Single Event Upset Studies Using the ATLAS SCT

CERN Document Server

Dafinca, A; The ATLAS collaboration; Weidberg, A R

2014-01-01

Single Event Upsets (SEU) are expected to occur during high luminosity running of the ATLAS SemiConductor Tracker (SCT). The SEU cross sections were measured in pion beams with momenta in the range 200 to 465 MeV/c and proton test beams at 24 GeV/c but the extrapolation to LHC conditions is non-trivial because of the range of particle types and momenta. The SEUs studied occur in the p-i-n photodiode and the registers in the ABCD chip. Comparisons between predicted SEU rates and those measured from ATLAS data are presented. The implications for ATLAS operation are discussed

Causal relationships between solar proton events and single event upsets for communication satellites

Science.gov (United States)

Lohmeyer, W. Q.; Cahoy, K.; Liu, Shiyang

In this work, we analyze a historical archive of single event upsets (SEUs) maintained by Inmarsat, one of the world's leading providers of global mobile satellite communications services. Inmarsat has operated its geostationary communication satellites and collected extensive satellite anomaly and telemetry data since 1990. Over the course of the past twenty years, the satellites have experienced more than 226 single event upsets (SEUs), a catch-all term for anomalies that occur in a satellite's electronics such as bit-flips, trips in power supplies, and memory changes in attitude control systems. While SEUs are seemingly random and difficult to predict, we correlate their occurrences to space weather phenomena, and specifically show correlations between SEUs and solar proton events (SPEs). SPEs are highly energetic protons that originate from solar coronal mass ejections (CMEs). It is thought that when these particles impact geostationary (GEO) satellites they can cause SEUs as well as solar array degradation. We calculate the associated statistical correlations that each SEU occurs within one day, one week, two weeks, and one month of 10 MeV SPEs between 10 - 10,000 particle flux units (pfu). However, we find that SPEs are most prevalent at solar maximum and that the SEUs on Inmarsat's satellites occur out of phase with the solar maximum. Ultimately, this suggests that SPEs are not the primary cause of the Inmarsat SEUs. A better understanding of the causal relationship between SPEs and SEUs will help the satellite communications industry develop component and operational space weather mitigation techniques as well as help the space weather community to refine radiation models.

Position sensitive regions in a generic radiation sensor based on single event upsets in dynamic RAMs

International Nuclear Information System (INIS)

Darambara, D.G.; Spyrou, N.M.

1997-01-01

Modern integrated circuits are highly complex systems and, as such, are susceptible to occasional failures. Semiconductor memory devices, particularly dynamic random access memories (dRAMs), are subject to random, transient single event upsets (SEUs) created by energetic ionizing radiation. These radiation-induced soft failures in the stored data of silicon based memory chips provide the foundation for a new, highly efficient, low cost generic radiation sensor. The susceptibility and the detection efficiency of a given dRAM device to SEUs is a complicated function of the circuit design and geometry, the operating conditions and the physics of the charge collection mechanisms involved. Typically, soft error rates measure the cumulative response of all sensitive regions of the memory by broad area chip exposure in ionizing radiation environments. However, this study shows that many regions of a dynamic memory are competing charge collection centres having different upset thresholds. The contribution to soft fails from discrete regions or individual circuit elements of the memory device is unambiguously separated. Hence the use of the dRAM as a position sensitive radiation detector, with high spatial resolution, is assessed and demonstrated. (orig.)

NEPP Update of Independent Single Event Upset Field Programmable Gate Array Testing

Science.gov (United States)

Berg, Melanie; Label, Kenneth; Campola, Michael; Pellish, Jonathan

2017-01-01

This presentation provides a NASA Electronic Parts and Packaging (NEPP) Program update of independent Single Event Upset (SEU) Field Programmable Gate Array (FPGA) testing including FPGA test guidelines, Microsemi RTG4 heavy-ion results, Xilinx Kintex-UltraScale heavy-ion results, Xilinx UltraScale+ single event effect (SEE) test plans, development of a new methodology for characterizing SEU system response, and NEPP involvement with FPGA security and trust.

The single event upset environment for avionics at high latitude

International Nuclear Information System (INIS)

Sims, A.J.; Dyer, C.S.; Peerless, C.L.; Farren, J.

1994-01-01

Modern avionic systems for civil and military applications are becoming increasingly reliant upon embedded microprocessors and associated memory devices. The phenomenon of single event upset (SEU) is well known in space systems and designers have generally been careful to use SEU tolerant devices or to implement error detection and correction (EDAC) techniques where appropriate. In the past, avionics designers have had no reason to consider SEU effects but is clear that the more prevalent use of memory devices combined with increasing levels of IC integration will make SEU mitigation an important design consideration for future avionic systems. To this end, it is necessary to work towards producing models of the avionics SEU environment which will permit system designers to choose components and EDAC techniques which are based on predictions of SEU rates correct to much better than an order of magnitude. Measurements of the high latitude SEU environment at avionics altitude have been made on board a commercial airliner. Results are compared with models of primary and secondary cosmic rays and atmospheric neutrons. Ground based SEU tests of static RAMs are used to predict rates in flight

Single Event Upset Studies Using the ATLAS SCT

CERN Document Server

Weidberg, A R; The ATLAS collaboration

2013-01-01

Single Event Upsets (SEU) are expected to occur during high luminosity running of the ATLAS SemiConductor Tracker (SCT). The SEU cross sections were measured in pion beams with momenta in the range 200 to 465 MeV/c and proton test beams at 24 GeV/c but the extrapolation to LHC conditions is non-trivial because of the range of particle types and momenta. The SEUs studied occur in the \\emph{p-i-n} photodiode and the registers in the ABCD chip. Comparisons between predicted SEU rates and those measured from ATLAS data are presented. The implications for ATLAS operation are discussed.

Device simulation of charge collection and single-event upset

International Nuclear Information System (INIS)

Dodd, P.E.

1996-01-01

In this paper the author reviews the current status of device simulation of ionizing-radiation-induced charge collection and single-event upset (SEU), with an emphasis on significant results of recent years. The author presents an overview of device-modeling techniques applicable to the SEU problem and the unique challenges this task presents to the device modeler. He examines unloaded simulations of radiation-induced charge collection in simple p/n diodes, SEU in dynamic random access memories (DRAM's), and SEU in static random access memories (SRAM's). The author concludes with a few thoughts on future issues likely to confront the SEU device modeler

Single Event Upset Energy Dependence In a Buck-Converter Power Supply Design

CERN Document Server

Drake, G; The ATLAS collaboration; Gopalakrishnan, A; Mahadik, S; Mellado, B; Proudfoot, J; Reed, R; Senthilkumaran, A; Stanek, R

2012-01-01

We present a study of Single Event Upsets (SEU) performed on a commercial pulse-width modulator controller chip for switching power supplies. We performed tests to study the probability of an SEU occurring as a function of incident particle (hadron) energy. We discuss the performance of the circuit, and present a solution using external circuitry to effectively eliminate the effect.

Single event upset mitigation techniques for FPGAs utilized in nuclear power plant digital instrumentation and control

International Nuclear Information System (INIS)

Wang Xin; Holbert, Keith E.; Clark, Lawrence T.

2011-01-01

Highlights: → Triple modular redundancy (TMR) implementation is the best solution for digital I and C. → Maximal probability of two simultaneous errors with TMR maximum partition is 4.44%. → Dual modular redundancy minimum logic partitioning design is an additional option. - Abstract: Field programmable gate arrays (FPGAs) are integrated circuits being increasingly used for digital instrumentation and control (I and C) in nuclear power plants (NPPs) because of low cost, re-configurability and low design turn-around time. However, to ensure reliability, proper design techniques must be employed since the memory and logic in FPGAs are susceptible to single event upsets (SEUs). Triple modular redundancy (TMR) has become a common SEU mitigation design technique because of its straightforward implementation and reliable results. Partitioned TMR approaches are introduced in this paper, and formulae derived indicate that the maximum probability of two simultaneous errors [P E ] max is inversely proportional to the number of logic partitions in a TMR design, when each redundant logic block in every logic partition has the same number of sensitive nodes. However, the maximum logic partitioning design cannot completely eliminate the possibility of two simultaneous upsets. For the example test circuit it is found that [P E ] max is reduced dramatically from 66.67% for minimum logic partitioning to 4.44% for maximum logic partitioning. Because TMR introduces significant overhead due to its full hardware redundancy, a dual modular redundancy approach is also examined for application to less demanding situations. By comparative analysis this study reaches the conclusion that the maximum logic partitioning TMR implementation is the best solution for digital I and C applications in NPPs where obtaining robustness is of the highest importance, despite its higher area overhead.

Investigation of radial dose effect on single event upset cross-section due to heavy ions using GEANT4

International Nuclear Information System (INIS)

Boorboor, S.; Feghhi, S.A.H.; Jafari, H.

2015-01-01

The heavy ions are the main cause to produce single event upset (SEU) damage on electronic devices since they are high LET radiations. The dimension of electronic components in new technology, arise a challenge in radiation effect estimations. Accurate investigations require fully considering the ion track in energy deposition as a radial dose distribution. In this work, the distribution of delta rays as well as LET have been calculated to determine ionization structure around ion track by a Monte Carlo code, GEANT4. The radial dose of several heavy ions with different energy in silicon was investigated and compared with the works by other authors in this field. The results showed that heavy ions with identical LET can have different SEU cross-section in silicon transistors. As a demonstrative example, according to our results, the error probability for 4.8 GeV iron was 8 times greater than that for 15 MeV carbon ions, in transistors with new process technology which have small dimension and low critical charges. Our results show that considering radial dose distribution considerably improves the accuracy of the SEU cross-section estimation in electronic devices especially for new technologies. - Highlights: • The single event upset is produced by heavy ions interaction on electronic devices. • The radial dose of several heavy ions in silicon was calculated by GEANT4. • Heavy ions with identical LET had different SEU cross-section in silicon transistors. • Low dimension and critical charge devices were more sensitive to radial dose effect

Low-energy neutron-induced single-event upsets in static random access memory

International Nuclear Information System (INIS)

Guo Xiaoqiang; Guo Hongxia; Wang Guizhen; Ling Dongsheng; Chen Wei; Bai Xiaoyan; Yang Shanchao; Liu Yan

2009-01-01

The visual analysis method of data process was provided for neutron-induced single-event upset(SEU) in static random access memory(SRAM). The SEU effects of six CMOS SRAMs with different feature size(from 0.13 μm to 1.50 μm) were studied. The SEU experiments were performed using the neutron radiation environment at Xi'an pulsed reactor. And the dependence of low-energy neutron-induced SEU cross section on SRAM's feature size was given. The results indicate that the decreased critical charge is the dominant factor for the increase of single event effect sensitivity of SRAM devices with decreased feature size. Small-sized SRAM devices are more sensitive than large-sized ones to single event effect induced by low-energy neutrons. (authors)

Investigation of Single Events Upsets in Silicon and GaAs Structures Using Reaction Calculations

Science.gov (United States)

1994-09-01

Cubed Corporation. The CREME (Cosmic-Ray-Effects on Microelectronics) (73) and the CRUP (Cos- mic Ray Upset Program) (74) are both from the Naval...knowledge, that is impossible to do in advance. The errors per bit day calculated using CREME and CRUP for a device exposed to Adams’ 90% worst-case...emitter junction was measured for alpha particles ion measurements and used in CREME (2) and CRUP from an Americium source in two ways: First, the (3

Microbeam mapping of single event latchups and single event upsets in CMOS SRAMs

International Nuclear Information System (INIS)

Barak, J.; Adler, E.; Fischer, B.E.; Schloegl, M.; Metzger, S.

1998-01-01

The first simultaneous microbeam mapping of single event upset (SEU) and latchup (SEL) in the CMOS RAM HM65162 is presented. The authors found that the shapes of the sensitive areas depend on V DD , on the ions being used and on the site on the chip being hit by the ion. In particular, they found SEL sensitive sites close to the main power supply lines between the memory-bit-arrays by detecting the accompanying current surge. All these SELs were also accompanied by bit-flips elsewhere in the memory (which they call indirect SEUs in contrast to the well known SEUs induced in the hit memory cell only). When identical SEL sensitive sites were hit farther away from the supply lines only indirect SEL sensitive sites could be detected. They interpret these events as latent latchups in contrast to the classical ones detected by their induced current surge. These latent SELs were probably decoupled from the main supply lines by the high resistivity of the local supply lines

Single-word multiple-bit upsets in static random access devices

International Nuclear Information System (INIS)

Koga, R.; Pinkerton, S.D.; Lie, T.J.; Crawford, K.B.

1993-01-01

Energetic ions and protons can cause single event upsets (SEUs) in static random access memory (SRAM) cells. In some cases multiple bits may be upset as the result of a single event. Space-borne electronics systems incorporating high-density SRAM are vulnerable to single-word multiple-bit upsets (SMUs). The authors review here recent observations of SMU, present the results of a systematic investigation of the physical cell arrangements employed in several currently available SRAM device types, and discuss implications for the occurrence and mitigation of SMU

Single Event Upset Energy Dependence In a Buck-Converter Power Supply Design

CERN Document Server

Drake, G; The ATLAS collaboration; De Lurgio, P; Stanek, R; Mellado, B; Gopalakrishnan, A; Mahadik, S; Reed, R; Senthilkumaran, A

2012-01-01

We present a study of Single Event Upsets performed on a commercial pulse-width modulator controller chip that we are using for a switching power supply design for the Atlas Tile Calorimeter at the LHC. We performed tests to study the probability of an SEU occurring as a function of incident particle (hadron) energy. We compare the results with prediction from theory. We discuss the performance of the circuit, and perform an analysis using Bendel parameters. We also present a solution that we found using external circuitry that eliminates the effect.

Acquisition and classification of static single-event upset cross section for SRAM-based FPGAs

International Nuclear Information System (INIS)

Yao Zhibin; Fan Ruyu; Guo Hongxia; Wang Zhongming; He Baoping; Zhang Fengqi; Zhang Keying

2011-01-01

In order to evaluate single event upsets (SEUs) in SRAM-based FPGAs and to find the sensitive resource in configuration memory, a heavy ions irradiation experiment was carried out on a Xilinx FPGAs device XCV300PQ240. The experiment was conducted to gain the static SEU cross section and classify the SEUs in configurations memory according to different resource uses. The results demonstrate that the inter-memory of SRAM-based FPGAs is extremely sensitive to heavy-ion-induced SEUs. The LUT and routing resources are the main source of SEUs in the configuration memory, which covers more than 97.46% of the total upsets. The SEU sensitivity of various resources is different. The IOB control bit and LUT elements are more sensitive,and more attention should be paid to the LUT elements in radiation hardening,which account for a quite large proportion of the configuration memory. (authors)

Single event upsets in semiconductor devices induced by highly ionising particles.

Science.gov (United States)

Sannikov, A V

2004-01-01

A new model of single event upsets (SEUs), created in memory cells by heavy ions and high energy hadrons, has been developed. The model takes into account the spatial distribution of charge collection efficiency over the cell area not considered in previous approaches. Three-dimensional calculations made by the HADRON code have shown good agreement with experimental data for the energy dependence of proton SEU cross sections, sensitive depths and other SEU observables. The model is promising for prediction of SEU rates for memory chips exposed in space and in high-energy experiments as well as for the development of a high-energy neutron dosemeter based on the SEU effect.

Single event upsets calculated from new ENDF/B-VI proton and neutron data up to 150 MeV

International Nuclear Information System (INIS)

Chadwick, M.B.

1999-01-01

Single-event upsets (SEU) in microelectronics are calculated from newly-developed silicon nuclear reaction recoil data that extend up to 150 MeV, for incident protons and neutrons. Calculated SEU cross sections are compared with measured data

The measurement and prediction of proton upset

Science.gov (United States)

Shimano, Y.; Goka, T.; Kuboyama, S.; Kawachi, K.; Kanai, T.

1989-12-01

The authors evaluate tolerance to proton upset for three kinds of memories and one microprocessor unit for space use by irradiating them with high-energy protons up to nearly 70 MeV. They predict the error rates of these memories using a modified semi-empirical equation of Bendel and Petersen (1983). A two-parameter method was used instead of Bendel's one-parameter method. There is a large difference between these two methods with regard to the fitted parameters. The calculation of upset rates in orbits were carried out using these parameters and NASA AP8MAC, AP8MIC. For the 93419 RAM the result of this calculation was compared with the in-orbit data taken on the MOS-1 spacecraft. A good agreement was found between the two sets of upset-rate data.

Application of RADSAFE to Model Single Event Upset Response of a 0.25 micron CMOS SRAM

Science.gov (United States)

Warren, Kevin M.; Weller, Robert A.; Sierawski, Brian; Reed, Robert A.; Mendenhall, Marcus H.; Schrimpf, Ronald D.; Massengill, Lloyd; Porter, Mark; Wilkerson, Jeff; LaBel, Kenneth A.;

Single event upset threshold estimation based on local laser irradiation

International Nuclear Information System (INIS)

Chumakov, A.I.; Egorov, A.N.; Mavritsky, O.B.; Yanenko, A.V.

1999-01-01

An approach for estimation of ion-induced SEU threshold based on local laser irradiation is presented. Comparative experiment and software simulation research were performed at various pulse duration and spot size. Correlation of single event threshold LET to upset threshold laser energy under local irradiation was found. The computer analysis of local laser irradiation of IC structures was developed for SEU threshold LET estimation. The correlation of local laser threshold energy with SEU threshold LET was shown. Two estimation techniques were suggested. The first one is based on the determination of local laser threshold dose taking into account the relation of sensitive area to local irradiated area. The second technique uses the photocurrent peak value instead of this relation. The agreement between the predicted and experimental results demonstrates the applicability of this approach. (authors)

Characterization of System Level Single Event Upset (SEU) Responses using SEU Data, Classical Reliability Models, and Space Environment Data

Science.gov (United States)

Berg, Melanie; Label, Kenneth; Campola, Michael; Xapsos, Michael

2017-01-01

We propose a method for the application of single event upset (SEU) data towards the analysis of complex systems using transformed reliability models (from the time domain to the particle fluence domain) and space environment data.

Calculation of neutron-induced single-event upset cross sections for semiconductor memory devices

International Nuclear Information System (INIS)

Ikeuchi, Taketo; Watanabe, Yukinobu; Nakashima, Hideki; Sun, Weili

2001-01-01

Neutron-induced single-event upset (SEU) cross sections for semiconductor memory devices are calculated by the Burst Generation Rate (BGR) method using LA150 data and QMD calculation in the neutron energy range between 20 MeV and 10 GeV. The calculated results are compared with the measured SEU cross sections for energies up to 160 MeV, and the validity of the calculation method and the nuclear data used is verified. The kind of reaction products and the neutron energy range that have the most effect on SEU are discussed. (author)

Implications of the spatial dependence of the single-event-upset threshold in SRAMs measured with a pulsed laser

International Nuclear Information System (INIS)

Buchner, S.; Langworthy, J.B.; Stapor, W.J.; Campbell, A.B.; Rivet, S.

1994-01-01

Pulsed laser light was used to measure single event upset (SEU) thresholds for a large number of memory cells in both CMOS and bipolar SRAMs. Results showed that small variations in intercell upset threshold could not explain the gradual rise in the curve of cross section versus linear energy transfer (LET). The memory cells exhibited greater intracell variations implying that the charge collection efficiency within a memory cell varies spatially and contributes substantially to the shape of the curve of cross section versus LET. The results also suggest that the pulsed laser can be used for hardness-assurance measurements on devices with sensitive areas larger than the diameter of the laser beam

Analyzing Test-As-You-Fly Single Event Upset (SEU) Responses using SEU Data, Classical Reliability Models, and Space Environment Data

Science.gov (United States)

Berg, Melanie; Label, Kenneth; Campola, Michael; Xapsos, Michael

2017-01-01

We propose a method for the application of single event upset (SEU) data towards the analysis of complex systems using transformed reliability models (from the time domain to the particle fluence domain) and space environment data.

Estimation of the LET threshold of single event upset of microelectronics in experiments with Cf-252

International Nuclear Information System (INIS)

Kuznetsov, N.V.; Nymmik, R.A.

1996-01-01

A method is proposed for analyzing single event upsets (SEU) in large scale integration circuits of random access memory (RAM) when exposed to Cf-252 fission fragments. The method makes is possible to find the RAM linear energy transfer (LET) threshold to be used for estimations of RAM SEU rates in space. The method is illustrated by analyzing experimental data for the 2 x 8 kbit CMOS/bulk RAM. (author)

Upset Prediction in Friction Welding Using Radial Basis Function Neural Network

Directory of Open Access Journals (Sweden)

Wei Liu

2013-01-01

Full Text Available This paper addresses the upset prediction problem of friction welded joints. Based on finite element simulations of inertia friction welding (IFW, a radial basis function (RBF neural network was developed initially to predict the final upset for a number of welding parameters. The predicted joint upset by the RBF neural network was compared to validated finite element simulations, producing an error of less than 8.16% which is reasonable. Furthermore, the effects of initial rotational speed and axial pressure on the upset were investigated in relation to energy conversion with the RBF neural network. The developed RBF neural network was also applied to linear friction welding (LFW and continuous drive friction welding (CDFW. The correlation coefficients of RBF prediction for LFW and CDFW were 0.963 and 0.998, respectively, which further suggest that an RBF neural network is an effective method for upset prediction of friction welded joints.

Single-Event Effect Performance of a Conductive-Bridge Memory EEPROM

Science.gov (United States)

Chen, Dakai; Wilcox, Edward; Berg, Melanie; Kim, Hak; Phan, Anthony; Figueiredo, Marco; Seidleck, Christina; LaBel, Kenneth

2015-01-01

We investigated the heavy ion single-event effect (SEE) susceptibility of the industry’s first stand-alone memory based on conductive-bridge memory (CBRAM) technology. The device is available as an electrically erasable programmable read-only memory (EEPROM). We found that single-event functional interrupt (SEFI) is the dominant SEE type for each operational mode (standby, dynamic read, and dynamic write/read). SEFIs occurred even while the device is statically biased in standby mode. Worst case SEFIs resulted in errors that filled the entire memory space. Power cycle did not always clear the errors. Thus the corrupted cells had to be reprogrammed in some cases. The device is also vulnerable to bit upsets during dynamic write/read tests, although the frequency of the upsets are relatively low. The linear energy transfer threshold for cell upset is between 10 and 20 megaelectron volts per square centimeter per milligram, with an upper limit cross section of 1.6 times 10(sup -11) square centimeters per bit (95 percent confidence level) at 10 megaelectronvolts per square centimeter per milligram. In standby mode, the CBRAM array appears invulnerable to bit upsets.

Airplane Upset Training Evaluation Report

Science.gov (United States)

Gawron, Valerie J.; Jones, Patricia M. (Technical Monitor)

2002-01-01

Airplane upset accidents are a leading factor in hull losses and fatalities. This study compared five types of airplane-upset training. Each group was composed of eight, non-military pilots flying in their probationary year for airlines operating in the United States. The first group, 'No aero / no upset,' was made up of pilots without any airplane upset training or aerobatic flight experience; the second group, 'Aero/no upset,' of pilots without any airplane-upset training but with aerobatic experience; the third group, 'No aero/upset,' of pilots who had received airplane-upset training in both ground school and in the simulator; the fourth group, 'Aero/upset,' received the same training as Group Three but in addition had aerobatic flight experience; and the fifth group, 'In-flight' received in-flight airplane upset training using an instrumented in-flight simulator. Recovery performance indicated that clearly training works - specifically, all 40 pilots recovered from the windshear upset. However few pilots were trained or understood the use of bank to change the direction of the lift vector to recover from nose high upsets. Further, very few thought of, or used differential thrust to recover from rudder or aileron induced roll upsets. In addition, recovery from icing-induced stalls was inadequate.

Notice of Violation of IEEE Publication PrinciplesJoint Redundant Residue Number Systems and Module Isolation for Mitigating Single Event Multiple Bit Upsets in Datapath

Science.gov (United States)

Li, Lei; Hu, Jianhao

2010-12-01

Notice of Violation of IEEE Publication Principles"Joint Redundant Residue Number Systems and Module Isolation for Mitigating Single Event Multiple Bit Upsets in Datapath"by Lei Li and Jianhao Hu,in the IEEE Transactions on Nuclear Science, vol.57, no.6, Dec. 2010, pp. 3779-3786After careful and considered review of the content and authorship of this paper by a duly constituted expert committee, this paper has been found to be in violation of IEEE's Publication Principles.This paper contains substantial duplication of original text from the paper cited below. The original text was copied without attribution (including appropriate references to the original author(s) and/or paper title) and without permission.Due to the nature of this violation, reasonable effort should be made to remove all past references to this paper, and future references should be made to the following articles:"Multiple Error Detection and Correction Based on Redundant Residue Number Systems"by Vik Tor Goh and M.U. Siddiqi,in the IEEE Transactions on Communications, vol.56, no.3, March 2008, pp.325-330"A Coding Theory Approach to Error Control in Redundant Residue Number Systems. I: Theory and Single Error Correction"by H. Krishna, K-Y. Lin, and J-D. Sun, in the IEEE Transactions on Circuits and Systems II: Analog and Digital Signal Processing, vol.39, no.1, Jan 1992, pp.8-17In this paper, we propose a joint scheme which combines redundant residue number systems (RRNS) with module isolation (MI) for mitigating single event multiple bit upsets (SEMBUs) in datapath. The proposed hardening scheme employs redundant residues to improve the fault tolerance for datapath and module spacings to guarantee that SEMBUs caused by charge sharing do not propagate among the operation channels of different moduli. The features of RRNS, such as independence, parallel and error correction, are exploited to establish the radiation hardening architecture for the datapath in radiation environments. In the proposed

Influence of edge effects on single event upset susceptibility of SOI SRAMs

International Nuclear Information System (INIS)

Gu, Song; Liu, Jie; Zhao, Fazhan; Zhang, Zhangang; Bi, Jinshun; Geng, Chao; Hou, Mingdong; Liu, Gang; Liu, Tianqi; Xi, Kai

2015-01-01

An experimental investigation of the single event upset (SEU) susceptibility for heavy ions at tilted incidence was performed. The differences of SEU cross-sections between tilted incidence and normal incidence at equivalent effective linear energy transfer were 21% and 57% for the silicon-on-insulator (SOI) static random access memories (SRAMs) of 0.5 μm and 0.18 μm feature size, respectively. The difference of SEU cross-section raised dramatically with increasing tilt angle for SOI SRAM of deep-submicron technology. The result of CRÈME-MC simulation for tilted irradiation of the sensitive volume indicates that the energy deposition spectrum has a substantial tail extending into the low energy region. The experimental results show that the influence of edge effects on SEU susceptibility cannot be ignored in particular with device scaling down

Single-Event Upset and Scaling Trends in New Generation of the Commercial SOI PowerPC Microprocessors

Science.gov (United States)

Irom, Farokh; Farmanesh, Farhad; Kouba, Coy K.

2006-01-01

Single-event upset effects from heavy ions are measured for Motorola silicon-on-insulator (SOI) microprocessor with 90 nm feature sizes. The results are compared with previous results for SOI microprocessors with feature sizes of 130 and 180 nm. The cross section of the 90 nm SOI processors is smaller than results for 130 and 180 nm counterparts, but the threshold is about the same. The scaling of the cross section with reduction of feature size and core voltage for SOI microprocessors is discussed.

Simulation of thermal-neutron-induced single-event upset using particle and heavy-ion transport code system

International Nuclear Information System (INIS)

Arita, Yutaka; Kihara, Yuji; Mitsuhasi, Junichi; Niita, Koji; Takai, Mikio; Ogawa, Izumi; Kishimoto, Tadafumi; Yoshihara, Tsutomu

2007-01-01

The simulation of a thermal-neutron-induced single-event upset (SEU) was performed on a 0.4-μm-design-rule 4 Mbit static random access memory (SRAM) using particle and heavy-ion transport code system (PHITS): The SEU rates obtained by the simulation were in very good agreement with the result of experiments. PHITS is a useful tool for simulating SEUs in semiconductor devices. To further improve the accuracy of the simulation, additional methods for tallying the energy deposition are required for PHITS. (author)

Characterization of System on a Chip (SoC) Single Event Upset (SEU) Responses Using SEU Data, Classical Reliability Models, and Space Environment Data

Science.gov (United States)

Berg, Melanie; Label, Kenneth; Campola, Michael; Xapsos, Michael

2017-01-01

We propose a method for the application of single event upset (SEU) data towards the analysis of complex systems using transformed reliability models (from the time domain to the particle fluence domain) and space environment data.

A simple analytical model of single-event upsets in bulk CMOS

Energy Technology Data Exchange (ETDEWEB)

Sogoyan, Armen V.; Chumakov, Alexander I.; Smolin, Anatoly A., E-mail: aasmol@spels.ru; Ulanova, Anastasia V.; Boruzdina, Anna B.

2017-06-01

During the last decade, multiple new methods of single event upset (SEU) rate prediction for aerospace systems have been proposed. Despite different models and approaches being employed in these methods, they all share relatively high usage complexity and require information about a device that is not always available to an end user. This work presents an alternative approach to estimating SEU cross-section as a function of linear energy transfer (LET) that can be further developed into a method of SEU rate prediction. The goal is to propose a simple, yet physics-based, approach with just two parameters that can be used even in situations when only a process node of the device is known. The developed approach is based on geometrical interpretation of SEU cross-section and an analytical solution to the diffusion problem obtained for a simplified IC topology model. A good fit of the model to the experimental data encompassing 7 generations of SRAMs is demonstrated.

A simple analytical model of single-event upsets in bulk CMOS

International Nuclear Information System (INIS)

Sogoyan, Armen V.; Chumakov, Alexander I.; Smolin, Anatoly A.; Ulanova, Anastasia V.; Boruzdina, Anna B.

2017-01-01

During the last decade, multiple new methods of single event upset (SEU) rate prediction for aerospace systems have been proposed. Despite different models and approaches being employed in these methods, they all share relatively high usage complexity and require information about a device that is not always available to an end user. This work presents an alternative approach to estimating SEU cross-section as a function of linear energy transfer (LET) that can be further developed into a method of SEU rate prediction. The goal is to propose a simple, yet physics-based, approach with just two parameters that can be used even in situations when only a process node of the device is known. The developed approach is based on geometrical interpretation of SEU cross-section and an analytical solution to the diffusion problem obtained for a simplified IC topology model. A good fit of the model to the experimental data encompassing 7 generations of SRAMs is demonstrated.

Evaluation of single-event upset tolerance on 64Mbit DRAM and 16Mbit DRAM

Energy Technology Data Exchange (ETDEWEB)

Nemoto, N; Shindou, H; Matsuzaki, K; Akutsu, T; Matsuda, S [National Space Development Agency of Japan, Tokyo (Japan); Hirao, T; Itoh, H; Nashiyama, I

1997-11-01

In recent years, reduction in the mission cost is regarded as one of the most important matters, and thus much effort has been made to reduce the cost of electronic components used in spacecrafts without diminishing their performance. On this policy, there has been a growing interest in space application of commercial devices such as highly integrated memory ICs because of low prices and high performance of such devices. To ensure success in this application, it is indispensable to investigate radiation effects, e.g., single-event and total-dose effects, on commercial devices precisely. In the present study, we have evaluated single-event upset (SEU) tolerance for 1Mbit, 4Mbit SRAM and 16Mbit, 64Mbit DRAM by irradiation of high energy heavy ions such as 175MeV-Ar{sup 8+} and 450MeV-Xe{sup 23+}. We observed these SEU tolerance in space. (author)

Talys calculations for evaluation of neutron-induced single-event upset cross sections

Energy Technology Data Exchange (ETDEWEB)

Bourselier, Jean-Christophe

2005-08-15

The computer code TALYS has been used to calculate interactions between cosmic-ray neutrons and silicon nuclei with the goal to describe single-event upset (SEU) cross sections in microelectronics devices. Calculations for the Si(n,X) reaction extend over an energy range of 2 to 200 MeV. The obtained energy spectra of the resulting residuals and light-ions have been integrated using several different critical charges as SEU threshold. It is found that the SEU cross section seems largely to be dominated by {sup 28}Si recoils from elastic scattering. Furthermore, the shape of the SEU cross section as a function of the energy of the incoming neutron changes drastically with decreasing critical charge. The results presented in this report stress the importance of performing studies at mono-energetic neutron beams to advance the understanding of the underlying mechanisms causing SEUs.

Single Event Upset in Static Random Access Memories in Atmospheric Neutron Environments

Science.gov (United States)

Arita, Yutaka; Takai, Mikio; Ogawa, Izumi; Kishimoto, Tadafumi

2003-07-01

Single-event upsets (SEUs) in a 0.4 μm 4 Mbit complementary metal oxide semiconductor (CMOS) static random access memory (SRAM) were investigated in various atmospheric neutron environments at sea level, at an altitude of 2612 m mountain, at an altitude of commercial airplane, and at an underground depth of 476 m. Neutron-induced SEUs increase with the increase in altitude. For a device with a borophosphosilicate glass (BPSG) film, SEU rates induced by thermal neutrons increase with the decrease in the cell charge of a memory cell. A thermal neutron-induced SEU is significant in SRAMs with a small cell charge. With the conditions of small cell charge, thermal neutron-induced SEUs account for 60% or more of the total neutron-induced SEUs. The SEU rate induced by atmospheric thermal neutrons can be estimated by an acceleration test using 252Cf.

Talys calculations for evaluation of neutron-induced single-event upset cross sections

International Nuclear Information System (INIS)

Bourselier, Jean-Christophe

2005-08-01

The computer code TALYS has been used to calculate interactions between cosmic-ray neutrons and silicon nuclei with the goal to describe single-event upset (SEU) cross sections in microelectronics devices. Calculations for the Si(n,X) reaction extend over an energy range of 2 to 200 MeV. The obtained energy spectra of the resulting residuals and light-ions have been integrated using several different critical charges as SEU threshold. It is found that the SEU cross section seems largely to be dominated by 28 Si recoils from elastic scattering. Furthermore, the shape of the SEU cross section as a function of the energy of the incoming neutron changes drastically with decreasing critical charge. The results presented in this report stress the importance of performing studies at mono-energetic neutron beams to advance the understanding of the underlying mechanisms causing SEUs

Solar particle induced upsets in the TDRS-1 attitude control system RAM during the October 1989 solar particle events

International Nuclear Information System (INIS)

Croley, D.R.; Garrett, H.B.; Murphy, G.B.; Garrard, T.L.

1995-01-01

The three large solar particle events, beginning on October 19, 1989 and lasting approximately six days, were characterized by high fluences of solar protons and heavy ions at 1 AU. During these events, an abnormally large number of upsets (243) were observed in the random access memory of the attitude control system (ACS) control processing electronics (CPE) on-board the geosynchronous TDRS-1 (Telemetry and Data Relay Satellite). The RAM unit affected was composed of eight Fairchild 93L422 memory chips. The Galileo spacecraft, launched on October 18, 1989 (one day prior to the solar particle events) observed the fluxes of heavy ions experienced by TDRS-1. Two solid-state detector telescopes on-board Galileo, designed to measure heavy ion species and energy, were turned on during time periods within each of the three separate events. The heavy ion data have been modeled and the time history of the events reconstructed to estimate heavy ion fluences. These fluences were converted to effective LET spectra after transport through the estimated shielding distribution around the TDRS-1 ACS system. The number of single event upsets (SEU) expected was calculated by integrating the measured cross section for the Fairchild 93L422 memory chip with average effective LET spectrum. The expected number of heavy ion induced SEU's calculated was 176. GOES-7 proton data, observed during the solar particle events, were used to estimate the number of proton-induced SEU's by integrating the proton fluence spectrum incident on the memory chips, with the two-parameter Bendel cross section for proton SEU's. The proton fluence spectrum at the device level was gotten by transporting the protons through the estimated shielding distribution. The number of calculated proton-induced SEU's was 72, yielding a total of 248 predicted SEU's, very close to the 243 observed SEU's

Single event upset in static random access memories in atmospheric neutron environments

CERN Document Server

Arita, Y; Ogawa, I; Kishimoto, T

2003-01-01

Single-event upsets (SEUs) in a 0.4 mu m 4Mbit complementary metal oxide semiconductor (CMOS) static random access memory (SRAM) were investigated in various atmospheric neutron environments at sea level, at an altitude of 2612 m mountain, at an altitude of commercial airplane, and at an underground depth of 476m. Neutron-induced SEUs increase with the increase in altitude. For a device with a borophosphosilicate glass (BPSG) film, SEU rates induced by thermal neutrons increase with the decrease in the cell charge of a memory cell. A thermal neutron-induced SEU is significant in SRAMs with a small cell charge. With the conditions of small cell charge, thermal neutron-induced SEUs account for 60% or more of the total neutron-induced SEUs. The SEU rate induced by atmospheric thermal neutrons can be estimated by an acceleration test using sup 2 sup 5 sup 2 Cf. (author)

Soft error evaluation in SRAM using α sources

International Nuclear Information System (INIS)

He Chaohui; Chu Jun; Ren Xueming; Xia Chunmei; Yang Xiupei; Zhang Weiwei; Wang Hongquan; Xiao Jiangbo; Li Xiaolin

2006-01-01

Soft errors in memories influence directly the reliability of products. To compare the ability of three different memories against soft errors by experiments of alpha particles irradiation, the numbers of soft errors are measured for three different SRAMs and the cross sections of single event upset (SEU) and failures in time (FIT) are calculated. According to the cross sections of SEU, the ability of A166M against soft errors is the best and then B166M, the last B200M. The average FIT of B166M is smaller than that of B200M, and that of A166M is the biggest among them. (authors)

Nuclear data relevant to single event upsets in semiconductor memories induced by cosmic-ray neutrons and protons

International Nuclear Information System (INIS)

Watanabe, Yukinobu

2008-01-01

The role of nuclear data is examined in the study of single event upset (SEU) phenomena in semiconductor memories caused by cosmic-ray neutrons and protons. Neutron and proton SEU cross sections are calculated with a simplified semi-empirical model using experimental heavy-ion SEU cross-sections and a dedicated database of neutron and proton induced reactions on 28 Si. Some impacts of the nuclear reaction data on SEU simulation are analyzed by investigating relative contribution of secondary ions and neutron elastic scattering to SEU and influence of simultaneous multiple ions emission on SEU. (author)

Single event upset studies on the CMS tracker APV25 readout chip

International Nuclear Information System (INIS)

Noah, E.; Bauer, T.; Bisello, D.; Faccio, F.; Friedl, M.; Fulcher, J.R.; Hall, G.; Huhtinen, M.; Kaminsky, A.; Pernicka, M.; Raymond, M.; Wyss, J.

2002-01-01

The microstrip tracker for the CMS experiment at the CERN Large Hadron Collider will be read out using APV25 chips. During high luminosity running the tracker will be exposed to particle fluxes up to 10 7 cm -2 s -1 , which raises concerns that the APV25 could occasionally suffer Single Event Upsets (SEUs). The effect of SEU on the APV25 has been studied to investigate implications for CMS detector operation and from the viewpoint of detailed circuit operation, to improve the understanding of its origin and what factors affect its magnitude. Simulations were performed to reconstruct the effects created by highly ionising particles striking sensitive parts of the circuits, along with consideration of the underlying mechanisms of charge deposition, collection and the consequences. A model to predict the behaviour of the memory circuits in the APV25 has been developed and data collected from dedicated experiments using both heavy ions and hadrons have been shown to support it

Solar Particle Induced Upsets in the TDRS-1 Attitude Control System RAM During the October 1989 Solar Particle Events

Science.gov (United States)

Croley, D. R.; Garrett, H. B.; Murphy, G. B.; Garrard,T. L.

1995-01-01

The three large solar particle events, beginning on October 19, 1989 and lasting approximately six days, were characterized by high fluences of solar protons and heavy ions at 1 AU. During these events, an abnormally large number of upsets (243) were observed in the random access memory of the attitude control system (ACS) control processing electronics (CPE) on-board the geosynchronous TDRS-1 (Telemetry and Data Relay Satellite). The RAM unit affected was composed of eight Fairchild 93L422 memory chips. The Galileo spacecraft, launched on October 18, 1989 (one day prior to the solar particle events) observed the fluxes of heavy ions experienced by TDRS-1. Two solid-state detector telescopes on-board Galileo, designed to measure heavy ion species and energy, were turned on during time periods within each of the three separate events. The heavy ion data have been modeled and the time history of the events reconstructed to estimate heavy ion fluences. These fluences were converted to effective LET spectra after transport through the estimated shielding distribution around the TDRS-1 ACS system. The number of single event upsets (SEU) expected was calculated by integrating the measured cross section for the Fairchild 93L422 memory chip with average effective LET spectrum. The expected number of heavy ion induced SEU's calculated was 176. GOES-7 proton data, observed during the solar particle events, were used to estimate the number of proton-induced SEU's by integrating the proton fluence spectrum incident on the memory chips, with the two-parameter Bendel cross section for proton SEU'S. The proton fluence spectrum at the device level was gotten by transporting the protons through the estimated shielding distribution. The number of calculated proton-induced SEU's was 72, yielding a total of 248 predicted SEU'S, very dose to the 243 observed SEU'S. These calculations uniquely demonstrate the roles that solar heavy ions and protons played in the production of SEU

Relationship between single-event upset immunity and fabrication processes of recent memories; Relations entre l'immunite au SEU et les procedes de fabrication de memoires recentes

Energy Technology Data Exchange (ETDEWEB)

Nemoto, N.; Shindou, H.; Kuboyama, S.; Matsuda, S. [National Space Development Agency of Japan, Ibaraki-ken (Japan); Itoh, H.; Okada, S.; Nashiyama, I. [Japan Atomic Energy Research Inst., Takasaki, Gunma (Japan)

1999-07-01

Single-Event upset (SEU) immunity for commercial devices were evaluated by irradiation tests using high-energy heavy ions. We show test results and describe the relationship between observed SEU and structures/fabrication processes. We have evaluated single-even upset (SEU) tolerance of recent commercial memory devices using high energy heavy ions in order to find relationship between SEU rate and their fabrication process. It was revealed that the change of the process parameter gives much effect for the SEU rate of the devices. (authors)

Single Event Upset Rate Estimates for a 16-K CMOS (Complementary Metal Oxide Semiconductor) SRAM (Static Random Access Memory).

Science.gov (United States)

1986-09-30

4 . ~**..ft.. ft . - - - ft SI TABLES 9 I. SA32~40 Single Event Upset Test, 1140-MeV Krypton, 9/l8/8~4. . .. .. .. .. .. .16 II. CRUP Simulation...cosmic ray interaction analysis described in the remainder of this report were calculated using the CRUP computer code 3 modified for funneling. The... CRUP code requires, as inputs, the size of a depletion region specified as a retangular parallel piped with dimensions a 9 b S c, the effective funnel

Corrected multiple upsets and bit reversals for improved 1-s resolution measurements

International Nuclear Information System (INIS)

Brucker, G.J.; Stassinopoulos, E.G.; Stauffer, C.A.

1994-01-01

Previous work has studied the generation of single and multiple errors in control and irradiated static RAM samples (Harris 6504RH) which were exposed to heavy ions for relatively long intervals of time (minute), and read out only after the beam was shut off. The present investigation involved storing 4k x 1 bit maps every second during 1 min ion exposures at low flux rates of 10 3 ions/cm 2 -s in order to reduce the chance of two sequential ions upsetting adjacent bits. The data were analyzed for the presence of adjacent upset bit locations in the physical memory plane, which were previously defined to constitute multiple upsets. Improvement in the time resolution of these measurements has provided more accurate estimates of multiple upsets. The results indicate that the percentage of multiples decreased from a high of 17% in the previous experiment to less than 1% for this new experimental technique. Consecutive double and triple upsets (reversals of bits) were detected. These were caused by sequential ions hitting the same bit, with one or two reversals of state occurring in a 1-min run. In addition to these results, a status review for these same parts covering 3.5 years of imprint damage recovery is also presented

Nuclear data relevant to single-event upsets (SEU) in microelectronics and their application to SEU simulation

International Nuclear Information System (INIS)

Watanabe, Yukinobu; Tukamoto, Yasuyuki; Kodama, Akihiro; Nakashima, Hideki

2004-01-01

A cross-section database for neutron-induced reactions on 28 Si was developed in the energy range between 2 MeV and 3 GeV in order to analyze single-event upsets (SEUs) phenomena induced by cosmic-ray neutrons in microelectronic devices. A simplified spherical device model was proposed for simulation of the initial process of SEUs. The model was applied to SEU cross-section calculations for semiconductor memory devices. The calculated results were compared with measured SEU cross-sections and the other simulation result. The dependence of SEU cross-sections on incident neutron energy and secondary ions having the most important effects on SEUs are discussed. (author)

Cosmic and terrestrial single-event radiation effects in dynamic random access memories

International Nuclear Information System (INIS)

Massengill, L.W.

1996-01-01

A review of the literature on single-event radiation effects (SEE) on MOS integrated-circuit dynamic random access memories (DRAM's) is presented. The sources of single-event (SE) radiation particles, causes of circuit information loss, experimental observations of SE information upset, technological developments for error mitigation, and relationships of developmental trends to SE vulnerability are discussed

Swift heavy ion induced single event upsets in high density UV-EPROM's

Energy Technology Data Exchange (ETDEWEB)

Dahiwale, S.S. [Department of Physics, University of Pune, Pune 7 (India); Shinde, N.S. [Department of Chemical Engineering, Mie University (Japan); Kanjilal, D. [Inter University Accelerator Center, New Delhi (India); Bhoraskar, V.N. [Department of Physics, University of Pune, Pune 7 (India); Dhole, S.D. [Department of Physics, University of Pune, Pune 7 (India)], E-mail: sanjay@physics.unipune.ernet.in

2008-04-15

A few high density UV-EPROM's (32Kb x 8) were irradiated with 5.41 MeV energy {alpha}-particles with fluences from 10{sup 4} to 10{sup 8} alphas/cm{sup 2} and 100 MeV nickel, iodine and silver ions for low fluences between 5 x 10{sup 7} and 10{sup 8} ions/cm{sup 2}. The energy and ion species was selected on the basis of predicted threshold values of linear energy transfer (LET) in silicon. The program which was stored in the memory found to be changed from 0 to 1 and 1 to 0 state, respectively. On the basis of changed states, the cross-sections ({sigma}) were calculated to investigate the single event effects/upsets. No upset was observed in case of {alpha}-particle since it has very low LET, but the SEU cross-section found to be more in case of Iodine i.e. 2.29 x 10{sup -3} cm{sup 2} than that of nickel, 2.12 x 10{sup -3} cm{sup 2} and silver, 2.26 x 10{sup -3}. This mainly attributes that LET for iodine is more as compared to silver and nickel ions, which deposits large amount of energy near the sensitive node of memory cell in the form of electron-hole pairs required to change the state. These measured SEU cross-section were also compared with theoretically predicted values along with the Weibull distribution fit to the ion induced experimental SEU data. The theoretical predicted SEU cross-section 3.27 x 10{sup -3} cm{sup 2} found to be in good agreement with the measured SEU cross-section.

Synergistic effects of total ionizing dose on single event upset sensitivity in static random access memory under proton irradiation

International Nuclear Information System (INIS)

Xiao Yao; Guo Hong-Xia; Zhang Feng-Qi; Zhao Wen; Wang Yan-Ping; Zhang Ke-Ying; Ding Li-Li; Luo Yin-Hong; Wang Yuan-Ming; Fan Xue

2014-01-01

Synergistic effects of the total ionizing dose (TID) on the single event upset (SEU) sensitivity in static random access memories (SRAMs) were studied by using protons. The total dose was cumulated with high flux protons during the TID exposure, and the SEU cross section was tested with low flux protons at several cumulated dose steps. Because of the radiation-induced off-state leakage current increase of the CMOS transistors, the noise margin became asymmetric and the memory imprint effect was observed. (interdisciplinary physics and related areas of science and technology)

Feasibility of a neutron detector-dosemeter based on single-event upsets in dynamic random-access memories

International Nuclear Information System (INIS)

Phillips, G.W.; August, R.A.; Campbell, A.B.; Nelson, M.E.; Guardala, N.A.; Price, J.L.; Moscovitch, M.

2002-01-01

The feasibility was investigated of a solid-state neutron detector/dosemeter based on single-event upset (SEU) effects in dynamic random-access memories (DRAMs), commonly used in computer memories. Such a device, which uses a neutron converter material to produce a charged particle capable of causing an upset, would be light-weight, low-power, and could be read simply by polling the memory for bit flips. It would have significant advantages over standard solid-state neutron dosemeters which require off-line processing for track etching and analysis. Previous efforts at developing an SEU neutron detector/dosemeter have suffered from poor response, which can be greatly enhanced by selecting a modern high-density DRAM chip for SEU sensitivity and by using a thin 10 B film as a converter. Past attempts to use 10 B were not successful because the average alpha particle energy was insufficient to penetrate to the sensitive region of the memory. This can be overcome by removing the surface passivation layer before depositing the 10 B film or by implanting 10B directly into the chip. Previous experimental data show a 10 3 increase in neutron sensitivity by chips containing borosilicate glass, which could be used in an SEU detector. The results are presented of simulations showing that the absolute efficiency of an SEU neutron dosemeter can be increased by at least a factor of 1000 over earlier designs. (author)

Error analysis and prevention of cosmic ion-induced soft errors in static CMOS RAMS

International Nuclear Information System (INIS)

Diehl, S.E.; Ochoa, A. Jr.; Dressendorfer, P.V.; Koga, R.; Kolasinski, W.A.

1982-06-01

Cosmic ray interactions with memory cells are known to cause temporary, random, bit errors in some designs. The sensitivity of polysilicon gate CMOS static RAM designs to logic upset by impinging ions has been studied using computer simulations and experimental heavy ion bombardment. Results of the simulations are confirmed by experimental upset cross-section data. Analytical models have been extended to determine and evaluate design modifications which reduce memory cell sensitivity to cosmic ions. A simple design modification, the addition of decoupling resistance in the feedback path, is shown to produce static RAMs immune to cosmic ray-induced bit errors

Study on relations between heavy ions single event upset cross sections and γ accumulated doses

International Nuclear Information System (INIS)

He Chaohui; Geng Bin; Wang Yanping; Peng Honglun; Yang Hailiang; Chen Xiaohua; Li Guozheng

2002-01-01

Experiments were done under 252 Cf and 60 Co γ source to study the relation between heavy ion Single Event Upset (SEU) cross sections and γ accumulated doses. There was no obvious rule and little influence of γ accumulated doses on SEU cross sections when Static Random Access Memories were in power off mode and static power on mode. In active measuring mode, the SEU cross section increased as the accumulated doses increasing when same data were written in memory cells. If reverse data, such as '55' and 'AA', were written in memory cells during the experiment, the SEU cross sections decreased to the level when memories were not irradiated under 60 Co γ source, even more small. It implied that the influence of γ accumulated doses on SEU cross sections can be set off by this method

SUPRA - Enhanced upset recovery simulation

NARCIS (Netherlands)

Groen, E.; Ledegang, W.; Field, J.; Smaili, H.; Roza, M.; Fucke, L.; Nooij, S.; Goman, M.; Mayrhofer, M.; Zaichik, L.E.; Grigoryev, M.; Biryukov, V.

