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Sample records for mode failure analysis

  1. Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures.

    Science.gov (United States)

    Ashley, Laura; Armitage, Gerry

    2010-12-01

    To empirically compare 2 different commonly used failure mode and effects analysis (FMEA) scoring procedures with respect to their resultant failure mode scores and prioritization: a mathematical procedure, where scores are assigned independently by FMEA team members and averaged, and a consensus procedure, where scores are agreed on by the FMEA team via discussion. A multidisciplinary team undertook a Healthcare FMEA of chemotherapy administration. This included mapping the chemotherapy process, identifying and scoring failure modes (potential errors) for each process step, and generating remedial strategies to counteract them. Failure modes were scored using both an independent mathematical procedure and a team consensus procedure. Almost three-fifths of the 30 failure modes generated were scored differently by the 2 procedures, and for just more than one-third of cases, the score discrepancy was substantial. Using the Healthcare FMEA prioritization cutoff score, almost twice as many failure modes were prioritized by the consensus procedure than by the mathematical procedure. This is the first study to empirically demonstrate that different FMEA scoring procedures can score and prioritize failure modes differently. It found considerable variability in individual team members' opinions on scores, which highlights the subjective and qualitative nature of failure mode scoring. A consensus scoring procedure may be most appropriate for FMEA as it allows variability in individuals' scores and rationales to become apparent and to be discussed and resolved by the team. It may also yield team learning and communication benefits unlikely to result from a mathematical procedure.

  2. A streamlined failure mode and effects analysis

    International Nuclear Information System (INIS)

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

    2014-01-01

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

  3. A streamlined failure mode and effects analysis.

    Science.gov (United States)

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

    2014-06-01

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

  4. A streamlined failure mode and effects analysis

    Energy Technology Data Exchange (ETDEWEB)

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

    2014-06-15

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

  5. Preliminary failure mode and effect analysis

    International Nuclear Information System (INIS)

    Addison, J.V.

    1972-01-01

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

  6. Failure Modes and Effects Analysis (FMEA): A Bibliography

    Science.gov (United States)

    2000-01-01

    Failure modes and effects analysis (FMEA) is a bottom-up analytical process that identifies process hazards, which helps managers understand vulnerabilities of systems, as well as assess and mitigate risk. It is one of several engineering tools and techniques available to program and project managers aimed at increasing the likelihood of safe and successful NASA programs and missions. This bibliography references 465 documents in the NASA STI Database that contain the major concepts, failure modes or failure analysis, in either the basic index of the major subject terms.

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

    International Nuclear Information System (INIS)

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

    2013-01-01

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

  8. Probabilistic analysis of ''common mode failures''

    International Nuclear Information System (INIS)

    Easterling, R.G.

    1978-01-01

    Common mode failure is a topic of considerable interest in reliability and safety analyses of nuclear reactors. Common mode failures are often discussed in terms of examples: two systems fail simultaneously due to an external event such as an earthquake; two components in redundant channels fail because of a common manufacturing defect; two systems fail because a component common to both fails; the failure of one system increases the stress on other systems and they fail. The common thread running through these is a dependence of some sort--statistical or physical--among multiple failure events. However, the nature of the dependence is not the same in all these examples. An attempt is made to model situations, such as the above examples, which have been termed ''common mode failures.'' In doing so, it is found that standard probability concepts and terms, such as statistically dependent and independent events, and conditional and unconditional probabilities, suffice. Thus, it is proposed that the term ''common mode failures'' be dropped, at least from technical discussions of these problems. A corollary is that the complementary term, ''random failures,'' should also be dropped. The mathematical model presented may not cover all situations which have been termed ''common mode failures,'' but provides insight into the difficulty of obtaining estimates of the probabilities of these events

  9. Failure mode and effects analysis of software-based automation systems

    International Nuclear Information System (INIS)

    Haapanen, P.; Helminen, A.

    2002-08-01

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

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

    International Nuclear Information System (INIS)

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

    2013-01-01

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

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

    International Nuclear Information System (INIS)

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

    1976-01-01

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

  12. Failure Mode and Effect Analysis for Wind Turbine Systems in China

    DEFF Research Database (Denmark)

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

    2017-01-01

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

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

    Science.gov (United States)

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

    2013-09-01

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

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

    Science.gov (United States)

    Flores, Melissa; Malin, Jane T.

    2013-01-01

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

  15. A quantitative method for Failure Mode and Effects Analysis

    NARCIS (Netherlands)

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

    2012-01-01

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

  16. Process Equipment Failure Mode Analysis in a Chemical Industry

    Directory of Open Access Journals (Sweden)

    J. Nasl Seraji

    2008-04-01

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

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

    Science.gov (United States)

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

    2015-05-01

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

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

    Science.gov (United States)

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

    2010-01-01

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

  19. Failure Modes of thin supported Membranes

    DEFF Research Database (Denmark)

    Hendriksen, Peter Vang; Høgsberg, J.R.; Kjeldsen, Ane Mette

    2007-01-01

    Four different failure modes relevant to tubular supported membranes (thin dense films on a thick porous support) were analyzed. The failure modes were: 1) Structural collapse due to external pressure 2) burst of locally unsupported areas, 3) formation of surface cracks in the membrane due to TEC......-mismatches, and finally 4) delamination between membrane and support due to expansion of the membrane on use. Design criteria to minimize risk of failure by the four different modes are discussed. The theoretical analysis of the two last failure modes is compared to failures observed on actual components....

  20. An engineering approach to common mode failure analysis

    International Nuclear Information System (INIS)

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

    1975-01-01

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

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

    Science.gov (United States)

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

    2017-11-01

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

  2. Failure modes and effects analysis of fusion magnet systems

    International Nuclear Information System (INIS)

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

    1988-12-01

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

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

    International Nuclear Information System (INIS)

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

    2011-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2015-06-15

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

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

    International Nuclear Information System (INIS)

    Huq, M.

    2015-01-01

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

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

    Science.gov (United States)

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

    2016-08-01

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

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

    Directory of Open Access Journals (Sweden)

    Benedictus Rahardjo

    2016-06-01

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

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

    Science.gov (United States)

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

    2016-01-01

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

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

    International Nuclear Information System (INIS)

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

    1996-06-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    1996-06-01

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

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

    International Nuclear Information System (INIS)

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

    2015-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2015-10-15

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

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

    International Nuclear Information System (INIS)

    Bartholomew, R.J.

    1982-01-01

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

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

    NARCIS (Netherlands)

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

    2007-01-01

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

  15. Defense against common-mode failures in protection system design

    International Nuclear Information System (INIS)

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

    1998-01-01

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

  16. Defense against common-mode failures in protection system design

    International Nuclear Information System (INIS)

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

    1997-01-01

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

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

    Science.gov (United States)

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

    2016-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

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

    International Nuclear Information System (INIS)

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

    2016-01-01

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

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

    International Nuclear Information System (INIS)

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

    2016-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2010-12-15

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

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

    Science.gov (United States)

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

    2010-12-01

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

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

    International Nuclear Information System (INIS)

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

    2010-01-01

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

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

    International Nuclear Information System (INIS)

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

    1995-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Ze-Ling Wang

    2017-01-01

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

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

    Science.gov (United States)

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

    2017-12-01

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

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

    Science.gov (United States)

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

    2011-01-01

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

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

    International Nuclear Information System (INIS)

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

    2009-01-01

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

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

    Science.gov (United States)

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

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

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

    Science.gov (United States)

    Sawant, M.; Christou, A.

    2012-12-01

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

  12. Advanced approaches to failure mode and effect analysis (FMEA applications

    Directory of Open Access Journals (Sweden)

    D. Vykydal

    2015-10-01

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

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

    Science.gov (United States)

    Chen, Ying-Chu; Tsai, Pei-Yi

    2017-06-01

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

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

    Directory of Open Access Journals (Sweden)

    MUHAMMAD AMIRUL BIN YUSOF

    2016-04-01

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

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

    International Nuclear Information System (INIS)

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

    2014-01-01

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

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

    Science.gov (United States)

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

    2015-10-01

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

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

    Science.gov (United States)

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

    2015-08-25

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

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

    International Nuclear Information System (INIS)

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

    2015-01-01

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

  19. Letter report seismic shutdown system failure mode and effect analysis

    International Nuclear Information System (INIS)

    KECK, R.D.

    1999-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Eva María Guerra-Alia

    2017-11-01

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

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

    Science.gov (United States)

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

    2015-11-01

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

  2. Failure mode analysis of a PCRV. Influence of some hypothesis

    International Nuclear Information System (INIS)

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

    1975-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2017-05-01

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

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

    Science.gov (United States)

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

    2017-05-01

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

  5. Potential failure mode and effects analysis for the ITER NB injector

    International Nuclear Information System (INIS)

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

    2009-01-01

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

  6. Containment failure modes preliminary analysis for Atucha-I nuclear power plant during severe accidents

    International Nuclear Information System (INIS)

    Baron, J.; Caballero, C.; Zarate, S.M.

    1997-01-01

    The present work has the objective to analyze the containment behavior of the Atucha-I nuclear power plant during a severe accident, as part of a probabilistic safety assessment (PSA). Initially, a generic description of the containment failure modes considered in other PSAs is performed. Then, the possible containment failure modes for Atucha I are qualitatively analyzed, according to it design peculiarities. These failure modes involve some substantial differences from other PSAs, due to the particular design of Atucha I. Among others, it is studied the influence of: moderator/coolant separation, existence of cooling Zircaloy channels, existence of filling bodies inside the pressure vessel, reactor cavity geometry, on-line refueling mode, and existence of a double shell containment (steel and concrete) with an annular separation room. As a functions of the before mentioning analysis, a series of parameters to be taken into account is defined, on a preliminary basis, for definition of the plant damage states. (author) [es

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

    Energy Technology Data Exchange (ETDEWEB)

    Lee C. Cadwallader

    2010-06-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

    Lee C. Cadwallader

    2007-08-01

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

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

    International Nuclear Information System (INIS)

    Lee C. Cadwallader

    2007-01-01

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

  10. Accelerated reliability demonstration under competing failure modes

    International Nuclear Information System (INIS)

    Luo, Wei; Zhang, Chun-hua; Chen, Xun; Tan, Yuan-yuan

    2015-01-01

    The conventional reliability demonstration tests are difficult to apply to products with competing failure modes due to the complexity of the lifetime models. This paper develops a testing methodology based on the reliability target allocation for reliability demonstration under competing failure modes at accelerated conditions. The specified reliability at mission time and the risk caused by sampling of the reliability target for products are allocated for each failure mode. The risk caused by degradation measurement fitting of the target for a product involving performance degradation is equally allocated to each degradation failure mode. According to the allocated targets, the accelerated life reliability demonstration test (ALRDT) plans for the failure modes are designed. The accelerated degradation reliability demonstration test plans and the associated ALRDT plans for the degradation failure modes are also designed. Next, the test plan and the decision rules for the products are designed. Additionally, the effects of the discreteness of sample size and accepted number of failures for failure modes on the actual risks caused by sampling for the products are investigated. - Highlights: • Accelerated reliability demonstration under competing failure modes is studied. • The method is based on the reliability target allocation involving the risks. • The test plan for the products is based on the plans for all the failure modes. • Both failure mode and degradation failure modes are considered. • The error of actual risks caused by sampling for the products is small enough

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2015-06-15

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

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

    International Nuclear Information System (INIS)

    Howe, J

    2015-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Magnezi R

    2016-12-01

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

  14. Accelerated Testing with Multiple Failure Modes under Several Temperature Conditions

    Directory of Open Access Journals (Sweden)

    Zongyue Yu

    2014-01-01

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

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

    International Nuclear Information System (INIS)

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

    2015-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2015-04-01

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

  17. Electrical failure analysis for root-cause determination

    International Nuclear Information System (INIS)

    Riddle, J.

    1990-01-01

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

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

    International Nuclear Information System (INIS)

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

    2006-01-01

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

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

    Science.gov (United States)

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

    2017-04-18

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

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

    International Nuclear Information System (INIS)

    Maskuniitty, M.; Pulkkinen, U.

    1995-01-01

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

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

    Science.gov (United States)

    Ursprung, Robert; Gray, James

    2010-03-01

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

  2. Metallized Film Capacitor Lifetime Evaluation and Failure Mode Analysis

    CERN Document Server

    Gallay, R.

    2015-06-15

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

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

    Directory of Open Access Journals (Sweden)

    Farhad Rahmati

    2015-02-01

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

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

    International Nuclear Information System (INIS)

    Hoisak, J; Manger, R; Dragojevic, I

    2015-01-01

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

  5. Failure mode and effects analysis on typical reactor trip system

    International Nuclear Information System (INIS)

    Eisawy, E.A.

    2010-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Sibel Ozilgen

    2012-09-01

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

  7. Augmenting health care failure modes and effects analysis with simulation

    DEFF Research Database (Denmark)

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

    2014-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

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

    International Nuclear Information System (INIS)

    Zheng, Yuanshui; Johnson, Randall; Larson, Gary

    2016-01-01

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

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

    International Nuclear Information System (INIS)

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

    2008-01-01

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

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

    OpenAIRE

    Dorina Hetharia

    2012-01-01

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

  12. Failure Modes

    DEFF Research Database (Denmark)

    Jakobsen, K. P.; Burcharth, H. F.; Ibsen, Lars Bo

    1999-01-01

    The present appendix contains the derivation of ten different limit state equations divided on three different failure modes. Five of the limit state equations can be used independently of the characteristics of the subsoil, whereas the remaining five can be used for either drained or undrained s...

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

    International Nuclear Information System (INIS)

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

    2008-01-01

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

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

    Directory of Open Access Journals (Sweden)

    I. Elbadawi

    2018-06-01

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

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

    Science.gov (United States)

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

    2013-09-06

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

  16. Failure modes of composite sandwich beams

    Directory of Open Access Journals (Sweden)

    Gdoutos E.

    2008-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-01-15

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

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

    International Nuclear Information System (INIS)

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

    2016-01-01

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

  19. Failure Mode and Effect Analysis of Subsea Multiphase Pump Equipment

    Directory of Open Access Journals (Sweden)

    Oluwatoyin Shobowale Kafayat

    2014-07-01

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

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

    International Nuclear Information System (INIS)

    Eggleston, F.T.

    1976-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

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

    International Nuclear Information System (INIS)

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

    2015-01-01

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

  3. Failure Modes and Effects Analysis on ITER DFLL-TBM system

    International Nuclear Information System (INIS)

    Hu Liqin; Yuan Run; Chen Hongli; Bai Yunqing

    2012-01-01

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

  4. Reliability analysis for the creep rupture mode of failure

    International Nuclear Information System (INIS)

    Vaidyanathan, S.

    1975-01-01

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

  5. Failure mode and effects analysis outputs: are they valid?

    Science.gov (United States)

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

    2012-06-10

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

  6. Development of an Automated Technique for Failure Modes and Effect Analysis

    DEFF Research Database (Denmark)

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

    1999-01-01

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

  7. Development of an automated technique for failure modes and effect analysis

    DEFF Research Database (Denmark)

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

    1999-01-01

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

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

    Science.gov (United States)

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

    2014-10-01

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

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

    International Nuclear Information System (INIS)

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

    2015-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2015-06-15

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

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

    International Nuclear Information System (INIS)

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

    2016-01-01

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

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

    Science.gov (United States)

    Jain, Khushboo

    2017-03-13

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

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

    Science.gov (United States)

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

    2015-06-13

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

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

    International Nuclear Information System (INIS)

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

    2012-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Tianhui Ma

    2016-01-01

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

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

    Science.gov (United States)

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

    2018-02-01

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

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

    OpenAIRE

    Ozilgen,Sibel

    2012-01-01

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

  19. Failure mode and effects analysis outputs: are they valid?

    Directory of Open Access Journals (Sweden)

    Shebl Nada

    2012-06-01

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

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

    Science.gov (United States)

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

    2012-07-01

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

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

    Directory of Open Access Journals (Sweden)

    Iraj Alimohammadi

    2014-06-01

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

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

    International Nuclear Information System (INIS)

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

    1983-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Lewis Goodrum

    2017-02-01

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

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

    International Nuclear Information System (INIS)

    Tashjian, B.M.

    1975-01-01

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

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

    Science.gov (United States)

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

    2016-11-01

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

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

    NARCIS (Netherlands)

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

    2013-01-01

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

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

    NARCIS (Netherlands)

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

    2013-01-01

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

  8. An Investigation of Digital Instrumentation and Control System Failure Modes

    International Nuclear Information System (INIS)

    Korsah, Kofi; Cetiner, Mustafa Sacit; Muhlheim, Michael David; Poore, Willis P. III

    2010-01-01

    A study sponsored by the Nuclear Regulatory Commission study was conducted to investigate digital instrumentation and control (DI and C) systems and module-level failure modes using a number of databases both in the nuclear and non-nuclear industries. The objectives of the study were to obtain relevant operational experience data to identify generic DI and C system failure modes and failure mechanisms, and to obtain generic insights, with the intent of using results to establish a unified framework for categorizing failure modes and mechanisms. Of the seven databases studied, the Equipment Performance Information Exchange database was found to contain the most useful data relevant to the study. Even so, the general lack of quality relative to the objectives of the study did not allow the development of a unified framework for failure modes and mechanisms of nuclear I and C systems. However, an attempt was made to characterize all the failure modes observed (i.e., without regard to the type of I and C equipment under consideration) into common categories. It was found that all the failure modes identified could be characterized as (a) detectable/preventable before failures, (b) age-related failures, (c) random failures, (d) random/sudden failures, or (e) intermittent failures. The percentage of failure modes characterized as (a) was significant, implying that a significant reduction in system failures could be achieved through improved online monitoring, exhaustive testing prior to installation, adequate configuration control or verification and validation, etc.

  9. Prediction of failure modes for concrete nuclear-containment buildings

    International Nuclear Information System (INIS)

    Butler, T.A.

    1982-01-01

    The failure modes and associated failure pressures for two common generic types of PWR containments are predicted. One building type is a lightly reinforced, posttensioned structure represented by the Zion nuclear reactor containment. The other is the normally reinforced Indian Point containment. Two-dimensional models of the buildings developed using the finite element method are used to predict the failure modes and failure pressures. Predicted failure modes for both containments involve loss of structural integrity at the intersection of the cylindrical sidewall with the base slab

  10. Failure modes of composite sandwich beams

    OpenAIRE

    Gdoutos E.; Daniel I.M.

    2008-01-01

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

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

    International Nuclear Information System (INIS)

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

    2015-01-01

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

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

    International Nuclear Information System (INIS)

    Spencer, C

    2004-01-01

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

  13. Design Analysis of the Mixed Mode Bending Sandwich Specimen

    DEFF Research Database (Denmark)

    Quispitupa, Amilcar; Berggreen, Christian; Carlsson, Leif A.

    2010-01-01

    A design analysis of the mixed mode bending (MMB) sandwich specimen for face–core interface fracture characterization is presented. An analysis of the competing failure modes in the foam cored sandwich specimens is performed in order to achieve face–core debond fracture prior to other failure modes...... for the chosen geometries and mixed mode loading conditions....

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

    OpenAIRE

    Syauqi, Qiqi Azwani; Susanty, Aries

    2016-01-01

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

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

    Science.gov (United States)

    2012-06-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-10-15

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

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

    International Nuclear Information System (INIS)

    Cheong, S-K; Kim, J

    2016-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

  19. Characterising mechanical transmission wire ropes’ typical failure modes

    Directory of Open Access Journals (Sweden)

    Edgar Espejo

    2007-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Dorina Hetharia

    2012-02-01

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

  1. Common cause failure analysis methodology for complex systems

    International Nuclear Information System (INIS)

    Wagner, D.P.; Cate, C.L.; Fussell, J.B.

    1977-01-01

    Common cause failure analysis, also called common mode failure analysis, is an integral part of a complex system reliability analysis. This paper extends existing methods of computer aided common cause failure analysis by allowing analysis of the complex systems often encountered in practice. The methods presented here aid in identifying potential common cause failures and also address quantitative common cause failure analysis

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

    Science.gov (United States)

    Deng, Xinyang; Jiang, Wen

    2017-09-12

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

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

    Science.gov (United States)

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

    2008-07-01

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

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

    Directory of Open Access Journals (Sweden)

    Kouroush Jenab

    2015-07-01

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

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

    International Nuclear Information System (INIS)

    Apostolakis, G.E.

    1975-11-01

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

  6. A study of common-mode failures

    International Nuclear Information System (INIS)

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

    1979-07-01

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

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

    Directory of Open Access Journals (Sweden)

    Denny Nurkertamanda

    2012-02-01

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

  8. Failure mode and effects analysis: A community practice perspective.

    Science.gov (United States)

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

    2017-11-01

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

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

    DEFF Research Database (Denmark)

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

    2002-01-01

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

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

    International Nuclear Information System (INIS)

    Spencer, Cherrill M

    2003-01-01

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

  11. Common mode failures in redundancy systems

    International Nuclear Information System (INIS)

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

    1978-01-01

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

  12. Common mode and coupled failure

    International Nuclear Information System (INIS)

    Taylor, J.R.

    1975-10-01

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

  13. Failure mode effect analysis and fault tree analysis as a combined methodology in risk management

    Science.gov (United States)

    Wessiani, N. A.; Yoshio, F.

    2018-04-01

    There have been many studies reported the implementation of Failure Mode Effect Analysis (FMEA) and Fault Tree Analysis (FTA) as a method in risk management. However, most of the studies usually only choose one of these two methods in their risk management methodology. On the other side, combining these two methods will reduce the drawbacks of each methods when implemented separately. This paper aims to combine the methodology of FMEA and FTA in assessing risk. A case study in the metal company will illustrate how this methodology can be implemented. In the case study, this combined methodology will assess the internal risks that occur in the production process. Further, those internal risks should be mitigated based on their level of risks.

  14. Application of FMEA-DEA (Failure Modes and Effect Analysis - Data Envelopment Analysis) to the air conditioning system of the control room a nuclear power plant

    International Nuclear Information System (INIS)

    Barbosa Junior, Gilberto Varanda

    2007-03-01

    This dissertation presents the FMEA-DEA analysis application to the air conditioning system of the control room of a nuclear power plant. After obtaining the failure modes, the index associated to the occurrence probability, the severity of the effects and the potential of detention, a priority order is established for the failure modes or deviations. This number is obtained by multiplying the three mentioned index that vary in a natural scale from 1 to 10, where the higher the index, the more critical the situation will be. In this work, it is intended to use a model based on the data envelopment analysis, DEA jointly with the FMEA, to identify the current efficiency of the system and which failure modes or deviations are considered more critical, and by means of the weights attributed for the mathematical modeling to identify which index are contributing more for these deviations. From this identification, improvements can be set, which may consider administrative changes, operator training and so on, thus adding value to the final product. (author)

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

    International Nuclear Information System (INIS)

    Giardina, M; Castiglia, F; Tomarchio, E

    2014-01-01

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

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

    Science.gov (United States)

    Li, Xixi; He, Mei; Wang, Haiyan

    2017-12-01

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

  17. Application of ISO22000 and Failure Mode and Effect Analysis (fmea) for Industrial Processing of Poultry Products

    Science.gov (United States)

    Varzakas, Theodoros H.; Arvanitoyannis, Ioannis S.

    Failure Mode and Effect Analysis (FMEA) model has been applied for the risk assessment of poultry slaughtering and manufacturing. In this work comparison of ISO22000 analysis with HACCP is carried out over poultry slaughtering, processing and packaging. Critical Control points and Prerequisite programs (PrPs) have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram and fishbone diagram).

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

    Science.gov (United States)

    Wong, Kam Cheong

    2016-04-06

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

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

    Science.gov (United States)

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

    2015-01-01

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

  20. Circuit breaker operation and potential failure modes during an earthquake

    International Nuclear Information System (INIS)

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

    1987-01-01

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

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

    International Nuclear Information System (INIS)

    Liao, Ching-Jong; Ho, Chao Chung

    2014-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2014-07-15

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

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

    Directory of Open Access Journals (Sweden)

    Yasamin Molavi-Taleghani

    2018-03-01

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

  4. Failure mode and effects analysis (FMEA) for the Space Shuttle solid rocket motor

    Science.gov (United States)

    Russell, D. L.; Blacklock, K.; Langhenry, M. T.

    1988-01-01

    The recertification of the Space Shuttle Solid Rocket Booster (SRB) and Solid Rocket Motor (SRM) has included an extensive rewriting of the Failure Mode and Effects Analysis (FMEA) and Critical Items List (CIL). The evolution of the groundrules and methodology used in the analysis is discussed and compared to standard FMEA techniques. Especially highlighted are aspects of the FMEA/CIL which are unique to the analysis of an SRM. The criticality category definitions are presented and the rationale for assigning criticality is presented. The various data required by the CIL and contribution of this data to the retention rationale is also presented. As an example, the FMEA and CIL for the SRM nozzle assembly is discussed in detail. This highlights some of the difficulties associated with the analysis of a system with the unique mission requirements of the Space Shuttle.

  5. Applying failure mode effects and criticality analysis in radiotherapy: Lessons learned and perspectives of enhancement

    International Nuclear Information System (INIS)

    Scorsetti, Marta; Signori, Chiara; Lattuada, Paola; Urso, Gaetano; Bignardi, Mario; Navarria, Pierina; Castiglioni, Simona; Mancosu, Pietro; Trucco, Paolo

    2010-01-01

    Introduction: The radiation oncology process along with its unique therapeutic properties is also potentially dangerous for the patient, and thus it should be delivered under a systematic risk control. To this aim incident reporting and analysis are not sufficient for assuring patient safety and proactive risk assessment should also be implemented. The paper accounts for some methodological solutions, lessons learned and opportunities for improvement, starting from the systematic application of the failure mode effects and criticality analysis (FMECA) technique to the radiotherapy process of an Italian hospital. Materials and methods: The analysis, performed by a working group made of experts of the radiotherapy unit, was organised into the following steps: (1) complete and detailed analysis of the process (integration definition for function modelling); (2) identification of possible failure modes (FM) of the process, representing sources of adverse events for the patient; (3) qualitative risk assessment of FMs, aimed at identifying priorities of intervention; (4) identification and planning of corrective actions. Results: Organisational and procedural corrective measures were implemented; a set of safety indexes for the process was integrated within the traditional quality assurance indicators measured by the unit. A strong commitment of all the professionals involved was observed and the study revealed to be a powerful 'tool' for dissemination of patient safety culture. Conclusion: The feasibility of FMECA in fostering radiotherapy safety was proven; nevertheless, some lessons learned as well as weaknesses of current practices in risk management open to future research for the integration of retrospective methods (e.g. incident reporting or root cause analysis) and risk assessment.

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

    International Nuclear Information System (INIS)

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

    1992-08-01

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

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

    International Nuclear Information System (INIS)

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

    1992-01-01

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

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

    International Nuclear Information System (INIS)

    Biazotto, Bruna; Tokarski, Marcio

    2014-01-01

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

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

    International Nuclear Information System (INIS)

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

    2011-01-01

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

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

    DEFF Research Database (Denmark)

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

    2017-01-01

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

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

    Science.gov (United States)

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

    1994-01-01

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

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

    Science.gov (United States)

    Rucitra, A. L.

    2018-03-01

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

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

    International Nuclear Information System (INIS)

    Aaslund, A.

    2000-03-01

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

  14. Accelerated Testing with Multiple Failure Modes under Several Temperature Conditions

    OpenAIRE

    Zongyue Yu; Zhiqian Ren; Junyong Tao; Xun Chen

    2014-01-01

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

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

    International Nuclear Information System (INIS)

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

    2016-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

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

    Science.gov (United States)

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

    2017-10-01

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

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

    International Nuclear Information System (INIS)

    Miller, L.G.

    1976-01-01

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

  19. [Failure mode and effects analysis on computerized drug prescriptions].

    Science.gov (United States)

    Paredes-Atenciano, J A; Roldán-Aviña, J P; González-García, Mercedes; Blanco-Sánchez, M C; Pinto-Melero, M A; Pérez-Ramírez, C; Calvo Rubio-Burgos, Miguel; Osuna-Navarro, F J; Jurado-Carmona, A M

    2015-01-01

    To identify and analyze errors in drug prescriptions of patients treated in a "high resolution" hospital by applying a Failure mode and effects analysis (FMEA).Material and methods A multidisciplinary group of medical specialties and nursing analyzed medical records where drug prescriptions were held in free text format. An FMEA was developed in which the risk priority index (RPI) was obtained from a cross-sectional observational study using an audit of the medical records, carried out in 2 phases: 1) Pre-intervention testing, and (2) evaluation of improvement actions after the first analysis. An audit sample size of 679 medical records from a total of 2,096 patients was calculated using stratified sampling and random selection of clinical events. Prescription errors decreased by 22.2% in the second phase. FMEA showed a greater RPI in "unspecified route of administration" and "dosage unspecified", with no significant decreases observed in the second phase, although it did detect, "incorrect dosing time", "contraindication due to drug allergy", "wrong patient" or "duplicate prescription", which resulted in the improvement of prescriptions. Drug prescription errors have been identified and analyzed by FMEA methodology, improving the clinical safety of these prescriptions. This tool allows updates of electronic prescribing to be monitored. To avoid such errors would require the mandatory completion of all sections of a prescription. Copyright © 2014 SECA. Published by Elsevier Espana. All rights reserved.

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

    International Nuclear Information System (INIS)

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

    2016-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

  2. Analysis of failures in concrete containments

    International Nuclear Information System (INIS)

    Moreno-Gonzalez, A.

    1989-09-01

    The function of Containment, in an accident event, is to avoid the release of radioactive substances into the surroundings. Containment failure, therefore, is defined as the appearance of leak paths to the external environment. These leak paths may appear either as a result of loss of leaktightness due to degradation of design conditions or structural failure with containment material break. This document is a survey of the state of the art of Containment Failure Analysis. It gives a detailed description of all failure mechanisms, indicating all the possible failure modes and their causes, right from failure resulting from degradation of the materials to structural failure and linear breake failure. Following the description of failure modes, possible failure criteria are identified, with special emphasis on structural failure criteria. These criteria have been obtained not only from existing codes but also from the latest experimental results. A chapter has been dedicated exclusively to failure criteria in conventional structures, for the purpose of evaluating the possibility of application to the case of containment. As the structural behaviour of the containment building is very complex, it is not possible to define failure through a single parameter. It is therefore advisable to define a methodology for containment failure analysis which could be applied to a particular containment. This methodology should include prevailing load and material conditions together with the behaviour of complex conditions such as the liner-anchorage-cracked concrete interaction

  3. The plant-specific impact of different pressurization rates in the probabilistic estimation of containment failure modes

    International Nuclear Information System (INIS)

    Ahn, Kwang Il; Yang, Joon Eon; Ha, Jae Joo

    2003-01-01

    The explicit consideration of different pressurization rates in estimating the probabilities of containment failure modes has a profound effect on the confidence of containment performance evaluation that is so critical for risk assessment of nuclear power plants. Except for the sophisticated NUREG-1150 study, many of the recent containment performance analyses (through level 2 PSAs or IPE back-end analyses) did not take into account an explicit distinction between slow and fast pressurization in their analyses. A careful investigation of both approaches shows that many of the approaches adopted in the recent containment performance analyses exactly correspond to the NUREG-1150 approach for the prediction of containment failure mode probabilities in the presence of fast pressurization. As a result, it was expected that the existing containment performance analysis results would be subjected to greater or less conservatism in light of the ultimate failure mode of the containment. The main purpose of this paper is to assess potential conservatism of a plant-specific containment performance analysis result in light of containment failure mode probabilities

  4. Preliminary Failure Modes, Effects and Criticality Analysis (FMECA) of the Brayton Isotope Power System (BIPS) Ground Demonstration System. Report 76-311965

    International Nuclear Information System (INIS)

    Miller, L.G.

    1976-01-01

    A Failure Modes, Effects and Criticality Analysis (FMECA) has been made of the Brayton Isotope Power System Ground Demonstration System (BIPS-GDS). Details of the analysis are discussed. The BIPS Flight System was recently analyzed in an AIRPHX report. Since the results of the Flight System FMECA are directly applicable to the BIPS to be tested in the GDS mode, the contents of the earlier FMECA have not been repeated in this current analysis. The BIPS-FS FMECA has been reviewed and determined to be essentially current

  5. Rubble Mound Breakwater Failure Modes

    DEFF Research Database (Denmark)

    Burcharth, H. F.; Z., Liu

    1995-01-01

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

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

    Science.gov (United States)

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

    2012-12-01

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

  7. Low-rise shear wall failure modes

    International Nuclear Information System (INIS)

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

    1991-01-01

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

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

    International Nuclear Information System (INIS)

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

    1978-07-01

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

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

    International Nuclear Information System (INIS)

    Lisboa, J.J.

    1988-01-01

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

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

    Science.gov (United States)

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

    2017-06-01

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

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

    Science.gov (United States)

    Rotem, Assa

    1990-01-01

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

  12. Application of Failure Mode and Effect Analysis (FMEA), cause and effect analysis, and Pareto diagram in conjunction with HACCP to a corn curl manufacturing plant.

    Science.gov (United States)

    Varzakas, Theodoros H; Arvanitoyannis, Ioannis S

    2007-01-01

    The Failure Mode and Effect Analysis (FMEA) model has been applied for the risk assessment of corn curl manufacturing. A tentative approach of FMEA application to the snacks industry was attempted in an effort to exclude the presence of GMOs in the final product. This is of crucial importance both from the ethics and the legislation (Regulations EC 1829/2003; EC 1830/2003; Directive EC 18/2001) point of view. The Preliminary Hazard Analysis and the Fault Tree Analysis were used to analyze and predict the occurring failure modes in a food chain system (corn curls processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram, and the fishbone diagram). Finally, Pareto diagrams were employed towards the optimization of GMOs detection potential of FMEA.

  13. Comprehensive protocol of traceability during IVF: the result of a multicentre failure mode and effect analysis.

    Science.gov (United States)

    Rienzi, L; Bariani, F; Dalla Zorza, M; Albani, E; Benini, F; Chamayou, S; Minasi, M G; Parmegiani, L; Restelli, L; Vizziello, G; Costa, A Nanni

    2017-08-01

    Can traceability of gametes and embryos be ensured during IVF? The use of a simple and comprehensive traceability system that includes the most susceptible phases during the IVF process minimizes the risk of mismatches. Mismatches in IVF are very rare but unfortunately possible with dramatic consequences for both patients and health care professionals. Traceability is thus a fundamental aspect of the treatment. A clear process of patient and cell identification involving witnessing protocols has to be in place in every unit. To identify potential failures in the traceability process and to develop strategies to mitigate the risk of mismatches, previously failure mode and effects analysis (FMEA) has been used effectively. The FMEA approach is however a subjective analysis, strictly related to specific protocols and thus the results are not always widely applicable. To reduce subjectivity and to obtain a widespread comprehensive protocol of traceability, a multicentre centrally coordinated FMEA was performed. Seven representative Italian centres (three public and four private) were selected. The study had a duration of 21 months (from April 2015 to December 2016) and was centrally coordinated by a team of experts: a risk analysis specialist, an expert embryologist and a specialist in human factor. Principal investigators of each centre were first instructed about proactive risk assessment and FMEA methodology. A multidisciplinary team to perform the FMEA analysis was then formed in each centre. After mapping the traceability process, each team identified the possible causes of mistakes in their protocol. A risk priority number (RPN) for each identified potential failure mode was calculated. The results of the FMEA analyses were centrally investigated and consistent corrective measures suggested. The teams performed new FMEA analyses after the recommended implementations. In each centre, this study involved: the laboratory director, the Quality Control & Quality

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

    Directory of Open Access Journals (Sweden)

    Jigar Doshi

    2017-06-01

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

  15. Reliability model for common mode failures in redundant safety systems

    International Nuclear Information System (INIS)

    Fleming, K.N.

    1974-12-01

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

  16. Failure Mode and Effects Analysis (FMEA) of the solid state full length rod control system

    International Nuclear Information System (INIS)

    Shopsky, W.E.

    1977-01-01

    The Full Length Rod Control System (FLRCS) controls the power to the rod drive mechanisms for rod movement in response to signals received from the Reactor Control System or from signals generated through Reactor Operator action. Rod movement is used to control reactivity of the reactor during plant operation. The Full Length Rod Control System is designed to perform its reactivity control function in conjunction with the Reactor Control and Protection System, to maintain the reactor core within design safety limits. By the use of a Failure Mode and Effects Analysis, it is shown that the FLRCS will perform its reactivity control functions considering the loss of single active components. That is, sufficient fault limiting control circuits are provided which blocks control rod movement and/or indicates presence of a fault condition at the Control Board. Reactor operator action or automatic reactor trip will thus mitigate the consequences of potential failure of the FLRCS. The analysis also qualitatively demonstrates the reliability of the FLRCS to perform its intended function

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

    Science.gov (United States)

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

    2018-04-01

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

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

    Science.gov (United States)

    1996-01-01

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

  19. The use of failure mode and effects analysis to construct an effective disposal and prevention mechanism for infectious hospital waste

    International Nuclear Information System (INIS)

    Ho, Chao Chung; Liao, Ching-Jong

    2011-01-01

    Highlights: → This study is based on a real case in a regional teaching hospital in Taiwan. → We use Failure mode and effects analysis (FMEA) as the evaluation method. → We successfully identify the risk factors of infectious waste disposal. → We propose plans for the detection of exceptional cases of infectious waste. - Abstract: In recent times, the quality of medical care has been continuously improving in medical institutions wherein patient-centred care has been emphasized. Failure mode and effects analysis (FMEA) has also been promoted as a method of basic risk management and as part of total quality management (TQM) for improving the quality of medical care and preventing mistakes. Therefore, a study was conducted using FMEA to evaluate the potential risk causes in the process of infectious medical waste disposal, devise standard procedures concerning the waste, and propose feasible plans for facilitating the detection of exceptional cases of infectious waste. The analysis revealed the following results regarding medical institutions: (a) FMEA can be used to identify the risk factors of infectious waste disposal. (b) During the infectious waste disposal process, six items were scored over 100 in the assessment of uncontrolled risks: erroneous discarding of infectious waste by patients and their families, erroneous discarding by nursing staff, erroneous discarding by medical staff, cleaning drivers pierced by sharp articles, cleaning staff pierced by sharp articles, and unmarked output units. Therefore, the study concluded that it was necessary to (1) provide education and training about waste classification to the medical staff, patients and their families, nursing staff, and cleaning staff; (2) clarify the signs of caution; and (3) evaluate the failure mode and strengthen the effects.

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

    Science.gov (United States)

    Mirzaei Rafsanjani, H.; Rezaei Nasab, A.

    2012-05-01

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

  1. Light water reactor lower head failure analysis

    International Nuclear Information System (INIS)

    Rempe, J.L.; Chavez, S.A.; Thinnes, G.L.

    1993-10-01

    This document presents the results from a US Nuclear Regulatory Commission-sponsored research program to investigate the mode and timing of vessel lower head failure. Major objectives of the analysis were to identify plausible failure mechanisms and to develop a method for determining which failure mode would occur first in different light water reactor designs and accident conditions. Failure mechanisms, such as tube ejection, tube rupture, global vessel failure, and localized vessel creep rupture, were studied. Newly developed models and existing models were applied to predict which failure mechanism would occur first in various severe accident scenarios. So that a broader range of conditions could be considered simultaneously, calculations relied heavily on models with closed-form or simplified numerical solution techniques. Finite element techniques-were employed for analytical model verification and examining more detailed phenomena. High-temperature creep and tensile data were obtained for predicting vessel and penetration structural response

  2. Light water reactor lower head failure analysis

    Energy Technology Data Exchange (ETDEWEB)

    Rempe, J.L.; Chavez, S.A.; Thinnes, G.L. [EG and G Idaho, Inc., Idaho Falls, ID (United States)] [and others

    1993-10-01

    This document presents the results from a US Nuclear Regulatory Commission-sponsored research program to investigate the mode and timing of vessel lower head failure. Major objectives of the analysis were to identify plausible failure mechanisms and to develop a method for determining which failure mode would occur first in different light water reactor designs and accident conditions. Failure mechanisms, such as tube ejection, tube rupture, global vessel failure, and localized vessel creep rupture, were studied. Newly developed models and existing models were applied to predict which failure mechanism would occur first in various severe accident scenarios. So that a broader range of conditions could be considered simultaneously, calculations relied heavily on models with closed-form or simplified numerical solution techniques. Finite element techniques-were employed for analytical model verification and examining more detailed phenomena. High-temperature creep and tensile data were obtained for predicting vessel and penetration structural response.

  3. Failure modes of low-rise shear walls

    International Nuclear Information System (INIS)

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

    1993-01-01

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

  4. Failure Mode and Effects Analysis: views of hospital staff in the UK.

    Science.gov (United States)

    Shebl, Nada; Franklin, Bryony; Barber, Nick; Burnett, Susan; Parand, Anam

    2012-01-01

    To explore health care professionals' experiences and perceptions of Failure Mode and Effects Analysis (FMEA), a team-based, prospective risk analysis technique. Semi-structured interviews were conducted with 21 operational leads (20 pharmacists, one nurse) in medicines management teams of hospitals participating in a national quality improvement programme. Interviews were transcribed, coded and emergent themes identified using framework analysis. Themes identified included perceptions and experiences of participants with FMEA, validity and reliability issues, and FMEA's use in practice. FMEA was considered to be a structured but subjective process that helps health care professionals get together to identify high risk areas of care. Both positive and negative opinions were expressed, with the majority of interviewees expressing positive views towards FMEA in relation to its structured nature and the use of a multidisciplinary team. Other participants criticised FMEA for being subjective and lacking validity. Most likely to restrict its widespread use were its time consuming nature and its perceived lack of validity and reliability. FMEA is a subjective but systematic tool that helps identify high risk areas, but its time consuming nature, difficulty with the scores and perceived lack of validity and reliability may limit its widespread use.

  5. Application of the failure modes and effects analysis technique to the emergency cooling system of an experimental nuclear power plant

    International Nuclear Information System (INIS)

    Conceicao Junior, Osmar; Silva, Antonio Teixeira e

    2009-01-01

    This study consists on the application of the failure modes and effects analysis (FMEA), a hazard identification and a risk assessment technique, to the emergency cooling system (ECS), of an experimental nuclear power plant. The choice of this technique was due to its detailed analysis of each component of the system, enabling the identification of all possible ways of failure and its related consequences (in order of importance), allowing the designer to improve the system, maximizing its security and reliability. Through the application of this methodology, it could be observed that the ECS is an intrinsically safe system, in spite of the modifications proposed. (author)

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2007-12-15

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

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

    International Nuclear Information System (INIS)

    Perisse, F.

    2003-07-01

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

  8. Goal-oriented failure analysis - a systems analysis approach to hazard identification

    International Nuclear Information System (INIS)

    Reeves, A.B.; Davies, J.; Foster, J.; Wells, G.L.

    1990-01-01

    Goal-Oriented Failure Analysis, GOFA, is a methodology which is being developed to identify and analyse the potential failure modes of a hazardous plant or process. The technique will adopt a structured top-down approach, with a particular failure goal being systematically analysed. A systems analysis approach is used, with the analysis being organised around a systems diagram of the plant or process under study. GOFA will also use checklists to supplement the analysis -these checklists will be prepared in advance of a group session and will help to guide the analysis and avoid unnecessary time being spent on identifying obvious failure modes or failing to identify certain hazards or failures. GOFA is being developed with the aim of providing a hazard identification methodology which is more efficient and stimulating than the conventional approach to HAZOP. The top-down approach should ensure that the analysis is more focused and the use of a systems diagram will help to pull the analysis together at an early stage whilst also helping to structure the sessions in a more stimulating way than the conventional techniques. GOFA will be, essentially, an extension of the HAZOP methodology. GOFA is currently being computerised using a knowledge-based systems approach for implementation. The Goldworks II expert systems development tool is being used. (author)

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

    International Nuclear Information System (INIS)

    Kang, Dae Il; Han, Sang Hoon

    2010-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Bloemer Wilhelm

    2010-01-01

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

  11. Revised Risk Priority Number in Failure Mode and Effects Analysis Model from the Perspective of Healthcare System

    Science.gov (United States)

    Rezaei, Fatemeh; Yarmohammadian, Mohmmad H.; Haghshenas, Abbas; Fallah, Ali; Ferdosi, Masoud

    2018-01-01

    Background: Methodology of Failure Mode and Effects Analysis (FMEA) is known as an important risk assessment tool and accreditation requirement by many organizations. For prioritizing failures, the index of “risk priority number (RPN)” is used, especially for its ease and subjective evaluations of occurrence, the severity and the detectability of each failure. In this study, we have tried to apply FMEA model more compatible with health-care systems by redefining RPN index to be closer to reality. Methods: We used a quantitative and qualitative approach in this research. In the qualitative domain, focused groups discussion was used to collect data. A quantitative approach was used to calculate RPN score. Results: We have studied patient's journey in surgery ward from holding area to the operating room. The highest priority failures determined based on (1) defining inclusion criteria as severity of incident (clinical effect, claim consequence, waste of time and financial loss), occurrence of incident (time - unit occurrence and degree of exposure to risk) and preventability (degree of preventability and defensive barriers) then, (2) risks priority criteria quantified by using RPN index (361 for the highest rate failure). The ability of improved RPN scores reassessed by root cause analysis showed some variations. Conclusions: We concluded that standard criteria should be developed inconsistent with clinical linguistic and special scientific fields. Therefore, cooperation and partnership of technical and clinical groups are necessary to modify these models. PMID:29441184

  12. Revised risk priority number in failure mode and effects analysis model from the perspective of healthcare system

    Directory of Open Access Journals (Sweden)

    Fatemeh Rezaei

    2018-01-01

    Full Text Available Background: Methodology of Failure Mode and Effects Analysis (FMEA is known as an important risk assessment tool and accreditation requirement by many organizations. For prioritizing failures, the index of “risk priority number (RPN” is used, especially for its ease and subjective evaluations of occurrence, the severity and the detectability of each failure. In this study, we have tried to apply FMEA model more compatible with health-care systems by redefining RPN index to be closer to reality. Methods: We used a quantitative and qualitative approach in this research. In the qualitative domain, focused groups discussion was used to collect data. A quantitative approach was used to calculate RPN score. Results: We have studied patient's journey in surgery ward from holding area to the operating room. The highest priority failures determined based on (1 defining inclusion criteria as severity of incident (clinical effect, claim consequence, waste of time and financial loss, occurrence of incident (time - unit occurrence and degree of exposure to risk and preventability (degree of preventability and defensive barriers then, (2 risks priority criteria quantified by using RPN index (361 for the highest rate failure. The ability of improved RPN scores reassessed by root cause analysis showed some variations. Conclusions: We concluded that standard criteria should be developed inconsistent with clinical linguistic and special scientific fields. Therefore, cooperation and partnership of technical and clinical groups are necessary to modify these models.

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

    Directory of Open Access Journals (Sweden)

    Lucas Zago NAVES

    2016-01-01

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

  14. Microstructural Study of IF-WS2 Failure Modes

    Directory of Open Access Journals (Sweden)

    Jamie Cook

    2014-07-01

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

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

    Directory of Open Access Journals (Sweden)

    Y Nazari

    2006-04-01

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

  16. Failure mechanism analysis of a discrete 650V enhancement mode GaN-on-Si power device with reverse conduction accelerated power cycling test

    DEFF Research Database (Denmark)

    Song, Sungyoung; Munk-Nielsen, Stig; Uhrenfeldt, Christian

    2017-01-01

    A commercial discrete enhancement mode gallium nitride power component employing advanced package technology without conventional bond wire possesses the ability for bidirectional conduction. The gallium nitride power components can provide not only higher forward conductivity but also superior...... of cycles to failure. In physical failure analysis, delamination of a solder joint between a chip and a copper layer of an aluminum print circuit board is observed with a scanning acoustic microscope....

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

    Science.gov (United States)

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

    2017-04-01

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

  18. Failure mode analysis of preliminary design of ITER divertor impurity monitor

    International Nuclear Information System (INIS)

    Kitazawa, Sin-iti; Ogawa, Hiroaki

    2016-01-01

    Highlights: • Divertor impurity influx monitor for ITER (DIM) is procured by JADA. • DIM is designed to observe light from nuclear fusion plasma directly. • DIM is under preliminary design phase. • Failure mode of DIM was prepared for RAMI analysis. • RAMI analysis on DIM was performed to reduce technical risks. - Abstract: The objective of the divertor impurity influx monitor (DIM) for ITER is to measure the parameters of impurities and hydrogen isotopes (tritium, deuterium, and hydrogen) in divertor plasma using visible and UV spectroscopic techniques in the 200–1000 nm wavelength range. In ITER, special provisions are required to ensure accuracy and full functionality of the diagnostic components under harsh conditions (high temperature, high magnetic field, high vacuum condition, and high radiation field). Japan Domestic Agency is preparing the preliminary design of the ITER DIM system, which will be installed in the upper, equatorial and lower ports. The optical and mechanical designs of the DIM are conducted to fit ITER’s requirements. The optical and mechanical designs meet the requirements of spatial resolution. Some auxiliary systems were examined via prototyping. The preliminary design of the ITER DIM system was evaluated by RAMI analysis. The availability of the designed system is adequately high to satisfy the project requirements. However, some equipment does not have certain designs, and this may cause potential technical risks. The preliminary design should be modified to reduce technical risks and to prepare the final design.

  19. New understandings of failure modes in SSL luminaires

    Science.gov (United States)

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

    2014-09-01

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

  20. Computer aided approach to qualitative and quantitative common cause failure analysis for complex systems

    International Nuclear Information System (INIS)

    Cate, C.L.; Wagner, D.P.; Fussell, J.B.

    1977-01-01

    Common cause failure analysis, also called common mode failure analysis, is an integral part of a complete system reliability analysis. Existing methods of computer aided common cause failure analysis are extended by allowing analysis of the complex systems often encountered in practice. The methods aid in identifying potential common cause failures and also address quantitative common cause failure analysis

  1. FRAC (failure rate analysis code): a computer program for analysis of variance of failure rates. An application user's guide

    International Nuclear Information System (INIS)

    Martz, H.F.; Beckman, R.J.; McInteer, C.R.

    1982-03-01

    Probabilistic risk assessments (PRAs) require estimates of the failure rates of various components whose failure modes appear in the event and fault trees used to quantify accident sequences. Several reliability data bases have been designed for use in providing the necessary reliability data to be used in constructing these estimates. In the nuclear industry, the Nuclear Plant Reliability Data System (NPRDS) and the In-Plant Reliability Data System (IRPDS), among others, were designed for this purpose. An important characteristic of such data bases is the selection and identification of numerous factors used to classify each component that is reported and the subsequent failures of each component. However, the presence of such factors often complicates the analysis of reliability data in the sense that it is inappropriate to group (that is, pool) data for those combinations of factors that yield significantly different failure rate values. These types of data can be analyzed by analysis of variance. FRAC (Failure Rate Analysis Code) is a computer code that performs an analysis of variance of failure rates. In addition, FRAC provides failure rate estimates

  2. Development of severe accident analysis code - Development of a finite element code for lower head failure analysis

    Energy Technology Data Exchange (ETDEWEB)

    Huh, Hoon; Lee, Choong Ho; Choi, Tae Hoon; Kim, Hyun Sup; Kim, Se Ho; Kang, Woo Jong; Seo, Chong Kwan [Korea Atomic Energy Research Institute, Taejon (Korea, Republic of)

    1995-08-01

    The study concerns the development of analysis models and computer codes for lower head failure analysis when a severe accident occurs in a nuclear reactor system. Although the lower head failure modes consists of several failure modes, the study this year was focused on the global rupture with the collapse pressure and mode by limit analysis and elastic deformation. The behavior of molten core causes elevation of temperature in the reactor vessel wall and deterioration of load-carrying capacity of a reactor vessel. The behavior of molten core and the heat transfer modes were, therefore, postulated in several types and the temperature distributions according to the assumed heat flux modes were calculated. The collapse pressure of a nuclear reactor lower head decreases rapidly with elevation of temperature as time passes. The calculation shows the safety of a nuclear reactor is enhanced with the lager collapse pressure when the hot spot is located far from the pole. 42 refs., 2 tabs., 31 figs. (author)

  3. Recognising and referring children exposed to domestic abuse: a multi-professional, proactive systems-based evaluation using a modified Failure Mode and Effects Analysis (FMEA).

    Science.gov (United States)

    Ashley, Laura; Armitage, Gerry; Taylor, Julie

    2017-03-01

    Failure Modes and Effects Analysis (FMEA) is a prospective quality assurance methodology increasingly used in healthcare, which identifies potential vulnerabilities in complex, high-risk processes and generates remedial actions. We aimed, for the first time, to apply FMEA in a social care context to evaluate the process for recognising and referring children exposed to domestic abuse within one Midlands city safeguarding area in England. A multidisciplinary, multi-agency team of 10 front-line professionals undertook the FMEA, using a modified methodology, over seven group meetings. The FMEA included mapping out the process under evaluation to identify its component steps, identifying failure modes (potential errors) and possible causes for each step and generating corrective actions. In this article, we report the output from the FMEA, including illustrative examples of the failure modes and corrective actions generated. We also present an analysis of feedback from the FMEA team and provide future recommendations for the use of FMEA in appraising social care processes and practice. Although challenging, the FMEA was unequivocally valuable for team members and generated a significant number of corrective actions locally for the safeguarding board to consider in its response to children exposed to domestic abuse. © 2016 John Wiley & Sons Ltd.

  4. Finite Element Analysis of Reinforced Concrete Beam-Column Connections with Governing Joint Shear Failure Mode

    Directory of Open Access Journals (Sweden)

    M.A. Najafgholipour

    Full Text Available Abstract Reinforced concrete (RC beam-column connections especially those without transverse reinforcement in joint region can exhibit brittle behavior when intensive damage is concentrated in the joint region during an earthquake event. Brittle behavior in the joint region can compromise the ductile design philosophy and the expected overall performance of structure when subjected to seismic loading. Considering the importance of joint shear failure influences on strength, ductility and stability of RC moment resisting frames, a finite element modeling which focuses on joint shear behavior is presented in this article. Nonlinear finite element analysis (FEA of RC beam-column connections is performed in order to investigate the joint shear failure mode in terms of joint shear capacity, deformations and cracking pattern. A 3D finite element model capable of appropriately modeling the concrete stress-strain behavior, tensile cracking and compressive damage of concrete and indirect modeling of steel-concrete bond is used. In order to define nonlinear behavior of concrete material, the concrete damage plasticity is applied to the numerical model as a distributed plasticity over the whole geometry. Finite element model is then verified against experimental results of two non-ductile beam-column connections (one exterior and one interior which are vulnerable to joint shear failure. The comparison between experimental and numerical results indicates that the FE model is able to simulate the performance of the beam-column connections and is able to capture the joint shear failure in RC beam-column connections.

  5. Analisis Risiko Makanan Halal Di Restoran Menggunakan Metode Failure Mode and Effect Analysis

    Directory of Open Access Journals (Sweden)

    Wildatus Sholichah

    2017-12-01

    Full Text Available The halal food served in restaurants is important for Muslim consumers and it is one of the most susceptible issues for restaurant business. Therefore, restaurant internal efforts to ensure the halal food by examining critical risks including the way to manage them become important to be execute by restaurant management. This research aims to create a model using Failure Mode and Effect Analysis (FMEA method to identify and analyze the existing risks. Moreover, it also explains some improvement programs toward the risk management. The results of the risk identification and analysis will be determined by using Risk Priority Number (RPN. It is categorized that 7% risk event is classified as ‘very high risk’, 50% as ‘high risk’, 25% as ‘moderate risk’, and 18% considered as ‘low risk’. Furthermore, the improvement programs explained in this research are about delivery order system, packaging improvement, and also training, reward and punishment system. These programs are mainly purposed to reduce the risk with ‘high risk’ category.

  6. Failure modes and natural control time for distributed vibrating systems

    International Nuclear Information System (INIS)

    Reid, R.M.

    1994-01-01

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

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

    International Nuclear Information System (INIS)

    Mathew, D; Alaei, P

    2016-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2016-06-15

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

  9. Systems analysis determining critical items, critical assembly processes, primary failure modes and corrective actions on ASST magnets

    International Nuclear Information System (INIS)

    Arden, C.S.

    1993-04-01

    During the assembly process through the completion of the Accelerator Surface String Test (ASST) phase one test, Magnet Systems Division Reliability Engineering has tracked all the known discrepancies utilizing the Failure Reporting, Analysis and Corrective Action System (FRACAS) and data base. This paper discusses the critical items, critical assembly processes, primary failure modes and corrective actions (lessons learned) based on actual data for the ASST magnets. The ASST magnets include seven Brookhaven Lab Dipoles (DCA-207 through 213), fourteen Fermi Lab Dipoles (DCA-310 through 323) and five Lawrence Berkeley Lab Quadrupoles (QCC-402 through 406). Between all the ASST magnets built there were one hundred eighty six (186) class one discrepancies reported out of approximately eleven hundred total discrepancy reports. The class one or critical discrepancies are defined as form, fit, function, safety or reliability problem. Each and every ASST magnet is considered a success, as they all achieved the quench performance requirements and were capable of being incorporated into the string test. This paper also discuss some specific magnet discrepancies, including failure cause(s), corrective action and possible open issues

  10. Systems analysis determining critical items, critical assembly processes, primary failure modes and corrective actions on ASST magnets

    International Nuclear Information System (INIS)

    Arden, C.S.

    1994-01-01

    During the assembly process through the completion of the Accelerator Surface String Test (ASST) phase one test, Magnet Systems Division Reliability Engineering has tracked all the known discrepancies utilizing the Failure Reporting, Analysis and Corrective Action System (FRACAS) and data base. This paper discusses the critical items, critical assembly processes, primary failure modes and corrective actions (lessons learned) based on actual data for the ASST magnets. The ASST magnets include seven Brookhaven Lab Dipoles (DCA-207 through 213), fourteen Fermi Lab Dipoles (DCA-310 through 323) and five Lawrence Berkeley Lab Quadrupoles (QCC-402 through 406). Between all the ASST magnets built there were one hundred eighty six (186) class one discrepancies reported out of approximately eleven hundred total discrepancy reports. The class one or critical discrepancies are defined as form, fit, function, safety or reliability problem. Each and every ASST magnet is considered a success, as they all achieved the quench performance requirements and were capable of being incorporated into the string test. This paper will also discuss some specific magnet discrepancies, including failure cause(s), corrective action and possible open issues

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

    International Nuclear Information System (INIS)

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

    1993-01-01

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

  12. PERBEDAAN RISK PRIORITY NUMBER DALAM FAILURE MODE AND EFFECTS ANALYSIS FMEA SISTEM ALAT BERAT HEAVY DUTY TRUCK HD 785-7

    Directory of Open Access Journals (Sweden)

    M. Syafwansyah Effendi

    2015-04-01

    Full Text Available Failure Mode and Efect Analysis (FMEA adalah jenis desain dan teknologi untuk menganalisis keandalan pencegahan, yang merupakan formula yang sistematis terstruktur untuk mengidentifikasi modus kerusakan yang potensial dalam desain atau manufaktur, kemudian mempelajari pengaruh kerusakan pada sistem, kemudian mengambil langkah-langkah yang diperlukan untuk mengkoreksi dan sebagai metode pencegahan sementara yang mengarah pada masalah dalam sistam keandalan. Secara tradisional, menggunakan teknologi dari FMEA adalah untuk memperbaiki keputusan dalam urutan dari besar Risk Priority Number (RPN ke yang lebih kecil State of art permasalahan yang mendasar dari RPN Failure and Efect Analysis adalah bagaimana menerapkannya dalam cakupan cukup luas dalam berbagai bidang sebagai alat atau metode yang bermanfaat untuk membantu menjustifikasi pengambilan suatu keputusan dalam menentukan keandalan suatu sistem. Dari penelitian-penelitian yang sudah dilakukan penerapan Model ini banyak dilakukan di lingkungan industri, dan belum ada yang mengapilikasikannya dalam menganalisa mode kegagalan sistem pada peralatan Berat terutama yang dioperasikan disektor pertambangan. Sehingga pada penelitian ini, adalah perlu untuk menguji apakah ada Perbedaan Dalam Risk Priority Number Failure Mode and Effects Analysis Pada Unit Sistem Alat Berat Heavy Duty Truck HD 785-7. Data diambil dari data History Preventive Maintanance pada sebuah perusahaan tambang di Kalimantan Selatan, selama periode 5 tahun. Unit yang diuji nilai RPN dan sistem adalah Mine Truck Heavy Duty Truck HD 785-7 sebagai sampel diambil 10 unit. Dari data tersebut nilai RPN dihitung masing-masing sistem. Selanjutnya data olahan tersebut di uji dengan uji ANOVA, dengan menggunakan uji F selanjutnya ilakukan analisis untuk setiap kelompok rata-rata atau pasangan rata-rata. Pengujian data dengan menggunakan uji Posteriori (Post Hoc uji Tukey HSD dan Duncan untuk melihat sistem yang mana dari 15 sistem yang rata

  13. Comprehensive reliability allocation method for CNC lathes based on cubic transformed functions of failure mode and effects analysis

    Science.gov (United States)

    Yang, Zhou; Zhu, Yunpeng; Ren, Hongrui; Zhang, Yimin

    2015-03-01

    Reliability allocation of computerized numerical controlled(CNC) lathes is very important in industry. Traditional allocation methods only focus on high-failure rate components rather than moderate failure rate components, which is not applicable in some conditions. Aiming at solving the problem of CNC lathes reliability allocating, a comprehensive reliability allocation method based on cubic transformed functions of failure modes and effects analysis(FMEA) is presented. Firstly, conventional reliability allocation methods are introduced. Then the limitations of direct combination of comprehensive allocation method with the exponential transformed FMEA method are investigated. Subsequently, a cubic transformed function is established in order to overcome these limitations. Properties of the new transformed functions are discussed by considering the failure severity and the failure occurrence. Designers can choose appropriate transform amplitudes according to their requirements. Finally, a CNC lathe and a spindle system are used as an example to verify the new allocation method. Seven criteria are considered to compare the results of the new method with traditional methods. The allocation results indicate that the new method is more flexible than traditional methods. By employing the new cubic transformed function, the method covers a wider range of problems in CNC reliability allocation without losing the advantages of traditional methods.

  14. Improving failure analysis efficiency by combining FTA and FMEA in a recursive manner

    NARCIS (Netherlands)

    Peeters, J.F.W.; Basten, R.J.I.; Tinga, Tiedo

    2018-01-01

    When designing a maintenance programme for a capital good, especially a new one, it is of key importance to accurately understand its failure behaviour. Failure mode and effects analysis (FMEA) and fault tree analysis (FTA) are two commonly used methods for failure analysis. FMEA is a bottom-up

  15. Improving failure analysis efficiency by combining FTA and FMEA in a recursive manner

    NARCIS (Netherlands)

    Peeters, J.F.W.; Basten, R.J.I.; Tinga, T.

    When designing a maintenance programme for a capital good, especially a new one, it is of key importance to accurately understand its failure behaviour. Failure mode and effects analysis (FMEA) and fault tree analysis (FTA) are two commonly used methods for failure analysis. FMEA is a bottom-up

  16. Proposal on How To Conduct a Biopharmaceutical Process Failure Mode and Effect Analysis (FMEA) as a Risk Assessment Tool.

    Science.gov (United States)

    Zimmermann, Hartmut F; Hentschel, Norbert

    2011-01-01

    With the publication of the quality guideline ICH Q9 "Quality Risk Management" by the International Conference on Harmonization, risk management has already become a standard requirement during the life cycle of a pharmaceutical product. Failure mode and effect analysis (FMEA) is a powerful risk analysis tool that has been used for decades in mechanical and electrical industries. However, the adaptation of the FMEA methodology to biopharmaceutical processes brings about some difficulties. The proposal presented here is intended to serve as a brief but nevertheless comprehensive and detailed guideline on how to conduct a biopharmaceutical process FMEA. It includes a detailed 1-to-10-scale FMEA rating table for occurrence, severity, and detectability of failures that has been especially designed for typical biopharmaceutical processes. The application for such a biopharmaceutical process FMEA is widespread. It can be useful whenever a biopharmaceutical manufacturing process is developed or scaled-up, or when it is transferred to a different manufacturing site. It may also be conducted during substantial optimization of an existing process or the development of a second-generation process. According to their resulting risk ratings, process parameters can be ranked for importance and important variables for process development, characterization, or validation can be identified. Health authorities around the world ask pharmaceutical companies to manage risk during development and manufacturing of pharmaceuticals. The so-called failure mode and effect analysis (FMEA) is an established risk analysis tool that has been used for decades in mechanical and electrical industries. However, the adaptation of the FMEA methodology to pharmaceutical processes that use modern biotechnology (biopharmaceutical processes) brings about some difficulties, because those biopharmaceutical processes differ from processes in mechanical and electrical industries. The proposal presented here

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2015-06-15

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

  18. Application of ISO 22000 and Failure Mode and Effect Analysis (FMEA) for industrial processing of salmon: a case study.

    Science.gov (United States)

    Arvanitoyannis, Ioannis S; Varzakas, Theodoros H

    2008-05-01

    The Failure Mode and Effect Analysis (FMEA) model was applied for risk assessment of salmon manufacturing. A tentative approach of FMEA application to the salmon industry was attempted in conjunction with ISO 22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (salmon processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points were identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram and fishbone diagram). In this work, a comparison of ISO 22000 analysis with HACCP is carried out over salmon processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the RPN per identified processing hazard. Fish receiving, casing/marking, blood removal, evisceration, filet-making cooling/freezing, and distribution were the processes identified as the ones with the highest RPN (252, 240, 210, 210, 210, 210, 200 respectively) and corrective actions were undertaken. After the application of corrective actions, a second calculation of RPN values was carried out resulting in substantially lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO 22000 system of a salmon processing industry is anticipated to prove advantageous to industrialists, state food inspectors, and consumers.

  19. Dependent failure analysis of NPP data bases

    International Nuclear Information System (INIS)

    Cooper, S.E.; Lofgren, E.V.; Samanta, P.K.; Wong Seemeng

    1993-01-01

    A technical approach for analyzing plant-specific data bases for vulnerabilities to dependent failures has been developed and applied. Since the focus of this work is to aid in the formulation of defenses to dependent failures, rather than to quantify dependent failure probabilities, the approach of this analysis is critically different. For instance, the determination of component failure dependencies has been based upon identical failure mechanisms related to component piecepart failures, rather than failure modes. Also, component failures involving all types of component function loss (e.g., catastrophic, degraded, incipient) are equally important to the predictive purposes of dependent failure defense development. Consequently, dependent component failures are identified with a different dependent failure definition which uses a component failure mechanism categorization scheme in this study. In this context, clusters of component failures which satisfy the revised dependent failure definition are termed common failure mechanism (CFM) events. Motor-operated valves (MOVs) in two nuclear power plant data bases have been analyzed with this approach. The analysis results include seven different failure mechanism categories; identified potential CFM events; an assessment of the risk-significance of the potential CFM events using existing probabilistic risk assessments (PRAs); and postulated defenses to the identified potential CFM events. (orig.)

  20. Study Of The Risks Arising From Natural Disasters And Hazards On Urban And Intercity Motorways By Using Failure Mode Effect Analysis (FMEA) Methods

    Science.gov (United States)

    DELİCE, Yavuz

    2015-04-01

    Highways, Located in the city and intercity locations are generally prone to many kind of natural disaster risks. Natural hazards and disasters that may occur firstly from highway project making to construction and operation stages and later during the implementation of highway maintenance and repair stages have to be taken into consideration. And assessment of risks that may occur against adverse situations is very important in terms of project design, construction, operation maintenance and repair costs. Making hazard and natural disaster risk analysis is largely depending on the definition of the likelihood of the probable hazards on the highways. However, assets at risk , and the impacts of the events must be examined and to be rated in their own. With the realization of these activities, intended improvements against natural hazards and disasters will be made with the utilization of Failure Mode Effects Analysis (FMEA) method and their effects will be analyzed with further works. FMEA, is a useful method to identify the failure mode and effects depending on the type of failure rate effects priorities and finding the most optimum economic and effective solution. Although relevant measures being taken for the identified risks by this analysis method , it may also provide some information for some public institutions about the nature of these risks when required. Thus, the necessary measures will have been taken in advance in the city and intercity highways. Many hazards and natural disasters are taken into account in risk assessments. The most important of these dangers can be listed as follows; • Natural disasters 1. Meteorological based natural disasters (floods, severe storms, tropical storms, winter storms, avalanches, etc.). 2. Geological based natural disasters (earthquakes, tsunamis, landslides, subsidence, sinkholes, etc) • Human originated disasters 1. Transport accidents (traffic accidents), originating from the road surface defects (icing

  1. FAILURE MODE EFFECTS AND CRITICALITY ANALYSIS (FMECA AS A QUALITY TOOL TO PLAN IMPROVEMENTS IN ULTRASONIC MOULD CLEANING SYSTEMS

    Directory of Open Access Journals (Sweden)

    Cristiano Fragassa

    2016-12-01

    Full Text Available Inside the complex process used for tire production, ultrasonic cleaning treatment probably represents the best solution to preserve the functionality of tire moulds, by removing residuals from moulds and keeping an unaltered quality for their surfaces. Ultrasonic Mould Cleaning Systems (UMCS is, however, a complicated technology that combines ultrasonic waves, high temperature and a succession of acid and basic attacks. At the same time, an UMCS plant, as part of a long productive chain, has to guarantee the highest productivity reducing failures and maintenances. This article describes the use of Failure Mode Effects and Criticality Analysis (FMECA as a methodology for improving quality in cleaning process. In particular, FMECA was utilized to identify potential defects in the original plant design, to recognize the inner causes of some failures actually occurred during operations and, finally, to suggest definitive re-design actions. Changes were implemented and the new UMCS offers a better quality in term of higher availability and productivity.

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

    International Nuclear Information System (INIS)

    Hoy, H.C.

    1983-07-01

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

  3. Optimisation of shock absorber process parameters using failure mode and effect analysis and genetic algorithm

    Science.gov (United States)

    Mariajayaprakash, Arokiasamy; Senthilvelan, Thiyagarajan; Vivekananthan, Krishnapillai Ponnambal

    2013-07-01

    The various process parameters affecting the quality characteristics of the shock absorber during the process were identified using the Ishikawa diagram and by failure mode and effect analysis. The identified process parameters are welding process parameters (squeeze, heat control, wheel speed, and air pressure), damper sealing process parameters (load, hydraulic pressure, air pressure, and fixture height), washing process parameters (total alkalinity, temperature, pH value of rinsing water, and timing), and painting process parameters (flowability, coating thickness, pointage, and temperature). In this paper, the process parameters, namely, painting and washing process parameters, are optimized by Taguchi method. Though the defects are reasonably minimized by Taguchi method, in order to achieve zero defects during the processes, genetic algorithm technique is applied on the optimized parameters obtained by Taguchi method.

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

    International Nuclear Information System (INIS)

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

    2017-01-01

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

  5. Application of the failure modes and effects analysis technique to theemergency cooling system of an experimental nuclear power plant

    International Nuclear Information System (INIS)

    Conceicao Junior, Osmar

    2009-01-01

    This study consists on the application of the Failure Modes and EffectsAnalysis (FMEA), a hazard identification and a risk assessment technique, tothe Emergency Cooling System (ECS) of an experimental nuclear power plant,which is responsible for mitigating the consequences of an eventual loss ofcoolant accident on the Pressurized Water Reactor (PWR). Such analysisintends to identify possible weaknesses on the design of the system andpropose some improvements in order to maximize its reliability. To achievethis goal a detailed study of the system was carried on (through itstechnical documentation), the correspondent reliability block diagram wasobtained, the FMEA analysis was executed and, finally, some suggestions werepresented. (author)

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

    International Nuclear Information System (INIS)

    Zhu, Wenjin; Fouladirad, Mitra; Bérenguer, Christophe

    2016-01-01

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

  7. Study on shielded pump system failure analysis method based on Bayesian network

    International Nuclear Information System (INIS)

    Bao Yilan; Huang Gaofeng; Tong Lili; Cao Xuewu

    2012-01-01

    This paper applies Bayesian network to the system failure analysis, with an aim to improve knowledge representation of the uncertainty logic and multi-fault states in system failure analysis. A Bayesian network for shielded pump failure analysis is presented, conducting fault parameter learning, updating Bayesian network parameter based on new samples. Finally, through the Bayesian network inference, vulnerability in this system, the largest possible failure modes, and the fault probability are obtained. The powerful ability of Bayesian network to analyze system fault is illustrated by examples. (authors)

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

    International Nuclear Information System (INIS)

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

    1987-11-01

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

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

    International Nuclear Information System (INIS)

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

    2007-01-01

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

  10. Optimal tread design for agricultural lug tires determined through failure analysis

    Directory of Open Access Journals (Sweden)

    Hyun Seok Song

    2018-04-01

    Full Text Available Agricultural lug tires, commonly used in tractors, must provide safe and stable support for the body of the vehicle and bear any additional load while effectively traversing rough, poor-quality ground surfaces. Many agricultural lug tires fail unexpectedly. In this study, we optimised and validated a tread design for agricultural lug tires intended to increase their durability using failure analysis. Specifically, we identified tire failure modes using indoor driving tests and failure mode effects analysis. Next, we developed a threedimensional tire model using the Ogden material model and finite element method. Using sensitivity analysis and response surface methodology, we optimised the tread design. Finally, we evaluated the durability of the new design using a tire prototype and drum test equipment. Results indicated that the optimised tread design decreased the tire tread stress by 16% and increased its time until cracking by 38% compared to conventional agricultural lug tires.

  11. Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation.

    Science.gov (United States)

    Powell, Emilie S; O'Connor, Lanty M; Nannicelli, Anna P; Barker, Lisa T; Khare, Rahul K; Seivert, Nicholas P; Holl, Jane L; Vozenilek, John A

    2014-06-01

    Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation. We conducted a FMECA, which prospectively identifies critical areas for improvement in systems and processes of care, across three diverse hospitals. A multidisciplinary group of participants described the process of emergency department (ED) sepsis resuscitation to then create a comprehensive map and table listing all process steps and identified process failures. High-risk failures in sepsis resuscitation from each of the institutions were compiled to identify common high-risk failures. Common high-risk failures included limited availability of equipment to place the central venous catheter and conduct invasive monitoring, and cognitive overload leading to errors in decision-making. Additionally, we identified great variability in care processes across institutions. Several common high-risk failures in sepsis care exist: a disparity in resources available across hospitals, a lack of adherence to the invasive components of care, and cognitive barriers that affect expert clinicians' decision-making capabilities. Future work may concentrate on dissemination of non-invasive alternatives and overcoming cognitive barriers in diagnosis and knowledge translation.

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

    DEFF Research Database (Denmark)

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

    1995-01-01

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

  13. An application of failure mode and effect analysis (FMEA to assess risks in petrochemical industry in Iran

    Directory of Open Access Journals (Sweden)

    Mehdi Kangavari

    2015-06-01

    Full Text Available Petrochemical industries have a high rate of accidents. Failure mode and effect analysis (FMEA is a systematic method and thus is capable of analyzing the risks of systems from concept phase to system disposal, detecting the failures in design stage, and determining the control measures and corrective actions for failures to reduce their impacts. The objectives of this research were to perform FMEA to identify risks in an Iranian petrochemical industry and determine the decrease of the risk priority number (RPN after implementation of intervention programs. This interventional study was performed at one petrochemical plant in Tehran, Iran in 2014. Relevant information about job categories and plant process was gathered using brainstorming techniques, fishbone diagram, and group decision making. The data were collected through interviews, observation, and documents investigations and was recorded in FMEA worksheets. The necessary corrective measures were performed on the basis of the results of initial FMEA. Forty eight failures were identified in welding unit by application of FMEA to assess risks. Welding processes especially working at height got the highest RPN. Obtained RPN for working at height before performing the corrective actions was 120 and the score was reduced to 96 after performing corrective measures. Calculated RPN for all processes was significantly reduced (p≤0.001 by implementing the corrective actions. Scores of RPN in all studied processes effectively decreased after performing corrective actions in a petrochemical industry. FMEA method is a useful tool for identifying risk intervention priorities and effectiveness in a studied petrochemical industry.

  14. Modes of failures: primary and secondary stresses

    International Nuclear Information System (INIS)

    Roche, R.L.

    1987-07-01

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

  15. Early failure analysis of machining centers: a case study

    International Nuclear Information System (INIS)

    Wang Yiqiang; Jia Yazhou; Jiang Weiwei

    2001-01-01

    To eliminate the early failures and improve the reliability, nine ex-factory machining centers are traced under field conditions in workshops. Their early failure information throughout the ex-factory run-in test is collected. The field early failure database is constructed based on the collection of field early failure data and the codification of data. Early failure mode and effects analysis is performed to indicate the weak subsystem of a machining center or the troublemaker. The distribution of the time between early failures is analyzed and the optimal ex-factory run-in test time for machining center that may expose sufficiently the early failures and cost minimum is discussed. Suggestions how to arrange ex-factory run-in test and how to take actions to reduce early failures for machining center is proposed

  16. Modelling the failure modes in geobag revetments.

    Science.gov (United States)

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

    2012-01-01

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

  17. USULAN PERBAIKAN KESELAMATAN KERJA MENGGUNAKAN METODE JOB SAFETY ANALYSIS (JSA DAN FAILURE MODE AND EFFECT ANALYSIS (FMEA

    Directory of Open Access Journals (Sweden)

    Ariel Levi

    2017-10-01

    Full Text Available PT Prima Utama Mitra Anda adalah perusahaan yang bergerak di bidang industri pembuatan box karoseri. Proses produksinya banyak menggunakan alat atau mesin yang dapat menyebabkan kecelakaan kerja. Data perusahaan menunjukkan terdapat 73 kasus kecelakaan kerja pada tahun 2013 dan 107 kasus kecelakaan kerja pada tahun 2014. Dengan demikian, perlu dilakukan tindakan perbaikan guna menghindari terjadinya kerugian. Dalam penelitian ini digunakan metode Job Safety Analysis (JSA dengan pendekatan metode Failure Mode and Effect Analysis (FMEA. Berdasarkan tahapan JSA, terdapat 86 jenis kecelakaan kerja dan diperoleh 5 pekerjaan kritis untuk dianalisis menggunakan metode FMEA. Setelah dilakukan perhitungan RPN, didapatkan 3 pekerjaan dengan tingkat kecelakaan paling tinggi, yaitu pekerjaan menggunakan mesin saw blade, pekerjaan menggunakan mesin las dan pekerjaan menggunakan mesin bor. Selanjutnya, pekerjaan tersebut diberi rekomendasi perbaikan berupa penyusunan Instruksi Kerja (IK. IK berisi langkah dasar pekerjaan, potensi bahaya, serta tata cara kerja yang benar. Selain menyusun IK, tingkat disiplin kerja juga perlu diperhatikan untuk membuktikan penyebab pasti kecelakaan kerja. Tingkat disiplin kerja dipengaruhi oleh beberapa faktor, yaitu tujuan dan kemampuan, teladan pimpinan, balas jasa, keadilan, pengawasan melekat, sanksi hukuman, ketegasan, dan hubungan kemanusiaan. Selain faktor-faktor tersebut, tingkat disiplin kerja dapat dibentuk melalui 2 cara, yaitu dengan disiplin preventif dan disiplin korektif.

  18. Studies on failure kind analysis of the radiologic medical equipment in general hospital

    International Nuclear Information System (INIS)

    Lee, Woo Cheul; Kim, Jeong Lae

    1999-01-01

    This paper included a data analysis of the unit of medical devices using maintenance recording card that had medical devices of unit failure mode, hospital of failure mode and MTBF. The results of the analysis were as follows : 1. Medical devices of unit failure mode was the highest in QC/PM such A hospital as 33.9%, B hospital 30.9%, C hospital 30.3%, second degree was the Electrical and Electronic failure such A hospital as 23.5%, B hospital 25.3%, C hospital 28%, third degree was mechanical failure such A hospital as 19.6%, B hospital 22.5%, C hospital 25.4%. 2. Hospital of failure mode was the highest in Mobile X-ray device(A hospital 62.5%, B hospital 69.5%, C hospital 37.4%), and was the lowest in Sono devices(A hospital 16.76%, B hospital 8.4%, C hospital 7%). 3. Mean time between failures(MTBT) was the highest in SONO devices and was the lowest in Mobile X-ray devices which have 200 - 400 failure hours. 4. Average failure ratio was the highest in Mobile X-ray devices(A hospital 31.3%, B hospital 34.8%, C hospital 18.7%), and was the lowest in Sono(Ultrasound) devices (A hospital 8.4%, B hospital 4.2%, C hospital 3.5%). 5. Failure ratio results of medical devices according to QC/PM part of unit failure mode were as follows ; A hospital was the highest part of QC/PM (50%) in Mamo X-ray device and was the lowest part of QC/PM(26.4%) in Gastro X-ray. B hospital was the highest part of QC/PM(56%) in Mobile X-ray device, and the lowest part of QC/PM(12%) in Gastro X-ray. C hospital was the highest part of QC/PM(60%) in R/F X-ray device, and the lowest a part of QC/PM(21%) in Universal X-ray. It was found that the units responsible for most failure decreased by systematic management. We made the preventive maintenance schedule focusing on adjustment of operating and dust removal

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

    Science.gov (United States)

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

    2011-01-01

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

  20. ANALISA PENENTUAN FAKTOR DOMINAN KEGAGALAN DESAIN KOMPONEN SEAT ASS’Y OIL FILTER DENGAN METODE FMEA (FAILUR MODE AND EFFECTS ANALYSIS DI PT. SELAMAT SEMPURNA TBK

    Directory of Open Access Journals (Sweden)

    Dimas Novrizal

    2013-10-01

    Full Text Available Filter oli terdiri dari berbagai macam komponen dan beberapa diantaranya adalah seat, elco  dan  seat  assy.  Kadangkalanya komponen-komponen tersebt  mengalami kegagalan desain. Dari bermacam-macam bentuk kegagalan yang berasal dari klaim pelanggan yang terangkum dalam Rekaman Klaim Pelanggan, ada yang memerlukan perhatian serius. Yaitu potensi kegagalan yang dominan. Untu mengetahui klaim yang dominan terhadap (potensial failure, dilakukan analisa terhadap bermacam-macam kegagalan yang ada.Kegagalan- kegagalam tersebut yang pada awalnya berbentuk kasus, ditransformasikan kedalam bentuk angka/nilai, yang  mana  nilai-nilai tersebut adalah sebuah standar  yang  telah  ditetapkan didalam Referensi Manual Potential Failure Mode and Efects Analysis (Chrysler Corporation, Ford Motor Company, General Motor Corporation. Dari nilai-nilai yang telah ditetapkan, yaitu nilai Detection serta nilai severity yang diperoleh dari brainstorming serta pengalaman team, serta nilai occurance yang diperoleh dari penghitungan nilai PPM yang kesemua Potensi kegagalan tersebut ditransformasikan kedalam Possible failure Rates, didapat nilai RPN. Nilai RPN itu adalah hasil perkalian dari ketiga unsur diatas. RPN yang telah dibuat listnya menggambarkan bahwa RPN dengan nilai 192, Potensial Failure Mode; Tinggi titik emboss tidak seragam, menduduki peringkat tertinggi. Meskipun demikian, Potential Failure yang lainpun juga perlu ditindak lanjuti sesuai hasil analisanya, yang mana perbaikan dilakukan dengan skala prioritas, dari RPN tertinggi ke RPN terendah. 

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

    DEFF Research Database (Denmark)

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

    2009-01-01

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

  2. Analysis of failure and maintenance experiences of motor operated valves in a Finnish nuclear power plant

    International Nuclear Information System (INIS)

    Simola, K.; Laakso, K.

    1992-01-01

    Operating experiences from 1981 up to 1989 of totally 104 motor operated closing valves (MOV) in different safety systems at TVO I and II nuclear power units were analysed in a systematic way. The qualitative methods used were failure mode and effects analysis (FMEA) and maintenance effects and criticality analysis (MECA). The failure descriptions were obtained from power plant's computerized failure reporting system. The reported 181 failure events were reanalysed and sorted according to specific classifications developed for the MOV function. Filled FMEA and MECA sheets on individual valves were stored in a microcomputer data base for further analyses. Analyses were performed for the failed mechanical and electrical valve parts, ways of detection of failure modes, failure effects, and repair and unavailability times

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

    Science.gov (United States)

    Liao, Ching-Jong; Ho, Chao Chung

    2014-07-01

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

  4. Failure Propagation Modeling and Analysis via System Interfaces

    Directory of Open Access Journals (Sweden)

    Lin Zhao

    2016-01-01

    Full Text Available Safety-critical systems must be shown to be acceptably safe to deploy and use in their operational environment. One of the key concerns of developing safety-critical systems is to understand how the system behaves in the presence of failures, regardless of whether that failure is triggered by the external environment or caused by internal errors. Safety assessment at the early stages of system development involves analysis of potential failures and their consequences. Increasingly, for complex systems, model-based safety assessment is becoming more widely used. In this paper we propose an approach for safety analysis based on system interface models. By extending interaction models on the system interface level with failure modes as well as relevant portions of the physical system to be controlled, automated support could be provided for much of the failure analysis. We focus on fault modeling and on how to compute minimal cut sets. Particularly, we explore state space reconstruction strategy and bounded searching technique to reduce the number of states that need to be analyzed, which remarkably improves the efficiency of cut sets searching algorithm.

  5. Reliability analysis based on the losses from failures.

    Science.gov (United States)

    Todinov, M T

    2006-04-01

    The conventional reliability analysis is based on the premise that increasing the reliability of a system will decrease the losses from failures. On the basis of counterexamples, it is demonstrated that this is valid only if all failures are associated with the same losses. In case of failures associated with different losses, a system with larger reliability is not necessarily characterized by smaller losses from failures. Consequently, a theoretical framework and models are proposed for a reliability analysis, linking reliability and the losses from failures. Equations related to the distributions of the potential losses from failure have been derived. It is argued that the classical risk equation only estimates the average value of the potential losses from failure and does not provide insight into the variability associated with the potential losses. Equations have also been derived for determining the potential and the expected losses from failures for nonrepairable and repairable systems with components arranged in series, with arbitrary life distributions. The equations are also valid for systems/components with multiple mutually exclusive failure modes. The expected losses given failure is a linear combination of the expected losses from failure associated with the separate failure modes scaled by the conditional probabilities with which the failure modes initiate failure. On this basis, an efficient method for simplifying complex reliability block diagrams has been developed. Branches of components arranged in series whose failures are mutually exclusive can be reduced to single components with equivalent hazard rate, downtime, and expected costs associated with intervention and repair. A model for estimating the expected losses from early-life failures has also been developed. For a specified time interval, the expected losses from early-life failures are a sum of the products of the expected number of failures in the specified time intervals covering the

  6. Adaptive Failure Identification for Healthcare Risk Analysis and Its Application on E-Healthcare

    Directory of Open Access Journals (Sweden)

    Kuo-Chung Chu

    2014-01-01

    Full Text Available To satisfy the requirement for diverse risk preferences, we propose a generic risk priority number (GRPN function that assigns a risk weight to each parameter such that they represent individual organization/department/process preferences for the parameters. This research applies GRPN function-based model to differentiate the types of risk, and primary data are generated through simulation. We also conduct sensitivity analysis on correlation and regression to compare it with the traditional RPN (TRPN. The proposed model outperforms the TRPN model and provides a practical, effective, and adaptive method for risk evaluation. In particular, the defined GRPN function offers a new method to prioritize failure modes in failure mode and effect analysis (FMEA. The different risk preferences considered in the healthcare example show that the modified FMEA model can take into account the various risk factors and prioritize failure modes more accurately. In addition, the model also can apply to a generic e-healthcare service environment with a hierarchical architecture.

  7. Application of Failure Mode and Effect Analysis (FMEA) and cause and effect analysis in conjunction with ISO 22000 to a snails (Helix aspersa) processing plant; A case study.

    Science.gov (United States)

    Arvanitoyannis, Ioannis S; Varzakas, Theodoros H

    2009-08-01

    Failure Mode and Effect Analysis (FMEA) has been applied for the risk assessment of snails manufacturing. A tentative approach of FMEA application to the snails industry was attempted in conjunction with ISO 22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (snails processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram, and fishbone diagram). In this work a comparison of ISO22000 analysis with HACCP is carried out over snails processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the RPN per identified processing hazard. Sterilization of tins, bioaccumulation of heavy metals, packaging of shells and poisonous mushrooms, were the processes identified as the ones with the highest RPN (280, 240, 147, 144, respectively) and corrective actions were undertaken. Following the application of corrective actions, a second calculation of RPN values was carried out leading to considerably lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO22000 system of a snails processing industry is considered imperative.

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

    International Nuclear Information System (INIS)

    Hoy, H.C.

    1984-01-01

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

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

    Science.gov (United States)

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

    2018-06-01

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

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

    International Nuclear Information System (INIS)

    Shopsky, W.E.

    1977-01-01

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

  11. Advances on the Failure Analysis of the Dam—Foundation Interface of Concrete Dams

    Directory of Open Access Journals (Sweden)

    Luis Altarejos-García

    2015-12-01

    Full Text Available Failure analysis of the dam-foundation interface in concrete dams is characterized by complexity, uncertainties on models and parameters, and a strong non-linear softening behavior. In practice, these uncertainties are dealt with a well-structured mixture of experience, best practices and prudent, conservative design approaches based on the safety factor concept. Yet, a sound, deep knowledge of some aspects of this failure mode remain unveiled, as they have been offset in practical applications by the use of this conservative approach. In this paper we show a strategy to analyse this failure mode under a reliability-based approach. The proposed methodology of analysis integrates epistemic uncertainty on spatial variability of strength parameters and data from dam monitoring. The purpose is to produce meaningful and useful information regarding the probability of occurrence of this failure mode that can be incorporated in risk-informed dam safety reviews. In addition, relationships between probability of failure and factors of safety are obtained. This research is supported by a more than a decade of intensive professional practice on real world cases and its final purpose is to bring some clarity, guidance and to contribute to the improvement of current knowledge and best practices on such an important dam safety concern.

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2000-01-01

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

  13. Launch Vehicle Failure Dynamics and Abort Triggering Analysis

    Science.gov (United States)

    Hanson, John M.; Hill, Ashely D.; Beard, Bernard B.

    2011-01-01

    Launch vehicle ascent is a time of high risk for an on-board crew. There are many types of failures that can kill the crew if the crew is still on-board when the failure becomes catastrophic. For some failure scenarios, there is plenty of time for the crew to be warned and to depart, whereas in some there is insufficient time for the crew to escape. There is a large fraction of possible failures for which time is of the essence and a successful abort is possible if the detection and action happens quickly enough. This paper focuses on abort determination based primarily on data already available from the GN&C system. This work is the result of failure analysis efforts performed during the Ares I launch vehicle development program. Derivation of attitude and attitude rate abort triggers to ensure that abort occurs as quickly as possible when needed, but that false positives are avoided, forms a major portion of the paper. Some of the potential failure modes requiring use of these triggers are described, along with analysis used to determine the success rate of getting the crew off prior to vehicle demise.

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

    Science.gov (United States)

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

    2016-01-01

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

  15. Lower head failure analysis

    International Nuclear Information System (INIS)

    Rempe, J.L.; Thinnes, G.L.; Allison, C.M.; Cronenberg, A.W.

    1991-01-01

    The US Nuclear Regulatory Commission is sponsoring a lower vessel head research program to investigate plausible modes of reactor vessel failure in order to determine (a) which modes have the greatest likelihood of occurrence during a severe accident and (b) the range of core debris and accident conditions that lead to these failures. This paper presents the methodology and preliminary results of an investigation of reactor designs and thermodynamic conditions using analytic closed-form approximations to assess the important governing parameters in non-dimensional form. Preliminary results illustrate the importance of vessel and tube geometrical parameters, material properties, and external boundary conditions on predicting vessel failure. Thermal analyses indicate that steady-state temperature distributions will occur in the vessel within several hours, although the exact time is dependent upon vessel thickness. In-vessel tube failure is governed by the tube-to-debris mass ratio within the lower head, where most penetrations are predicted to fail if surrounded by molten debris. Melt penetration distance is dependent upon the effective flow diameter of the tube. Molten debris is predicted to penetrate through tubes with a larger effective flow diameter, such as a boiling water reactor (BWR) drain nozzle. Ex-vessel tube failure for depressurized reactor vessels is predicted to be more likely for a BWR drain nozzle penetration because of its larger effective diameter. At high pressures (between ∼0.1 MPa and ∼12 MPa) ex-vessel tube rupture becomes a dominant failure mechanism, although tube ejection dominates control rod guide tube failure at lower temperatures. However, tube ejection and tube rupture predictions are sensitive to the vessel and tube radial gap size and material coefficients of thermal expansion

  16. Risk Assessment of Total Coliform in X WTP’s Water Production Using Failure Mode And Effect Analysis Method

    Directory of Open Access Journals (Sweden)

    Bella Apriliani Amanda

    2017-07-01

    Full Text Available The greatest risk of drinking water supply is a failure to provide safe drinking water for communities. Based on IPA Kedunguling testing report on March 2016 noted that sample exceeding the quality standart of Peraturan Menteri Kesehatan RI No 492/2010 for the total coliform quality standart. The presence of total coliforms indicating water contamination by pathogen means the water is not safe to consume. The disinfection process has an importance rule in pathogen inactivation. Disinfectant performance is influenced by temperature, pH, turbidity, and the presence of organic materials. One way to control the quality of water produced by using a risk management approach Failure Modes and Effect Analysis (FMEA methods. The potential risks should be measured to determine causes of the problems and find the appropriate risk reduction. The risk assessment is using Risk Priority Number (RPN scale as a basis prioritization of remedial action on issues. Based on identification and risk analysis using FMEA known that the greatest risk of failure is the stipulation of chlorine dose and organic substances (category of high risk level; residual chlorine (category of moderate risk level; turbidity and pH (very low risk level category. Improvement proposal that can be done to reduce total coliforms presence in IPA Kedunguling is by increasing residual chlorine to 0.6 mg/l, set a daily chlorine level, controlling DBPs forming by lowering the concentration of organic precursor using granular activated carbon (GAC or aeration, by lowering the dose of disinfectant, set aside DBPs after the compound is formed using granular activated carbon (GAC, turbidity and pH monitoring, and regularly washing the filters

  17. Analysis of the failure of a vacuum spin-pit drive turbine spindle shaft

    OpenAIRE

    Pettitt, Jason M.

    2005-01-01

    The Naval Postgraduate School's Rotor Spin Research Facility experienced a failure in the Spring of 2005 in which the rotor dropped from the drive turbine and caused extensive damage. A failure analysis of the drive turbine spindle shaft was conducted in order to determine the cause of failure: whether due to a material or design flaw. Also, a dynamic analysis was conducted in order to determine the natural modes present in the system and the associated frequencies that could have contributed...

  18. Effectiveness and cost of failure mode and effects analysis methodology to reduce neurosurgical site infections.

    Science.gov (United States)

    Hover, Alexander R; Sistrunk, William W; Cavagnol, Robert M; Scarrow, Alan; Finley, Phillip J; Kroencke, Audrey D; Walker, Judith L

    2014-01-01

    Mercy Hospital Springfield is a tertiary care facility with 32 000 discharges and 15 000 inpatient surgeries in 2011. From June 2009 through January 2011, a stable inpatient elective neurosurgery infection rate of 2.15% was observed. The failure mode and effects analysis (FMEA) methodology to reduce inpatient neurosurgery infections was utilized. Following FMEA implementation, overall elective neurosurgery infection rates were reduced to 1.51% and sustained through May 2012. Compared with baseline, the post-FMEA deep-space and organ infection rate was reduced by 41% (P = .052). Overall hospital inpatient clean surgery infection rates for the same time frame did not decrease to the same extent, suggesting a specific effect of the FMEA. The study team believes that the FMEA interventions resulted in 14 fewer expected infections, $270 270 in savings, a 168-day reduction in expected length of stay, and 22 fewer readmissions. Given the serious morbidity and cost of health care-associated infections, the study team concludes that FMEA implementation was clinically cost-effective. © 2013 by the American College of Medical Quality.

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

    International Nuclear Information System (INIS)

    Yanagisawa, Kazuaki

    1992-03-01

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

  20. Structural failure modes in vertical tanks: reinforcement evaluation and solutions

    International Nuclear Information System (INIS)

    Alcantud Abellan, M.; Orden Martinez, A.

    1995-01-01

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

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

    International Nuclear Information System (INIS)

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

    2004-01-01

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

  2. Application of FMEA-DEA (Failure Modes and Effect Analysis - Data Envelopment Analysis) to the air conditioning system of the control room a nuclear power plant; Aplicacao de FMEA-DEA ao sistema de ar condicionado da sala de controle de uma usina nuclear

    Energy Technology Data Exchange (ETDEWEB)

    Barbosa, Junior, Gilberto Varanda

    2007-03-15

    This dissertation presents the FMEA-DEA analysis application to the air conditioning system of the control room of a nuclear power plant. After obtaining the failure modes, the index associated to the occurrence probability, the severity of the effects and the potential of detention, a priority order is established for the failure modes or deviations. This number is obtained by multiplying the three mentioned index that vary in a natural scale from 1 to 10, where the higher the index, the more critical the situation will be. In this work, it is intended to use a model based on the data envelopment analysis, DEA jointly with the FMEA, to identify the current efficiency of the system and which failure modes or deviations are considered more critical, and by means of the weights attributed for the mathematical modeling to identify which index are contributing more for these deviations. From this identification, improvements can be set, which may consider administrative changes, operator training and so on, thus adding value to the final product. (author)

  3. Analysis Method of Common Cause Failure on Non-safety Digital Control System

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Yun Goo; Oh, Eun Gse [KHNP, Daejeon (Korea, Republic of)

    2014-08-15

    The effects of common cause failure on safety digital instrumentation and control system had been considered in defense in depth analysis with safety analysis method. However, the effects of common cause failure on non-safety digital instrumentation and control system also should be evaluated. The common cause failure can be included in credible failure on the non-safety system. In the I and C architecture of nuclear power plant, many design feature has been applied for the functional integrity of control system. One of that is segmentation. Segmentation defenses the propagation of faults in the I and C architecture. Some of effects from common cause failure also can be limited by segmentation. Therefore, in this paper there are two type of failure mode, one is failures in one control group which is segmented, and the other is failures in multiple control group because that the segmentation cannot defense all effects from common cause failure. For each type, the worst failure scenario is needed to be determined, so the analysis method has been proposed in this paper. The evaluation can be qualitative when there is sufficient justification that the effects are bounded in previous safety analysis. When it is not bounded in previous safety analysis, additional analysis should be done with conservative assumptions method of previous safety analysis or best estimation method with realistic assumptions.

  4. Failure analysis of motor bearing of sea water pump in nuclear power plant

    International Nuclear Information System (INIS)

    Bian Chunhua; Zhang Wei

    2015-01-01

    The motor bearing of sea water pump in Qinshan Phase II Nuclear Power plant broke after only one year's using. This paper introduces failure analysis process of the motor bearing. Chemical composition analysis, metallic phase analysis, micrographic examination, and hardness analysis, dimension analysis of each part of the bearing, as well as the high temperature and low temperature performance analysis of lubricating grease are performed. According to the analysis above mentioned, the failure mode of the bearing is wearing, and the reason of wearing is inappropriate installation of the bearing. (authors)

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

    Directory of Open Access Journals (Sweden)

    Gamal Rashed

    2015-06-01

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

  6. RISIKO RANTAI PASOK KAKAO DI INDONESIA DENGAN METODE ANALYTIC NETWORK PROCESS DAN FAILURE MODE EFFECT ANALYSIS TERINTEGRASI

    Directory of Open Access Journals (Sweden)

    Harumi Aini

    2015-03-01

    Full Text Available Cocoa is one of the plantation commodities whose role is quite important for the national economy of Indonesia. However, the cocoa industry faces several problems including the various risks involved in the cocoa supply chain. The aim of this study were: 1 Identify the various risks involved in the cocoa supply chain, 2 analyze and evaluate the supply chain actors members with the highest risk in the cocoa supply chain management, and 3 understand how to evaluate and mitigate the highest risk in the cocoa supply chain effectively and efficiently. An Integrated Analytic Network Process (ANP and Weighted Failure Mode Effect Analysis (WFMEA method will be used to determine and analyze the highest risk in the cocoa supply chain. The results of the priority of the members of the value chain in the cocoa supply chain risk management are the farmer (0.408 with the risk of having the greatest priority is production risk (0.221. Risk control could be done by improving the productivity and competitiveness of cocoa.Keywords: ANP, FMEA, cocoa, risk management, supply chainABSTRAKKakao merupakan salah satu komoditas perkebunan yang peranannya cukup penting bagi perekonomian Indonesia. Industri kakao menghadapi beberapa masalah termasuk berbagai risiko yang timbul dalam rantai pasokan kakao. Tujuan penelitian ini adalah 1 mengidentifikasi macam-macam risiko pada rantai pasok kakao, 2 menganalisis dan mengevaluasi anggota pelaku rantai pasok dengan risiko tertinggi dalam manajemen rantai pasok kakao, dan 3 mengetahui cara mengevaluasi dan memitigasi risiko tertinggi pada rantai pasok kakao dengan efektif dan efisien. Metode Analytic Network Process (ANP dan Weighted Failure Mode Effect Analysis (WFMEA terintegrasi digunakan untuk mengetahui dan menganalisis risiko tertinggi dalam rantai pasokan kakao. Hasil prioritas anggota pelaku rantai pasok dalam manajemen risiko rantai pasokan kakao petani (0,408 dengan risiko yang memiliki prioritas terbesar adalah

  7. Analysis of dependent failures in the ORNL precursor study

    International Nuclear Information System (INIS)

    Ballard, G.M.

    1985-01-01

    The study of dependent failures (or common cause/mode failures) in the safety assessment of potentially hazardous plant is one of the significant areas of uncertainty in performing probabilistic safety studies. One major reason for this uncertainty is that data on dependent failures is apparently not readily available in sufficient quantity to assist in the development and validation of models. The incident reports that were compiled for the ORNL study on Precursors to Severe Core Damage Accidents (NUREG/CR-2497) provide an opportunity to look at the importance of dependent failures in the most significant incidents of recent reactor operations, to look at the success of probabilistic risk assessment (PRA) methods in accounting for the contribution of dependent failures, and to look at the dependent failure incidents with the aim of identifying the most significant problem areas. In this paper an analysis has been made of the incidents compiled in NUREG/CR-2497 and events involving multiple failures which were not independent have been identified. From this analysis it is clear that dependent failures are a very significant contributor to the precursor incidents. The method of enumeration of accident frequency used in NUREG-2497 can be shown to take account of dependent failures and this may be a significant factor contributing to the apparent difference between the precursor accident frequency and typical PRA frequencies

  8. An assessment of BWR [boiling water reactor] Mark III containment challenges, failure modes, and potential improvements in performance

    International Nuclear Information System (INIS)

    Schroeder, J.A.; Pafford, D.J.; Kelly, D.L.; Jones, K.R.; Dallman, F.J.

    1991-01-01

    This report describes risk-significant challenges posed to Mark III containment systems by severe accidents as identified for Grand Gulf. Design similarities and differences between the Mark III plants that are important to containment performance are summarized. The accident sequences responsible for the challenges and the postulated containment failure modes associated with each challenge are identified and described. Improvements are discussed that have the potential either to prevent or delay containment failure, or to mitigate the offsite consequences of a fission product release. For each of these potential improvements, a qualitative analysis is provided. A limited quantitative risk analysis is provided for selected potential improvements. 21 refs., 5 figs., 46 tabs

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

    International Nuclear Information System (INIS)

    Wang Wenbin; Banjevic, Dragan; Pecht, Michael

    2010-01-01

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

  10. Seismic failure modes and seismic safety of Hardfill dam

    Directory of Open Access Journals (Sweden)

    Kun Xiong

    2013-04-01

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

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

    Science.gov (United States)

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

    2014-06-01

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

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

    International Nuclear Information System (INIS)

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

    1987-11-01

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

  13. Failure analysis of PB-1 (EBTS Be/Cu mockup)

    International Nuclear Information System (INIS)

    Odegard, B.C. Jr.; Cadden, C.H.

    1996-11-01

    Failure analysis was done on PB-1 (series of Be tiles joined to Cu alloy) following a tile failure during a high heat flux experiment in EBTS (electron beam test system). This heat flux load simulated ambient conditions inside ITER; the Be tiles were bonded to the Cu alloy using low-temperature diffusion bonding, which is being considered for fabricating plasma facing components in ITER. Results showed differences between the EBTS failure and a failure during a room temperature tensile test. The latter occurred at the Cu-Be interface in an intermetallic phase formed by reaction of the two metals at the bonding temperature. Fracture strengths measured by these tests were over 300 MPa. The high heat flux specimens failed at the Cu-Cu diffusion bond. Fracture morphology in both cases was a mixed mode of dimple rupture and transgranular cleavage. Several explanations for this difference in failure mechanism are suggested

  14. The failure mode of natural silk epoxy triggered composite tubes

    International Nuclear Information System (INIS)

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

    2012-01-01

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

  15. Failure analysis of axle shaft of a fork lift

    Directory of Open Access Journals (Sweden)

    Souvik Das

    2015-04-01

    Full Text Available An axle shaft of fork lift failed at operation within 296 h of service. The shaft transmits torque from discrepancy to wheel through planetary gear arrangement. A section of fractured axle shaft made of induction-hardened steel was analyzed to determine the root cause of the failure. Optical microscopies as well as field emission gun scanning electron microscopy (FEG-SEM along with energy dispersive spectroscopy (EDS were carried out to characterize the microstructure. Hardness profile throughout the cross-section was evaluated by micro-hardness measurements. Chemical analysis indicated that the shaft was made of 42CrMo4 steel grade as per specification. Microstructural analysis and micro-hardness profile revealed that the shaft was improperly heat treated resulting in a brittle case, where crack was found to initiate from the case in a brittle mode in contrast to ductile mode within the core. This behaviour was related to differences in microstructure, which was observed to be martensitic within the case with a micro-hardness equivalent to 735 HV, and a mixture of non-homogeneous structure of pearlite and ferrite within the core with a hardness of 210 HV. The analysis suggests that the fracture initiated from the martensitic case as brittle mode due to improper heat treatment process (high hardness. Moreover the inclusions along the hot working direction i.e. in the longitudinal axis made the component more susceptible to failure.

  16. Analysis of acetal toilet fill valve supply line nut failure

    Directory of Open Access Journals (Sweden)

    Anthony Timpanaro

    2017-10-01

    Full Text Available In recent years, there has been a rise in the number of product liability cases involving the failure of toilet water supply line acetal plastic nuts. These nuts can fail in service, causing water leaks that result in significant property and financial losses. This study examines three possible failure modes of acetal plastic toilet water supply nuts. The three failure modes tested were all due to over load failure of the acetal nut and are as follows: (1 Overtightening of the supply line acetal nut, (2 Supply line lateral pull and, (3 Embrittled supply line lateral pull. Additionally, a “hand-tight” torque survey was conducted. The fracture surfaces and characteristics of these failure tests were examined with Stereo Microscopy and Scanning Electron Microscopy (SEM. The failure modes were compared and contrasted to provide guidance in determination of cause in these investigations.

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

    International Nuclear Information System (INIS)

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

    2014-01-01

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

  18. Study and analysis of failure modes of the electrolytic capacitors and thyristors, applied to the protection system of the LHC (Large Hadron Collider); Etude et analyse des modes de defaillances des condensateurs electrolytiques a l'aluminium et des thyristors: appliquees au systeme de protection du LHC (Large Hadron Collider)

    Energy Technology Data Exchange (ETDEWEB)

    Perisse, F

    2003-07-15

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

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

    Directory of Open Access Journals (Sweden)

    Peng Li

    2016-10-01

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

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

    DEFF Research Database (Denmark)

    Cooke, R.; Paulsen, J.L.

    1997-01-01

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

  1. Failure modes of a concrete nuclear-containment building subjected to hydrogen detonation

    International Nuclear Information System (INIS)

    Fugelso, L.E.; Butler, T.A.

    1983-01-01

    Calculated response for the Indian Point reactor containment building to static internal pressure and one case of a dynamic pressure representing hydrogen combustion and detonation are presented. Comparison of the potential failure modes is made. 9 figures

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

    Science.gov (United States)

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

    2013-09-01

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

  3. PACC information management code for common cause failures analysis

    International Nuclear Information System (INIS)

    Ortega Prieto, P.; Garcia Gay, J.; Mira McWilliams, J.

    1987-01-01

    The purpose of this paper is to present the PACC code, which, through an adequate data management, makes the task of computerized common-mode failure analysis easier. PACC processes and generates information in order to carry out the corresponding qualitative analysis, by means of the boolean technique of transformation of variables, and the quantitative analysis either using one of several parametric methods or a direct data-base. As far as the qualitative analysis is concerned, the code creates several functional forms for the transformation equations according to the user's choice. These equations are subsequently processed by boolean manipulation codes, such as SETS. The quantitative calculations of the code can be carried out in two different ways: either starting from a common cause data-base, or through parametric methods, such as the Binomial Failure Rate Method, the Basic Parameters Method or the Multiple Greek Letter Method, among others. (orig.)

  4. Failure Modes Effects and Criticality Analysis, an Underutilized Safety, Reliability, Project Management and Systems Engineering Tool

    Science.gov (United States)

    Mullin, Daniel Richard

    2013-09-01

    The majority of space programs whether manned or unmanned for science or exploration require that a Failure Modes Effects and Criticality Analysis (FMECA) be performed as part of their safety and reliability activities. This comes as no surprise given that FMECAs have been an integral part of the reliability engineer's toolkit since the 1950s. The reasons for performing a FMECA are well known including fleshing out system single point failures, system hazards and critical components and functions. However, in the author's ten years' experience as a space systems safety and reliability engineer, findings demonstrate that the FMECA is often performed as an afterthought, simply to meet contract deliverable requirements and is often started long after the system requirements allocation and preliminary design have been completed. There are also important qualitative and quantitative components often missing which can provide useful data to all of project stakeholders. These include; probability of occurrence, probability of detection, time to effect and time to detect and, finally, the Risk Priority Number. This is unfortunate as the FMECA is a powerful system design tool that when used effectively, can help optimize system function while minimizing the risk of failure. When performed as early as possible in conjunction with writing the top level system requirements, the FMECA can provide instant feedback on the viability of the requirements while providing a valuable sanity check early in the design process. It can indicate which areas of the system will require redundancy and which areas are inherently the most risky from the onset. Based on historical and practical examples, it is this author's contention that FMECAs are an immense source of important information for all involved stakeholders in a given project and can provide several benefits including, efficient project management with respect to cost and schedule, system engineering and requirements management

  5. Analysis of failure modes in multislice computed tomography during primary trauma survey; Analyse von Verzoegerungen der Schockraumdiagnostik bei Einsatz der Mehrschicht-Spiral-Computertomografie

    Energy Technology Data Exchange (ETDEWEB)

    Siebers, C.; Stegmaier, J.; Kirchhoff, C.; Kanz, K.G. [Chirurgische Klinik, Klinikum der Univ. Muenchen (Germany); Wirth, S.; Koerner, M.; Pfeifer, K.J. [Inst. fuer Klinische Radiologie, Klinikum der Univ. Muenchen (Germany); Kay, M.V. [Plansafe GmbH, Muenchen (Germany)

    2008-08-15

    Purpose: in the case of major trauma, immediate recognition and treatment of life-threatening conditions are essential. An increasing number of European trauma centers use MSCT during the primary trauma survey due to its high diagnostic precision and speed. However, there is currently little empirical data about failures in this process to practice quality assurance. The aim of this study was to evaluate this process under operating resuscitation conditions and to identify failure modes that caused delays in completion. Materials and methods: an independent study monitor documented the course of trauma room treatment during a 10-month period. The inclusion criteria were patients who were admitted directly from the accident scene and the study monitor was present at the time of admission. Results: according to our ATLS-based trauma algorithm whole-body CT (WBCT) consists of non-contrast head CT (CCT) and contrast-enhanced trunk CT (TCT). 57 trauma patients receiving 45 WBCT. 5 single CCT and 4 single TCT studies were evaluated. After initial resuscitation, CCT was obtained within 17 min of trauma room admission (IQR 13.0 - 20.0). In 20% (95%CI 9 - 31%) of the cases, a CCT delay of median 5.0 min (IQR 3.8 - 8.0) was observed caused by e.g. earings, piercings and ECG cables in the scan field or intoxicated patients. Contrast-enhanced TCT was performed after 23.0 min (IQR 19.0 - 27.0). Due to preventable errors 12 of the 49 TCT studies were delayed (25%95%CI 12 - 37%) for 5 min (IQR 3.0 - 8.0). Conclusion: under ''front line'' conditions every fifth CCT and every fourth TCT study was completed with a median delay of 5 min. An independent process analysis revealed that unpreventable delays were due to uncooperative patients or system failure. Preventable delays were due to errors such as short intravenous lines or deviation from trauma room algorithms. Preventable delays could be avoided by addressing human and technical aspects such as revising

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

    Directory of Open Access Journals (Sweden)

    Nia Budi Puspitasari

    2017-07-01

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

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

    International Nuclear Information System (INIS)

    Sun Beiyun; Chen Xiangyue; Zhai Aibin; Mao Congguang

    2009-01-01

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

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

    Science.gov (United States)

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

    2017-11-10

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

  9. Statistical analysis of nuclear power plant pump failure rate variability: some preliminary results

    International Nuclear Information System (INIS)

    Martz, H.F.; Whiteman, D.E.

    1984-02-01

    In-Plant Reliability Data System (IPRDS) pump failure data on over 60 selected pumps in four nuclear power plants are statistically analyzed using the Failure Rate Analysis Code (FRAC). A major purpose of the analysis is to determine which environmental, system, and operating factors adequately explain the variability in the failure data. Catastrophic, degraded, and incipient failure severity categories are considered for both demand-related and time-dependent failures. For catastrophic demand-related pump failures, the variability is explained by the following factors listed in their order of importance: system application, pump driver, operating mode, reactor type, pump type, and unidentified plant-specific influences. Quantitative failure rate adjustments are provided for the effects of these factors. In the case of catastrophic time-dependent pump failures, the failure rate variability is explained by three factors: reactor type, pump driver, and unidentified plant-specific influences. Finally, point and confidence interval failure rate estimates are provided for each selected pump by considering the influential factors. Both types of estimates represent an improvement over the estimates computed exclusively from the data on each pump

  10. Model Based Approach for Identification of Gears and Bearings Failure Modes

    Directory of Open Access Journals (Sweden)

    Renata Klein

    2011-01-01

    Full Text Available This paper describes the algorithms that were used for analysis of the PHM’09 gear-box. The purpose of the analysis was to detect and identify faults in various components of the gear-box. Each of the 560 vibration recordings presented a different set of faults, including distributed and localized gear faults, typical bearing faults and shaft faults. Each fault had to be pinpointed precisely.In the following sections we describe the algorithms used for finding faults in bearings, gears and shafts, and the conclusions that were reached. A special blend of pattern recognition and signal processing methods was applied.Bearings were analyzed using the orders representation of the envelope of a band pass filtered signal and an envelope of the de-phased signal. A special search algorithm was applied for bearings features extraction. The diagnostics of the bearings failure modes was carried out automatically. Gears were analyzed using the order domains, the quefrency of orders, and the derivatives of the phase average.

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

    International Nuclear Information System (INIS)

    1979-10-01

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

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

    Directory of Open Access Journals (Sweden)

    Nestor Ciociano

    2017-03-01

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

  13. Study and analysis of failure modes of the electrolytic capacitors and thyristors, applied to the protection system of the LHC (Large Hadron Collider); Etude et analyse des modes de defaillances des condensateurs electrolytiques a l'aluminium et des thyristors: appliquees au systeme de protection du LHC (Large Hadron Collider)

    Energy Technology Data Exchange (ETDEWEB)

    Perisse, F

    2003-07-15

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

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

    International Nuclear Information System (INIS)

    Li Hui; Ou Jinping

    2008-01-01

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

  15. Analytical criteria for fuel failure modes observed in reactivity initiated accidents

    International Nuclear Information System (INIS)

    Luxat, J.C.

    2005-01-01

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

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

    Science.gov (United States)

    Sghaireen, Mohd G

    2015-06-01

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

  17. Reliability analysis and prediction of mixed mode load using Markov Chain Model

    International Nuclear Information System (INIS)

    Nikabdullah, N.; Singh, S. S. K.; Alebrahim, R.; Azizi, M. A.; K, Elwaleed A.; Noorani, M. S. M.

    2014-01-01

    The aim of this paper is to present the reliability analysis and prediction of mixed mode loading by using a simple two state Markov Chain Model for an automotive crankshaft. The reliability analysis and prediction for any automotive component or structure is important for analyzing and measuring the failure to increase the design life, eliminate or reduce the likelihood of failures and safety risk. The mechanical failures of the crankshaft are due of high bending and torsion stress concentration from high cycle and low rotating bending and torsional stress. The Markov Chain was used to model the two states based on the probability of failure due to bending and torsion stress. In most investigations it revealed that bending stress is much serve than torsional stress, therefore the probability criteria for the bending state would be higher compared to the torsion state. A statistical comparison between the developed Markov Chain Model and field data was done to observe the percentage of error. The reliability analysis and prediction was derived and illustrated from the Markov Chain Model were shown in the Weibull probability and cumulative distribution function, hazard rate and reliability curve and the bathtub curve. It can be concluded that Markov Chain Model has the ability to generate near similar data with minimal percentage of error and for a practical application; the proposed model provides a good accuracy in determining the reliability for the crankshaft under mixed mode loading

  18. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.

    Science.gov (United States)

    Fassett, William E

    2011-10-10

    As colleges and schools of pharmacy develop core courses related to patient safety, course-level outcomes will need to include both knowledge and performance measures. Three key performance outcomes for patient safety coursework, measured at the course level, are the ability to perform root cause analyses and healthcare failure mode effects analyses, and the ability to generate effective safety communications using structured formats such as the Situation-Background-Assessment-Recommendation (SBAR) situational briefing model. Each of these skills is widely used in patient safety work and competence in their use is essential for a pharmacist's ability to contribute as a member of a patient safety team.

  19. Failure modes of laminate structures

    Energy Technology Data Exchange (ETDEWEB)

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

    1987-06-01

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

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

    International Nuclear Information System (INIS)

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

    2009-01-01

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

  1. Failure analysis of bolted joints in foam-core sandwich composites

    DEFF Research Database (Denmark)

    Zabihpoor, M.; Moslemian, Ramin; Afshin, M.

    2008-01-01

    This study represents an effort to predict the bearing strength, failure modes, and failure load of bolted joints in foam-core sandwich composites. The studied joints have been used in a light full composite airplane. By using solid laminates, a new design for the joint zone is developed. These s......This study represents an effort to predict the bearing strength, failure modes, and failure load of bolted joints in foam-core sandwich composites. The studied joints have been used in a light full composite airplane. By using solid laminates, a new design for the joint zone is developed...

  2. UAV Swarm Behavior Modeling for Early Exposure of Failure Modes

    Science.gov (United States)

    2016-09-01

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

  3. Common-Cause Failure Analysis in Event Assessment

    International Nuclear Information System (INIS)

    Rasmuson, D.M.; Kelly, D.L.

    2008-01-01

    This paper reviews the basic concepts of modeling common-cause failures (CCFs) in reliability and risk studies and then applies these concepts to the treatment of CCF in event assessment. The cases of a failed component (with and without shared CCF potential) and a component being unavailable due to preventive maintenance or testing are addressed. The treatment of two related failure modes (e.g. failure to start and failure to run) is a new feature of this paper, as is the treatment of asymmetry within a common-cause component group

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

    International Nuclear Information System (INIS)

    Kurisaka, Kenichi

    1998-08-01

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

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

    DEFF Research Database (Denmark)

    Chen, Yuxiang; Li, Wuhua; Iannuzzo, Francesco

    2018-01-01

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

  6. Periodic imperfect preventive maintenance with two categories of competing failure modes

    Energy Technology Data Exchange (ETDEWEB)

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

    2006-04-15

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

  7. Periodic imperfect preventive maintenance with two categories of competing failure modes

    International Nuclear Information System (INIS)

    Zequeira, R.I.; Berenguer, C.

    2006-01-01

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

  8. Failure probabilistic model of CNC lathes

    International Nuclear Information System (INIS)

    Wang Yiqiang; Jia Yazhou; Yu Junyi; Zheng Yuhua; Yi Shangfeng

    1999-01-01

    A field failure analysis of computerized numerical control (CNC) lathes is described. Field failure data was collected over a period of two years on approximately 80 CNC lathes. A coding system to code failure data was devised and a failure analysis data bank of CNC lathes was established. The failure position and subsystem, failure mode and cause were analyzed to indicate the weak subsystem of a CNC lathe. Also, failure probabilistic model of CNC lathes was analyzed by fuzzy multicriteria comprehensive evaluation

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

    International Nuclear Information System (INIS)

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

    1993-01-01

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

  10. Failure rate modeling using fault tree analysis and Bayesian network: DEMO pulsed operation turbine study case

    International Nuclear Information System (INIS)

    Dongiovanni, Danilo Nicola; Iesmantas, Tomas

    2016-01-01

    Highlights: • RAMI (Reliability, Availability, Maintainability and Inspectability) assessment of secondary heat transfer loop for a DEMO nuclear fusion plant. • Definition of a fault tree for a nuclear steam turbine operated in pulsed mode. • Turbine failure rate models update by mean of a Bayesian network reflecting the fault tree analysis in the considered scenario. • Sensitivity analysis on system availability performance. - Abstract: Availability will play an important role in the Demonstration Power Plant (DEMO) success from an economic and safety perspective. Availability performance is commonly assessed by Reliability Availability Maintainability Inspectability (RAMI) analysis, strongly relying on the accurate definition of system components failure modes (FM) and failure rates (FR). Little component experience is available in fusion application, therefore requiring the adaptation of literature FR to fusion plant operating conditions, which may differ in several aspects. As a possible solution to this problem, a new methodology to extrapolate/estimate components failure rate under different operating conditions is presented. The DEMO Balance of Plant nuclear steam turbine component operated in pulse mode is considered as study case. The methodology moves from the definition of a fault tree taking into account failure modes possibly enhanced by pulsed operation. The fault tree is then translated into a Bayesian network. A statistical model for the turbine system failure rate in terms of subcomponents’ FR is hence obtained, allowing for sensitivity analyses on the structured mixture of literature and unknown FR data for which plausible value intervals are investigated to assess their impact on the whole turbine system FR. Finally, the impact of resulting turbine system FR on plant availability is assessed exploiting a Reliability Block Diagram (RBD) model for a typical secondary cooling system implementing a Rankine cycle. Mean inherent availability

  11. Failure rate modeling using fault tree analysis and Bayesian network: DEMO pulsed operation turbine study case

    Energy Technology Data Exchange (ETDEWEB)

    Dongiovanni, Danilo Nicola, E-mail: danilo.dongiovanni@enea.it [ENEA, Nuclear Fusion and Safety Technologies Department, via Enrico Fermi 45, Frascati 00040 (Italy); Iesmantas, Tomas [LEI, Breslaujos str. 3 Kaunas (Lithuania)

    2016-11-01

    Highlights: • RAMI (Reliability, Availability, Maintainability and Inspectability) assessment of secondary heat transfer loop for a DEMO nuclear fusion plant. • Definition of a fault tree for a nuclear steam turbine operated in pulsed mode. • Turbine failure rate models update by mean of a Bayesian network reflecting the fault tree analysis in the considered scenario. • Sensitivity analysis on system availability performance. - Abstract: Availability will play an important role in the Demonstration Power Plant (DEMO) success from an economic and safety perspective. Availability performance is commonly assessed by Reliability Availability Maintainability Inspectability (RAMI) analysis, strongly relying on the accurate definition of system components failure modes (FM) and failure rates (FR). Little component experience is available in fusion application, therefore requiring the adaptation of literature FR to fusion plant operating conditions, which may differ in several aspects. As a possible solution to this problem, a new methodology to extrapolate/estimate components failure rate under different operating conditions is presented. The DEMO Balance of Plant nuclear steam turbine component operated in pulse mode is considered as study case. The methodology moves from the definition of a fault tree taking into account failure modes possibly enhanced by pulsed operation. The fault tree is then translated into a Bayesian network. A statistical model for the turbine system failure rate in terms of subcomponents’ FR is hence obtained, allowing for sensitivity analyses on the structured mixture of literature and unknown FR data for which plausible value intervals are investigated to assess their impact on the whole turbine system FR. Finally, the impact of resulting turbine system FR on plant availability is assessed exploiting a Reliability Block Diagram (RBD) model for a typical secondary cooling system implementing a Rankine cycle. Mean inherent availability

  12. Service reliability assessment using failure mode and effect analysis ...

    African Journals Online (AJOL)

    user

    Statistical Process Control Teng and Ho (1996) .... are still remaining left on modelling the interaction between impact of internal service failure and ..... Design error proofing: development of automated error-proofing information systems, Proceedings of.

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

    Energy Technology Data Exchange (ETDEWEB)

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

    1999-12-31

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    1998-12-31

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

  15. Safety Management of a Clinical Process Using Failure Mode and Effect Analysis: Continuous Renal Replacement Therapies in Intensive Care Unit Patients.

    Science.gov (United States)

    Sanchez-Izquierdo-Riera, Jose Angel; Molano-Alvarez, Esteban; Saez-de la Fuente, Ignacio; Maynar-Moliner, Javier; Marín-Mateos, Helena; Chacón-Alves, Silvia

    2016-01-01

    The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases: 1) Retrospective observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.

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

    Science.gov (United States)

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

    2012-01-01

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

  17. Standard guide for corrosion-related failure analysis

    CERN Document Server

    American Society for Testing and Materials. Philadelphia

    2000-01-01

    1.1 This guide covers key issues to be considered when examining metallic failures when corrosion is suspected as either a major or minor causative factor. 1.2 Corrosion-related failures could include one or more of the following: change in surface appearance (for example, tarnish, rust, color change), pin hole leak, catastrophic structural failure (for example, collapse, explosive rupture, implosive rupture, cracking), weld failure, loss of electrical continuity, and loss of functionality (for example, seizure, galling, spalling, swelling). 1.3 Issues covered include overall failure site conditions, operating conditions at the time of failure, history of equipment and its operation, corrosion product sampling, environmental sampling, metallurgical and electrochemical factors, morphology (mode) or failure, and by considering the preceding, deducing the cause(s) of corrosion failure. This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibili...

  18. Analisa Keandalan Sistem Distribusi 20 kV PT.PLN Rayon Lumajang dengan Metode FMEA (Failure Modes and Effects Analysis

    Directory of Open Access Journals (Sweden)

    Achmad Fatoni

    2017-01-01

    Full Text Available Saat ini tingkat keandalan dari suatu sistem distribusi adalah sangat penting guna menjamin kontinuitas supply tenaga listrik kepada konsumen. Karena itu, disadari pentingnya otomatisasi sistem distribusi yang salah satunya dapat dicapai dengan menggunakan sectionalizer. Tugas Akhir ini dibuat dengan tujuan menghitung indeks keandalan dari sistem distribusi 20 kV Rayon Lumajang. Metode yang digunakan adalah FMEA (Failure Mode and Effect Analysis, di mana indeks kegagalan dari setiap peralatan utama sistem distribusi diperhitungkan dalam mencari indeks keandalan sistem secara menyeluruh. Sejumlah studi kasus dilakukan guna melihat pengaruh dari jumlah serta lokasi penempatan sectionalizer dan juga fuse di sepanjang jaringan terhadap indeks keandalan sistem. Pada akhirnya, solusi optimal akan memberikan nilai indeks keandalan sistem distribusi yang terbaik. Berdasarkan hasil analisa, dengan penambahan fuse pada penyulang sukodono dapat menaikkan Indeks Keandalan SAIFI yang semula bernilai 6.6088 menjadi bernilai 5.4176, lalu dengan adanya penambahan sectionalizer pada penyulang sukodono maka dapat menaikkan indeks keandalan SAIDI yang awalnya bernilai 7.6737  menjadi bernilai 6.4431.

  19. ANALISIS TOTAL PRODUCTIVE MAINTENANCE DENGAN METODE OVERALL EQUIPMENT EFFECTIVENESS DAN FUZZY FAILURE MODE AND EFFECTS ANALYSIS

    Directory of Open Access Journals (Sweden)

    Supriyadi Supriyadi

    2017-11-01

    Full Text Available Ash Handling System merupakan suatu bagian dari pembangkit listrik tenaga uap dengan bahan bakar batu bara yang berfungsi untuk menyalurkan limbah pembuangan sisa hasil proses pembakaran batu bara pada boiler. Sisa pembakaran terbagi menjadi fly ash dan bottom ash. Untuk sisa pembakaran fly ash akan disalurkan menuju ke Electrostatic Precipitator untuk ditangkap  dengan metode corona dan ditransfer menuju penampungan fly ash dengan cara dimampatkan bersama udara dari kompresor yang melalui pipa-pipa dan tabung transporter. Sedangkan untuk sisa pembakaran bottom ash akan disalurkan dengan alat yang disebut SSC (Submerged Scraper Conveyor. Gangguan pada SSC dapat terjadi mulai dari belt putus, masalah pada penggerak, hingga masalah pada kelistrikan dan instrumennya. Penelitian ini bertujuan untuk mengetahui nilai OEE, mengetahui dampak gangguan belt sobek, mengetahui penyebab terjadinya belt conveyor sobek dan melakukan estimasi hasil perbaikan dari sisi biaya. Penelitian ini menggunakan metode Overall Equipment Effectiveness (OEE dan Fuzzy Failure Mode and Effects Analysis. Hasil penelitian menunjukkan bahwa rata-rata nilai OEE pada tahun 2015 sekitar 52,05%, masih di bawah standar nilai OEE sebesar 85%. Penyebab utamanya adalah adanya gangguan belt sobek karena gesekan belt dengan support return ketika belt conveyor mengalami jogging yang berdampak pada terganggunya penyaluran abu. Modifikasi dapat menghindari kerugian perusahaan sebesar Rp. 582.548.800,00.

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

    Energy Technology Data Exchange (ETDEWEB)

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

    1996-09-30

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

  1. Structural failure analysis of reactor vessels due to molten core debris

    International Nuclear Information System (INIS)

    Pfeiffer, P.A.

    1993-01-01

    Maintaining structural integrity of the reactor vessel during a postulated core melt accident is an important safety consideration in the design of the vessel. This paper addresses the failure predictions of the vessel due to thermal and pressure loadings from the molten core debris depositing on the lower head of the vessel. Different loading combinations were considered based on a wet or dry cavity and pressurization of the vessel based on operating pressure or atmospheric (pipe break). The analyses considered both short term (minutes) and long term (days) failure modes. Short term failure modes include creep at elevated temperatures and plastic instabilities of the structure. Long term failure modes are caused by creep rupture that lead to plastic instability of the structure. The analyses predict the reactor vessel will remain intact after the core melt has deposited on the lower vessel head

  2. Tools for Developing a Quality Management Program: Proactive Tools (Process Mapping, Value Stream Mapping, Fault Tree Analysis, and Failure Mode and Effects Analysis)

    International Nuclear Information System (INIS)

    Rath, Frank

    2008-01-01

    This article examines the concepts of quality management (QM) and quality assurance (QA), as well as the current state of QM and QA practices in radiotherapy. A systematic approach incorporating a series of industrial engineering-based tools is proposed, which can be applied in health care organizations proactively to improve process outcomes, reduce risk and/or improve patient safety, improve through-put, and reduce cost. This tool set includes process mapping and process flowcharting, failure modes and effects analysis (FMEA), value stream mapping, and fault tree analysis (FTA). Many health care organizations do not have experience in applying these tools and therefore do not understand how and when to use them. As a result there are many misconceptions about how to use these tools, and they are often incorrectly applied. This article describes these industrial engineering-based tools and also how to use them, when they should be used (and not used), and the intended purposes for their use. In addition the strengths and weaknesses of each of these tools are described, and examples are given to demonstrate the application of these tools in health care settings

  3. Application of cleaner production tools and failure modes and effects analysis in pig slaughterhourses

    Directory of Open Access Journals (Sweden)

    J. M. Fonseca

    2017-07-01

    Full Text Available Cleaner production programs (CP and Failure Modes and Effects Analysis (FMEA are tools used to improve the sustainability of industries, ensuring greater profitability, quality, reliability and safety of their products and services. The meat industry is among the most polluting industries because of the large amounts of organic waste produced during meat processing. The objective of this study was to combine the CP and FMEA tools and to apply them in a pig slaughterhouse in order to detect critical points along the production chain that have a major environmental impact and to establish corrective and preventive actions that could minimize these problems. The results showed that water is the most consumed resource by the industry and also the main producer of waste due to microbiological contamination with animal feces and blood and meat residues. All impacts were found to be real due to their daily occurrence in the industry. Their severity, occurrence, detection and coverage were classified as moderate and high, high, low and moderate, and moderate and high, respectively. The application of the CP and FMEA tools was efficient in identifying and evaluating the environmental impacts caused by the slaughter and processing of pork carcasses. Liquid slaughter effluents and solid wastes (blood and bones are the factors that pose the greatest risks to the environment. The substitution of treatment plant chemicals with decomposing microorganisms, composting, and the production of animal meal and feed from solid waste are appropriate measures the industry could adopt to minimize the contamination of water resources and soil.

  4. Application of ISO22000, failure mode, and effect analysis (FMEA) cause and effect diagrams and pareto in conjunction with HACCP and risk assessment for processing of pastry products.

    Science.gov (United States)

    Varzakas, Theodoros H

    2011-09-01

    The Failure Mode and Effect Analysis (FMEA) model has been applied for the risk assessment of pastry processing. A tentative approach of FMEA application to the pastry industry was attempted in conjunction with ISO22000. Preliminary Hazard Analysis was used to analyze and predict the occurring failure modes in a food chain system (pastry processing plant), based on the functions, characteristics, and/or interactions of the ingredients or the processes, upon which the system depends. Critical Control points have been identified and implemented in the cause and effect diagram (also known as Ishikawa, tree diagram, and fishbone diagram). In this work a comparison of ISO22000 analysis with HACCP is carried out over pastry processing and packaging. However, the main emphasis was put on the quantification of risk assessment by determining the Risk Priority Number (RPN) per identified processing hazard. Storage of raw materials and storage of final products at -18°C followed by freezing were the processes identified as the ones with the highest RPN (225, 225, and 144 respectively) and corrective actions were undertaken. Following the application of corrective actions, a second calculation of RPN values was carried out leading to considerably lower values (below the upper acceptable limit of 130). It is noteworthy that the application of Ishikawa (Cause and Effect or Tree diagram) led to converging results thus corroborating the validity of conclusions derived from risk assessment and FMEA. Therefore, the incorporation of FMEA analysis within the ISO22000 system of a pastry processing industry is considered imperative.

  5. On the need for revising healthcare failure mode and effect analysis for assessing potential for patient harm in healthcare processes

    International Nuclear Information System (INIS)

    Abrahamsen, Håkon Bjorheim; Abrahamsen, Eirik Bjorheim; Høyland, Sindre

    2016-01-01

    Healthcare Failure Mode and Effect Analysis is a proactive, systematic method adapted from safety-critical industries increasingly used to assess the potential for patient harm in high-risk healthcare processes. In this paper we review and discuss this method. We point to some weaknesses and finally argue for two adjustments. One adjustment is regarding the way in which risk is evaluated, and the other is to adopt a broader evaluation of barrier performance. Examples are given from prehospital critical care and from the operating room environment within hospitals to illustrate these ideas. - Highlights: • This article discusses the appropriateness of using HFMEA in healthcare processes. • We conclude that HFMEA has an important role to play in such contexts. • We argue for two adjustments in the traditional HFMEA. • One is regarding the way risk is evaluated. • The other is to adopt a broader evaluation of barrier performance.

  6. Use of failure modes, effects, and criticality analysis to compare the vulnerabilities of laparoscopic versus open appendectomy.

    Science.gov (United States)

    Guida, Edoardo; Rosati, Ubaldo; Pini Prato, Alessio; Avanzini, Stefano; Pio, Luca; Ghezzi, Michele; Jasonni, Vincenzo; Mattioli, Girolamo

    2015-06-01

    To measure the feasibility of using FMECA applied to the surgery and then compare the vulnerabilities of laparoscopic versus open appendectomy by using FMECA. The FMECA study was performed on each single selected phase of appendectomy and on complication-related data during the period January 1, 2009, to December 31, 2010. The risk analysis phase was completed by evaluation of the criticality index (CI) of each appendectomy-related failure mode (FM). The CI is calculated by multiplying the estimated frequency of occurrence (O) of the FM, by the expected severity of the injury to the patient (S), and the detectability (D) of the FM. In the first year of analysis (2009), 177 appendectomies were performed, 110 open and 67 laparoscopic. Eleven adverse events were related to the open appendectomy: 1 bleeding (CI: 8) and 10 postoperative infections (CI: 32). Three adverse events related to the laparoscopic approach were recorded: 1 postoperative infection (CI: 8) and 2 incorrect extractions of the appendix through the umbilical port (CI: 6). In the second year of analysis (2010), 158 appendectomies were performed, 69 open and 89 laparoscopic. Four adverse events were related to the open appendectomy: 1 incorrect management of the histological specimen (CI: 2), 1 dehiscence of the surgical wound (CI: 6), and 2 infections (CI: 6). No adverse events were recorded in laparoscopic approach. FMECA helped the staff compare the 2 approaches through an accurate step-by-step analysis, highlighting that laparoscopic appendectomy is feasible and safe, associated with a lower incidence of infection and other complications, reduced length of hospital stay, and an apparent lower procedure-related risk.

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

    Science.gov (United States)

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

    2011-11-01

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

  8. Classification and calculation of primary failure modes in bread production line

    International Nuclear Information System (INIS)

    Tsarouhas, Panagiotis H.

    2009-01-01

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

  9. Analysis of Failure Causes and the Criticality Degree of Elements of Motor Vehicle’s Drum Brakes

    Directory of Open Access Journals (Sweden)

    D. Ćatić

    2014-09-01

    Full Text Available The introduction of the paper gives the basic concepts, historical development of methods of Fault Tree Analysis - FTA and Failure Modes, Effects and Criticality Analysis - FMECA for analysis of the reliability and safety of technical systems and importance of applying this method is highlighted. Failure analysis is particularly important for systems whose failures lead to the endangerment of people safety, such as, for example, the braking system of motor vehicles. For the failure analysis of the considered device, it is necessary to know the structure, functioning, working conditions and all factors that have a greater or less influence on its reliability. By formation of the fault tree of drum brakes in braking systems of commercial vehicles, it was established a causal relation between the different events that lead to a reduction in performance or complete failure of the braking system. Based on data from exploitation, using FMECA methods, determination of the criticality degree of drum brake’s elements on the reliable and safe operation of the braking system is performed.

  10. Failure Mode and Effect Analysis (FMEA) Applications to Identify Iron Sand Reject and Losses in Cement Industry : A Case Study

    Science.gov (United States)

    Helia, V. N.; Wijaya, W. N.

    2017-06-01

    One of the main raw materials required in the manufacture of cement is iron sand. Data from the Procurement Department on XYZ Company shows that the number of defective iron sand (reject) fluctuates every month. Iron sand is an important raw material in the cement production process, so that the amount of iron sand reject and losses got financial and non-financial impact. This study aims to determine the most dominant activity as the cause of rejection and losses of iron sands and suggest improvements that can be made by using the approach of FMEA (Failure Mode and Effect Analysis). Data collection techniques in this study was using the method of observation, interviews, and focus group discussion (FGD) as well as the assessment of the experts to identify it. Results from this study is there are four points of the most dominant cause of the defect of iron sand (mining activities, acceptance, examination and delivery). Recommendation for overcoming these problem is presented (vendor improvement).

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

    Directory of Open Access Journals (Sweden)

    Dong Xin

    2017-06-01

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

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

    International Nuclear Information System (INIS)

    Bickel, J.H.

    1983-01-01

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

  13. Analysis of lower head failure with simplified models and a finite element code

    Energy Technology Data Exchange (ETDEWEB)

    Koundy, V. [CEA-IPSN-DPEA-SEAC, Service d' Etudes des Accidents, Fontenay-aux-Roses (France); Nicolas, L. [CEA-DEN-DM2S-SEMT, Service d' Etudes Mecaniques et Thermiques, Gif-sur-Yvette (France); Combescure, A. [INSA-Lyon, Lab. Mecanique des Solides, Villeurbanne (France)

    2001-07-01

    The objective of the OLHF (OECD lower head failure) experiments is to characterize the timing, mode and size of lower head failure under high temperature loading and reactor coolant system pressure due to a postulated core melt scenario. Four tests have been performed at Sandia National Laboratories (USA), in the frame of an OECD project. The experimental results have been used to develop and validate predictive analysis models. Within the framework of this project, several finite element calculations were performed. In parallel, two simplified semi-analytical methods were developed in order to get a better understanding of the role of various parameters on the creep phenomenon, e.g. the behaviour of the lower head material and its geometrical characteristics on the timing, mode and location of failure. Three-dimensional modelling of crack opening and crack propagation has also been carried out using the finite element code Castem 2000. The aim of this paper is to present the two simplified semi-analytical approaches and to report the status of the 3D crack propagation calculations. (authors)

  14. Failure analysis: Status and future trends

    International Nuclear Information System (INIS)

    Anderson, R.E.; Soden, J.M.; Henderson, C.L.

    1995-01-01

    Failure analysis is a critical element in the integrated circuit manufacturing industry. This paper reviews the changing role of failure analysis and describes major techniques employed in the industry today. Several advanced failure analysis techniques that meet the challenges imposed by advancements in integrated circuit technology are described and their applications are discussed. Future trends in failure analysis needed to keep pace with the continuing advancements in integrated circuit technology are anticipated

  15. STRESS AND FAILURE ANALYSIS OF RAPIDLY ROTATING ASTEROID (29075) 1950 DA

    International Nuclear Information System (INIS)

    Hirabayashi, Masatoshi; Scheeres, Daniel J.

    2015-01-01

    Rozitis et al. recently reported that near-Earth asteroid (29075) 1950 DA, whose bulk density ranges from 1.0 g cm –3 to 2.4 g cm –3 , is a rubble pile and requires a cohesive strength of at least 44-76 Pa to keep from failing due to its fast spin period. Since their technique for giving failure conditions required the averaged stress over the whole volume, it discarded information about the asteroid's failure mode and internal stress condition. This paper develops a finite element model and revisits the stress and failure analysis of 1950 DA. For the modeling, we do not consider material hardening and softening. Under the assumption of an associated flow rule and uniform material distribution, we identify the deformation process of 1950 DA when its constant cohesion reaches the lowest value that keeps its current shape. The results show that to avoid structural failure the internal core requires a cohesive strength of at least 75-85 Pa. It suggests that for the failure mode of this body, the internal core first fails structurally, followed by the surface region. This implies that if cohesion is constant over the whole volume, the equatorial ridge of 1950 DA results from a material flow going outward along the equatorial plane in the internal core, but not from a landslide as has been hypothesized. This has additional implications for the likely density of the interior of the body

  16. An assessment of BWR [boiling water reactor] Mark-II containment challenges, failure modes, and potential improvements in performance

    International Nuclear Information System (INIS)

    Kelly, D.L.; Jones, K.R.; Dallman, R.J.; Wagner, K.C.

    1990-07-01

    This report assesses challenges to BWR Mark II containment integrity that could potentially arise from severe accidents. Also assessed are some potential improvements that could prevent core damage or containment failure, or could mitigate the consequences of such failure by reducing the release of fission products to the environment. These challenges and improvements are analyzed via a limited quantitative risk/benefit analysis of a generic BWR/4 reactor with Mark II containment. Point estimate frequencies of the dominant core damage sequences are obtained and simple containment event trees are constructed to evaluate the response of the containment to these severe accident sequences. The resulting containment release modes are then binned into source term release categories, which provide inputs to the consequence analysis. The output of the consequences analysis is used to construct an overall base case risk profile. Potential improvements and sensitivities are evaluated by modifying the event tree spilt fractions, thus generating a revised risk profile. Several important sensitivity cases are examined to evaluate the impact of phenomenological uncertainties on the final results. 75 refs., 25 figs., 65 tabs

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

    Science.gov (United States)

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

    2017-01-01

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

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

    Science.gov (United States)

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

    2018-01-01

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

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

    International Nuclear Information System (INIS)

    Jaross, R.A.

    1983-09-01

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

  20. Mode I Failure of Armor Ceramics: Experiments and Modeling

    Science.gov (United States)

    Meredith, Christopher; Leavy, Brian

    2017-06-01

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

  1. Local buckling failure analysis of high-strength pipelines

    Institute of Scientific and Technical Information of China (English)

    Yan Li; Jian Shuai; Zhong-Li Jin; Ya-Tong Zhao; Kui Xu

    2017-01-01

    Pipelines in geological disaster regions typically suffer the risk of local buckling failure because of slender structure and complex load.This paper is meant to reveal the local buckling behavior of buried pipelines with a large diameter and high strength,which are under different conditions,including pure bending and bending combined with internal pressure.Finite element analysis was built according to previous data to study local buckling behavior of pressurized and unpressurized pipes under bending conditions and their differences in local buckling failure modes.In parametric analysis,a series of parameters,including pipe geometrical dimension,pipe material properties and internal pressure,were selected to study their influences on the critical bending moment,critical compressive stress and critical compressive strain of pipes.Especially the hardening exponent of pipe material was introduced to the parameter analysis by using the Ramberg-Osgood constitutive model.Results showed that geometrical dimensions,material and internal pressure can exert similar effects on the critical bending moment and critical compressive stress,which have different,even reverse effects on the critical compressive strain.Based on these analyses,more accurate design models of critical bending moment and critical compressive stress have been proposed for high-strength pipelines under bending conditions,which provide theoretical methods for highstrength pipeline engineering.

  2. Failure Analysis of Alumina Reinforced Aluminum Microtruss and Tube Composites

    Science.gov (United States)

    Chien, Hsueh Fen (Karen)

    The energy absorption capacity of cellular materials can be dramatically increased by applying a structural coating. This thesis examined the failure mechanisms of alumina reinforced 3003 aluminum alloy microtrusses and tubes. Alumina coatings were produced by hard anodizing and by plasma electrolytic oxidation (PEO). The relatively thin and discontinuous oxide coating at the hinge acted as a localized weak spot which triggered a chain reaction of failure, including oxide fracture, oxide spallation, oxide penetration to the aluminum core and severe local plastic deformation of the core. For the PEO microtrusses, delamination occurred within the oxide coating resulting in a global strut buckling failure mode. A new failure mode for the anodized tubes was observed: (i) axisymmetric folding of the aluminum core, (ii) longitudinal fracture, and (iii) alumina pulverization. Overall, the alumina coating enhanced the buckling resistance of the composites, while the aluminum core supported the oxide during the damage propagation.

  3. Dynamic behavior and identification of failure modes of cooling towers

    International Nuclear Information System (INIS)

    Serhan, S.J.

    1994-01-01

    The major thrust of this paper is to provide an engineering assessment of two hyperboloidal 540-foot high reinforced concrete cooling towers at a nuclear power plant relative to the proposed construction of a new safety-related facility in the shadow of these cooling towers. A three-dimensional full 360-degree finite-element model that is capable of realistically representing the response of the two cooling towers subjected to the plant design-basis safe shutdown earthquake, 90 mph wind, and 300 mph tornado is used to create a data pool which supports the proposed construction of the new facility. Dynamic time history analyses are performed to represent the complex interplay of the dynamic characteristics of the cooling towers and the input wind-pressure excitation in terms of gust factors. This study resulted in the confirmation and enhancement of many of the important aspects in the design/analysis methodologies for cooling towers reported in literature. In summary, this study provides a high confidence that no significant damage will be caused to the two cooling towers when subjected to the plant design-basis safe shutdown earthquake and the 90 mph basic wind velocity. However, the two cooling towers are expected to collapse if subjected in a direct hit to a 300 mph tornado. The nonlinear finite element analyses including base uplift performed for this study and the literature research on past failures of cooling towers due to severe wind storms confirm that the mode of failure will not be the overturning cantilever tree-type and the towers will collapse inwardly with the exception of few isolated debris

  4. Abutments with reduced diameter for both cement and screw retentions: analysis of failure modes and misfit of abutment-crown-connections after cyclic loading.

    Science.gov (United States)

    Moris, Izabela Cristina Maurício; Faria, Adriana Cláudia Lapria; Ribeiro, Ricardo Faria; Rodrigues, Renata Cristina Silveira

    2017-04-01

    The aim of this study was to analyze failure modes and misfit of abutments with reduced diameter for both cement and screw retentions after cyclic loading. Forty morse-taper abutment/implant sets of titanium were divided into four groups (N = 10): G4.8S-4.8 abutment with screw-retained crown; G4.8C-4.8 abutment with cemented crown; G3.8S-3.8 abutment with screw-retained crown; and G3.8C-3.8 abutment with cemented crown. Copings were waxed on castable cylinders and cast by oxygen gas flame and injected by centrifugation. After, esthetic veneering ceramic was pressed on these copings for obtaining metalloceramic crowns of upper canine. Cemented crowns were cemented on abutments with provisional cement (Temp Bond NE), and screw-retained crowns were tightened to their abutments with torque recommended by manufacturer (10 N cm). The misfit was measured using a stereomicroscope in a 10× magnification before and after cyclic loading (300,000 cycles). Tests were visually monitored, and failures (decementation, screw loosening and fractures) were registered. Misfit was analyzed by mixed linear model while failure modes by chi-square test (α = 0.05). Cyclic loading affected misfit of 3.8C (P ≤ 0.0001), 3.8S (P = 0.0055) and 4.8C (P = 0.0318), but not of 4.8S (P = 0.1243). No differences were noted between 3.8S with 4.8S before (P = 0.1550) and after (P = 0.9861) cyclic loading, but 3.8C was different from 4.8C only after (P = 0.0015) loading. Comparing different types of retentions at the same diameter abutment, significant difference was noted before and after cyclic loading for 3.8 and 4.8 abutments. Analyzing failure modes, retrievable failures were present at 3.8S and 3.8C groups, while irretrievable were only present at 3.8S. The cyclic loading decreased misfit of cemented and screw-retained crowns on reduced diameter abutments, and misfit of cemented crowns is greater than screw-retained ones. Abutments of reduced diameter failed more than

  5. The failure combination method: presentation, application to a simple collection of systems

    International Nuclear Information System (INIS)

    Llory, M.; Villemeur, A.

    1981-11-01

    The main advantages of this particular method for analyzing the reliability and safety of systems, the method of failure combinations, are presented. This is an inductive method of analysis; it makes it possible to pursue the Failure Modes and Effect Analysis (FMEA) until overall failures are obtained. In this manner, through an inductive approach all the combinations of failure modes leading to abnormal functioning of systems are obtained. It also makes it possible to carry out the overall study of complex systems in interaction and the systematic inventory of abnormal functioning of these systems, as from the failure modes of the components and their combinations. It can be used as from the design stages of systems and is an excellent dialogue tool between the various specialists concerned in problems of safety, operation and reliability [fr

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

    International Nuclear Information System (INIS)

    Montierth, L.; Morse, R.

    1984-01-01

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

  7. An estimation method of system failure frequency using both structure and component failure data

    International Nuclear Information System (INIS)

    Takaragi, Kazuo; Sasaki, Ryoichi; Shingai, Sadanori; Tominaga, Kenji

    1981-01-01

    In recent years, the importance of reliability analysis is appreciated for large systems such as nuclear power plants. A reliability analysis method is described for a whole system, using structure failure data for its main working subsystem and component failure data for its safety protection subsystem. The subsystem named main working system operates normally, and the subsystem named safety protection system acts as standby or protection. Thus the main and the protection systems are given mutually different failure data; then, between the subsystems, there exists common mode failure, i.e. the component failure affecting the reliability of both two. A calculation formula for sytem failure frequency is first derived. Then, a calculation method with digraphs is proposed for conditional system failure probability. Finally the results of numerical calculation are given for the purpose of explanation. (J.P.N.)

  8. Quality Risk Evaluation of the Food Supply Chain Using a Fuzzy Comprehensive Evaluation Model and Failure Mode, Effects, and Criticality Analysis

    Directory of Open Access Journals (Sweden)

    Libiao Bai

    2018-01-01

    Full Text Available Evaluating the quality risk level in the food supply chain can reduce quality information asymmetry and food quality incidents and promote nationally integrated regulations for food quality. In order to evaluate it, a quality risk evaluation indicator system for the food supply chain is constructed based on an extensive literature review in this paper. Furthermore, a mathematical model based on the fuzzy comprehensive evaluation model (FCEM and failure mode, effects, and criticality analysis (FMECA for evaluating the quality risk level in the food supply chain is developed. A computational experiment aimed at verifying the effectiveness and feasibility of this proposed model is conducted on the basis of a questionnaire survey. The results suggest that this model can be used as a general guideline to assess the quality risk level in the food supply chain and achieve the most important objective of providing a reference for the public and private sectors when making decisions on food quality management.

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

    Directory of Open Access Journals (Sweden)

    Henrique N. P. Oliva

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

  10. Failure trend analysis for safety related components of Korean standard NPPs

    International Nuclear Information System (INIS)

    Choi, Sun Yeong; Han, Sang Hoon

    2005-01-01

    The component reliability data of Korean NPP that reflects the plant specific characteristics is required necessarily for PSA of Korean nuclear power plants. We have performed a project to develop the component reliability database (KIND, Korea Integrated Nuclear Reliability Database) and S/W for database management and component reliability analysis. Based on the system, we have collected the component operation data and failure/repair data during from plant operation date to 2002 for YGN 3, 4 and UCN 3, 4 plants. Recently, we provided the component failure rate data for UCN 3, 4 standard PSA model from the KIND. We evaluated the components that have high-ranking failure rates with the component reliability data from plant operation date to 1998 and 2000 for YGN 3,4 and UCN 3, 4 respectively. We also identified their failure mode that occurred frequently. In this study, we analyze the component failure trend and perform site comparison based on the generic data by using the component reliability data which is extended to 2002 for UCN 3, 4 and YGN 3, 4 respectively. We focus on the major safety related rotating components such as pump, EDG etc

  11. Analysis of blowout fractures using cine mode MRI

    International Nuclear Information System (INIS)

    Kawahara, Masaaki; Shiihara, Kumiko; Kimura, Hisashi; Fukai, Sakuko; Tabuchi, Akio; Kojo, Tuyoshi

    1995-01-01

    By observing conventional CT and MRI images, it is difficult to distinguish extension failure from adhesion, bone fracture or damage to the extraocular muscle, any one of which may be the direct cause of the eye movement disturbance accompanying blowout fracture. We therefore carried out dynamic analysis of eye movement disturbance using a cine mode MRI. We put seven fixation points in the gantry of the MRI and filmed eye movement disturbances by the gradient echo method, using a surface coil and holding the vision on each fixation point. We also video recorded the CRT monitor of the MRI to obtain dynamic MRI images. The subjects comprised 5 cases (7-23 years old). In 4 cases, we started orthoptic treatment, saccadic eye movement training, convergence training and fusional amplitude training after surgery, with only orthoptic treatment in the 5 th case. In all cases, fusion area improvement was recognized during training. In 2 cases examined by cine mode MRI before and after surgery, we observed improved eye movement after training, the effectiveness of which was thereby proven. Also, using cine mode MRI we were able to determine the character of incarcerated tissue and the cause of eye movement disturbance. We conclude that it blowout fracture, cine mode MRI may be useful in selecting treatment and observing its effectiveness. (author)

  12. Reliability analysis for dynamic configurations of systems with three failure modes

    International Nuclear Information System (INIS)

    Pham, Hoang

    1999-01-01

    Analytical models for computing the reliability of dynamic configurations of systems, such as majority and k-out-of-n, assuming that units and systems are subject to three types of failures: stuck-at-0, stuck-at-1, and stuck-at-x are presented in this paper. Formulas for determining the optimal design policies that maximize the reliability of dynamic k-out-of-n configurations subject to three types of failures are defined. The comparisons of the reliability modeling functions are also obtained. The optimum system size and threshold value k that minimize the expected cost of dynamic k-out-of-n configurations are also determined

  13. Common cause failure data collection and analysis for safety-related components of TRIGA SSR-14MW Pitesti, Romania

    International Nuclear Information System (INIS)

    Radu, G.; Mladin, D.

    2003-01-01

    This paper presents a study performed on the set of common cause failures (CCF) of safety-related components of the research reactor TRIGA SSR-14 MW Pitesti. The data collected cover a period of 20 years, from 1979 to 2000. The sources of data are Shift Supervisor Reports, Work Authorizations, and Reactor Log Books. Events collected are analyzed by failure mode and degrees of failure. Qualitative analysis of root causes, coupling factors and corrective actions and quantitative analysis of CCF events are studied. The objective of this work is to develop qualitative insights in the nature of the reported events and to build a site-specific common cause events database. (author)

  14. Dynamic Analysis of Cable-Stayed Bridges Affected by Accidental Failure Mechanisms under Moving Loads

    Directory of Open Access Journals (Sweden)

    Fabrizio Greco

    2013-01-01

    Full Text Available The dynamic behavior of cable-stayed bridges subjected to moving loads and affected by an accidental failure in the cable suspension system is investigated. The main aim of the paper is to quantify, numerically, the dynamic amplification factors of typical kinematic and stress design variables, by means of a parametric study developed in terms of the structural characteristics of the bridge components. The bridge formulation is developed by using a geometric nonlinear formulation, in which the effects of local vibrations of the stays and of large displacements in the girder and the pylons are taken into account. Explicit time dependent damage laws, reproducing the failure mechanism in the cable system, are considered to investigate the influence of the failure mode characteristics on the dynamic bridge behavior. The analysis focuses attention on the influence of the inertial characteristics of the moving loads, by accounting coupling effects arising from the interaction between girder and moving system. Sensitivity analyses of typical design bridge variables are proposed. In particular, the effects produced by the moving system characteristics, the tower typologies, and the failure mode characteristics involved in the cable system are investigated by means of comparisons between damaged and undamaged bridge configurations.

  15. Automatic Monitoring System Design and Failure Probability Analysis for River Dikes on Steep Channel

    Science.gov (United States)

    Chang, Yin-Lung; Lin, Yi-Jun; Tung, Yeou-Koung

    2017-04-01

    The purposes of this study includes: (1) design an automatic monitoring system for river dike; and (2) develop a framework which enables the determination of dike failure probabilities for various failure modes during a rainstorm. The historical dike failure data collected in this study indicate that most dikes in Taiwan collapsed under the 20-years return period discharge, which means the probability of dike failure is much higher than that of overtopping. We installed the dike monitoring system on the Chiu-She Dike which located on the middle stream of Dajia River, Taiwan. The system includes: (1) vertical distributed pore water pressure sensors in front of and behind the dike; (2) Time Domain Reflectometry (TDR) to measure the displacement of dike; (3) wireless floating device to measure the scouring depth at the toe of dike; and (4) water level gauge. The monitoring system recorded the variation of pore pressure inside the Chiu-She Dike and the scouring depth during Typhoon Megi. The recorded data showed that the highest groundwater level insides the dike occurred 15 hours after the peak discharge. We developed a framework which accounts for the uncertainties from return period discharge, Manning's n, scouring depth, soil cohesion, and friction angle and enables the determination of dike failure probabilities for various failure modes such as overtopping, surface erosion, mass failure, toe sliding and overturning. The framework was applied to Chiu-She, Feng-Chou, and Ke-Chuang Dikes on Dajia River. The results indicate that the toe sliding or overturning has the highest probability than other failure modes. Furthermore, the overall failure probability (integrate different failure modes) reaches 50% under 10-years return period flood which agrees with the historical failure data for the study reaches.

  16. Failure detection system risk reduction assessment

    Science.gov (United States)

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

    2012-01-01

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

  17. Performance and sensitivity analysis of the generalized likelihood ratio method for failure detection. M.S. Thesis

    Science.gov (United States)

    Bueno, R. A.

    1977-01-01

    Results of the generalized likelihood ratio (GLR) technique for the detection of failures in aircraft application are presented, and its relationship to the properties of the Kalman-Bucy filter is examined. Under the assumption that the system is perfectly modeled, the detectability and distinguishability of four failure types are investigated by means of analysis and simulations. Detection of failures is found satisfactory, but problems in identifying correctly the mode of a failure may arise. These issues are closely examined as well as the sensitivity of GLR to modeling errors. The advantages and disadvantages of this technique are discussed, and various modifications are suggested to reduce its limitations in performance and computational complexity.

  18. Crash Causation In Nigerian Roads – Failure Mode Analysis | Dike ...

    African Journals Online (AJOL)

    The results of many researches on the causes of road traffic accidents have always resolved around three main factors, the human, environmental and vehicular factors. In this study, emphasis was placed on the vehicular factor in road traffic accident. It looked into detail on those vehicle components whose failures result in ...

  19. Root cause analysis of SI line-seated thermal sleeve separation failures

    International Nuclear Information System (INIS)

    Jo, Jong Chull; Jhung, Myung Jo; Kim, Hho Jung

    2004-01-01

    At conventional pressurized water reactors, a thermal sleeve (named simply 'sleeve' hereafter) is seated inside the nozzle part of each Safety Injection (SI) branch pipe to prevent and relieve potential excessive transient thermal stress in the nozzle wall when a cold water is injected during the safety injection mode Recently, mechanical failures that the sleeves are separated from the SI branch pipe and fall into the connected cold leg main pipe were occurred in sequence at Yonggwang units 5 and 6 and Ulchin unit 5. There were many activities and efforts to figure out the causes of those failures with experts' reasoning, but the proposed causes were derived from superficial views rather than physically concrete grounds or analysis results. The prerequisites to find out the root causes of failure mechanism will be to identify the flow situation in the pipe junction area connecting the cold leg with the SI pipe and to know the vibration characteristics of sleeves. This paper investigates the flow field in the pipe junction thru a numerical simulation and vibration characteristics of thermal sleeves thru a modal analysis, from which the root causes of sleeve separation mechanism are analyzed

  20. Isogeometric failure analysis

    NARCIS (Netherlands)

    Verhoosel, C.V.; Scott, M.A.; Borden, M.J.; Borst, de R.; Hughes, T.J.R.; Mueller-Hoeppe, D.; Loehnert, S.; Reese, S.

    2011-01-01

    Isogeometric analysis is a versatile tool for failure analysis. On the one hand, the excellent control over the inter-element continuity conditions enables a natural incorporation of continuum constitutive relations that incorporate higher-order strain gradients, as in gradient plasticity or damage.

  1. Failure mode and dynamic behavior of nanophase iron under compression

    Energy Technology Data Exchange (ETDEWEB)

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

    1999-12-17

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

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

    Science.gov (United States)

    Interbartolo, Michael

    2009-01-01

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

  3. Failure Analysis

    International Nuclear Information System (INIS)

    Iorio, A.F.; Crespi, J.C.

    1987-01-01

    After ten years of operation at the Atucha I Nuclear Power Station a gear belonging to a pressurized heavy water reactor refuelling machine, failed. The gear box was used to operate the inlet-outlet heavy-water valve of the machine. Visual examination of the gear device showed an absence of lubricant and that several gear teeth were broken at the root. Motion was transmitted with a speed-reducing device with controlled adjustable times in order to produce a proper fitness of the valve closure. The aim of this paper is to discuss the results of the gear failure analysis in order to recommend the proper solution to prevent further failures. (Author)

  4. Cube or block. Statistical analysis, historial review, failure mode and behaviour; Cubo o bloque. Ajuste estadistico, analisis historico, modo de fallo y comportamiento

    Energy Technology Data Exchange (ETDEWEB)

    Negro, V.; Varela, O.; Campo, J. M. del; Lopez Gutierrez, J. S.

    2010-07-01

    Many different concrete shapes have been developed as armour units for rubble mound breakwaters. Nearly all are mass concrete construction and can be classified as random placed or regular patterns Placed. the majority of artificial armour unit are placed in two layers and they are massive. they intended to function in a similar way to natural rock (cubes, blocks, antifer cubes,...). More complex armour units were designed to achieve greater stability by obtaining a high degree of interlock (dolosse, accropode, Xbloc, core-loc,...). finally, the third group are the regular pattern placed units with a greater percentage of voids for giving a stronger dissipation of cement hydration (cob, shed, hollow cubes,...), This research deals about the comparison between two massive concrete units, the cubes and the blocks and the analysis of the geometry, the porosity, the construction process and the failure mode. The first stage is the statistical analysis. the scope of it is based on the historical reference of the Spanish Breakwaters with main layer of cubes and blocks (ministry of Public Works, General Directorate of Ports, 1988). (Author) 9 refs.

  5. Statistical analysis of events related to emergency diesel generators failures in the nuclear industry

    Energy Technology Data Exchange (ETDEWEB)

    Kančev, Duško, E-mail: dusko.kancev@ec.europa.eu [European Commission, DG-JRC, Institute for Energy and Transport, P.O. Box 2, NL-1755 ZG Petten (Netherlands); Duchac, Alexander; Zerger, Benoit [European Commission, DG-JRC, Institute for Energy and Transport, P.O. Box 2, NL-1755 ZG Petten (Netherlands); Maqua, Michael [Gesellschaft für Anlagen-und-Reaktorsicherheit (GRS) mbH, Schwetnergasse 1, 50667 Köln (Germany); Wattrelos, Didier [Institut de Radioprotection et de Sûreté Nucléaire (IRSN), BP 17 - 92262 Fontenay-aux-Roses Cedex (France)

    2014-07-01

    Highlights: • Analysis of operating experience related to emergency diesel generators events at NPPs. • Four abundant operating experience databases screened. • Delineating important insights and conclusions based on the operating experience. - Abstract: This paper is aimed at studying the operating experience related to emergency diesel generators (EDGs) events at nuclear power plants collected from the past 20 years. Events related to EDGs failures and/or unavailability as well as all the supporting equipment are in the focus of the analysis. The selected operating experience was analyzed in detail in order to identify the type of failures, attributes that contributed to the failure, failure modes potential or real, discuss risk relevance, summarize important lessons learned, and provide recommendations. The study in this particular paper is tightly related to the performing of statistical analysis of the operating experience. For the purpose of this study EDG failure is defined as EDG failure to function on demand (i.e. fail to start, fail to run) or during testing, or an unavailability of an EDG, except of unavailability due to regular maintenance. The Gesellschaft für Anlagen und Reaktorsicherheit mbH (GRS) and Institut de Radioprotection et de Sûreté Nucléaire (IRSN) databases as well as the operating experience contained in the IAEA/NEA International Reporting System for Operating Experience and the U.S. Licensee Event Reports were screened. The screening methodology applied for each of the four different databases is presented. Further on, analysis aimed at delineating the causes, root causes, contributing factors and consequences are performed. A statistical analysis was performed related to the chronology of events, types of failures, the operational circumstances of detection of the failure and the affected components/subsystems. The conclusions and results of the statistical analysis are discussed. The main findings concerning the testing

  6. Statistical analysis of events related to emergency diesel generators failures in the nuclear industry

    International Nuclear Information System (INIS)

    Kančev, Duško; Duchac, Alexander; Zerger, Benoit; Maqua, Michael; Wattrelos, Didier

    2014-01-01

    Highlights: • Analysis of operating experience related to emergency diesel generators events at NPPs. • Four abundant operating experience databases screened. • Delineating important insights and conclusions based on the operating experience. - Abstract: This paper is aimed at studying the operating experience related to emergency diesel generators (EDGs) events at nuclear power plants collected from the past 20 years. Events related to EDGs failures and/or unavailability as well as all the supporting equipment are in the focus of the analysis. The selected operating experience was analyzed in detail in order to identify the type of failures, attributes that contributed to the failure, failure modes potential or real, discuss risk relevance, summarize important lessons learned, and provide recommendations. The study in this particular paper is tightly related to the performing of statistical analysis of the operating experience. For the purpose of this study EDG failure is defined as EDG failure to function on demand (i.e. fail to start, fail to run) or during testing, or an unavailability of an EDG, except of unavailability due to regular maintenance. The Gesellschaft für Anlagen und Reaktorsicherheit mbH (GRS) and Institut de Radioprotection et de Sûreté Nucléaire (IRSN) databases as well as the operating experience contained in the IAEA/NEA International Reporting System for Operating Experience and the U.S. Licensee Event Reports were screened. The screening methodology applied for each of the four different databases is presented. Further on, analysis aimed at delineating the causes, root causes, contributing factors and consequences are performed. A statistical analysis was performed related to the chronology of events, types of failures, the operational circumstances of detection of the failure and the affected components/subsystems. The conclusions and results of the statistical analysis are discussed. The main findings concerning the testing

  7. Failure mode and effect analysis oriented to risk-reduction interventions in intraoperative electron radiation therapy: the specific impact of patient transportation, automation, and treatment planning availability.

    Science.gov (United States)

    López-Tarjuelo, Juan; Bouché-Babiloni, Ana; Santos-Serra, Agustín; Morillo-Macías, Virginia; Calvo, Felipe A; Kubyshin, Yuri; Ferrer-Albiach, Carlos

    2014-11-01

    Industrial companies use failure mode and effect analysis (FMEA) to improve quality. Our objective was to describe an FMEA and subsequent interventions for an automated intraoperative electron radiotherapy (IOERT) procedure with computed tomography simulation, pre-planning, and a fixed conventional linear accelerator. A process map, an FMEA, and a fault tree analysis are reported. The equipment considered was the radiance treatment planning system (TPS), the Elekta Precise linac, and TN-502RDM-H metal-oxide-semiconductor-field-effect transistor in vivo dosimeters. Computerized order-entry and treatment-automation were also analyzed. Fifty-seven potential modes and effects were identified and classified into 'treatment cancellation' and 'delivering an unintended dose'. They were graded from 'inconvenience' or 'suboptimal treatment' to 'total cancellation' or 'potentially wrong' or 'very wrong administered dose', although these latter effects were never experienced. Risk priority numbers (RPNs) ranged from 3 to 324 and totaled 4804. After interventions such as double checking, interlocking, automation, and structural changes the final total RPN was reduced to 1320. FMEA is crucial for prioritizing risk-reduction interventions. In a semi-surgical procedure like IOERT double checking has the potential to reduce risk and improve quality. Interlocks and automation should also be implemented to increase the safety of the procedure. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  8. Failure Atlas for Rolling Bearings in Wind Turbines

    Energy Technology Data Exchange (ETDEWEB)

    Tallian, T. E.

    2006-01-01

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

  9. Analysis of canned-motor pump jamming failure in start hot standby mode

    International Nuclear Information System (INIS)

    Mo Zhengyu; Liu Hua; Wu Chao; Li Haifeng; Yu Zhongbin

    2009-01-01

    The reason of a canned-motor pump start failure is deduced in this paper. It is shown that the undersized gap of the lower guide bearing causes the start failure. By the stripping inspection data, the design value of the guide bearing gap, the cumulative departure of manufacturing assembly and the preloading of the bearing liner lead to the undersized gap. The test result shows that the improved canned-motor pump can start up successfully. (authors)

  10. The application of Petri nets to failure analysis

    International Nuclear Information System (INIS)

    Liu, T.S.; Chiou, S.B.

    1997-01-01

    Unlike the technique of fault tree analysis that has been widely applied to system failure analysis in reliability engineering, this study presents a Petri net approach to failure analysis. It is essentially a graphical method for describing relations between conditions and events. The use of Petri nets in failure analysis enables to replace logic gate functions in fault trees, efficiently obtain minimal cut sets, and absorb models. It is demonstrated that for failure analysis Petri nets are more efficient than fault trees. In addition, this study devises an alternative; namely, a trapezoidal graph method in order to account for failure scenarios. Examples validate this novel method in dealing with failure analysis

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2018-02-01

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

  12. Failure Modes in Concrete Repair Systems due to Ongoing Corrosion

    Directory of Open Access Journals (Sweden)

    Mladena Luković

    2017-01-01

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

  13. Temperature effect on the performance of a dissipative dielectric elastomer generator with failure modes

    International Nuclear Information System (INIS)

    Chen, S E; Deng, L; He, Z C; Li, Eric; Li, G Y

    2016-01-01

    Research on dielectric elastomer generators (DEGs) which can be utilized to convert mechanical energy to electrical energy has gained wide attention lately. However, very few works account for the operating temperature, viscoelasticity and current leakage in the analysis of DEGs simultaneously. In this study, under several compound four-stroke conversion cycles, the electromechanical performance and energy conversion of a dissipative DEG made of a very-high-bond (VHB) elastomer are investigated at different operating temperatures. The performance parameters such as energy density and conversion efficiency are calculated under different temperatures. Moreover, the common failure modes of the generator are considered: material rupture, loss of tension, electrical breakdown and electromechanical instability. The numerical results have distinctly shown that the operating temperature plays an important role in the performance of DEGs, which could possibly make a larger conversion efficiency for the DEG. (paper)

  14. Failure analysis of superconducting bearings

    Energy Technology Data Exchange (ETDEWEB)

    Rastogi, Amit; Campbell, A M; Coombs, T A [Department of Engineering, University of Cambridge, Cambridge CB2 1PZ (United Kingdom)

    2006-06-01

    The dynamics of superconductor bearings in a cryogenic failure scenario have been analyzed. As the superconductor warms up, the rotor goes through multiple resonance frequencies, begins to slow down and finally touches down when the superconductor goes through its transition temperature. The bearing can be modelled as a system of springs with axial, radial and cross stiffness. These springs go through various resonant modes as the temperature of the superconductor begins to rise. We have presented possible explanations for such behavio0008.

  15. Degradation mode analysis: An approach to establish effective predictive maintenance tasks

    International Nuclear Information System (INIS)

    Sonnett, D.E.; Douglass, P.T.; Barnard, D.D.

    1991-01-01

    A significant number of nuclear generating stations have been employing Reliability Centered Maintenance methodology to arrive at applicable and effective maintenance tasks for their plant equipment. The resultant endpoint of most programs has been an increased emphasis on predictive maintenance as the task of choice for monitoring and trending plant equipment condition to address failure mechanisms of the analyses. Many of these plants have spent several years conducting reliability centered analysis before they seriously begin implementing predictive program improvements. In this paper we present another methodology, entitled Degradation Mode Analysis, which provides a more direct method to quickly and economically achieve the major benefit of reliability centered analysis, namely predictive maintenance. (author)

  16. Reliability Analysis of Fatigue Failure of Cast Components for Wind Turbines

    Directory of Open Access Journals (Sweden)

    Hesam Mirzaei Rafsanjani

    2015-04-01

    Full Text Available Fatigue failure is one of the main failure modes for wind turbine drivetrain components made of cast iron. The wind turbine drivetrain consists of a variety of heavily loaded components, like the main shaft, the main bearings, the gearbox and the generator. The failure of each component will lead to substantial economic losses such as cost of lost energy production and cost of repairs. During the design lifetime, the drivetrain components are exposed to variable loads from winds and waves and other sources of loads that are uncertain and have to be modeled as stochastic variables. The types of loads are different for offshore and onshore wind turbines. Moreover, uncertainties about the fatigue strength play an important role in modeling and assessment of the reliability of the components. In this paper, a generic stochastic model for fatigue failure of cast iron components based on fatigue test data and a limit state equation for fatigue failure based on the SN-curve approach and Miner’s rule is presented. The statistical analysis of the fatigue data is performed using the Maximum Likelihood Method which also gives an estimate of the statistical uncertainties. Finally, illustrative examples are presented with reliability analyses depending on various stochastic models and partial safety factors.

  17. Integration of Value Stream Map and Healthcare Failure Mode and Effect Analysis into Six Sigma Methodology to Improve Process of Surgical Specimen Handling.

    Science.gov (United States)

    Hung, Sheng-Hui; Wang, Pa-Chun; Lin, Hung-Chun; Chen, Hung-Ying; Su, Chao-Ton

    2015-01-01

    Specimen handling is a critical patient safety issue. Problematic handling process, such as misidentification (of patients, surgical site, and specimen counts), specimen loss, or improper specimen preparation can lead to serious patient harms and lawsuits. Value stream map (VSM) is a tool used to find out non-value-added works, enhance the quality, and reduce the cost of the studied process. On the other hand, healthcare failure mode and effect analysis (HFMEA) is now frequently employed to avoid possible medication errors in healthcare process. Both of them have a goal similar to Six Sigma methodology for process improvement. This study proposes a model that integrates VSM and HFMEA into the framework, which mainly consists of define, measure, analyze, improve, and control (DMAIC), of Six Sigma. A Six Sigma project for improving the process of surgical specimen handling in a hospital was conducted to demonstrate the effectiveness of the proposed model.

  18. Preventing blood transfusion failures: FMEA, an effective assessment method.

    Science.gov (United States)

    Najafpour, Zhila; Hasoumi, Mojtaba; Behzadi, Faranak; Mohamadi, Efat; Jafary, Mohamadreza; Saeedi, Morteza

    2017-06-30

    Failure Mode and Effect Analysis (FMEA) is a method used to assess the risk of failures and harms to patients during the medical process and to identify the associated clinical issues. The aim of this study was to conduct an assessment of blood transfusion process in a teaching general hospital, using FMEA as the method. A structured FMEA was recruited in our study performed in 2014, and corrective actions were implemented and re-evaluated after 6 months. Sixteen 2-h sessions were held to perform FMEA in the blood transfusion process, including five steps: establishing the context, selecting team members, analysis of the processes, hazard analysis, and developing a risk reduction protocol for blood transfusion. Failure modes with the highest risk priority numbers (RPNs) were identified. The overall RPN scores ranged from 5 to 100 among which, four failure modes were associated with RPNs over 75. The data analysis indicated that failures with the highest RPNs were: labelling (RPN: 100), transfusion of blood or the component (RPN: 100), patient identification (RPN: 80) and sampling (RPN: 75). The results demonstrated that mis-transfusion of blood or blood component is the most important error, which can lead to serious morbidity or mortality. Provision of training to the personnel on blood transfusion, knowledge raising on hazards and appropriate preventative measures, as well as developing standard safety guidelines are essential, and must be implemented during all steps of blood and blood component transfusion.

  19. The interaction of NDE and failure analysis

    International Nuclear Information System (INIS)

    Nichols, R.W.

    1988-01-01

    This paper deals with the use of Non-Destructive Examination (NDE) and failure analysis for the assessment of the structural integrity. It appears that failure analysis enables to know whether NDE is required or not, and can help to direct NDE into the most useful directions by identifying the areas where it is most important that defects are absent. It also appears that failure analysis can help the operator to decide which NDE method is best suited to the component studied and provides detailed specifications for this NDE method. The interaction between failure analysis and NDE is then described. (TEC)

  20. The interaction of NDE and failure analysis

    Energy Technology Data Exchange (ETDEWEB)

    Nichols, R W

    1988-12-31

    This paper deals with the use of Non-Destructive Examination (NDE) and failure analysis for the assessment of the structural integrity. It appears that failure analysis enables to know whether NDE is required or not, and can help to direct NDE into the most useful directions by identifying the areas where it is most important that defects are absent. It also appears that failure analysis can help the operator to decide which NDE method is best suited to the component studied and provides detailed specifications for this NDE method. The interaction between failure analysis and NDE is then described. (TEC).

  1. Reliability and Failure Modes of a Hybrid Ceramic Abutment Prototype.

    Science.gov (United States)

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

    2018-01-01

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

  2. Implementation of a computational system at the Center for Nuclear Technology Development, for systematization the application of the FMEA - Failure Mode and Effects Analysis, for identification of dangerous and developed risks evaluation; Implementacao de um sistema computacional no Centro de Desenvolvimento da Tecnologia Nuclear para sistemarizar a aplicacao da tecnica FMEA - Failure Mode and Effects Analysis - na identificacao de perigos e avaliacao de riscos desenvolvida

    Energy Technology Data Exchange (ETDEWEB)

    Correa, Danyel Pontelo; Vasconcelos, Vanderley de, E-mail: dpc@cdtn.b, E-mail: vasconv@cdtn.b [Centro de Desenvolvimento da Tecnologia Nuclear (CDTN/CNEN-MG), Belo Horizonte, MG (Brazil)

    2009-07-01

    The regulatory bodies request risks evaluations for nuclear and radioactive licensing purposes. In Brazil those evaluations are contained by the safety analysis reports requested by the Brazilian Nuclear Energy Commission (CNEN), and risk analysis studies requested by the environment organisms. A risk evaluation includes the identification of the risks and the accident sequence which can occur, and the estimation of the frequency and his undesirable effects on the industrial installations, the public, and the environment. The identification and the risk analysis are particularly important for the implementation of a health, environment and safety integrated management according to the regulation instruments ISO 14001, BS 8800 and OHSAS 18001. The utilization of the risk identification techniques and the risk analysis is performed at the non nuclear industry, in a non standard form by the various sectors of an enterprise, diminishing the effectiveness of the recommended actions based on risk indexes. However, for the nuclear licensing, the CNEN request through their regulatory instruments and standard formats, that the risks, the failure mechanisms and detection be identified, which can allow the preventive and mitigate actions. This paper proposes the utilization of the FMEA (Failure Mode and Effects Analysis) technique in the licensing process. It was implemented a software through the Excel program, using the Visual Basic for Applications program which allows the automation and the standardization of FMEA studies as well

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

    International Nuclear Information System (INIS)

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

    1991-01-01

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

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

    Science.gov (United States)

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

    2013-01-01

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

  5. Influence of reinforcement's corrosion into hyperstatic reinforced concrete beams: a probabilistic failure scenarios analysis

    Directory of Open Access Journals (Sweden)

    G. P. PELLIZZER

    Full Text Available AbstractThis work aims to study the mechanical effects of reinforcement's corrosion in hyperstatic reinforced concrete beams. The focus is the probabilistic determination of individual failure scenarios change as well as global failure change along time. The limit state functions assumed describe analytically bending and shear resistance of reinforced concrete rectangular cross sections as a function of steel and concrete resistance and section dimensions. It was incorporated empirical laws that penalize the steel yield stress and the reinforcement's area along time in addition to Fick's law, which models the chloride penetration into concrete pores. The reliability theory was applied based on Monte Carlo simulation method, which assesses each individual probability of failure. The probability of global structural failure was determined based in the concept of failure tree. The results of a hyperstatic reinforced concrete beam showed that reinforcements corrosion make change into the failure scenarios modes. Therefore, unimportant failure modes in design phase become important after corrosion start.

  6. Analysis of non simultaneous common mode failures. Application to the reliability assessment of the decay heat removal of the RNR 1500 project

    International Nuclear Information System (INIS)

    Natta, M.; Bloch, M.

    1991-01-01

    The experience with the LMFBR PHENIX has shown many cases of failures on identical and redundant components, which were close in time but not simultaneous and due to the same causes such as a design error, an unappropriate material, corrosion, ... Since the decay heat removal (DHR) must be assured for a long period after shutdown of the reactor, the overall reliability of the DHR system depends much on this type of successive failures by common mode causes, for which the usual β factor methods are not appropriate since they imply that the several failures are simultaneous. In this communication, two methods will be presented. The first one was used to assess the reliability of the DHR system of the RNR 1500 project. In this method, one modelize the occurrence of successive failures on n identical files by a sudden jump of the failure rate from the value λ attributed to the first failure to the value λ' attributed to the (n-1) still available files. This method leads to a quite natural quantification of the interest of diversity for highly redundant systems. For the RNR 1500 project where, in case of the loss of normal DHR path through the steam generators, the decay heat is removed by four separated sodium loops of 26 MW unit capacity in forced convection, the probabilistic assessment shows that it is necessary to diversify the sodium-sodium heat exchanger in order to fullfil the upper limit of 10 -7 /year for the probability of failure of DHR. A separate assessment for the main sequence leading to DHR loss was performed using a different method in which the successive failures are interpreted as a premature end of life, the lifetimes being directly used as random variables. This Monte-Carlo type method, which can be applied to any type of lifetime distribution, leads to results consistent to those obtained with the first one

  7. Integration of Value Stream Map and Healthcare Failure Mode and Effect Analysis into Six Sigma Methodology to Improve Process of Surgical Specimen Handling

    Directory of Open Access Journals (Sweden)

    Sheng-Hui Hung

    2015-01-01

    Full Text Available Specimen handling is a critical patient safety issue. Problematic handling process, such as misidentification (of patients, surgical site, and specimen counts, specimen loss, or improper specimen preparation can lead to serious patient harms and lawsuits. Value stream map (VSM is a tool used to find out non-value-added works, enhance the quality, and reduce the cost of the studied process. On the other hand, healthcare failure mode and effect analysis (HFMEA is now frequently employed to avoid possible medication errors in healthcare process. Both of them have a goal similar to Six Sigma methodology for process improvement. This study proposes a model that integrates VSM and HFMEA into the framework, which mainly consists of define, measure, analyze, improve, and control (DMAIC, of Six Sigma. A Six Sigma project for improving the process of surgical specimen handling in a hospital was conducted to demonstrate the effectiveness of the proposed model.

  8. Failure mode and effect analysis oriented to risk-reduction interventions in intraoperative electron radiation therapy: The specific impact of patient transportation, automation, and treatment planning availability

    International Nuclear Information System (INIS)

    López-Tarjuelo, Juan; Bouché-Babiloni, Ana; Santos-Serra, Agustín; Morillo-Macías, Virginia; Calvo, Felipe A.; Kubyshin, Yuri

    2014-01-01

    Background and purpose: Industrial companies use failure mode and effect analysis (FMEA) to improve quality. Our objective was to describe an FMEA and subsequent interventions for an automated intraoperative electron radiotherapy (IOERT) procedure with computed tomography simulation, pre-planning, and a fixed conventional linear accelerator. Material and methods: A process map, an FMEA, and a fault tree analysis are reported. The equipment considered was the radiance treatment planning system (TPS), the Elekta Precise linac, and TN-502RDM-H metal–oxide-semiconductor-field-effect transistor in vivo dosimeters. Computerized order-entry and treatment-automation were also analyzed. Results: Fifty-seven potential modes and effects were identified and classified into ‘treatment cancellation’ and ‘delivering an unintended dose’. They were graded from ‘inconvenience’ or ‘suboptimal treatment’ to ‘total cancellation’ or ‘potentially wrong’ or ‘very wrong administered dose’, although these latter effects were never experienced. Risk priority numbers (RPNs) ranged from 3 to 324 and totaled 4804. After interventions such as double checking, interlocking, automation, and structural changes the final total RPN was reduced to 1320. Conclusions: FMEA is crucial for prioritizing risk-reduction interventions. In a semi-surgical procedure like IOERT double checking has the potential to reduce risk and improve quality. Interlocks and automation should also be implemented to increase the safety of the procedure

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

    Science.gov (United States)

    Musani, Aatif

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

  10. SU-C-BRD-02: A Team Focused Clinical Implementation and Failure Mode and Effects Analysis of HDR Skin Brachytherapy Using Valencia and Leipzig Surface Applicators

    International Nuclear Information System (INIS)

    Sayler, E; Harrison, A; Eldredge-Hindy, H; Dinome, J; Munro, S; Anne, R; Comber, E; Lockamy, V

    2014-01-01

    Purpose: and Leipzig applicators (VLAs) are single-channel brachytherapy surface applicators used to treat skin lesions up to 2cm diameter. Source dwell times can be calculated and entered manually after clinical set-up or ultrasound. This procedure differs dramatically from CT-based planning; the novelty and unfamiliarity could lead to severe errors. To build layers of safety and ensure quality, a multidisciplinary team created a protocol and applied Failure Modes and Effects Analysis (FMEA) to the clinical procedure for HDR VLA skin treatments. Methods: team including physicists, physicians, nurses, therapists, residents, and administration developed a clinical procedure for VLA treatment. The procedure was evaluated using FMEA. Failure modes were identified and scored by severity, occurrence, and detection. The clinical procedure was revised to address high-scoring process nodes. Results: Several key components were added to the clinical procedure to minimize risk probability numbers (RPN): -Treatments are reviewed at weekly QA rounds, where physicians discuss diagnosis, prescription, applicator selection, and set-up. Peer review reduces the likelihood of an inappropriate treatment regime. -A template for HDR skin treatments was established in the clinical EMR system to standardize treatment instructions. This reduces the chances of miscommunication between the physician and planning physicist, and increases the detectability of an error during the physics second check. -A screen check was implemented during the second check to increase detectability of an error. -To reduce error probability, the treatment plan worksheet was designed to display plan parameters in a format visually similar to the treatment console display. This facilitates data entry and verification. -VLAs are color-coded and labeled to match the EMR prescriptions, which simplifies in-room selection and verification. Conclusion: Multidisciplinary planning and FMEA increased delectability and

  11. Extended Testability Analysis Tool

    Science.gov (United States)

    Melcher, Kevin; Maul, William A.; Fulton, Christopher

    2012-01-01

    The Extended Testability Analysis (ETA) Tool is a software application that supports fault management (FM) by performing testability analyses on the fault propagation model of a given system. Fault management includes the prevention of faults through robust design margins and quality assurance methods, or the mitigation of system failures. Fault management requires an understanding of the system design and operation, potential failure mechanisms within the system, and the propagation of those potential failures through the system. The purpose of the ETA Tool software is to process the testability analysis results from a commercial software program called TEAMS Designer in order to provide a detailed set of diagnostic assessment reports. The ETA Tool is a command-line process with several user-selectable report output options. The ETA Tool also extends the COTS testability analysis and enables variation studies with sensor sensitivity impacts on system diagnostics and component isolation using a single testability output. The ETA Tool can also provide extended analyses from a single set of testability output files. The following analysis reports are available to the user: (1) the Detectability Report provides a breakdown of how each tested failure mode was detected, (2) the Test Utilization Report identifies all the failure modes that each test detects, (3) the Failure Mode Isolation Report demonstrates the system s ability to discriminate between failure modes, (4) the Component Isolation Report demonstrates the system s ability to discriminate between failure modes relative to the components containing the failure modes, (5) the Sensor Sensor Sensitivity Analysis Report shows the diagnostic impact due to loss of sensor information, and (6) the Effect Mapping Report identifies failure modes that result in specified system-level effects.

  12. 14 CFR 417.224 - Probability of failure analysis.

    Science.gov (United States)

    2010-01-01

    ... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Probability of failure analysis. 417.224..., DEPARTMENT OF TRANSPORTATION LICENSING LAUNCH SAFETY Flight Safety Analysis § 417.224 Probability of failure..., must account for launch vehicle failure probability in a consistent manner. A launch vehicle failure...

  13. A model-based prognostic approach to predict interconnect failure using impedance analysis

    Energy Technology Data Exchange (ETDEWEB)

    Kwon, Dae Il; Yoon, Jeong Ah [Dept. of System Design and Control Engineering. Ulsan National Institute of Science and Technology, Ulsan (Korea, Republic of)

    2016-10-15

    The reliability of electronic assemblies is largely affected by the health of interconnects, such as solder joints, which provide mechanical, electrical and thermal connections between circuit components. During field lifecycle conditions, interconnects are often subjected to a DC open circuit, one of the most common interconnect failure modes, due to cracking. An interconnect damaged by cracking is sometimes extremely hard to detect when it is a part of a daisy-chain structure, neighboring with other healthy interconnects that have not yet cracked. This cracked interconnect may seem to provide a good electrical contact due to the compressive load applied by the neighboring healthy interconnects, but it can cause the occasional loss of electrical continuity under operational and environmental loading conditions in field applications. Thus, cracked interconnects can lead to the intermittent failure of electronic assemblies and eventually to permanent failure of the product or the system. This paper introduces a model-based prognostic approach to quantitatively detect and predict interconnect failure using impedance analysis and particle filtering. Impedance analysis was previously reported as a sensitive means of detecting incipient changes at the surface of interconnects, such as cracking, based on the continuous monitoring of RF impedance. To predict the time to failure, particle filtering was used as a prognostic approach using the Paris model to address the fatigue crack growth. To validate this approach, mechanical fatigue tests were conducted with continuous monitoring of RF impedance while degrading the solder joints under test due to fatigue cracking. The test results showed the RF impedance consistently increased as the solder joints were degraded due to the growth of cracks, and particle filtering predicted the time to failure of the interconnects similarly to their actual timesto- failure based on the early sensitivity of RF impedance.

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

    International Nuclear Information System (INIS)

    Son, Young Kap

    2011-01-01

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

  15. Reliability Analysis of Fatigue Failure of Cast Components for Wind Turbines

    OpenAIRE

    Hesam Mirzaei Rafsanjani; John Dalsgaard Sørensen

    2015-01-01

    Fatigue failure is one of the main failure modes for wind turbine drivetrain components made of cast iron. The wind turbine drivetrain consists of a variety of heavily loaded components, like the main shaft, the main bearings, the gearbox and the generator. The failure of each component will lead to substantial economic losses such as cost of lost energy production and cost of repairs. During the design lifetime, the drivetrain components are exposed to variable loads from winds and waves an...

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

    OpenAIRE

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

    2018-01-01

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

  17. Fuzzy Failure Analysis: A New Approach to Service Quality Analysis in Higher Education Institutions (Case Study: Vali-e-asr University of Rafsanjan-Iran)

    Science.gov (United States)

    Takalo, Salim Karimi; Abadi, Ali Reza Naser Sadr; Vesal, Seyed Mahdi; Mirzaei, Amir; Nawaser, Khaled

    2013-01-01

    In recent years, concurrent with steep increase in the growth of higher education institutions, improving of educational service quality with an emphasis on students' satisfaction has become an important issue. The present study is going to use the Failure Mode and Effect Analysis (FMEA) in order to evaluate the quality of educational services in…

  18. Field failure mechanisms for photovoltaic modules

    Science.gov (United States)

    Dumas, L. N.; Shumka, A.

    1981-01-01

    Beginning in 1976, Department of Energy field centers have installed and monitored a number of field tests and application experiments using current state-of-the-art photovoltaic modules. On-site observations of module physical and electrical degradation, together with in-depth laboratory analysis of failed modules, permits an overall assessment of the nature and causes of early field failures. Data on failure rates are presented, and key failure mechanisms are analyzed with respect to origin, effect, and prospects for correction. It is concluded that all failure modes identified to date are avoidable or controllable through sound design and production practices.

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

    Science.gov (United States)

    Li, Xibing; Du, Kun; Li, Diyuan

    2015-11-01

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

  20. Functional-logic simulation of IP-blocks dose functional failures

    Directory of Open Access Journals (Sweden)

    Vyacheslav M. Barbashov

    2017-11-01

    Full Text Available The technique of functional-logical simulation of System-on-Chip (SoC total dose radiation failures is presented based on fuzzy logic sets theory. An analysis of the capabilities of this approach for IP-blocks radiation behavior is carried out along with the analysis of operating modes under irradiation influence on IP-blocks radiation behavior. The following elements of this technique application for simulation of dose radiation failures of various types of IP-units are studied: logical elements, memory units and cells, processors. Examples of criterial membership functions and operability functions construction are given for these IP-units and for various critical parameters characterizing their failures. It is shown that when modeling total dose failures it is necessary to take into account the influence of the functional mode on the model parameters. The technique proposed allows improving the reliability of the SoC radiation hardness estimation, also for the purpose of solving the problems of information security of electronic devices.

  1. Failure Analysis Of Industrial Boiler Pipe

    International Nuclear Information System (INIS)

    Natsir, Muhammad; Soedardjo, B.; Arhatari, Dewi; Andryansyah; Haryanto, Mudi; Triyadi, Ari

    2000-01-01

    Failure analysis of industrial boiler pipe has been done. The tested pipe material is carbon steel SA 178 Grade A refer to specification data which taken from Fertilizer Company. Steps in analysis were ; collection of background operation and material specification, visual inspection, dye penetrant test, radiography test, chemical composition test, hardness test, metallography test. From the test and analysis result, it is shown that the pipe failure caused by erosion and welding was shown porosity and incomplete penetration. The main cause of failure pipe is erosion due to cavitation, which decreases the pipe thickness. Break in pipe thickness can be done due to decreasing in pipe thickness. To anticipate this problem, the ppe will be replaced with new pipe

  2. Combinatorial analysis of systems with competing failures subject to failure isolation and propagation effects

    International Nuclear Information System (INIS)

    Xing Liudong; Levitin, Gregory

    2010-01-01

    This paper considers the reliability analysis of binary-state systems, subject to propagated failures with global effect, and failure isolation phenomena. Propagated failures with global effect are common-cause failures originated from a component of a system/subsystem causing the failure of the entire system/subsystem. Failure isolation occurs when the failure of one component (referred to as a trigger component) causes other components (referred to as dependent components) within the same system to become isolated from the system. On the one hand, failure isolation makes the isolated dependent components unusable; on the other hand, it prevents the propagation of failures originated from those dependent components. However, the failure isolation effect does not exist if failures originated in the dependent components already propagate globally before the trigger component fails. In other words, there exists a competition in the time domain between the failure of the trigger component that causes failure isolation and propagated failures originated from the dependent components. This paper presents a combinatorial method for the reliability analysis of systems subject to such competing propagated failures and failure isolation effect. Based on the total probability theorem, the proposed method is analytical, exact, and has no limitation on the type of time-to-failure distributions for the system components. An illustrative example is given to demonstrate the basics and advantages of the proposed method.

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

    Energy Technology Data Exchange (ETDEWEB)

    Lee, Su Won

    2011-02-15

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

  4. The Effect of CFRP Length on the Failure Mode of Strengthened Concrete Beams

    Directory of Open Access Journals (Sweden)

    Jun Ding

    2014-06-01

    Full Text Available This paper reports the effects of carbon fiber-reinforced polymer (CFRP length on the failure process, pattern and crack propagation for a strengthened concrete beam with an initial notch. The experiments measuring load-bearing capacity for concrete beams with various CFRP lengths have been performed, wherein the crack opening displacements (COD at the initial notch are also measured. The application of CFRP can significantly improve the load-bearing capacity, and the failure modes seem different with various CFRP lengths. The stress profiles in the concrete material around the crack tip, at the end of CFRP and at the interface between the concrete and CFRP are then calculated using the finite element method. The experiment measurements are validated by theoretical derivation and also support the finite element analysis. The results show that CFRP can significantly increase the ultimate load of the beam, while such an increase stops as the length reaches 0.15 m. It is also concluded that the CFRP length can influence the stress distribution at three critical stress regions for strengthened concrete beams. However, the optimum CFRP lengths vary with different critical stress regions. For the region around the crack tip, it is 0.15 m; for the region at the interface it is 0.25 m, and for the region at the end of CFRP, it is 0.30 m. In conclusion, the optimum CFRP length in this work is 0.30 m, at which CFRP strengthening is fully functioning, which thus provides a good reference for the retrofitting of buildings.

  5. Face/core interface fracture characterization of mixed mode bending sandwich specimens

    DEFF Research Database (Denmark)

    Quispitupa, Amilcar; Berggreen, Christian; Carlsson, L.A.

    2011-01-01

    and PVC H45, H100 and H250 foam core materials were evaluated. A methodology to perform precracking on fracture specimens in order to achieve a sharp and representative crack front is outlined. The mixed mode loading was controlled in the mixed mode bending (MMB) test rig by changing the loading......Debonding of the core from the face sheets is a critical failure mode in sandwich structures. This paper presents an experimental study on face/core debond fracture of foam core sandwich specimens under a wide range of mixed mode loading conditions. Sandwich beams with E‐glass fibre face sheets...... application point (lever arm distance). Finite element analysis was performed to determine the mode‐mixity at the crack tip. The results showed that the face/core interface fracture toughness increased with increased mode II loading. Post failure analysis of the fractured specimens revealed that the crack...

  6. Failure rate analysis using GLIMMIX

    International Nuclear Information System (INIS)

    Moore, L.M.; Hemphill, G.M.; Martz, H.F.

    1998-01-01

    This paper illustrates use of a recently developed SAS macro, GLIMMIX, for implementing an analysis suggested by Wolfinger and O'Connell (1993) in modeling failure count data with random as well as fixed factor effects. Interest in this software tool arose from consideration of modernizing the Failure Rate Analysis Code (FRAC), developed at Los Alamos National Laboratory in the early 1980's by Martz, Beckman and McInteer (1982). FRAC is a FORTRAN program developed to analyze Poisson distributed failure count data as a log-linear model, possibly with random as well as fixed effects. These statistical modeling assumptions are a special case of generalized linear mixed models, identified as GLMM in the current statistics literature. In the nearly 15 years since FRAC was developed, there have been considerable advances in computing capability, statistical methodology and available statistical software tools allowing worthwhile consideration of the tasks of modernizing FRAC. In this paper, the approaches to GLMM estimation implemented in GLIMMIX and in FRAC are described and a comparison of results for the two approaches is made with data on catastrophic time-dependent pump failures from a report by Martz and Whiteman (1984). Additionally, statistical and graphical model diagnostics are suggested and illustrated with the GLIMMIX analysis results

  7. Seismic ratchet-fatigue failure of piping systems

    International Nuclear Information System (INIS)

    Severud, L.K.; Anderson, M.J.; Lindquist, M.R.; Weiner, E.O.

    1986-01-01

    Failures of piping systems during earthquakes have been rare. Those that have failed were either made of brittle material such as cast iron, were rigid systems between major components where component relative seismic motions tore the pipe out of the component, or were high pressure systems where a ratchet-fatigue fracture followed a local bulging of the pipe diameter. Tests to failure of an unpressurized 3-in. and a pressurized 6-in. diameter carbon steel nuclear pipe systems subjected to high level shaking have been accomplished. Failure analyses of these tests are presented and correlated to the test results. It was found that failure of the unpressurized system could be correlated well with standard ASME type fatigue analysis predictions. Moreover, the pressurized system failure occurred in significantly less load cycles than predicted by standard fatigue analysis. However, a ratchet-fatigue and ductility exhaustion analysis of the pressurized system did correlate very well. These findings indicate modifications to design analysis methods and the present ASME Code piping design rules may be appropriate to cover the ratchet-fatigue failure mode

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

    Science.gov (United States)

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

    2017-12-11

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

  9. Environmental risk assessment of low density polyethylene unit using the method of failure mode and effect analysis

    Directory of Open Access Journals (Sweden)

    Salati Parinaz

    2012-01-01

    Full Text Available The ninth olefin plan of Arya Sasol Petrochemical Company (A.S.P.C. is regarded the largest gas Olefin Unit located on Pars Special Economic Energy Zone (P.S.E.E.Z. Considering the importance of the petrochemical unit, its environmental assessment seems necessary to identify and reduce potential hazards. For this purpose, after determining the scope of the study area, identification and measurement of the environmental parameters, environmental risk assessment of the unit was carried out using Environment Failure Mode and Effect Analysis (EFMEA. Using the noted method, sources causing environmental risks were identified, rated and prioritized. Beside, the impacts of the environmental aspects derived from the unit activities as well as their consequences were also analyzed. Furthermore, the identified impacts were prioritized based on Risk Priority Number (RPN and severity level of the consequences imposed on the affected environment. After performing statistical calculations, it was found that the environmental aspects owing the risk priority number higher than 15 have a high level of risk. Results obtained from Low Density Polyethylene Unit revealed that the highest risk belongs to the emergency vent system with risk priority number equal to 48. It is occurred due to imperfect performance of the reactor safety system leading to the emissions of ethylene gas, particles, and radioactive steam as well as air and noise pollutions. Results derived from secondary assessment of the environmental aspects, through difference in calculated RPN and activities risk levels showed that employing modern methods and risk assessment are have remarkably reduced the severity of risk and consequently detracted the damages and losses incurred on the environment.

  10. Failure diagnosis and fault tree analysis

    International Nuclear Information System (INIS)

    Weber, G.

    1982-07-01

    In this report a methodology of failure diagnosis for complex systems is presented. Systems which can be represented by fault trees are considered. This methodology is based on switching algebra, failure diagnosis of digital circuits and fault tree analysis. Relations between these disciplines are shown. These relations are due to Boolean algebra and Boolean functions used throughout. It will be shown on this basis that techniques of failure diagnosis and fault tree analysis are useful to solve the following problems: 1. describe an efficient search of all failed components if the system is failed. 2. Describe an efficient search of all states which are close to a system failure if the system is still operating. The first technique will improve the availability, the second the reliability and safety. For these problems, the relation to methods of failure diagnosis for combinational circuits is required. Moreover, the techniques are demonstrated for a number of systems which can be represented by fault trees. (orig./RW) [de

  11. Failure and damage analysis of advanced materials

    CERN Document Server

    Sadowski, Tomasz

    2015-01-01

    The papers in this volume present basic concepts and new developments in failure and damage analysis with focus on advanced materials such as composites, laminates, sandwiches and foams, and also new metallic materials. Starting from some mathematical foundations (limit surfaces, symmetry considerations, invariants) new experimental results and their analysis are shown. Finally, new concepts for failure prediction and analysis will be introduced and discussed as well as new methods of failure and damage prediction for advanced metallic and non-metallic materials. Based on experimental results the traditional methods will be revised.

  12. Failure analysis of real-time systems

    International Nuclear Information System (INIS)

    Jalashgar, A.; Stoelen, K.

    1998-01-01

    This paper highlights essential aspects of real-time software systems that are strongly related to the failures and their course of propagation. The significant influence of means-oriented and goal-oriented system views in the description, understanding and analysing of those aspects is elaborated. The importance of performing failure analysis prior to reliability analysis of real-time systems is equally addressed. Problems of software reliability growth models taking the properties of such systems into account are discussed. Finally, the paper presents a preliminary study of a goal-oriented approach to model the static and dynamic characteristics of real-time systems, so that the corresponding analysis can be based on a more descriptive and informative picture of failures, their effects and the possibility of their occurrence. (author)

  13. Analysis of Moderator System Failure Accidents by Using New Method for Wolsong-1 CANDU 6 Reactor

    Energy Technology Data Exchange (ETDEWEB)

    Jin, Dongsik; Kim, Jonghyun; Cho, Cheonhwey [Atomic Creative Technology Co., Ltd., Daejeon (Korea, Republic of); Kim, Sungmin [Korea Hydro and Nuclear Power Co., Ltd., Daejeon (Korea, Republic of)

    2013-05-15

    To reconfirm the safety of moderator system failure accidents, the safety analysis by using the reactor physics code, RFSP-IST, coupled with the thermal hydraulics code, CATHENA is performed additionally. In the present paper, the newly developed analysis method is briefly described and the results obtained from the moderator system failure accident simulations for Wolsong-1 CANDU 6 reactor by using the new method are summarized. The safety analysis of the moderator system failure accidents for Wolsong-1 CANDU 6 reactor was carried out by using the new code system, i. e., CATHENA and RFSP-IST, instead of the non-IST old codes, namely, SMOKIN G-2 and MODSTBOIL. The analysis results by using the new method revealed as same with the results by using the old method that the fuel integrity is warranted because the localized power peak remained well below the limits and, most importantly, the reactor operation enters into the self-shutdown mode due to the substantial loss of moderator D{sub 2}O inventory from the moderator system. In the analysis results obtained by using the old method, it was predicted that the ROP trip conditions occurred for the transient cases which are also studied in the present paper. But, in the new method, it was found that the ROP trip conditions did not occur. Consequently, in the safety analysis performed additionally by using the new method, the safety of moderator system failure accidents was reassured. In the future, the new analysis method by using the IST codes instead of the non-IST old codes for the moderator system failure accidents is strongly recommended.

  14. Failure mechanisms for compacted uranium oxide fuel cores

    International Nuclear Information System (INIS)

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

    1980-01-01

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

  15. Automated multiple failure FMEA

    International Nuclear Information System (INIS)

    Price, C.J.; Taylor, N.S.

    2002-01-01

    Failure mode and effects analysis (FMEA) is typically performed by a team of engineers working together. In general, they will only consider single point failures in a system. Consideration of all possible combinations of failures is impractical for all but the simplest example systems. Even if the task of producing the FMEA report for the full multiple failure scenario were automated, it would still be impractical for the engineers to read, understand and act on all of the results. This paper shows how approximate failure rates for components can be used to select the most likely combinations of failures for automated investigation using simulation. The important information can be automatically identified from the resulting report, making it practical for engineers to study and act on the results. The strategy described in the paper has been applied to a range of electrical subsystems, and the results have confirmed that the strategy described here works well for realistically complex systems

  16. Implementation of a computational system at the Center for Nuclear Technology Development, for systematization the application of the FMEA - Failure Mode and Effects Analysis, for identification of dangerous and developed risks evaluation

    International Nuclear Information System (INIS)

    Correa, Danyel Pontelo; Vasconcelos, Vanderley de

    2009-01-01

    The regulatory bodies request risks evaluations for nuclear and radioactive licensing purposes. In Brazil those evaluations are contained by the safety analysis reports requested by the Brazilian Nuclear Energy Commission (CNEN), and risk analysis studies requested by the environment organisms. A risk evaluation includes the identification of the risks and the accident sequence which can occur, and the estimation of the frequency and his undesirable effects on the industrial installations, the public, and the environment. The identification and the risk analysis are particularly important for the implementation of a health, environment and safety integrated management according to the regulation instruments ISO 14001, BS 8800 and OHSAS 18001. The utilization of the risk identification techniques and the risk analysis is performed at the non nuclear industry, in a non standard form by the various sectors of an enterprise, diminishing the effectiveness of the recommended actions based on risk indexes. However, for the nuclear licensing, the CNEN request through their regulatory instruments and standard formats, that the risks, the failure mechanisms and detection be identified, which can allow the preventive and mitigate actions. This paper proposes the utilization of the FMEA (Failure Mode and Effects Analysis) technique in the licensing process. It was implemented a software through the Excel program, using the Visual Basic for Applications program which allows the automation and the standardization of FMEA studies as well

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

    Science.gov (United States)

    Zhao, Bo; Li, Yuanchun

    2015-01-01

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

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

    Directory of Open Access Journals (Sweden)

    Bo Zhao

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

  19. Failure Modes Analysis for the MSU-RIA Driver Linac

    CERN Document Server

    Wu, Xiaoyu; Gorelov, Dmitry; Grimm, Terry L; Marti, Felix; York, