2 and 3 (Southern California Edison). The motivation for addressing the second objective is based on the current lack of comprehensive literature on CE/Bechtel design containment failure modes and mechanisms for accidents that progress beyond the design basis limits. The first part of this paper addresses severe accident phenomena-related failure mechanisms in CE/Bechtel-designed containments. The second part of this work provides a comparative study of containment response among several CE plants

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

International Nuclear Information System (INIS)

Ibanez-Rosello, B; Bautista-Ballesteros, J; Bonaque, J; Lliso, F; Carmona, V; Gimeno, J; Ouhib, Z; Perez-Calatayud, J

2016-01-01

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

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

Energy Technology Data Exchange (ETDEWEB)

Ibanez-Rosello, B; Bautista-Ballesteros, J; Bonaque, J; Lliso, F; Carmona, V; Gimeno, J [Hospital La Fe, Valencia, Valencia (Spain); Ouhib, Z [Lynn Regional Cancer Center, Delray Beach, FL (United States); Perez-Calatayud, J [Hospital La Fe, Valencia, Valencia (Spain); Clinica Benidorm, Benidorm, Alicante (Spain)

2016-06-15

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

Concrete containment integrity program at EPRI

International Nuclear Information System (INIS)

Winkleblack, R.K.; Tang, Y.K.

1984-01-01

Many in the nuclear power plant business believe that the catastrophic failure mode for reactor containment structures is unrealistic. One of the goals of the EPRI containment integrity program is to demonstrate that this is true. The objective of the program is to provide the utility industry with an experimental data base and a test-validated analytical method for realistically evaluating the actual over-pressure capability of concrete containment buildings and to predict leakage behavior if higher pressures were to occur. The ultimate goal of this research effort is to characterize the containment leakage mode and rate as a function of internal pressure and time so that the risk can be realistically assessed for hypothetical degraded core accidents. Progress in the first and second phases of the three-phase analytical and testing efforts is discussed

An analysis of containment venting as a severe accident mitigation strategy for the BWR Mark II containment

International Nuclear Information System (INIS)

Kelly, D.L.; Galyean, W.J.

1990-01-01

An evaluation of a BWR/4 reactor with a Mark-II containment has identified the effects of containment venting on core damage frequency and containment failure mode, and has performed a limited evaluation of the effects on the off-site consequences. The analysis was founded upon an existing probabilistic risk assessment (PRA) with the addition of a proposed filtered containment venting system, based on the Swedish Filtra system installed at the Barseback nuclear power station in southern Sweden. Three different containment venting strategies were examined for their effects on plant risk. These are discussed

Cost Based Failure Modes and Effects Analysis (FMEA) for Systems of Accelerator Magnets

International Nuclear Information System (INIS)

Spencer, Cherrill M

2003-01-01

The proposed Next Linear Collider (NLC) has a proposed 85% overall availability goal, the availability specifications for all its 7200 magnets and their 6167 power supplies are 97.5% each. Thus all of the electromagnets and their power supplies must be highly reliable or quickly repairable. Improved reliability or repairability comes at a higher cost. We have developed a set of analysis procedures for magnet designers to use as they decide how much effort to exert, i.e. how much money to spend, to improve the reliability of a particular style of magnet. We show these procedures being applied to a standard SLAC electromagnet design in order to make it reliable enough to meet the NLC availability specs. First, empirical data from SLAC's accelerator failure database plus design experience are used to calculate MTBF for failure modes identified through a FMEA. Availability for one particular magnet can be calculated. Next, labor and material costs to repair magnet failures are used in a Monte Carlo simulation to calculate the total cost of all failures over a 30-year lifetime. Opportunity costs are included. Engineers choose from amongst various designs by comparing lifecycle costs

Failure mode and dynamic behavior of nanophase iron under compression

Energy Technology Data Exchange (ETDEWEB)

Jia, D.; Ramesh, K.T.; Ma, E.

1999-12-17

Materials with ultra-fine grains down to the nanophase range (<100 nm) have been attracting considerable interest because of their unique properties compared with conventional materials. In general, the understanding of the deformation behavior of ultrafine- and nano-grained metals and alloys is still in the rudimentary stage. In this paper, the authors report on the compressive deformation behavior and failure mode of near full-density (99.2% of theoretical density) elemental Fe with an average grain size of 80 nm. Even less is known about the behavior of ultrafine- or nano-grained alloys under dynamic loading of high strain rates. Such response is relevant to possible applications of these alloys under impact conditions, such as for kinetic energy penetrators currently under investigation. The authors will present the results of high-strain-rate (Kolsky bar) tests for nano-Fe and compare them with those obtained in quasi-static compression tests of the same material. The authors demonstrate that little strain rate sensitivity is observable in the rate of 10{sup {minus}4} to 3 x 10{sup +3} s{sup {minus}1}, in sharp contrast to the strong rate sensitivity known for conventional coarse-grained bcc Fe. The weak rate dependence is correlated with shear banding as the dominant deformation and failure mechanism. This strain rate hardening behavior, together with the high strength, absence of strain hardening, and failure mechanism observed, are discussed in the context of potential applications for penetrator materials.

Fuzzy-based failure mode and effect analysis (FMEA) of a hybrid molten carbonate fuel cell (MCFC) and gas turbine system for marine propulsion

Science.gov (United States)

Ahn, Junkeon; Noh, Yeelyong; Park, Sung Ho; Choi, Byung Il; Chang, Daejun

2017-10-01

This study proposes a fuzzy-based FMEA (failure mode and effect analysis) for a hybrid molten carbonate fuel cell and gas turbine system for liquefied hydrogen tankers. An FMEA-based regulatory framework is adopted to analyze the non-conventional propulsion system and to understand the risk picture of the system. Since the participants of the FMEA rely on their subjective and qualitative experiences, the conventional FMEA used for identifying failures that affect system performance inevitably involves inherent uncertainties. A fuzzy-based FMEA is introduced to express such uncertainties appropriately and to provide flexible access to a risk picture for a new system using fuzzy modeling. The hybrid system has 35 components and has 70 potential failure modes, respectively. Significant failure modes occur in the fuel cell stack and rotary machine. The fuzzy risk priority number is used to validate the crisp risk priority number in the FMEA.

Lunar Module ECS (Environmental Control System) - Design Considerations and Failure Modes. Part 1

Science.gov (United States)

Interbartolo, Michael

2009-01-01

Design considerations and failure modes for the Lunar Module (LM) Environmental Control System (ECS) are described. An overview of the the oxygen supply and cabin pressurization, atmosphere revitalization, water management and heat transport systems are provided. Design considerations including reliability, flight instrumentation, modularization and the change to the use of batteries instead of fuel cells are discussed. A summary is provided for the LM ECS general testing regime.

Development of a container failure function for titanium

International Nuclear Information System (INIS)

Ikeda, B.M.; Shoesmith, D.W.

1990-01-01

Any prediction of container failure times will be based on measurements of crevice corrosion rates under conditions that simulate those anticipated in a waste vault. Since there is a good mechanistic understanding of crevice corrosion in titanium alloys, this is a reasonable approach. Some containers are assumed to fail immediately because of undetected fabrication defects. Experiments designed to measure corrosion penetration rates are under way. Uniform corrosion rates will be determined from weight-gain measurements and estimated from measurements of oxide thickness using Auger spectroscopy. Crevice corrosion can be estimated by counting the number of pits and corroded areas within the crevice using an image analyzer. By performing such analyses on a wide range of specimens under a variety of conditions the authors hope to determine the susceptibilities of titanium alloys to crevice corrosion; measure the uniform and crevice corrosion rates as a function of temperature and chloride concentration; measure the extent of hydrogen pickup as a function of temperature and chloride concentration; and predict the lifetime of containers under Canadian waste vault conditions

Posttest analysis of a 1:4-scale prestressed concrete containment vessel model

International Nuclear Information System (INIS)

Dameron, R.A.; Rashid, Y.R.; Hessheimer, M.F.

2003-01-01

The Nuclear Power Engineering Corporation (NUPEC) of Japan and the U.S. Nuclear Regulatory Commission (NRC), Office of Nuclear Regulatory Research, co-sponsored a Cooperative Containment Research Program at Sandia National Laboratories (SNL) in Albuquerque, New Mexico. As part of the program, a prestressed concrete containment vessel (PCCV) model was subjected to a series of overpressurization tests at SNL beginning in July 2000 and culminating in a functional failure mode or Limit State Test (LST) in September 2000 and a Structural Failure Mode Test (SFMT) in November 2001. The PCCV model, uniformly scaled at 1:4, is representative of the containment structure of an actual Pressurized Water Reactor (PWR) plant (OHI-3) in Japan. The objectives of the pressurization tests were to obtain measurement of the structural response to pressure loading beyond design basis accident in order to validate analytical modeling, to find pressure capacity of the model, and to observe its failure mechanisms. This paper compares results of pretest analytical studies of the PCCV model to the PCCV high pressure test measurements and describes results of post-test analytical studies. These analyses have been performed by ANATECH Corp. under contract with Sandia National Laboratories. The post-test analysis represents the third phase of a comprehensive PCCV analysis effort. The first phase consisted of preliminary analyses to determine what finite element models would be necessary for the pretest prediction analyses, and the second phase consisted of the pretest prediction analyses. The principal objectives of the post-test analyses were: (1) to provide insights to improve the analytical methods for predicting the structural response and failure modes of a prestressed concrete containment, and (2) to evaluate by analysis any phenomena or failure mode observed during the test that had not been explicitly predicted by analysis. In addition to summarizing comparisons between measured

Degradation and failure characteristics of NPP containment protective coating systems

Energy Technology Data Exchange (ETDEWEB)

Sindelar, R.L.

2000-03-30

A research program to investigate the performance and potential for failure of Service Level 1 coating systems used in nuclear power plant containment is in progress. The research activities are aligned to address phenomena important to cause failure as identified by the industry coatings expert panel. The period of interest for performance covers the time from application of the coating through 40 years of service, followed by a medium-to-large break loss-of-coolant accident scenario, which is a design basis accident (DBA) scenario. The interactive program elements are discussed in this report and the application of these elements to the System 5 coating system (polyamide epoxy primer, carbon steel substrate) is used to evaluate performance.

Degradation and failure characteristics of NPP containment protective coating systems

International Nuclear Information System (INIS)

Sindelar, R.L.

2000-01-01

A research program to investigate the performance and potential for failure of Service Level 1 coating systems used in nuclear power plant containment is in progress. The research activities are aligned to address phenomena important to cause failure as identified by the industry coatings expert panel. The period of interest for performance covers the time from application of the coating through 40 years of service, followed by a medium-to-large break loss-of-coolant accident scenario, which is a design basis accident (DBA) scenario. The interactive program elements are discussed in this report and the application of these elements to the System 5 coating system (polyamide epoxy primer, carbon steel substrate) is used to evaluate performance

PENERAPAN FUZZY ANALYTIC HIERARCHY PROCESS DALAM METODE MULTI ATTRIBUTE FAILURE MODE ANALYSIS UNTUK MENGIDENTIFIKASI PENYEBAB KEGAGALAN POTENSIAL PADA PROSES PRODUKSI

Directory of Open Access Journals (Sweden)

Dorina Hetharia

2012-02-01

Full Text Available Banyak metode dalam Total Quality Management (TQM yang dapat digunakan untuk melakukan perbaikan kualitas produk dan jasa. Salah satunya adalah Multi Attribute Failure Mode Analysis (MAFMA, yang dapat digunakan untuk mengeliminasi atau mengurangi kemungkinan terjadinya kegagalan bila dilihat dari faktor penyebabnya, sehingga dapat mencegah terulang kembali kegagalan tersebut. MAFMA merupakan pengembangan dari Failure Mode and Effect Analysis (FMEA, yang mengintegrasikan atribut severity, occurance, dan detectability dengan aspek ekonomi yakni expected cost. Pada FMEA, penentuan penyebab kegagalan potensial suatu produk dilakukan dengan memberikan nilai (score pada atribut severity, occurance, dan detectability, yang dilanjutkan dengan menghitung nilai Risk Priority Number (RPN tertinggi. Sedangkan pada MAFMA, penentuan penyebab kegagalan potensial dilakukan dengan pemberian bobot pada ke-empat atribut. Pemberian bobot tersebut menggunakan Analytic Hierarchy Process (AHP dengan logika fuzy. Atribut severity, occurance, detectability dan expected cost pada MAFMA dimasukkan sebagai level kriteria dalam struktur hirarkhi AHP, sedangkan penyebab-penyebab kegagalan akan menjadi level alternatif pada struktur hirarkhi tersebut. Studi kasus pada PT Pelita Cengkareng Paper & Co. menunjukkan bahwa bobot  kriteria severity sebesar 0.3461, kriteria occurance sebesar 0.0848, kriteria detectability sebesar 0.1741 dan kriteria expected cost sebesar 0.3950.Sedangkan penyebab kegagalan potensial adalah penggumpalan chemical dengan bobot tertinggi sebesar 0.210. Kata kunci: AHP, logika fuzzy, MAFMA     There are several methods of Total Quality Management (TQM that can be used to improve quality of product and service. One of those is Multi Attribute Failure Mode Analysis (MAFMA, which can be used to eliminate or minimize the failure probability based on its causal factor, so we can prevent the same failure in the future. MAFMA is development of Failure Mode

Margins Associated with Loss of Assured Safety for Systems with Multiple Time-Dependent Failure Modes.

Energy Technology Data Exchange (ETDEWEB)

Helton, Jon C. [Arizona State Univ., Tempe, AZ (United States); Brooks, Dusty Marie [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Sallaberry, Cedric Jean-Marie. [Engineering Mechanics Corp. of Columbus, OH (United States)

2018-02-01

Representations for margins associated with loss of assured safety (LOAS) for weak link (WL)/strong link (SL) systems involving multiple time-dependent failure modes are developed. The following topics are described: (i) defining properties for WLs and SLs, (ii) background on cumulative distribution functions (CDFs) for link failure time, link property value at link failure, and time at which LOAS occurs, (iii) CDFs for failure time margins defined by (time at which SL system fails) – (time at which WL system fails), (iv) CDFs for SL system property values at LOAS, (v) CDFs for WL/SL property value margins defined by (property value at which SL system fails) – (property value at which WL system fails), and (vi) CDFs for SL property value margins defined by (property value of failing SL at time of SL system failure) – (property value of this SL at time of WL system failure). Included in this presentation is a demonstration of a verification strategy based on defining and approximating the indicated margin results with (i) procedures based on formal integral representations and associated quadrature approximations and (ii) procedures based on algorithms for sampling-based approximations.

Failure Modes in Concrete Repair Systems due to Ongoing Corrosion

Directory of Open Access Journals (Sweden)

Mladena Luković

2017-01-01

Full Text Available Corrosion of steel reinforcement is the main cause of deterioration in reinforced concrete structures. It can result in cracking and spalling of the concrete cover. After the damaged cover is repaired, reinforcement corrosion might continue and even accelerate. While the development of the corrosion cell is difficult to control, the damage can be possibly delayed and controlled by use of a suitable repair material. The lattice fracture model is used in this paper to investigate the performance of strain hardening cementitious composite (SHCC in concrete repair systems exposed to ongoing corrosion. Numerical results were verified by experimental tests when SHCC, nonreinforced material (repair mortar, and commercial repair mortar are used as repair materials. In experiments, reinforcement bars (surrounded by a repair material were exposed to accelerated corrosion tests. The influence of the substrate surface preparation, the type of repair material, the interface, and the substrate strength on the resulting damage and failure mode of repair systems are discussed. In general, SHCC repair enables distributed cracking with small crack widths, up to several times smaller compared to repair mortar. Furthermore, more warning signs prior to the final failure are present in the SHCC repair system.

Biaxial failure criteria and stress-strain response for concrete of containment structure

International Nuclear Information System (INIS)

Lee, S. K.; Woo, S. K.; Song, Y. C.; Kweon, Y. K.; Cho, C. H.

2001-01-01

Biaxial failure criteria and stress-strain response for plain concrete of containment structure on nuclear power plants are studied under uniaxial and biaxial stress(compression-compression, compression-tension, and tension-tension combined stress). The concrete specimens of a square plate type are used for uniaxial and biaxial loading. The experimental data indicate that the strength of concrete under biaxial compression, f 2 /f 1 =-1/-1, is 17 percent larger than under uniaxial compression and the poisson's ratio of concrete is 0.1745. On the base of the results, a biaxial failure envelope for plain concrete that the uniaxial strength is 5660 psi are provided, and the biaxial failure behaviors for three biaxial loading areas are plotted respectively. And, various analytical equations having the reliability are proposed for representations of the biaxial failure criteria and stress-strain response curves of concrete

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

Science.gov (United States)

Rucitra, A. L.

2018-03-01

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

Failure modes and effects analysis as a design tool for nuclear safety systems

International Nuclear Information System (INIS)

Tashjian, B.M.

1975-01-01

The activities of nuclear power plant designers are monitored by government and industry to an unprecedented degree. This involves not only rigid design and quality assurance criteria, but extensive documentation and reporting. The failure modes and effects analysis (FMEA) is a technique for checking designs and assuring quality. Included in the FMEA is a system of documentation. A simplified example of the reactor protective system (RPS) is used to illustrate the method. (U.S.)

Failure mode and effect analysis on safety critical components of space travel

Directory of Open Access Journals (Sweden)

Kouroush Jenab

2015-07-01

Full Text Available Sending men to space has never been an ordinary activity, it requires years of planning and preparation in order to have a chance of success. The payoffs of reliable and repeatable space flight are many, including both Commercial and Military opportunities. In order for reliable and repeatable space flight to become a reality, catastrophic failures need to be detected and mitigated before they occur. It can be shown that small pieces of a design which seem ordinary can create devastating impacts if not designed and tested properly. This paper will address the use of a Failure Mode, Effects, and Criticality Analysis (FMECA with modified Risk Priority Number (RPN and its application to safety critical design components of shuttle liftoff. An example will be presented here which specifically focuses on the Solid Rocket Boosters (SRBs to illustrate the FMECA approach to reliable space travel.

Failure mode and effect analysis in asset maintenance : a multiple case study in the process industry

NARCIS (Netherlands)

Braaksma, Jan; Klingenberg, W.; Veldman, J.

2013-01-01

Failure mode and effect analysis (FMEA) is an important method for designing and prioritising preventive maintenance activities and is often used as the basis for preventive maintenance planning. Although FMEA was studied extensively, most of the published work so far covers FMEA concept design.

Failure mode and effect analysis in asset maintenance: a multiple case study in the process industry

NARCIS (Netherlands)

Braaksma, Anne Johannes Jan; Klingenberg, W.; Veldman, Jasper

2013-01-01

Failure mode and effect analysis (FMEA) is an important method for designing and prioritising preventive maintenance activities and is often used as the basis for preventive maintenance planning. Although FMEA was studied extensively, most of the published work so far covers FMEA concept design.

Modular titanium alloy neck adapter failures in hip replacement - failure mode analysis and influence of implant material

Directory of Open Access Journals (Sweden)

Bloemer Wilhelm

2010-01-01

Full Text Available Abstract Background Modular neck adapters for hip arthroplasty stems allow the surgeon to modify CCD angle, offset and femoral anteversion intraoperatively. Fretting or crevice corrosion may lead to failure of such a modular device due to high loads or surface contamination inside the modular coupling. Unfortunately we have experienced such a failure of implants and now report our clinical experience with the failures in order to advance orthopaedic material research and joint replacement surgery. The failed neck adapters were implanted between August 2004 and November 2006 a total of about 5000 devices. After this period, the titanium neck adapters were replaced by adapters out of cobalt-chromium. Until the end of 2008 in total 1.4% (n = 68 of the implanted titanium alloy neck adapters failed with an average time of 2.0 years (0.7 to 4.0 years postoperatively. All, but one, patients were male, their average age being 57.4 years (36 to 75 years and the average weight 102.3 kg (75 to 130 kg. The failures of neck adapters were divided into 66% with small CCD of 130° and 60% with head lengths of L or larger. Assuming an average time to failure of 2.8 years, the cumulative failure rate was calculated with 2.4%. Methods A series of adapter failures of titanium alloy modular neck adapters in combination with a titanium alloy modular short hip stem was investigated. For patients having received this particular implant combination risk factors were identified which were associated with the occurence of implant failure. A Kaplan-Meier survival-failure-analysis was conducted. The retrieved implants were analysed using microscopic and chemical methods. Modes of failure were simulated in biomechanical tests. Comparative tests included modular neck adapters made of titanium alloy and cobalt chrome alloy material. Results Retrieval examinations and biomechanical simulation revealed that primary micromotions initiated fretting within the modular tapered neck

Geotechnical Failure of a Concrete Crown Wall on a Rubble Mound Breakwater Considering Sliding Failure and Rupture Failure of Foundation

DEFF Research Database (Denmark)

Christiani, E.; Burcharth, H. F.; Sørensen, John Dalsgaard

1995-01-01

Sliding and rupture failure in the rubble mound are considered in this paper. In order to describe these failure modes the wave breaking forces have to be accounted for. Wave breaking forces on a crown wall are determined from Burcharth's wave force formula Burcharth (1992). Overtopping rates...... are calculated for a given design by Bradbury et al. (1988a,b) and compared to acceptable overtopping rates, prior to a determininstic design. The method of foundation stability analysis is presented by the example of a translation slip failure involving kinematically correct slip surfaces and failure zones...... in friction based soil. Rupture failure modes for a crown wall with a plane base and a crown wall with an extended leg on the seaward side will be formulated. The failure modes are described by limit state functions. This allows a deterministic analysis to be performed....

Failure Mode and Effects Analysis (FMEA) of the Emergency Core Cooling System (ECCS) for a Westinghouse type 312, three loop pressurized water reactor

International Nuclear Information System (INIS)

Shopsky, W.E.

1977-01-01

The Emergency Core Cooling System (ECCS) is a Safeguards System designed to cool the core in the unlikely event of a Loss-of-Coolant Accident (LOCA) in the primary reactor coolant system as well as to provide additional shutdown capability following a steam break accident. The system is designed for a high reliability of providing emergency coolant and shutdown reactivity to the core for all anticipated occurrences of such accidents. The ECCS by performing its intended function assures that fuel and clad damage is minimized during accident conditions thus reducing release of fission products from the fuel. The ECCS is designed to perform its function despite sustaining a single failure by the judicious use of equipment and flow path redundancy within and outside the containment structure. By the use of an analytic tool, a Failure Mode and Effects Analysis (FMEA), it is shown that the ECCS is in compliance with the Single Failure Criterion established for active failures of fluid systems during short and long term cooling of the reactor core following a LOCA or steam break accident. An analysis was also performed with regards to passive failure of ECCS components during long-term cooling of the core following an accident. The design of the ECCS was verified as being able to tolerate a single passive failure during long-term cooling of the reactor core following an accident. The FMEA conducted qualitatively demonstrates the reliability of the ECCS (concerning active components) to perform its intended safety function

Reliability and Failure Modes of a Hybrid Ceramic Abutment Prototype.

Science.gov (United States)

Silva, Nelson Rfa; Teixeira, Hellen S; Silveira, Lucas M; Bonfante, Estevam A; Coelho, Paulo G; Thompson, Van P

2018-01-01

A ceramic and metal abutment prototype was fatigue tested to determine the probability of survival at various loads. Lithium disilicate CAD-milled abutments (n = 24) were cemented to titanium sleeve inserts and then screw attached to titanium fixtures. The assembly was then embedded at a 30° angle in polymethylmethacrylate. Each (n = 24) was restored with a resin-cemented machined lithium disilicate all-ceramic central incisor crown. Single load (lingual-incisal contact) to failure was determined for three specimens. Fatigue testing (n = 21) was conducted employing the step-stress method with lingual mouth motion loading. Failures were recorded, and reliability calculations were performed using proprietary software. Probability Weibull curves were calculated with 90% confidence bounds. Fracture modes were classified with a stereomicroscope, and representative samples imaged with scanning electron microscopy. Fatigue results indicated that the limiting factor in the current design is the fatigue strength of the abutment screw, where screw fracture often leads to failure of the abutment metal sleeve and/or cracking in the implant fixture. Reliability for completion of a mission at 200 N load for 50K cycles was 0.38 (0.52% to 0.25 90% CI) and for 100K cycles was only 0.12 (0.26 to 0.05)-only 12% predicted to survive. These results are similar to those from previous studies on metal to metal abutment/fixture systems where screw failure is a limitation. No ceramic crown or ceramic abutment initiated fractures occurred, supporting the research hypothesis. The limiting factor in performance was the screw failure in the metal-to-metal connection between the prototyped abutment and the fixture, indicating that this configuration should function clinically with no abutment ceramic complications. The combined ceramic with titanium sleeve abutment prototype performance was limited by the fatigue degradation of the abutment screw. In fatigue, no ceramic crown or ceramic

Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critical patients.

Science.gov (United States)

Viejo Moreno, R; Sánchez-Izquierdo Riera, J Á; Molano Álvarez, E; Barea Mendoza, J A; Temprano Vázquez, S; Díaz Castellano, L; Montejo González, J C

2016-11-01

To improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. A contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact. Patients admitted to the adult polyvalent ICU of a third-level hospital center. A total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. A series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. Indication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. A total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures. The failure mode and effects analysis allowed us to identify improvements in the prevention of

Risk Assessment Planning for Airborne Systems: An Information Assurance Failure Mode, Effects and Criticality Analysis Methodology

Science.gov (United States)

2012-06-01

Visa Investigate Data Breach March 30, 2012 Visa and MasterCard are investigating whether a data security breach at one of the main companies that...30). MasterCard and Visa Investigate Data Breach . New York Times . Stamatis, D. (2003). Failure Mode Effect Analysis: FMEA from Theory to Execution

Risk assessment of look‒alike, sound‒alike (LASA medication errors in an Italian hospital pharmacy: A model based on the ‘Failure Mode and Effect Analysis’

Directory of Open Access Journals (Sweden)

Nestor Ciociano

2017-03-01

Full Text Available Introduction: Look alike/sound alike (LASA drugs errors can take place in hospital wards, and they can place patients at risk for adverse events and death. This study was aimed to realize a risk assessment model for preventing LASA drugs distribution errors by the ‘S.Giovanni di Dio e Ruggi d’Aragona’ hospital pharmacy, in Salerno, Italy. Methods: We used the ‘Failure Mode and Effect Analysis’ (FMEA technique in combination with the Recommendations released by the Italian Ministry of Health in 2010. Our analysis led to the identification of the potential failure modes, together with their causes and effects, using the risk priority number (RPN scoring system. A paired T test was used to compare means of RPN 1 and RPN 2, respectively before and after their application, in order to evaluate the effectiveness of corrective actions. Results: In total, 6 phases, 16 steps, and 13 different potential failure modes were identified. The highest ranked failure modes, with an RPN score of 48 pertained to wrong drug dosage selection. Some of the critical failure modes in sample processing (phases n.1, 2, 3, and 4 were improved by 69.7% in the RPN by focusing on automated technology systems. T test showed that the difference between RPN 1 and RPN 2 was statistically significant for all corrective measures provided by our action plan. Conclusions: Our study showed a lot of potential failure modes related to LASA drugs distribution system provided by the hospital pharmacy. Information technology solutions can be effective to reduce this risk, but the potential for error will remain unless these systems are carefully implemented.

Risk assessment of component failure modes and human errors using a new FMECA approach: application in the safety analysis of HDR brachytherapy

International Nuclear Information System (INIS)

Giardina, M; Castiglia, F; Tomarchio, E

2014-01-01

Failure mode, effects and criticality analysis (FMECA) is a safety technique extensively used in many different industrial fields to identify and prevent potential failures. In the application of traditional FMECA, the risk priority number (RPN) is determined to rank the failure modes; however, the method has been criticised for having several weaknesses. Moreover, it is unable to adequately deal with human errors or negligence. In this paper, a new versatile fuzzy rule-based assessment model is proposed to evaluate the RPN index to rank both component failure and human error. The proposed methodology is applied to potential radiological over-exposure of patients during high-dose-rate brachytherapy treatments. The critical analysis of the results can provide recommendations and suggestions regarding safety provisions for the equipment and procedures required to reduce the occurrence of accidental events. (paper)

Electrical failure analysis for root-cause determination

International Nuclear Information System (INIS)

Riddle, J.

1990-01-01

This paper outlines a practical failure analysis sequence. Several technical definitions are required. A failure is defined as a component that was operating in a system where the system malfunctioned and the replacement of the device restored system functionality. The failure mode is the malfunctioning behavior of the device. The failure mechanism is the underlying cause or source of the failure mode. The failure mechanism is the root cause of the failure mode. The failure analysis procedure needs to be adequately refined to result in the determination of the cause of failure to the degree that corrective action or design changes will prevent recurrence of the failure mode or mechanism. An example of a root-cause determination analysis performed for a nuclear power industry customer serves to illustrate the analysis methodology

Probabilistic fracture failure analysis of nuclear piping containing defects using R6 method

International Nuclear Information System (INIS)

Lin, Y.C.; Xie, Y.J.; Wang, X.H.

2004-01-01

Failure analysis of in-service nuclear piping containing defects is an important subject in the nuclear power plants. Considering the uncertainties in various internal operating loadings and external forces, including earthquake and wind, flaw sizes, material fracture toughness and flow stress, this paper presents a probabilistic assessment methodology for in-service nuclear piping containing defects, which is especially designed for programming. A general sampling computation method of the stress intensity factor (SIF), in the form of the relationship between the SIF and the axial force, bending moment and torsion, is adopted in the probabilistic assessment methodology. This relationship has been successfully used in developing the software, Safety Assessment System of In-service Pressure Piping Containing Flaws (SAPP-2003), based on a well-known engineering safety assessment procedure R6. A numerical example is given to show the application of the SAPP-2003 software. The failure probabilities of each defect and the whole piping can be obtained by this software

Study and analysis of failure modes of the electrolytic capacitors and thyristors, applied to the protection system of the LHC (Large Hadron Collider)

International Nuclear Information System (INIS)

Perisse, F.

2003-07-01

The study presented in this thesis is a contribution about the analysis of failures modes of electrolytic capacitors and thyristors. The studied components are main elements of the protection system of the superconductive magnets of the LHC. The study of the ageing of the electrolytic capacitors has shown that their reliability is strongly related to their technological characteristic. Evolution of their principal indicator of ageing (ESR) can be modeled according to different laws chosen according to their running mode. It appears that the prediction of failure of these components other than that due to wear can be only statistical taking into account the many causes of failure involving various modes of failure. In order to be able to evaluate influence of the ageing of the electrolytic capacitors on a system, simple models taking into account this parameters as well as the effective temperature of the component are proposed. An acceptable precision taking into account the simplicity of the models is obtained. The study of the thyristors has shown that these components have little drift of parameters in static ageing, on the other hand of many failures by short-circuit were observed. These failures always have a local origin, and are due to defects of the components. The breakdown voltage strongly depends on the quality of the thyristor as well as the technology employed. (author)

A collapse mode of failure in powder-filled fuel elements

International Nuclear Information System (INIS)

Feraday, M.A.; Chalder, G.H.

1964-01-01

Two swaged fuel elements containing crushed, fused UO 2 powder were irradiated in a pressurized water loop at high heat ratings (∫Kdθ = 48 w/cm). The fuel elements were 2.0 cm in diameter and were sheathed in nickel-free Zircaloy--2 of 0.038 cm thickness. One element failed when the sheath ruptured at the top of a longitudinal ridge in the sheath after a burn-up of approximately 2550 MWd/TeU. No evidence was found that outgassing of the UO 2 contributed to the failure. Dimensional and structural changes observed in the fuel elements led to the conclusion that ridging of the sheath resulted from the action of coolant pressure on the diametral clearance formed by sintering and shrinkage of the UO 2 . Failure resulted due to severe local deformation accompanying one or more power cycles following ridge formation. (author)

Excitation of contained modes by high energy nuclei and correlated cyclotron emission

International Nuclear Information System (INIS)

Coppi, B.; Penn, G.; Riconda, C.

1997-01-01

In experiments with fusing plasmas, enhanced radiation emission at the harmonics of the cyclotron frequency of fusion reaction products has been observed. A theory is presented that explains key features of these observations and indicates the possibility of extracting significant information about the fusion product population distribution, both in velocity space and over the plasma cross section. The considered model is consistent in particular with the fact that, in DT plasmas, the radiation peaks occur at frequencies corresponding to harmonics of the α particles cyclotron frequency Ω a evaluated at the outer edge of the plasma column, and that a transition to a open-quotes continuumclose quotes spectrum at high frequencies (ω approx-gt 7Ω α ) can be identified. In this model, the radiation is the result of the excitation of radially open-quotes containedclose quotes modes which are driven unstable by the fusion products. The modes considered to be responsible for the discrete part of the spectrum are spatially localized near the plasma edge. The radial containment, which is associated mainly with the inhomogeneity of the plasma density, is in fact a fundamental characteristic since only contained modes can grow out of a relatively weak mode-particle interaction and justify the detected emission power levels. The contained mode is a solution to a set of macroscopic equations, in which the electron motion is tied to that of the magnetic field (Hall effect). The growth rate has been evaluated considering the particle orbits in a toroidal confinement configuration and modelling the distribution function of the interacting particles with the energy at birth before slowing down occurs. The growth rate depends linearly on the α-particle density and can be larger than, or of the order of, the bounce frequency of the magnetically trapped α-particles, which can have a resonant interaction with the mode. According to the theoretical model presented, the discrete

Nonlinear failure analysis of a reinforced concrete containment under internal pressure

International Nuclear Information System (INIS)

Sharma, S.; Wang, Y.K.; Reich, M.

1984-01-01

A detailed nonlinear finite element model is used to investigate the failure response of the Indian Point containment building under severe accident pressures. Refined material models are used to describe the complex stress-strain behavior of the liner and rebar steels, the plain concrete and the reinforced concrete. Structural geometry of the containment is idealized by eight layers of axisymmetric finite elements through the wall thickness in order to closely model the actual placement of the rebars. Soil stiffness under the containment base mat is modeled by a series of nonlinear spring elements. Numerical results presented in the paper describe cracking and plastic deformation (in compression) of the concrete, yielding of the liner and rebar steels and eventual loss of the load carrying capacity of the containment. The results are compared with available data from the previous studies for this containment. 8 references, 9 figures

Predictability of steel containment response near failure track 3 - structural integrity, dynamic behavior, and seismic design

International Nuclear Information System (INIS)

Costello, J.F.; Ludwigsen, J.S.; Luk, V.K.; Hessheimer, M.F.

2000-01-01

The Nuclear Power Engineering Corporation of Japan and the US Nuclear Regulatory Commission Office of Nuclear Regulatory Research, are co-sponsoring and jointly funding a Cooperative Containment Research Program at Sandia National Laboratories, Albuquerque, New Mexico, USA. As a part of this program, a steel containment vessel model and contact structure assembly was tested to failure with over pressurization at Sandia on December 11--12, 1996. The steel containment vessel model was a mixed-scale model (1:10 in geometry and 1:4 in shell thickness) of a steel containment for an improved Mark-II Boiling Water Reactor plant in Japan. The contact structure, which is a thick, bell-shaped steel shell separated at a nominally uniform distance from the model, provides a simplified representation of features of the concrete reactor shield building in the actual plant. The objective of the internal pressurization test was to provide measurement data of the structural response of the model up to its failure in order to validate analytical modeling, to find its pressure capacity, and to observe the failure model and mechanisms

Failure Modes and Effects Analysis on ITER DFLL-TBM system

International Nuclear Information System (INIS)

Hu Liqin; Yuan Run; Chen Hongli; Bai Yunqing

2012-01-01

As required for licensing process, accident analyses of International Thermonuclear Experimental Reactor (ITER) accounting for site specifications and design changes will be updated. Chinese Dual-Functional Lithium-Lead-Test Blanket Module (DFLL-TBM) system is a key safety-related component of ITER, its detailed safety analysis, which was designated to demonstrate the integrated technologies of both Helium single coolant (SLL) blanket and Helium-LiPb dual coolant (DLL) blanket, was performed. Failure Modes and Effects Analysis (FMEA) was applied to perform the safety analysis of DFLL-TBM. This study described the process of FMEA studies on DFLL-TBM system. All safety-related Postulated Initiating Events (PIEs) was identified. And a set of PIEs recommended to be taken into account in the further deterministic transient analyses were defined for both SLL and DLL blanket concepts separately.

Reliability prediction of engineering systems with competing failure modes due to component degradation

International Nuclear Information System (INIS)

Son, Young Kap

2011-01-01

Reliability of an engineering system depends on two reliability metrics: the mechanical reliability, considering component failures, that a functional system topology is maintained and the performance reliability of adequate system performance in each functional configuration. Component degradation explains not only the component aging processes leading to failure in function, but also system performance change over time. Multiple competing failure modes for systems with degrading components in terms of system functionality and system performance are considered in this paper with the assumption that system functionality is not independent of system performance. To reduce errors in system reliability prediction, this paper tries to extend system performance reliability prediction methods in open literature through combining system mechanical reliability from component reliabilities and system performance reliability. The extended reliability prediction method provides a useful way to compare designs as well as to determine effective maintenance policy for efficient reliability growth. Application of the method to an electro-mechanical system, as an illustrative example, is explained in detail, and the prediction results are discussed. Both mechanical reliability and performance reliability are compared to total system reliability in terms of reliability prediction errors

Preliminary analysis of a 1:4 scale prestressed concrete containment vessel model

International Nuclear Information System (INIS)

Dameron, R.A.; Rashid, Y.R.; Luk, V.K.; Hessheimer, M.F.

1997-01-01

Sandia National Laboratories is conducting a research program to investigate the integrity of nuclear containment structures. As part of the program Sandia will construct an instrumented 1:4 scale model of a prestressed concrete containment vessel (PCCV) for pressurized water reactors (PWR), which will be pressure tested up to its ultimate capacity. One of the key program objectives is to develop validated methods to predict the structural performance of containment vessels when subjected to beyond design basis loadings. Analytical prediction of structural performance requires a stepwise, systematic approach that addresses all potential failure modes. The analysis effort includes two and three-dimensional nonlinear finite element analyses of the PCCV test model to evaluate its structural performance under very high internal pressurization. Such analyses have been performed using the nonlinear concrete constitutive model, ANACAP-U, in conjunction with the ABAQUS general purpose finite element code. The analysis effort is carried out in three phases: preliminary analysis; pretest prediction; and post-test data interpretation and analysis evaluation. The preliminary analysis phase serves to provide instrumentation support and identify candidate failure modes. The associated tasks include the preliminary prediction of failure pressure and probable failure locations and the development of models to be used in the detailed failure analyses. This paper describes the modeling approaches and some of the results obtained in the first phase of the analysis effort

Overpressurization performance of containment structures

International Nuclear Information System (INIS)

Barr, P.; Bleackley, M.; Harrop, L.P.; Hargreaves, J.; Jowett, J.; Phillips, D.W.

1987-01-01

The containment building of a PWR is the outermost engineered barrier between the reactor and the environment. The most important element of such a containment system is the pressure boundary structure and its associated seals and penetrations. This containment structure is designed deterministically to withstand a number of loads and load combinations of which the dominant one is generally the internal pressure due to the double-ended guillotine break in one of the primary circuit loops. Typically, the design basis large LOCA produces a peak pressure increase in the region of 0.3 MPa in some 10 seconds and with a duration of up to a few tens of seconds. The assessment of overpressure performance of the containment structure is a key component of the PWR safety case, and is usually carried out by estimating a static factor of safety to some failure limit state. These estimates can be made using simple force-balance calculations or complicated finite element calculations, and both approaches have merit. In this paper we examine these approaches and discuss their value in estimating failure pressures and failure modes for a variety of internal pressurization transients. This discussion covers both general design and risk considerations and is illustrated by numerical examples taken from previous and on-going analysis

Tensile Mechanical Properties and Failure Modes of a Basalt Fiber/Epoxy Resin Composite Material

OpenAIRE

He, Jingjing; Shi, Junping; Cao, Xiaoshan; Hu, Yifeng

2018-01-01

Uniaxial tensile tests of basalt fiber/epoxy (BF/EP) composite material with four different fiber orientations were conducted under four different fiber volume fractions, and the variations of BF/EP composite material failure modes and tensile mechanical properties were analyzed. The results show that when the fiber volume fraction is constant, the tensile strength, elastic modulus, and limiting strain of BF/EP composite material all decrease with increasing fiber orientation angle. When the ...

Separate effects testing and analyses to investigate liner tearing of the 1:6-scale reinforced concrete containment building

International Nuclear Information System (INIS)

Spletzer, B.L.; Lambert, L.D.; Bergman, V.L.

1995-06-01

The overpressurization of a 1:6-scale reinforced concrete containment building demonstrated that liner tearing is a plausible failure mode in such structures under severe accident conditions. A combined experimental and analytical program was developed to determine the important parameters which affect liner tearing and to develop reasonably simple analytical methods for predicting when tearing will occur. Three sets of test specimens were designed to allow individual control over and investigation of the mechanisms believed to be important in causing failure of the liner plate. The series of tests investigated the effect on liner tearing produced by the anchorage system, the loading conditions, and the transition in thickness from the liner to the insert plate. Before testing, the specimens were analyzed using two- and three-dimensional finite element models. Based on the analysis, the failure mode and corresponding load conditions were predicted for each specimen. Test data and post-test examination of test specimens show mixed agreement with the analytical predictions with regard to failure mode and specimen response for most tests. Many similarities were also observed between the response of the liner in the 1:6-scale reinforced concrete containment model and the response of the test specimens. This work illustrates the fact that the failure mechanism of a reinforced concrete containment building can be greatly influenced by details of liner and anchorage system design. Further, it significantly increases the understanding of containment building response under severe conditions

Software Tool for Automated Failure Modes and Effects Analysis (FMEA) of Hydraulic Systems

DEFF Research Database (Denmark)

Stecki, J. S.; Conrad, Finn; Oh, B.

2002-01-01

Offshore, marine,aircraft and other complex engineering systems operate in harsh environmental and operational conditions and must meet stringent requirements of reliability, safety and maintability. To reduce the hight costs of development of new systems in these fields improved the design...... management techniques and a vast array of computer aided techniques are applied during design and testing stages. The paper present and discusses the research and development of a software tool for automated failure mode and effects analysis - FMEA - of hydraulic systems. The paper explains the underlying...

Performance of Sequoyah Containment Anchorage System

International Nuclear Information System (INIS)

Fanous, F.; Greimann, L.; Wassef, W.; Bluhm, D.

1993-01-01

Deformation of a steel containment anchorage system during a severe accident may result in a leakage path at the containment boundaries. Current design criteria are based on either ductile or brittle failure modes of headed bolts that do not account for factors such as cracking of the containment basemat or deformation of the anchor bolt that may affect the behavior of the containment anchorage system. The purpose of this study was to investigate the performance of a typical ice condenser containment's anchorage system. This was accomplished by analyzing the Sequoyah Containment Anchorage System. Based on a strength of materials approach and assuming that the anchor bolts are resisting the uplift caused by the internal pressure, one can estimate that the failure of the anchor bolts would occur at a containment pressure of 79 psig. To verify these results and to calibrate the strength of materials equation, the Sequoyah containment anchorage system was analyzed with the ABAQUS program using a three-dimensional, finite-element model. The model included portions of the steel containment building, shield building, anchor bolt assembly, reinforced concrete mat and soil foundation material

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

Science.gov (United States)

Li, Xibing; Du, Kun; Li, Diyuan

2015-11-01

True triaxial tests have been carried out on granite, sandstone and cement mortar using cubic specimens with the process of unloading the minor principal stress. The strengths and failure modes of the three rock materials are studied in the processes of unloading σ 3 and loading σ 1 by the newly developed true triaxial test system under different σ 2, aiming to study the mechanical responses of the rock in underground excavation at depth. It shows that the rock strength increases with the raising of the intermediate principal stress σ 2 when σ 3 is unloaded to zero. The true triaxial strength criterion by the power-law relationship can be used to fit the testing data. The "best-fitting" material parameters A and n ( A > 1.4 and n plastic deformation. The maximum extension strain criterion Stacey (Int J Rock Mech Min Sci Geomech Abstr 651 18(6):469-474, 1981) can be used to explain the change of failure mode from shear to slabbing for strong and hard rocks under true triaxial unloading test condition.

How to apply clinical cases and medical literature in the framework of a modified "failure mode and effects analysis" as a clinical reasoning tool--an illustration using the human biliary system.

Science.gov (United States)

Wong, Kam Cheong

2016-04-06

Clinicians use various clinical reasoning tools such as Ishikawa diagram to enhance their clinical experience and reasoning skills. Failure mode and effects analysis, which is an engineering methodology in origin, can be modified and applied to provide inputs into an Ishikawa diagram. The human biliary system is used to illustrate a modified failure mode and effects analysis. The anatomical and physiological processes of the biliary system are reviewed. Failure is defined as an abnormality caused by infective, inflammatory, obstructive, malignancy, autoimmune and other pathological processes. The potential failures, their effect(s), main clinical features, and investigation that can help a clinician to diagnose at each anatomical part and physiological process are reviewed and documented in a modified failure mode and effects analysis table. Relevant medical and surgical cases are retrieved from the medical literature and weaved into the table. A total of 80 clinical cases which are relevant to the modified failure mode and effects analysis for the human biliary system have been reviewed and weaved into a designated table. The table is the backbone and framework for further expansion. Reviewing and updating the table is an iterative and continual process. The relevant clinical features in the modified failure mode and effects analysis are then extracted and included in the relevant Ishikawa diagram. This article illustrates an application of engineering methodology in medicine, and it sows the seeds of potential cross-pollination between engineering and medicine. Establishing a modified failure mode and effects analysis can be a teamwork project or self-directed learning process, or a mix of both. Modified failure mode and effects analysis can be deployed to obtain inputs for an Ishikawa diagram which in turn can be used to enhance clinical experiences and clinical reasoning skills for clinicians, medical educators, and students.

Posttest analysis of the 1:6 scale reinforced concrete containment

International Nuclear Information System (INIS)

Pfeiffer, P.A.; Kennedy, J.M.; Marchertas, A.H.

1989-01-01

A prediction of the response of the Sandia National Laboratories 1:6-scale reinforced concrete containment model test was made by Argonne National Laboratory. ANL along with nine other organizations performed a detailed nonlinear response analysis of the 1:6-scale model containment subjected to overpressurization in the fall of 1986. The two-dimensional code Temp-Stress and the three-dimensional Neptune code were utilized to predict the global response of the structure, to identify global failure sites and the corresponding failure pressures, and to identify some local failure sites and pressure levels. A series of axisymmetric models was studied with the two-dimensional computer program Temp-Stress. The comparison of these pretest computations with test data from the containment model has provided a test for the capability of the respective finite element codes to predict global failure modes, and hence serves as a validation of these codes. The two-dimensional analyses are discussed in this paper

APPLICATION OF FAILURE MODE & EFFECT ANALYSIS (FMEA FOR CONTINUOUS QUALITY IMPROVEMENT - MULTIPLE CASE STUDIES IN AUTOMOBILE SMES

Directory of Open Access Journals (Sweden)

Jigar Doshi

2017-06-01

Full Text Available Failure Mode and Effects Analysis (FMEA is a quality tool used to identify potential failures and related effects on processes and products, so continuous improvement in quality can be achieved by reducing them. The purpose of this research paper is to showcase the contribution of FMEA to achieve Continuous Quality Improvement (CQI by multiple case study research. The outcome research conducted by implementing FMEA; one of the Auto Core Tools (ACTs, in the automobile Small and Medium Enterprises (SMEs in Gujarat, India is presented in this paper which depict various means of Continuous Quality Improvements. The case study based research was carried out in four automobile SMEs; all of them are supplied to automotive Original Equipment Manufacturer (OEM. The FMEA was implemented with the help of Cross Functional Team (CFT to identify the potential failure modes and effects, in overall effect on Continuous Quality Improvement. The outcome of FMEA at four companies' reveals the scope of improvement exists in the manufacturing process. Implementation of those improvement points shows the definite signs of continuous improvement of the quality of process and product as well. The FMEA and subsequent implementations had reduced the quality rejections around 3% to 4% in case companies.

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

Science.gov (United States)

1996-01-01

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

Evaluation of strength and failure of brittle rock containing initial cracks under lithospheric conditions

Science.gov (United States)

Li, Xiaozhao; Qi, Chengzhi; Shao, Zhushan; Ma, Chao

2018-02-01

Natural brittle rock contains numerous randomly distributed microcracks. Crack initiation, growth, and coalescence play a predominant role in evaluation for the strength and failure of brittle rocks. A new analytical method is proposed to predict the strength and failure of brittle rocks containing initial microcracks. The formulation of this method is based on an improved wing crack model and a suggested micro-macro relation. In this improved wing crack model, the parameter of crack angle is especially introduced as a variable, and the analytical stress-crack relation considering crack angle effect is obtained. Coupling the proposed stress-crack relation and the suggested micro-macro relation describing the relation between crack growth and axial strain, the stress-strain constitutive relation is obtained to predict the rock strength and failure. Considering different initial microcrack sizes, friction coefficients and confining pressures, effects of crack angle on tensile wedge force acting on initial crack interface are studied, and effects of crack angle on stress-strain constitutive relation of rocks are also analyzed. The strength and crack initiation stress under different crack angles are discussed, and the value of most disadvantaged angle triggering crack initiation and rock failure is founded. The analytical results are similar to the published study results. Rationality of this proposed analytical method is verified.

Fracture resistance and failure modes of polymer infiltrated ceramic endocrown restorations with variations in margin design and occlusal thickness.

Science.gov (United States)

Taha, Doaa; Spintzyk, Sebastian; Schille, Christine; Sabet, Ahmed; Wahsh, Marwa; Salah, Tarek; Geis-Gerstorfer, Jürgen

2017-12-11

The purpose of this in vitro study was to assess the effect of varying the margin designs and the occlusal thicknesses on the fracture resistance and mode of failures of endodontically treated teeth restored with polymer infiltrated ceramic endocrown restorations. Root canal treated mandibular molars were divided into four groups (n=8) and were prepared to receive Computer-Aided Design/Computer-Aided Manufacturing (CAD/CAM) fabricated polymer infiltrated ceramic endocrowns (ENAMIC blocks). Group B2 represents teeth prepared with a butt joint design receiving endocrowns with 2mm occlusal thickness and the same for group B3.5 but with 3.5mm occlusal thickness. Group S2 represents teeth prepared with 1mm shoulder finish line receiving endocrowns with 2mm occlusal thickness and the same for group S3.5 but with 3.5mm occlusal thickness. After cementation and thermal aging, fracture resistance test was performed and failure modes were observed. Group S3.5 showed the highest mean fracture load value (1.27±0.31kN). Endocrowns with shoulder finish line had significantly higher mean fracture resistance values than endocrowns with butt margin (p<0.05). However, the results were not statistically significant regarding the restoration thickness. Evaluation of the fracture modes revealed no statistically significant difference between the modes of failure of tested groups. For the restoration of endodontically treated teeth, adding a short axial wall and shoulder finish line can increase the fracture resistance. However, further investigations, especially the fatigue behavior, are needed to ensure this effect applies with small increases of restoration thickness. Copyright © 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

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

Science.gov (United States)

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

2017-06-01

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

Effect of length of thinning area on the failure behavior of carbon steel pipe containing a defect of wall thinning

International Nuclear Information System (INIS)

Kim, Jin Weon; Park, Chi Yong

2003-01-01

The present study performed pipe failure tests using 102 mm-Sch. 80 carbon steel pipe with various simulated wall thinning defects, to investigate the effect of axial length of wall thinning and internal pressure on the failure behavior of pipe thinned by flow accelerated corrosion (FAC). The tests were conducted under loading conditions of four-point bending with and without internal pressure. The results showed that a failure mode of pipe with a defect depended on the magnitude of internal pressure and axial thinning length as well as stress type and thinning depth and circumferential angle. Both load carrying capability (LCC) and deformation capability (DC) were depended on stress type in the thinning area and dimensions of thinning defect. For applying tensile stress to the thinned area, the dependence of LCC on the axial length of wall thinning was determined by circumferential thinning angle, and the DC was proportionally increased with increase in axial length of wall thinning regardless of the circumferential angle. For applying compressive stress to thinned area, however, the LCC was decreased with increase in axial length of the thinned area. Also, the effect of internal pressure on failure behavior was characterized by failure mode of thinned pipe, and it promoted crack occurrence and mitigated a local buckling of the thinned area

Failure mechanisms for compacted uranium oxide fuel cores

International Nuclear Information System (INIS)

Berghaus, D.G.; Peacock, H.B.

1980-01-01

Tension, compression, and shear tests were performed on test specimens of aluminum-clad, compacted powder fuel cores to determine failure mechanisms of the core material. The core, which consists of 70% uranium oxide in an aluminum matrix, frequently fails during post-extrusion drawing. Tests were conducted to various strain levels up to failure of the core. Sections were made of tested specimens to microscopically study initiation of failure. Two failure modes wee observed. Tensile failure mode is initiated by prior tensile failure of uranium oxide particles with the separation path strongly influenced by the arrangement of particles. Delamination mode consists of the separation of laminae formed during extrusion of tubes. Separation proceeds from fine cracks formed parallel to the laminae. Tensile failure mode was experienced in tension and shear tests. Delamination mode was produced in compression tests

Failure Mode and Effect Analysis of the Application Software of the Safety-critical I and C System in APR1400

Energy Technology Data Exchange (ETDEWEB)

Kim, Koheun; Kim, Yong geul; Choi, Woong seok; Sohn, Se do [KEPCO Engineering and Construction, Daejeon (Korea, Republic of)

2016-10-15

In APR1400, the computer software hazard analysis is performed by hazard and operability analysis (HAZOP) method. Meanwhile, HAZOP has its limitation and cannot be considered better than fault tree analysis (FTA) or failure mode and effect (FMEA) analysis. HAZOP assumes that the system has been carefully studied, and all possible hazards, their effects or consequences and remedies are incorporated in the system. But incorporating every possible event in the design is impossible. In this light, this paper attempts to use FMEA method for evaluating the risk for safety-critical instrumentation and control (I and C) system software for NPP which is more practically than HAZOP. It is possible because the software failures are due to systematic faults that causing simultaneous failure in multiple division when the triggering event happens. This analysis is applied to safety-critical system of Shin-Hanul units 1 and 2 NPP, i.e., APR1400. Through SFMEA, the critical software failure modes and tasks that could result in CCF are identified and also evaluated to determine the associated risk level (e.g. high or intermediate or low) based on the failure effect. Biggest benefit from this analysis comparing with HAZOP is it can reveal the possible weak points and provide the guidance to the V and V team by helping to generate the test cases.

Decentralized Sliding Mode Observer Based Dual Closed-Loop Fault Tolerant Control for Reconfigurable Manipulator against Actuator Failure

Science.gov (United States)

Zhao, Bo; Li, Yuanchun

2015-01-01

This paper considers a decentralized fault tolerant control (DFTC) scheme for reconfigurable manipulators. With the appearance of norm-bounded failure, a dual closed-loop trajectory tracking control algorithm is proposed on the basis of the Lyapunov stability theory. Characterized by the modularization property, the actuator failure is estimated by the proposed decentralized sliding mode observer (DSMO). Moreover, the actuator failure can be treated in view of the local joint information, so its control performance degradation is independent of other normal joints. In addition, the presented DFTC scheme is significantly simplified in terms of the structure of the controller due to its dual closed-loop architecture, and its feasibility is highly reflected in the control of reconfigurable manipulators. Finally, the effectiveness of the proposed DFTC scheme is demonstrated using simulations. PMID:26181826

Decentralized Sliding Mode Observer Based Dual Closed-Loop Fault Tolerant Control for Reconfigurable Manipulator against Actuator Failure.

Directory of Open Access Journals (Sweden)

Bo Zhao

Full Text Available This paper considers a decentralized fault tolerant control (DFTC scheme for reconfigurable manipulators. With the appearance of norm-bounded failure, a dual closed-loop trajectory tracking control algorithm is proposed on the basis of the Lyapunov stability theory. Characterized by the modularization property, the actuator failure is estimated by the proposed decentralized sliding mode observer (DSMO. Moreover, the actuator failure can be treated in view of the local joint information, so its control performance degradation is independent of other normal joints. In addition, the presented DFTC scheme is significantly simplified in terms of the structure of the controller due to its dual closed-loop architecture, and its feasibility is highly reflected in the control of reconfigurable manipulators. Finally, the effectiveness of the proposed DFTC scheme is demonstrated using simulations.

Leaking Containers: Success and Failure in Controlling the Mosquito Aedes aegypti in Brazil.

Science.gov (United States)

Löwy, Ilana

2017-04-01

In 1958, the Pan American Health Organization declared that Brazil had successfully eradicated the mosquito Aedes aegypti, responsible for the transmission of yellow fever, dengue fever, chikungunya, and Zika virus. Yet in 2016 the Brazilian minister of health described the situation of dengue fever as "catastrophic." Discussing the recent epidemic of Zika virus, which amplified the crisis produced by the persistence of dengue fever, Brazil's president declared in January 2016 that "we are in the process of losing the war against the mosquito Aedes aegypti." I discuss the reasons for the failure to contain Aedes in Brazil and the consequences of this failure. A longue durée perspective favors a view of the Zika epidemic that does not present it as a health crisis to be contained with a technical solution alone but as a pathology that has the persistence of deeply entrenched structural problems and vulnerabilities.

Investigation of radial shear in the wall-base juncture of a 1:4 scale prestressed concrete containment vessel model

Energy Technology Data Exchange (ETDEWEB)

Dameron, R.A.; Rashid, Y.R. [ANATECH Corp., San Diego, CA (United States); Luk, V.K.; Hessheimer, M.F. [Sandia National Labs., Albuquerque, NM (United States)

1998-04-01

Construction of a prestressed concrete containment vessel (PCCV) model is underway as part of a cooperative containment research program at Sandia National Laboratories. The work is co-sponsored by the Nuclear Power Engineering Corporation (NUPEC) of Japan and US Nuclear Regulatory Commission (NRC). Preliminary analyses of the Sandia 1:4 Scale PCCV Model have determined axisymmetric global behavior and have estimated the potential for failure in several areas, including the wall-base juncture and near penetrations. Though the liner tearing failure mode has been emphasized, the assumption of a liner tearing failure mode is largely based on experience with reinforced concrete containments. For the PCCV, the potential for shear failure at or near the liner tearing pressure may be considerable and requires detailed investigation. This paper examines the behavior of the PCCV in the region most susceptible to a radial shear failure, the wall-basemat juncture region. Prediction of shear failure in concrete structures is a difficult goal, both experimentally and analytically. As a structure begins to deform under an applied system of forces that produce shear, other deformation modes such as bending and tension/compression begin to influence the response. Analytically, difficulties lie in characterizing the decrease in shear stiffness and shear stress and in predicting the associated transfer of stress to reinforcement as cracks become wider and more extensive. This paper examines existing methods for representing concrete shear response and existing criteria for predicting shear failure, and it discusses application of these methods and criteria to the study of the 1:4 scale PCCV.

Investigation of radial shear in the wall-base juncture of a 1:4 scale prestressed concrete containment vessel model

International Nuclear Information System (INIS)

Dameron, R.A.; Rashid, Y.R.; Luk, V.K.; Hessheimer, M.F.

1998-04-01

Construction of a prestressed concrete containment vessel (PCCV) model is underway as part of a cooperative containment research program at Sandia National Laboratories. The work is co-sponsored by the Nuclear Power Engineering Corporation (NUPEC) of Japan and US Nuclear Regulatory Commission (NRC). Preliminary analyses of the Sandia 1:4 Scale PCCV Model have determined axisymmetric global behavior and have estimated the potential for failure in several areas, including the wall-base juncture and near penetrations. Though the liner tearing failure mode has been emphasized, the assumption of a liner tearing failure mode is largely based on experience with reinforced concrete containments. For the PCCV, the potential for shear failure at or near the liner tearing pressure may be considerable and requires detailed investigation. This paper examines the behavior of the PCCV in the region most susceptible to a radial shear failure, the wall-basemat juncture region. Prediction of shear failure in concrete structures is a difficult goal, both experimentally and analytically. As a structure begins to deform under an applied system of forces that produce shear, other deformation modes such as bending and tension/compression begin to influence the response. Analytically, difficulties lie in characterizing the decrease in shear stiffness and shear stress and in predicting the associated transfer of stress to reinforcement as cracks become wider and more extensive. This paper examines existing methods for representing concrete shear response and existing criteria for predicting shear failure, and it discusses application of these methods and criteria to the study of the 1:4 scale PCCV

Modeling freedom from progression for standard-risk medulloblastoma: a mathematical tumor control model with multiple modes of failure

DEFF Research Database (Denmark)

Brodin, Nils Patrik; Vogelius, Ivan R.; Bjørk-Eriksson, Thomas

2013-01-01

As pediatric medulloblastoma (MB) is a relatively rare disease, it is important to extract the maximum information from trials and cohort studies. Here, a framework was developed for modeling tumor control with multiple modes of failure and time-to-progression for standard-risk MB, using published...

Analisis Potensi Kecelakaan Kerja Pada CV. Automotive Workshop Dengan Metode Failure Mode and Effect Analysis

OpenAIRE

Syauqi, Qiqi Azwani; Susanty, Aries

2016-01-01

[Potential Analysis of Work Accidents at CV. Automotive Workshop using Failure Mode and Effect Analysis Method] Nowadays the global automotive industry, especially in developing countries has increased along with the increasing number of internet users and mobile penetration, the GDP rate increase of the developing countries and the growth of middle class-society, which makes the car sales in these countries increased anually. According to Carmudi, Semarang was the second-highest of the car l...

Effects of national culture on human failures in container shipping: the moderating role of Confucian dynamism.

Science.gov (United States)

Lu, Chin-Shan; Lai, Kee-hung; Lun, Y H Venus; Cheng, T C E

2012-11-01

Recent reports on work safety in container shipping operations highlight high frequencies of human failures. In this study, we empirically examine the effects of seafarers' perceptions of national culture on the occurrence of human failures affecting work safety in shipping operations. We develop a model adopting Hofstede's national culture construct, which comprises five dimensions, namely power distance, collectivism/individualism, uncertainty avoidance, masculinity/femininity, and Confucian dynamism. We then formulate research hypotheses from theory and test the hypotheses using survey data collected from 608 seafarers who work on global container carriers. Using a point scale for evaluating seafarers' perception of the five national culture dimensions, we find that Filipino seafarers score highest on collectivism, whereas Chinese and Taiwanese seafarers score highest on Confucian dynamism, followed by collectivism, masculinity, power distance, and uncertainty avoidance. The results also indicate that Taiwanese seafarers have a propensity for uncertainty avoidance and masculinity, whereas Filipino seafarers lean more towards power distance, masculinity, and collectivism, which are consistent with the findings of Hofstede and Bond (1988). The results suggest that there will be fewer human failures in container shipping operations when power distance is low, and collectivism and uncertainty avoidance are high. Specifically, this study finds that Confucian dynamism plays an important moderating role as it affects the strength of associations between some national culture dimensions and human failures. Finally, we discuss our findings' contribution to the development of national culture theory and their managerial implications for reducing the occurrence of human failures in shipping operations. Copyright © 2012 Elsevier Ltd. All rights reserved.

Failure by void coalescence in metallic materials containing primary and secondary voids subject to intense shearing

DEFF Research Database (Denmark)

Nielsen, Kim Lau; Tvergaard, Viggo

2011-01-01

Failure under intense shearing at close to zero stress triaxiality is widely observed for ductile metallic materials, and is identified in experiments as smeared-out dimples on the fracture surface. Numerical cell-model studies of equal sized voids have revealed that the mechanism governing...... this shear failure mode boils down to the interaction between primary voids which rotate and elongate until coalescence occurs under severe plastic deformation of the internal ligaments. The objective of this paper is to analyze this failure mechanism of primary voids and to study the effect of smaller...... secondary damage that co-exists with or nucleation in the ligaments between larger voids that coalesce during intense shearing. A numerical cell-model study is carried out to gain a parametric understanding of the overall material response for different initial conditions of the two void populations...

Failure of MPC overpack and inner container under corrosion and mechanical stresses in a backfilled drift

International Nuclear Information System (INIS)

Ladkany, S.G.; Rajagopalan, R.

1995-01-01

The thickness and time at failure of the 100mm thick overpack and the 9.5mm thick inner container of a Multi-purpose canister have been assessed due to loads resulting from temperature, overburden, backfill pressure and seismic loads. Critical stresses at various reduced thicknesses, resulting from pitting corrosion over the years of emplacement, have been evaluated using Finite element analysis. Both simple and continuous support conditions of the overpack have been considered in the analysis. The anticipated failure time due to corrosion of overpack and inner container is further reduced due to overburden, self and seismic loads

A survey of SiC power MOSFETs short-circuit robustness and failure mode analysis

DEFF Research Database (Denmark)

Ceccarelli, L.; Reigosa, P. D.; Iannuzzo, F.

2017-01-01

The aim of this paper is to provide an extensive overview about the state-of-art commercially available SiC power MOSFET, focusing on their short-circuit ruggedness. A detailed literature investigation has been carried out, in order to collect and understand the latest research contribution within...... this topic and create a survey of the present scenario of SiC MOSFETs reliability evaluation and failure mode analysis, pointing out the evolution and improvements as well as the future challenges in this promising device technology....

Failure modes of laminate structures

Energy Technology Data Exchange (ETDEWEB)

Gordon, L.B.; Druce, R.L.; Wilson, M.J.

1987-06-01

Laminate structures composed of alternating thin layers of conductor and dielectric material are commonly used in energy storage and transmission components. The failure of the dielectric layers in regions of high field stress, with applied 60 Hz ac, dc and impulse voltages, was studied. Several geometries were compared, including staggered and flush edges. Electrical trees developed between the laminated dielectric layers. The visual characteristics and growth rates of the electrical trees under ac, dc and impulse stresses were different. Partial discharge detection and analysis was used to measure the inception voltage and discharge activity at the conductor edge voids, to observe tree formation and growth, and to predict impending failure due to dielectric erosion. Electric field distributions were modeled and partial discharge inception levels were estimated from known void geometries. The staggered edge geometry appears to enhance the electric field stress at the recessed electrode.

Probabilistic evaluation of concrete containment capacity for beyond design basis internal pressures

International Nuclear Information System (INIS)

Tang, H.T.; Dameron, R.A.; Rashid, Y.R.

1995-01-01

For beyond design basis internal pressure loading, experimental studies have demonstrated that the most probable failure mode governing the ultimate functional capacity of concrete containments is leak rather than break. Based on leak rates measured in experiments, a prediction formula for leak rate as functions of containment liner size and internal pressure has been postulated. The determination of liner tear is cast in a probabilistic framework. In calculating leakage, particular attention is paid to the evaluation of leakage versus rupture and the loading rates that may be required to leapfrog over a leakage mode. (orig.)

Dynamic stability and failure modes of slopes in discontinuous rock mass

International Nuclear Information System (INIS)

Shimizu, Yasuhiro; Aydan, O.; Ichikawa, Yasuaki; Kawamoto, Toshikazu.

1988-01-01

The stability of rock slopes during earthquakes are of great concern in rock engineering works such as highway, dam, and nuclear power station constructions. As rock mass in nature is usually discontinuous, the stability of rock slopes will be geverned by the spatial distribution of discontinuities in relation with the geometry of slope and their mechanical properties rather than the rock element. The authors have carried out some model tests on discontinuous rock slopes using three different model tests techniques in order to investigate the dynamic behaviour and failure modes of the slopes in discontinuous rock mass. This paper describes the findings and observations made on model rock slopes with various discontinuity patterns and slope geometry. In addition some stability criterions are developed and the calculated results are compared with those of experiments. (author)

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

Science.gov (United States)

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.

Microstructure-based constitutive modeling of TRIP steel: Prediction of ductility and failure modes under different loading conditions

International Nuclear Information System (INIS)

Choi, K.S.; Liu, W.N.; Sun, X.; Khaleel, M.A.

2009-01-01

We study the ultimate ductility and failure modes of a commercial transformation-induced plasticity (TRIP) 800 steel under different loading conditions with an advanced microstructure-based finite-element analysis. The representative volume element (RVE) for the TRIP 800 under examination is developed based on an actual microstructure obtained from scanning electron microscopy. The ductile failure of the TRIP 800 under different loading conditions is predicted in the form of plastic strain localization without any prescribed failure criteria for the individual phases. This indicates that the microstructure-level inhomogeneity of the various constituent phases can be the key factor influencing the final ductility of the TRIP 800 steel under different loading conditions. Comparisons of the computational results with experimental measurements suggest that the microstructure-based modeling approach accurately captures the overall macroscopic behavior of the TRIP 800 steel under different loading and boundary conditions.

Correlation of electrical reactor cable failure with materials degradation

International Nuclear Information System (INIS)

Stuetzer, O.M.

1986-03-01

Complete circuit failure (shortout) of electrical cables typically used in nuclear power plant containments is investigated. Failure modes are correlated with the mechanical deterioration of the elastomeric cable materials. It is found that for normal reactor operation, electrical cables are reliable and safe over very long periods. During high temperature excursions, however, cables pulled across corners under high stress may short out due to conductor creep. Severe cracking will occur in short times during high temperatures (>150 0 C) and in times of the order of years at elevated temperatures (100 0 C to 140 0 C). A theoretical treatment of stress distribution responsible for creep and for cracking by J.E. Reaugh of Science Applications, Inc. is contained in the Appendix. 29 refs., 32 figs

Stochastic failure modelling of unidirectional composite ply failure

International Nuclear Information System (INIS)

Whiteside, M.B.; Pinho, S.T.; Robinson, P.

2012-01-01

Stochastic failure envelopes are generated through parallelised Monte Carlo Simulation of a physically based failure criteria for unidirectional carbon fibre/epoxy matrix composite plies. Two examples are presented to demonstrate the consequence on failure prediction of both statistical interaction of failure modes and uncertainty in global misalignment. Global variance-based Sobol sensitivity indices are computed to decompose the observed variance within the stochastic failure envelopes into contributions from physical input parameters. The paper highlights a selection of the potential advantages stochastic methodologies offer over the traditional deterministic approach.

Reliability analysis of steel-containment strength

International Nuclear Information System (INIS)

Greimann, L.G.; Fanous, F.; Wold-Tinsae, A.; Ketalaar, D.; Lin, T.; Bluhm, D.

1982-06-01

A best estimate and uncertainty assessment of the resistance of the St. Lucie, Cherokee, Perry, WPPSS and Browns Ferry containment vessels was performed. The Monte Carlo simulation technique and second moment approach were compared as a means of calculating the probability distribution of the containment resistance. A uniform static internal pressure was used and strain ductility was taken as the failure criterion. Approximate methods were developed and calibrated with finite element analysis. Both approximate and finite element analyses were performed on the axisymmetric containment structure. An uncertainty assessment of the containment strength was then performed by the second moment reliability method. Based upon the approximate methods, the cumulative distribution for the resistance of each of the five containments (shell modes only) is presented

Prevention is better: the case of the underutilized failure mode effect analysis in patient safety

Directory of Open Access Journals (Sweden)

Lewis Goodrum

2017-02-01

Full Text Available Abstract Prospective hazard analysis methodologies, like failure modes and effects analysis (FMEA, have been tried and tested in the engineering industry and are more recently gaining momentum in healthcare. Considering FMEA’s evidence based successes, this commentary makes the case that healthcare is underutilizing the methodology by relying on retrospective hazard analysis. Healthcare leaders should determine where prospective hazard analysis principles could be better built into care delivery planning and processes that will enhance patient safety.

Preliminary Failure Modes, Effects and Criticality Analysis (FMECA) of the conceptual Brayton Isotope Power System (BIPS) Flight System

International Nuclear Information System (INIS)

Miller, L.G.

1976-01-01

A failure modes, effects and criticality analysis (FMECA) was made of the Brayton Isotope Power System Flight System (BIPS-FS) as presently conceived. The components analyzed include: Mini-BRU; Heat Source Assembly (HSA); Mini-Brayton Recuperator (MBR); Space Radiator; Ducts and Bellows, Insulation System; Controls; and Isotope Heat Source (IHS)

ANALISIS IDENTIFIKASI MASALAH DENGAN MENGGUNAKAN METODE FAILURE MODE AND EFFECT ANALYSIS (FMEA DAN RISK PRIORITY NUMBER (RPN PADA SUB ASSEMBLY LINE (Studi Kasus : PT. Toyota Motor Manufacturing Indonesia

Directory of Open Access Journals (Sweden)

Nia Budi Puspitasari

2017-07-01

Abstract The failure rate is a problem that has always attempted to be minimized by a company in order to improve the quality of products, and also were conducted by oleh Toyota Motor Manufacturing Indonesia (PT. TMMIN which is consistent in producting a quality product.  Knowing that in 2016 there is a defect GAP at 50 ppm, PT. TMMIN needs to identify the failures that occur in their company. FMEA is a method to identify and analyze the failure modes in detail that can able to know the cause and impact of each failures, so we get the proper repairment. FMEA that is used in PT. TMMIN case study indicate various modes of failure in assembly-line, then known the alternatives to repair for any prioritize failures. The priorities failures can be seen in the Risk Priority Number (RPN. Based on the RPN resulting, we can obtain the priority failures in  assembly-line of PT. TMMIN that are about the part installation errors, failures due to foreign objects in the part, and the failure of the piston assembly errors.

The effect of transverse shear on the face sheets failure modes of sandwich beams loaded in three points bending

OpenAIRE

BOUROUIS FAIROUZ; MILI FAYCAL

2012-01-01

Sandwich beams loaded in three points bending may fail in several ways including tension or compression failure of facings. In this paper , The effect of the transverse shear on the face yielding and face wrinkling failure modes of sandwich beams loaded in three points bending have been studied, the beams were made of various composites materials carbon/epoxy, kevlar/epoxy, glass/epoxy at sequence [+θ/-θ]3s, [0°/90°]3s. . The stresses in the face were calculated using maximum stress criterion...

Nanowire failure: long = brittle and short = ductile.

Science.gov (United States)

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

2012-02-08

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

Simplified containment event tree analysis for the Sequoyah Ice Condenser containment

International Nuclear Information System (INIS)

Galyean, W.J.; Schroeder, J.A.; Pafford, D.J.

1990-12-01

An evaluation of a Pressurized Water Reactor (PER) ice condenser containment was performed. In this evaluation, simplified containment event trees (SCETs) were developed that utilized the vast storehouse of information generated by the NRC's Draft NUREG-1150 effort. Specifically, the computer programs and data files produced by the NUREG-1150 analysis of Sequoyah were used to electronically generate SCETs, as opposed to the NUREG-1150 accident progression event trees (APETs). This simplification was performed to allow graphic depiction of the SCETs in typical event tree format, which facilitates their understanding and use. SCETs were developed for five of the seven plant damage state groups (PDSGs) identified by the NUREG-1150 analyses, which includes: both short- and long-term station blackout sequences (SBOs), transients, loss-of-coolant accidents (LOCAs), and anticipated transient without scram (ATWS). Steam generator tube rupture (SGTR) and event-V PDSGs were not analyzed because of their containment bypass nature. After being benchmarked with the APETs, in terms of containment failure mode and risk, the SCETs were used to evaluate a number of potential containment modifications. The modifications were examined for their potential to mitigate or prevent containment failure from hydrogen burns or direct impingement on the containment by the core, (both factors identified as significant contributors to risk in the NUREG-1150 Sequoyah analysis). However, because of the relatively low baseline risk postulated for Sequoyah (i.e., 12 person-rems per reactor year), none of the potential modifications appear to be cost effective. 15 refs., 10 figs. , 17 tabs

Loads on EPR containment after RPV failure at high pressure; Belastungen des EPR-Containments in Falle eines RDB-Versagens bei hohem Druck

Energy Technology Data Exchange (ETDEWEB)

Jacobs, G.

1995-08-01

As regards the desgin of the EPR, the general strategy is to eliminate, the vessel failure at high pressure by preventive and mitigative measures. The design proposals involved trust in the reliability of dedicated devices (relief valves) for rapid depressurization. The aim is to attain a lower pressure level at the moment of vessel failure, so that the containment is capable to cope with the blowdown impact on the pit walls and the vessel supporting structures. Nevertheless, the potential of a high-pressure failure of the vessel must be kept in mind, whatever well thought-out and reliable preventive depressurization measures might be. Therefore, the reactor pressure blowdown has been studied in order to quantify the ultimate containment load, which might support future design requirements. The calculations were performed with the LWR transient analysis thermal-hydraulics computer code REALAP5/MOD3. In previous analyses, the nodalization of the problem was based on the geometrical conditions of a typical German 1300 MW(e) NPP. In the present analysis a new input model has been used, which was based on the EPR conditions. (orig./HP)

Mechanical behavior and localized failure modes in a porous basalt from the Azores

Science.gov (United States)

Loaiza, S.; Fortin, J.; Schubnel, A.; Guéguen, Y.; Moreira, M.; Vinciguerra, S.

2012-04-01

Basaltic rocks are the main component of the oceanic upper crust. This is of potential interest for water and geothermal resources, or for storage of CO2. The aim of our work is to investigate experimentally the mechanical behavior and the failure modes of porous basalt as well as the permeability evolution during deformation. Cylindrical basalt samples, from the Azores, of 30 mm in diameter and 60 mm in length were deformed the triaxial cell of the Laboratoire de Geologie at the Ecole Normale Supérieure (Paris) at room temperature and at a constant axial strain rate of 10-5 s-1. The initial porosity of the sample was 18%. The Geodesign triaxial cell can reach 300MPa confining pressure; axial load is performed through a piston and can reach 900 MPa (for a 30mm diameter sample); maximum pore pressure is 100MPa (applied using two precision volumetric pumps). In our study, a set of experiments were performed at confining pressure in the range of 25-290 MPa. The samples were deformed under saturated conditions at a constant pore pressure of 5MPa. Two volumetric pumps kept the pore pressure constant, and the pore volume variations were recorded. The evolution of the porosity was calculated from the total volume variation inside the volumetric pumps. Permeability measurements were performed using the steady-state technique. Our result shows that two modes of deformation can be highlighted in this basalt. At low confining pressure (Pc < 50 MPa), the differential stress attains a peak before the sample undergoes strain softening; the failure of sample occurs by shear localization. Yet, the brittle regime is commonly observed in this low Pc range, the experiments performed at confining pressure higher than 50 MPa, show a totally different mode of deformation. In this second mode of deformation, an appreciable inelastic porosity reduction is observed. Comparing to the hydrostatic loading, the rock sample started to compact beyond a critical stress state; and from then

Failure modes of valve-regulated lead-acid batteries for electric bicycle applications in deep discharge

Energy Technology Data Exchange (ETDEWEB)

Guo, Yonglang; Tang, Shengqun [College of Chemistry and Chemical Engineering, Fuzhou University, Fuzhou 350108 (China); Meng, Gang; Yang, Shijun [Hubei Camel Storage Battery Co. Ltd., Gucheng 441705 (China)

2009-06-01

The 36 or 48 V valve-regulated lead-acid (VRLA) battery packs have been widely applied to the power sources of electric bicycles or light electric scooters in China. The failure modes of the 12 V/10 Ah VRLA batteries have been studied by the cycle life test at C{sub 2} discharge rate and 100% depth of discharge (DOD). It indicates that the main cause of the battery failure in this cycle duty is the softening and shedding of positive active mass (PAM) rather than individual water loss, recombination efficiency or sulfation, etc. When the electrolyte saturation falls to a certain extent, the high oxygen recombination current leads to the depolarization of the negative plate and the shift of the positive plate to a higher potential. The violent oxygen evolution accelerates the softening of PAM and the end of cycle life. (author)

An unusual mode of failure of a tripolar constrained acetabular liner: a case report.

LENUS (Irish Health Repository)

Banks, Louisa N

2012-02-01

Dislocation after primary total hip arthroplasty (THA) is the most commonly encountered complication and is unpleasant for both the patient and the surgeon. Constrained acetabular components can be used to treat or prevent instability after primary total hip arthroplasty. We present the case of a 42-year-old female with a BMI of 41. At 18 months post-primary THA the patient underwent further revision hip surgery after numerous (more than 20) dislocations. She had a tripolar Trident acetabular cup (Stryker-Howmedica-Osteonics, Rutherford, New Jersey) inserted. Shortly afterwards the unusual mode of failure of the constrained acetabular liner was noted from radiographs in that the inner liner had dissociated from the outer. The reinforcing ring remained intact and in place. We believe that the patient\\'s weight, combined with poor abductor musculature caused excessive demand on the device leading to failure at this interface when the patient flexed forward. Constrained acetabular components are useful implants to treat instability but have been shown to have up to 42% long-term failure rates with problems such as dissociated inserts, dissociated constraining rings and dissociated femoral rings being sited. Sometimes they may be the only option left in difficult cases such as illustrated here, but still unfortunately have the capacity to fail in unusual ways.

An unusual mode of failure of a tripolar constrained acetabular liner: a case report.

Science.gov (United States)

Banks, Louisa N; McElwain, John P

2010-04-01

Dislocation after primary total hip arthroplasty (THA) is the most commonly encountered complication and is unpleasant for both the patient and the surgeon. Constrained acetabular components can be used to treat or prevent instability after primary total hip arthroplasty. We present the case of a 42-year-old female with a BMI of 41. At 18 months post-primary THA the patient underwent further revision hip surgery after numerous (more than 20) dislocations. She had a tripolar Trident acetabular cup (Stryker-Howmedica-Osteonics, Rutherford, New Jersey) inserted. Shortly afterwards the unusual mode of failure of the constrained acetabular liner was noted from radiographs in that the inner liner had dissociated from the outer. The reinforcing ring remained intact and in place. We believe that the patient's weight, combined with poor abductor musculature caused excessive demand on the device leading to failure at this interface when the patient flexed forward. Constrained acetabular components are useful implants to treat instability but have been shown to have up to 42% long-term failure rates with problems such as dissociated inserts, dissociated constraining rings and dissociated femoral rings being sited. Sometimes they may be the only option left in difficult cases such as illustrated here, but still unfortunately have the capacity to fail in unusual ways.

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

Science.gov (United States)

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

2017-04-01

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

Statistical analysis on failure-to-open/close probability of motor-operated valve in sodium system

International Nuclear Information System (INIS)

Kurisaka, Kenichi

1998-08-01

The objective of this work is to develop basic data for examination on efficiency of preventive maintenance and actuation test from the standpoint of failure probability. This work consists of a statistical trend analysis of valve failure probability in a failure-to-open/close mode on time since installation and time since last open/close action, based on the field data of operating- and failure-experience. In this work, the terms both dependent and independent on time were considered in the failure probability. The linear aging model was modified and applied to the first term. In this model there are two terms with both failure rates in proportion to time since installation and to time since last open/close-demand. Because of sufficient statistical population, motor-operated valves (MOV's) in sodium system were selected to be analyzed from the CORDS database which contains operating data and failure data of components in the fast reactors and sodium test facilities. According to these data, the functional parameters were statistically estimated to quantify the valve failure probability in a failure-to-open/close mode, with consideration of uncertainty. (J.P.N.)

Protecting against failure by brittle fracture in ferritic steel shipping containers

International Nuclear Information System (INIS)

Schwartz, M.W.; Langland, R.T.

1983-01-01

The possible use of ferritic steels for the containment structure of shipping casks has motivated the development of criteria for assuring the integrity of these casks under both normal and hypothetical accident conditions specified in Part 71 of the Code of Federal Regulations. The US Nuclear Regulatory Commission Regulation Guide 7.6 provides design criteria for preventing ductile failure steel shipping containers. The research described in this paper deals with criteria for preventing brittle fracture of ferritic steel shipping containers. Initially guidelines were developed for ferritic steel up to four inches thick (I). This was followed by an investigation of various criteria that might be used for monolithic thick walled casks greater than four inches thick (2). Three categories of safety are identified in the design of shipping containers. Category I, the highest level of safety, is appropriate for containment systems for spent nuclear fuel and high level waste transport packaging. In Category I, containers are designed to the highest level of safety and brittle fracture is essentially not possible. Categories II and III represent levels of safety commensurate with the consequences of release of lower levels of radioactivity. In these latter categories, consideration of factors contributing to brittle fracture, good engineering practice, and careful selection of material make brittle fracture unlikely under environmental conditions encountered during shipping. This paper will deal primarily with Category I containers. The guidelines for Category II and III containers are fully described elsewhere. 5 references, 10 figures, 3 tables

Severe accident progression perspectives for Mark I containments based on the IPE results

International Nuclear Information System (INIS)

Lin, C.C.; Lehner, J.R.; Pratt, W.T.; Drouin, M.

1995-01-01

Based on level 2 analyses in IPE (Individual Plant Examination) submittals accident progression, perspectives were obtained for all containment types. These perspectives consisted of insights on containment failure modes, releases therein, and factors responsible for the results. To illustrate the types of perspectives acquired on severe accident progresssion, insights obtained for (BWR) Mark I containments are discussed here. Mark I containments have high strength but small volumes and rely on pressure suppression pools to condense steam released from the reactor coolant system during an accident. Accidents causing structural failure of the drywell shortly after the core debris melts through the reactor vessel were found to be dominant contributors to risk. Importance of individual containment failure mechanisms depends on plant features and in some cases on modeling assumptions; however the following mechanisms were found important: drywell shell melt-through caused by direct contact with core debris and drywell failure caused by rapid pressure/temperature pulses at time of vessel melt-through. Drywell failure caused by gradual pressure/temperature buildup due to gases and steam released during core/concrete interactions is important in some IPEs. In other IPEs vent was an important contributor. However, accidents that bypass containment (eg interfacing systems LOCA)or involve containment isolation failure were not important contributors to the CDF in any of the IPEs for Mark I plants. These accidents are also not important to risk (even though they can involve large fission product release) because their frequencies of occurrence are so much lower than frequencies of early structural failure caused by other accidents that dominate the CDF

Mechanics of Unidirectional Fiber-Reinforced Composites: Buckling Modes and Failure Under Compression Along Fibers

Science.gov (United States)

Paimushin, V. N.; Kholmogorov, S. A.; Gazizullin, R. K.

2018-01-01

One-dimensional linearized problems on the possible buckling modes of an internal or peripheral layer of unidirectional multilayer composites with rectilinear fibers under compression in the fiber direction are considered. The investigations are carried out using the known Kirchhoff-Love and Timoshenko models for the layers. The binder, modeled as an elastic foundation, is described by the equations of elasticity theory, which are simplified in accordance to the model of a transversely soft layer and are integrated along the transverse coordinate considering the kinematic coupling relations for a layer and foundation layers. Exact analytical solutions of the problems formulated are found, which are used to calculate a composite made of an HSE 180 REM prepreg based on a unidirectional carbon fiber tape. The possible buckling modes of its internal and peripheral layers are identified. Calculation results are compared with experimental data obtained earlier. It is concluded that, for the composite studied, the flexural buckling of layers in the uniform axial compression of specimens along fibers is impossible — the failure mechanism is delamination with buckling of a fiber bundle according to the pure shear mode. It is realized (due to the low average transverse shear modulus) at the value of the ultimate compression stress equal to the average shear modulus. It is shown that such a shear buckling mode can be identified only on the basis of equations constructed using the Timoshenko shear model to describe the deformation process of layers.

Correlation of electrical reactor cable failure with materials degradation

Energy Technology Data Exchange (ETDEWEB)

Stuetzer, O.M.

1986-03-01

Complete circuit failure (shortout) of electrical cables typically used in nuclear power plant containments is investigated. Failure modes are correlated with the mechanical deterioration of the elastomeric cable materials. It is found that for normal reactor operation, electrical cables are reliable and safe over very long periods. During high temperature excursions, however, cables pulled across corners under high stress may short out due to conductor creep. Severe cracking will occur in short times during high temperatures (>150/sup 0/C) and in times of the order of years at elevated temperatures (100/sup 0/C to 140/sup 0/C). A theoretical treatment of stress distribution responsible for creep and for cracking by J.E. Reaugh of Science Applications, Inc. is contained in the Appendix. 29 refs., 32 figs.

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

Science.gov (United States)

Varzakas, Theodoros H.; Arvanitoyannis, Ioannis S.

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

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

Science.gov (United States)

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

2017-08-01

Can traceability of gametes and embryos be ensured during IVF? The use of a simple and comprehensive traceability system that includes the most susceptible phases during the IVF process minimizes the risk of mismatches. Mismatches in IVF are very rare but unfortunately possible with dramatic consequences for both patients and health care professionals. Traceability is thus a fundamental aspect of the treatment. A clear process of patient and cell identification involving witnessing protocols has to be in place in every unit. To identify potential failures in the traceability process and to develop strategies to mitigate the risk of mismatches, previously failure mode and effects analysis (FMEA) has been used effectively. The FMEA approach is however a subjective analysis, strictly related to specific protocols and thus the results are not always widely applicable. To reduce subjectivity and to obtain a widespread comprehensive protocol of traceability, a multicentre centrally coordinated FMEA was performed. Seven representative Italian centres (three public and four private) were selected. The study had a duration of 21 months (from April 2015 to December 2016) and was centrally coordinated by a team of experts: a risk analysis specialist, an expert embryologist and a specialist in human factor. Principal investigators of each centre were first instructed about proactive risk assessment and FMEA methodology. A multidisciplinary team to perform the FMEA analysis was then formed in each centre. After mapping the traceability process, each team identified the possible causes of mistakes in their protocol. A risk priority number (RPN) for each identified potential failure mode was calculated. The results of the FMEA analyses were centrally investigated and consistent corrective measures suggested. The teams performed new FMEA analyses after the recommended implementations. In each centre, this study involved: the laboratory director, the Quality Control & Quality