2012-01-01

The SUPRA research project - Simulation of Upset Recovery in Aviation - has been funded by the European Union 7th Framework Program to enhance the flight simulation envelope for upset recovery simulation. Within the project an extended aerodynamic model, capturing the key aerodynamics during and

Neutron-induced Single Event Upset on the RPC front-end chips for the CMS experiment

Energy Technology Data Exchange (ETDEWEB)

Abbrescia, M.; Colaleo, A.; Iaselli, G.; Loddo, F.; Maggi, M.; Marangelli, B.; Natali, S.; Nuzzo, S.; Pugliese, G.; Ranieri, A.; Romano, F.; Altieri, S.; Belli, G.; Bruno, G.; Guida, R.; Merlo, M.; Ratti, S.P.; Riccardi, C.; Torre, P.; Vitulo, P. E-mail: paolo.vitulo@pv.infn.it; De Bari, A.; Manera, S

2002-05-21

Neutrons from a reactor and from a cyclotron have been used to characterise the CMS Resistive Plate Chambers (RPCs) front-end chip to neutron-induced damaging events. Single Event Upset (SEU) cross-sections have been measured up to 60 MeV for different chip thresholds. Tests at a reactor were done with an integrated fast (E{sub n}>3 MeV) neutron fluence of 1.7x10{sup 10} cm{sup -2} and a thermal neutron fluence of 9.5x10{sup 11} cm{sup -2}. High-energy neutrons from a cyclotron were used up to a fluence of 10{sup 12} cm{sup -2}. Data indicate the existence of a chip SEU sensitivity already at thermal energy and a saturated SEU cross-section from 3 to 60 MeV. Values of the SEU cross-sections from the thermal run well agree with those obtained by another CMS group that uses the same technology (0.8 {mu}m BiCMOS) though with different architecture. Cross-sections obtained with fast neutrons (from 3 MeV to about 10 MeV) are consistently higher by one order of magnitude compared to the thermal one. The average time between consecutive SEU events in each chip of the CMS barrel RPCs can be estimated to be 1 h.

Sex differences in the events that elicit jealousy among homosexuals

OpenAIRE

Dijkstra, Pieternel; Groothof, Hinke A. K.; Poel, Gerda A.; Laverman, Teunis, T. G.; Schrier, Michiel; Buunk, Bram P.

2008-01-01

When individuals are asked which event would upset them more - a partner's emotional infidelity or a partner's sexual infidelity- among heterosexuals more men than women select a partner's sexual infidelity as the most upsetting event, whereas more more women than men select a partner's emotional infidelity as the most upsetting event. Because homosexuals' mating psychology is unlike that of heterosexuals, the present study examinend which of these two events is more upsetting in a sample of ...

Critical lengths of error events in convolutional codes

DEFF Research Database (Denmark)

Justesen, Jørn

1994-01-01

If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilities. This result applies to typical long codes, but it may also be useful for modeling error events in specific codes......If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilities. This result applies to typical long codes, but it may also be useful for modeling error events in specific codes...

Critical Lengths of Error Events in Convolutional Codes

DEFF Research Database (Denmark)

Justesen, Jørn; Andersen, Jakob Dahl

1998-01-01

If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilities. This result applies to typical long codes, but it may also be useful for modeling error events in specific codes......If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilities. This result applies to typical long codes, but it may also be useful for modeling error events in specific codes...

FPGA-based Bit-Error-Rate Tester for SEU-hardened Optical Links

CERN Document Server

Detraz, S; Moreira, P; Papadopoulos, S; Papakonstantinou, I; Seif El Nasr, S; Sigaud, C; Soos, C; Stejskal, P; Troska, J; Versmissen, H

2009-01-01

The next generation of optical links for future High-Energy Physics experiments will require components qualified for use in radiation-hard environments. To cope with radiation induced single-event upsets, the physical layer protocol will include Forward Error Correction (FEC). Bit-Error-Rate (BER) testing is a widely used method to characterize digital transmission systems. In order to measure the BER with and without the proposed FEC, simultaneously on several devices, a multi-channel BER tester has been developed. This paper describes the architecture of the tester, its implementation in a Xilinx Virtex-5 FPGA device and discusses the experimental results.

Evaluation of the upset risk in CMOS SRAM through full three dimensional simulation

International Nuclear Information System (INIS)

Moreau, Y.; Gasiot, J.; Duzellier, S.

1995-01-01

Upsets caused by incident heavy ion on CMOS static RAM are studied here. Three dimensional device simulations, based on a description of a full epitaxial CMOS inverter, and experimental results are reported for evaluation of single and multiple bit error risk. The particular influences of hit location and incidence angle are examined

Impact of temperature on single event upset measurement by heavy ions in SRAM devices

International Nuclear Information System (INIS)

Liu Tianqi; Geng Chao; Zhang Zhangang; Gu Song; Tong Teng; Xi Kai; Hou Mingdong; Liu Jie; Zhao Fazhan; Liu Gang; Han Zhengsheng

2014-01-01

The temperature dependence of single event upset (SEU) measurement both in commercial bulk and silicon on insulator (SOI) static random access memories (SRAMs) has been investigated by experiment in the Heavy Ion Research Facility in Lanzhou (HIRFL). For commercial bulk SRAM, the SEU cross section measured by 12 C ions is very sensitive to the temperature. The temperature test of SEU in SOI SRAM was conducted by 209 Bi and 12 C ions, respectively, and the SEU cross sections display a remarkable growth with the elevated temperature for 12 C ions but keep constant for 209 Bi ions. The impact of temperature on SEU measurement was analyzed by Monte Carlo simulation. It is revealed that the SEU cross section is significantly affected by the temperature around the threshold linear energy transfer of SEU occurrence. As the SEU occurrence approaches saturation, the SEU cross section gradually exhibits less temperature dependency. Based on this result, the experimental data measured in HIRFL was analyzed, and then a reasonable method of predicting the on-orbit SEU rate was proposed. (semiconductor devices)

Single-event effect ground test issues

International Nuclear Information System (INIS)

Koga, R.

1996-01-01

Ground-based single event effect (SEE) testing of microcircuits permits characterization of device susceptibility to various radiation induced disturbances, including: (1) single event upset (SEU) and single event latchup (SEL) in digital microcircuits; (2) single event gate rupture (SEGR), and single event burnout (SEB) in power transistors; and (3) bit errors in photonic devices. These characterizations can then be used to generate predictions of device performance in the space radiation environment. This paper provides a general overview of ground-based SEE testing and examines in critical depth several underlying conceptual constructs relevant to the conduct of such tests and to the proper interpretation of results. These more traditional issues are contrasted with emerging concerns related to the testing of modern, advanced microcircuits

Proton upset rate prediction: a new sensitive volume concept definition

International Nuclear Information System (INIS)

Inguimbert, Christophe

1999-01-01

We present a model for predicting proton induced single event upset rate. The approach uses heavy ion cross section experimental data combined with nuclear reaction calculations in order to determine the proton upset cross section. The p+Si nuclear reaction as well as the Si(p, p)Si Coulombic scattering are described. The upset rate calculation depends on the energy deposited available in the charge collection region (sensitive region). This region is treated as a rectangular parallelepiped of thickness d at depth h. The sensitive thickness d is used as an input parameter in our model we have developed an original method to probe the sensitive region to evaluate d with reasonable accuracy d. We use short range ions and we propose a new mathematical analysis of these experimental data to determine h and d. This method consists in de-convoluting the heavy ion upset cross section σ_S_E_U(r) by the LET function of the incident ion LET(r) (r is the range of the incident ion). Our results are in relatively good agreement with other models. The accuracy of the method allows us to discuss the validity of the sensitive volume concept. Furthermore, we extrapolate an internal gain factor α that permit to take into account the charge collection mechanisms. α and d serve for quick and reasonably accurate prediction of proton induced SEU cross section in microelectronic devices. (author) [fr

Comparison of analytical models and experimental results for single-event upset in CMOS SRAMs

International Nuclear Information System (INIS)

Mnich, T.M.; Diehl, S.E.; Shafer, B.D.

1983-01-01

In an effort to design fully radiation-hardened memories for satellite and deep-space applications, a 16K and a 2K CMOS static RAM were modeled for single-particle upset during the design stage. The modeling resulted in the addition of a hardening feedback resistor in the 16K remained tentatively unaltered. Subsequent experiments, using the Lawrence Berkeley Laboratories' 88-inch cyclotron to accelerate krypton and oxygen ions, established an upset threshold for the 2K and the 16K without resistance added, as well as a hardening threshold for the 16K with feedback resistance added. Results for the 16K showed it to be hardenable to the higher level than previously published data for other unhardened 16K RAMs. The data agreed fairly well with the modeling results; however, a close look suggests that modification of the simulation methodology is required to accurately predict the resistance necessary to harden the RAM cell

An Approach for the Assessment of System Upset Resilience

Science.gov (United States)

Torres-Pomales, Wilfredo

2013-01-01

This report describes an approach for the assessment of upset resilience that is applicable to systems in general, including safety-critical, real-time systems. For this work, resilience is defined as the ability to preserve and restore service availability and integrity under stated conditions of configuration, functional inputs and environmental conditions. To enable a quantitative approach, we define novel system service degradation metrics and propose a new mathematical definition of resilience. These behavioral-level metrics are based on the fundamental service classification criteria of correctness, detectability, symmetry and persistence. This approach consists of a Monte-Carlo-based stimulus injection experiment, on a physical implementation or an error-propagation model of a system, to generate a system response set that can be characterized in terms of dimensional error metrics and integrated to form an overall measure of resilience. We expect this approach to be helpful in gaining insight into the error containment and repair capabilities of systems for a wide range of conditions.

Preventing Medication Error Based on Knowledge Management Against Adverse Event

OpenAIRE

Hastuti, Apriyani Puji; Nursalam, Nursalam; Triharini, Mira

2017-01-01

Introductions: Medication error is one of many types of errors that could decrease the quality and safety of healthcare. Increasing number of adverse events (AE) reflects the number of medication errors. This study aimed to develop a model of medication error prevention based on knowledge management. This model is expected to improve knowledge and skill of nurses to prevent medication error which is characterized by the decrease of adverse events (AE). Methods: This study consisted of two sta...

Monte Carlo calculation of the cross-section of single event upset induced by 14MeV neutrons

International Nuclear Information System (INIS)

Li, H.; Deng, J.Y.; Chang, D.M.

2005-01-01

High-density static random access memory may experience single event upsets (SEU) in neutron environments. We present a new method to calculate the SEU cross-section. Our method is based on explicit generation and transport of the secondary reaction products and detailed accounting for energy loss by ionization. Instead of simulating the behavior of the circuit, we use the Monte Carlo method to simulate the process of energy deposition in sensitive volumes. Thus, we do not need to know details about the circuit. We only need a reasonable guess for the size of the sensitive volumes. In the Monte Carlo simulation, the cross-section of SEU induced by 14MeV neutrons is calculated. We can see that the Monte Carlo simulation not only can provide a new method to calculate SEU cross-section, but also can give a detailed description about random process of the SEU

Development of a Nuclear Reaction Database on Silicon for Simulation of Neutron-Induced Single-Event Upsets in Microelectronics and its Application

International Nuclear Information System (INIS)

Watanabe, Yukinobu; Kodama, Akihiro; Tukamoto, Yasuyuki; Nakashima, Hideki

2005-01-01

We have developed a cross-section database for neutron-induced reactions on 28Si in the energy range between 2 MeV and 3 GeV in order to analyze single-event upsets (SEUs) phenomena induced by cosmic-ray neutrons in microelectronic devices. A simplified spherical device model is proposed for simulation of the initial processes of SEUs. The model is applied to SEU cross-section calculations for semiconductor memory devices. The calculated results are compared with measured SEU cross sections and the other simulation result. The dependence of SEU cross sections on incident neutron energy and secondary ions having the most important effects on SEUs are discussed

Adverse Drug Events caused by Serious Medication Administration Errors

Science.gov (United States)

Sawarkar, Abhivyakti; Keohane, Carol A.; Maviglia, Saverio; Gandhi, Tejal K; Poon, Eric G

2013-01-01

OBJECTIVE To determine how often serious or life-threatening medication administration errors with the potential to cause patient harm (or potential adverse drug events) result in actual patient harm (or adverse drug events (ADEs)) in the hospital setting. DESIGN Retrospective chart review of clinical events that transpired following observed medication administration errors. BACKGROUND Medication errors are common at the medication administration stage for hospitalized patients. While many of these errors are considered capable of causing patient harm, it is not clear how often patients are actually harmed by these errors. METHODS In a previous study where 14,041 medication administrations in an acute-care hospital were directly observed, investigators discovered 1271 medication administration errors, of which 133 had the potential to cause serious or life-threatening harm to patients and were considered serious or life-threatening potential ADEs. In the current study, clinical reviewers conducted detailed chart reviews of cases where a serious or life-threatening potential ADE occurred to determine if an actual ADE developed following the potential ADE. Reviewers further assessed the severity of the ADE and attribution to the administration error. RESULTS Ten (7.5% [95% C.I. 6.98, 8.01]) actual adverse drug events or ADEs resulted from the 133 serious and life-threatening potential ADEs, of which 6 resulted in significant, three in serious, and one life threatening injury. Therefore 4 (3% [95% C.I. 2.12, 3.6]) serious and life threatening potential ADEs led to serious or life threatening ADEs. Half of the ten actual ADEs were caused by dosage or monitoring errors for anti-hypertensives. The life threatening ADE was caused by an error that was both a transcription and a timing error. CONCLUSION Potential ADEs at the medication administration stage can cause serious patient harm. Given previous estimates of serious or life-threatening potential ADE of 1.33 per 100

Application of reactors for testing neutron-induced upsets in commercial SRAMs

International Nuclear Information System (INIS)

Griffin, P.J.; Luera, T.F.; Sexton, F.W.; Cooper, P.J.; Karr, S.G.; Hash, G.L.; Fuller, E.

1997-01-01

Reactor neutron environments can be used to test/screen the sensitivity of unhardened commercial SRAMs to low-LET neutron-induced upset. Tests indicate both thermal/epithermal (< 1 keV) and fast neutrons can cause upsets in unhardened parts. Measured upset rates in reactor environments can be used to model the upset rate for arbitrary neutron spectra

Single event upset and charge collection measurements using high energy protons and neutrons

International Nuclear Information System (INIS)

Normand, E.; Oberg, D.L.; Wert, J.L.; Ness, J.D.; Majewski, P.P.; Wender, S.; Gavron, A.

1994-01-01

RAMs, microcontrollers and surface barrier detectors were exposed to beams of high energy protons and neutrons to measure the induced number of upsets as well as energy deposition. The WNR facility at Los Alamos provided a neutron spectrum similar to that of the atmospheric neutrons. Its effect on devices was compared to that of protons with energies of 200, 400, 500, and 800 MeV. Measurements indicate that SEU cross sections for 400 MeV protons are similar to those induced by the atmospheric neutron spectrum

Upset in response to a Sibling's partner's infidelities.

Science.gov (United States)

Michalski, Richard L; Shackelford, Todd K; Salmon, Catherine A

2007-03-01

Using data collected from people with at least one brother and one sister, and consistent with an evolutionary perspective, we find that older men and women (a) are more upset by a brother's partner's sexual infidelity than by her emotional infidelity and (b) are more upset by a sister's partner's emotional infidelity than by his sexual infidelity. There were no effects of participant sex or sex of in-law on upset over a sibling's partner's infidelities, but there was an effect of participant sex on reports of upset over one's own partner's infidelities. The results suggest that the key variable among older participants is the sex of the sibling or, correspondingly, the sex of the sibling's partner, as predicted from an evolutionary analysis of reproductive costs, and not the sex of the participant, as predicted from a socialization perspective. Discussion offers directions for future work on jealousy.

Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review.

Science.gov (United States)

Mekonnen, Alemayehu B; Alhawassi, Tariq M; McLachlan, Andrew J; Brien, Jo-Anne E

2018-03-01

Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5-20.1%), while adverse drug events causing admission were reported in 2.8% (0.7-6.4%) of patients but it was reported that a median of 43.5% (20.0-47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0-0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8-72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5-50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge

The supply voltage scaled dependency of the recovery of single event upset in advanced complementary metal—oxide—semiconductor static random-access memory cells

International Nuclear Information System (INIS)

Li Da-Wei; Qin Jun-Rui; Chen Shu-Ming

2013-01-01

Using computer-aided design three-dimensional simulation technology, the supply voltage scaled dependency of the recovery of single event upset and charge collection in static random-access memory cells are investigated. It reveals that the recovery linear energy transfer threshold decreases with the supply voltage reducing, which is quite attractive for dynamic voltage scaling and subthreshold circuit radiation-hardened design. Additionally, the effect of supply voltage on charge collection is also investigated. It is concluded that the supply voltage mainly affects the bipolar gain of the parasitical bipolar junction transistor (BJT) and the existence of the source plays an important role in supply voltage variation. (geophysics, astronomy, and astrophysics)

Modeling the cosmic-ray-induced soft-error rate in integrated circuits: An overview

International Nuclear Information System (INIS)

Srinivasan, G.R.

1996-01-01

This paper is an overview of the concepts and methodologies used to predict soft-error rates (SER) due to cosmic and high-energy particle radiation in integrated circuit chips. The paper emphasizes the need for the SER simulation using the actual chip circuit model which includes device, process, and technology parameters as opposed to using either the discrete device simulation or generic circuit simulation that is commonly employed in SER modeling. Concepts such as funneling, event-by-event simulation, nuclear history files, critical charge, and charge sharing are examined. Also discussed are the relative importance of elastic and inelastic nuclear collisions, rare event statistics, and device vs. circuit simulations. The semi-empirical methodologies used in the aerospace community to arrive at SERs [also referred to as single-event upset (SEU) rates] in integrated circuit chips are reviewed. This paper is one of four in this special issue relating to SER modeling. Together, they provide a comprehensive account of this modeling effort, which has resulted in a unique modeling tool called the Soft-Error Monte Carlo Model, or SEMM

Sex differences in the events that elicit jealousy among homosexuals

NARCIS (Netherlands)

Dijkstra, Pieternel; Groothof, Hinke A. K.; Poel, Gerda A.; Laverman, Teunis, T. G.; Schrier, Michiel; Buunk, Bram P.

2008-01-01

When individuals are asked which event would upset them more - a partner's emotional infidelity or a partner's sexual infidelity- among heterosexuals more men than women select a partner's sexual infidelity as the most upsetting event, whereas more more women than men select a partner's emotional

Study of run time errors of the ATLAS Pixel Detector in the 2012 data taking period

CERN Document Server

AUTHOR|(INSPIRE)INSPIRE-00339072

2013-05-16

The high resolution silicon Pixel detector is critical in event vertex reconstruction and in particle track reconstruction in the ATLAS detector. During the pixel data taking operation, some modules (Silicon Pixel sensor +Front End Chip+ Module Control Chip (MCC)) go to an auto-disable state, where the Modules don’t send the data for storage. Modules become operational again after reconfiguration. The source of the problem is not fully understood. One possible source of the problem is traced to the occurrence of single event upset (SEU) in the MCC. Such a module goes to either a Timeout or Busy state. This report is the study of different types and rates of errors occurring in the Pixel data taking operation. Also, the study includes the error rate dependency on Pixel detector geometry.

UpSet: Visualization of Intersecting Sets

Science.gov (United States)

Lex, Alexander; Gehlenborg, Nils; Strobelt, Hendrik; Vuillemot, Romain; Pfister, Hanspeter

2016-01-01

Understanding relationships between sets is an important analysis task that has received widespread attention in the visualization community. The major challenge in this context is the combinatorial explosion of the number of set intersections if the number of sets exceeds a trivial threshold. In this paper we introduce UpSet, a novel visualization technique for the quantitative analysis of sets, their intersections, and aggregates of intersections. UpSet is focused on creating task-driven aggregates, communicating the size and properties of aggregates and intersections, and a duality between the visualization of the elements in a dataset and their set membership. UpSet visualizes set intersections in a matrix layout and introduces aggregates based on groupings and queries. The matrix layout enables the effective representation of associated data, such as the number of elements in the aggregates and intersections, as well as additional summary statistics derived from subset or element attributes. Sorting according to various measures enables a task-driven analysis of relevant intersections and aggregates. The elements represented in the sets and their associated attributes are visualized in a separate view. Queries based on containment in specific intersections, aggregates or driven by attribute filters are propagated between both views. We also introduce several advanced visual encodings and interaction methods to overcome the problems of varying scales and to address scalability. UpSet is web-based and open source. We demonstrate its general utility in multiple use cases from various domains. PMID:26356912

Cause analysis and preventives for human error events in Daya Bay NPP

International Nuclear Information System (INIS)

Huang Weigang; Zhang Li

1998-01-01

Daya Bay Nuclear Power Plant is put into commercial operation in 1994 Until 1996, there are 368 human error events in operating and maintenance area, occupying 39% of total events. These events occurred mainly in the processes of maintenance, test equipment isolation and system on-line, in particular in refuelling and maintenance. The author analyses root causes for human errorievents, which are mainly operator omission or error procedure deficiency; procedure not followed; lack of training; communication failures; work management inadequacy. The protective measures and treatment principle for human error events are also discussed, and several examples applying them are given. Finally, it is put forward that key to prevent human error event lies in the coordination and management, person in charge of work, and good work habits of staffs

Development of Single-Event Upset hardened programmable logic devices in deep submicron CMOS

International Nuclear Information System (INIS)

Bonacini, S.

2007-11-01

The electronics associated to the particle detectors of the Large Hadron Collider (LHC), under construction at CERN, will operate in a very harsh radiation environment. Commercial Off-The-Shelf (COTS) components cannot be used in the vicinity of particle collision due to their poor radiation tolerance. This thesis is a contribution to the effort to cover the need for radiation-tolerant SEU-robust (Single Event Upset) programmable components for application in high energy physics experiments. Two components are under development: a Programmable Logic Device (PLD) and a Field-Programmable Gate Array (FPGA). The PLD is a fuse-based, 10-input, 8-I/O general architecture device in 0.25 μm CMOS technology. The FPGA under development is a 32*32 logic block array, equivalent to ∼ 25 k gates, in 0.13 μm CMOS. The irradiation test results obtained in the CMOS 0.25 μm technology demonstrate good robustness of the circuit up to an LET (Linear Energy Transfer) of 79.6 cm 2 *MeV/mg, which make it suitable for the target environment. The CMOS 0.13 μm circuit has showed robustness to an LET of 37.4 cm 2 *MeV/mg in the static test mode and has increased sensitivity in the dynamic test mode. This work focused also on the research for an SEU-robust register in both the mentioned technologies. The SEU-robust register is employed as a user data flip-flop in the FPGA and PLD designs and as a configuration cell as well in the FPGA design

An advanced SEU tolerant latch based on error detection

Science.gov (United States)

Xu, Hui; Zhu, Jianwei; Lu, Xiaoping; Li, Jingzhao

2018-05-01

This paper proposes a latch that can mitigate SEUs via an error detection circuit. The error detection circuit is hardened by a C-element and a stacked PMOS. In the hold state, a particle strikes the latch or the error detection circuit may cause a fault logic state of the circuit. The error detection circuit can detect the upset node in the latch and the fault output will be corrected. The upset node in the error detection circuit can be corrected by the C-element. The power dissipation and propagation delay of the proposed latch are analyzed by HSPICE simulations. The proposed latch consumes about 77.5% less energy and 33.1% less propagation delay than the triple modular redundancy (TMR) latch. Simulation results demonstrate that the proposed latch can mitigate SEU effectively. Project supported by the National Natural Science Foundation of China (Nos. 61404001, 61306046), the Anhui Province University Natural Science Research Major Project (No. KJ2014ZD12), the Huainan Science and Technology Program (No. 2013A4011), and the National Natural Science Foundation of China (No. 61371025).

Error Analysis of Satellite Precipitation-Driven Modeling of Flood Events in Complex Alpine Terrain

Directory of Open Access Journals (Sweden)

Yiwen Mei

2016-03-01

Full Text Available The error in satellite precipitation-driven complex terrain flood simulations is characterized in this study for eight different global satellite products and 128 flood events over the Eastern Italian Alps. The flood events are grouped according to two flood types: rain floods and flash floods. The satellite precipitation products and runoff simulations are evaluated based on systematic and random error metrics applied on the matched event pairs and basin-scale event properties (i.e., rainfall and runoff cumulative depth and time series shape. Overall, error characteristics exhibit dependency on the flood type. Generally, timing of the event precipitation mass center and dispersion of the time series derived from satellite precipitation exhibits good agreement with the reference; the cumulative depth is mostly underestimated. The study shows a dampening effect in both systematic and random error components of the satellite-driven hydrograph relative to the satellite-retrieved hyetograph. The systematic error in shape of the time series shows a significant dampening effect. The random error dampening effect is less pronounced for the flash flood events and the rain flood events with a high runoff coefficient. This event-based analysis of the satellite precipitation error propagation in flood modeling sheds light on the application of satellite precipitation in mountain flood hydrology.

Review of Research On Guidance for Recovery from Pitch Axis Upsets

Science.gov (United States)

Harrison, Stephanie J.

2016-01-01

A literature review was conducted to identify past efforts in providing control guidance for aircraft upset recovery including stall recovery. Because guidance is integrally linked to the intended function of aircraft attitude awareness and upset recognition, it is difficult, if not impossible, to consider these issues separately. This literature review covered the aspects of instrumentation and display symbologies for attitude awareness, aircraft upset recognition, upset and stall alerting, and control guidance. Many different forms of symbology have been investigated including, but not limited to, pitch scale depictions, attitude indicator icons, horizon symbology, attitude recovery arrows, and pitch trim indicators. Past research on different visual and alerting strategies that provide advisories, cautions, and warnings to pilots before entering an unusual attitude (UA) are also discussed. Finally, potential control guidance for recovery from upset or unusual attitudes, including approach-to-stall and stall conditions, are reviewed. Recommendations for future research are made.

Error Analysis in the Joint Event Location/Seismic Calibration Inverse Problem

National Research Council Canada - National Science Library

Rodi, William L

2006-01-01

This project is developing new mathematical and computational techniques for analyzing the uncertainty in seismic event locations, as induced by observational errors and errors in travel-time models...

Analysis of human error and organizational deficiency in events considering risk significance

International Nuclear Information System (INIS)

Lee, Yong Suk; Kim, Yoonik; Kim, Say Hyung; Kim, Chansoo; Chung, Chang Hyun; Jung, Won Dea

2004-01-01

In this study, we analyzed human and organizational deficiencies in the trip events of Korean nuclear power plants. K-HPES items were used in human error analysis, and the organizational factors by Jacobs and Haber were used for organizational deficiency analysis. We proposed the use of CCDP as a risk measure to consider risk information in prioritizing K-HPES items and organizational factors. Until now, the risk significance of events has not been considered in human error and organizational deficiency analysis. Considering the risk significance of events in the process of analysis is necessary for effective enhancement of nuclear power plant safety by focusing on causes of human error and organizational deficiencies that are associated with significant risk

A Novel Application of Machine Learning Methods to Model Microcontroller Upset Due to Intentional Electromagnetic Interference

Science.gov (United States)

Bilalic, Rusmir

A novel application of support vector machines (SVMs), artificial neural networks (ANNs), and Gaussian processes (GPs) for machine learning (GPML) to model microcontroller unit (MCU) upset due to intentional electromagnetic interference (IEMI) is presented. In this approach, an MCU performs a counting operation (0-7) while electromagnetic interference in the form of a radio frequency (RF) pulse is direct-injected into the MCU clock line. Injection times with respect to the clock signal are the clock low, clock rising edge, clock high, and the clock falling edge periods in the clock window during which the MCU is performing initialization and executing the counting procedure. The intent is to cause disruption in the counting operation and model the probability of effect (PoE) using machine learning tools. Five experiments were executed as part of this research, each of which contained a set of 38,300 training points and 38,300 test points, for a total of 383,000 total points with the following experiment variables: injection times with respect to the clock signal, injected RF power, injected RF pulse width, and injected RF frequency. For the 191,500 training points, the average training error was 12.47%, while for the 191,500 test points the average test error was 14.85%, meaning that on average, the machine was able to predict MCU upset with an 85.15% accuracy. Leaving out the results for the worst-performing model (SVM with a linear kernel), the test prediction accuracy for the remaining machines is almost 89%. All three machine learning methods (ANNs, SVMs, and GPML) showed excellent and consistent results in their ability to model and predict the PoE on an MCU due to IEMI. The GP approach performed best during training with a 7.43% average training error, while the ANN technique was most accurate during the test with a 10.80% error.

Approaches to proton single-event rate calculations

International Nuclear Information System (INIS)

Petersen, E.L.

1996-01-01

This article discusses the fundamentals of proton-induced single-event upsets and of the various methods that have been developed to calculate upset rates. Two types of approaches are used based on nuclear-reaction analysis. Several aspects can be analyzed using analytic methods, but a complete description is not available. The paper presents an analytic description for the component due to elastic-scattering recoils. There have been a number of studies made using Monte Carlo methods. These can completely describe the reaction processes, including the effect of nuclear reactions occurring outside the device-sensitive volume. They have not included the elastic-scattering processes. The article describes the semiempirical approaches that are most widely used. The quality of previous upset predictions relative to space observations is discussed and leads to comments about the desired quality of future predictions. Brief sections treat the possible testing limitation due to total ionizing dose effects, the relationship of proton and heavy-ion upsets, upsets due to direct proton ionization, and relative proton and cosmic-ray upset rates

Proton induced single event upset cross section prediction for 0.15 μm six-transistor (6T) silicon-on-insulator static random access memories

International Nuclear Information System (INIS)

Li Lei; Zhou Wanting; Liu Huihua

2012-01-01

In this paper, an efficient physics-based method to estimate the saturated proton upset cross section for six-transistor (6T) silicon-on-insulator (SOI) static random access memory (SRAM) cells using layout and technology parameters is proposed. This method calculates the effects of radiation based on device physics. The simple method handles the problem with ease by SPICE simulations, which can be divided into two stages. At first, it uses a standard SPICE program to predict the cross section for recoiling heavy ions with linear energy transfer (LET) of 14 MeV-cm 2 /mg. Then, the predicted cross section for recoiling heavy ions with LET of 14 MeV-cm 2 /mg is used to estimate the saturated proton upset cross section for 6T SOI SRAM cells with a simple model. The calculated proton induced upset cross section based on this method is in good agreement with the test results of 6T SOI SRAM cells processed using 0.15 μm technology. (author)

Interactive analysis of human error factors in NPP operation events

International Nuclear Information System (INIS)

Zhang Li; Zou Yanhua; Huang Weigang

2010-01-01

Interactive of human error factors in NPP operation events were introduced, and 645 WANO operation event reports from 1999 to 2008 were analyzed, among which 432 were found relative to human errors. After classifying these errors with the Root Causes or Causal Factors, and then applying SPSS for correlation analysis,we concluded: (1) Personnel work practices are restricted by many factors. Forming a good personnel work practices is a systematic work which need supports in many aspects. (2)Verbal communications,personnel work practices, man-machine interface and written procedures and documents play great roles. They are four interaction factors which often come in bundle. If some improvements need to be made on one of them,synchronous measures are also necessary for the others.(3) Management direction and decision process, which are related to management,have a significant interaction with personnel factors. (authors)

A software solution to estimate the SEU-induced soft error rate for systems implemented on SRAM-based FPGAs

International Nuclear Information System (INIS)

Wang Zhongming; Lu Min; Yao Zhibin; Guo Hongxia

2011-01-01

SRAM-based FPGAs are very susceptible to radiation-induced Single-Event Upsets (SEUs) in space applications. The failure mechanism in FPGA's configuration memory differs from those in traditional memory device. As a result, there is a growing demand for methodologies which could quantitatively evaluate the impact of this effect. Fault injection appears to meet such requirement. In this paper, we propose a new methodology to analyze the soft errors in SRAM-based FPGAs. This method is based on in depth understanding of the device architecture and failure mechanisms induced by configuration upsets. The developed programs read in the placed and routed netlist, search for critical logic nodes and paths that may destroy the circuit topological structure, and then query a database storing the decoded relationship of the configurable resources and corresponding control bit to get the sensitive bits. Accelerator irradiation test and fault injection experiments were carried out to validate this approach. (semiconductor integrated circuits)

Trend analysis of human error events and assessment of their proactive prevention measure at Rokkasho reprocessing plant

International Nuclear Information System (INIS)

Yamazaki, Satoru; Tanaka, Izumi; Wakabayashi, Toshio

2012-01-01

A trend analysis of human error events is important for preventing the recurrence of human error events. We propose a new method for identifying the common characteristics from results of trend analysis, such as the latent weakness of organization, and a management process for strategic error prevention. In this paper, we describe a trend analysis method for human error events that have been accumulated in the organization and the utilization of the results of trend analysis to prevent accidents proactively. Although the systematic analysis of human error events, the monitoring of their overall trend, and the utilization of the analyzed results have been examined for the plant operation, such information has never been utilized completely. Sharing information on human error events and analyzing their causes lead to the clarification of problems in the management and human factors. This new method was applied to the human error events that occurred in the Rokkasho reprocessing plant from 2010 October. Results revealed that the output of this method is effective in judging the error prevention plan and that the number of human error events is reduced to about 50% those observed in 2009 and 2010. (author)

Results from the First Two Flights of the Static Computer Memory Integrity Testing Experiment

Science.gov (United States)

Hancock, Thomas M., III

1999-01-01

This paper details the scientific objectives, experiment design, data collection method, and post flight analysis following the first two flights of the Static Computer Memory Integrity Testing (SCMIT) experiment. SCMIT is designed to detect soft-event upsets in passive magnetic memory. A soft-event upset is a change in the logic state of active or passive forms of magnetic memory, commonly referred to as a "Bitflip". In its mildest form a soft-event upset can cause software exceptions, unexpected events, start spacecraft safeing (ending data collection) or corrupted fault protection and error recovery capabilities. In it's most severe form loss of mission or spacecraft can occur. Analysis after the first flight (in 1991 during STS-40) identified possible soft-event upsets to 25% of the experiment detectors. Post flight analysis after the second flight (in 1997 on STS-87) failed to find any evidence of soft-event upsets. The SCMIT experiment is currently scheduled for a third flight in December 1999 on STS-101.

Modeling and control of a DC upset resistance butt welding process

NARCIS (Netherlands)

Naus, G.J.L.; Meulenberg, R.; Molengraft, van de M.J.G.

2007-01-01

This paper presents the analysis and synthesis of modeling and control of the DC upset resistance butt welding process used in rim production lines. A new control strategy is developed, enabling active control of the welding seam temperature and the upset size. As a result, set-up times and energy

Reactor internals design/analysis for normal, upset, and faulted conditions

International Nuclear Information System (INIS)

Burke, F.R.

1977-06-01

The analytical procedures used by Babcock and Wilcox to demonstrate the structural integrity of the 205-FA reactor internals are described. Analytical results are presented and compared to ASME Code allowable limits for Normal, Upset, and Faulted conditions. The particular faulted condition considered is a simultaneous loss-of-coolant accident and safe shutdown earthquake. The operating basis earthquake is addressed as an Upset condition

FinFET memory cell improvements for higher immunity against single event upsets

Science.gov (United States)

Sajit, Ahmed Sattar

The 21st century is witnessing a tremendous demand for transistors. Life amenities have incorporated the transistor in every aspect of daily life, ranging from toys to rocket science. Day by day, scaling down the transistor is becoming an imperious necessity. However, it is not a straightforward process; instead, it faces overwhelming challenges. Due to these scaling changes, new technologies, such as FinFETs for example, have emerged as alternatives to the conventional bulk-CMOS technology. FinFET has more control over the channel, therefore, leakage current is reduced. FinFET could bridge the gap between silicon devices and non-silicon devices. The semiconductor industry is now incorporating FinFETs in systems and subsystems. For example, Intel has been using them in their newest processors, delivering potential saving powers and increased speeds to memory circuits. Memory sub-systems are considered a vital component in the digital era. In memory, few rows are read or written at a time, while the most rows are static; hence, reducing leakage current increases the performance. However, as a transistor shrinks, it becomes more vulnerable to the effects from radioactive particle strikes. If a particle hits a node in a memory cell, the content might flip; consequently, leading to corrupting stored data. Critical fields, such as medical and aerospace, where there are no second chances and cannot even afford to operate at 99.99% accuracy, has induced me to find a rigid circuit in a radiated working environment. This research focuses on a wide spectrum of memories such as 6T SRAM, 8T SRAM, and DICE memory cells using FinFET technology and finding the best platform in terms of Read and Write delay, susceptibility level of SNM, RSNM, leakage current, energy consumption, and Single Event Upsets (SEUs). This research has shown that the SEU tolerance that 6T and 8T FinFET SRAMs provide may not be acceptable in medical and aerospace applications where there is a very high

Upset Over Sexual versus Emotional Infidelity Among Gay, Lesbian, Bisexual, and Heterosexual Adults.

Science.gov (United States)

Frederick, David A; Fales, Melissa R

2016-01-01

One hypothesis derived from evolutionary perspectives is that men are more upset than women by sexual infidelity and women are more upset than men by emotional infidelity. The proposed explanation is that men, in contrast to women, face the risk of unwittingly investing in genetically unrelated offspring. Most studies, however, have relied on small college or community samples of heterosexual participants. We examined upset over sexual versus emotional jealousy among 63,894 gay, lesbian, bisexual, and heterosexual participants. Participants imagined which would upset them more: their partners having sex with someone else (but not falling in love with them) or their partners falling in love with someone else (but not having sex with them). Consistent with this evolutionary perspective, heterosexual men were more likely than heterosexual women to be upset by sexual infidelity (54 vs. 35 %) and less likely than heterosexual women to be upset by emotional infidelity (46 vs. 65 %). This gender difference emerged across age groups, income levels, history of being cheated on, history of being unfaithful, relationship type, and length. The gender difference, however, was limited to heterosexual participants. Bisexual men and women did not differ significantly from each other in upset over sexual infidelity (30 vs. 27 %), regardless of whether they were currently dating a man (35 vs. 29 %) or woman (28 vs. 20 %). Gay men and lesbian women also did not differ (32 vs. 34 %). The findings present strong evidence that a gender difference exists in a broad sample of U.S. adults, but only among heterosexuals.

A trend analysis of human error events for proactive prevention of accidents. Methodology development and effective utilization

International Nuclear Information System (INIS)

Hirotsu, Yuko; Ebisu, Mitsuhiro; Aikawa, Takeshi; Matsubara, Katsuyuki

2006-01-01

This paper described methods for analyzing human error events that has been accumulated in the individual plant and for utilizing the result to prevent accidents proactively. Firstly, a categorization framework of trigger action and causal factors of human error events were reexamined, and the procedure to analyze human error events was reviewed based on the framework. Secondly, a method for identifying the common characteristics of trigger action data and of causal factor data accumulated by analyzing human error events was clarified. In addition, to utilize the results of trend analysis effectively, methods to develop teaching material for safety education, to develop the checkpoints for the error prevention and to introduce an error management process for strategic error prevention were proposed. (author)

Investigations on human error hazards in recent unintended trip events of Korean nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Kim, Sa Kil; Jang, Tong Il; Lee, Yong Hee; Shin, Kwang Hyeon [KAERI, Daejeon (Korea, Republic of)

2012-10-15

According to the Operational Performance Information System (OPIS) which has been operated to improve the public understanding by the KINS (Korea Institute of Nuclear Safety), unintended trip events by mainly human errors counted up to 38 cases (18.7%) from 2000 to 2011. Although the Nuclear Power Plant (NPP) industry in Korea has been making efforts to reduce the human errors which have largely contributed to trip events, the human error rate might keep increasing. Interestingly, digital based I and C systems is the one of the reduction factors of unintended reactor trips. Human errors, however, have occurred due to the digital based I and C systems because those systems require new or changed behaviors to the NPP operators. Therefore, it is necessary that the investigations of human errors consider a new methodology to find not only tangible behavior but also intangible behavior such as organizational behaviors. In this study we investigated human errors to find latent factors such as decisions and conditions in the all of the unintended reactor trip events during last dozen years. To find them, we applied the HFACS (Human Factors Analysis and Classification System) which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. The objective of this study is to find latent factors behind of human errors in nuclear reactor trip events. Therefore, a method to investigate unintended trip events by human errors and the results will be discussed in more detail.

Investigations on human error hazards in recent unintended trip events of Korean nuclear power plants

International Nuclear Information System (INIS)

Kim, Sa Kil; Jang, Tong Il; Lee, Yong Hee; Shin, Kwang Hyeon

2012-01-01

According to the Operational Performance Information System (OPIS) which has been operated to improve the public understanding by the KINS (Korea Institute of Nuclear Safety), unintended trip events by mainly human errors counted up to 38 cases (18.7%) from 2000 to 2011. Although the Nuclear Power Plant (NPP) industry in Korea has been making efforts to reduce the human errors which have largely contributed to trip events, the human error rate might keep increasing. Interestingly, digital based I and C systems is the one of the reduction factors of unintended reactor trips. Human errors, however, have occurred due to the digital based I and C systems because those systems require new or changed behaviors to the NPP operators. Therefore, it is necessary that the investigations of human errors consider a new methodology to find not only tangible behavior but also intangible behavior such as organizational behaviors. In this study we investigated human errors to find latent factors such as decisions and conditions in the all of the unintended reactor trip events during last dozen years. To find them, we applied the HFACS (Human Factors Analysis and Classification System) which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. The objective of this study is to find latent factors behind of human errors in nuclear reactor trip events. Therefore, a method to investigate unintended trip events by human errors and the results will be discussed in more detail

Single event effects and performance predictions for space applications of RISC processors

International Nuclear Information System (INIS)

Kimbrough, J.R.; Colella, N.J.; Denton, S.M.; Shaeffer, D.L.; Shih, D.; Wilburn, J.W.; Coakley, P.G.; Casteneda, C.; Koga, R.; Clark, D.A.; Ullmann, J.L.

1994-01-01

Proton and ion Single Event Phenomena (SEP) tests were performed on 32-b processors including R3000A's from all commercial manufacturers along with the Performance PR3400 family, Integrated Device Technology Inc. 79R3081, LSI Logic Corporation LR33000HC, and Intel i80960MX parts. The microprocessors had acceptable upset rates for operation in a low earth orbit or a lunar mission such as CLEMENTINE with a wide range in proton total dose failure. Even though R3000A devices are 60% smaller in physical area than R3000 devices, there was a 340% increase in device Single Event Upset (SEU) cross section. Software tests of varying complexity demonstrate that registers and other functional blocks using register architecture dominate the cross section. The current approach of giving a single upset cross section can lead to erroneous upset rates depending on the application software

Categorizing errors and adverse events for learning: a provider perspective.

Science.gov (United States)

Ginsburg, Liane R; Chuang, You-Ta; Richardson, Julia; Norton, Peter G; Berta, Whitney; Tregunno, Deborah; Ng, Peggy

2009-01-01

There is little agreement in the literature as to what types of patient safety events (PSEs) should be the focus for learning, change and improvement, and we lack clear and universally accepted definitions of error. In particular, the way front-line providers or managers understand and categorize different types of errors, adverse events and near misses and the kinds of events this audience believes to be valuable for learning are not well understood. Focus groups of front-line providers, managers and patient safety officers were used to explore how people in healthcare organizations understand and categorize different types of PSEs in the context of bringing about learning from such events. A typology of PSEs was developed from the focus group data and then mailed, along with a short questionnaire, to focus group participants for member checking and validation. Four themes emerged from our data: (1) incidence study categories are problematic for those working in organizations; (2) preventable events should be the focus for learning; (3) near misses are an important but complex category, differentiated based on harm potential and proximity to patients; (4) staff disagree on whether events causing severe harm or events with harm potential are most valuable for learning. A typology of PSEs based on these themes and checked by focus group participants indicates that staff and their managers divide events into simple categories of minor and major events, which are differentiated based on harm or harm potential. Confusion surrounding patient safety terminology detracts from the abilities of providers to talk about and reflect on a range of PSEs, and from opportunities to enhance learning, reduce event reoccurrence and improve patient safety at the point of care.

Event-Related Potentials for Post-Error and Post-Conflict Slowing

Science.gov (United States)

Chang, Andrew; Chen, Chien-Chung; Li, Hsin-Hung; Li, Chiang-Shan R.

2014-01-01

In a reaction time task, people typically slow down following an error or conflict, each called post-error slowing (PES) and post-conflict slowing (PCS). Despite many studies of the cognitive mechanisms, the neural responses of PES and PCS continue to be debated. In this study, we combined high-density array EEG and a stop-signal task to examine event-related potentials of PES and PCS in sixteen young adult participants. The results showed that the amplitude of N2 is greater during PES but not PCS. In contrast, the peak latency of N2 is longer for PCS but not PES. Furthermore, error-positivity (Pe) but not error-related negativity (ERN) was greater in the stop error trials preceding PES than non-PES trials, suggesting that PES is related to participants' awareness of the error. Together, these findings extend earlier work of cognitive control by specifying the neural correlates of PES and PCS in the stop signal task. PMID:24932780

Upset in Response to a Sibling’s Partner’s Infidelity

OpenAIRE

Dafni Hellstrand; Elisavet Chrysochoou

2015-01-01

Existing evidence suggests that the psychological design of romantic jealousy differs for men and women: Men are more likely than women to report greater upset in response to a partner’s sexual than emotional infidelity, whereas women are more likely than men to report greater upset in response to a partner’s emotional than sexual infidelity. However, the observed sex difference can be explained after the fact by both an evolutionary analysis of past reproductive costs and a social constructi...

Human error probability estimation using licensee event reports

International Nuclear Information System (INIS)

Voska, K.J.; O'Brien, J.N.

1984-07-01

Objective of this report is to present a method for using field data from nuclear power plants to estimate human error probabilities (HEPs). These HEPs are then used in probabilistic risk activities. This method of estimating HEPs is one of four being pursued in NRC-sponsored research. The other three are structured expert judgment, analysis of training simulator data, and performance modeling. The type of field data analyzed in this report is from Licensee Event reports (LERs) which are analyzed using a method specifically developed for that purpose. However, any type of field data or human errors could be analyzed using this method with minor adjustments. This report assesses the practicality, acceptability, and usefulness of estimating HEPs from LERs and comprehensively presents the method for use

Fabrication and properties of Y-Ba-Cu-O high Tc superconductor by upset-forging method

International Nuclear Information System (INIS)

Chang, Ho Jung; Kang, Kae Myung; Song, Jin Tae

1990-01-01

YBa 2 Cu 3 O 7-x oxide superconductors was fabricated by sintering process and upset-forging method, respectively, and microstructures and conduction properties were compared. There was no difference in crystal structure the (001) x-ray reflection presumably due to preferred crystal orientation of the YBa 2 Cu 3 O 7-x superconductor. Furthermore, the grain size of the 123-phase increased as the reduction ratio became larger during the upset-forging. The critical temperature for zero resistivity of both samples was almost the same, i.e., about 90K. These results have demonstrated the potential of producing YBa 2 Cu 3 O 7-x superconducting wire or tape effectively using a upset-forging method. The critical current density of the upset-forged sample, however, was lower than that of the sintered one, which fact might be ascribed to microcrack formation during fast upset-forging. (Author)

Negative cognitive errors and positive illusions for negative divorce events: predictors of children's psychological adjustment.

Science.gov (United States)

Mazur, E; Wolchik, S A; Sandler, I N

1992-12-01

This study examined the relations among negative cognitive errors regarding hypothetical negative divorce events, positive illusions about those same events, actual divorce events, and psychological adjustment in 38 8- to 12-year-old children whose parents had divorced within the previous 2 years. Children's scores on a scale of negative cognitive errors (catastrophizing, overgeneralizing, and personalizing) correlated significantly with self-reported symptoms of anxiety and self-esteem, and with maternal reports of behavior problems. Children's scores on a scale measuring positive illusions (high self-regard, illusion of personal control, and optimism for the future) correlated significantly with less self-reported aggression. Both appraisal types accounted for variance in some measures of symptomatology beyond that explained by actual events. There was no significant association between children's negative cognitive errors and positive illusions. The implications of these results for theories of negative cognitive errors and of positive illusions, as well as for future research, are discussed.

Task types and error types involved in the human-related unplanned reactor trip events

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun

2008-01-01

In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1%), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed

Task types and error types involved in the human-related unplanned reactor trip events

Energy Technology Data Exchange (ETDEWEB)

Kim, Jae Whan; Park, Jin Kyun [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2008-12-15

In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1%), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed.

Challenge and Error: Critical Events and Attention-Related Errors

Science.gov (United States)

Cheyne, James Allan; Carriere, Jonathan S. A.; Solman, Grayden J. F.; Smilek, Daniel

2011-01-01

Attention lapses resulting from reactivity to task challenges and their consequences constitute a pervasive factor affecting everyday performance errors and accidents. A bidirectional model of attention lapses (error [image omitted] attention-lapse: Cheyne, Solman, Carriere, & Smilek, 2009) argues that errors beget errors by generating attention…

Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event.

Science.gov (United States)

Meurier, C E

2000-07-01

Human errors are common in clinical practice, but they are under-reported. As a result, very little is known of the types, antecedents and consequences of errors in nursing practice. This limits the potential to learn from errors and to make improvement in the quality and safety of nursing care. The aim of this study was to use an Organizational Accident Model to analyse critical incidents of errors in nursing. Twenty registered nurses were invited to produce a critical incident report of an error (which had led to an adverse event or potentially could have led to an adverse event) they had made in their professional practice and to write down their responses to the error using a structured format. Using Reason's Organizational Accident Model, supplemental information was then collected from five of the participants by means of an individual in-depth interview to explore further issues relating to the incidents they had reported. The detailed analysis of one of the incidents is discussed in this paper, demonstrating the effectiveness of this approach in providing insight into the chain of events which may lead to an adverse event. The case study approach using critical incidents of clinical errors was shown to provide relevant information regarding the interaction of organizational factors, local circumstances and active failures (errors) in producing an adverse or potentially adverse event. It is suggested that more use should be made of this approach to understand how errors are made in practice and to take appropriate preventative measures.

Dynamic effect in ultrasonic assisted micro-upsetting

Science.gov (United States)

Presz, Wojciech

2018-05-01

The use of ultrasonic assistance in microforming is becoming more and more popular. Mainly due to the beneficial effect of vibrations on the flow of plastic deformation reported already in the 50s of the last century. The influence is of two types: surface and volume. The surface effect is mainly the reduction of friction forces, and volumetric is the impact on the dislocation movement and even on phase transitions. The work focuses on the dynamic aspect of vibration assisted microforming. The use of ultrasonic vibrations at a frequency of 20 kHz and an amplitude of 16 µm, in the micro-upsetting process of an aluminum sample resulted in a high concentration of strain on both ends of the sample - at 14% of the height on both sides. There was observed (in relation to deformations of the sample without vibrations) 150-250% increase and a 50% decrease in strain in the center of the sample. At the same time, the larger deformations occurred from the impact side of the punch. Analyzing the course of forces of the upsetting process in the loading and unloading phase as well as the process of breaking glass samples, the spring deflections of key system elements and their natural frequencies were determined or calculated. Based on the determined or calculated parameters of the test stand, it was shown that during the micro-upsetting process the punch may detach from the sample surface and this is the main reason for the phenomena occurring. Detach of the punch is also the cause of the observed instability of the measurement of force, which should be considered unbelievable in such a situation.

Latency and mode of error detection as reflected in Swedish licensee event reports

Energy Technology Data Exchange (ETDEWEB)

Svenson, Ola; Salo, Ilkka [Stockholm Univ., (Sweden). Dept. of Psychology

2002-03-01

Licensee event reports (LERs) from an industry provide important information feedback about safety to the industry itself, the regulators and to the public. LERs from four nuclear power reactors were analyzed to find out about detection times, mode of detection and qualitative differences in reports from different reactors. The reliability of the coding was satisfactory and measured as the covariance between the ratings from two independent judges. The results showed differences in detection time across the reactors. On the average about ten percent of the errors remained undetected for 100 weeks or more, but the great majority of errors were detected soon after their first appearance in the plant. On the average 40 percent of the errors were detected in regular tests and 40 per cent through alarms. Operators found about 10 per cent of the errors through noticing something abnormal in the plant. The remaining errors were detected in various other ways. There were qualitative differences between the LERs from the different reactors reflecting the different conditions in the plants. The number of reports differed by a magnitude 1:2 between the different plants. However, a greater number of LERs can indicate both higher safety standards (e.g., a greater willingness to report all possible events to be able to learn from them) and lower safety standards (e.g., reporting as few events as possible to make a good impression). It was pointed out that LERs are indispensable in order to maintain safety of an industry and that the differences between plants found in the analyses of this study indicate how error reports can be used to initiate further investigations for improved safety.

Latency and mode of error detection as reflected in Swedish licensee event reports

International Nuclear Information System (INIS)

Svenson, Ola; Salo, Ilkka

2002-03-01

Licensee event reports (LERs) from an industry provide important information feedback about safety to the industry itself, the regulators and to the public. LERs from four nuclear power reactors were analyzed to find out about detection times, mode of detection and qualitative differences in reports from different reactors. The reliability of the coding was satisfactory and measured as the covariance between the ratings from two independent judges. The results showed differences in detection time across the reactors. On the average about ten percent of the errors remained undetected for 100 weeks or more, but the great majority of errors were detected soon after their first appearance in the plant. On the average 40 percent of the errors were detected in regular tests and 40 per cent through alarms. Operators found about 10 per cent of the errors through noticing something abnormal in the plant. The remaining errors were detected in various other ways. There were qualitative differences between the LERs from the different reactors reflecting the different conditions in the plants. The number of reports differed by a magnitude 1:2 between the different plants. However, a greater number of LERs can indicate both higher safety standards (e.g., a greater willingness to report all possible events to be able to learn from them) and lower safety standards (e.g., reporting as few events as possible to make a good impression). It was pointed out that LERs are indispensable in order to maintain safety of an industry and that the differences between plants found in the analyses of this study indicate how error reports can be used to initiate further investigations for improved safety

Microstructure and mechanical properties of resistance upset butt welded 304 austenitic stainless steel joints

International Nuclear Information System (INIS)

Sharifitabar, M.; Halvaee, A.; Khorshahian, S.

2011-01-01

Graphical abstract: Three different microstructural zones formed at different distances from the joint interface in resistance upset butt welding of 304 austenitic stainless steel. Highlights: → Evaluation of microstructure in resistance upset welding of 304 stainless steel. → Evaluation of welding parameters effects on mechanical properties of the joint. → Introducing the optimum welding condition for joining stainless steel bars. -- Abstract: Resistance upset welding (UW) is a widely used process for joining metal parts. In this process, current, time and upset pressure are three parameters that affect the quality of welded products. In the present research, resistance upset butt welding of 304 austenitic stainless steel and effect of welding power and upset pressure on microstructure, tensile strength and fatigue life of the joint were investigated. Microstructure of welds were studied using scanning electron microscopy (SEM). X-ray diffraction (XRD) analysis was used to distinguish the phase(s) that formed at the joint interface and in heat affected zone (HAZ). Energy dispersive spectroscopy (EDS) linked to the SEM was used to determine chemical composition of phases formed at the joint interface. Fatigue tests were performed using a pull-push fatigue test machine and the fatigue properties were analyzed drawing stress-number of cycles to failure (S-N) curves. Also tensile strength tests were performed. Finally tensile and fatigue fracture surfaces were studied by SEM. Results showed that there were three different microstructural zones at different distances from the joint interface and delta ferrite phase has formed in these regions. There was no precipitation of chromium carbide at the joint interface and in the HAZ. Tensile and fatigue strengths of the joint decreased with welding power. Increasing of upset pressure has also considerable influence on tensile strength of the joint. Fractography of fractured samples showed that formation of hot spots at

Neutron detection using soft errors in dynamic random access memories

International Nuclear Information System (INIS)

Darambara, D.G.; Spyrou, N.M.

1992-01-01

The fact that energetic alpha particles have been observed to be capable of inducing single-event upsets in integrated circuit memories has become a topic of considerable interest in the past few years. One recognized difficulty with dynamic random access memory devices (dRAMs) is that the alpha-particle 'contamination' present within the dRAM encapsulating material interact sufficiently as to corrupt stored data. The authors essentially utilized the fact that these corruptions may be induced in dRAMs by the interaction of charged particles with the chip of the dRAM itself as a basis of a hardware system for neutron detection with a view to applications in neutron imaging and elemental analysis. The design incorporates a bank of dRAMs on which the particles are incident. Initially, these particles were alpha particles from an appropriate alpha-emitting source employed to assess system parameters. The sensitivity of the device to logic state upsets by ionizing radiation is a function of design and technology parameters, inducing storage node area, node capacitance, operating voltage, minority carrier lifetime, electric fields pattern in the bulk silicon, and specific device geometry. The soft error rate of the device in a given package depends on the flux of alphas, the energy spectrum, the distribution of incident angles, the target area, the total stored charge, the collection efficiency, the cell geometry, the supply voltage, the cycle and refreshing time, and the noise margin

Statistics and methodology of multiple cell upset characterization under heavy ion irradiation

International Nuclear Information System (INIS)

Zebrev, G.I.; Gorbunov, M.S.; Useinov, R.G.; Emeliyanov, V.V.; Ozerov, A.I.; Anashin, V.S.; Kozyukov, A.E.; Zemtsov, K.S.

2015-01-01

Mean and partial cross-section concepts and their connections to multiplicity and statistics of multiple cell upsets (MCUs) in highly-scaled digital memories are introduced and discussed. The important role of the experimental determination of the upset statistics is emphasized. It was found that MCU may lead to quasi-linear dependence of cross-sections on linear energy transfer (LET). A new form of function for interpolation of mean cross-section dependences on LET has been proposed

A Model for Microcontroller Functionality Upset Induced by External Pulsed Electromagnetic Irradiation

Science.gov (United States)

2016-11-21

AFRL-RD-PS- AFRL-RD-PS- TN-2016-0003 TN-2016-0003 A Model for Microcontroller Functionality Upset Induced by External Pulsed Electromagnetic...TYPE Technical Note 3. DATES COVERED (From - To) 22-11-2015 – 21-11-2016 4. TITLE AND SUBTITLE A Model for Microcontroller Functionality Upset Induced by... microcontroller (µC) subjected to external irradiation by a narrowband electromagnetic (EM) pulse. In our model, the state of a µC is completely specified by

Soft error rate analysis methodology of multi-Pulse-single-event transients

International Nuclear Information System (INIS)

Zhou Bin; Huo Mingxue; Xiao Liyi

2012-01-01

As transistor feature size scales down, soft errors in combinational logic because of high-energy particle radiation is gaining more and more concerns. In this paper, a combinational logic soft error analysis methodology considering multi-pulse-single-event transients (MPSETs) and re-convergence with multi transient pulses is proposed. In the proposed approach, the voltage pulse produced at the standard cell output is approximated by a triangle waveform, and characterized by three parameters: pulse width, the transition time of the first edge, and the transition time of the second edge. As for the pulse with the amplitude being smaller than the supply voltage, the edge extension technique is proposed. Moreover, an efficient electrical masking model comprehensively considering transition time, delay, width and amplitude is proposed, and an approach using the transition times of two edges and pulse width to compute the amplitude of pulse is proposed. Finally, our proposed firstly-independently-propagating-secondly-mutually-interacting (FIP-SMI) is used to deal with more practical re-convergence gate with multi transient pulses. As for MPSETs, a random generation model of MPSETs is exploratively proposed. Compared to the estimates obtained using circuit level simulations by HSpice, our proposed soft error rate analysis algorithm has 10% errors in SER estimation with speed up of 300 when the single-pulse-single-event transient (SPSET) is considered. We have also demonstrated the runtime and SER decrease with the increment of P0 using designs from the ISCAS-85 benchmarks. (authors)

Modeling of Single Event Transients With Dual Double-Exponential Current Sources: Implications for Logic Cell Characterization

Science.gov (United States)

Black, Dolores A.; Robinson, William H.; Wilcox, Ian Z.; Limbrick, Daniel B.; Black, Jeffrey D.

2015-08-01

Single event effects (SEE) are a reliability concern for modern microelectronics. Bit corruptions can be caused by single event upsets (SEUs) in the storage cells or by sampling single event transients (SETs) from a logic path. An accurate prediction of soft error susceptibility from SETs requires good models to convert collected charge into compact descriptions of the current injection process. This paper describes a simple, yet effective, method to model the current waveform resulting from a charge collection event for SET circuit simulations. The model uses two double-exponential current sources in parallel, and the results illustrate why a conventional model based on one double-exponential source can be incomplete. A small set of logic cells with varying input conditions, drive strength, and output loading are simulated to extract the parameters for the dual double-exponential current sources. The parameters are based upon both the node capacitance and the restoring current (i.e., drive strength) of the logic cell.

Upset in Response to a Sibling’s Partner’s Infidelity

Directory of Open Access Journals (Sweden)

Dafni Hellstrand

2015-08-01

Full Text Available Existing evidence suggests that the psychological design of romantic jealousy differs for men and women: Men are more likely than women to report greater upset in response to a partner’s sexual than emotional infidelity, whereas women are more likely than men to report greater upset in response to a partner’s emotional than sexual infidelity. However, the observed sex difference can be explained after the fact by both an evolutionary analysis of past reproductive costs and a social constructionist analysis of social and gender role training. Attempting to disentangle these competing perspectives, researchers have measured participants’ upset in response to a sibling’s or a child’s partner’s infidelities. In contrast to what a socialization perspective would predict, participants’ sex did not seem to affect their responses; the key variable was the sex of the sibling or the child, in line with a heuristic application of the evolutionary perspective. The present study attempted not only to test these competing hypotheses but also to extend previous work by involving participants with a gay or lesbian sibling and examining whether participants’ responses are triggered by their sibling’s or sibling’s partner’s sex. In line with an evolutionary perspective, participants’ sex did not assert an effect on their responses. The key variable seemed to be the sex of the sibling (rather than the sex of the sibling’s partner, with participants reporting greater levels of upset in response to the sexual than emotional infidelity of a gay brother’s partner and to the emotional than sexual infidelity of a lesbian sister’s partner. The ensuing discussion offers suggestions for future work on sex-specific triggers of jealousy.

Single-event transients (SET) in analog circuits

International Nuclear Information System (INIS)

Chen Panxun; Zhou Kaiming

2006-01-01

A new phenomenon of single- event upset is introduced. The transient signal is produced in the output of analog circuits after a heavy ion strikes. The transient upset can influence the circuit connected with the output of analog circuits. For example, the output of operational amplifier can be connected with the input of a digital counter, and the pulse of sufficiently high transient output induced by an ion can increase counts of the counter. On the other hand, the transient voltage signal at the output of analog circuits can change the stage of other circuits. (authors)

Stability and performance analysis of a jump linear control system subject to digital upsets

Science.gov (United States)

Wang, Rui; Sun, Hui; Ma, Zhen-Yang

2015-04-01

This paper focuses on the methodology analysis for the stability and the corresponding tracking performance of a closed-loop digital jump linear control system with a stochastic switching signal. The method is applied to a flight control system. A distributed recoverable platform is implemented on the flight control system and subject to independent digital upsets. The upset processes are used to stimulate electromagnetic environments. Specifically, the paper presents the scenarios that the upset process is directly injected into the distributed flight control system, which is modeled by independent Markov upset processes and independent and identically distributed (IID) processes. A theoretical performance analysis and simulation modelling are both presented in detail for a more complete independent digital upset injection. The specific examples are proposed to verify the methodology of tracking performance analysis. The general analyses for different configurations are also proposed. Comparisons among different configurations are conducted to demonstrate the availability and the characteristics of the design. Project supported by the Young Scientists Fund of the National Natural Science Foundation of China (Grant No. 61403395), the Natural Science Foundation of Tianjin, China (Grant No. 13JCYBJC39000), the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry, China, the Tianjin Key Laboratory of Civil Aircraft Airworthiness and Maintenance in Civil Aviation of China (Grant No. 104003020106), and the Fund for Scholars of Civil Aviation University of China (Grant No. 2012QD21x).

Single Versus Multiple Events Error Potential Detection in a BCI-Controlled Car Game With Continuous and Discrete Feedback.

Science.gov (United States)

Kreilinger, Alex; Hiebel, Hannah; Müller-Putz, Gernot R

2016-03-01

This work aimed to find and evaluate a new method for detecting errors in continuous brain-computer interface (BCI) applications. Instead of classifying errors on a single-trial basis, the new method was based on multiple events (MEs) analysis to increase the accuracy of error detection. In a BCI-driven car game, based on motor imagery (MI), discrete events were triggered whenever subjects collided with coins and/or barriers. Coins counted as correct events, whereas barriers were errors. This new method, termed ME method, combined and averaged the classification results of single events (SEs) and determined the correctness of MI trials, which consisted of event sequences instead of SEs. The benefit of this method was evaluated in an offline simulation. In an online experiment, the new method was used to detect erroneous MI trials. Such MI trials were discarded and could be repeated by the users. We found that, even with low SE error potential (ErrP) detection rates, feasible accuracies can be achieved when combining MEs to distinguish erroneous from correct MI trials. Online, all subjects reached higher scores with error detection than without, at the cost of longer times needed for completing the game. Findings suggest that ErrP detection may become a reliable tool for monitoring continuous states in BCI applications when combining MEs. This paper demonstrates a novel technique for detecting errors in online continuous BCI applications, which yields promising results even with low single-trial detection rates.

Considerations for analysis of time-to-event outcomes measured with error: Bias and correction with SIMEX.

Science.gov (United States)

Oh, Eric J; Shepherd, Bryan E; Lumley, Thomas; Shaw, Pamela A

2018-04-15

For time-to-event outcomes, a rich literature exists on the bias introduced by covariate measurement error in regression models, such as the Cox model, and methods of analysis to address this bias. By comparison, less attention has been given to understanding the impact or addressing errors in the failure time outcome. For many diseases, the timing of an event of interest (such as progression-free survival or time to AIDS progression) can be difficult to assess or reliant on self-report and therefore prone to measurement error. For linear models, it is well known that random errors in the outcome variable do not bias regression estimates. With nonlinear models, however, even random error or misclassification can introduce bias into estimated parameters. We compare the performance of 2 common regression models, the Cox and Weibull models, in the setting of measurement error in the failure time outcome. We introduce an extension of the SIMEX method to correct for bias in hazard ratio estimates from the Cox model and discuss other analysis options to address measurement error in the response. A formula to estimate the bias induced into the hazard ratio by classical measurement error in the event time for a log-linear survival model is presented. Detailed numerical studies are presented to examine the performance of the proposed SIMEX method under varying levels and parametric forms of the error in the outcome. We further illustrate the method with observational data on HIV outcomes from the Vanderbilt Comprehensive Care Clinic. Copyright © 2017 John Wiley & Sons, Ltd.

Sex differences in the events that elicit jealousy among homosexuals

NARCIS (Netherlands)

Dijkstra, Pieternel; Groothof, H.; Poel, G.A.; Haverman, T.TG; Buunk, Abraham (Bram)

When individuals ale asked which event would upset them more-a partner's emotional infidelity or a partner's sexual infidelity-among heterosexuals more men than women select a partner's sexual infidelity as the most distressing event, whereas more women than men select a partner's emotional

Standardizing Medication Error Event Reporting in the U.S. Department of Defense

National Research Council Canada - National Science Library

Nosek, Ronald A., Jr; McMeekin, Judy; Rake, Geoffrey W

2005-01-01

...) began an aggressive examination of medical errors and the strategies for minimizing them. A primary goal was the creation of a standardized medication event reporting system, including a central registry for the compilation of reported data...

Single event effect testing of the Intel 80386 family and the 80486 microprocessor

International Nuclear Information System (INIS)

Moran, A.; LaBel, K.; Gates, M.; Seidleck, C.; McGraw, R.; Broida, M.; Firer, J.; Sprehn, S.

1996-01-01

The authors present single event effect test results for the Intel 80386 microprocessor, the 80387 coprocessor, the 82380 peripheral device, and on the 80486 microprocessor. Both single event upset and latchup conditions were monitored

Challenges in disclosure of adverse events and errors in surgery; perspectives from sub-Saharan Africa.

Science.gov (United States)

Ibrahim, Abdulrasheed; Garba, Ekundayo Stephen; Asuku, Malachy Eneye

2012-01-01

Surgery in sub-Saharan Africa is widely known to be done against a background of poverty and illiteracy, late presentation with complicated pathologies, and a desperate lack of infrastructure. In addition, patient autonomy and self determination are highly flavored by cultural practices and religious beliefs. Any of these factors can influence the pattern and disclosure of adverse events and errors. The impact of these in the relationships between surgeons and patients, and between health institutions and patients must be considered as it may affect disclosure and response to errors. This article identifies the peculiar socioeconomic and cultural challenges that may hinder disclosure and proposes strategies for instituting disclosure of errors and adverse events services in Sub-Saharan Africa.

Experimental study on heavy-ion single event effect on nanometer DDR SRAM

International Nuclear Information System (INIS)

Luo Yinhong; Zhang Fengqi; Guo Hongxia; Zhou Hui; Wang Yanping; Zhang Keying

2013-01-01

Single event effect experimental study on 90 nm and 65 nm DDR SRAM were carried out, single event upset (SEU) cross section was discussed as a function of several parameters such as feature size, test pattern, incidence angle, supply voltage. Key influence factors and effect rule were analyzed. Feasibility of the current test method was discussed. Results indicate that, SEU cross section reduces as technologies scale down; the influence of test pattern and power supply on SEU cross section is small; tilt angle increases SEU cross section due to multiple upset increasement. The applicability of cosine tilt test method is correlative to ion species and linear energy transfer (LET) values. (authors)

An investigation on unintended reactor trip events in terms of human error hazards of Korean nuclear power plants

International Nuclear Information System (INIS)

Kim, Sa Kil; Lee, Yong Hee; Jang, Tong Il; Oh, Yeon Ju; Shin, Kwang Hyeon

2014-01-01

Highlights: • A methodology to identify human error hazards has been established. • The proposed methodology is a preventive approach to identify not only human error causes but also its hazards. • Using the HFACS framework we tried to find out not causations but all of the hazards and relationships among them. • We determined countermeasures against human errors through dealing with latent factors such as organizational influences. - Abstract: A new approach for finding the hazards of human errors, and not just their causes, in the nuclear industry is currently required. This is because finding causes of human errors is really impossible owing to the multiplicity of causes in each case. Thus, this study aims at identifying the relationships among human error hazards and determining the strategies for preventing human error events by means of a reanalysis of the reactor trip events in Korea NPPs. We investigated human errors to find latent factors such as decisions and conditions in all of the unintended reactor trip events during the last dozen years. In this study, we applied the HFACS (Human Factors Analysis and Classification System), which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. Using the HFACS framework, we tried to find out not the causations but all of the hazards and their relationships in terms of organizational factors. Through the trial, we proposed not only meaningful frequencies of each hazards also correlations of them. Also, considering the correlations of each hazards, we suggested useful strategies to prevent human error event. A method to investigate unintended nuclear reactor trips by human errors and the results will be discussed in more detail

CREME96 and Related Error Rate Prediction Methods

Science.gov (United States)

Adams, James H., Jr.

2012-01-01

Predicting the rate of occurrence of single event effects (SEEs) in space requires knowledge of the radiation environment and the response of electronic devices to that environment. Several analytical models have been developed over the past 36 years to predict SEE rates. The first error rate calculations were performed by Binder, Smith and Holman. Bradford and Pickel and Blandford, in their CRIER (Cosmic-Ray-Induced-Error-Rate) analysis code introduced the basic Rectangular ParallelePiped (RPP) method for error rate calculations. For the radiation environment at the part, both made use of the Cosmic Ray LET (Linear Energy Transfer) spectra calculated by Heinrich for various absorber Depths. A more detailed model for the space radiation environment within spacecraft was developed by Adams and co-workers. This model, together with a reformulation of the RPP method published by Pickel and Blandford, was used to create the CR ME (Cosmic Ray Effects on Micro-Electronics) code. About the same time Shapiro wrote the CRUP (Cosmic Ray Upset Program) based on the RPP method published by Bradford. It was the first code to specifically take into account charge collection from outside the depletion region due to deformation of the electric field caused by the incident cosmic ray. Other early rate prediction methods and codes include the Single Event Figure of Merit, NOVICE, the Space Radiation code and the effective flux method of Binder which is the basis of the SEFA (Scott Effective Flux Approximation) model. By the early 1990s it was becoming clear that CREME and the other early models needed Revision. This revision, CREME96, was completed and released as a WWW-based tool, one of the first of its kind. The revisions in CREME96 included improved environmental models and improved models for calculating single event effects. The need for a revision of CREME also stimulated the development of the CHIME (CRRES/SPACERAD Heavy Ion Model of the Environment) and MACREE (Modeling and

Radiation-hardened MRAM-based LUT for non-volatile FPGA soft error mitigation with multi-node upset tolerance

Science.gov (United States)

Zand, Ramtin; DeMara, Ronald F.

2017-12-01

In this paper, we have developed a radiation-hardened non-volatile lookup table (LUT) circuit utilizing spin Hall effect (SHE)-magnetic random access memory (MRAM) devices. The design is motivated by modeling the effect of radiation particles striking hybrid complementary metal oxide semiconductor/spin based circuits, and the resistive behavior of SHE-MRAM devices via established and precise physics equations. The models developed are leveraged in the SPICE circuit simulator to verify the functionality of the proposed design. The proposed hardening technique is based on using feedback transistors, as well as increasing the radiation capacity of the sensitive nodes. Simulation results show that our proposed LUT circuit can achieve multiple node upset (MNU) tolerance with more than 38% and 60% power-delay product improvement as well as 26% and 50% reduction in device count compared to the previous energy-efficient radiation-hardened LUT designs. Finally, we have performed a process variation analysis showing that the MNU immunity of our proposed circuit is realized at the cost of increased susceptibility to transistor and MRAM variations compared to an unprotected LUT design.

Medication errors: an analysis comparing PHICO's closed claims data and PHICO's Event Reporting Trending System (PERTS).

Science.gov (United States)

Benjamin, David M; Pendrak, Robert F

2003-07-01

Clinical pharmacologists are all dedicated to improving the use of medications and decreasing medication errors and adverse drug reactions. However, quality improvement requires that some significant parameters of quality be categorized, measured, and tracked to provide benchmarks to which future data (performance) can be compared. One of the best ways to accumulate data on medication errors and adverse drug reactions is to look at medical malpractice data compiled by the insurance industry. Using data from PHICO insurance company, PHICO's Closed Claims Data, and PHICO's Event Reporting Trending System (PERTS), this article examines the significance and trends of the claims and events reported between 1996 and 1998. Those who misread history are doomed to repeat the mistakes of the past. From a quality improvement perspective, the categorization of the claims and events is useful for reengineering integrated medication delivery, particularly in a hospital setting, and for redesigning drug administration protocols on low therapeutic index medications and "high-risk" drugs. Demonstrable evidence of quality improvement is being required by state laws and by accreditation agencies. The state of Florida requires that quality improvement data be posted quarterly on the Web sites of the health care facilities. Other states have followed suit. The insurance industry is concerned with costs, and medication errors cost money. Even excluding costs of litigation, an adverse drug reaction may cost up to $2500 in hospital resources, and a preventable medication error may cost almost $4700. To monitor costs and assess risk, insurance companies want to know what errors are made and where the system has broken down, permitting the error to occur. Recording and evaluating reliable data on adverse drug events is the first step in improving the quality of pharmacotherapy and increasing patient safety. Cost savings and quality improvement evolve on parallel paths. The PHICO data

An assessment of the risk significance of human errors in selected PSAs and operating events

International Nuclear Information System (INIS)

Palla, R.L. Jr.; El-Bassioni, A.

1991-01-01

Sensitivity studies based on Probabilistic Safety Assessments (PSAs) for a pressurized water reactor and a boiling water reactor are described. In each case human errors modeled in the PSAs were categorized according to such factors as error type, location, timing, and plant personnel involved. Sensitivity studies were then conducted by varying the error rates in each category and evaluating the corresponding change in total core damage frequency and accident sequence frequency. Insights obtained are discussed and reasons for differences in risk sensitivity between plants are explored. A separate investigation into the role of human error in risk-important operating events is also described. This investigation involved the analysis of data from the USNRC Accident Sequence Precursor program to determine the effect of operator-initiated events on accident precursor trends, and to determine whether improved training can be correlated to current trends. The findings of this study are also presented. 5 refs., 15 figs., 1 tab

Test CMOS/SOS RAM for transient radiation upset comparative research and failure analysis

International Nuclear Information System (INIS)

Nikiforov, A.Y.; Poljakov, I.V.

1995-01-01

The test Complementary Metal-Oxide-Semiconductor/Silicon-on-Sapphire Random Access Memory (CMOS/SOS RAM) with eight types of memory cells was designed and tested at high dose rates with a flash X-ray machine and laser simulator. The memory cell (MC) design with additional transistors and RC-chain was found to be upset free up to 2 x 10 12 rad(Si)/s. An inversion effect was discovered in which almost 100% logic upset was observed in poorly protected memory cell arrays at very high dose rates

Students’ Written Production Error Analysis in the EFL Classroom Teaching: A Study of Adult English Learners Errors

Directory of Open Access Journals (Sweden)

Ranauli Sihombing

2016-12-01

Full Text Available Errors analysis has become one of the most interesting issues in the study of Second Language Acquisition. It can not be denied that some teachers do not know a lot about error analysis and related theories of how L1, L2 or foreign language acquired. In addition, the students often feel upset since they find a gap between themselves and the teachers for the errors the students make and the teachers’ understanding about the error correction. The present research aims to investigate what errors adult English learners make in written production of English. The significances of the study is to know what errors students make in writing that the teachers can find solution to the errors the students make for a better English language teaching and learning especially in teaching English for adults. The study employed qualitative method. The research was undertaken at an airline education center in Bandung. The result showed that syntax errors are more frequently found than morphology errors, especially in terms of verb phrase errors. It is recommended that it is important for teacher to know the theory of second language acquisition in order to know how the students learn and produce theirlanguage. In addition, it will be advantages for teachers if they know what errors students frequently make in their learning, so that the teachers can give solution to the students for a better English language learning achievement.   DOI: https://doi.org/10.24071/llt.2015.180205

How to Cope with the Rare Human Error Events Involved with organizational Factors in Nuclear Power Plants

Energy Technology Data Exchange (ETDEWEB)

Kim, Sa Kil; Luo, Meiling; Lee, Yong Hee [Korea Atomic Research Institute, Daejeon (Korea, Republic of)

2014-10-15

The current human error guidelines (e.g. US DOD handbooks, US NRC Guidelines) are representative tools to prevent human errors. These tools, however, have limits that they do not adapt all operating situations and circumstances such as design base events. In other words, these tools are only adapted foreseeable standardized operating situations and circumstances. In this study, our research team proposed an evidence-based approach such as UK's safety case to coping with the rare human error events such as TMI, Chernobyl, Fukushima accidents. These accidents are representative events involved with rare human errors. Our research team defined the 'rare human errors' as the follow three characterized events; Extremely low frequency Extremely high complicated structure Extremely serious damage of human life and property A safety case is a structured argument, supported by evidence, intended to justify that a system is acceptably safe. The definition by UK defense standard 00-56 issue 4 states that such an evidence-based approach can be contrast with a prescriptive approach to safety certification, which require safety to be justified using a prescribed process. Safety managements and safety regulatory activities based on safety case are effective to control organizational factors in terms of integrated safety management. Especially safety issues relevant with public acceptance are useful to provide practical evidences to the public reasonably. European Union including UK has developed the concept of engineered safety management system to deal with public acceptance using the safety case. In Korea nuclear industry, the Korean Atomic Research Institute has firstly performed a basic research to adapt the safety case in the field of radioactive waste according to the IAEA SSG-23(KAERI/TR-4497, 4531). Excepting the radioactive waste, there is no try to adapt the safety case yet. Most incidents and accidents involved human during operating NPPs have a tendency

How to Cope with the Rare Human Error Events Involved with organizational Factors in Nuclear Power Plants

International Nuclear Information System (INIS)

Kim, Sa Kil; Luo, Meiling; Lee, Yong Hee

2014-01-01

The current human error guidelines (e.g. US DOD handbooks, US NRC Guidelines) are representative tools to prevent human errors. These tools, however, have limits that they do not adapt all operating situations and circumstances such as design base events. In other words, these tools are only adapted foreseeable standardized operating situations and circumstances. In this study, our research team proposed an evidence-based approach such as UK's safety case to coping with the rare human error events such as TMI, Chernobyl, Fukushima accidents. These accidents are representative events involved with rare human errors. Our research team defined the 'rare human errors' as the follow three characterized events; Extremely low frequency Extremely high complicated structure Extremely serious damage of human life and property A safety case is a structured argument, supported by evidence, intended to justify that a system is acceptably safe. The definition by UK defense standard 00-56 issue 4 states that such an evidence-based approach can be contrast with a prescriptive approach to safety certification, which require safety to be justified using a prescribed process. Safety managements and safety regulatory activities based on safety case are effective to control organizational factors in terms of integrated safety management. Especially safety issues relevant with public acceptance are useful to provide practical evidences to the public reasonably. European Union including UK has developed the concept of engineered safety management system to deal with public acceptance using the safety case. In Korea nuclear industry, the Korean Atomic Research Institute has firstly performed a basic research to adapt the safety case in the field of radioactive waste according to the IAEA SSG-23(KAERI/TR-4497, 4531). Excepting the radioactive waste, there is no try to adapt the safety case yet. Most incidents and accidents involved human during operating NPPs have a tendency

Are Sexual and Emotional Infidelity Equally Upsetting to Men and Women? Making Sense of Forced-Choice Responses

Directory of Open Access Journals (Sweden)

David A. Lishner

2008-10-01

Full Text Available Forced-choice measures that assess reactions to imagined sexual and emotional infidelity are ubiquitous in studies testing the Jealousy as a Specific Innate Module (JSIM model. One potential problem with such measures is that they fail to identify respondents who find both forms of infidelity equally upsetting. To examine this issue, an experiment was conducted in which two groups of participants imagined a romantic infidelity after which participants in the first group used a traditional forced-choice measure to indicate whether they found sexual or emotional infidelity more upsetting. Participants in the second group instead used a modified forced-choice measure that allowed them also to indicate whether they found both forms of infidelity equally upsetting. Consistent with previous research, those given the traditional forced-choice measure tended to respond in a manner that supported the JSIM model. However, the majority of participants given the modified measure indicated that both forms of infidelity were equally upsetting.

Trend analysis of nuclear reactor automatic trip events subjected to operator's human error at United States nuclear power plants

International Nuclear Information System (INIS)

Takagawa, Kenichi

2009-01-01

Trends in nuclear reactor automatic trip events due to human errors during plant operating mode have been analyzed by extracting 20 events which took place in the United States during the period of seven years from 2002 to 2008, cited in the LERs (Licensee Event Reports) submitted to the US Nuclear Regulatory Commission (NRC). It was shown that the yearly number of events was relatively large before 2005, and thereafter the number decreased. A period of stable operation, in which the yearly number was kept very small, continued for about three years, and then the yearly number turned to increase again. Before 2005, automatic trip events occurred more frequently during periodic inspections or start-up/shut-down operations. The recent trends, however, indicate that trip events became more frequent due to human errors during daily operations. Human errors were mostly caused by the self-conceit and carelessness of operators through the whole period. The before mentioned trends in the yearly number of events might be explained as follows. The decrease in the automatic trip events is attributed to sharing trouble information, leading as a consequence to improvement of the manual and training for the operations which have a higher potential risk of automatic trip. Then, while the period of stable operation continued, some operators came to pay less attention to preventing human errors and not interest in the training, leading to automatic trip events in reality due to miss-operation. From these analyses on trouble experiences in the US, we learnt the followings to prevent the occurrence similar troubles in Japan: Operators should be thoroughly skilled in basic actions to prevent human errors as persons concerned. And it should be further emphasized that they should elaborate by imaging actual plant operations even though the simulator training gives them successful experiences. (author)

Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative

National Research Council Canada - National Science Library

Harris, Daniel M; Westfall, John M; Fernald, Douglas H; Duclos, Christine W; West, David R; Niebauer, Linda; Marr, Linda; Quintela, Javan; Main, Deborah S

2005-01-01

.... This paper presents a mixed methods approach to analyzing narrative error event reports. Mixed methods studies integrate one or more qualitative and quantitative techniques for data collection and analysis...

Solid-state resistance upset welding: A process with unique advantages for advanced materials

International Nuclear Information System (INIS)

Kanne, W.R. Jr.

1993-01-01

Solid-state resistance upset welding is suitable for joining many alloys that are difficult to weld using fusion processes. Since no melting takes place, the weld metal retains many of the characteristics of the base metal. Resulting welds have a hot worked structure, and thereby have higher strength than fusion welds in the same mate. Since the material being joined is not melted, compositional gradients are not introduced, second phase materials are minimally disrupted, and minor alloying elements, do not affect weldability. Solid-state upset welding has been adapted for fabrication of structures considered very large compared to typical resistance welding applications. The process has been used for closure of capsules, small vessels, and large containers. Welding emphasis has been on 304L stainless steel, the material for current applications. Other materials have, however, received enough attention to have demonstrated capability for joining alloys that are not readily weldable using fusion welding methods. A variety of other stainless steels (including A-286), superalloys (including TD nickel), refractory metals (including tungsten), and aluminum alloys (including 2024) have been successfully upset welded

Comparison between ground tests and flight data for two static 32 KB memories

International Nuclear Information System (INIS)

Cheynet, Ph.; Velazco, R.; Cheynet, Ph.; Ecoffet, R.; Duzellier, S.; David, J.P.; Loquet, J.G.

1999-01-01

The study concerns two 32 K-byte static memories, one from Hitachi (HM62256) and the other (HM65756) from Matra-MHS. The results correspond to around one year of measurement in high radiation orbit and a total of 268 upsets were detected. As a preliminary conclusion it can be stated that the MHS SRAM is probably at least 4 times more sensitive to SEU (single event upset) than the Hitachi SRAM. The Hitachi memory has exhibited what we call ''stuck-at'' bit errors. This kind of event is identified when the same address and data is found in error (fixed read data) for several consecutive read cycles. A confrontation of SEU rates derived from predictions to those measured in flight has shown that: - error rate is underestimated for HM62256 using standard prediction models, - error rate can be under or over-estimated for HM65756 but the dispersion on heavy-ion ground results does not allow us to conclude. (A.C.)

Upset Prevention and Recovery for Unimpaired and Impaired Aircraft, Phase II

Data.gov (United States)

National Aeronautics and Space Administration — The objective of the project is the development of an on-board envelope estimation, protection and upset recovery tool to address loss of control incidents in...

Soft-error tolerance and energy consumption evaluation of embedded computer with magnetic random access memory in practical systems using computer simulations

Science.gov (United States)

Nebashi, Ryusuke; Sakimura, Noboru; Sugibayashi, Tadahiko

2017-08-01

We evaluated the soft-error tolerance and energy consumption of an embedded computer with magnetic random access memory (MRAM) using two computer simulators. One is a central processing unit (CPU) simulator of a typical embedded computer system. We simulated the radiation-induced single-event-upset (SEU) probability in a spin-transfer-torque MRAM cell and also the failure rate of a typical embedded computer due to its main memory SEU error. The other is a delay tolerant network (DTN) system simulator. It simulates the power dissipation of wireless sensor network nodes of the system using a revised CPU simulator and a network simulator. We demonstrated that the SEU effect on the embedded computer with 1 Gbit MRAM-based working memory is less than 1 failure in time (FIT). We also demonstrated that the energy consumption of the DTN sensor node with MRAM-based working memory can be reduced to 1/11. These results indicate that MRAM-based working memory enhances the disaster tolerance of embedded computers.

Translational errors as an early event in prion conversion.

Science.gov (United States)

Hatin, I; Bidou, L; Cullin, C; Rousset, J P

2001-01-01

A prion is an infectious, altered form of a cellular protein which can self-propagate and affect normal phenotype. Prion conversion has been observed for mammalian and yeast proteins but molecular mechanisms that trigger this process remain unclear. Up to now, only post-translational models have been explored. In this work, we tested the hypothesis that co-translational events may be implicated in the conformation changes of the Ure2p protein of Saccharomyces cerevisiae. This protein can adopt a prion conformation leading to an [URE3] phenotype which can be easily assessed and quantified. We analyzed the effect of two antibiotics, known to affect translation, on [URE3] conversion frequency. For cells treated with G418 we observed a parallel increase of translational errors rate and frequency of [URE3] conversion. By contrast, cycloheximide which was not found to affect translational fidelity, has no influence on the induction of [URE3] phenotype. These results raise the possibility that the mechanism of prion conversion might not only involve alternative structures of strictly identical molecules but also aberrant proteins resulting from translational errors.

The educational inclusion of the students with upsets of the oral communication

Directory of Open Access Journals (Sweden)

Merling Murguia Moré

2015-09-01

Full Text Available The educational inclusion imposes challenges to the National System of Education, to optimize the attention to the students with upsets of the oral communication. Is the objective of the article to share the design of an investigation that assists to the scientific problem how to contribute to the improvement of the educational inclusion of the students with upsets of the oral communication? The employment of the investigation-action-participativa it drives to the execution of the objective related with the construction of a pedagogic model for the improvement of this process. The results of the investigation will constitute a necessary contribution to the educational inclusion in the National System of Education

Investigation and control of factors influencing resistance upset butt welding.

NARCIS (Netherlands)

Kerstens, N.F.H.

2010-01-01

The purpose of this work is to investigate the factors influencing the resistance upset butt welding process to obtain an understanding of the metal behaviour and welding process characteristics, so that new automotive steels can be welded with reduced development time and fewer failures in

upSET, the Drosophila homologue of SET3, Is Required for Viability and the Proper Balance of Active and Repressive Chromatin Marks

Directory of Open Access Journals (Sweden)

Kyle A. McElroy

2017-02-01

Full Text Available Chromatin plays a critical role in faithful implementation of gene expression programs. Different post-translational modifications (PTMs of histone proteins reflect the underlying state of gene activity, and many chromatin proteins write, erase, bind, or are repelled by, these histone marks. One such protein is UpSET, the Drosophila homolog of yeast Set3 and mammalian KMT2E (MLL5. Here, we show that UpSET is necessary for the proper balance between active and repressed states. Using CRISPR/Cas-9 editing, we generated S2 cells that are mutant for upSET. We found that loss of UpSET is tolerated in S2 cells, but that heterochromatin is misregulated, as evidenced by a strong decrease in H3K9me2 levels assessed by bulk histone PTM quantification. To test whether this finding was consistent in the whole organism, we deleted the upSET coding sequence using CRISPR/Cas-9, which we found to be lethal in both sexes in flies. We were able to rescue this lethality using a tagged upSET transgene, and found that UpSET protein localizes to transcriptional start sites (TSS of active genes throughout the genome. Misregulated heterochromatin is apparent by suppressed position effect variegation of the wm4 allele in heterozygous upSET-deleted flies. Using nascent-RNA sequencing in the upSET-mutant S2 lines, we show that this result applies to heterochromatin genes generally. Our findings support a critical role for UpSET in maintaining heterochromatin, perhaps by delimiting the active chromatin environment.

Gender differences in the pathway from adverse life events to adolescent emotional and behavioural problems via negative cognitive errors.

Science.gov (United States)

Flouri, Eirini; Panourgia, Constantina

2011-06-01

The aim of this study was to test for gender differences in how negative cognitive errors (overgeneralizing, catastrophizing, selective abstraction, and personalizing) mediate the association between adverse life events and adolescents' emotional and behavioural problems (measured with the Strengths and Difficulties Questionnaire). The sample consisted of 202 boys and 227 girls (aged 11-15 years) from three state secondary schools in disadvantaged areas in one county in the South East of England. Control variables were age, ethnicity, special educational needs, exclusion history, family structure, family socio-economic disadvantage, and verbal cognitive ability. Adverse life events were measured with Tiet et al.'s (1998) Adverse Life Events Scale. For both genders, we assumed a pathway from adverse life events to emotional and behavioural problems via cognitive errors. We found no gender differences in life adversity, cognitive errors, total difficulties, peer problems, or hyperactivity. In both boys and girls, even after adjustment for controls, cognitive errors were related to total difficulties and emotional symptoms, and life adversity was related to total difficulties and conduct problems. The life adversity/conduct problems association was not explained by negative cognitive errors in either gender. However, we found gender differences in how adversity and cognitive errors produced hyperactivity and internalizing problems. In particular, life adversity was not related, after adjustment for controls, to hyperactivity in girls and to peer problems and emotional symptoms in boys. Cognitive errors fully mediated the effect of life adversity on hyperactivity in boys and on peer and emotional problems in girls.

Direct Observation of Asperity Deformation of Specimen with Random Rough Surface in Upsetting Process

DEFF Research Database (Denmark)

Azushima, A.; Kuba, S.; Tani, S.

2004-01-01

The trapping behavior of liquid lubricant and contact behavior of asperities at the workpiece-tool interface during upsetting and indentation are observed directly using a compression subpress which consists of a transparent die made of sapphire, a microscope with a CCD camera and a video system....... The experiments are carried out without lubricant and with lubricant. Specimens used are commercially pure A1100 Aluminum with a random rough surface. From this observation, the change in the fraction of real contact area is measured by an image processor. The real contact area ratios in upsetting experiment...

Technology-Induced Errors and Adverse Event Reporting in an Organizational Learning Perspective.

Science.gov (United States)

Vinther, Line Dausel; Jensen, Christian Møller; Hjelmager, Ditte Meulengracht; Lyhne, Nicoline; Nøhr, Christian

2017-01-01

This paper addresses the possibilities of evaluating technology-induced errors, through the utilization of experiences of the Danish adverse event reporting system. The learning loop in the adverse event reporting system is identified and analyzed, to examine which elements can be utilized to evaluate technologies. The empirical data was collected through interviews and a workshop with members of the nursing staff at a nursing home in Aalborg, Denmark. It was found that, the establishment of sustainable feedback learning loops depends on shared visions in the organization and how creating shared visions requires involvement and participation. Secondly, care workers must possess fundamental knowledge about the technologies available to them. Thirdly comprehensive classification of adverse events should be established to allow for a systematic and goal directed feed-back process.

Analysis by Monte Carlo simulations of the sensitivity to single event upset of SRAM memories under spatial proton or terrestrial neutron environment

International Nuclear Information System (INIS)

Lambert, D.

2006-07-01

Electronic systems in space and terrestrial environments are subjected to a flow of particles of natural origin, which can induce dysfunctions. These particles can cause Single Event Upsets (SEU) in SRAM memories. Although non-destructive, the SEU can have consequences on the equipment functioning in applications requiring a great reliability (airplane, satellite, launcher, medical, etc). Thus, an evaluation of the sensitivity of the component technology is necessary to predict the reliability of a system. In atmospheric environment, the SEU sensitivity is mainly caused by the secondary ions resulting from the nuclear reactions between the neutrons and the atoms of the component. In space environment, the protons with strong energies induce the same effects as the atmospheric neutrons. In our work, a new code of prediction of the rate of SEU has been developed (MC-DASIE) in order to quantify the sensitivity for a given environment and to explore the mechanisms of failures according to technology. This code makes it possible to study various technologies of memories SRAM (Bulk and SOI) in neutron and proton environment between 1 MeV and 1 GeV. Thus, MC-DASIE was used with experiment data to study the effect of integration on the sensitivity of the memories in terrestrial environment, a comparison between the neutron and proton irradiations and the influence of the modeling of the target component on the calculation of the rate of SEU. (author)

[Event-related EEG potentials associated with error detection in psychiatric disorder: literature review].

Science.gov (United States)

Balogh, Lívia; Czobor, Pál

2010-01-01

Error-related bioelectric signals constitute a special subgroup of event-related potentials. Researchers have identified two evoked potential components to be closely related to error processing, namely error-related negativity (ERN) and error-positivity (Pe), and they linked these to specific cognitive functions. In our article first we give a brief description of these components, then based on the available literature, we review differences in error-related evoked potentials observed in patients across psychiatric disorders. The PubMed and Medline search engines were used in order to identify all relevant articles, published between 2000 and 2009. For the purpose of the current paper we reviewed publications summarizing results of clinical trials. Patients suffering from schizophrenia, anorexia nervosa or borderline personality disorder exhibited a decrease in the amplitude of error-negativity when compared with healthy controls, while in cases of depression and anxiety an increase in the amplitude has been observed. Some of the articles suggest specific personality variables, such as impulsivity, perfectionism, negative emotions or sensitivity to punishment to underlie these electrophysiological differences. Research in the field of error-related electric activity has come to the focus of psychiatry research only recently, thus the amount of available data is significantly limited. However, since this is a relatively new field of research, the results available at present are noteworthy and promising for future electrophysiological investigations in psychiatric disorders.

High electrical resistivity Nd-Fe-B die-upset magnet doped with eutectic DyF3–LiF salt mixture

Directory of Open Access Journals (Sweden)

K. M. Kim

2017-05-01

Full Text Available Nd-Fe-B-type die-upset magnet with high electrical resistivity was prepared by doping of eutectic DyF3–LiF salt mixture. Mixture of melt-spun Nd-Fe-B flakes (MQU-F: Nd13.6Fe73.6Co6.6Ga0.6B5.6 and eutectic binary (DyF3–LiF salt (25 mol% DyF3 – 75 mol% LiF was hot-pressed and then die-upset. By adding the eutectic salt mixture (> 4 wt%, electrical resistivity of the die-upset magnet was enhanced to over 400 μΩ.cm compared to 190 μΩ.cm of the un-doped magnet. Remarkable enhancement of the electrical resistivity was attributed to homogeneous and continuous coverage of the interface between flakes by the easily melted eutectic salt dielectric mixture. It was revealed that active substitution of the Nd atoms in neighboring flakes by the Dy atoms from the added (DyF3–LiF salt mixture had occurred during such a quick thermal processing of hot-pressing and die-upsetting. This Dy substitution led to coercivity enhancement in the die-upset magnet doped with the eutectic (DyF3–LiF salt mixture. Coercivity and remanence of the die-upset magnet doped with (DyF3–LiF salt mixture was as good as those of the DyF3-doped magnet.

Crying without a cause and being easily upset in two-year-olds: heritability and predictive power of behavioral problems.

Science.gov (United States)

Groen-Blokhuis, Maria M; Middeldorp, Christel M; M van Beijsterveldt, Catharina E; Boomsma, Dorret I

2011-10-01

In order to estimate the influence of genetic and environmental factors on 'crying without a cause' and 'being easily upset' in 2-year-old children, a large twin study was carried out. Prospective data were available for ~18,000 2-year-old twin pairs from the Netherlands Twin Register. A bivariate genetic analysis was performed using structural equation modeling in the Mx software package. The influence of maternal personality characteristics and demographic and lifestyle factors was tested to identify specific risk factors that may underlie the shared environment of twins. Furthermore, it was tested whether crying without a cause and being easily upset were predictive of later internalizing, externalizing and attention problems. Crying without a cause yielded a heritability estimate of 60% in boys and girls. For easily upset, the heritability was estimated at 43% in boys and 31% in girls. The variance explained by shared environment varied between 35% and 63%. The correlation between crying without a cause and easily upset (r = .36) was explained both by genetic and shared environmental factors. Birth cohort, gestational age, socioeconomic status, parental age, parental smoking behavior and alcohol use during pregnancy did not explain the shared environmental component. Neuroticism of the mother explained a small proportion of the additive genetic, but not of the shared environmental effects for easily upset. Crying without a cause and being easily upset at age 2 were predictive of internalizing, externalizing and attention problems at age 7, with effect sizes of .28-.42. A large influence of shared environmental factors on crying without a cause and easily upset was detected. Although these effects could be specific to these items, we could not explain them by personality characteristics of the mother or by demographic and lifestyle factors, and we recognize that these effects may reflect other maternal characteristics. A substantial influence of genetic factors

Cognitive Moderators of Children's Adjustment to Stressful Divorce Events: The Role of Negative Cognitive Errors and Positive Illusions.

Science.gov (United States)

Mazur, Elizabeth; Wolchik, Sharlene A.; Virdin, Lynn; Sandler, Irwin N.; West, Stephen G.

1999-01-01

Examined whether children's cognitive biases moderated impact of stressful divorce-related events on adjustment in 9- to 12-year olds. Found that endorsing negative cognitive errors for hypothetical divorce events moderated relations between stressful divorce events and self- and maternal-reports of internalizing and externalizing symptoms for…

Multi-bits error detection and fast recovery in RISC cores

International Nuclear Information System (INIS)

Wang Jing; Yang Xing; Zhang Weigong; Shen Jiao; Qiu Keni; Zhao Yuanfu

2015-01-01

The particles-induced soft errors are a major threat to the reliability of microprocessors. Even worse, multi-bits upsets (MBUs) are ever-increased due to the rapidly shrinking feature size of the IC on a chip. Several architecture-level mechanisms have been proposed to protect microprocessors from soft errors, such as dual and triple modular redundancies (DMR and TMR). However, most of them are inefficient to combat the growing multi-bits errors or cannot well balance the critical paths delay, area and power penalty. This paper proposes a novel architecture, self-recovery dual-pipeline (SRDP), to effectively provide soft error detection and recovery with low cost for general RISC structures. We focus on the following three aspects. First, an advanced DMR pipeline is devised to detect soft error, especially MBU. Second, SEU/MBU errors can be located by enhancing self-checking logic into pipelines stage registers. Third, a recovery scheme is proposed with a recovery cost of 1 or 5 clock cycles. Our evaluation of a prototype implementation exhibits that the SRDP can successfully detect particle-induced soft errors up to 100% and recovery is nearly 95%, the other 5% will inter a specific trap. (paper)

Multi-bits error detection and fast recovery in RISC cores

Science.gov (United States)

Jing, Wang; Xing, Yang; Yuanfu, Zhao; Weigong, Zhang; Jiao, Shen; Keni, Qiu

2015-11-01

The particles-induced soft errors are a major threat to the reliability of microprocessors. Even worse, multi-bits upsets (MBUs) are ever-increased due to the rapidly shrinking feature size of the IC on a chip. Several architecture-level mechanisms have been proposed to protect microprocessors from soft errors, such as dual and triple modular redundancies (DMR and TMR). However, most of them are inefficient to combat the growing multi-bits errors or cannot well balance the critical paths delay, area and power penalty. This paper proposes a novel architecture, self-recovery dual-pipeline (SRDP), to effectively provide soft error detection and recovery with low cost for general RISC structures. We focus on the following three aspects. First, an advanced DMR pipeline is devised to detect soft error, especially MBU. Second, SEU/MBU errors can be located by enhancing self-checking logic into pipelines stage registers. Third, a recovery scheme is proposed with a recovery cost of 1 or 5 clock cycles. Our evaluation of a prototype implementation exhibits that the SRDP can successfully detect particle-induced soft errors up to 100% and recovery is nearly 95%, the other 5% will inter a specific trap.

Development and Flight Testing of an Automated Upset Recovery System, Phase I

Data.gov (United States)

National Aeronautics and Space Administration — Loss of control (LOC) due to upset is one of the main causes of accidents in manned aircraft and is already emerging as a significant causal factor in unmanned...

Injecting Artificial Memory Errors Into a Running Computer Program

Science.gov (United States)

Bornstein, Benjamin J.; Granat, Robert A.; Wagstaff, Kiri L.

2008-01-01

Single-event upsets (SEUs) or bitflips are computer memory errors caused by radiation. BITFLIPS (Basic Instrumentation Tool for Fault Localized Injection of Probabilistic SEUs) is a computer program that deliberately injects SEUs into another computer program, while the latter is running, for the purpose of evaluating the fault tolerance of that program. BITFLIPS was written as a plug-in extension of the open-source Valgrind debugging and profiling software. BITFLIPS can inject SEUs into any program that can be run on the Linux operating system, without needing to modify the program s source code. Further, if access to the original program source code is available, BITFLIPS offers fine-grained control over exactly when and which areas of memory (as specified via program variables) will be subjected to SEUs. The rate of injection of SEUs is controlled by specifying either a fault probability or a fault rate based on memory size and radiation exposure time, in units of SEUs per byte per second. BITFLIPS can also log each SEU that it injects and, if program source code is available, report the magnitude of effect of the SEU on a floating-point value or other program variable.

A mediation skills model to manage disclosure of errors and adverse events to patients.

Science.gov (United States)

Liebman, Carol B; Hyman, Chris Stern

2004-01-01

In 2002 Pennsylvania became the first state to impose on hospitals a statutory duty to notify patients in writing of a serious event. If the disclosure conversations are carefully planned, properly executed, and responsive to patients' needs, this new requirement creates possible benefits for both patient safety and litigation risk management. This paper describes a model for accomplishing these goals that encourages health care providers to communicate more effectively with patients following an adverse event or medical error, learn from mistakes, respond to the concerns of patients and families after an adverse event, and arrive at a fair and cost-effective resolution of valid claims.

Final results of the supra project : Improved Simulation of Upset Recovery

NARCIS (Netherlands)

Fucke, L.; Groen, E.; Goman, M.; Abramov, N.; Wentink, M.; Nooij, S.; Zaichik, L.E.; Khrabrov, A.

2012-01-01

The objective of the European research project SUPRA (Simulation of Upset Recovery in Aviation) is to develop technologies that eventually contribute to a reduction of risk of Loss of control - in flight (LOC-I) accidents, today's major cause of fatal accidents in commercial aviation. To this end

CMOS/SOS RAM transient radiation upset and ''inversion'' effect investigation

International Nuclear Information System (INIS)

Nikiforov, A.Y.; Poljakov, I.V.

1996-01-01

The Complementary Metal-Oxide-Semiconductor/Silicon-on-Sapphire Random Access Memory (CMOS/SOS RAM) transient upset and inversion effect were investigated with pulsed laser, pulsed voltage generator and low-intensity light simulators. It was found that the inversion of information occurs due to memory cell photocurrents simultaneously with the power supply voltage drop transfer to memory cells outputs

Dynamics Modeling and Simulation of Large Transport Airplanes in Upset Conditions

Science.gov (United States)

Foster, John V.; Cunningham, Kevin; Fremaux, Charles M.; Shah, Gautam H.; Stewart, Eric C.; Rivers, Robert A.; Wilborn, James E.; Gato, William

2005-01-01

As part of NASA's Aviation Safety and Security Program, research has been in progress to develop aerodynamic modeling methods for simulations that accurately predict the flight dynamics characteristics of large transport airplanes in upset conditions. The motivation for this research stems from the recognition that simulation is a vital tool for addressing loss-of-control accidents, including applications to pilot training, accident reconstruction, and advanced control system analysis. The ultimate goal of this effort is to contribute to the reduction of the fatal accident rate due to loss-of-control. Research activities have involved accident analyses, wind tunnel testing, and piloted simulation. Results have shown that significant improvements in simulation fidelity for upset conditions, compared to current training simulations, can be achieved using state-of-the-art wind tunnel testing and aerodynamic modeling methods. This paper provides a summary of research completed to date and includes discussion on key technical results, lessons learned, and future research needs.

A viable on-chip FPGA configuration memory scrubbing approach for CBM-ToF

Energy Technology Data Exchange (ETDEWEB)

Oancea, Andrei-Dumitru; Stuellein, Christian; Manz, Sebastian; Gebelein, Jano; Kebschull, Udo [Infrastruktur und Rechnersysteme in der Informationsverarbeitung (IRI), Goethe-Universitaet, Senckenberganlage 31, 60325 Frankfurt am Main (Germany); Collaboration: CBM-Collaboration

2015-07-01

The ToF Detector of the CBM Experiment will be equipped with FPGA-based read-out boards (ROBs). These ROBs will be operated in a radiation environment, and therefore need a mitigation mechanism against soft errors in the SRAM-based configuration memories of the FPGAs. The proposed approach combines intrinsic on-chip single upset correction with extrinsic selective frame scrubbing for multiple-bit upsets. The slow control is realized using the GBT-SCA, which is capable of handling interrupts. This enables the new approach of event-driven configuration frame correction. While conventional blind scrubbing leads to a continuous load on the control path, the selective frame scrubbing reduces this load to a minimum. For verification purposes, radiation tests with a proton beam were performed at COSY, Juelich. The occurred soft errors were classified into single and multiple- bit upsets, enabling an estimation of the rate at which extrinsic intervention is necessary.

Ductile failure in upsetting of a rapid-solidification-processed aluminium alloy

NARCIS (Netherlands)

Habraken, F.A.C.M.; Dautzenberg, J.H.

1993-01-01

Cold upset-tests have been performed on a Rapid Solidification Processed (RSP) aluminium-alloy, produced by the ‘melt-spun ribbons’-process out of 70% car-scrap and 30% primary scrap. The ribbons are hot extruded, resulting in 29 mm diameter bar. Its properties regarding plastic flow and fracture

Direct observation of asperity deformation of specimens with random rough surfaces in upsetting and indentation processes

DEFF Research Database (Denmark)

Azushima, A.; Kuba, S.; Tani, S.

2006-01-01

The trapping behavior of liquid lubricant and contact behavior of asperities at the workpiece-tool interface during upsetting and indentation are observed directly using a compression subpress which consists of a transparent die made of sapphire, a microscope with a CCD camera and a video system....... The experiments are carried out without lubricant and with lubricant. Specimens used are commercially pure A1100 aluminum with a random rough surface. From these observations, the change in the fraction of real contact area is measured by an image processor. The real contact area ratios in upsetting experiments...

The single-event effect evaluation technology for nano integrated circuits

International Nuclear Information System (INIS)

Zheng Hongchao; Zhao Yuanfu; Yue Suge; Fan Long; Du Shougang; Chen Maoxin; Yu Chunqing

2015-01-01

Single-event effects of nano scale integrated circuits are investigated. Evaluation methods for single-event transients, single-event upsets, and single-event functional interrupts in nano circuits are summarized and classified in detail. The difficulties in SEE testing are discussed as well as the development direction of test technology, with emphasis placed on the experimental evaluation of a nano circuit under heavy ion, proton, and laser irradiation. The conclusions in this paper are based on many years of testing at accelerator facilities and our present understanding of the mechanisms for SEEs, which have been well verified experimentally. (paper)

Development of a new cause classification method considering plant ageing and human errors for adverse events which occurred in nuclear power plants and some results of its application

International Nuclear Information System (INIS)

Miyazaki, Takamasa

2007-01-01

The adverse events which occurred in nuclear power plants are analyzed to prevent similar events, and in the analysis of each event, the cause of the event is classified by a cause classification method. This paper shows a new cause classification method which is improved in several points as follows: (1) the whole causes are systematically classified into three major categories such as machine system, operation system and plant outside causes, (2) the causes of the operation system are classified into several management errors normally performed in a nuclear power plant, (3) the content of ageing is defined in detail for their further analysis, (4) human errors are divided and defined by the error stage, (5) human errors can be related to background factors, and so on. This new method is applied to the adverse events which occurred in domestic and overseas nuclear power plants in 2005. From these results, it is clarified that operation system errors account for about 60% of the whole causes, of which approximately 60% are maintenance errors, about 40% are worker's human errors, and that the prevention of maintenance errors, especially worker's human errors is crucial. (author)

Analysis of Task Types and Error Types of the Human Actions Involved in the Human-related Unplanned Reactor Trip Events

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun; Jung, Won Dea

2008-02-01

This report provides the task types and error types involved in the unplanned reactor trip events that have occurred during 1986 - 2006. The events that were caused by the secondary system of the nuclear power plants amount to 67 %, and the remaining 33 % was by the primary system. The contribution of the activities of the plant personnel was identified as the following order: corrective maintenance (25.7 %), planned maintenance (22.8 %), planned operation (19.8 %), periodic preventive maintenance (14.9 %), response to a transient (9.9 %), and design/manufacturing/installation (9.9%). According to the analysis of error modes, the error modes such as control failure (22.2 %), wrong object (18.5 %), omission (14.8 %), wrong action (11.1 %), and inadequate (8.3 %) take up about 75 % of all the unplanned trip events. The analysis of the cognitive functions involved showed that the planning function makes the highest contribution to the human actions leading to unplanned reactor trips, and it is followed by the observation function (23.4%), the execution function (17.8 %), and the interpretation function (10.3 %). The results of this report are to be used as important bases for development of the error reduction measures or development of the error mode prediction system for the test and maintenance tasks in nuclear power plants

Analysis of Task Types and Error Types of the Human Actions Involved in the Human-related Unplanned Reactor Trip Events

Energy Technology Data Exchange (ETDEWEB)

Kim, Jae Whan; Park, Jin Kyun; Jung, Won Dea

2008-02-15

This report provides the task types and error types involved in the unplanned reactor trip events that have occurred during 1986 - 2006. The events that were caused by the secondary system of the nuclear power plants amount to 67 %, and the remaining 33 % was by the primary system. The contribution of the activities of the plant personnel was identified as the following order: corrective maintenance (25.7 %), planned maintenance (22.8 %), planned operation (19.8 %), periodic preventive maintenance (14.9 %), response to a transient (9.9 %), and design/manufacturing/installation (9.9%). According to the analysis of error modes, the error modes such as control failure (22.2 %), wrong object (18.5 %), omission (14.8 %), wrong action (11.1 %), and inadequate (8.3 %) take up about 75 % of all the unplanned trip events. The analysis of the cognitive functions involved showed that the planning function makes the highest contribution to the human actions leading to unplanned reactor trips, and it is followed by the observation function (23.4%), the execution function (17.8 %), and the interpretation function (10.3 %). The results of this report are to be used as important bases for development of the error reduction measures or development of the error mode prediction system for the test and maintenance tasks in nuclear power plants.

Single event effects in pulse width modulation controllers

International Nuclear Information System (INIS)

Penzin, S.H.; Crain, W.R.; Crawford, K.B.; Hansel, S.J.; Kirshman, J.F.; Koga, R.

1996-01-01

SEE testing was performed on pulse width modulation (PWM) controllers which are commonly used in switching mode power supply systems. The devices are designed using both Set-Reset (SR) flip-flops and Toggle (T) flip-flops which are vulnerable to single event upset (SEU) in a radiation environment. Depending on the implementation of the different devices the effect can be significant in spaceflight hardware

High-energy heavy ion testing of VLSI devices for single event ...

Indian Academy of Sciences (India)

Unknown

per describes the high-energy heavy ion radiation testing of VLSI devices for single event upset (SEU) ... The experimental set up employed to produce low flux of heavy ions viz. silicon ... through which they pass, leaving behind a wake of elec- ... for use in Bus Management Unit (BMU) and bulk CMOS ... was scheduled.

Single event effects induced by 15.14 MeV/u 136Xe ions

International Nuclear Information System (INIS)

Hou Mingdong; Zhang Qingxiang; Liu Jie; Wang Zhiguang; Jin Yunfan; Zhu Zhiyong; Zhen Honglou; Liu Changlong; Chen Xiaoxi; Wei Xinguo; Zhang Lin; Fan Youcheng; Zhu Zhourong; Zhang Yiting

2002-01-01

Single event effects induced by 15.14 MeV/u 136 Xe ions in different batches of 32k x 8 bits static random access memory are studied. The incident angle dependences of the cross sections for single event upset and single event latch up are presented. The SEE cross sections are plotted versus energy loss instead of linear energy transfer value in sensitive region. The depth of sensitive volume and thickness of 'dead' layer above the sensitive volume are estimated

Investigation and control of factors influencing resistance upset butt welding.

OpenAIRE

Kerstens, N.F.H.

2010-01-01

The purpose of this work is to investigate the factors influencing the resistance upset butt welding process to obtain an understanding of the metal behaviour and welding process characteristics, so that new automotive steels can be welded with reduced development time and fewer failures in production. In principle the welding process is rather simple, the materials to be joined are clamped between two electrodes and pressed together. Because there is an interface present with a higher resist...

Dealing with unexpected events on the flight deck : A conceptual model of startle and surprise

NARCIS (Netherlands)

Landman, H.M.; Groen, E.L.; Paassen, M.M. van; Bronkhorst, A.W.; Mulder, M.

2017-01-01

Objective: A conceptual model is proposed in order to explain pilot performance in surprising and startling situations. Background: Today’s debate around loss of control following in-flight events and the implementation of upset prevention and recovery training has highlighted the importance of

Working group of experts on rare events in human error analysis and quantification

International Nuclear Information System (INIS)

Goodstein, L.P.

1977-01-01

In dealing with the reference problem of rare events in nuclear power plants, the group has concerned itself with the man-machine system and, in particular, with human error analysis and quantification. The Group was requested to review methods of human reliability prediction, to evaluate the extent to which such analyses can be formalized and to establish criteria to be met by task conditions and system design which would permit a systematic, formal analysis. Recommendations are given on the Fessenheim safety system

Future challenges in single event effects for advanced CMOS technologies

International Nuclear Information System (INIS)

Guo Hongxia; Wang Wei; Luo Yinhong; Zhao Wen; Guo Xiaoqiang; Zhang Keying

2010-01-01

SEE have became a substantial Achilles heel for the reliability of space-based advanced CMOS technologies with features size downscaling. Future space and defense systems require identification and understanding of single event effects to develop hardening approaches for advanced technologies, including changes in device geometry and materials affect energy deposition, charge collection,circuit upset, parametric degradation devices. Topics covered include the impact of technology scaling on radiation response, including single event transients in high speed digital circuits, evidence for single event effects caused by proton direct ionization, and the impact for SEU induced by particle energy effects and indirect ionization. The single event effects in CMOS replacement technologies are introduced briefly. (authors)

Analysis of Control Strategies for Aircraft Flight Upset Recovery

Science.gov (United States)

Crespo, Luis G.; Kenny, Sean P.; Cox, David E.; Muri, Daniel G.

2012-01-01

This paper proposes a framework for studying the ability of a control strategy, consisting of a control law and a command law, to recover an aircraft from ight conditions that may extend beyond the normal ight envelope. This study was carried out (i) by evaluating time responses of particular ight upsets, (ii) by evaluating local stability over an equilibrium manifold that included stall, and (iii) by bounding the set in the state space from where the vehicle can be safely own to wings-level ight. These states comprise what will be called the safely recoverable ight envelope (SRFE), which is a set containing the aircraft states from where a control strategy can safely stabilize the aircraft. By safe recovery it is implied that the tran- sient response stays between prescribed limits before converging to a steady horizontal ight. The calculation of the SRFE bounds yields the worst-case initial state corresponding to each control strategy. This information is used to compare alternative recovery strategies, determine their strengths and limitations, and identify the most e ective strategy. In regard to the control law, the authors developed feedback feedforward laws based on the gain scheduling of multivariable controllers. In regard to the command law, which is the mechanism governing the exogenous signals driving the feed- forward component of the controller, we developed laws with a feedback structure that combines local stability and transient response considera- tions. The upset recovery of the Generic Transport Model, a sub-scale twin-engine jet vehicle developed by NASA Langley Research Center, is used as a case study.

Cognitive moderators of children's adjustment to stressful divorce events: the role of negative cognitive errors and positive illusions.

Science.gov (United States)

Mazur, E; Wolchik, S A; Virdin, L; Sandler, I N; West, S G

1999-01-01

This study examined whether children's cognitive appraisal biases moderate the impact of stressful divorce-related events on psychological adjustment in 355 children ages 9 to 12, whose families had experienced divorce within the past 2 years. Multiple regression indicated that endorsement of negative cognitive errors for hypothetical divorce events moderates the relations between stressful divorce events and self- and maternal reports of internalizing and externalizing symptoms, but only for older children. Positive illusions buffer the effects of stressful divorce events on child-reported depression and mother-reported externalizing problems. Implications of these results for theories of stress and coping, as well as for interventions for children of divorced families, are discussed.

Prediction of particle orientation in simple upsetting process of NdFeB magnets

Energy Technology Data Exchange (ETDEWEB)

Chang, Chao-Cheng; Hsiao, Po-Jen [Department of Mold and Die Engineering, National Kaohsiung University of Applied Sciences, 415 Chien-Kung Road, Sanmin District, Kaohsiung 80778, Taiwan (China); You, Jr-Shiang; Chen, Yen-Ju; Chang, Can-Xun [Metal Forming Technology Section, Metal Processing R and D Department, Metal Industries Research and Development Centre, 1001 Kaonan Highway, Kaohsiung 81160, Taiwan (China)

2013-12-16

The magnetic properties of NdFeB magnets are strongly affected by crystallographic texture which is highly associated with particle orientation. This study proposed a method for predicting the particle orientation in the simple upsetting process of NdFeB magnets. The method is based on finite element simulation with flow net analysis. The magnets in a cylindrical form were compressed by two flat dies in a chamber filled with argon at 750°C. Three forming speeds were taken into account in order to obtain flow stress curves used in simulations. The micrographs of the cross sections of the deformed magnets show that the particle deformation significantly increases with the compression. The phenomenon was also predicted by the proposed method. Both simulated and experimental results show that the inhomogeneity of the texture of the NdFeB magnets can be increased by the simple upsetting process. The predicted particle orientations were in a good agreement with those examined in the deformed magnets. The proposed method for predicting particle orientations can also be used in other forming processes of NdFeB magnets.

Prediction of particle orientation in simple upsetting process of NdFeB magnets

International Nuclear Information System (INIS)

Chang, Chao-Cheng; Hsiao, Po-Jen; You, Jr-Shiang; Chen, Yen-Ju; Chang, Can-Xun

2013-01-01

The magnetic properties of NdFeB magnets are strongly affected by crystallographic texture which is highly associated with particle orientation. This study proposed a method for predicting the particle orientation in the simple upsetting process of NdFeB magnets. The method is based on finite element simulation with flow net analysis. The magnets in a cylindrical form were compressed by two flat dies in a chamber filled with argon at 750°C. Three forming speeds were taken into account in order to obtain flow stress curves used in simulations. The micrographs of the cross sections of the deformed magnets show that the particle deformation significantly increases with the compression. The phenomenon was also predicted by the proposed method. Both simulated and experimental results show that the inhomogeneity of the texture of the NdFeB magnets can be increased by the simple upsetting process. The predicted particle orientations were in a good agreement with those examined in the deformed magnets. The proposed method for predicting particle orientations can also be used in other forming processes of NdFeB magnets

Nurses' systems thinking competency, medical error reporting, and the occurrence of adverse events: a cross-sectional study.

Science.gov (United States)

Hwang, Jee-In; Park, Hyeoun-Ae

2017-12-01

Healthcare professionals' systems thinking is emphasized for patient safety. To report nurses' systems thinking competency, and its relationship with medical error reporting and the occurrence of adverse events. A cross-sectional survey using a previously validated Systems Thinking Scale (STS), was conducted. Nurses from two teaching hospitals were invited to participate in the survey. There were 407 (60.3%) completed surveys. The mean STS score was 54.5 (SD 7.3) out of 80. Nurses with higher STS scores were more likely to report medical errors (odds ratio (OR) = 1.05; 95% confidence interval (CI) = 1.02-1.08) and were less likely to be involved in the occurrence of adverse events (OR = 0.96; 95% CI = 0.93-0.98). Nurses showed moderate systems thinking competency. Systems thinking was a significant factor associated with patient safety. Impact Statement: The findings of this study highlight the importance of enhancing nurses' systems thinking capacity to promote patient safety.

The modulating effect of personality traits on neural error monitoring: evidence from event-related FMRI.

Science.gov (United States)

Sosic-Vasic, Zrinka; Ulrich, Martin; Ruchsow, Martin; Vasic, Nenad; Grön, Georg

2012-01-01

The present study investigated the association between traits of the Five Factor Model of Personality (Neuroticism, Extraversion, Openness for Experiences, Agreeableness, and Conscientiousness) and neural correlates of error monitoring obtained from a combined Eriksen-Flanker-Go/NoGo task during event-related functional magnetic resonance imaging in 27 healthy subjects. Individual expressions of personality traits were measured using the NEO-PI-R questionnaire. Conscientiousness correlated positively with error signaling in the left inferior frontal gyrus and adjacent anterior insula (IFG/aI). A second strong positive correlation was observed in the anterior cingulate gyrus (ACC). Neuroticism was negatively correlated with error signaling in the inferior frontal cortex possibly reflecting the negative inter-correlation between both scales observed on the behavioral level. Under present statistical thresholds no significant results were obtained for remaining scales. Aligning the personality trait of Conscientiousness with task accomplishment striving behavior the correlation in the left IFG/aI possibly reflects an inter-individually different involvement whenever task-set related memory representations are violated by the occurrence of errors. The strong correlations in the ACC may indicate that more conscientious subjects were stronger affected by these violations of a given task-set expressed by individually different, negatively valenced signals conveyed by the ACC upon occurrence of an error. Present results illustrate that for predicting individual responses to errors underlying personality traits should be taken into account and also lend external validity to the personality trait approach suggesting that personality constructs do reflect more than mere descriptive taxonomies.

The modulating effect of personality traits on neural error monitoring: evidence from event-related FMRI.

Directory of Open Access Journals (Sweden)

Zrinka Sosic-Vasic

Full Text Available The present study investigated the association between traits of the Five Factor Model of Personality (Neuroticism, Extraversion, Openness for Experiences, Agreeableness, and Conscientiousness and neural correlates of error monitoring obtained from a combined Eriksen-Flanker-Go/NoGo task during event-related functional magnetic resonance imaging in 27 healthy subjects. Individual expressions of personality traits were measured using the NEO-PI-R questionnaire. Conscientiousness correlated positively with error signaling in the left inferior frontal gyrus and adjacent anterior insula (IFG/aI. A second strong positive correlation was observed in the anterior cingulate gyrus (ACC. Neuroticism was negatively correlated with error signaling in the inferior frontal cortex possibly reflecting the negative inter-correlation between both scales observed on the behavioral level. Under present statistical thresholds no significant results were obtained for remaining scales. Aligning the personality trait of Conscientiousness with task accomplishment striving behavior the correlation in the left IFG/aI possibly reflects an inter-individually different involvement whenever task-set related memory representations are violated by the occurrence of errors. The strong correlations in the ACC may indicate that more conscientious subjects were stronger affected by these violations of a given task-set expressed by individually different, negatively valenced signals conveyed by the ACC upon occurrence of an error. Present results illustrate that for predicting individual responses to errors underlying personality traits should be taken into account and also lend external validity to the personality trait approach suggesting that personality constructs do reflect more than mere descriptive taxonomies.

Random access memory immune to single event upset using a T-resistor

Science.gov (United States)

Ochoa, Jr., Agustin

1989-01-01

In a random access memory cell, a resistance "T" decoupling network in each leg of the cell reduces random errors caused by the interaction of energetic ions with the semiconductor material forming the cell. The cell comprises two parallel legs each containing a series pair of complementary MOS transistors having a common gate connected to the node between the transistors of the opposite leg. The decoupling network in each leg is formed by a series pair of resistors between the transistors together with a third resistor interconnecting the junction between the pair of resistors and the gate of the transistor pair forming the opposite leg of the cell.

Event (error and near-miss) reporting and learning system for process improvement in radiation oncology.

Science.gov (United States)

Mutic, Sasa; Brame, R Scott; Oddiraju, Swetha; Parikh, Parag; Westfall, Melisa A; Hopkins, Merilee L; Medina, Angel D; Danieley, Jonathan C; Michalski, Jeff M; El Naqa, Issam M; Low, Daniel A; Wu, Bin

2010-09-01

The value of near-miss and error reporting processes in many industries is well appreciated and typically can be supported with data that have been collected over time. While it is generally accepted that such processes are important in the radiation therapy (RT) setting, studies analyzing the effects of organized reporting and process improvement systems on operation and patient safety in individual clinics remain scarce. The purpose of this work is to report on the design and long-term use of an electronic reporting system in a RT department and compare it to the paper-based reporting system it replaced. A specifically designed web-based system was designed for reporting of individual events in RT and clinically implemented in 2007. An event was defined as any occurrence that could have, or had, resulted in a deviation in the delivery of patient care. The aim of the system was to support process improvement in patient care and safety. The reporting tool was designed so individual events could be quickly and easily reported without disrupting clinical work. This was very important because the system use was voluntary. The spectrum of reported deviations extended from minor workflow issues (e.g., scheduling) to errors in treatment delivery. Reports were categorized based on functional area, type, and severity of an event. The events were processed and analyzed by a formal process improvement group that used the data and the statistics collected through the web-based tool for guidance in reengineering clinical processes. The reporting trends for the first 24 months with the electronic system were compared to the events that were reported in the same clinic with a paper-based system over a seven-year period. The reporting system and the process improvement structure resulted in increased event reporting, improved event communication, and improved identification of clinical areas which needed process and safety improvements. The reported data were also useful for the

Patient safety incident reports related to traditional Japanese Kampo medicines: medication errors and adverse drug events in a university hospital for a ten-year period.

Science.gov (United States)

Shimada, Yutaka; Fujimoto, Makoto; Nogami, Tatsuya; Watari, Hidetoshi; Kitahara, Hideyuki; Misawa, Hiroki; Kimbara, Yoshiyuki

2017-12-21

Kampo medicine is traditional Japanese medicine, which originated in ancient traditional Chinese medicine, but was introduced and developed uniquely in Japan. Today, Kampo medicines are integrated into the Japanese national health care system. Incident reporting systems are currently being widely used to collect information about patient safety incidents that occur in hospitals. However, no investigations have been conducted regarding patient safety incident reports related to Kampo medicines. The aim of this study was to survey and analyse incident reports related to Kampo medicines in a Japanese university hospital to improve future patient safety. We selected incident reports related to Kampo medicines filed in Toyama University Hospital from May 2007 to April 2017, and investigated them in terms of medication errors and adverse drug events. Out of 21,324 total incident reports filed in the 10-year survey period, we discovered 108 Kampo medicine-related incident reports. However, five cases were redundantly reported; thus, the number of actual incidents was 103. Of those, 99 incidents were classified as medication errors (77 administration errors, 15 dispensing errors, and 7 prescribing errors), and four were adverse drug events, namely Kampo medicine-induced interstitial pneumonia. The Kampo medicine (crude drug) that was thought to induce interstitial pneumonia in all four cases was Scutellariae Radix, which is consistent with past reports. According to the incident severity classification system recommended by the National University Hospital Council of Japan, of the 99 medication errors, 10 incidents were classified as level 0 (an error occurred, but the patient was not affected) and 89 incidents were level 1 (an error occurred that affected the patient, but did not cause harm). Of the four adverse drug events, two incidents were classified as level 2 (patient was transiently harmed, but required no treatment), and two incidents were level 3b (patient was

Statistical errors in Monte Carlo estimates of systematic errors

Energy Technology Data Exchange (ETDEWEB)

Roe, Byron P. [Department of Physics, University of Michigan, Ann Arbor, MI 48109 (United States)]. E-mail: byronroe@umich.edu

2007-01-01

For estimating the effects of a number of systematic errors on a data sample, one can generate Monte Carlo (MC) runs with systematic parameters varied and examine the change in the desired observed result. Two methods are often used. In the unisim method, the systematic parameters are varied one at a time by one standard deviation, each parameter corresponding to a MC run. In the multisim method (see ), each MC run has all of the parameters varied; the amount of variation is chosen from the expected distribution of each systematic parameter, usually assumed to be a normal distribution. The variance of the overall systematic error determination is derived for each of the two methods and comparisons are made between them. If one focuses not on the error in the prediction of an individual systematic error, but on the overall error due to all systematic errors in the error matrix element in data bin m, the number of events needed is strongly reduced because of the averaging effect over all of the errors. For simple models presented here the multisim model was far better if the statistical error in the MC samples was larger than an individual systematic error, while for the reverse case, the unisim model was better. Exact formulas and formulas for the simple toy models are presented so that realistic calculations can be made. The calculations in the present note are valid if the errors are in a linear region. If that region extends sufficiently far, one can have the unisims or multisims correspond to k standard deviations instead of one. This reduces the number of events required by a factor of k{sup 2}.

Statistical errors in Monte Carlo estimates of systematic errors

International Nuclear Information System (INIS)

Roe, Byron P.

2007-01-01

For estimating the effects of a number of systematic errors on a data sample, one can generate Monte Carlo (MC) runs with systematic parameters varied and examine the change in the desired observed result. Two methods are often used. In the unisim method, the systematic parameters are varied one at a time by one standard deviation, each parameter corresponding to a MC run. In the multisim method (see ), each MC run has all of the parameters varied; the amount of variation is chosen from the expected distribution of each systematic parameter, usually assumed to be a normal distribution. The variance of the overall systematic error determination is derived for each of the two methods and comparisons are made between them. If one focuses not on the error in the prediction of an individual systematic error, but on the overall error due to all systematic errors in the error matrix element in data bin m, the number of events needed is strongly reduced because of the averaging effect over all of the errors. For simple models presented here the multisim model was far better if the statistical error in the MC samples was larger than an individual systematic error, while for the reverse case, the unisim model was better. Exact formulas and formulas for the simple toy models are presented so that realistic calculations can be made. The calculations in the present note are valid if the errors are in a linear region. If that region extends sufficiently far, one can have the unisims or multisims correspond to k standard deviations instead of one. This reduces the number of events required by a factor of k 2

Operator errors

International Nuclear Information System (INIS)

Knuefer; Lindauer

1980-01-01

Besides that at spectacular events a combination of component failure and human error is often found. Especially the Rasmussen-Report and the German Risk Assessment Study show for pressurised water reactors that human error must not be underestimated. Although operator errors as a form of human error can never be eliminated entirely, they can be minimized and their effects kept within acceptable limits if a thorough training of personnel is combined with an adequate design of the plant against accidents. Contrary to the investigation of engineering errors, the investigation of human errors has so far been carried out with relatively small budgets. Intensified investigations in this field appear to be a worthwhile effort. (orig.)

Development of Single-Event Upset hardened programmable logic devices in deep submicron CMOS; Developpement de circuits logiques programmables resistants aux aleas logiques en technologie CMOS submicrometrique

Energy Technology Data Exchange (ETDEWEB)

Bonacini, S

2007-11-15

The electronics associated to the particle detectors of the Large Hadron Collider (LHC), under construction at CERN, will operate in a very harsh radiation environment. Commercial Off-The-Shelf (COTS) components cannot be used in the vicinity of particle collision due to their poor radiation tolerance. This thesis is a contribution to the effort to cover the need for radiation-tolerant SEU-robust (Single Event Upset) programmable components for application in high energy physics experiments. Two components are under development: a Programmable Logic Device (PLD) and a Field-Programmable Gate Array (FPGA). The PLD is a fuse-based, 10-input, 8-I/O general architecture device in 0.25 {mu}m CMOS technology. The FPGA under development is a 32*32 logic block array, equivalent to {approx} 25 k gates, in 0.13 {mu}m CMOS. The irradiation test results obtained in the CMOS 0.25 {mu}m technology demonstrate good robustness of the circuit up to an LET (Linear Energy Transfer) of 79.6 cm{sup 2}*MeV/mg, which make it suitable for the target environment. The CMOS 0.13 {mu}m circuit has showed robustness to an LET of 37.4 cm{sup 2}*MeV/mg in the static test mode and has increased sensitivity in the dynamic test mode. This work focused also on the research for an SEU-robust register in both the mentioned technologies. The SEU-robust register is employed as a user data flip-flop in the FPGA and PLD designs and as a configuration cell as well in the FPGA design.

Errors in causal inference: an organizational schema for systematic error and random error.

Science.gov (United States)

Suzuki, Etsuji; Tsuda, Toshihide; Mitsuhashi, Toshiharu; Mansournia, Mohammad Ali; Yamamoto, Eiji

2016-11-01

To provide an organizational schema for systematic error and random error in estimating causal measures, aimed at clarifying the concept of errors from the perspective of causal inference. We propose to divide systematic error into structural error and analytic error. With regard to random error, our schema shows its four major sources: nondeterministic counterfactuals, sampling variability, a mechanism that generates exposure events and measurement variability. Structural error is defined from the perspective of counterfactual reasoning and divided into nonexchangeability bias (which comprises confounding bias and selection bias) and measurement bias. Directed acyclic graphs are useful to illustrate this kind of error. Nonexchangeability bias implies a lack of "exchangeability" between the selected exposed and unexposed groups. A lack of exchangeability is not a primary concern of measurement bias, justifying its separation from confounding bias and selection bias. Many forms of analytic errors result from the small-sample properties of the estimator used and vanish asymptotically. Analytic error also results from wrong (misspecified) statistical models and inappropriate statistical methods. Our organizational schema is helpful for understanding the relationship between systematic error and random error from a previously less investigated aspect, enabling us to better understand the relationship between accuracy, validity, and precision. Copyright © 2016 Elsevier Inc. All rights reserved.

Research on generation mechanism of single event transient current generated in the semiconductor using ion accelerator

International Nuclear Information System (INIS)

Hirao, Toshio

2007-01-01

Single-event upset (SEU) is triggered when an amount of electric charges induced by energetic ion incidence exceeds a value known as a critical charge in a very short time period. Therefore, accurate evaluation of electric charge and understanding of basic mechanism of SEU are necessary for the improvement of SEU torrance of electronic devices. In this paper, the collected charges for the single event transient current induced on semiconductor by heavy ion microbeams, and application to use microbeam for single event studies are presented. (author)

High energy hadron-induced errors in memory chips

Energy Technology Data Exchange (ETDEWEB)

Peterson, R.J. [University of Colorado, Boulder, CO (United States)

2001-09-01

We have measured probabilities for proton, neutron and pion beams from accelerators to induce temporary or soft errors in a wide range of modern 16 Mb and 64 Mb dRAM memory chips, typical of those used in aircraft electronics. Relations among the cross sections for these particles are deduced, and failure rates for aircraft avionics due to cosmic rays are evaluated. Measurement of alpha pha particle yields from pions on aluminum, as a surrogate for silicon, indicate that these reaction products are the proximate cause of the charge deposition resulting in errors. Heavy ions can cause damage to solar panels and other components in satellites above the atmosphere, by the heavy ionization trails they leave. However, at the earth's surface or at aircraft altitude it is known that cosmic rays, other than heavy ions, can cause soft errors in memory circuit components. Soft errors are those confusions between ones and zeroes that cause wrong contents to be stored in the memory, but without causing permanent damage to the circuit. As modern aircraft rely increasingly upon computerized and automated systems, these soft errors are important threats to safety. Protons, neutrons and pions resulting from high energy cosmic ray bombardment of the atmosphere pervade our environment. These particles do not induce damage directly by their ionization loss, but rather by reactions in the materials of the microcircuits. We have measured many cross sections for soft error upsets (SEU) in a broad range of commercial 16 Mb and 64 Mb dRAMs with accelerator beams. Here we define {sigma} SEU = induced errors/number of sample bits x particles/cm{sup 2}. We compare {sigma} SEU to find relations among results for these beams, and relations to reaction cross sections in order to systematize effects. We have modelled cosmic ray effects upon the components we have studied. (Author)

High energy hadron-induced errors in memory chips

International Nuclear Information System (INIS)

Peterson, R.J.

2001-01-01

We have measured probabilities for proton, neutron and pion beams from accelerators to induce temporary or soft errors in a wide range of modern 16 Mb and 64 Mb dRAM memory chips, typical of those used in aircraft electronics. Relations among the cross sections for these particles are deduced, and failure rates for aircraft avionics due to cosmic rays are evaluated. Measurement of alpha pha particle yields from pions on aluminum, as a surrogate for silicon, indicate that these reaction products are the proximate cause of the charge deposition resulting in errors. Heavy ions can cause damage to solar panels and other components in satellites above the atmosphere, by the heavy ionization trails they leave. However, at the earth's surface or at aircraft altitude it is known that cosmic rays, other than heavy ions, can cause soft errors in memory circuit components. Soft errors are those confusions between ones and zeroes that cause wrong contents to be stored in the memory, but without causing permanent damage to the circuit. As modern aircraft rely increasingly upon computerized and automated systems, these soft errors are important threats to safety. Protons, neutrons and pions resulting from high energy cosmic ray bombardment of the atmosphere pervade our environment. These particles do not induce damage directly by their ionization loss, but rather by reactions in the materials of the microcircuits. We have measured many cross sections for soft error upsets (SEU) in a broad range of commercial 16 Mb and 64 Mb dRAMs with accelerator beams. Here we define σ SEU = induced errors/number of sample bits x particles/cm 2 . We compare σ SEU to find relations among results for these beams, and relations to reaction cross sections in order to systematize effects. We have modelled cosmic ray effects upon the components we have studied. (Author)

Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.

Science.gov (United States)

Starmer, Amy J; Sectish, Theodore C; Simon, Dennis W; Keohane, Carol; McSweeney, Maireade E; Chung, Erica Y; Yoon, Catherine S; Lipsitz, Stuart R; Wassner, Ari J; Harper, Marvin B; Landrigan, Christopher P

2013-12-04

Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children's Hospital. Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal

Simulation Study of Flap Effects on a Commercial Transport Airplane in Upset Conditions

Science.gov (United States)

Cunningham, Kevin; Foster, John V.; Shah, Gautam H.; Stewart, Eric C.; Ventura, Robin N.; Rivers, Robert A.; Wilborn, James E.; Gato, William

2005-01-01

As part of NASA's Aviation Safety and Security Program, a simulation study of a twinjet transport airplane crew training simulation was conducted to address fidelity for upset or loss of control conditions and to study the effect of flap configuration in those regimes. Piloted and desktop simulations were used to compare the baseline crew training simulation model with an enhanced aerodynamic model that was developed for high-angle-of-attack conditions. These studies were conducted with various flap configurations and addressed the approach-to-stall, stall, and post-stall flight regimes. The enhanced simulation model showed that flap configuration had a significant effect on the character of departures that occurred during post-stall flight. Preliminary comparisons with flight test data indicate that the enhanced model is a significant improvement over the baseline. Some of the unrepresentative characteristics that are predicted by the baseline crew training simulation for flight in the post-stall regime have been identified. This paper presents preliminary results of this simulation study and discusses key issues regarding predicted flight dynamics characteristics during extreme upset and loss-of-control flight conditions with different flap configurations.

Some aspects of barreling in sintered plain carbon steel powder metallurgy preforms during cold upsetting

Directory of Open Access Journals (Sweden)

Sumesh Narayan

2012-04-01

Full Text Available The present research establishes a relationship of bulged diameter with densification and hydrostatic stress in forming of sintered iron (Fe powder metallurgy preforms cold upset under two different frictional conditions, namely, nil/no and graphite lubricant condition. Sintered plain carbon steel cylindrical preforms with carbon (C contents of 0, 0.35, 0.75 and 1.1% with constant initial theoretical density of 84% and aspect ratio of 0.4 and 0.6 were prepared using a suitable die-set assembly on a 1 MN capacity hydraulic press and sintered for 90 minutes at 1200 °C. Each sintered preform was cold upset under two different frictional constraints. It is seen that the degree of bulging reduces with reducing frictional constraints at the die contact surface. Further, it is found that the bulging ratio changed as a function of relative density and hydrostatic stress, respectively, according to the power law equations.

Effect of Friction on Barreling during cold Upset Forging of Aluminium 6082 Alloy Solid cylinders

Science.gov (United States)

Priyadarshini, Amrita; Kiran, C. P.; Suresh, K.

2018-03-01

Friction is one of the significant factors in forging operations since it affects metal flow in the die, forming load, strain distribution, tool and die life, surface quality of the product etc. In upset forging, the frictional forces at the die-workpiece interface oppose the outward flow of the material due to which the specimen develops a barrel shape. As a result, the deformation becomes non-uniform or inhomogeneous which is undesirable. Barreling can be reduced by applying effective lubricant on the surface of the platens. The objective of the present work is to study experimentally the effect of various frictional conditions (dry, grease, mineral oil) on barreling during upset forging of aluminum 6082 solid cylinders of different aspect ratio (length/diameter: 0.5, 0.75, 1). The friction coefficients are determined using the ring compression test. Curvature of barrel is determined based on the assumption that the curvature of the barrel follows the geometry of circular arc.

An audit strategy for time-to-event outcomes measured with error: application to five randomized controlled trials in oncology.

Science.gov (United States)

Dodd, Lori E; Korn, Edward L; Freidlin, Boris; Gu, Wenjuan; Abrams, Jeffrey S; Bushnell, William D; Canetta, Renzo; Doroshow, James H; Gray, Robert J; Sridhara, Rajeshwari

2013-10-01

Measurement error in time-to-event end points complicates interpretation of treatment effects in clinical trials. Non-differential measurement error is unlikely to produce large bias [1]. When error depends on treatment arm, bias is of greater concern. Blinded-independent central review (BICR) of all images from a trial is commonly undertaken to mitigate differential measurement-error bias that may be present in hazard ratios (HRs) based on local evaluations. Similar BICR and local evaluation HRs may provide reassurance about the treatment effect, but BICR adds considerable time and expense to trials. We describe a BICR audit strategy [2] and apply it to five randomized controlled trials to evaluate its use and to provide practical guidelines. The strategy requires BICR on a subset of study subjects, rather than a complete-case BICR, and makes use of an auxiliary-variable estimator. When the effect size is relatively large, the method provides a substantial reduction in the size of the BICRs. In a trial with 722 participants and a HR of 0.48, an average audit of 28% of the data was needed and always confirmed the treatment effect as assessed by local evaluations. More moderate effect sizes and/or smaller trial sizes required larger proportions of audited images, ranging from 57% to 100% for HRs ranging from 0.55 to 0.77 and sample sizes between 209 and 737. The method is developed for a simple random sample of study subjects. In studies with low event rates, more efficient estimation may result from sampling individuals with events at a higher rate. The proposed strategy can greatly decrease the costs and time associated with BICR, by reducing the number of images undergoing review. The savings will depend on the underlying treatment effect and trial size, with larger treatment effects and larger trials requiring smaller proportions of audited data.

Trend analysis and comparison of operators' human error events occurred at overseas and domestic nuclear power plants

International Nuclear Information System (INIS)

Takagawa, Kenichi

2006-01-01

Human errors by operators at overseas and domestic nuclear power plants during the period from 2002 to 2005 were compared and their trends analyzed. The most frequently cited cause of such errors was 'insufficient team monitoring' (inadequate superiors' and other crews' instructions and supervision) both at overseas and domestic plants, followed by 'insufficient self-checking' (lack of cautions by the operator himself). A comparison of the effects of the errors on the operations of plants in Japan and the United Sates showed that the drop in plant output and plant shutdowns at plants in Japan were approximately one-tenth of those in the United States. The ratio of automatic reactor trips to the total number of human errors reported is about 6% for both Japanese and American plants. Looking at changes in the incidence of human errors by years of occurrence, although a distinctive trend cannot be identified for domestic nuclear power plants due to insufficient reported cases, 'inadequate self-checking' as a factor contributing to human errors at overseas nuclear power plants has decreased significantly over the past four years. Regarding changes in the effects of human errors on the operations of plants during the four-year period, events leading to an automatic reactor trip have tended to increase at American plants. Conceivable factors behind this increasing tendency included lack of operating experience by a team (e.g., plant transients and reactor shutdowns and startups) and excessive dependence on training simulators. (author)

Error-related brain activity and error awareness in an error classification paradigm.

Science.gov (United States)

Di Gregorio, Francesco; Steinhauser, Marco; Maier, Martin E

2016-10-01

Error-related brain activity has been linked to error detection enabling adaptive behavioral adjustments. However, it is still unclear which role error awareness plays in this process. Here, we show that the error-related negativity (Ne/ERN), an event-related potential reflecting early error monitoring, is dissociable from the degree of error awareness. Participants responded to a target while ignoring two different incongruent distractors. After responding, they indicated whether they had committed an error, and if so, whether they had responded to one or to the other distractor. This error classification paradigm allowed distinguishing partially aware errors, (i.e., errors that were noticed but misclassified) and fully aware errors (i.e., errors that were correctly classified). The Ne/ERN was larger for partially aware errors than for fully aware errors. Whereas this speaks against the idea that the Ne/ERN foreshadows the degree of error awareness, it confirms the prediction of a computational model, which relates the Ne/ERN to post-response conflict. This model predicts that stronger distractor processing - a prerequisite of error classification in our paradigm - leads to lower post-response conflict and thus a smaller Ne/ERN. This implies that the relationship between Ne/ERN and error awareness depends on how error awareness is related to response conflict in a specific task. Our results further indicate that the Ne/ERN but not the degree of error awareness determines adaptive performance adjustments. Taken together, we conclude that the Ne/ERN is dissociable from error awareness and foreshadows adaptive performance adjustments. Our results suggest that the relationship between the Ne/ERN and error awareness is correlative and mediated by response conflict. Copyright © 2016 Elsevier Inc. All rights reserved.

Visual correlation analytics of event-based error reports for advanced manufacturing

OpenAIRE

Nazir, Iqbal

2017-01-01

With the growing digitalization and automation in the manufacturing domain, an increasing amount of process data and error reports become available. To minimize the number of errors and maximize the efficiency of the production line, it is important to analyze the generated error reports and find solutions that can reduce future errors. However, not all errors have the equal importance, as some errors may be the result of previously occurred errors. Therefore, it is important for domain exper...

Soft error rate estimations of the Kintex-7 FPGA within the ATLAS Liquid Argon (LAr) Calorimeter

International Nuclear Information System (INIS)

Wirthlin, M J; Harding, A; Takai, H

2014-01-01

This paper summarizes the radiation testing performed on the Xilinx Kintex-7 FPGA in an effort to determine if the Kintex-7 can be used within the ATLAS Liquid Argon (LAr) Calorimeter. The Kintex-7 device was tested with wide-spectrum neutrons, protons, heavy-ions, and mixed high-energy hadron environments. The results of these tests were used to estimate the configuration ram and block ram upset rate within the ATLAS LAr. These estimations suggest that the configuration memory will upset at a rate of 1.1 × 10 −10 upsets/bit/s and the bram memory will upset at a rate of 9.06 × 10 −11 upsets/bit/s. For the Kintex 7K325 device, this translates to 6.85 × 10 −3 upsets/device/s for configuration memory and 1.49 × 10 −3 for block memory

Post-event human decision errors: operator action tree/time reliability correlation

International Nuclear Information System (INIS)

Hall, R.E.; Fragola, J.; Wreathall, J.

1982-11-01

This report documents an interim framework for the quantification of the probability of errors of decision on the part of nuclear power plant operators after the initiation of an accident. The framework can easily be incorporated into an event tree/fault tree analysis. The method presented consists of a structure called the operator action tree and a time reliability correlation which assumes the time available for making a decision to be the dominating factor in situations requiring cognitive human response. This limited approach decreases the magnitude and complexity of the decision modeling task. Specifically, in the past, some human performance models have attempted prediction by trying to emulate sequences of human actions, or by identifying and modeling the information processing approach applicable to the task. The model developed here is directed at describing the statistical performance of a representative group of hypothetical individuals responding to generalized situations

Post-event human decision errors: operator action tree/time reliability correlation

Energy Technology Data Exchange (ETDEWEB)

Hall, R E; Fragola, J; Wreathall, J

1982-11-01

This report documents an interim framework for the quantification of the probability of errors of decision on the part of nuclear power plant operators after the initiation of an accident. The framework can easily be incorporated into an event tree/fault tree analysis. The method presented consists of a structure called the operator action tree and a time reliability correlation which assumes the time available for making a decision to be the dominating factor in situations requiring cognitive human response. This limited approach decreases the magnitude and complexity of the decision modeling task. Specifically, in the past, some human performance models have attempted prediction by trying to emulate sequences of human actions, or by identifying and modeling the information processing approach applicable to the task. The model developed here is directed at describing the statistical performance of a representative group of hypothetical individuals responding to generalized situations.

Statistical errors in Monte Carlo estimates of systematic errors

Science.gov (United States)

Roe, Byron P.

2007-01-01

For estimating the effects of a number of systematic errors on a data sample, one can generate Monte Carlo (MC) runs with systematic parameters varied and examine the change in the desired observed result. Two methods are often used. In the unisim method, the systematic parameters are varied one at a time by one standard deviation, each parameter corresponding to a MC run. In the multisim method (see ), each MC run has all of the parameters varied; the amount of variation is chosen from the expected distribution of each systematic parameter, usually assumed to be a normal distribution. The variance of the overall systematic error determination is derived for each of the two methods and comparisons are made between them. If one focuses not on the error in the prediction of an individual systematic error, but on the overall error due to all systematic errors in the error matrix element in data bin m, the number of events needed is strongly reduced because of the averaging effect over all of the errors. For simple models presented here the multisim model was far better if the statistical error in the MC samples was larger than an individual systematic error, while for the reverse case, the unisim model was better. Exact formulas and formulas for the simple toy models are presented so that realistic calculations can be made. The calculations in the present note are valid if the errors are in a linear region. If that region extends sufficiently far, one can have the unisims or multisims correspond to k standard deviations instead of one. This reduces the number of events required by a factor of k2. The specific terms unisim and multisim were coined by Peter Meyers and Steve Brice, respectively, for the MiniBooNE experiment. However, the concepts have been developed over time and have been in general use for some time.

Triple modular redundancy (TMR) in a configurable fault-tolerant processor (CFTP) for space applications

OpenAIRE

Yuan, Rong

2003-01-01

Approved for public release, distribution is unlimited Without the protection of atmosphere, space systems have to mitigate radiation effects. Several different technologies are used to deal with different radiation effects in order to keep the space device work properly. One of the radiation effects called Single Event Upset (SEU) can change the state of a component or data on the bus. A single error is possible to cause a system failure if it is not corrected. Besides error correction, a...

NI Based System for Seu Testing of Memory Chips for Avionics

Directory of Open Access Journals (Sweden)

Boruzdina Anna

2016-01-01

Full Text Available This paper presents the results of implementation of National Instrument based system for Single Event Upset testing of memory chips into neutron generator experimental facility, which used for SEU tests for avionics purposes. Basic SEU testing algorithm with error correction and constant errors detection is presented. The issues of radiation shielding of NI based system are discussed and solved. The examples of experimental results show the applicability of the presented system for SEU memory testing under neutrons influence.

Single event effects induced by 15.14 MeV/u sup 1 sup 3 sup 6 Xe ions

CERN Document Server

Hou Ming Dong; LiuJie; Wang Zhi Guang; Jin Yun Fan; Zhu Zhi Yong; Zhen Hong Lou; Liu Chang Long; Chen Xiao Xi; Wei Xin Guo; Zhang Li; Fan You Cheng; Zhu Zhou Rong; Zhang Yiting

2002-01-01

Single event effects induced by 15.14 MeV/u sup 1 sup 3 sup 6 Xe ions in different batches of 32k x 8 bits static random access memory are studied. The incident angle dependences of the cross sections for single event upset and single event latch up are presented. The SEE cross sections are plotted versus energy loss instead of linear energy transfer value in sensitive region. The depth of sensitive volume and thickness of 'dead' layer above the sensitive volume are estimated

Accelerated testing for cosmic soft-error rate

International Nuclear Information System (INIS)

Ziegler, J.F.; Muhlfeld, H.P.; Montrose, C.J.; Curtis, H.W.; O'Gorman, T.J.; Ross, J.M.

1996-01-01

This paper describes the experimental techniques which have been developed at IBM to determine the sensitivity of electronic circuits to cosmic rays at sea level. It relates IBM circuit design and modeling, chip manufacture with process variations, and chip testing for SER sensitivity. This vertical integration from design to final test and with feedback to design allows a complete picture of LSI sensitivity to cosmic rays. Since advanced computers are designed with LSI chips long before the chips have been fabricated, and the system architecture is fully formed before the first chips are functional, it is essential to establish the chip reliability as early as possible. This paper establishes techniques to test chips that are only partly functional (e.g., only 1Mb of a 16Mb memory may be working) and can establish chip soft-error upset rates before final chip manufacturing begins. Simple relationships derived from measurement of more than 80 different chips manufactured over 20 years allow total cosmic soft-error rate (SER) to be estimated after only limited testing. Comparisons between these accelerated test results and similar tests determined by ''field testing'' (which may require a year or more of testing after manufacturing begins) show that the experimental techniques are accurate to a factor of 2

A random access memory immune to single event upset using a T-Resistor

Science.gov (United States)

Ochoa, A. Jr.

1987-10-28

In a random access memory cell, a resistance ''T'' decoupling network in each leg of the cell reduces random errors caused by the interaction of energetic ions with the semiconductor material forming the cell. The cell comprises two parallel legs each containing a series pair of complementary MOS transistors having a common gate connected to the node between the transistors of the opposite leg. The decoupling network in each leg is formed by a series pair of resistors between the transistors together with a third resistor interconnecting the junction between the pair of resistors and the gate of the transistor pair forming the opposite leg of the cell. 4 figs.

Human Error Assessmentin Minefield Cleaning Operation Using Human Event Analysis

Directory of Open Access Journals (Sweden)

Mohammad Hajiakbari

2015-12-01

Full Text Available Background & objective: Human error is one of the main causes of accidents. Due to the unreliability of the human element and the high-risk nature of demining operations, this study aimed to assess and manage human errors likely to occur in such operations. Methods: This study was performed at a demining site in war zones located in the West of Iran. After acquiring an initial familiarity with the operations, methods, and tools of clearing minefields, job task related to clearing landmines were specified. Next, these tasks were studied using HTA and related possible errors were assessed using ATHEANA. Results: de-mining task was composed of four main operations, including primary detection, technical identification, investigation, and neutralization. There were found four main reasons for accidents occurring in such operations; walking on the mines, leaving mines with no action, error in neutralizing operation and environmental explosion. The possibility of human error in mine clearance operations was calculated as 0.010. Conclusion: The main causes of human error in de-mining operations can be attributed to various factors such as poor weather and operating conditions like outdoor work, inappropriate personal protective equipment, personality characteristics, insufficient accuracy in the work, and insufficient time available. To reduce the probability of human error in de-mining operations, the aforementioned factors should be managed properly.

Errors in Neonatology

OpenAIRE

Antonio Boldrini; Rosa T. Scaramuzzo; Armando Cuttano

2013-01-01

Introduction: Danger and errors are inherent in human activities. In medical practice errors can lean to adverse events for patients. Mass media echo the whole scenario. Methods: We reviewed recent published papers in PubMed database to focus on the evidence and management of errors in medical practice in general and in Neonatology in particular. We compared the results of the literature with our specific experience in Nina Simulation Centre (Pisa, Italy). Results: In Neonatology the main err...

Specimen Identification Errors in Breast Biopsies: Age Matters. Report of Two Near-Miss Events and Review of the Literature.

Science.gov (United States)

Tozbikian, Gary; Gemignani, Mary L; Brogi, Edi

2017-09-01

The consequences of patient identification errors due to specimen mislabeling can be deleterious. We describe two near-miss events involving mislabeled breast specimens from two patients who sought treatment at our institution. In both cases, microscopic review of the slides identified inconsistencies between the histologic findings and patient age, unveiling specimen identification errors. By correlating the clinical information with the microscopic findings, we identified mistakes that had occurred at the time of specimen accessioning at the original laboratories. In both cases, thanks to a timely reassignment of the specimens, the patients suffered no harm. These cases highlight the importance of routine clinical and pathologic correlation as a critical component of quality assurance and patient safety. A review of possible specimen identification errors in the anatomic pathology setting is presented. © 2017 Wiley Periodicals, Inc.

Single Event Effects Test Facility Options at the Oak Ridge National Laboratory

Energy Technology Data Exchange (ETDEWEB)

Riemer, Bernie [ORNL; Gallmeier, Franz X [ORNL; Dominik, Laura J [ORNL

2015-01-01

Increasing use of microelectronics of ever diminishing feature size in avionics systems has led to a growing Single Event Effects (SEE) susceptibility arising from the highly ionizing interactions of cosmic rays and solar particles. Single event effects caused by atmospheric radiation have been recognized in recent years as a design issue for avionics equipment and systems. To ensure a system meets all its safety and reliability requirements, SEE induced upsets and potential system failures need to be considered, including testing of the components and systems in a neutron beam. Testing of integrated circuits (ICs) and systems for use in radiation environments requires the utilization of highly advanced laboratory facilities that can run evaluations on microcircuits for the effects of radiation. This paper provides a background of the atmospheric radiation phenomenon and the resulting single event effects, including single event upset (SEU) and latch up conditions. A study investigating requirements for future single event effect irradiation test facilities and developing options at the Spallation Neutron Source (SNS) is summarized. The relatively new SNS with its 1.0 GeV proton beam, typical operation of 5000 h per year, expertise in spallation neutron sources, user program infrastructure, and decades of useful life ahead is well suited for hosting a world-class SEE test facility in North America. Emphasis was put on testing of large avionics systems while still providing tunable high flux irradiation conditions for component tests. Makers of ground-based systems would also be served well by these facilities. Three options are described; the most capable, flexible, and highest-test-capacity option is a new stand-alone target station using about one kW of proton beam power on a gas-cooled tungsten target, with dual test enclosures. Less expensive options are also described.

Three-dimensional simulation of charge collection and multiple-bit upset in Si devices

International Nuclear Information System (INIS)

Dodd, P.E.; Sexton, F.W.; Winokur, P.S.

1994-01-01

In this paper, three-dimensional numerical simulation is used to explore the basic charge-collection mechanisms in silicon n + /p diodes. For diodes on lightly-doped substrates ( 15 cm -3 ) struck by a 100-MeV Fe ion, the funneling effect is very strong and essentially all collection is by funnel-assisted drift. This drift collection may occur as late as several nanoseconds after the strike, later than is usually associated with drift collection. For moderately-doped substrates (∼1 x 10 16 cm -3 ) and epitaxial structures grown on heavily-doped substrates, the funnel effect is weaker and drift and diffusion are of more equal importance. For 5-MeV He (α-particle) strikes with low-density charge tracks, the charge-collection transient exhibits both drift and diffusion regimes regardless of the substrate doping. Simulations of diodes with passive external loads indicate that while the current response is altered considerably by the load, total collected charge is not greatly affected for the simple resistive loads studied. Three-dimensional mixed-mode simulation is performed to investigate charge-collection behavior and upset mechanisms in complete CMOS SRAM cells. Simulations of double SRAM cell structures indicate that only collection by diffusion from ''between-node'' strikes is capable of producing multiple-bit upsets in the simulated technology. Limitations of the simulations, specifically carrier-carrier scattering models and large concentration gradients, are also discussed

Analyzing temozolomide medication errors: potentially fatal.

Science.gov (United States)

Letarte, Nathalie; Gabay, Michael P; Bressler, Linda R; Long, Katie E; Stachnik, Joan M; Villano, J Lee

2014-10-01

The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.

Experimental Research and Method for Calculation of 'Upsetting-with-Buckling' Load at the Impression-Free (Dieless Preforming of Workpiece

Directory of Open Access Journals (Sweden)

Kukhar Volodymir

2018-01-01

Full Text Available This paper presents the results of experimental studies of load characteristic changes during the upsetting of high billets with the upsetting ratio (height to diameter ratio from 3.0 to 6.0, which is followed by buckling. Such pass is an effective way of preforming the workpiece for production of forgings with a bended axis or dual forming, and belongs to impression-free (dieless operation of bulk forming. Based on the experimental data analysis, an engineering method for calculation of workpiece pre-forming load as a maximum buckling force has been developed. The analysis of the obtained data confirmed the possibility of performing of this pre-forming operation on the main forging equipment, since the load of shaping by buckling does not exceed the load of the dieforging.

Experimental Research and Method for Calculation of 'Upsetting-with-Buckling' Load at the Impression-Free (Dieless) Preforming of Workpiece

Science.gov (United States)

Kukhar, Volodymir; Artiukh, Victor; Prysiazhnyi, Andrii; Pustovgar, Andrey

2018-03-01

This paper presents the results of experimental studies of load characteristic changes during the upsetting of high billets with the upsetting ratio (height to diameter ratio) from 3.0 to 6.0, which is followed by buckling. Such pass is an effective way of preforming the workpiece for production of forgings with a bended axis or dual forming, and belongs to impression-free (dieless) operation of bulk forming. Based on the experimental data analysis, an engineering method for calculation of workpiece pre-forming load as a maximum buckling force has been developed. The analysis of the obtained data confirmed the possibility of performing of this pre-forming operation on the main forging equipment, since the load of shaping by buckling does not exceed the load of the dieforging.

Impact of Measurement Error on Synchrophasor Applications

Energy Technology Data Exchange (ETDEWEB)

Liu, Yilu [Univ. of Tennessee, Knoxville, TN (United States); Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Gracia, Jose R. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Ewing, Paul D. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Zhao, Jiecheng [Univ. of Tennessee, Knoxville, TN (United States); Tan, Jin [Univ. of Tennessee, Knoxville, TN (United States); Wu, Ling [Univ. of Tennessee, Knoxville, TN (United States); Zhan, Lingwei [Univ. of Tennessee, Knoxville, TN (United States)

2015-07-01

Phasor measurement units (PMUs), a type of synchrophasor, are powerful diagnostic tools that can help avert catastrophic failures in the power grid. Because of this, PMU measurement errors are particularly worrisome. This report examines the internal and external factors contributing to PMU phase angle and frequency measurement errors and gives a reasonable explanation for them. It also analyzes the impact of those measurement errors on several synchrophasor applications: event location detection, oscillation detection, islanding detection, and dynamic line rating. The primary finding is that dynamic line rating is more likely to be influenced by measurement error. Other findings include the possibility of reporting nonoscillatory activity as an oscillation as the result of error, failing to detect oscillations submerged by error, and the unlikely impact of error on event location and islanding detection.

Upsetting the apple cart: a community anticoagulation clinic survey of life event factors that undermine safe therapy.

Science.gov (United States)

Edmundson, Sarah; Stuenkel, Diane L; Connolly, Phyllis M

2005-09-01

Anticoagulation therapy is a life-enhancing therapy for patients who are at risk for embolic events secondary to atrial fibrillation, valve replacement, and other comorbidities. Clinicians are motivated to decrease the amount of time that patients are either under- or over-anticoagulated, common conditions that decrease patient safety at either extreme. The primary purpose of this descriptive study was to examine the relationship between personal life event factors as measured by Norbeck's Life Events Questionnaire, core demographics such as age and income, and anticoagulation regulation. Although many factors affect anticoagulation therapy, the precise impact of life events, positive or negative, is unknown. The salient findings of this study (n = 202) showed a small, though statistically significant, inverse relationship (r = -0.184, P < .01) between negative life events and decreased time within therapeutic international normalized ratio. Total Life Event scores showed a statistically significant inverse relationship (r = -0.159, P < .05) to international normalized ratio time within therapeutic level. Lower income was inversely associated with higher negative Life Event scores (r = -0.192, P < .01). The findings demonstrate the need for strategies that address the potential impact of life events in conjunction with coexisting screening measures used in anticoagulation clinics. Implications for this study are limited by lack of methodology documenting concurrent social support factors and limitations of the research tool to reflect life event issues specific to outpatient seniors.

Insight and Lessons Learned on Organizational Factors and Safety Culture from the Review of Human Error-related Events of NPPs in Korea

International Nuclear Information System (INIS)

Kim, Ji Tae; Lee, Dhong Hoon; Choi, Young Sung

2014-01-01

Event investigation is one of the key means of enhancing nuclear safety deriving effective measures and preventing recurrences. However, it is difficult to analyze organizational factors and safety culture. This paper tries to review human error-related events from perspectives of organizational factors and safety culture, and to derive insights and lessons learned in developing the regulatory infrastructure of plant oversight on safety culture

Insight and Lessons Learned on Organizational Factors and Safety Culture from the Review of Human Error-related Events of NPPs in Korea

Energy Technology Data Exchange (ETDEWEB)

Kim, Ji Tae; Lee, Dhong Hoon; Choi, Young Sung [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2014-08-15

Event investigation is one of the key means of enhancing nuclear safety deriving effective measures and preventing recurrences. However, it is difficult to analyze organizational factors and safety culture. This paper tries to review human error-related events from perspectives of organizational factors and safety culture, and to derive insights and lessons learned in developing the regulatory infrastructure of plant oversight on safety culture.

Epidemiology of Adverse Events and Medical Errors in the Care of Cardiology Patients.

Science.gov (United States)

Ohta, Yoshinori; Miki, Izumi; Kimura, Takeshi; Abe, Mitsuru; Sakuma, Mio; Koike, Kaoru; Morimoto, Takeshi

2016-11-02

There have been epidemiological studies of adverse events (AEs) among general patients but those of patients cared by cardiologist are not well scrutinized. We investigated the occurrence of AEs and medical errors (MEs) among adult patients with cardiology in Japan. We conducted a cross-sectional study of adult outpatients at a Japanese teaching hospital from February through November 2006. We measured AE and ME incidents from patient report, which were verified by medical records, laboratory data, incident reports, and prescription queries. Two independent physicians reviewed the incidents to determine whether they were AEs or MEs and to assess severity and symptoms. We identified 144 AEs and 30 MEs (16.3 and 3.9 per 100 patients, respectively). Of the 144 AEs, 99 were solely adverse drug events (ADEs), 20 were solely non-ADEs, and the remaining 25 were both causes. The most frequent symptoms of ADEs were skin and allergic reactions due to medication. The most frequent symptoms of non-ADEs were bleeding due to therapeutic interventions. Among AEs, 12% was life threatening. Life-threatening AEs were 25% of non-ADEs and 5% of ADEs (P = 0.0003). Among the 30 MEs, 21MEs (70%) were associated with drugs. Adverse events were common among cardiology patients. Adverse drug events were the most frequent AEs, and non-ADEs were more critical than ADEs. Such data should be recognized among practicing physicians to improve the patients' outcomes.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

A study of the recovery from 120 events

International Nuclear Information System (INIS)

Baumont, Genevieve; Menage, F.; Bigot, F.

1998-01-01

The author reports a study which aimed at providing additional information for improving safety by using event analysis. The approach concentrates on the dynamics of error detection and the way errors and shortcomings are managed. The study is based on a systematic analysis of 120 events in nuclear power plants. The authors first outline the differences between the activities described in significant events and that which is assumed to take place during event and accident situations. They describe the methods used to transpose human reliability PSA model to event analysis, report the analysis (event selection, data studied during event analysis, types of errors). Studies concern events during power operation or plant outage. Results are analyzed in terms of number of events, percentage of error type, percentage of activation of engineered safety features before operators recovered the situation. They comment who recovers the error and how it is recovered, and more precisely discuss the case of multiple error situations

Toward Joint Hypothesis-Tests Seismic Event Screening Analysis: Ms|mb and Event Depth

Energy Technology Data Exchange (ETDEWEB)

Anderson, Dale [Los Alamos National Laboratory; Selby, Neil [AWE Blacknest

2012-08-14

Well established theory can be used to combine single-phenomenology hypothesis tests into a multi-phenomenology event screening hypothesis test (Fisher's and Tippett's tests). Commonly used standard error in Ms:mb event screening hypothesis test is not fully consistent with physical basis. Improved standard error - Better agreement with physical basis, and correctly partitions error to include Model Error as a component of variance, correctly reduces station noise variance through network averaging. For 2009 DPRK test - Commonly used standard error 'rejects' H0 even with better scaling slope ({beta} = 1, Selby et al.), improved standard error 'fails to rejects' H0.

UNDERSTANDING OR NURSES' REACTIONS TO ERRORS AND USING THIS UNDERSTANDING TO IMPROVE PATIENT SAFETY.

Science.gov (United States)

Taifoori, Ladan; Valiee, Sina

2015-09-01

The operating room can be home to many different types of nursing errors due to the invasiveness of OR procedures. The nurses' reactions towards errors can be a key factor in patient safety. This article is based on a study, with the aim of investigating nurses' reactions toward nursing errors and the various contributing and resulting factors, conducted at Kurdistan University of Medical Sciences in Sanandaj, Iran in 2014. The goal of the study was to determine how OR nurses' reacted to nursing errors with the goal of having this information used to improve patient safety. Research was conducted as a cross-sectional descriptive study. The participants were all nurses employed in the operating rooms of the teaching hospitals of Kurdistan University of Medical Sciences, which was selected by a consensus method (170 persons). The information was gathered through questionnaires that focused on demographic information, error definition, reasons for error occurrence, and emotional reactions for error occurrence, and emotional reactions toward the errors. 153 questionnaires were completed and analyzed by SPSS software version 16.0. "Not following sterile technique" (82.4 percent) was the most reported nursing error, "tiredness" (92.8 percent) was the most reported reason for the error occurrence, "being upset at having harmed the patient" (85.6 percent) was the most reported emotional reaction after error occurrence", with "decision making for a better approach to tasks the next time" (97.7 percent) as the most common goal and "paying more attention to details" (98 percent) was the most reported planned strategy for future improved outcomes. While healthcare facilities are focused on planning for the prevention and elimination of errors it was shown that nurses can also benefit from support after error occurrence. Their reactions, and coping strategies, need guidance and, with both individual and organizational support, can be a factor in improving patient safety.

Approximation errors during variance propagation

International Nuclear Information System (INIS)

Dinsmore, Stephen

1986-01-01

Risk and reliability analyses are often performed by constructing and quantifying large fault trees. The inputs to these models are component failure events whose probability of occuring are best represented as random variables. This paper examines the errors inherent in two approximation techniques used to calculate the top event's variance from the inputs' variance. Two sample fault trees are evaluated and several three dimensional plots illustrating the magnitude of the error over a wide range of input means and variances are given

Sources of Error and the Statistical Formulation of M S: m b Seismic Event Screening Analysis

Science.gov (United States)

Anderson, D. N.; Patton, H. J.; Taylor, S. R.; Bonner, J. L.; Selby, N. D.

2014-03-01

The Comprehensive Nuclear-Test-Ban Treaty (CTBT), a global ban on nuclear explosions, is currently in a ratification phase. Under the CTBT, an International Monitoring System (IMS) of seismic, hydroacoustic, infrasonic and radionuclide sensors is operational, and the data from the IMS is analysed by the International Data Centre (IDC). The IDC provides CTBT signatories basic seismic event parameters and a screening analysis indicating whether an event exhibits explosion characteristics (for example, shallow depth). An important component of the screening analysis is a statistical test of the null hypothesis H 0: explosion characteristics using empirical measurements of seismic energy (magnitudes). The established magnitude used for event size is the body-wave magnitude (denoted m b) computed from the initial segment of a seismic waveform. IDC screening analysis is applied to events with m b greater than 3.5. The Rayleigh wave magnitude (denoted M S) is a measure of later arriving surface wave energy. Magnitudes are measurements of seismic energy that include adjustments (physical correction model) for path and distance effects between event and station. Relative to m b, earthquakes generally have a larger M S magnitude than explosions. This article proposes a hypothesis test (screening analysis) using M S and m b that expressly accounts for physical correction model inadequacy in the standard error of the test statistic. With this hypothesis test formulation, the 2009 Democratic Peoples Republic of Korea announced nuclear weapon test fails to reject the null hypothesis H 0: explosion characteristics.

Upset due to a single particle caused propagated transients in a bulk CMOS microprocessor

International Nuclear Information System (INIS)

Leavy, J.F.; Hoffmann, L.F.; Shoran, R.W.; Johnson, M.T.

1991-01-01

This paper reports on data pattern advances observed in preset, single event upset (SEU) hardened clocked flip-flops, during static Cf-252 exposures on a bulk CMOS microprocessor, that were attributable to particle caused anomalous clock signals, or propagated transients. SPICE simulations established that particle strikes in the output nodes of a clock control logic flip-flop could produce transients of sufficient amplitude and duration to be accepted as legitimate pulses by clock buffers fed by the flip-flop's output nodes. The buffers would then output false clock pulses, thereby advancing the state of the present flip-flops. Masking the clock logic on one of the test chips made the flip-flop data advance cease, confirming the clock logic as the source of the SEU. By introducing N 2 gas, at reduced pressures, into the SEU test chamber to attenuate Cf-252 particle LET's, a 24-26 MeV-cm 2 /mg LET threshold was deduced. Subsequent tests, at the 88-inch cyclotron at Berkeley, established an LET threshold of 30 MeV-cm 2 /mg (283 MeV Cu at 0 degrees) for the generation of false clocks. Cyclotron SEU tests are considered definitive, while Cf-252 data usually is not. However, in this instance Cf-252 tests proved analytically useful, providing SEU characterization data that was both timely and inexpensive

Representing cognitive activities and errors in HRA trees

International Nuclear Information System (INIS)

Gertman, D.I.

1992-01-01

A graphic representation method is presented herein for adapting an existing technology--human reliability analysis (HRA) event trees, used to support event sequence logic structures and calculations--to include a representation of the underlying cognitive activity and corresponding errors associated with human performance. The analyst is presented with three potential means of representing human activity: the NUREG/CR-1278 HRA event tree approach; the skill-, rule- and knowledge-based paradigm; and the slips, lapses, and mistakes paradigm. The above approaches for representing human activity are integrated in order to produce an enriched HRA event tree -- the cognitive event tree system (COGENT)-- which, in turn, can be used to increase the analyst's understanding of the basic behavioral mechanisms underlying human error and the representation of that error in probabilistic risk assessment. Issues pertaining to the implementation of COGENT are also discussed

Analysis of cosmic ray neutron-induced single-event phenomena

International Nuclear Information System (INIS)

Tukamoto, Yasuyuki; Watanabe, Yukinobu; Nakashima, Hideki

2003-01-01

We have developed a database of cross sections for the n+ 28 Si reaction in the energy range between 2 MeV and 3 GeV in order to analyze single-event upset (SEU) phenomena induced by cosmic-ray neutrons in semiconductor memory devices. The data are applied to calculations of SEU cross sections using the Burst Generation Rate (BGR) model including two parameters, critical charge and effective depth. The calculated results are compared with measured SEU cross-sections for energies up to 160 MeV, and the reaction products that provide important effects on SEU are mainly investigated. (author)

Team errors: definition and taxonomy

International Nuclear Information System (INIS)

Sasou, Kunihide; Reason, James

1999-01-01

In error analysis or error management, the focus is usually upon individuals who have made errors. In large complex systems, however, most people work in teams or groups. Considering this working environment, insufficient emphasis has been given to 'team errors'. This paper discusses the definition of team errors and its taxonomy. These notions are also applied to events that have occurred in the nuclear power industry, aviation industry and shipping industry. The paper also discusses the relations between team errors and Performance Shaping Factors (PSFs). As a result, the proposed definition and taxonomy are found to be useful in categorizing team errors. The analysis also reveals that deficiencies in communication, resource/task management, excessive authority gradient, excessive professional courtesy will cause team errors. Handling human errors as team errors provides an opportunity to reduce human errors

Reward positivity: Reward prediction error or salience prediction error?

Science.gov (United States)

Heydari, Sepideh; Holroyd, Clay B

2016-08-01

The reward positivity is a component of the human ERP elicited by feedback stimuli in trial-and-error learning and guessing tasks. A prominent theory holds that the reward positivity reflects a reward prediction error signal that is sensitive to outcome valence, being larger for unexpected positive events relative to unexpected negative events (Holroyd & Coles, 2002). Although the theory has found substantial empirical support, most of these studies have utilized either monetary or performance feedback to test the hypothesis. However, in apparent contradiction to the theory, a recent study found that unexpected physical punishments also elicit the reward positivity (Talmi, Atkinson, & El-Deredy, 2013). The authors of this report argued that the reward positivity reflects a salience prediction error rather than a reward prediction error. To investigate this finding further, in the present study participants navigated a virtual T maze and received feedback on each trial under two conditions. In a reward condition, the feedback indicated that they would either receive a monetary reward or not and in a punishment condition the feedback indicated that they would receive a small shock or not. We found that the feedback stimuli elicited a typical reward positivity in the reward condition and an apparently delayed reward positivity in the punishment condition. Importantly, this signal was more positive to the stimuli that predicted the omission of a possible punishment relative to stimuli that predicted a forthcoming punishment, which is inconsistent with the salience hypothesis. © 2016 Society for Psychophysiological Research.

Adverse Life Events and Emotional and Behavioral Problems in Adolescence: The Role of Non-Verbal Cognitive Ability and Negative Cognitive Errors

Science.gov (United States)

Flouri, Eirini; Panourgia, Constantina

2011-01-01

The aim of this study was to test whether negative cognitive errors (overgeneralizing, catastrophizing, selective abstraction, and personalizing) mediate the moderator effect of non-verbal cognitive ability on the association between adverse life events (life stress) and emotional and behavioral problems in adolescence. The sample consisted of 430…

The effects of cosmic radiation on implantable medical devices

International Nuclear Information System (INIS)

Bradley, P.

1996-01-01

Metal oxide semiconductor (MOS) integrated circuits, with the benefits of low power consumption, represent the state of the art technology for implantable medical devices. Three significant sources of radiation are classified as having the ability to damage or alter the behavior of implantable electronics; Secondary neutron cosmic radiation, alpha particle radiation from the device packaging and therapeutic doses(up to 70 Gγ) of high energy radiation used in radiation oncology. The effects of alpha particle radiation from the packaging may be eliminated by the use of polyimide or silicone rubber die coatings. The relatively low incidence of therapeutic radiation incident on an implantable device and the use of die coating leaves cosmic radiation induced secondary neutron single event upset (SEU) as the main pervasive ionising radiation threat to the reliability of implantable devices. A theoretical model which predicts the susceptibility of a RAM cell to secondary neutron cosmic radiation induced SEU is presented. The model correlates well within the statistical uncertainty associated with both the theoretical and field estimate. The predicted Soft Error Rate (SER) is 4.8 x l0 -12 upsets/(bit hr) compared to an observed upset rate of 8.5 x 10 -12 upsets/(bit hr) from 20 upsets collected over a total of 284672 device days. The predicted upset rate may increase by up to 20% when consideration is given to patients flying in aircraft The upset rate is also consistent with the expected geographical variations of the secondary cosmic ray neutron flux, although insufficient upsets precluded a statistically significant test. This is the first clinical data set obtained indicating the effects of cosmic radiation on implantable devices. Importantly, it may be used to predict the susceptibility of future to the implantable device designs to the effects of cosmic radiation

An SEU resistant 256K SOI SRAM

Science.gov (United States)

Hite, L. R.; Lu, H.; Houston, T. W.; Hurta, D. S.; Bailey, W. E.

1992-12-01

A novel SEU (single event upset) resistant SRAM (static random access memory) cell has been implemented in a 256K SOI (silicon on insulator) SRAM that has attractive performance characteristics over the military temperature range of -55 to +125 C. These include worst-case access time of 40 ns with an active power of only 150 mW at 25 MHz, and a worst-case minimum WRITE pulse width of 20 ns. Measured SEU performance gives an Adams 10 percent worst-case error rate of 3.4 x 10 exp -11 errors/bit-day using the CRUP code with a conservative first-upset LET threshold. Modeling does show that higher bipolar gain than that measured on a sample from the SRAM lot would produce a lower error rate. Measurements show the worst-case supply voltage for SEU to be 5.5 V. Analysis has shown this to be primarily caused by the drain voltage dependence of the beta of the SOI parasitic bipolar transistor. Based on this, SEU experiments with SOI devices should include measurements as a function of supply voltage, rather than the traditional 4.5 V, to determine the worst-case condition.

Interplay between Hippocampal Sharp-Wave-Ripple Events and Vicarious Trial and Error Behaviors in Decision Making.

Science.gov (United States)

Papale, Andrew E; Zielinski, Mark C; Frank, Loren M; Jadhav, Shantanu P; Redish, A David

2016-12-07

Current theories posit that memories encoded during experiences are subsequently consolidated into longer-term storage. Hippocampal sharp-wave-ripple (SWR) events have been linked to this consolidation process during sleep, but SWRs also occur during awake immobility, where their role remains unclear. We report that awake SWR rates at the reward site are inversely related to the prevalence of vicarious trial and error (VTE) behaviors, thought to be involved in deliberation processes. SWR rates were diminished immediately after VTE behaviors and an increase in the rate of SWR events at the reward site predicted a decrease in subsequent VTE behaviors at the choice point. Furthermore, SWR disruptions increased VTE behaviors. These results suggest an inverse relationship between SWRs and VTE behaviors and suggest that awake SWRs and associated planning and memory consolidation mechanisms are engaged specifically in the context of higher levels of behavioral certainty. Copyright © 2016 Elsevier Inc. All rights reserved.

Errors in Neonatology

Directory of Open Access Journals (Sweden)

Antonio Boldrini

2013-06-01

Full Text Available Introduction: Danger and errors are inherent in human activities. In medical practice errors can lean to adverse events for patients. Mass media echo the whole scenario. Methods: We reviewed recent published papers in PubMed database to focus on the evidence and management of errors in medical practice in general and in Neonatology in particular. We compared the results of the literature with our specific experience in Nina Simulation Centre (Pisa, Italy. Results: In Neonatology the main error domains are: medication and total parenteral nutrition, resuscitation and respiratory care, invasive procedures, nosocomial infections, patient identification, diagnostics. Risk factors include patients’ size, prematurity, vulnerability and underlying disease conditions but also multidisciplinary teams, working conditions providing fatigue, a large variety of treatment and investigative modalities needed. Discussion and Conclusions: In our opinion, it is hardly possible to change the human beings but it is likely possible to change the conditions under they work. Voluntary errors report systems can help in preventing adverse events. Education and re-training by means of simulation can be an effective strategy too. In Pisa (Italy Nina (ceNtro di FormazIone e SimulazioNe NeonAtale is a simulation center that offers the possibility of a continuous retraining for technical and non-technical skills to optimize neonatological care strategies. Furthermore, we have been working on a novel skill trainer for mechanical ventilation (MEchatronic REspiratory System SImulator for Neonatal Applications, MERESSINA. Finally, in our opinion national health policy indirectly influences risk for errors. Proceedings of the 9th International Workshop on Neonatology · Cagliari (Italy · October 23rd-26th, 2013 · Learned lessons, changing practice and cutting-edge research

Technique for human-error sequence identification and signification

International Nuclear Information System (INIS)

Heslinga, G.

1988-01-01

The aim of the present study was to investigate whether the event-tree technique can be used for the analysis of sequences of human errors that could cause initiating events. The scope of the study was limited to a consideration of the performance of procedural actions. The event-tree technique was modified to adapt it for this study and will be referred to as the 'Technique for Human-Error-Sequence Identification and Signification' (THESIS). The event trees used in this manner, i.e. THESIS event trees, appear to present additional problems if they are applied to human performance instead of technical systems. These problems, referred to as the 'Man-Related Features' of THESIS, are: the human capability to choose among several procedures, the ergonomics of the panel layout, human actions of a continuous nature, dependence between human errors, human capability to recover possible errors, the influence of memory during the recovery attempt, variability in human performance and correlations between human;erropr probabilities. The influence of these problems on the applicability of THESIS was assessed by means of mathematical analysis, field studies and laboratory experiments (author). 130 refs.; 51 figs.; 24 tabs

A comparative evaluation of emerging methods for errors of commission based on applications to the Davis-Besse (1985) event

International Nuclear Information System (INIS)

Reer, B.; Dang, V.N.; Hirschberg, S.; Straeter, O.

1999-12-01

In considering the human role in accidents, the classical PSA methodology applied today focuses primarily on the omissions of actions required of the operators at specific points in the scenario models. A practical, proven methodology is not available for systematically identifying and analyzing the scenario contexts in which the operators might perform inappropriate actions that aggravate the scenario. As a result, typical PSA's do not comprehensively treat these actions, referred to as errors of commission (EOCs). This report presents the results of a joint project of the Paul Scherrer Institut (PSI, Villigen, Switzerland) and the Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS, Garching, Germany) that examined some methods recently proposed for addressing the EOC issue. Five methods were investigated: 1 ) ATHEANA, 2) the Borssele screening methodology. 3) CREAM, 4) CAHR, and 5) CODA. In addition to a comparison of their scope, basic assumptions, and analytical approach, the methods were each applied in the analysis of PWR Loss of Feedwater scenarios based on the 1985 Davis-Besse event, in which the operator response included actions that can be categorized as EOCs. The aim was to compare how the methods consider a concrete scenario in which EOCs have in fact been observed. These case applications show how the methods are used in practical terms and constitute a common basis for comparing the methods and the insights that they provide. The identification of the potentially significant EOCs to be analysed in the PSA is currently the central problem for their treatment. The identification or search scheme has to consider an extensive set of potential actions that the operators may take. These actions may take place instead of required actions, for example, because the operators fail to assess the plant state correctly, or they may occur even when no action is required. As a result of this broad search space, most methodologies apply multiple schemes to

Medication errors : the impact of prescribing and transcribing errors on preventable harm in hospitalised patients

NARCIS (Netherlands)

van Doormaal, J.E.; van der Bemt, P.M.L.A.; Mol, P.G.M.; Egberts, A.C.G.; Haaijer-Ruskamp, F.M.; Kosterink, J.G.W.; Zaal, Rianne J.

Background: Medication errors (MEs) affect patient safety to a significant extent. Because these errors can lead to preventable adverse drug events (pADEs), it is important to know what type of ME is the most prevalent cause of these pADEs. This study determined the impact of the various types of

Crying without a cause and being easily upset in two-year-olds: heritability and predictive power of behavioral problems

NARCIS (Netherlands)

Groen-Blokhuis, Maria M.; Middeldorp, Christel M.; van Beijsterveldt, Catharina E.; Boomsma, Dorret I.

2011-01-01

In order to estimate the influence of genetic and environmental factors on 'crying without a cause' and 'being easily upset' in 2-year-old children, a large twin study was carried out. Prospective data were available for ~18,000 2-year-old twin pairs from the Netherlands Twin Register. A bivariate

Crying Without a Cause and Being Easily Upset in Two-Year-Olds: Heritability and Predictive Power of Behavioral Problems

NARCIS (Netherlands)

Groen-Blokhuis, M.M.; Middeldorp, C.M.; van Beijsterveldt, C.E.M.; Boomsma, D.I.

2011-01-01

In order to estimate the influence of genetic and environmental factors on 'crying without a cause' and 'being easily upset' in 2-year-old children, a large twin study was carried out. Prospective data were available for ∼18,000 2-year-old twin pairs from the Netherlands Twin Register. A bivariate

Interval sampling methods and measurement error: a computer simulation.

Science.gov (United States)

Wirth, Oliver; Slaven, James; Taylor, Matthew A

2014-01-01

A simulation study was conducted to provide a more thorough account of measurement error associated with interval sampling methods. A computer program simulated the application of momentary time sampling, partial-interval recording, and whole-interval recording methods on target events randomly distributed across an observation period. The simulation yielded measures of error for multiple combinations of observation period, interval duration, event duration, and cumulative event duration. The simulations were conducted up to 100 times to yield measures of error variability. Although the present simulation confirmed some previously reported characteristics of interval sampling methods, it also revealed many new findings that pertain to each method's inherent strengths and weaknesses. The analysis and resulting error tables can help guide the selection of the most appropriate sampling method for observation-based behavioral assessments. © Society for the Experimental Analysis of Behavior.

Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital.

Science.gov (United States)

Clarke, Damian L; Furlong, Heidi; Laing, Grant L; Aldous, Colleen; Thomson, Sandie Rutherford

2013-10-22

Several authors have suggested that the traditional surgical morbidity and mortality meeting be developed as a tool to identify surgical errors and turn them into learning opportunities for staff. We report our experience with these meetings. A structured template was developed for each morbidity and mortality meeting. We used a grid to analyse mortality and classify the death as: (i) death expected/death unexpected; and (ii) death unpreventable/death preventable. Individual cases were then analysed using a combination of error taxonomies. During the period June - December 2011, a total of 400 acute admissions (195 trauma and 205 non-trauma) were managed at Edendale Hospital, Pietermaritzburg, South Africa. During this period, 20 morbidity and mortality meetings were held, at which 30 patients were discussed. There were 10 deaths, of which 5 were unexpected and potentially avoidable. A total of 43 errors were recognised, all in the domain of the acute admissions ward. There were 33 assessment failures, 5 logistical failures, 5 resuscitation failures, 16 errors of execution and 27 errors of planning. Seven patients experienced a number of errors, of whom 5 died. Error theory successfully dissected out the contribution of error to adverse events in our institution. Translating this insight into effective strategies to reduce the incidence of error remains a challenge. Using the examples of error identified at the meetings as educational cases may help with initiatives that directly target human error in trauma care.

Human errors in NPP operations

International Nuclear Information System (INIS)

Sheng Jufang

1993-01-01

Based on the operational experiences of nuclear power plants (NPPs), the importance of studying human performance problems is described. Statistical analysis on the significance or frequency of various root-causes and error-modes from a large number of human-error-related events demonstrate that the defects in operation/maintenance procedures, working place factors, communication and training practices are primary root-causes, while omission, transposition, quantitative mistake are the most frequent among the error-modes. Recommendations about domestic research on human performance problem in NPPs are suggested

Threat and error management for anesthesiologists: a predictive risk taxonomy

Science.gov (United States)

Ruskin, Keith J.; Stiegler, Marjorie P.; Park, Kellie; Guffey, Patrick; Kurup, Viji; Chidester, Thomas

2015-01-01

Purpose of review Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care. Recent findings Threat and error management (TEM) describes adverse events in terms of risks or challenges that are present in an operational environment (threats) and the actions of specific personnel that potentiate or exacerbate those threats (errors). TEM is a technique widely used in aviation, and can be adapted for the use in a medical setting to predict high-risk situations and prevent errors in the perioperative period. A threat taxonomy is a novel way of classifying and predicting the hazards that can occur in the operating room. TEM can be used to identify error-producing situations, analyze adverse events, and design training scenarios. Summary TEM offers a multifaceted strategy for identifying hazards, reducing errors, and training physicians. A threat taxonomy may improve analysis of critical events with subsequent development of specific interventions, and may also serve as a framework for training programs in risk mitigation. PMID:24113268

Representing cognitive activities and errors in HRA trees

International Nuclear Information System (INIS)

Gertman, D.I.

1992-01-01

This paper discusses development of a means by which to present cognitive information in human reliability assessment (HRA) event trees. The descriptions found in probabilistic risk assessments (PRAs) regarding the demands on, and the resulting performance of, nuclear power plant (NPP) crews often make use of the technique for human error rate prediction (THERP), which provides a mechanism, the HRA event tree, for presenting the analyst's conceptualization of the activities underlying performance and the errors associated with that performance. When using THERP, analysts have often omitted the more complex elements of human cognition from these trees. There has yet to be a concerted effort to take theory, principles, and data from cognitive psychology and wed it to the logic structure of the HRA event tree. This paper attempts to do so. The COGENT modeling scheme (cognitively based HRA event trees) adds two taxonomies to the HRA event tree proposed by Swain and Guttman. The first taxonomy, the one proposed by Norman and Reason, describes the type of error committed and implies something about the underlying cognition as well. The second of these, the Rasmussen taxonomy, provides description regarding the skill-based, rule-based, or knowledge-based behavior underlying the execution of tasks. It is not apparent and must be deduced from the pattern of errors exhibited by personnel

The action characterization matrix: A link between HERA (Human Events Reference for ATHEANA) and ATHEANA (a technique for human error analysis)

International Nuclear Information System (INIS)

Hahn, H.A.

1997-01-01

The Technique for Human Error Analysis (ATHEANA) is a newly developed human reliability analysis (HRA) methodology that aims to facilitate better representation and integration of human performance into probabilistic risk assessment (PRA) modeling and quantification by analyzing risk-significant operating experience in the context of existing behavior science models. The fundamental premise of ATHEANA is that error-forcing contexts (EFCs), which refer to combinations of equipment/material conditions and performance shaping factors (PSFs), set up or create the conditions under which unsafe actions (UAs) can occur. ATHEANA is being developed in the context of nuclear power plant (NPP) PRAs, and much of the language used to describe the method and provide examples of its application are specific to that industry. Because ATHEANA relies heavily on the analysis of operational events that have already occurred as a mechanism for generating creative thinking about possible EFCs, a database, called the Human Events Reference for ATHEANA (HERA), has been developed to support the methodology. Los Alamos National Laboratory's (LANL) Human Factors Group has recently joined the ATHEANA project team; LANL is responsible for further developing the database structure and for analyzing additional exemplar operational events for entry into the database. The Action Characterization Matrix (ACM) is conceived as a bridge between the HERA database structure and ATHEANA. Specifically, the ACM allows each unsafe action or human failure event to be characterized according to its representation along each of six different dimensions: system status, initiator status, unsafe action mechanism, information processing stage, equipment/material conditions, and performance shaping factors. This report describes the development of the ACM and provides details on the structure and content of its dimensions

Detecting medication errors in the New Zealand pharmacovigilance database: a retrospective analysis.

Science.gov (United States)

Kunac, Desireé L; Tatley, Michael V

2011-01-01

Despite the traditional focus being adverse drug reactions (ADRs), pharmacovigilance centres have recently been identified as a potentially rich and important source of medication error data. To identify medication errors in the New Zealand Pharmacovigilance database (Centre for Adverse Reactions Monitoring [CARM]), and to describe the frequency and characteristics of these events. A retrospective analysis of the CARM pharmacovigilance database operated by the New Zealand Pharmacovigilance Centre was undertaken for the year 1 January-31 December 2007. All reports, excluding those relating to vaccines, clinical trials and pharmaceutical company reports, underwent a preventability assessment using predetermined criteria. Those events deemed preventable were subsequently classified to identify the degree of patient harm, type of error, stage of medication use process where the error occurred and origin of the error. A total of 1412 reports met the inclusion criteria and were reviewed, of which 4.3% (61/1412) were deemed preventable. Not all errors resulted in patient harm: 29.5% (18/61) were 'no harm' errors but 65.5% (40/61) of errors were deemed to have been associated with some degree of patient harm (preventable adverse drug events [ADEs]). For 5.0% (3/61) of events, the degree of patient harm was unable to be determined as the patient outcome was unknown. The majority of preventable ADEs (62.5% [25/40]) occurred in adults aged 65 years and older. The medication classes most involved in preventable ADEs were antibacterials for systemic use and anti-inflammatory agents, with gastrointestinal and respiratory system disorders the most common adverse events reported. For both preventable ADEs and 'no harm' events, most errors were incorrect dose and drug therapy monitoring problems consisting of failures in detection of significant drug interactions, past allergies or lack of necessary clinical monitoring. Preventable events were mostly related to the prescribing and

Abnormal error monitoring in math-anxious individuals: evidence from error-related brain potentials.

Directory of Open Access Journals (Sweden)

Macarena Suárez-Pellicioni

Full Text Available This study used event-related brain potentials to investigate whether math anxiety is related to abnormal error monitoring processing. Seventeen high math-anxious (HMA and seventeen low math-anxious (LMA individuals were presented with a numerical and a classical Stroop task. Groups did not differ in terms of trait or state anxiety. We found enhanced error-related negativity (ERN in the HMA group when subjects committed an error on the numerical Stroop task, but not on the classical Stroop task. Groups did not differ in terms of the correct-related negativity component (CRN, the error positivity component (Pe, classical behavioral measures or post-error measures. The amplitude of the ERN was negatively related to participants' math anxiety scores, showing a more negative amplitude as the score increased. Moreover, using standardized low resolution electromagnetic tomography (sLORETA we found greater activation of the insula in errors on a numerical task as compared to errors in a non-numerical task only for the HMA group. The results were interpreted according to the motivational significance theory of the ERN.

Changes in medical errors after implementation of a handoff program.

Science.gov (United States)

Starmer, Amy J; Spector, Nancy D; Srivastava, Rajendu; West, Daniel C; Rosenbluth, Glenn; Allen, April D; Noble, Elizabeth L; Tse, Lisa L; Dalal, Anuj K; Keohane, Carol A; Lipsitz, Stuart R; Rothschild, Jeffrey M; Wien, Matthew F; Yoon, Catherine S; Zigmont, Katherine R; Wilson, Karen M; O'Toole, Jennifer K; Solan, Lauren G; Aylor, Megan; Bismilla, Zia; Coffey, Maitreya; Mahant, Sanjay; Blankenburg, Rebecca L; Destino, Lauren A; Everhart, Jennifer L; Patel, Shilpa J; Bale, James F; Spackman, Jaime B; Stevenson, Adam T; Calaman, Sharon; Cole, F Sessions; Balmer, Dorene F; Hepps, Jennifer H; Lopreiato, Joseph O; Yu, Clifton E; Sectish, Theodore C; Landrigan, Christopher P

2014-11-06

Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events

The magnitude and effects of extreme solar particle events

Directory of Open Access Journals (Sweden)

Jiggens Piers

2014-06-01

Full Text Available The solar energetic particle (SEP radiation environment is an important consideration for spacecraft design, spacecraft mission planning and human spaceflight. Herein is presented an investigation into the likely severity of effects of a very large Solar Particle Event (SPE on technology and humans in space. Fluences for SPEs derived using statistical models are compared to historical SPEs to verify their appropriateness for use in the analysis which follows. By combining environment tools with tools to model effects behind varying layers of spacecraft shielding it is possible to predict what impact a large SPE would be likely to have on a spacecraft in Near-Earth interplanetary space or geostationary Earth orbit. Also presented is a comparison of results generated using the traditional method of inputting the environment spectra, determined using a statistical model, into effects tools and a new method developed as part of the ESA SEPEM Project allowing for the creation of an effect time series on which statistics, previously applied to the flux data, can be run directly. The SPE environment spectra is determined and presented as energy integrated proton fluence (cm−2 as a function of particle energy (in MeV. This is input into the SHIELDOSE-2, MULASSIS, NIEL, GRAS and SEU effects tools to provide the output results. In the case of the new method for analysis, the flux time series is fed directly into the MULASSIS and GEMAT tools integrated into the SEPEM system. The output effect quantities include total ionising dose (in rads, non-ionising energy loss (MeV g−1, single event upsets (upsets/bit and the dose in humans compared to established limits for stochastic (or cancer-causing effects and tissue reactions (such as acute radiation sickness in humans given in grey-equivalent and sieverts respectively.

Benzodiazepine Use During Hospitalization: Automated Identification of Potential Medication Errors and Systematic Assessment of Preventable Adverse Events.

Directory of Open Access Journals (Sweden)

David Franklin Niedrig

Full Text Available Benzodiazepines and "Z-drug" GABA-receptor modulators (BDZ are among the most frequently used drugs in hospitals. Adverse drug events (ADE associated with BDZ can be the result of preventable medication errors (ME related to dosing, drug interactions and comorbidities. The present study evaluated inpatient use of BDZ and related ME and ADE.We conducted an observational study within a pharmacoepidemiological database derived from the clinical information system of a tertiary care hospital. We developed algorithms that identified dosing errors and interacting comedication for all administered BDZ. Associated ADE and risk factors were validated in medical records.Among 53,081 patients contributing 495,813 patient-days BDZ were administered to 25,626 patients (48.3% on 115,150 patient-days (23.2%. We identified 3,372 patient-days (2.9% with comedication that inhibits BDZ metabolism, and 1,197 (1.0% with lorazepam administration in severe renal impairment. After validation we classified 134, 56, 12, and 3 cases involving lorazepam, zolpidem, midazolam and triazolam, respectively, as clinically relevant ME. Among those there were 23 cases with associated adverse drug events, including severe CNS-depression, falls with subsequent injuries and severe dyspnea. Causality for BDZ was formally assessed as 'possible' or 'probable' in 20 of those cases. Four cases with ME and associated severe ADE required administration of the BDZ antagonist flumazenil.BDZ use was remarkably high in the studied setting, frequently involved potential ME related to dosing, co-medication and comorbidities, and rarely cases with associated ADE. We propose the implementation of automated ME screening and validation for the prevention of BDZ-related ADE.

A comparative evaluation of emerging methods for errors of commission based on applications to the Davis-Besse (1985) event

Energy Technology Data Exchange (ETDEWEB)

Reer, B.; Dang, V.N.; Hirschberg, S. [Paul Scherrer Inst., Nuclear Energy and Safety Research Dept., CH-5232 Villigen PSI (Switzerland); Straeter, O. [Gesellschaft fur Anlagen- und Reaktorsicherheit (Germany)

1999-12-01

In considering the human role in accidents, the classical PSA methodology applied today focuses primarily on the omissions of actions required of the operators at specific points in the scenario models. A practical, proven methodology is not available for systematically identifying and analyzing the scenario contexts in which the operators might perform inappropriate actions that aggravate the scenario. As a result, typical PSA's do not comprehensively treat these actions, referred to as errors of commission (EOCs). This report presents the results of a joint project of the Paul Scherrer Institut (PSI, Villigen, Switzerland) and the Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS, Garching, Germany) that examined some methods recently proposed for addressing the EOC issue. Five methods were investigated: 1 ) ATHEANA, 2) the Borssele screening methodology. 3) CREAM, 4) CAHR, and 5) CODA. In addition to a comparison of their scope, basic assumptions, and analytical approach, the methods were each applied in the analysis of PWR Loss of Feedwater scenarios based on the 1985 Davis-Besse event, in which the operator response included actions that can be categorized as EOCs. The aim was to compare how the methods consider a concrete scenario in which EOCs have in fact been observed. These case applications show how the methods are used in practical terms and constitute a common basis for comparing the methods and the insights that they provide. The identification of the potentially significant EOCs to be analysed in the PSA is currently the central problem for their treatment. The identification or search scheme has to consider an extensive set of potential actions that the operators may take. These actions may take place instead of required actions, for example, because the operators fail to assess the plant state correctly, or they may occur even when no action is required. As a result of this broad search space, most methodologies apply multiple schemes to

Search for gamma-ray events in the BATSE data base

Science.gov (United States)

Lewin, Walter

1994-01-01

We find large location errors and error radii in the locations of channel 1 Cygnus X-1 events. These errors and their associated uncertainties are a result of low signal-to-noise ratios (a few sigma) in the two brightest detectors for each event. The untriggered events suffer from similarly low signal-to-noise ratios, and their location errors are expected to be at least as large as those found for Cygnus X-1 with a given signal-to-noise ratio. The statistical error radii are consistent with those found for Cygnus X-1 and with the published estimates. We therefore expect approximately 20 - 30 deg location errors for the untriggered events. Hence, many of the untriggered events occurring within a few months of the triggered activity from SGR 1900 plus 14 are indeed consistent with the SGR source location, although Cygnus X-1 is also a good candidate.

Radiation tolerance and mitigation strategies for FPGA:s in the ATLAS TileCal Demonstrator

CERN Document Server

Akerstedt, H; The ATLAS collaboration

2013-01-01

During 2014, demonstrator electronics will be installed in a Tile calorimeter "drawer" to get long term experience with the inherently redundant electronics proposed for a full upgrade scheduled for 2022. The new system, being FPGA-based, uses dense programmable logic which must be proven to be sufficently radiation tolerant. It must be protected against radiation induced single event upsets that corrupt memory and logic functions. Radiation induced errors need to be found and compensated for in time, to minimize data loss but also to avoid permanent damage. Strategies for detecting and correcting radiation induced errors in the Kintex-7 FPGA:s of the demonstrator are evaluated and discussed.

Radiation tolerance and mitigation strategies for FPGA:s in the ATLAS TileCal Demonstrator

CERN Document Server

Akerstedt, H; The ATLAS collaboration; Drake, G; Muschter, S; Oreglia, M; Tang, F; Anderson, K; Paramonov, A

2013-01-01

During 2014, upgrade-demonstrator electronics will be installed in a Tile calorimeter drawer to obtain long term experience with the inherently redundant electronics proposed for a full upgrade scheduled for 2022. The new, FPGA-based system uses dense programmable logic, which must be proven to be sufficiently radiation tolerant. It must also be protected against radiation induced single event upsets that can corrupt memory and logic Radiation induced errors need to be found and compensated for in time to minimize data loss, and also to avoid permanent damage. Strategies for detecting and correcting radiation induced errors in the Kintex-7 FPGAs on the demonstrator electronics are evaluated and discussed.

Static Computer Memory Integrity Testing (SCMIT): An experiment flown on STS-40 as part of GAS payload G-616

Science.gov (United States)

Hancock, Thomas

1993-01-01

This experiment investigated the integrity of static computer memory (floppy disk media) when exposed to the environment of low earth orbit. The experiment attempted to record soft-event upsets (bit-flips) in static computer memory. Typical conditions that exist in low earth orbit that may cause soft-event upsets include: cosmic rays, low level background radiation, charged fields, static charges, and the earth's magnetic field. Over the years several spacecraft have been affected by soft-event upsets (bit-flips), and these events have caused a loss of data or affected spacecraft guidance and control. This paper describes a commercial spin-off that is being developed from the experiment.

Prediction of human errors by maladaptive changes in event-related brain networks

NARCIS (Netherlands)

Eichele, T.; Debener, S.; Calhoun, V.D.; Specht, K.; Engel, A.K.; Hugdahl, K.; Cramon, D.Y. von; Ullsperger, M.

2008-01-01

Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional Mill and applying independent component analysis followed by deconvolution of hemodynamic responses, we

Intelligent error correction method applied on an active pixel sensor based star tracker

Science.gov (United States)

Schmidt, Uwe

2005-10-01

Star trackers are opto-electronic sensors used on-board of satellites for the autonomous inertial attitude determination. During the last years star trackers became more and more important in the field of the attitude and orbit control system (AOCS) sensors. High performance star trackers are based up today on charge coupled device (CCD) optical camera heads. The active pixel sensor (APS) technology, introduced in the early 90-ties, allows now the beneficial replacement of CCD detectors by APS detectors with respect to performance, reliability, power, mass and cost. The company's heritage in star tracker design started in the early 80-ties with the launch of the worldwide first fully autonomous star tracker system ASTRO1 to the Russian MIR space station. Jena-Optronik recently developed an active pixel sensor based autonomous star tracker "ASTRO APS" as successor of the CCD based star tracker product series ASTRO1, ASTRO5, ASTRO10 and ASTRO15. Key features of the APS detector technology are, a true xy-address random access, the multiple windowing read out and the on-chip signal processing including the analogue to digital conversion. These features can be used for robust star tracking at high slew rates and under worse conditions like stray light and solar flare induced single event upsets. A special algorithm have been developed to manage the typical APS detector error contributors like fixed pattern noise (FPN), dark signal non-uniformity (DSNU) and white spots. The algorithm works fully autonomous and adapts to e.g. increasing DSNU and up-coming white spots automatically without ground maintenance or re-calibration. In contrast to conventional correction methods the described algorithm does not need calibration data memory like full image sized calibration data sets. The application of the presented algorithm managing the typical APS detector error contributors is a key element for the design of star trackers for long term satellite applications like

Measurements of proton upset induced in Cmos devices synthesis of CEA studies

International Nuclear Information System (INIS)

Mijuin, D.; Buisson, J.; Brunet, J.P.; Murat, J.; Chapuis, T.

1990-01-01

Within its space activities, the Departement d'Electronique et d'Instrumentation Nucleaire (DEIN) is involved in a research program regarding the behaviour of electronic components submitted to the type of radiations encountered in earth orbits or by planetary probes. Located at Saclay, the SATURNE synchrotron is a tool well suited to simulate the effects of high energy cosmic particles. The DEIN has thus carried out several experimental runs in which CMOS SRAM were irradiated with a proton beam. SATURNE is a synchrotron designed for basic research in the physics of light particles and heavy ions of intermediate energy. The energy supplied to the protons lies between 0.2 and 2.9 GeV with an intensity larger than 10 12 protons cycle -1 . During the experiment and in order to lower the proton energy under 200 MeV, an Al-absorber was used. The flux measurement was obtained by two different methods: measurement by activation and measurement by counting (scintillator coupled with a PM). The increase number of upsets during irradiation was determined, on line, for each cycle, by a testor using a comparative hardware method. The testor was designed by the DEIN. Latch-up was also detected. The results, presented in this paper, were obtained during the run of September 1990. The upset cross-sections per bit of static memories MHS 65162. MHS 65641, MOSTEK 48H64 and HYUNDAI 6116 were measured for 1000, 200, 158.9, 147.5, 122.6, 93.3 and 66.2 MeV. These experimental values were fitted using the Bendel equation with two variable parameters proposed by Stapor and al (3). The results of the run of September 1990 encourage us to pursue our studies. By now, it seems necessary to improve the experimental line (elimination of the parasitic effects generated by the Al-absorber) and to upgrade the methods used for measuring the flux

Soft errors in modern electronic systems

CERN Document Server

Nicolaidis, Michael

2010-01-01

This book provides a comprehensive presentation of the most advanced research results and technological developments enabling understanding, qualifying and mitigating the soft errors effect in advanced electronics, including the fundamental physical mechanisms of radiation induced soft errors, the various steps that lead to a system failure, the modelling and simulation of soft error at various levels (including physical, electrical, netlist, event driven, RTL, and system level modelling and simulation), hardware fault injection, accelerated radiation testing and natural environment testing, s

Self-efficacy for controlling upsetting thoughts and emotional eating in family caregivers.

Science.gov (United States)

MacDougall, Megan; Steffen, Ann

2017-10-01

Self-efficacy for controlling upsetting thoughts was examined as a predictor of emotional eating by family caregivers of physically and cognitively impaired older adults. Adult women (N = 158) providing healthcare assistance for an older family member completed an online survey about caregiving stressors, depressive symptoms, self-efficacy, and emotional eating. A stress process framework was used as a conceptual model to guide selection of variables predicting emotional eating scores. A hierarchical multiple regression was conducted and the overall model was significant (R 2 = .21, F(4,153) = 10.02, p accounting for IADL, role overload, and depression scores. These findings replicate previous research demonstrating the relationship between managing cognitions about caregiving and behavioral responses to stressors, and point to the importance of addressing cognitive processes in efforts to improve caregiver health behaviors.

Single event phenomena in atmospheric neutron environments

International Nuclear Information System (INIS)

Gossett, C.A.; Hughlock, B.W.; Katoozi, M.; LaRue, G.S.; Wender, S.A.

1993-01-01

As integrated circuit technology achieves higher density through smaller feature sizes and as the airplane manufacturing industry integrates more sophisticated electronic components into the design of new aircraft, it has become increasingly important to evaluate the contribution of single event effects, primarily Single Event Upset (SEU), to the safety and reliability of commercial aircraft. In contrast to the effects of radiation on electronic systems in space applications for which protons and heavy ions are of major concern, in commercial aircraft applications the interactions of high energy neutrons are the dominant cause of single event effects. These high energy neutrons are produced by the interaction of solar and galactic cosmic rays, principally protons and heavy ions, in the upper atmosphere. This paper will describe direct experimental measurements of neutron-induced Single Event Effect (SEE) rates in commercial high density static random access memories in a neutron environment characteristic of that at commercial airplane altitudes. The first experimental measurements testing current models for neutron-silicon burst generation rates will be presented, as well as measurements of charge collection in silicon test structures as a function of neutron energy. These are the first laboratory SEE and charge collection measurements using a particle beam having a continuum energy spectrum and with a shape nearly identical to that observed during flight

To Leave a Praxis to Itself May Be to Upset It in Unintended Ways

DEFF Research Database (Denmark)

Olsen, Poul Bitsch; Axel, Erik

by the researchers on a conception of situated praxis, of conflictual cooperation, and on an interest in morals and the meaning of upsetting practices. The organization of the material may hopefully provoke discussions around praxis as part of its further development. Thus, our presentation is based on a notion...... of praxis. Praxis is formed by the reciprocal differentiations of acts. In order to be able to act here, we try to arrange things to be done in specific ways there. In order to build the house here, we arrange a supply of inhabitants here, a conglomerate of producers there etc.. Furthermore, what we achieve...

Clinical errors and medical negligence.

Science.gov (United States)

Oyebode, Femi

2013-01-01

This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3-16% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems. Copyright © 2013 S. Karger AG, Basel.

Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative.

Science.gov (United States)

Lobaugh, Lauren M Y; Martin, Lizabeth D; Schleelein, Laura E; Tyler, Donald C; Litman, Ronald S

2017-09-01

Wake Up Safe is a quality improvement initiative of the Society for Pediatric Anesthesia that contains a deidentified registry of serious adverse events occurring in pediatric anesthesia. The aim of this study was to describe and characterize reported medication errors to find common patterns amenable to preventative strategies. In September 2016, we analyzed approximately 6 years' worth of medication error events reported to Wake Up Safe. Medication errors were classified by: (1) medication category; (2) error type by phase of administration: prescribing, preparation, or administration; (3) bolus or infusion error; (4) provider type and level of training; (5) harm as defined by the National Coordinating Council for Medication Error Reporting and Prevention; and (6) perceived preventability. From 2010 to the time of our data analysis in September 2016, 32 institutions had joined and submitted data on 2087 adverse events during 2,316,635 anesthetics. These reports contained details of 276 medication errors, which comprised the third highest category of events behind cardiac and respiratory related events. Medication errors most commonly involved opioids and sedative/hypnotics. When categorized by phase of handling, 30 events occurred during preparation, 67 during prescribing, and 179 during administration. The most common error type was accidental administration of the wrong dose (N = 84), followed by syringe swap (accidental administration of the wrong syringe, N = 49). Fifty-seven (21%) reported medication errors involved medications prepared as infusions as opposed to 1 time bolus administrations. Medication errors were committed by all types of anesthesia providers, most commonly by attendings. Over 80% of reported medication errors reached the patient and more than half of these events caused patient harm. Fifteen events (5%) required a life sustaining intervention. Nearly all cases (97%) were judged to be either likely or certainly preventable. Our findings

The impact of different background errors in the assimilation of satellite radiances and in-situ observational data using WRFDA for three rainfall events over Iran

Science.gov (United States)

Zakeri, Zeinab; Azadi, Majid; Ghader, Sarmad

2018-01-01

Satellite radiances and in-situ observations are assimilated through Weather Research and Forecasting Data Assimilation (WRFDA) system into Advanced Research WRF (ARW) model over Iran and its neighboring area. Domain specific background error based on x and y components of wind speed (UV) control variables is calculated for WRFDA system and some sensitivity experiments are carried out to compare the impact of global background error and the domain specific background errors, both on the precipitation and 2-m temperature forecasts over Iran. Three precipitation events that occurred over the country during January, September and October 2014 are simulated in three different experiments and the results for precipitation and 2-m temperature are verified against the verifying surface observations. Results show that using domain specific background error improves 2-m temperature and 24-h accumulated precipitation forecasts consistently, while global background error may even degrade the forecasts compared to the experiments without data assimilation. The improvement in 2-m temperature is more evident during the first forecast hours and decreases significantly as the forecast length increases.

A capacitively coupled dose-rate-dependent transient upset mechanism in a bipolar memory

International Nuclear Information System (INIS)

Turfler, R.M.; Pease, R.L.; Dinger, G.; Armstrong, B.

1992-01-01

This paper reports on a pattern sensitivity that was observed in the threshold dose rate response of a bipolar 16K PROM for radiation pulse widths of 20-100 ns. For the worst case pattern, the upset threshold was a factor of three lower than for the commonly used checkerboard pattern. The mechanism for this pattern sensitivity was found to be a capacitively coupled voltage transient on a sensitive node which caused a low-to-high transition at the output. A design fix was implemented to significantly alter the ratio of the two parasitic capacitances in a capacitive divider which reduced the amplitude of the voltage transient at the sensitive node. It was demonstrated that in the redesign, the pattern sensitivity was eliminated

The effectiveness of risk management program on pediatric nurses' medication error.

Science.gov (United States)

Dehghan-Nayeri, Nahid; Bayat, Fariba; Salehi, Tahmineh; Faghihzadeh, Soghrat

2013-09-01

Medication therapy is one of the most complex and high-risk clinical processes that nurses deal with. Medication error is the most common type of error that brings about damage and death to patients, especially pediatric ones. However, these errors are preventable. Identifying and preventing undesirable events leading to medication errors are the main risk management activities. The aim of this study was to investigate the effectiveness of a risk management program on the pediatric nurses' medication error rate. This study is a quasi-experimental one with a comparison group. In this study, 200 nurses were recruited from two main pediatric hospitals in Tehran. In the experimental hospital, we applied the risk management program for a period of 6 months. Nurses of the control hospital did the hospital routine schedule. A pre- and post-test was performed to measure the frequency of the medication error events. SPSS software, t-test, and regression analysis were used for data analysis. After the intervention, the medication error rate of nurses at the experimental hospital was significantly lower (P error-reporting rate was higher (P medical environment, applying the quality-control programs such as risk management can effectively prevent the occurrence of the hospital undesirable events. Nursing mangers can reduce the medication error rate by applying risk management programs. However, this program cannot succeed without nurses' cooperation.

SENTINEL EVENTS

Directory of Open Access Journals (Sweden)

Andrej Robida

2004-09-01

the surveyed persons agreed to disclosure of the event to a patient but this was the case in less than half of the occasions.Conclusions. The small number of reports of sentinel events, late or incomplete reporting of conducted analyses of root causes and plans for future prevention of these events and survey data showed the state of culture in the majority of hospitals. Fear of reporting and therefore, hiding of errors or ascribing errors to the »usual« complications of a disease or procedures, the reaction of leadership to quickly find a culprit for the event, disregarding a serious approach to analyze the event and taking measures for their future prevention leads to the culture of silence. Root cause analysis of the events showed that the reason frequently lies in systems and processes and not in individuals. Health care will never be without risks for patients. However, with an open approach without the blaming and shaming of individuals, implementation of reporting the events in hospitals and other health care facilities with clear goals of patient safety, standardization of equipment, materials, and processes and education on patient safety many sentinel events and medical errors could and should be prevented.

Exploring human error in military aviation flight safety events using post-incident classification systems.

Science.gov (United States)

Hooper, Brionny J; O'Hare, David P A

2013-08-01

Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classification System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identification of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the influence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fixed-wing and rotary-wing operations. This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008. Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fixed wing (23%) incidents. Both classificatory systems showed significant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors. Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.

Investigation of human performance events at French power stations

International Nuclear Information System (INIS)

Ghertman, F.; Griffon-Fouco, M.

1985-01-01

This paper is concerned with the collection of data on human errors that occur at operating power plants. Three collection methods are used, each relating to a difference level of analysis. (1) Simplified statistical analysis of the causes of human errors: Events which have occurred at operating power plants and which are attributable to human errors are selected. The errors thus identified are analysed briefly and are described by a simplified classification, statistical analysis then being applied to find the principal factors underlying these errors. By way of example, an analysis is given of data on emergency shut-downs involving a human error component that occurred at 900 MW(e) PWR plants during 1982, 1983, 1984. (2) In-depth statistical analysis of the causes of certain human errors: The errors selected are analysed and described by means of a detailed classification. By way of example, the collection and evaluation of data on human errors occurring during periodic tests at a 900 MW(e) power plant over a period of six months are described. (3) In-depth analysis of certain events due to human errors: The events selected are analysed by means of a method which reconstitutes the multicausal aspect of the event and of each human error. By way of example, a description is given of an emergency core cooling required at a 900 MW(e) PWR plant. In conclusion, it is explained how these three methods of collection play complementary roles

Negligence, genuine error, and litigation

OpenAIRE

Sohn DH

2013-01-01

David H SohnDepartment of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USAAbstract: Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort syst...

Survey of Quantitative Research Metrics to Assess Pilot Performance in Upset Recovery

Science.gov (United States)

Le Vie, Lisa R.

2016-01-01

Accidents attributable to in-flight loss of control are the primary cause for fatal commercial jet accidents worldwide. The National Aeronautics and Space Administration (NASA) conducted a literature review to determine and identify the quantitative standards for assessing upset recovery performance. This review contains current recovery procedures for both military and commercial aviation and includes the metrics researchers use to assess aircraft recovery performance. Metrics include time to first input, recognition time and recovery time and whether that input was correct or incorrect. Other metrics included are: the state of the autopilot and autothrottle, control wheel/sidestick movement resulting in pitch and roll, and inputs to the throttle and rudder. In addition, airplane state measures, such as roll reversals, altitude loss/gain, maximum vertical speed, maximum/minimum air speed, maximum bank angle and maximum g loading are reviewed as well.

Event-by-event jet quenching

Energy Technology Data Exchange (ETDEWEB)

Fries, R.J.; Rodriguez, R.; Ramirez, E.

2010-08-14

High momentum jets and hadrons can be used as probes for the quark gluon plasma (QGP) formed in nuclear collisions at high energies. We investigate the influence of fluctuations in the fireball on jet quenching observables by comparing propagation of light quarks and gluons through averaged, smooth QGP fireballs with event-by-event jet quenching using realistic inhomogeneous fireballs. We find that the transverse momentum and impact parameter dependence of the nuclear modification factor R{sub AA} can be fit well in an event-by-event quenching scenario within experimental errors. However the transport coefficient {cflx q} extracted from fits to the measured nuclear modification factor R{sub AA} in averaged fireballs underestimates the value from event-by-event calculations by up to 50%. On the other hand, after adjusting {cflx q} to fit R{sub AA} in the event-by-event analysis we find residual deviations in the azimuthal asymmetry v{sub 2} and in two-particle correlations, that provide a possible faint signature for a spatial tomography of the fireball. We discuss a correlation function that is a measure for spatial inhomogeneities in a collision and can be constrained from data.

Event-by-event jet quenching

Energy Technology Data Exchange (ETDEWEB)

Rodriguez, R. [Cyclotron Institute and Physics Department, Texas A and M University, College Station, TX 77843 (United States); Fries, R.J., E-mail: rjfries@comp.tamu.ed [Cyclotron Institute and Physics Department, Texas A and M University, College Station, TX 77843 (United States); RIKEN/BNL Research Center, Brookhaven National Laboratory, Upton, NY 11973 (United States); Ramirez, E. [Physics Department, University of Texas El Paso, El Paso, TX 79968 (United States)

2010-09-27

High momentum jets and hadrons can be used as probes for the quark gluon plasma (QGP) formed in nuclear collisions at high energies. We investigate the influence of fluctuations in the fireball on jet quenching observables by comparing propagation of light quarks and gluons through averaged, smooth QGP fireballs with event-by-event jet quenching using realistic inhomogeneous fireballs. We find that the transverse momentum and impact parameter dependence of the nuclear modification factor R{sub AA} can be fit well in an event-by-event quenching scenario within experimental errors. However the transport coefficient q extracted from fits to the measured nuclear modification factor R{sub AA} in averaged fireballs underestimates the value from event-by-event calculations by up to 50%. On the other hand, after adjusting q to fit R{sub AA} in the event-by-event analysis we find residual deviations in the azimuthal asymmetry v{sub 2} and in two-particle correlations, that provide a possible faint signature for a spatial tomography of the fireball. We discuss a correlation function that is a measure for spatial inhomogeneities in a collision and can be constrained from data.

Texture evolution maps for upset deformation of body-centered cubic metals

International Nuclear Information System (INIS)

Lee, Myoung-Gyu; Wang, Jue; Anderson, Peter M.

2007-01-01

Texture evolution maps are used as a tool to visualize texture development during upset deformation in body-centered cubic metals. These maps reveal initial grain orientations that tend toward normal direction (ND)|| versus ND|| . To produce these maps, a finite element analysis (FEA) with a rate-dependent crystal plasticity constitutive relation for tantalum is used. A reference case having zero workpiece/die friction shows that ∼64% of randomly oriented grains rotate toward ND|| and ∼36% rotate toward ND|| . The maps show well-established trends that increasing strain rate sensitivity and decreasing latent-to-self hardening ratio reduce both and percentages, leading to more diffuse textures. Reducing operative slip systems from both {1 1 0}/ and {1 1 2}/ to just {1 1 0}/ has a mixed effect: it increases the percentage but decreases the percentage. Reducing the number of slip systems and increasing the number of FEA integration points per grain strengthen - texture bands that are observed experimentally

Human decision error (HUMDEE) trees

International Nuclear Information System (INIS)

Ostrom, L.T.

1993-01-01

Graphical presentations of human actions in incident and accident sequences have been used for many years. However, for the most part, human decision making has been underrepresented in these trees. This paper presents a method of incorporating the human decision process into graphical presentations of incident/accident sequences. This presentation is in the form of logic trees. These trees are called Human Decision Error Trees or HUMDEE for short. The primary benefit of HUMDEE trees is that they graphically illustrate what else the individuals involved in the event could have done to prevent either the initiation or continuation of the event. HUMDEE trees also present the alternate paths available at the operator decision points in the incident/accident sequence. This is different from the Technique for Human Error Rate Prediction (THERP) event trees. There are many uses of these trees. They can be used for incident/accident investigations to show what other courses of actions were available and for training operators. The trees also have a consequence component so that not only the decision can be explored, also the consequence of that decision

Technical errors and complications in orthopaedic trauma surgery

NARCIS (Netherlands)

Meeuwis, M.A.; de Jongh, M.A.C.; Roukema, J.A.; van der Heijden, F.H.W.M.; Verhofstad, M. H. J.

2016-01-01

Introduction Adverse events and associated morbidity and subsequent costs receive increasing attention in clinical practice and research. As opposed to complications, errors are not described or analysed in literature on fracture surgery. The aim of this study was to provide a description of errors

Analysis of Employee's Survey for Preventing Human-Errors

International Nuclear Information System (INIS)

Sung, Chanho; Kim, Younggab; Joung, Sanghoun

2013-01-01

Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses

Analyzing the Influence of the Angles of Incidence and Rotation on MBU Events Induced by Low LET Heavy Ions in a 28-nm SRAM-Based FPGA

Science.gov (United States)

Tonfat, Jorge; Kastensmidt, Fernanda Lima; Artola, Laurent; Hubert, Guillaume; Medina, Nilberto H.; Added, Nemitala; Aguiar, Vitor A. P.; Aguirre, Fernando; Macchione, Eduardo L. A.; Silveira, Marcilei A. G.

2017-08-01

This paper shows the impact of low linear energy transfer heavy ions on the reliability of 28-nm Bulk static random access memory (RAM) cells from Artix-7 field-programmable gate array. Irradiation tests on the ground showed significant differences in the multiple bit upset cross section of configuration RAM and block RAM memory cells under various angles of incidence and rotation of the device. Experimental data are analyzed at transistor level by using the single-event effect prediction tool called multiscale single-event phenomenon prediction platform coupled with SPICE simulations.

The Psychological Assessment in Operational Events

International Nuclear Information System (INIS)

Abramova, V.N.; Volkov, E.V.

1998-01-01

The possibilities of Psychological Assessment in Operational Events in nuclear power engineering are discussed. The approach of psychology use in quantitative analysis of direct and root causes of operational events is presented. The main attention is paid to the practical method of investigation of an individual who makes an error. The socio-technical system elements can be considered by this method as the external conditions, affecting correctness or errors of actions. The types of errors (violation, mistake, slips) can be clarified. The direct causes of failures and sources of probable root causes of errors also can be defined. Experience shows that the psychological situation of events caused by a human error depends on professional competence, motivation and some professionally important psychological qualities of a person, his functional state, psycho-physiological qualities, characteristics of mentality, attention and memory. In an emergency situation successful personnel performance is mainly effected by such professional qualities as the ability to take the lead in actions, to resolve urgent problems of minimizing the scale of the accident significance; personal participation in dangerous procedures of the accident follow-up, even risking one's life; devotion to one's job; resolute and bold actions; high level of self-control; thoroughness and conscientiousness. External means of activity, influencing the events, include ergonomic characteristics of working place, ergonomics of events technology. External means can be also defined by socio-psychological situation in a group, which refers to the data of social conditions, social-political situation, relationships between people, and by organizational factors. (authors)

Formulation of a strategy for monitoring control integrity in critical digital control systems

Science.gov (United States)

Belcastro, Celeste M.; Fischl, Robert; Kam, Moshe

1991-01-01

Advanced aircraft will require flight critical computer systems for stability augmentation as well as guidance and control that must perform reliably in adverse, as well as nominal, operating environments. Digital system upset is a functional error mode that can occur in electromagnetically harsh environments, involves no component damage, can occur simultaneously in all channels of a redundant control computer, and is software dependent. A strategy is presented for dynamic upset detection to be used in the evaluation of critical digital controllers during the design and/or validation phases of development. Critical controllers must be able to be used in adverse environments that result from disturbances caused by an electromagnetic source such as lightning, high intensity radiated field (HIRF), and nuclear electromagnetic pulses (NEMP). The upset detection strategy presented provides dynamic monitoring of a given control computer for degraded functional integrity that can result from redundancy management errors and control command calculation error that could occur in an electromagnetically harsh operating environment. The use is discussed of Kalman filtering, data fusion, and decision theory in monitoring a given digital controller for control calculation errors, redundancy management errors, and control effectiveness.

Analysis for Human-related Events during the Overhaul

Energy Technology Data Exchange (ETDEWEB)

Kim, Ji Tae; Kim, Min Chull; Choi, Dong Won; Lee, Durk Hun [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2011-10-15

The event frequency due to human error is decreasing among 20 operating Nuclear Power Plants (NPPs) excluding the NPP (Shin-Kori unit-1) in the commissioning stage since 2008. However, the events due to human error during an overhaul (O/H) occur annually (see Table I). An analysis for human-related events during the O/H was performed. Similar problems were identified for each event from the analysis and also, organizational and safety cultural factors were also identified

A Recent Revisit Study on the Human Error Events of Nuclear Facilities in Korea

International Nuclear Information System (INIS)

Lee, Y.-H.

2016-01-01

After Fukushima accident we have launched two new projects in Korea. One is for the development of the countermeasures for human errors in nuclear facilities, and the other is for the safety culture of nuclear power plant itself. There had happened several succeeding events that turned out to be the typical flags of the human and organizational factor issues for the safety of the other socio-technical systems as well as nuclear power plants in Korea. The second safety culture project was an ambitious development to establish an infra system utilising system dynamics, business process modeling and big-data techniques to provide effective and efficient information basis to various interest parties related to the nuclear power plants. However the project has been drastically cancelled last year without any further discussion on the original issues raised before in Korea. It may come not only from the conflicting perspectives among the different approaches to nuclear safety culture but also from the misunderstandings on the human factors for the nuclear safety.

Pharyngitis – fatal infectious disease or medical error?

Directory of Open Access Journals (Sweden)

Marta Rorat

2015-08-01

Full Text Available Reporting on adverse events is essential to create a culture of safety, which focuses on protecting doctors and patients from medical errors. We present a fatal case of Streptococcus C pharyngitis in a 56-year-old man. The clinical course and the results of additional diagnostics and autopsy showed that sepsis followed by multiple organ failure was the ultimate cause of death. The clinical course appeared fatal due to a chain of adverse events, including errors made by the physicians caring for the patient for 10 days.

A preliminary taxonomy of medical errors in family practice.

Science.gov (United States)

Dovey, S M; Meyers, D S; Phillips, R L; Green, L A; Fryer, G E; Galliher, J M; Kappus, J; Grob, P

2002-09-01

To develop a preliminary taxonomy of primary care medical errors. Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. The National Network for Family Practice and Primary Care Research. Family physicians. Medical error category, context, and consequence. Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Statistical analysis with measurement error or misclassification strategy, method and application

CERN Document Server

Yi, Grace Y

2017-01-01

This monograph on measurement error and misclassification covers a broad range of problems and emphasizes unique features in modeling and analyzing problems arising from medical research and epidemiological studies. Many measurement error and misclassification problems have been addressed in various fields over the years as well as with a wide spectrum of data, including event history data (such as survival data and recurrent event data), correlated data (such as longitudinal data and clustered data), multi-state event data, and data arising from case-control studies. Statistical Analysis with Measurement Error or Misclassification: Strategy, Method and Application brings together assorted methods in a single text and provides an update of recent developments for a variety of settings. Measurement error effects and strategies of handling mismeasurement for different models are closely examined in combination with applications to specific problems. Readers with diverse backgrounds and objectives can utilize th...

Climbing fibers predict movement kinematics and performance errors.

Science.gov (United States)

Streng, Martha L; Popa, Laurentiu S; Ebner, Timothy J

2017-09-01

Requisite for understanding cerebellar function is a complete characterization of the signals provided by complex spike (CS) discharge of Purkinje cells, the output neurons of the cerebellar cortex. Numerous studies have provided insights into CS function, with the most predominant view being that they are evoked by error events. However, several reports suggest that CSs encode other aspects of movements and do not always respond to errors or unexpected perturbations. Here, we evaluated CS firing during a pseudo-random manual tracking task in the monkey ( Macaca mulatta ). This task provides extensive coverage of the work space and relative independence of movement parameters, delivering a robust data set to assess the signals that activate climbing fibers. Using reverse correlation, we determined feedforward and feedback CSs firing probability maps with position, velocity, and acceleration, as well as position error, a measure of tracking performance. The direction and magnitude of the CS modulation were quantified using linear regression analysis. The major findings are that CSs significantly encode all three kinematic parameters and position error, with acceleration modulation particularly common. The modulation is not related to "events," either for position error or kinematics. Instead, CSs are spatially tuned and provide a linear representation of each parameter evaluated. The CS modulation is largely predictive. Similar analyses show that the simple spike firing is modulated by the same parameters as the CSs. Therefore, CSs carry a broader array of signals than previously described and argue for climbing fiber input having a prominent role in online motor control. NEW & NOTEWORTHY This article demonstrates that complex spike (CS) discharge of cerebellar Purkinje cells encodes multiple parameters of movement, including motor errors and kinematics. The CS firing is not driven by error or kinematic events; instead it provides a linear representation of each

Influences of lubricant pocket geometry and working conditions upon micro lubrication mechanisms in upsetting and strip drawing

DEFF Research Database (Denmark)

Shimizu, Ichiro; Martins, P. A. F.; Bay, Niels

2010-01-01

, during upsetting and strip drawing, by means of a rigid-viscoplastic finite-element formulation. Special emphasis is placed on the effect of pocket geometry on the build-up of hydrostatic pressure, which is responsible for the onset of micro-lubrication mechanisms. A good agreement is found between......Micro-lubricant pockets located in the surface of plastically deforming workpieces are recognised to improve the performance of fluid lubrication in a metal-forming process. This work investigates the joint influence of pocket geometry and process working conditions on micro-lubrication mechanisms...

Chernobyl - system accident or human error?

International Nuclear Information System (INIS)

Stang, E.

1996-01-01

Did human error cause the Chernobyl disaster? The standard point of view is that operator error was the root cause of the disaster. This was also the view of the Soviet Accident Commission. The paper analyses the operator errors at Chernobyl in a system context. The reactor operators committed errors that depended upon a lot of other failures that made up a complex accident scenario. The analysis is based on Charles Perrow's analysis of technological disasters. Failure possibility is an inherent property of high-risk industrial installations. The Chernobyl accident consisted of a chain of events that were both extremely improbable and difficult to predict. It is not reasonable to put the blame for the disaster on the operators. (author)

Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention.

Science.gov (United States)

Goedecke, Thomas; Ord, Kathryn; Newbould, Victoria; Brosch, Sabine; Arlett, Peter

2016-06-01

A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Reducing the risk of medication errors is a shared responsibility between patients, healthcare professionals, regulators and the pharmaceutical industry at all levels of healthcare delivery. In 2015, the EU regulatory network released a two-part good practice guide on medication errors to support both the pharmaceutical industry and regulators in the implementation of the changes introduced with the EU pharmacovigilance legislation. These changes included a modification of the 'adverse reaction' definition to include events associated with medication errors, and the requirement for national competent authorities responsible for pharmacovigilance in EU Member States to collaborate and exchange information on medication errors resulting in harm with national patient safety organisations. To facilitate reporting and learning from medication errors, a clear distinction has been made in the guidance between medication errors resulting in adverse reactions, medication errors without harm, intercepted medication errors and potential errors. This distinction is supported by an enhanced MedDRA(®) terminology that allows for coding all stages of the medication use process where the error occurred in addition to any clinical consequences. To better understand the causes and contributing factors, individual case safety reports involving an error should be followed-up with the primary reporter to gather information relevant for the conduct of root cause analysis where this may be appropriate. Such reports should also be summarised in periodic safety update reports and addressed in risk management plans. Any risk minimisation and prevention strategy for medication errors should consider all stages of a medicinal product's life-cycle, particularly the main sources and types of medication errors during product development. This article

Addressing Medical Errors in Hand Surgery

OpenAIRE

Johnson, Shepard P.; Adkinson, Joshua M.; Chung, Kevin C.

2014-01-01

Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is...

Combining empirical approaches and error modelling to enhance predictive uncertainty estimation in extrapolation for operational flood forecasting. Tests on flood events on the Loire basin, France.

Science.gov (United States)

Berthet, Lionel; Marty, Renaud; Bourgin, François; Viatgé, Julie; Piotte, Olivier; Perrin, Charles

2017-04-01

An increasing number of operational flood forecasting centres assess the predictive uncertainty associated with their forecasts and communicate it to the end users. This information can match the end-users needs (i.e. prove to be useful for an efficient crisis management) only if it is reliable: reliability is therefore a key quality for operational flood forecasts. In 2015, the French flood forecasting national and regional services (Vigicrues network; www.vigicrues.gouv.fr) implemented a framework to compute quantitative discharge and water level forecasts and to assess the predictive uncertainty. Among the possible technical options to achieve this goal, a statistical analysis of past forecasting errors of deterministic models has been selected (QUOIQUE method, Bourgin, 2014). It is a data-based and non-parametric approach based on as few assumptions as possible about the forecasting error mathematical structure. In particular, a very simple assumption is made regarding the predictive uncertainty distributions for large events outside the range of the calibration data: the multiplicative error distribution is assumed to be constant, whatever the magnitude of the flood. Indeed, the predictive distributions may not be reliable in extrapolation. However, estimating the predictive uncertainty for these rare events is crucial when major floods are of concern. In order to improve the forecasts reliability for major floods, an attempt at combining the operational strength of the empirical statistical analysis and a simple error modelling is done. Since the heteroscedasticity of forecast errors can considerably weaken the predictive reliability for large floods, this error modelling is based on the log-sinh transformation which proved to reduce significantly the heteroscedasticity of the transformed error in a simulation context, even for flood peaks (Wang et al., 2012). Exploratory tests on some operational forecasts issued during the recent floods experienced in

Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses.

Science.gov (United States)

Baldwin, Abigail; Rodriguez, Elizabeth S

2016-02-01

The prevalence of medication errors associated with chemotherapy administration is not precisely known. Little evidence exists concerning the extent or nature of errors; however, some evidence demonstrates that errors are related to prescribing. This article demonstrates how the review of chemotherapy orders by a designated nurse known as a verification nurse (VN) at a National Cancer Institute-designated comprehensive cancer center helps to identify prescribing errors that may prevent chemotherapy administration mistakes and improve patient safety in outpatient infusion units. This article will describe the role of the VN and details of the verification process. To identify benefits of the VN role, a retrospective review and analysis of chemotherapy near-miss events from 2009-2014 was performed. A total of 4,282 events related to chemotherapy were entered into the Reporting to Improve Safety and Quality system. A majority of the events were categorized as near-miss events, or those that, because of chance, did not result in patient injury, and were identified at the point of prescribing.

High cortisol awakening response is associated with impaired error monitoring and decreased post-error adjustment.

Science.gov (United States)

Zhang, Liang; Duan, Hongxia; Qin, Shaozheng; Yuan, Yiran; Buchanan, Tony W; Zhang, Kan; Wu, Jianhui

2015-01-01

The cortisol awakening response (CAR), a rapid increase in cortisol levels following morning awakening, is an important aspect of hypothalamic-pituitary-adrenocortical axis activity. Alterations in the CAR have been linked to a variety of mental disorders and cognitive function. However, little is known regarding the relationship between the CAR and error processing, a phenomenon that is vital for cognitive control and behavioral adaptation. Using high-temporal resolution measures of event-related potentials (ERPs) combined with behavioral assessment of error processing, we investigated whether and how the CAR is associated with two key components of error processing: error detection and subsequent behavioral adjustment. Sixty university students performed a Go/No-go task while their ERPs were recorded. Saliva samples were collected at 0, 15, 30 and 60 min after awakening on the two consecutive days following ERP data collection. The results showed that a higher CAR was associated with slowed latency of the error-related negativity (ERN) and a higher post-error miss rate. The CAR was not associated with other behavioral measures such as the false alarm rate and the post-correct miss rate. These findings suggest that high CAR is a biological factor linked to impairments of multiple steps of error processing in healthy populations, specifically, the automatic detection of error and post-error behavioral adjustment. A common underlying neural mechanism of physiological and cognitive control may be crucial for engaging in both CAR and error processing.

Methodology for assessment of safety risk due to potential accidents in US gaseous diffusion plants

International Nuclear Information System (INIS)

Turner, J.H.; O'Kain, D.U.

1991-01-01

Gaseous diffusion plants that operate in the United States represent a unique combination of nuclear and chemical hazards. Assessing and controlling the health, safety, and environmental risks that can result from natural phenomena events, process upset conditions, and operator errors require a unique methodology. Such a methodology has been developed for the diffusion plants and is being utilized to assess and control the risk of operating the plants. A summary of the methodology developed to assess the unique safety risks at the US gaseous diffusion plants is presented in this paper

Automating the CMS DAQ

International Nuclear Information System (INIS)

Bauer, G; Darlea, G-L; Gomez-Ceballos, G; Bawej, T; Chaze, O; Coarasa, J A; Deldicque, C; Dobson, M; Dupont, A; Gigi, D; Glege, F; Gomez-Reino, R; Hartl, C; Hegeman, J; Masetti, L; Behrens, U; Branson, J; Cittolin, S; Holzner, A; Erhan, S

2014-01-01

We present the automation mechanisms that have been added to the Data Acquisition and Run Control systems of the Compact Muon Solenoid (CMS) experiment during Run 1 of the LHC, ranging from the automation of routine tasks to automatic error recovery and context-sensitive guidance to the operator. These mechanisms helped CMS to maintain a data taking efficiency above 90% and to even improve it to 95% towards the end of Run 1, despite an increase in the occurrence of single-event upsets in sub-detector electronics at high LHC luminosity.

Designing for a safe response to operational and severe accident initiators in the Integral Fast Reactor

International Nuclear Information System (INIS)

Vilim, R.B.

1994-01-01

A method is described for optimizing the plant control strategy for a liquid metal reactor with respect to safety margins sustained in unprotected upset events. The optimization is performed subject to the normal requirements for reactor startup, load change and compensation for reactivity changes over the cycle. The method provides a formal approach to the process of exploiting the innate self-regulating property of a metal fueled reactor to make it less dependent on operator action and less vulnerable to automatic control system fault and/or operator error

Cascade of neural events leading from error commission to subsequent awareness revealed using EEG source imaging.

Directory of Open Access Journals (Sweden)

Monica Dhar

Full Text Available The goal of the present study was to shed light on the respective contributions of three important action monitoring brain regions (i.e. cingulate cortex, insula, and orbitofrontal cortex during the conscious detection of response errors. To this end, fourteen healthy adults performed a speeded Go/Nogo task comprising Nogo trials of varying levels of difficulty, designed to elicit aware and unaware errors. Error awareness was indicated by participants with a second key press after the target key press. Meanwhile, electromyogram (EMG from the response hand was recorded in addition to high-density scalp electroencephalogram (EEG. In the EMG-locked grand averages, aware errors clearly elicited an error-related negativity (ERN reflecting error detection, and a later error positivity (Pe reflecting conscious error awareness. However, no Pe was recorded after unaware errors or hits. These results are in line with previous studies suggesting that error awareness is associated with generation of the Pe. Source localisation results confirmed that the posterior cingulate motor area was the main generator of the ERN. However, inverse solution results also point to the involvement of the left posterior insula during the time interval of the Pe, and hence error awareness. Moreover, consecutive to this insular activity, the right orbitofrontal cortex (OFC was activated in response to aware and unaware errors but not in response to hits, consistent with the implication of this area in the evaluation of the value of an error. These results reveal a precise sequence of activations in these three non-overlapping brain regions following error commission, enabling a progressive differentiation between aware and unaware errors as a function of time elapsed, thanks to the involvement first of interoceptive or proprioceptive processes (left insula, later leading to the detection of a breach in the prepotent response mode (right OFC.

In-hospital fellow coverage reduces communication errors in the surgical intensive care unit.

Science.gov (United States)

Williams, Mallory; Alban, Rodrigo F; Hardy, James P; Oxman, David A; Garcia, Edward R; Hevelone, Nathanael; Frendl, Gyorgy; Rogers, Selwyn O

2014-06-01

Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events. A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods. Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (Pcommunicated 89% of events during IHFC vs 51% of events during HC (PCommunication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, Pcommunicated 66% of events (94% IHFC vs 52% HC, PCommunication errors were lower in all ICUs during IHFC (Pcommunication errors. Copyright © 2014 Elsevier Inc. All rights reserved.

SEU Prediction from SET modeling using multi-node collection in bulk transistors and SRAMs down to the 65 nm technology node

International Nuclear Information System (INIS)

Artola, L.; Hubert, G.; Duzellier, S.; Artola, L.; Bezerra, F.; Warren, K.M.; Massengill, L.W.; Gaillardin, M.; Paillet, Ph.; Raine, M.; Girard, S.; Schrimpf, R.D.; Reed, R.A.; Weller, R.A.; Ahlbin, J.R.

2011-01-01

A new methodology of prediction for SEU is proposed based on SET modeling. The modeling of multi-node charge collection is performed using the ADDICT model for predicting single event transients and upsets in bulk transistors and SRAMs down to 65 nm. The predicted single event upset cross sections agree well with experimental data for SRAMs. (authors)

Positive events protect children from causal false memories for scripted events.

Science.gov (United States)

Melinder, Annika; Toffalini, Enrico; Geccherle, Eleonora; Cornoldi, Cesare

2017-11-01

Adults produce fewer inferential false memories for scripted events when their conclusions are emotionally charged than when they are neutral, but it is not clear whether the same effect is also found in children. In the present study, we examined this issue in a sample of 132 children aged 6-12 years (mean 9 years, 3 months). Participants encoded photographs depicting six script-like events that had a positively, negatively, or a neutral valenced ending. Subsequently, true and false recognition memory of photographs related to the observed scripts was tested as a function of emotionality. Causal errors-a type of false memory thought to stem from inferential processes-were found to be affected by valence: children made fewer causal errors for positive than for neutral or negative events. Hypotheses are proposed on why adults were found protected against inferential false memories not only by positive (as for children) but also by negative endings when administered similar versions of the same paradigm.

Statistical analysis of lifetime determinations in the presence of large errors

International Nuclear Information System (INIS)

Yost, G.P.

1984-01-01

The lifetimes of the new particles are very short, and most of the experiments which measure decay times are subject to measurement errors which are not negligible compared with the decay times themselves. Bartlett has analyzed the problem of lifetime estimation if the error on each event is small or zero. For the case of non-negligible measurement errors, σsub(i), on each event, we are interested in a few basic questions: How well does maximum likelihood work. That is, (a) are the errors reasonable, (b) is the answer unbiased, and (c) are there other estimators with superior performance. We concentrate on the results of our Monte Carlo investigation for the case in which the experiment is sensitive over all times -infinity< xsub(i)< infinity

Compendium of Single Event Effects, Total Ionizing Dose, and Displacement Damage for Candidate Spacecraft Electronics for NASA

Science.gov (United States)

LaBel, Kenneth A.; OBryan, Martha V.; Chen, Dakai; Campola, Michael J.; Casey, Megan C.; Pellish, Jonathan A.; Lauenstein, Jean-Marie; Wilcox, Edward P.; Topper, Alyson D.; Ladbury, Raymond L.;

Error-related potentials during continuous feedback: using EEG to detect errors of different type and severity

Science.gov (United States)

Spüler, Martin; Niethammer, Christian

2015-01-01

When a person recognizes an error during a task, an error-related potential (ErrP) can be measured as response. It has been shown that ErrPs can be automatically detected in tasks with time-discrete feedback, which is widely applied in the field of Brain-Computer Interfaces (BCIs) for error correction or adaptation. However, there are only a few studies that concentrate on ErrPs during continuous feedback. With this study, we wanted to answer three different questions: (i) Can ErrPs be measured in electroencephalography (EEG) recordings during a task with continuous cursor control? (ii) Can ErrPs be classified using machine learning methods and is it possible to discriminate errors of different origins? (iii) Can we use EEG to detect the severity of an error? To answer these questions, we recorded EEG data from 10 subjects during a video game task and investigated two different types of error (execution error, due to inaccurate feedback; outcome error, due to not achieving the goal of an action). We analyzed the recorded data to show that during the same task, different kinds of error produce different ErrP waveforms and have a different spectral response. This allows us to detect and discriminate errors of different origin in an event-locked manner. By utilizing the error-related spectral response, we show that also a continuous, asynchronous detection of errors is possible. Although the detection of error severity based on EEG was one goal of this study, we did not find any significant influence of the severity on the EEG. PMID:25859204

Error-related potentials during continuous feedback: using EEG to detect errors of different type and severity

Directory of Open Access Journals (Sweden)

Martin eSpüler

2015-03-01

Full Text Available When a person recognizes an error during a task, an error-related potential (ErrP can be measured as response. It has been shown that ErrPs can be automatically detected in tasks with time-discrete feedback, which is widely applied in the field of Brain-Computer Interfaces (BCIs for error correction or adaptation. However, there are only a few studies that concentrate on ErrPs during continuous feedback.With this study, we wanted to answer three different questions: (i Can ErrPs be measured in electroencephalography (EEG recordings during a task with continuous cursor control? (ii Can ErrPs be classified using machine learning methods and is it possible to discriminate errors of different origins? (iii Can we use EEG to detect the severity of an error? To answer these questions, we recorded EEG data from 10 subjects during a video game task and investigated two different types of error (execution error, due to inaccurate feedback; outcome error, due to not achieving the goal of an action. We analyzed the recorded data to show that during the same task, different kinds of error produce different ErrP waveforms and have a different spectral response. This allows us to detect and discriminate errors of different origin in an event-locked manner. By utilizing the error-related spectral response, we show that also a continuous, asynchronous detection of errors is possible.Although the detection of error severity based on EEG was one goal of this study, we did not find any significant influence of the severity on the EEG.

Operational validation - current status and opportunities for improvement

International Nuclear Information System (INIS)

Davey, E.

2002-01-01

The design of nuclear plant systems and operational practices is based on the application of multiple defenses to minimize the risk of occurrence of safety and production challenges and upsets. With such an approach, the effectiveness of individual or combinations of design and operational features in preventing upset challenges should be known. A longstanding industry concern is the adverse impact errors in human performance can have on plant safety and production. To minimize the risk of error occurrence, designers and operations staff routinely employ multiple design and operational defenses. However, the effectiveness of individual or combinations of defensive features in minimizing error occurrence are generally only known in a qualitative sense. More importantly, the margins to error or upset occurrence provided by combinations of design or operational features are generally not characterized during design or operational validation. This paper provides some observations and comments on current validation practice as it relates to operational human performance concerns. The paper also discusses opportunities for future improvement in validation practice in terms of the resilience of validation results to operating changes and characterization of margins to safety or production challenge. (author)

NASA Electronic Parts and Packaging Field Programmable Gate Array Single Event Effects Test Guideline Update

Science.gov (United States)

Berg, Melanie D.; LaBel, Kenneth A.

2018-01-01

The following are updated or new subjects added to the FPGA SEE Test Guidelines manual: academic versus mission specific device evaluation, single event latch-up (SEL) test and analysis, SEE response visibility enhancement during radiation testing, mitigation evaluation (embedded and user-implemented), unreliable design and its affects to SEE Data, testing flushable architectures versus non-flushable architectures, intellectual property core (IP Core) test and evaluation (addresses embedded and user-inserted), heavy-ion energy and linear energy transfer (LET) selection, proton versus heavy-ion testing, fault injection, mean fluence to failure analysis, and mission specific system-level single event upset (SEU) response prediction. Most sections within the guidelines manual provide information regarding best practices for test structure and test system development. The scope of this manual addresses academic versus mission specific device evaluation and visibility enhancement in IP Core testing.

A qualitative description of human error

International Nuclear Information System (INIS)

Li Zhaohuan

1992-11-01

The human error has an important contribution to risk of reactor operation. The insight and analytical model are main parts in human reliability analysis. It consists of the concept of human error, the nature, the mechanism of generation, the classification and human performance influence factors. On the operating reactor the human error is defined as the task-human-machine mismatch. The human error event is focused on the erroneous action and the unfavored result. From the time limitation of performing a task, the operation is divided into time-limited and time-opened. The HCR (human cognitive reliability) model is suited for only time-limited. The basic cognitive process consists of the information gathering, cognition/thinking, decision making and action. The human erroneous action may be generated in any stage of this process. The more natural ways to classify human errors are presented. The human performance influence factors including personal, organizational and environmental factors are also listed

A qualitative description of human error

Energy Technology Data Exchange (ETDEWEB)

Zhaohuan, Li [Academia Sinica, Beijing, BJ (China). Inst. of Atomic Energy

1992-11-01

The human error has an important contribution to risk of reactor operation. The insight and analytical model are main parts in human reliability analysis. It consists of the concept of human error, the nature, the mechanism of generation, the classification and human performance influence factors. On the operating reactor the human error is defined as the task-human-machine mismatch. The human error event is focused on the erroneous action and the unfavored result. From the time limitation of performing a task, the operation is divided into time-limited and time-opened. The HCR (human cognitive reliability) model is suited for only time-limited. The basic cognitive process consists of the information gathering, cognition/thinking, decision making and action. The human erroneous action may be generated in any stage of this process. The more natural ways to classify human errors are presented. The human performance influence factors including personal, organizational and environmental factors are also listed.

Notes on human error analysis and prediction

International Nuclear Information System (INIS)

Rasmussen, J.

1978-11-01

The notes comprise an introductory discussion of the role of human error analysis and prediction in industrial risk analysis. Following this introduction, different classes of human errors and role in industrial systems are mentioned. Problems related to the prediction of human behaviour in reliability and safety analysis are formulated and ''criteria for analyzability'' which must be met by industrial systems so that a systematic analysis can be performed are suggested. The appendices contain illustrative case stories and a review of human error reports for the task of equipment calibration and testing as found in the US Licensee Event Reports. (author)

Drought Persistence Errors in Global Climate Models

Science.gov (United States)

Moon, H.; Gudmundsson, L.; Seneviratne, S. I.

2018-04-01

The persistence of drought events largely determines the severity of socioeconomic and ecological impacts, but the capability of current global climate models (GCMs) to simulate such events is subject to large uncertainties. In this study, the representation of drought persistence in GCMs is assessed by comparing state-of-the-art GCM model simulations to observation-based data sets. For doing so, we consider dry-to-dry transition probabilities at monthly and annual scales as estimates for drought persistence, where a dry status is defined as negative precipitation anomaly. Though there is a substantial spread in the drought persistence bias, most of the simulations show systematic underestimation of drought persistence at global scale. Subsequently, we analyzed to which degree (i) inaccurate observations, (ii) differences among models, (iii) internal climate variability, and (iv) uncertainty of the employed statistical methods contribute to the spread in drought persistence errors using an analysis of variance approach. The results show that at monthly scale, model uncertainty and observational uncertainty dominate, while the contribution from internal variability is small in most cases. At annual scale, the spread of the drought persistence error is dominated by the statistical estimation error of drought persistence, indicating that the partitioning of the error is impaired by the limited number of considered time steps. These findings reveal systematic errors in the representation of drought persistence in current GCMs and suggest directions for further model improvement.

Applicability of LET to single events in microelectronic structures

Science.gov (United States)

Xapsos, Michael A.

1992-12-01

LET is often used as a single parameter to determine the energy deposited in a microelectronic structure by a single event. The accuracy of this assumption is examined for ranges of ion energies and volumes of silicon appropriate for modern microelectronics. It is shown to be accurate only under very restricted conditions. Significant differences arise because (1) LET is related to energy lost by the ion, not energy deposited in the volume; and (2) LET is an average value and does not account for statistical variations in energy deposition. Criteria are suggested for determining when factors other than LET should be considered, and new analytical approaches are presented to account for them. One implication of these results is that improvements can be made in space upset rate predictions by incorporating the new methods into currently used codes such as CREME and CRUP.

Effects of Cabin Upsets on Adsorption Columns for Air Revitalization

Science.gov (United States)

LeVan, Douglas

1999-01-01

The National Aeronautics and Space Administration (NASA) utilizes adsorption technology as part of contaminant removal systems designed for long term missions. A variety of trace contaminants can be effectively removed from gas streams by adsorption onto activated carbon. An activated carbon adsorption column meets NASA's requirements of a lightweight and efficient means of controlling trace contaminant levels aboard spacecraft and space stations. The activated carbon bed is part of the Trace Contaminant Control System (TCCS) which is utilized to purify the cabin atmosphere. TCCS designs oversize the adsorption columns to account for irregular fluctuations in cabin atmospheric conditions. Variations in the cabin atmosphere include changes in contaminant concentrations, temperature, and relative humidity. Excessively large deviations from typical conditions can result from unusual crew activity, equipment malfunctions, or even fires. The research carried out under this award focussed in detail on the effects of cabin upsets on the performance of activated carbon adsorption columns. Both experiments and modeling were performed with an emphasis on the roll of a change in relative humidity on adsorption of trace contaminants. A flow through fixed-bed apparatus was constructed at the NASA Ames Research Center, and experiments were performed there. Modeling work was performed at the University of Virginia.

Soft error rate simulation and initial design considerations of neutron intercepting silicon chip (NISC)

Science.gov (United States)

Celik, Cihangir

Advances in microelectronics result in sub-micrometer electronic technologies as predicted by Moore's Law, 1965, which states the number of transistors in a given space would double every two years. The most available memory architectures today have submicrometer transistor dimensions. The International Technology Roadmap for Semiconductors (ITRS), a continuation of Moore's Law, predicts that Dynamic Random Access Memory (DRAM) will have an average half pitch size of 50 nm and Microprocessor Units (MPU) will have an average gate length of 30 nm over the period of 2008-2012. Decreases in the dimensions satisfy the producer and consumer requirements of low power consumption, more data storage for a given space, faster clock speed, and portability of integrated circuits (IC), particularly memories. On the other hand, these properties also lead to a higher susceptibility of IC designs to temperature, magnetic interference, power supply, and environmental noise, and radiation. Radiation can directly or indirectly affect device operation. When a single energetic particle strikes a sensitive node in the micro-electronic device, it can cause a permanent or transient malfunction in the device. This behavior is called a Single Event Effect (SEE). SEEs are mostly transient errors that generate an electric pulse which alters the state of a logic node in the memory device without having a permanent effect on the functionality of the device. This is called a Single Event Upset (SEU) or Soft Error . Contrary to SEU, Single Event Latchup (SEL), Single Event Gate Rapture (SEGR), or Single Event Burnout (SEB) they have permanent effects on the device operation and a system reset or recovery is needed to return to proper operations. The rate at which a device or system encounters soft errors is defined as Soft Error Rate (SER). The semiconductor industry has been struggling with SEEs and is taking necessary measures in order to continue to improve system designs in nano

Analysis of Employee's Survey for Preventing Human-Errors

Energy Technology Data Exchange (ETDEWEB)

Sung, Chanho; Kim, Younggab; Joung, Sanghoun [KHNP Central Research Institute, Daejeon (Korea, Republic of)

2013-10-15

Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses.

[Medication errors in a neonatal unit: One of the main adverse events].

Science.gov (United States)

Esqué Ruiz, M T; Moretones Suñol, M G; Rodríguez Miguélez, J M; Sánchez Ortiz, E; Izco Urroz, M; de Lamo Camino, M; Figueras Aloy, J

2016-04-01

Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. An analysis was performed on the ME declared in a neonatal unit. A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.

Sensation seeking and error processing.

Science.gov (United States)

Zheng, Ya; Sheng, Wenbin; Xu, Jing; Zhang, Yuanyuan

2014-09-01

Sensation seeking is defined by a strong need for varied, novel, complex, and intense stimulation, and a willingness to take risks for such experience. Several theories propose that the insensitivity to negative consequences incurred by risks is one of the hallmarks of sensation-seeking behaviors. In this study, we investigated the time course of error processing in sensation seeking by recording event-related potentials (ERPs) while high and low sensation seekers performed an Eriksen flanker task. Whereas there were no group differences in ERPs to correct trials, sensation seeking was associated with a blunted error-related negativity (ERN), which was female-specific. Further, different subdimensions of sensation seeking were related to ERN amplitude differently. These findings indicate that the relationship between sensation seeking and error processing is sex-specific. Copyright © 2014 Society for Psychophysiological Research.

A novel back-up control structure to manage nonroutine steam upsets in industrial methanol distillation columns

DEFF Research Database (Denmark)

Udugama, Isuru A.; Zander, Cornina; Mansouri, Seyed Soheil

2017-01-01

Industrial methanol production plants have extensive heat integration to achieve energy efficient operations where steam generated from these heat integration operations are used to provide reboiler duty for methanol distillation columns that purify crude methanol produced into industrial AA grade...... supervisory layer to control the column during these non-routine process upsets. These control schemes were tested against realistic reboiler duty disturbances that can occur in an industrial process. The tests revealed that both the MPC and supervisory systems control structures are able to regulate...... the process, even during sudden drops in reboiler duty. However, the cost of implementation and the relative simplicity will likely favour the implementation of the supervisory control structure in an industrial environment....

Error and discrepancy in radiology: inevitable or avoidable?

Science.gov (United States)

Brady, Adrian P

2017-02-01

Errors and discrepancies in radiology practice are uncomfortably common, with an estimated day-to-day rate of 3-5% of studies reported, and much higher rates reported in many targeted studies. Nonetheless, the meaning of the terms "error" and "discrepancy" and the relationship to medical negligence are frequently misunderstood. This review outlines the incidence of such events, the ways they can be categorized to aid understanding, and potential contributing factors, both human- and system-based. Possible strategies to minimise error are considered, along with the means of dealing with perceived underperformance when it is identified. The inevitability of imperfection is explained, while the importance of striving to minimise such imperfection is emphasised. • Discrepancies between radiology reports and subsequent patient outcomes are not inevitably errors. • Radiologist reporting performance cannot be perfect, and some errors are inevitable. • Error or discrepancy in radiology reporting does not equate negligence. • Radiologist errors occur for many reasons, both human- and system-derived. • Strategies exist to minimise error causes and to learn from errors made.

Communicating natural hazards. The case of marine extreme events and the importance of the forecast's errors.

Science.gov (United States)

Marone, Eduardo; Camargo, Ricardo

2013-04-01

Scientific knowledge has to fulfill some necessary conditions. Among them, it has to be properly communicated. Usually, scientists (mis)understand that the communication requirement is satisfied by publishing their results on peer reviewed journals. Society claims for information in other formats or languages and other tools and approaches have to be used, otherwise the scientific discoveries will not fulfill its social mean. However, scientists are not so well trained to do so. These facts are particularly relevant when the scientific work has to deal with natural hazards, which do not affect just a lab or a computer experiment, but the life and fate of human beings. We are actually working with marine extreme events related with sea level changes, waves and other coastal hazards. Primary, the work is developed on the classic scientific format, but focusing not only in the stochastic way of predicting such extreme events, but estimating the potential errors the forecasting methodologies intrinsically have. The scientific results are translated to a friendly format required by stakeholders (which are financing part of the work). Finally, we hope to produce a document prepared for the general public. Each of the targets has their own characteristics and we have to use the proper communication tools and languages. Also, when communicating such knowledge, we have to consider that stakeholders and general public have no obligation of understanding the scientific language, but scientists have the responsibility of translating their discoveries and predictions in a proper way. The information on coastal hazards is analyzed in statistical and numerical ways, departing from long term observation of, for instance, sea level. From the analysis it is possible to recognize different natural regimes and to present the return times of extreme events, while from the numerical models, properly tuned to reproduce the same past ocean behavior using hindcast approaches, it is

Soft error mechanisms, modeling and mitigation

CERN Document Server

Sayil, Selahattin

2016-01-01

This book introduces readers to various radiation soft-error mechanisms such as soft delays, radiation induced clock jitter and pulses, and single event (SE) coupling induced effects. In addition to discussing various radiation hardening techniques for combinational logic, the author also describes new mitigation strategies targeting commercial designs. Coverage includes novel soft error mitigation techniques such as the Dynamic Threshold Technique and Soft Error Filtering based on Transmission gate with varied gate and body bias. The discussion also includes modeling of SE crosstalk noise, delay and speed-up effects. Various mitigation strategies to eliminate SE coupling effects are also introduced. Coverage also includes the reliability of low power energy-efficient designs and the impact of leakage power consumption optimizations on soft error robustness. The author presents an analysis of various power optimization techniques, enabling readers to make design choices that reduce static power consumption an...

Effect of material parameters on stress wave propagation during fast upsetting

Institute of Scientific and Technical Information of China (English)

WANG Zhong-jin; CHENG Li-dong

2008-01-01

Based'on a dynamic analysis method and an explicit algorithm, a dynamic explicit finite element code was developed for modeling the fast upsetting process of block under drop hammer impact, in which the hammer velocity during the deformation was calculated by energy conservation law according to the operating principle of hammer equipment. The stress wave propagation and its effect on the deformation were analyzed by the stress and strain distributions. Industrial pure lead, oxygen-free high-conductivity (OFHC) copper and 7039 aluminum alloy were chosen to investigate the effect of material parameters on the stress wave propagation. The results show that the stress wave propagates from top to bottom of block, and then reflects back when it reaches the bottom surface. After that, stress wave propagates and reflects repeatedly between the upper surface and bottom surface. The stress wave propagation has a significant effect on the deformation at the initial stage, and then becomes weak at the middle-final stage. When the ratio of elastic modulus or the slope of stress-strain curve to mass density becomes larger, the velocity of stress wave propagation increases, and the influence of stress wave on the deformation becomes small.

Texture evolution in upset-forged P/M and wrought tantalum: Experimentation and modeling

International Nuclear Information System (INIS)

Bingert, J.F.; Desch, P.B.; Bingert, S.R.; Maudlin, P.J.; Tome, C.N.

1997-11-01

Preferred orientations in polycrystalline materials can significantly affect their physical and mechanical response through the retention of anisotropic properties inherent to the single crystal. In this study the texture evolution in upset-forged PIM and wrought tantalum was measured as a function of initial texture, compressive strain, and relative position in the pressing. A / duplex fiber texture parallel to the compression axis was generally observed, with varying degrees of a radial component evident in the wrought material. The development of deformation textures derives from restricted crystallographic slip conditions that generate lattice rotations, and these grain reorientations can be modeled as a function of the prescribed deformation gradient. Texture development was simulated for equivalent deformations using both a modified Taylor approach and a viscoplastic self-consistent (VPSC) model. A comparison between the predicted evolution and experimental results shows a good correlation with the texture components, but an overly sharp prediction at large strains from both the Taylor and VPSC models

Calculating method on human error probabilities considering influence of management and organization

International Nuclear Information System (INIS)

Gao Jia; Huang Xiangrui; Shen Zupei

1996-01-01

This paper is concerned with how management and organizational influences can be factored into quantifying human error probabilities on risk assessments, using a three-level Influence Diagram (ID) which is originally only as a tool for construction and representation of models of decision-making trees or event trees. An analytical model of human errors causation has been set up with three influence levels, introducing a method for quantification assessments (of the ID), which can be applied into quantifying probabilities) of human errors on risk assessments, especially into the quantification of complex event trees (system) as engineering decision-making analysis. A numerical case study is provided to illustrate the approach

Trial application of a technique for human error analysis (ATHEANA)

International Nuclear Information System (INIS)

Bley, D.C.; Cooper, S.E.; Parry, G.W.

1996-01-01

The new method for HRA, ATHEANA, has been developed based on a study of the operating history of serious accidents and an understanding of the reasons why people make errors. Previous publications associated with the project have dealt with the theoretical framework under which errors occur and the retrospective analysis of operational events. This is the first attempt to use ATHEANA in a prospective way, to select and evaluate human errors within the PSA context

Influence of planning time and treatment complexity on radiation therapy errors.

Science.gov (United States)

Gensheimer, Michael F; Zeng, Jing; Carlson, Joshua; Spady, Phil; Jordan, Loucille; Kane, Gabrielle; Ford, Eric C

2016-01-01

Radiation treatment planning is a complex process with potential for error. We hypothesized that shorter time from simulation to treatment would result in rushed work and higher incidence of errors. We examined treatment planning factors predictive for near-miss events. Treatments delivered from March 2012 through October 2014 were analyzed. Near-miss events were prospectively recorded and coded for severity on a 0 to 4 scale; only grade 3-4 (potentially severe/critical) events were studied in this report. For 4 treatment types (3-dimensional conformal, intensity modulated radiation therapy, stereotactic body radiation therapy [SBRT], neutron), logistic regression was performed to test influence of treatment planning time and clinical variables on near-miss events. There were 2257 treatment courses during the study period, with 322 grade 3-4 near-miss events. SBRT treatments had more frequent events than the other 3 treatment types (18% vs 11%, P = .04). For the 3-dimensional conformal group (1354 treatments), univariate analysis showed several factors predictive of near-miss events: longer time from simulation to first treatment (P = .01), treatment of primary site versus metastasis (P < .001), longer treatment course (P < .001), and pediatric versus adult patient (P = .002). However, on multivariate regression only pediatric versus adult patient remained predictive of events (P = 0.02). For the intensity modulated radiation therapy, SBRT, and neutron groups, time between simulation and first treatment was not found to be predictive of near-miss events on univariate or multivariate regression. When controlling for treatment technique and other clinical factors, there was no relationship between time spent in radiation treatment planning and near-miss events. SBRT and pediatric treatments were more error-prone, indicating that clinical and technical complexity of treatments should be taken into account when targeting safety interventions. Copyright © 2015 American

The District Nursing Clinical Error Reduction Programme.

Science.gov (United States)

McGraw, Caroline; Topping, Claire

2011-01-01

The District Nursing Clinical Error Reduction (DANCER) Programme was initiated in NHS Islington following an increase in the number of reported medication errors. The objectives were to reduce the actual degree of harm and the potential risk of harm associated with medication errors and to maintain the existing positive reporting culture, while robustly addressing performance issues. One hundred medication errors reported in 2007/08 were analysed using a framework that specifies the factors that predispose to adverse medication events in domiciliary care. Various contributory factors were identified and interventions were subsequently developed to address poor drug calculation and medication problem-solving skills and incorrectly transcribed medication administration record charts. Follow up data were obtained at 12 months and two years. The evaluation has shown that although medication errors do still occur, the programme has resulted in a marked shift towards a reduction in the associated actual degree of harm and the potential risk of harm.

Development of a programming model for radiation-resistant software

International Nuclear Information System (INIS)

Eichhorn, G.; Piercey, R.B.

1984-01-01

The adverse effects of ionizing radiation on microelectronic systems include cumulative dosage effects, single-event upsets (SEU's) and latch-up. Most frequent, especially when the radiation environment includes heavy ions, are SEU's. Unfortunately SEU's are difficult to detect since they can be read (in RAM or ROM) as valid addresses. They can however be handled in software by proper techniques. The authors refer to their method as MRS - Maximally Redundant Software. The MRS programming model which the authors are developing uses multiply redundant boot blocks, majority voting, periodic refresh, and error recovery techniques to minimize the deleterious effects of SEU's. 1 figure

Pulsed laser-induced SEU in integrated circuits

International Nuclear Information System (INIS)

Buchner, S.; Kang, K.; Stapor, W.J.; Campbell, A.B.; Knudson, A.R.; McDonald, P.; Rivet, S.

1990-01-01

The authors have used a pulsed picosecond laser to measure the threshold for single event upset (SEU) and single event latchup (SEL) for two different kinds of integrated circuits. The relative thresholds show good agreement with published ion upset data. The consistency of the results together with the advantages of using a laser system suggest that the pulsed laser can be used for SEU/SEL hardness assurance of integrated circuits

Significant events caused by extraneous acts

International Nuclear Information System (INIS)

Verlaeken, J.

1987-01-01

The operating experience feedback system of VINCOTTE, called ARIANE, consists, among others, of preparing synthesis reports on specific safety concerns. A recent report deals with significant events caused by extranous acts. Events attributable to human error are numerous. Confusion errors have already been analysed in several publications (NES IRS 664 etc.). However, are described here some ten incidents where extranous acts occurred: ZION 2 (September 76), OYSTER CREEK (May 79), PALISADES (January 81), CATAWBA (August 85), etc. The contributing factors for these unfortunate initiatives are explained; several resort to psychological influences. Corrective actions are discussed, and some general lessons are drawn. (author)

Evolution of microstructure and texture in copper during repetitive extrusion-upsetting and subsequent annealing

DEFF Research Database (Denmark)

Chen, Q.; Shu, D. Y.; Lin, J.

2017-01-01

The evolution of the microstructure and texture in copper has been studied during repetitive extrusion-upsetting (REU) to a total von Mises strain of 4.7 and during subsequent annealing at different temperatures. It is found that the texture is significantly altered by each deformation pass...... strain of 4.7 is measured to be ∼0.3μm. This refined microstructure is unstable at room temperature as is evident from the presence of a small number of recrystallized grains in the deformed matrix. Pronounced recrystallization took place during annealing at 200 °C for 1 h with recrystallized grains...... developing predominantly in high misorientation regions. At 350 ºC the microstructure is fully recrystallized with an average grain size of only 2.3 μm and a very weak crystallographic texture. This REU-processed and subsequently annealed material is considered to be potentially suitable for using...

Methods of Run-Time Error Detection in Distributed Process Control Software

DEFF Research Database (Denmark)

Drejer, N.

In this thesis, methods of run-time error detection in application software for distributed process control is designed. The error detection is based upon a monitoring approach in which application software is monitored by system software during the entire execution. The thesis includes definition...... and constraint evaluation is designed for the modt interesting error types. These include: a) semantical errors in data communicated between application tasks; b) errors in the execution of application tasks; and c) errors in the timing of distributed events emitted by the application software. The design...... of error detection methods includes a high level software specification. this has the purpose of illustrating that the designed can be used in practice....

Error and discrepancy in radiology: inevitable or avoidable?

OpenAIRE

Brady, Adrian P.

2016-01-01

Abstract Errors and discrepancies in radiology practice are uncomfortably common, with an estimated day-to-day rate of 3?5% of studies reported, and much higher rates reported in many targeted studies. Nonetheless, the meaning of the terms ?error? and ?discrepancy? and the relationship to medical negligence are frequently misunderstood. This review outlines the incidence of such events, the ways they can be categorized to aid understanding, and potential contributing factors, both human- and ...

Risk analysis of brachytherapy events

International Nuclear Information System (INIS)

Buricova, P.; Zackova, H.; Hobzova, L.; Novotny, J.; Kindlova, A.

2005-01-01

For prevention radiological events it is necessary to identify hazardous situation and to analyse the nature of committed errors. Though the recommendation on the classification and prevention of radiological events: Radiological accidents has been prepared in the framework of Czech Society of Radiation Oncology, Biology and Physics and it was approved by Czech regulatory body (SONS) in 1999, only a few reports have been submitted up to now from brachytherapy practice. At the radiotherapy departments attention has been paid more likely to the problems of dominant teletherapy treatments. But in the two last decades the usage of brachytherapy methods has gradually increased because .nature of this treatment well as the possibilities of operating facility have been completely changed: new radionuclides of high activity are introduced and sophisticate afterloading systems controlled by computers are used. Consequently also the nature of errors, which can occurred in the clinical practice, has been changing. To determine the potentially hazardous parts of procedure the so-called 'process tree', which follows the flow of entire treatment process, has been created for most frequent type of applications. Marking the location of errors on the process tree indicates where failures occurred and accumulation of marks along branches show weak points in the process. Analysed data provide useful information to prevent medical events in brachytherapy .The results strength the requirements given in Recommendations of SONS and revealed the need for its amendment. They call especially for systematic registration of the events. (authors)

DETECTING AND REPORTING THE FRAUDS AND ERRORS BY THE AUDITOR

OpenAIRE

Ovidiu Constantin Bunget; Alin Constantin Dumitrescu

2009-01-01

Responsibility for preventing and detecting fraud rest with management entities.Although the auditor is not and cannot be held responsible for preventing fraud and errors, in yourwork, he can have a positive role in preventing fraud and errors by deterring their occurrence. Theauditor should plan and perform the audit with an attitude of professional skepticism, recognizingthat condition or events may be found that indicate that fraud or error may exist.Based on the audit risk assessment, aud...

NASA Electronic Parts and Packaging (NEPP) Field Programmable Gate Array (FPGA) Single Event Effects (SEE) Test Guideline Update

Science.gov (United States)

Berg, Melanie D.; LaBel, Kenneth A.

2018-01-01

The following are updated or new subjects added to the FPGA SEE Test Guidelines manual: academic versus mission specific device evaluation, single event latch-up (SEL) test and analysis, SEE response visibility enhancement during radiation testing, mitigation evaluation (embedded and user-implemented), unreliable design and its affects to SEE Data, testing flushable architectures versus non-flushable architectures, intellectual property core (IP Core) test and evaluation (addresses embedded and user-inserted), heavy-ion energy and linear energy transfer (LET) selection, proton versus heavy-ion testing, fault injection, mean fluence to failure analysis, and mission specific system-level single event upset (SEU) response prediction. Most sections within the guidelines manual provide information regarding best practices for test structure and test system development. The scope of this manual addresses academic versus mission specific device evaluation and visibility enhancement in IP Core testing.

Lessons-Learned from an Event during Overhaul

Energy Technology Data Exchange (ETDEWEB)

Kim, Jitae [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2013-05-15

The event frequency, also including portion of human errors, has been decreasing compared to last ten years. However, events due to human errors during overhaul occur every year. From analyzed results for human-related events during overhaul, similar problems were identified. And organizational and safety cultural factors were also identified. On the other hand, another event during overhaul is analyzed and Lessons-Learned is drawn in an aspect of the operators' situation awareness. There was an event during overhaul and the analyzed results drawn Lessons-Learned in the aspect of the operators' situation awareness. From the analysis, several alarms and variation of plant parameters during overhaul can occur due to various maintenance works and tests. And in the aspect of the situation awareness, operators can miss, neglect, or not recognize the abnormal situation due to other maintenance activities occurring simultaneously. Therefore, countermeasures such as operator education or training, development of operator support systems, and further researches should be necessary to cope with these problems.

Lessons-Learned from an Event during Overhaul

International Nuclear Information System (INIS)

Kim, Jitae

2013-01-01

The event frequency, also including portion of human errors, has been decreasing compared to last ten years. However, events due to human errors during overhaul occur every year. From analyzed results for human-related events during overhaul, similar problems were identified. And organizational and safety cultural factors were also identified. On the other hand, another event during overhaul is analyzed and Lessons-Learned is drawn in an aspect of the operators' situation awareness. There was an event during overhaul and the analyzed results drawn Lessons-Learned in the aspect of the operators' situation awareness. From the analysis, several alarms and variation of plant parameters during overhaul can occur due to various maintenance works and tests. And in the aspect of the situation awareness, operators can miss, neglect, or not recognize the abnormal situation due to other maintenance activities occurring simultaneously. Therefore, countermeasures such as operator education or training, development of operator support systems, and further researches should be necessary to cope with these problems

A Human Error Analysis Procedure for Identifying Potential Error Modes and Influencing Factors for Test and Maintenance Activities

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun

2010-01-01

Periodic or non-periodic test and maintenance (T and M) activities in large, complex systems such as nuclear power plants (NPPs) are essential for sustaining stable and safe operation of the systems. On the other hand, it also has been raised that human erroneous actions that might occur during T and M activities has the possibility of incurring unplanned reactor trips (RTs) or power derate, making safety-related systems unavailable, or making the reliability of components degraded. Contribution of human errors during normal and abnormal activities of NPPs to the unplanned RTs is known to be about 20% of the total events. This paper introduces a procedure for predictively analyzing human error potentials when maintenance personnel perform T and M tasks based on a work procedure or their work plan. This procedure helps plant maintenance team prepare for plausible human errors. The procedure to be introduced is focusing on the recurrent error forms (or modes) in execution-based errors such as wrong object, omission, too little, and wrong action

Undetected latent failures of safety-related systems. Preliminary survey of events in nuclear power plants 1980-1997

International Nuclear Information System (INIS)

Lydell, B.

1998-03-01

This report summarizes results and insights from a preliminary survey of events involving undetected, latent failures of safety-related systems. The survey was limited to events where mispositioned equipment (e.g., valves, switches) remained undetected, thus rendering standby equipment or systems unavailable for short or long time periods. Typically, these events were symptoms of underlying latent errors (e.g., design errors, procedure errors, unanalyzed safety conditions) and programmatic errors. The preliminary survey identified well over 300 events. Of these, 95 events are documented in this report. Events involving mispositioned equipment are commonplace. Most events are discovered soon after occurrence, however. But as evidenced by the survey results, some events remained undetected beyond several shift changes. The recommendations developed by the survey emphasize the importance of applying modern root cause analysis techniques to the event analysis to ensure that the causes and implications of occurred events are fully understood

Negligence, genuine error, and litigation

Directory of Open Access Journals (Sweden)

Sohn DH

2013-02-01

Full Text Available David H SohnDepartment of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USAAbstract: Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort system in the United States; and review current and future solutions, including medical malpractice reform, alternative dispute resolution, health courts, and no-fault compensation systems. The current political environment favors investigation of non-cap tort reform remedies; investment into more rational oversight systems, such as health courts or no-fault systems may reap both quantitative and qualitative benefits for a less costly and safer health system.Keywords: medical malpractice, tort reform, no fault compensation, alternative dispute resolution, system errors

Error sensitivity analysis in 10-30-day extended range forecasting by using a nonlinear cross-prediction error model

Science.gov (United States)

Xia, Zhiye; Xu, Lisheng; Chen, Hongbin; Wang, Yongqian; Liu, Jinbao; Feng, Wenlan

2017-06-01

Extended range forecasting of 10-30 days, which lies between medium-term and climate prediction in terms of timescale, plays a significant role in decision-making processes for the prevention and mitigation of disastrous meteorological events. The sensitivity of initial error, model parameter error, and random error in a nonlinear crossprediction error (NCPE) model, and their stability in the prediction validity period in 10-30-day extended range forecasting, are analyzed quantitatively. The associated sensitivity of precipitable water, temperature, and geopotential height during cases of heavy rain and hurricane is also discussed. The results are summarized as follows. First, the initial error and random error interact. When the ratio of random error to initial error is small (10-6-10-2), minor variation in random error cannot significantly change the dynamic features of a chaotic system, and therefore random error has minimal effect on the prediction. When the ratio is in the range of 10-1-2 (i.e., random error dominates), attention should be paid to the random error instead of only the initial error. When the ratio is around 10-2-10-1, both influences must be considered. Their mutual effects may bring considerable uncertainty to extended range forecasting, and de-noising is therefore necessary. Second, in terms of model parameter error, the embedding dimension m should be determined by the factual nonlinear time series. The dynamic features of a chaotic system cannot be depicted because of the incomplete structure of the attractor when m is small. When m is large, prediction indicators can vanish because of the scarcity of phase points in phase space. A method for overcoming the cut-off effect ( m > 4) is proposed. Third, for heavy rains, precipitable water is more sensitive to the prediction validity period than temperature or geopotential height; however, for hurricanes, geopotential height is most sensitive, followed by precipitable water.

SEU ground and flight data in static random access memories

International Nuclear Information System (INIS)

Liu, J.; Duan, J.L.; Hou, M.D.; Sun, Y.M.; Yao, H.J.; Mo, D.; Zhang, Q.X.; Wang, Z.G.; Jin, Y.F.; Cai, J.R.; Ye, Z.H.; Han, J.W.; Lin, Y.L.; Huang, Z.

2006-01-01

This paper presents the vulnerabilities of single event effects (SEEs) simulated by heavy ions on ground and observed on SJ-5 research satellite in space for static random access memories (SRAMs). A single event upset (SEU) prediction code has been used to estimate the proton-induced upset rates based on the ground test curve of SEU cross-section versus heavy ion linear energy transfer (LET). The result agrees with that of the flight data

Undetected latent failures of safety-related systems. Preliminary survey of events in nuclear power plants 1980-1997

Energy Technology Data Exchange (ETDEWEB)

Lydell, B. [RSA Technologies, Vista, CA (United States)

1998-03-01

This report summarizes results and insights from a preliminary survey of events involving undetected, latent failures of safety-related systems. The survey was limited to events where mispositioned equipment (e.g., valves, switches) remained undetected, thus rendering standby equipment or systems unavailable for short or long time periods. Typically, these events were symptoms of underlying latent errors (e.g., design errors, procedure errors, unanalyzed safety conditions) and programmatic errors. The preliminary survey identified well over 300 events. Of these, 95 events are documented in this report. Events involving mispositioned equipment are commonplace. Most events are discovered soon after occurrence, however. But as evidenced by the survey results, some events remained undetected beyond several shift changes. The recommendations developed by the survey emphasize the importance of applying modern root cause analysis techniques to the event analysis to ensure that the causes and implications of occurred events are fully understood. 7 refs, 4 tabs, 3 figs. Also available at the SKI Home page: //www.ski.se.

TH-B-BRC-01: How to Identify and Resolve Potential Clinical Errors

Energy Technology Data Exchange (ETDEWEB)

Das, I. [NYU Langone Medical Center, New York, NY (United States)

2016-06-15

Radiation treatment consists of a chain of events influenced by the quality of machine operation, beam data commissioning, machine calibration, patient specific data, simulation, treatment planning, imaging and treatment delivery. There is always a chance that the clinical medical physicist may make or fail to detect an error in one of the events that may impact on the patient’s treatment. In the clinical scenario, errors may be systematic and, without peer review, may have a low detectability because they are not part of routine QA procedures. During treatment, there might be errors on machine that needs attention. External reviews of some of the treatment delivery components by independent reviewers, like IROC, can detect errors, but may not be timely. The goal of this session is to help junior clinical physicists identify potential errors as well as the approach of quality assurance to perform a root cause analysis to find and eliminate an error and to continually monitor for errors. A compilation of potential errors will be presented by examples of the thought process required to spot the error and determine the root cause. Examples may include unusual machine operation, erratic electrometer reading, consistent lower electron output, variation in photon output, body parts inadvertently left in beam, unusual treatment plan, poor normalization, hot spots etc. Awareness of the possibility and detection of error in any link of the treatment process chain will help improve the safe and accurate delivery of radiation to patients. Four experts will discuss how to identify errors in four areas of clinical treatment. D. Followill, NIH grant CA 180803.

TH-B-BRC-01: How to Identify and Resolve Potential Clinical Errors

International Nuclear Information System (INIS)

Das, I.

2016-01-01

Radiation treatment consists of a chain of events influenced by the quality of machine operation, beam data commissioning, machine calibration, patient specific data, simulation, treatment planning, imaging and treatment delivery. There is always a chance that the clinical medical physicist may make or fail to detect an error in one of the events that may impact on the patient’s treatment. In the clinical scenario, errors may be systematic and, without peer review, may have a low detectability because they are not part of routine QA procedures. During treatment, there might be errors on machine that needs attention. External reviews of some of the treatment delivery components by independent reviewers, like IROC, can detect errors, but may not be timely. The goal of this session is to help junior clinical physicists identify potential errors as well as the approach of quality assurance to perform a root cause analysis to find and eliminate an error and to continually monitor for errors. A compilation of potential errors will be presented by examples of the thought process required to spot the error and determine the root cause. Examples may include unusual machine operation, erratic electrometer reading, consistent lower electron output, variation in photon output, body parts inadvertently left in beam, unusual treatment plan, poor normalization, hot spots etc. Awareness of the possibility and detection of error in any link of the treatment process chain will help improve the safe and accurate delivery of radiation to patients. Four experts will discuss how to identify errors in four areas of clinical treatment. D. Followill, NIH grant CA 180803

EVENT PLANNING USING FUNCTION ANALYSIS

Energy Technology Data Exchange (ETDEWEB)

Lori Braase; Jodi Grgich

2011-06-01

Event planning is expensive and resource intensive. Function analysis provides a solid foundation for comprehensive event planning (e.g., workshops, conferences, symposiums, or meetings). It has been used at Idaho National Laboratory (INL) to successfully plan events and capture lessons learned, and played a significant role in the development and implementation of the “INL Guide for Hosting an Event.” Using a guide and a functional approach to planning utilizes resources more efficiently and reduces errors that could be distracting or detrimental to an event. This integrated approach to logistics and program planning – with the primary focus on the participant – gives us the edge.

Human error as a source of disturbances in Swedish nuclear power plants

International Nuclear Information System (INIS)

Sokolowski, E.

1985-01-01

Events involving human errors at the Swedish nuclear power plants are registered and periodically analyzed. The philosophy behind the scheme for data collection and analysis is discussed. Human errors cause about 10% of the disturbances registered. Only a small part of these errors are committed by operators in the control room. These and other findings differ from those in other countries. Possible reasons are put forward

Design Margin Elimination Through Robust Timing Error Detection at Ultra-Low Voltage

OpenAIRE

Reyserhove, Hans; Dehaene, Wim

2017-01-01

This paper discusses a timing error masking-aware ARM Cortex M0 microcontroller system. Through in-path timing error detection, operation at the point-of-first-failure is possi- ble without corrupting the pipeline state, effectively eliminat- ing traditional timing margins. Error events are flagged and gathered to allow dynamic voltage scaling. The error-aware microcontroller was implemented in a 40nm CMOS process and realizes ultra-low voltage operation down to 0.29V at 5MHz consuming 12.90p...

Study of Errors among Nursing Students

Directory of Open Access Journals (Sweden)

Ella Koren

2007-09-01

Full Text Available The study of errors in the health system today is a topic of considerable interest aimed at reducing errors through analysis of the phenomenon and the conclusions reached. Errors that occur frequently among health professionals have also been observed among nursing students. True, in most cases they are actually “near errors,” but these could be a future indicator of therapeutic reality and the effect of nurses' work environment on their personal performance. There are two different approaches to such errors: (a The EPP (error prone person approach lays full responsibility at the door of the individual involved in the error, whether a student, nurse, doctor, or pharmacist. According to this approach, handling consists purely in identifying and penalizing the guilty party. (b The EPE (error prone environment approach emphasizes the environment as a primary contributory factor to errors. The environment as an abstract concept includes components and processes of interpersonal communications, work relations, human engineering, workload, pressures, technical apparatus, and new technologies. The objective of the present study was to examine the role played by factors in and components of personal performance as compared to elements and features of the environment. The study was based on both of the aforementioned approaches, which, when combined, enable a comprehensive understanding of the phenomenon of errors among the student population as well as a comparison of factors contributing to human error and to error deriving from the environment. The theoretical basis of the study was a model that combined both approaches: one focusing on the individual and his or her personal performance and the other focusing on the work environment. The findings emphasize the work environment of health professionals as an EPE. However, errors could have been avoided by means of strict adherence to practical procedures. The authors examined error events in the

Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms.

Science.gov (United States)

Fox, Michael D; Bump, Gregory M; Butler, Gabriella A; Chen, Ling-Wan; Buchert, Andrew R

2017-01-30

Reporting medical errors is a focus of the patient safety movement. As frontline physicians, residents are optimally positioned to recognize errors and flaws in systems of care. Previous work highlights the difficulty of engaging residents in identification and/or reduction of medical errors and in integrating these trainees into their institutions' cultures of safety. The authors describe the implementation of a longitudinal, discipline-based, multifaceted curriculum to enhance the reporting of errors by pediatric residents at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center. The key elements of this curriculum included providing the necessary education to identify medical errors with an emphasis on systems-based causes, modeling of error reporting by faculty, and integrating error reporting and discussion into the residents' daily activities. The authors tracked monthly error reporting rates by residents and other health care professionals, in addition to serious harm event rates at the institution. The interventions resulted in significant increases in error reports filed by residents, from 3.6 to 37.8 per month over 4 years (P error reporting correlated with a decline in serious harm events, from 15.0 to 8.1 per month over 4 years (P = 0.01). Integrating patient safety into the everyday resident responsibilities encourages frequent reporting and discussion of medical errors and leads to improvements in patient care. Multiple simultaneous interventions are essential to making residents part of the safety culture of their training hospitals.

Disclosing harmful medical errors to patients: tackling three tough cases.

Science.gov (United States)

Gallagher, Thomas H; Bell, Sigall K; Smith, Kelly M; Mello, Michelle M; McDonald, Timothy B

2009-09-01

A gap exists between recommendations to disclose errors to patients and current practice. This gap may reflect important, yet unanswered questions about implementing disclosure principles. We explore some of these unanswered questions by presenting three real cases that pose challenging disclosure dilemmas. The first case involves a pancreas transplant that failed due to the pancreas graft being discarded, an error that was not disclosed partly because the family did not ask clarifying questions. Relying on patient or family questions to determine the content of disclosure is problematic. We propose a standard of materiality that can help clinicians to decide what information to disclose. The second case involves a fatal diagnostic error that the patient's widower was unaware had happened. The error was not disclosed out of concern that disclosure would cause the widower more harm than good. This case highlights how institutions can overlook patients' and families' needs following errors and emphasizes that benevolent deception has little role in disclosure. Institutions should consider whether involving neutral third parties could make disclosures more patient centered. The third case presents an intraoperative cardiac arrest due to a large air embolism where uncertainty around the clinical event was high and complicated the disclosure. Uncertainty is common to many medical errors but should not deter open conversations with patients and families about what is and is not known about the event. Continued discussion within the medical profession about applying disclosure principles to real-world cases can help to better meet patients' and families' needs following medical errors.

Automated Testing with Targeted Event Sequence Generation

DEFF Research Database (Denmark)

Jensen, Casper Svenning; Prasad, Mukul R.; Møller, Anders

2013-01-01

Automated software testing aims to detect errors by producing test inputs that cover as much of the application source code as possible. Applications for mobile devices are typically event-driven, which raises the challenge of automatically producing event sequences that result in high coverage...

Methods of Run-Time Error Detection in Distributed Process Control Software

DEFF Research Database (Denmark)

Drejer, N.

of generic run-time error types, design of methods of observing application software behaviorduring execution and design of methods of evaluating run time constraints. In the definition of error types it is attempted to cover all relevant aspects of the application softwaree behavior. Methods of observation......In this thesis, methods of run-time error detection in application software for distributed process control is designed. The error detection is based upon a monitoring approach in which application software is monitored by system software during the entire execution. The thesis includes definition...... and constraint evaluation is designed for the modt interesting error types. These include: a) semantical errors in data communicated between application tasks; b) errors in the execution of application tasks; and c) errors in the timing of distributed events emitted by the application software. The design...

MODELS OF AIR TRAFFIC CONTROLLERS ERRORS PREVENTION IN TERMINAL CONTROL AREAS UNDER UNCERTAINTY CONDITIONS

Directory of Open Access Journals (Sweden)

Volodymyr Kharchenko

2017-03-01

Full Text Available Purpose: the aim of this study is to research applied models of air traffic controllers’ errors prevention in terminal control areas (TMA under uncertainty conditions. In this work the theoretical framework descripting safety events and errors of air traffic controllers connected with the operations in TMA is proposed. Methods: optimisation of terminal control area formal description based on the Threat and Error management model and the TMA network model of air traffic flows. Results: the human factors variables associated with safety events in work of air traffic controllers under uncertainty conditions were obtained. The Threat and Error management model application principles to air traffic controller operations and the TMA network model of air traffic flows were proposed. Discussion: Information processing context for preventing air traffic controller errors, examples of threats in work of air traffic controllers, which are relevant for TMA operations under uncertainty conditions.

Failures without errors: quantification of context in HRA

International Nuclear Information System (INIS)

Fujita, Yushi; Hollnagel, Erik

2004-01-01

PSA-cum-human reliability analysis (HRA) has traditionally used individual human actions, hence individual 'human errors', as a meaningful unit of analysis. This is inconsistent with the current understanding of accidents, which points out that the notion of 'human error' is ill defined and that adverse events more often are the due to the working conditions than to people. Several HRA approaches, such as ATHEANA and CREAM have recognised this conflict and proposed ways to deal with it. This paper describes an improvement of the basic screening method in CREAM, whereby a rating of the performance conditions can be used to calculate a Mean Failure Rate directly without invoking the notion of human error

Errors as a Means of Reducing Impulsive Food Choice.

Science.gov (United States)

Sellitto, Manuela; di Pellegrino, Giuseppe

2016-06-05

Nowadays, the increasing incidence of eating disorders due to poor self-control has given rise to increased obesity and other chronic weight problems, and ultimately, to reduced life expectancy. The capacity to refrain from automatic responses is usually high in situations in which making errors is highly likely. The protocol described here aims at reducing imprudent preference in women during hypothetical intertemporal choices about appetitive food by associating it with errors. First, participants undergo an error task where two different edible stimuli are associated with two different error likelihoods (high and low). Second, they make intertemporal choices about the two edible stimuli, separately. As a result, this method decreases the discount rate for future amounts of the edible reward that cued higher error likelihood, selectively. This effect is under the influence of the self-reported hunger level. The present protocol demonstrates that errors, well known as motivationally salient events, can induce the recruitment of cognitive control, thus being ultimately useful in reducing impatient choices for edible commodities.

SIMULATED HUMAN ERROR PROBABILITY AND ITS APPLICATION TO DYNAMIC HUMAN FAILURE EVENTS

Energy Technology Data Exchange (ETDEWEB)

Herberger, Sarah M.; Boring, Ronald L.

2016-10-01

Abstract Objectives: Human reliability analysis (HRA) methods typically analyze human failure events (HFEs) at the overall task level. For dynamic HRA, it is important to model human activities at the subtask level. There exists a disconnect between dynamic subtask level and static task level that presents issues when modeling dynamic scenarios. For example, the SPAR-H method is typically used to calculate the human error probability (HEP) at the task level. As demonstrated in this paper, quantification in SPAR-H does not translate to the subtask level. Methods: Two different discrete distributions were generated for each SPAR-H Performance Shaping Factor (PSF) to define the frequency of PSF levels. The first distribution was a uniform, or uninformed distribution that assumed the frequency of each PSF level was equally likely. The second non-continuous distribution took the frequency of PSF level as identified from an assessment of the HERA database. These two different approaches were created to identify the resulting distribution of the HEP. The resulting HEP that appears closer to the known distribution, a log-normal centered on 1E-3, is the more desirable. Each approach then has median, average and maximum HFE calculations applied. To calculate these three values, three events, A, B and C are generated from the PSF level frequencies comprised of subtasks. The median HFE selects the median PSF level from each PSF and calculates HEP. The average HFE takes the mean PSF level, and the maximum takes the maximum PSF level. The same data set of subtask HEPs yields starkly different HEPs when aggregated to the HFE level in SPAR-H. Results: Assuming that each PSF level in each HFE is equally likely creates an unrealistic distribution of the HEP that is centered at 1. Next the observed frequency of PSF levels was applied with the resulting HEP behaving log-normally with a majority of the values under 2.5% HEP. The median, average and maximum HFE calculations did yield

Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes.

Science.gov (United States)

Verghese, Abraham; Charlton, Blake; Kassirer, Jerome P; Ramsey, Meghan; Ioannidis, John P A

2015-12-01

Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences. A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting. Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to perform the physical examination in 63%; 14% reported that the correct physical examination sign was elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought. Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the finding was 2, but many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66 took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen, groin, and genitourinary area could reduce the reported oversights by half. Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform the relevant examination. Copyright © 2015 Elsevier Inc. All rights reserved.

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Science.gov (United States)

Espin, Sherry; Levinson, Wendy; Regehr, Glenn; Baker, G Ross; Lingard, Lorelei

2006-01-01

Calls abound for a culture change in health care to improve patient safety. However, effective change cannot proceed without a clear understanding of perceptions and beliefs about error. In this study, we describe and compare operative team members' and patients' perceptions of error, reporting of error, and disclosure of error. Thirty-nine interviews of team members (9 surgeons, 9 nurses, 10 anesthesiologists) and patients (11) were conducted at 2 teaching hospitals using 4 scenarios as prompts. Transcribed responses to open questions were analyzed by 2 researchers for recurrent themes using the grounded-theory method. Yes/no answers were compared across groups using chi-square analyses. Team members and patients agreed on what constitutes an error. Deviation from standards and negative outcome were emphasized as definitive features. Patients and nurse professionals differed significantly in their perception of whether errors should be reported. Nurses were willing to report only events within their disciplinary scope of practice. Although most patients strongly advocated full disclosure of errors (what happened and how), team members preferred to disclose only what happened. When patients did support partial disclosure, their rationales varied from that of team members. Both operative teams and patients define error in terms of breaking the rules and the concept of "no harm no foul." These concepts pose challenges for treating errors as system failures. A strong culture of individualism pervades nurses' perception of error reporting, suggesting that interventions are needed to foster collective responsibility and a constructive approach to error identification.

Savannah River Site human error data base development for nonreactor nuclear facilities

International Nuclear Information System (INIS)

Benhardt, H.C.; Held, J.E.; Olsen, L.M.; Vail, R.E.; Eide, S.A.

1994-01-01

As part of an overall effort to upgrade and streamline methodologies for safety analyses of nonreactor nuclear facilities at the Savannah River Site (SRS), a human error data base has been developed and is presented in this report. The data base fulfills several needs of risk analysts supporting safety analysis report (SAR) development. First, it provides a single source for probabilities or rates for a wide variety of human errors associated with the SRS nonreactor nuclear facilities. Second, it provides a documented basis for human error probabilities or rates. And finally, it provides actual SRS-specific human error data to support many of the error probabilities or rates. Use of a single, documented reference source for human errors, supported by SRS-specific human error data, will improve the consistency and accuracy of human error modeling by SRS risk analysts. It is envisioned that SRS risk analysts will use this report as both a guide to identifying the types of human errors that may need to be included in risk models such as fault and event trees, and as a source for human error probabilities or rates. For each human error in this report, ffime different mean probabilities or rates are presented to cover a wide range of conditions and influencing factors. The ask analysts must decide which mean value is most appropriate for each particular application. If other types of human errors are needed for the risk models, the analyst must use other sources. Finally, if human enors are dominant in the quantified risk models (based on the values obtained fmm this report), then it may be appropriate to perform detailed human reliability analyses (HRAS) for the dominant events. This document does not provide guidance for such refined HRAS; in such cases experienced human reliability analysts should be involved

Proceedings from Specialists Meeting on human performance in operational events

International Nuclear Information System (INIS)

1998-01-01

This conference on human performance in operational events is composed of 34 papers, grouped in 11 sessions. After an invited contribution on the human factor in the nuclear industry, the sessions are: session 1 (Operational events: Human performance in operational events - how to improve it?, Human performance research strategies for human performance, The development of a model of control room operator cognition), session 2 (Operational response: A study of the recovery from 120 events, Empirical study of the influence of organizational and procedural characteristics on team performance in the emergency situation using plant simulators, Cognitive skills and nuclear power plant operational decision making), session 3 (PSA for Probabilistic Safety Analysis: A sensitivity study of human errors in optimizing surveillance test interval (STI) and allowed outage time (AOT) of standby safety system, Analysis of Parks nuclear power plant personnel activity during safety related event sequences, An EDF project to update the Probabilistic Human Reliability Assessment PHRA methodology), session 4 (modelling with ATHEANA: Atheana, a technique for human error analysis, an overview of its methodological basis, Common elements on operational events across technologies, Results of nuclear power plant application of new technique for human error analysis), session 5 (Regulatory practice: US.NRC Research and analysis activities concerning human reliability assessment and human performance evaluation, Introduction of simulator-based examinations and its effects on the nuclear industry, Regulatory monitoring of human performance in PWR operation in France), session 6 (Simulation: Human performance in Bavarian nuclear power plant as a preventive element, Human performance event database, Crew situation awareness, diagnoses and performance in simulated nuclear power plant process disturbances), session 7 (Operator aids: Development of a plant navigation system, Operation system

Error processing - evidence from intracerebral ERP recordings

Czech Academy of Sciences Publication Activity Database

Brázdil, M.; Roman, R.; Falkenstein, M.; Daniel, P.; Jurák, Pavel; Rektor, I.

2002-01-01

Roč. 146, č. 4 (2002), s. - ISSN 1432-1106 R&D Projects: GA ČR GA102/95/0467; GA ČR GA102/02/1339 Institutional research plan: CEZ:AV0Z2065902 Keywords : error processing * event-related potentials * intracerebral recordings Subject RIV: FA - Cardiovascular Diseases incl. Cardiotharic Surgery

Analysis of gross error rates in operation of commercial nuclear power stations

International Nuclear Information System (INIS)

Joos, D.W.; Sabri, Z.A.; Husseiny, A.A.

1979-01-01

Experience in operation of US commercial nuclear power plants is reviewed over a 25-month period. The reports accumulated in that period on events of human error and component failure are examined to evaluate gross operator error rates. The impact of such errors on plant operation and safety is examined through the use of proper taxonomies of error, tasks and failures. Four categories of human errors are considered; namely, operator, maintenance, installation and administrative. The computed error rates are used to examine appropriate operator models for evaluation of operator reliability. Human error rates are found to be significant to a varying degree in both BWR and PWR. This emphasizes the import of considering human factors in safety and reliability analysis of nuclear systems. The results also indicate that human errors, and especially operator errors, do indeed follow the exponential reliability model. (Auth.)

Negligence, genuine error, and litigation

Science.gov (United States)

Sohn, David H

2013-01-01

Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort system in the United States; and review current and future solutions, including medical malpractice reform, alternative dispute resolution, health courts, and no-fault compensation systems. The current political environment favors investigation of non-cap tort reform remedies; investment into more rational oversight systems, such as health courts or no-fault systems may reap both quantitative and qualitative benefits for a less costly and safer health system. PMID:23426783

Phenotyping for patient safety: algorithm development for electronic health record based automated adverse event and medical error detection in neonatal intensive care.

Science.gov (United States)

Li, Qi; Melton, Kristin; Lingren, Todd; Kirkendall, Eric S; Hall, Eric; Zhai, Haijun; Ni, Yizhao; Kaiser, Megan; Stoutenborough, Laura; Solti, Imre

2014-01-01

Although electronic health records (EHRs) have the potential to provide a foundation for quality and safety algorithms, few studies have measured their impact on automated adverse event (AE) and medical error (ME) detection within the neonatal intensive care unit (NICU) environment. This paper presents two phenotyping AE and ME detection algorithms (ie, IV infiltrations, narcotic medication oversedation and dosing errors) and describes manual annotation of airway management and medication/fluid AEs from NICU EHRs. From 753 NICU patient EHRs from 2011, we developed two automatic AE/ME detection algorithms, and manually annotated 11 classes of AEs in 3263 clinical notes. Performance of the automatic AE/ME detection algorithms was compared to trigger tool and voluntary incident reporting results. AEs in clinical notes were double annotated and consensus achieved under neonatologist supervision. Sensitivity, positive predictive value (PPV), and specificity are reported. Twelve severe IV infiltrates were detected. The algorithm identified one more infiltrate than the trigger tool and eight more than incident reporting. One narcotic oversedation was detected demonstrating 100% agreement with the trigger tool. Additionally, 17 narcotic medication MEs were detected, an increase of 16 cases over voluntary incident reporting. Automated AE/ME detection algorithms provide higher sensitivity and PPV than currently used trigger tools or voluntary incident-reporting systems, including identification of potential dosing and frequency errors that current methods are unequipped to detect. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Development of a framework to estimate human error for diagnosis tasks in advanced control room

International Nuclear Information System (INIS)

Kim, Ar Ryum; Jang, In Seok; Seong, Proong Hyun

2014-01-01

In the emergency situation of nuclear power plants (NPPs), a diagnosis of the occurring events is crucial for managing or controlling the plant to a safe and stable condition. If the operators fail to diagnose the occurring events or relevant situations, their responses can eventually inappropriate or inadequate Accordingly, huge researches have been performed to identify the cause of diagnosis error and estimate the probability of diagnosis error. D.I Gertman et al. asserted that 'the cognitive failures stem from erroneous decision-making, poor understanding of rules and procedures, and inadequate problem solving and this failures may be due to quality of data and people's capacity for processing information'. Also many researchers have asserted that human-system interface (HSI), procedure, training and available time are critical factors to cause diagnosis error. In nuclear power plants, a diagnosis of the event is critical for safe condition of the system. As advanced main control room is being adopted in nuclear power plants, the operators may obtain the plant data via computer-based HSI and procedure. Also many researchers have asserted that HSI, procedure, training and available time are critical factors to cause diagnosis error. In this regards, using simulation data, diagnosis errors and its causes were identified. From this study, some useful insights to reduce diagnosis errors of operators in advanced main control room were provided

Root-Cause Analysis of a Potentially Sentinel Transfusion Event: Lessons for Improvement of Patient Safety

Directory of Open Access Journals (Sweden)

Ali Reza Jeddian

2012-09-01

Full Text Available Errors prevention and patient safety in transfusion medicine are a serious concern. Errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. Root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. To specify system vulnerabilities and illustrate the potential of such an approach, we describe the root cause analysis of a case of transfusion error in emergency ward that could have been fatal. After reporting of the mentioned event, through reviewing records and interviews with the responsible personnel, the details of the incident were elaborated. Then, an expert panel meeting was held to define event timeline and the care and service delivery problems and discuss their underlying causes, safeguards and preventive measures. Root cause analysis of the mentioned event demonstrated that certain defects of the system and the ensuing errors were main causes of the event. It also points out systematic corrective actions. It can be concluded that health care organizations should endeavor to provide opportunities to discuss errors and adverse events and introduce preventive measures to find areas where resources need to be allocated to improve patient safety.

On the Spatial and Temporal Sampling Errors of Remotely Sensed Precipitation Products

Directory of Open Access Journals (Sweden)

Ali Behrangi

2017-11-01

Full Text Available Observation with coarse spatial and temporal sampling can cause large errors in quantification of the amount, intensity, and duration of precipitation events. In this study, the errors resulting from temporal and spatial sampling of precipitation events were quantified and examined using the latest version (V4 of the Global Precipitation Measurement (GPM mission integrated multi-satellite retrievals for GPM (IMERG, which is available since spring of 2014. Relative mean square error was calculated at 0.1° × 0.1° every 0.5 h between the degraded (temporally and spatially and original IMERG products. The temporal and spatial degradation was performed by producing three-hour (T3, six-hour (T6, 0.5° × 0.5° (S5, and 1.0° × 1.0° (S10 maps. The results show generally larger errors over land than ocean, especially over mountainous regions. The relative error of T6 is almost 20% larger than T3 over tropical land, but is smaller in higher latitudes. Over land relative error of T6 is larger than S5 across all latitudes, while T6 has larger relative error than S10 poleward of 20°S–20°N. Similarly, the relative error of T3 exceeds S5 poleward of 20°S–20°N, but does not exceed S10, except in very high latitudes. Similar results are also seen over ocean, but the error ratios are generally less sensitive to seasonal changes. The results also show that the spatial and temporal relative errors are not highly correlated. Overall, lower correlations between the spatial and temporal relative errors are observed over ocean than over land. Quantification of such spatiotemporal effects provides additional insights into evaluation studies, especially when different products are cross-compared at a range of spatiotemporal scales.

An error taxonomy system for analysis of haemodialysis incidents.

Science.gov (United States)

Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

2014-12-01

This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Human Errors - A Taxonomy for Describing Human Malfunction in Industrial Installations

DEFF Research Database (Denmark)

Rasmussen, Jens

1982-01-01

This paper describes the definition and the characteristics of human errors. Different types of human behavior are classified, and their relation to different error mechanisms are analyzed. The effect of conditioning factors related to affective, motivating aspects of the work situation as well...... as physiological factors are also taken into consideration. The taxonomy for event analysis, including human malfunction, is presented. Possibilities for the prediction of human error are discussed. The need for careful studies in actual work situations is expressed. Such studies could provide a better...

Error detection, handling and recovery at the High Level Trigger of the ATLAS experiment at the LHC

CERN Document Server

AUTHOR|(INSPIRE)INSPIRE-00223972; The ATLAS collaboration

2016-01-01

The complexity of the ATLAS High Level Trigger (HLT) requires a robust system for error detection and handling during online data-taking; it also requires an offline system for the recovery of events where no trigger decision could be made online. The error detection and handling ensure smooth operation of the trigger system and provide debugging information necessary for offline analysis and diagnosis. In this presentation, we give an overview of the error detection, handling and recovery of problematic events at the HLT of ATLAS.

Charge collection and SEU mechanisms

Science.gov (United States)

Musseau, O.

1994-01-01

In the interaction of cosmic ions with microelectronic devices a dense electron-hole plasma is created along the ion track. Carriers are separated and transported by the electric field and under the action of the concentration gradient. The subsequent collection of these carriers induces a transient current at some electrical node of the device. This "ionocurrent" (single ion induced current) acts as any electrical perturbation in the device, propagating in the circuit and inducing failures. In bistable systems (registers, memories) the stored data can be upset. In clocked devices (microprocessors) the parasitic perturbation may propagate through the device to the outputs. This type of failure only effects the information, and do not degrade the functionally of the device. The purpose of this paper is to review the mechanisms of single event upset in microelectronic devices. Experimental and theoretical results are presented, and actual questions and problems are discussed. A brief introduction recalls the creation of the dense plasma of electron-hole pairs. The basic processes for charge collection in a simple np junction (drift and diffusion) are presented. The funneling-field effect is discussed and experimental results are compared to numerical simulations and semi-empirical models. Charge collection in actual microelectronic structures is then presented. Due to the parasitic elements, coupling effects are observed. Geometrical effects, in densely packed structures, results in multiple errors. Electronic couplings are due to the carriers in excess, acting as minority carriers, that trigger parasitic bipolar transistors. Single event upset of memory cells is discussed, based on numerical and experimental data. The main parameters for device characterization are presented. From the physical interpretation of charge collection mechanisms, the intrinsic sensitivity of various microelectronic technologies is determined and compared to experimental data. Scaling laws

Statistical error in simulations of Poisson processes: Example of diffusion in solids

Science.gov (United States)

Nilsson, Johan O.; Leetmaa, Mikael; Vekilova, Olga Yu.; Simak, Sergei I.; Skorodumova, Natalia V.

2016-08-01

Simulations of diffusion in solids often produce poor statistics of diffusion events. We present an analytical expression for the statistical error in ion conductivity obtained in such simulations. The error expression is not restricted to any computational method in particular, but valid in the context of simulation of Poisson processes in general. This analytical error expression is verified numerically for the case of Gd-doped ceria by running a large number of kinetic Monte Carlo calculations.

The role of financial auditor in detecting and reporting fraud and error

OpenAIRE

Bunget, Ovidiu-Constantin

2009-01-01

Responsibility for preventing and detecting fraud rest with management entities. Although the auditor is not and cannot be held responsible for preventing fraud and errors, in your work, he can have a positive role in preventing fraud and errors by deterring their occurrence. The auditor should plan and perform the audit with an attitude of professional skepticism, recognizing that condition or events may be found that indicate that fraud or error may exist. Based on the audit risk asse...

A monitor for the laboratory evaluation of control integrity in digital control systems operating in harsh electromagnetic environments

Science.gov (United States)

Belcastro, Celeste M.; Fischl, Robert; Kam, Moshe

1992-01-01

This paper presents a strategy for dynamically monitoring digital controllers in the laboratory for susceptibility to electromagnetic disturbances that compromise control integrity. The integrity of digital control systems operating in harsh electromagnetic environments can be compromised by upsets caused by induced transient electrical signals. Digital system upset is a functional error mode that involves no component damage, can occur simultaneously in all channels of a redundant control computer, and is software dependent. The motivation for this work is the need to develop tools and techniques that can be used in the laboratory to validate and/or certify critical aircraft controllers operating in electromagnetically adverse environments that result from lightning, high-intensity radiated fields (HIRF), and nuclear electromagnetic pulses (NEMP). The detection strategy presented in this paper provides dynamic monitoring of a given control computer for degraded functional integrity resulting from redundancy management errors, control calculation errors, and control correctness/effectiveness errors. In particular, this paper discusses the use of Kalman filtering, data fusion, and statistical decision theory in monitoring a given digital controller for control calculation errors.

Electrophysiological correlates of error processing in borderline personality disorder.

Science.gov (United States)

Ruchsow, Martin; Walter, Henrik; Buchheim, Anna; Martius, Philipp; Spitzer, Manfred; Kächele, Horst; Grön, Georg; Kiefer, Markus

2006-05-01

The electrophysiological correlates of error processing were investigated in patients with borderline personality disorder (BPD) using event-related potentials (ERP). Twelve patients with BPD and 12 healthy controls were additionally rated with the Barratt impulsiveness scale (BIS-10). Participants performed a Go/Nogo task while a 64 channel EEG was recorded. Three ERP components were of special interest: error-related negativity (ERN)/error negativity (Ne), early error positivity (early Pe) reflecting automatic error processing, and the late Pe component which is thought to mirror the awareness of erroneous responses. We found smaller amplitudes of the ERN/Ne in patients with BPD compared to controls. Moreover, significant correlations with the BIS-10 non-planning sub-score could be demonstrated for both the entire group and the patient group. No between-group differences were observed for the early and late Pe components. ERP measures appear to be a suitable tool to study clinical time courses in BPD.

A stochastic dynamic model for human error analysis in nuclear power plants

Science.gov (United States)

Delgado-Loperena, Dharma

Nuclear disasters like Three Mile Island and Chernobyl indicate that human performance is a critical safety issue, sending a clear message about the need to include environmental press and competence aspects in research. This investigation was undertaken to serve as a roadmap for studying human behavior through the formulation of a general solution equation. The theoretical model integrates models from two heretofore-disassociated disciplines (behavior specialists and technical specialists), that historically have independently studied the nature of error and human behavior; including concepts derived from fractal and chaos theory; and suggests re-evaluation of base theory regarding human error. The results of this research were based on comprehensive analysis of patterns of error, with the omnipresent underlying structure of chaotic systems. The study of patterns lead to a dynamic formulation, serving for any other formula used to study human error consequences. The search for literature regarding error yielded insight for the need to include concepts rooted in chaos theory and strange attractors---heretofore unconsidered by mainstream researchers who investigated human error in nuclear power plants or those who employed the ecological model in their work. The study of patterns obtained from the rupture of a steam generator tube (SGTR) event simulation, provided a direct application to aspects of control room operations in nuclear power plant operations. In doing so, the conceptual foundation based in the understanding of the patterns of human error analysis can be gleaned, resulting in reduced and prevent undesirable events.

Action errors, error management, and learning in organizations.

Science.gov (United States)

Frese, Michael; Keith, Nina

2015-01-03

Every organization is confronted with errors. Most errors are corrected easily, but some may lead to negative consequences. Organizations often focus on error prevention as a single strategy for dealing with errors. Our review suggests that error prevention needs to be supplemented by error management--an approach directed at effectively dealing with errors after they have occurred, with the goal of minimizing negative and maximizing positive error consequences (examples of the latter are learning and innovations). After defining errors and related concepts, we review research on error-related processes affected by error management (error detection, damage control). Empirical evidence on positive effects of error management in individuals and organizations is then discussed, along with emotional, motivational, cognitive, and behavioral pathways of these effects. Learning from errors is central, but like other positive consequences, learning occurs under certain circumstances--one being the development of a mind-set of acceptance of human error.

Modeling coherent errors in quantum error correction

Science.gov (United States)

Greenbaum, Daniel; Dutton, Zachary

2018-01-01

Analysis of quantum error correcting codes is typically done using a stochastic, Pauli channel error model for describing the noise on physical qubits. However, it was recently found that coherent errors (systematic rotations) on physical data qubits result in both physical and logical error rates that differ significantly from those predicted by a Pauli model. Here we examine the accuracy of the Pauli approximation for noise containing coherent errors (characterized by a rotation angle ɛ) under the repetition code. We derive an analytic expression for the logical error channel as a function of arbitrary code distance d and concatenation level n, in the small error limit. We find that coherent physical errors result in logical errors that are partially coherent and therefore non-Pauli. However, the coherent part of the logical error is negligible at fewer than {ε }-({dn-1)} error correction cycles when the decoder is optimized for independent Pauli errors, thus providing a regime of validity for the Pauli approximation. Above this number of correction cycles, the persistent coherent logical error will cause logical failure more quickly than the Pauli model would predict, and this may need to be combated with coherent suppression methods at the physical level or larger codes.

A methodology for collection and analysis of human error data based on a cognitive model: IDA

International Nuclear Information System (INIS)

Shen, S.-H.; Smidts, C.; Mosleh, A.

1997-01-01

This paper presents a model-based human error taxonomy and data collection. The underlying model, IDA (described in two companion papers), is a cognitive model of behavior developed for analysis of the actions of nuclear power plant operating crew during abnormal situations. The taxonomy is established with reference to three external reference points (i.e. plant status, procedures, and crew) and four reference points internal to the model (i.e. information collected, diagnosis, decision, action). The taxonomy helps the analyst: (1) recognize errors as such; (2) categorize the error in terms of generic characteristics such as 'error in selection of problem solving strategies' and (3) identify the root causes of the error. The data collection methodology is summarized in post event operator interview and analysis summary forms. The root cause analysis methodology is illustrated using a subset of an actual event. Statistics, which extract generic characteristics of error prone behaviors and error prone situations are presented. Finally, applications of the human error data collection are reviewed. A primary benefit of this methodology is to define better symptom-based and other auxiliary procedures with associated training to minimize or preclude certain human errors. It also helps in design of control rooms, and in assessment of human error probabilities in the probabilistic risk assessment framework. (orig.)

Simulation of pulsed-ionizing-radiation-induced errors in CMOS memory circuits

International Nuclear Information System (INIS)

Massengill, L.W.

1987-01-01

Effects of transient ionizing radiation on complementary metal-oxide-semiconductor (CMOS) memory circuits was studied by computer simulation. Simulation results have uncovered the dominant mechanism leading to information loss (upset) in dense (CMOS) circuits: rail span collapse. This effect is the catastrophic reduction in the local power supply at a RAM cell location due to the conglomerate radiation-induced photocurrents from all other RAM cells flowing through the power-supply-interconnect distribution. Rail-span collapse leads to reduced RAM cell-noise margins and can predicate upset. Results show that rail-span collapse in the dominant pulsed radiation effect in many memory circuits, preempting local circuit responses to the radiation. Several techniques to model power-supply noise, such as that arising from rail span collapse, are presented in this work. These include an analytical model for design optimization against these effects, a hierarchical computer-analysis technique for efficient power bus noise simulation in arrayed circuits, such as memories, and a complete circuit-simulation tool for noise margin analysis of circuits with arbitrary topologies

Applications Of Monte Carlo Radiation Transport Simulation Techniques For Predicting Single Event Effects In Microelectronics

International Nuclear Information System (INIS)

Warren, Kevin; Reed, Robert; Weller, Robert; Mendenhall, Marcus; Sierawski, Brian; Schrimpf, Ronald

2011-01-01

MRED (Monte Carlo Radiative Energy Deposition) is Vanderbilt University's Geant4 application for simulating radiation events in semiconductors. Geant4 is comprised of the best available computational physics models for the transport of radiation through matter. In addition to basic radiation transport physics contained in the Geant4 core, MRED has the capability to track energy loss in tetrahedral geometric objects, includes a cross section biasing and track weighting technique for variance reduction, and additional features relevant to semiconductor device applications. The crucial element of predicting Single Event Upset (SEU) parameters using radiation transport software is the creation of a dosimetry model that accurately approximates the net collected charge at transistor contacts as a function of deposited energy. The dosimetry technique described here is the multiple sensitive volume (MSV) model. It is shown to be a reasonable approximation of the charge collection process and its parameters can be calibrated to experimental measurements of SEU cross sections. The MSV model, within the framework of MRED, is examined for heavy ion and high-energy proton SEU measurements of a static random access memory.

On Error Analysis of ORIGEN Decay Data Library Based on ENDF/B-VII.1 via Decay Heat Estimation after a Fission Event

Energy Technology Data Exchange (ETDEWEB)

Kim, Do Heon; Gil, Choong-Sup; Lee, Young-Ouk [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2015-10-15

The method is strongly dependent on the available nuclear structure data, i.e., fission product yield data and decay data. Consequently, the improvements in the nuclear structure data could have guaranteed more reliable decay heat estimation for short cooling times after fission. The SCALE-6.1.3 code package includes the ENDF/B-VII.0-based fission product yield data and ENDF/B-VII.1-based decay data libraries for the ORIGEN-S code. The generation and validation of the new ORIGEN-S yield data libraries based on the recently available fission product yield data such as ENDF/B-VII.1, JEFF-3.1.1, JENDL/FPY-2011, and JENDL-4.0 have been presented in the previous study. According to the study, the yield data library in the SCALE-6.1.3 could be regarded as the latest one because it resulted in almost the same outcomes as the ENDF/B-VII.1. A research project on the production of the nuclear structure data for decay heat estimation of nuclear fuel has been carried out in Korea Atomic Energy Research Institute (KAERI). The data errors contained in the ORIGEN-S decay data library of SCALE-6.1.3 have been clearly identified by their changing variables. Also, the impacts of the decay data errors have been analyzed by estimating the decay heats for the fission product nuclides and their daughters after {sup 235}U thermal-neutron fission. Although the impacts of decay data errors are quite small, it reminds us the possible importance of decay data when estimating the decay heat for short cooling times after a fission event.

Specialist Physicians' Attitudes and Practice Patterns Regarding Disclosure of Pre-referral Medical Errors.

Science.gov (United States)

Dossett, Lesly A; Kauffmann, Rondi M; Lee, Jay S; Singh, Harkamal; Lee, M Catherine; Morris, Arden M; Jagsi, Reshma; Quinn, Gwendolyn P; Dimick, Justin B

2018-06-01

Our objective was to determine specialist physicians' attitudes and practices regarding disclosure of pre-referral errors. Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral. We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure. Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the profession's reputation, and to patient-physician relationships. Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development.

Heuristic thinking: interdisciplinary perspectives on medical error

Directory of Open Access Journals (Sweden)

Annegret F. Hannawa

2013-12-01

Full Text Available Approximately 43 million adverse events occur across the globe each year at a cost of at least 23 million disability-adjusted life years and $132 billion in excess health care spending, ranking this safety burden among the top 10 medical causes of disability in the world.1 These findings are likely to be an understatement of the actual severity of the problem, given that the numbers merely reflect seven types of adverse events and completely neglect ambulatory care, and of course they only cover reported incidents. Furthermore, they do not include statistics on children and incidents from India and China, which host more than a third of the world’s population. Best estimates imply that about two thirds of these incidents are preventable. Thus, from a public health perspective, medical errors are a seri- ous global health burden, in fact ahead of high-profile health problems like AIDS and cancer. Interventions to date have not reduced medical errors to satisfactory rates. Even today, far too often, hand hygiene is not practiced properly (even in developed countries, surgical procedures take place in underequipped operating theaters, and checklists are missing or remain uncompleted. The healthcare system seems to be failing in managing its errors − it is costing too much, and the complexity of care causes severe safety hazards that too often harm rather than help patients. In response to this evolving discussion, the International Society for Quality in Healthcare recently nominated an Innovations Team that is now developing new strategies. One of the emerging themes is that the medical field cannot resolve this problem on its own. Instead, interdisciplinary collaborations are needed to advance effective, evidence-based interventions that will eventually result in competent changes. In March 2013, the Institute of Communication and Health at the University of Lugano organized a conference on Communicating Medical Error (COME 2013 in

A real-time assessment of factors influencing medication events.

Science.gov (United States)

Dollarhide, Adrian W; Rutledge, Thomas; Weinger, Matthew B; Fisher, Erin Stucky; Jain, Sonia; Wolfson, Tanya; Dresselhaus, Timothy R

2014-01-01

Reducing medical error is critical to improving the safety and quality of healthcare. Physician stress, fatigue, and excessive workload are performance-shaping factors (PSFs) that may influence medical events (actual administration errors and near misses), but direct relationships between these factors and patient safety have not been clearly defined. This study assessed the real-time influence of emotional stress, workload, and sleep deprivation on self-reported medication events by physicians in academic hospitals. During an 18-month study period, 185 physician participants working at four university-affiliated teaching hospitals reported medication events using a confidential reporting application on handheld computers. Emotional stress scores, perceived workload, patient case volume, clinical experience, total sleep, and demographic variables were also captured via the handheld computers. Medication event reports (n = 11) were then correlated with these demographic and PSFs. Medication events were associated with 36.1% higher perceived workload (p sleep (p = .10). These results confirm the effect of factors influencing medication events, and support attention to both provider and hospital environmental characteristics for improving patient safety. © 2013 National Association for Healthcare Quality.

Disasters of endoscopic surgery and how to avoid them: error analysis.

Science.gov (United States)

Troidl, H

1999-08-01

For every innovation there are two sides to consider. For endoscopic surgery the positive side is more comfort for the patient, and the negative side is new complications, even disasters, such as injuries to organs (e.g., the bowel), vessels, and the common bile duct. These disasters are rare and seldom reported in the scientific world, as at conferences, at symposiums, and in publications. Today there are many methods for testing an innovation (controlled clinical trials, consensus conferences, audits, and confidential inquiries). Reporting "complications," however, does not help to avoid them. We need real methods for avoiding negative failures. The failure analysis is the method of choice in industry. If an airplane crashes, error analysis starts immediately. Humans make errors, and making errors means punishment. Failure analysis means rigorously and objectively investigating a clinical situation to find clinical relevant information for avoiding these negative events in the future. Error analysis has four important steps: (1) What was the clinical situation? (2) What has happened? (3) Most important: Why did it happen? (4) How do we avoid the negative event or disaster in the future. Error analysis has decisive advantages. It is easy to perform; it supplies clinically relevant information to help avoid it; and there is no need for money. It can be done everywhere; and the information is available in a short time. The other side of the coin is that error analysis is of course retrospective, it may not be objective, and most important it will probably have legal consequences. To be more effective in medicine and surgery we must handle our errors using a different approach. According to Sir Karl Popper: "The consituation is that we have to learn from our errors. To cover up failure is therefore the biggest intellectual sin.

FDA Adverse Event Reporting System (FAERS): Latest Quartely Data Files

Data.gov (United States)

U.S. Department of Health & Human Services — The FDA Adverse Event Reporting System (FAERS) is a database that contains information on adverse event and medication error reports submitted to FDA. The database...

Towards Multimodal Error Management:Experimental Evaluation of User Strategies in Event of Faulty Application Behavior in Automotive Environments

Directory of Open Access Journals (Sweden)

Gregor McGlaun

2004-10-01

Full Text Available In this work, we present the results of a study analyzing the reactions of subjects on simulated errors of a dedicated in-car interface for controlling infotainment and communication services. The test persons could operate the system, using different input modalities, such as natural or command speech as well as head and hand gestures, or classical tactile paradigms. In various situational contexts, we scrutinized the interaction patterns the test participants applied to overcome different operation tasks. Moreover, we evaluated individual user behavior concerning modality transitions and individual fallback strategies in case of system errors. Two different error types (Hidden System Errors and Apparent System Errors were provoked. As a result, we found out that initially, i.e. with the system working properly, most users prefer tactile or speech interaction. In case of Hidden System Errors, mostly changes from speech to tactile interaction and vice versa occurred. Concerning Apparent System Errors, 87% of the subjects automatically interrupted or cancelled their input procedure. 73% of all test persons who continued interaction, when the reason for the faulty system behavior was gone, strictly kept the selected modality. Regarding the given input vocabulary, none of the subjects selected head or hand gesture input as the leading fallback modality.

Applying modern error theory to the problem of missed injuries in trauma.

Science.gov (United States)

Clarke, D L; Gouveia, J; Thomson, S R; Muckart, D J J

2008-06-01

Modern theory of human error has helped reduce the incidence of adverse events in commercial aviation. It remains unclear whether these lessons are applicable to adverse events in trauma surgery. Missed injuries in a large metropolitan surgical service were prospectively audited and analyzed using a modern error taxonomy to define its applicability to trauma. A prospective database of all patients who experienced a missed injury during a 6-month period in a busy surgical service was maintained from July 2006. A missed injury was defined as one that escaped detection from primary assessment to operative exploration. Each missed injury was recorded and categorized. The clinical significance of the error and the level of physician responsible was documented. Errors were divided into planning or execution errors, acts of omission or commission, or violations, slips, and lapses. A total of 1,024 trauma patients were treated by the surgical services over the 6-month period from July to December 2006 in Pietermaritzburg. Thirty-four patients (2.5%) with missed injuries were identified during this period. There were 29 men and 5 women with an average age of 29 years (range: 21-67 years). In 14 patients, errors were related to inadequate clinical assessment. In 11 patients errors involved the misinterpretation of, or failure to respond to radiological imaging. There were 9 cases in which an injury was missed during surgical exploration. Overall mortality was 27% (9 patients). In 5 cases death was directly attributable to the missed injury. The level of the physicians making the error was consultant surgeon (4 cases), resident in training (15 cases), career medical officer (2 cases), referring doctor (6 cases). Missed injuries are uncommon and are made by all grades of staff. They are associated with increased morbidity and mortality. Understanding the pattern of these errors may help develop error-reduction strategies. Current taxonomies help in understanding the error

Integrating natural language processing expertise with patient safety event review committees to improve the analysis of medication events.

Science.gov (United States)

Fong, Allan; Harriott, Nicole; Walters, Donna M; Foley, Hanan; Morrissey, Richard; Ratwani, Raj R

2017-08-01

Many healthcare providers have implemented patient safety event reporting systems to better understand and improve patient safety. Reviewing and analyzing these reports is often time consuming and resource intensive because of both the quantity of reports and length of free-text descriptions in the reports. Natural language processing (NLP) experts collaborated with clinical experts on a patient safety committee to assist in the identification and analysis of medication related patient safety events. Different NLP algorithmic approaches were developed to identify four types of medication related patient safety events and the models were compared. Well performing NLP models were generated to categorize medication related events into pharmacy delivery delays, dispensing errors, Pyxis discrepancies, and prescriber errors with receiver operating characteristic areas under the curve of 0.96, 0.87, 0.96, and 0.81 respectively. We also found that modeling the brief without the resolution text generally improved model performance. These models were integrated into a dashboard visualization to support the patient safety committee review process. We demonstrate the capabilities of various NLP models and the use of two text inclusion strategies at categorizing medication related patient safety events. The NLP models and visualization could be used to improve the efficiency of patient safety event data review and analysis. Copyright © 2017 Elsevier B.V. All rights reserved.

Error-Induced Learning as a Resource-Adaptive Process in Young and Elderly Individuals

Science.gov (United States)

Ferdinand, Nicola K.; Weiten, Anja; Mecklinger, Axel; Kray, Jutta

Thorndike described in his law of effect [44] that actions followed by positive events are more likely to be repeated in the future, whereas actions that are followed by negative outcomes are less likely to be repeated. This implies that behavior is evaluated in the light of its potential consequences, and non-reward events (i.e., errors) must be detected for reinforcement learning to take place. In short, humans have to monitor their performance in order to detect and correct errors, and this allows them to successfully adapt their behavior to changing environmental demands and acquire new behavior, i.e., to learn.

Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.

Science.gov (United States)

McKaig, Donald; Collins, Christine; Elsaid, Khaled A

2014-09-01

A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site. During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors. Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.

The probability and the management of human error

International Nuclear Information System (INIS)

Dufey, R.B.; Saull, J.W.

2004-01-01

Embedded within modern technological systems, human error is the largest, and indeed dominant contributor to accident cause. The consequences dominate the risk profiles for nuclear power and for many other technologies. We need to quantify the probability of human error for the system as an integral contribution within the overall system failure, as it is generally not separable or predictable for actual events. We also need to provide a means to manage and effectively reduce the failure (error) rate. The fact that humans learn from their mistakes allows a new determination of the dynamic probability and human failure (error) rate in technological systems. The result is consistent with and derived from the available world data for modern technological systems. Comparisons are made to actual data from large technological systems and recent catastrophes. Best estimate values and relationships can be derived for both the human error rate, and for the probability. We describe the potential for new approaches to the management of human error and safety indicators, based on the principles of error state exclusion and of the systematic effect of learning. A new equation is given for the probability of human error (λ) that combines the influences of early inexperience, learning from experience (ε) and stochastic occurrences with having a finite minimum rate, this equation is λ 5.10 -5 + ((1/ε) - 5.10 -5 ) exp(-3*ε). The future failure rate is entirely determined by the experience: thus the past defines the future

Brain State Before Error Making in Young Patients With Mild Spastic Cerebral Palsy.

Science.gov (United States)

Hakkarainen, Elina; Pirilä, Silja; Kaartinen, Jukka; van der Meere, Jaap J

2015-10-01

In the present experiment, children with mild spastic cerebral palsy and a control group carried out a memory recognition task. The key question was if errors of the patient group are foreshadowed by attention lapses, by weak motor preparation, or by both. Reaction times together with event-related potentials associated with motor preparation (frontal late contingent negative variation), attention (parietal P300), and response evaluation (parietal error-preceding positivity) were investigated in instances where 3 subsequent correct trials preceded an error. The findings indicated that error responses of the patient group are foreshadowed by weak motor preparation in correct trials directly preceding an error. © The Author(s) 2015.

Errors and Correction of Precipitation Measurements in China

Institute of Scientific and Technical Information of China (English)

REN Zhihua; LI Mingqin

2007-01-01

In order to discover the range of various errors in Chinese precipitation measurements and seek a correction method, 30 precipitation evaluation stations were set up countrywide before 1993. All the stations are reference stations in China. To seek a correction method for wind-induced error, a precipitation correction instrument called the "horizontal precipitation gauge" was devised beforehand. Field intercomparison observations regarding 29,000 precipitation events have been conducted using one pit gauge, two elevated operational gauges and one horizontal gauge at the above 30 stations. The range of precipitation measurement errors in China is obtained by analysis of intercomparison measurement results. The distribution of random errors and systematic errors in precipitation measurements are studied in this paper.A correction method, especially for wind-induced errors, is developed. The results prove that a correlation of power function exists between the precipitation amount caught by the horizontal gauge and the absolute difference of observations implemented by the operational gauge and pit gauge. The correlation coefficient is 0.99. For operational observations, precipitation correction can be carried out only by parallel observation with a horizontal precipitation gauge. The precipitation accuracy after correction approaches that of the pit gauge. The correction method developed is simple and feasible.

Detailed semantic analyses of human error incidents occurring at nuclear power plant in USA (interim report). Characteristics of human error incidents occurring in the period from 1992 to 1996

International Nuclear Information System (INIS)

Hirotsu, Yuko; Tsuge, Tadashi; Sano, Toshiaki; Takano, Kenichi; Gouda, Hidenori

2001-01-01

CRIEPI has been conducting detailed analyses of all human error incidents at domestic nuclear power plants (NPPs) collected from Japanese Licensee Event Reports (LERs) using J-HPES (Japanese version of HPES) as an analysis method. Results obtained by the analyses have been stored in J-HPES database. Since 1999, human error incidents have been selected from U.S. LERs, and they are analyzed using J-HPES. In this report, the results, which classified error action, cause, and preventive measure, are summarized for U.S. human error cases occurring in the period from 1992 to 1996. It was suggested as a result of classification that the categories of error action were almost the same as those of Japanese human error cases. Therefore, problems in the process of error action and checkpoints for preventing errors will be extracted by analyzing both U.S. and domestic human error cases. It was also suggested that the interrelations between error actions, causes, and organizational factors could be identified. While taking these suggestions into consideration, we will continue to analyze U.S. human error cases. (author)

Period, epoch, and prediction errors of ephemerides from continuous sets of timing measurements

Science.gov (United States)

Deeg, H. J.

2015-06-01

Space missions such as Kepler and CoRoT have led to large numbers of eclipse or transit measurements in nearly continuous time series. This paper shows how to obtain the period error in such measurements from a basic linear least-squares fit, and how to correctly derive the timing error in the prediction of future transit or eclipse events. Assuming strict periodicity, a formula for the period error of these time series is derived, σP = σT (12 / (N3-N))1 / 2, where σP is the period error, σT the timing error of a single measurement, and N the number of measurements. Compared to the iterative method for period error estimation by Mighell & Plavchan (2013), this much simpler formula leads to smaller period errors, whose correctness has been verified through simulations. For the prediction of times of future periodic events, usual linear ephemeris were epoch errors are quoted for the first time measurement, are prone to an overestimation of the error of that prediction. This may be avoided by a correction for the duration of the time series. An alternative is the derivation of ephemerides whose reference epoch and epoch error are given for the centre of the time series. For long continuous or near-continuous time series whose acquisition is completed, such central epochs should be the preferred way for the quotation of linear ephemerides. While this work was motivated from the analysis of eclipse timing measures in space-based light curves, it should be applicable to any other problem with an uninterrupted sequence of discrete timings for which the determination of a zero point, of a constant period and of the associated errors is needed.

Some aspects of statistical modeling of human-error probability

International Nuclear Information System (INIS)

Prairie, R.R.

1982-01-01

Human reliability analyses (HRA) are often performed as part of risk assessment and reliability projects. Recent events in nuclear power have shown the potential importance of the human element. There are several on-going efforts in the US and elsewhere with the purpose of modeling human error such that the human contribution can be incorporated into an overall risk assessment associated with one or more aspects of nuclear power. An effort that is described here uses the HRA (event tree) to quantify and model the human contribution to risk. As an example, risk analyses are being prepared on several nuclear power plants as part of the Interim Reliability Assessment Program (IREP). In this process the risk analyst selects the elements of his fault tree that could be contributed to by human error. He then solicits the HF analyst to do a HRA on this element

A Quantitative Index to Support Recurrence Prevention Plans of Human-Related Events

Energy Technology Data Exchange (ETDEWEB)

Kim, Yochan; Park, Jinkyun; Jung, Wondea [KAERI, Daejeon (Korea, Republic of); Kim, Do Sam; Lee, Durk Hun [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2015-05-15

In Korea, HuRAM+ (Human related event Root cause Analysis Method plus) was developed to scrutinize the causes of the human-related events. The information of the human-related events investigated by the HuRAM+ method has been also managed by a database management system, R-tracer. It is obvious that accumulating data of human error causes aims to support plans that reduce recurrences of similar events. However, in spite of the efforts for the development of the human error database, it was indicated that the database does not provide useful empirical basis for establishment of the recurrence prevention plans, because the framework to interpret the collected data and apply the insights from the data into the prevention plants has not been developed yet. In this paper, in order to support establishment of the recurrence prevention plans, a quantitative index, Human Error Repeat Interval (HERI), was proposed and its applications to human error prevention were introduced. In this paper, a quantitative index, the HERI was proposed and the statistics of HERIs were introduced. These estimations can be employed to evaluate effects of recurrence prevention plans to human errors. If a mean HERI score is low and the linear trend is not positive, it can be suspected that the recurrence prevention plans applied every human-related event has not been effectively propagated. For reducing repetitive error causes, the system design or operational culture can be reviewed. If there is a strong and negative trend, systematic investigation of the root causes behind these trends is required. Likewise, we expect that the HERI index will provide significant basis for establishing or adjusting prevention plans of human errors. The accurate estimation and application of HERI scores is expected to be done after accumulating more data. When a scatter plot of HERIs is fitted by two or more models, a statistical model selection method can be employed. Some criteria have been introduced by

A Quantitative Index to Support Recurrence Prevention Plans of Human-Related Events

International Nuclear Information System (INIS)

Kim, Yochan; Park, Jinkyun; Jung, Wondea; Kim, Do Sam; Lee, Durk Hun

2015-01-01

In Korea, HuRAM+ (Human related event Root cause Analysis Method plus) was developed to scrutinize the causes of the human-related events. The information of the human-related events investigated by the HuRAM+ method has been also managed by a database management system, R-tracer. It is obvious that accumulating data of human error causes aims to support plans that reduce recurrences of similar events. However, in spite of the efforts for the development of the human error database, it was indicated that the database does not provide useful empirical basis for establishment of the recurrence prevention plans, because the framework to interpret the collected data and apply the insights from the data into the prevention plants has not been developed yet. In this paper, in order to support establishment of the recurrence prevention plans, a quantitative index, Human Error Repeat Interval (HERI), was proposed and its applications to human error prevention were introduced. In this paper, a quantitative index, the HERI was proposed and the statistics of HERIs were introduced. These estimations can be employed to evaluate effects of recurrence prevention plans to human errors. If a mean HERI score is low and the linear trend is not positive, it can be suspected that the recurrence prevention plans applied every human-related event has not been effectively propagated. For reducing repetitive error causes, the system design or operational culture can be reviewed. If there is a strong and negative trend, systematic investigation of the root causes behind these trends is required. Likewise, we expect that the HERI index will provide significant basis for establishing or adjusting prevention plans of human errors. The accurate estimation and application of HERI scores is expected to be done after accumulating more data. When a scatter plot of HERIs is fitted by two or more models, a statistical model selection method can be employed. Some criteria have been introduced by

An Estimation of Human Error Probability of Filtered Containment Venting System Using Dynamic HRA Method

Energy Technology Data Exchange (ETDEWEB)

Jang, Seunghyun; Jae, Moosung [Hanyang University, Seoul (Korea, Republic of)

2016-10-15

The human failure events (HFEs) are considered in the development of system fault trees as well as accident sequence event trees in part of Probabilistic Safety Assessment (PSA). As a method for analyzing the human error, several methods, such as Technique for Human Error Rate Prediction (THERP), Human Cognitive Reliability (HCR), and Standardized Plant Analysis Risk-Human Reliability Analysis (SPAR-H) are used and new methods for human reliability analysis (HRA) are under developing at this time. This paper presents a dynamic HRA method for assessing the human failure events and estimation of human error probability for filtered containment venting system (FCVS) is performed. The action associated with implementation of the containment venting during a station blackout sequence is used as an example. In this report, dynamic HRA method was used to analyze FCVS-related operator action. The distributions of the required time and the available time were developed by MAAP code and LHS sampling. Though the numerical calculations given here are only for illustrative purpose, the dynamic HRA method can be useful tools to estimate the human error estimation and it can be applied to any kind of the operator actions, including the severe accident management strategy.

A logic programming approach to medical errors in imaging.

Science.gov (United States)

Rodrigues, Susana; Brandão, Paulo; Nelas, Luís; Neves, José; Alves, Victor

2011-09-01

In 2000, the Institute of Medicine reported disturbing numbers on the scope it covers and the impact of medical error in the process of health delivery. Nevertheless, a solution to this problem may lie on the adoption of adverse event reporting and learning systems that can help to identify hazards and risks. It is crucial to apply models to identify the adverse events root causes, enhance the sharing of knowledge and experience. The efficiency of the efforts to improve patient safety has been frustratingly slow. Some of this insufficiency of progress may be assigned to the lack of systems that take into account the characteristic of the information about the real world. In our daily lives, we formulate most of our decisions normally based on incomplete, uncertain and even forbidden or contradictory information. One's knowledge is less based on exact facts and more on hypothesis, perceptions or indications. From the data collected on our adverse event treatment and learning system on medical imaging, and through the use of Extended Logic Programming to knowledge representation and reasoning, and the exploitation of new methodologies for problem solving, namely those based on the perception of what is an agent and/or multi-agent systems, we intend to generate reports that identify the most relevant causes of error and define improvement strategies, concluding about the impact, place of occurrence, form or type of event recorded in the healthcare institutions. The Eindhoven Classification Model was extended and adapted to the medical imaging field and used to classify adverse events root causes. Extended Logic Programming was used for knowledge representation with defective information, allowing for the modelling of the universe of discourse in terms of data and knowledge default. A systematization of the evolution of the body of knowledge about Quality of Information embedded in the Root Cause Analysis was accomplished. An adverse event reporting and learning system

Nurse-perceived Patient Adverse Events and Nursing Practice Environment

Directory of Open Access Journals (Sweden)

Jeong-Hee Kang

2014-09-01

Full Text Available Objectives: To evaluate the occurrence of patient adverse events in Korean hospitals as perceived by nurses and examine the correlation between patient adverse events with the nurse practice environment at nurse and hospital level. Methods: In total, 3096 nurses working in 60 general inpatient hospital units were included. A two-level logistic regression analysis was performed. Results: At the hospital level, patient adverse events included patient falls (60.5%, nosocomial infections (51.7%, pressure sores (42.6% and medication errors (33.3%. Among the hospital-level explanatory variables associated with the nursing practice environment, ‘physician- nurse relationship’ correlated with medication errors while ‘education for improving quality of care’ affected patient falls. Conclusions: The doctor-nurse relationship and access to education that can improve the quality of care at the hospital level may help decrease the occurrence of patient adverse events.

Optimization of resistively hardened latches

International Nuclear Information System (INIS)

Gagne, G.; Savaria, Y.

1990-01-01

The design of digital circuits tolerant to single-event upsets is considered. The results of a study are presented on which an analytical model was used to predict the behavior of a standard resistively hardened latch. It is shown that a worst case analysis for all possible single-event upset situations (on the latch or in the logic) can be derived from studying the effects of a transient disturbed write cycle. The existence of an intrinsic minimum write period to tolerate a transient of a given duration is also demonstrated

A Dynamic Approach to Modeling Dependence Between Human Failure Events

Energy Technology Data Exchange (ETDEWEB)

Boring, Ronald Laurids [Idaho National Laboratory

2015-09-01

In practice, most HRA methods use direct dependence from THERP—the notion that error be- gets error, and one human failure event (HFE) may increase the likelihood of subsequent HFEs. In this paper, we approach dependence from a simulation perspective in which the effects of human errors are dynamically modeled. There are three key concepts that play into this modeling: (1) Errors are driven by performance shaping factors (PSFs). In this context, the error propagation is not a result of the presence of an HFE yielding overall increases in subsequent HFEs. Rather, it is shared PSFs that cause dependence. (2) PSFs have qualities of lag and latency. These two qualities are not currently considered in HRA methods that use PSFs. Yet, to model the effects of PSFs, it is not simply a matter of identifying the discrete effects of a particular PSF on performance. The effects of PSFs must be considered temporally, as the PSFs will have a range of effects across the event sequence. (3) Finally, there is the concept of error spilling. When PSFs are activated, they not only have temporal effects but also lateral effects on other PSFs, leading to emergent errors. This paper presents the framework for tying together these dynamic dependence concepts.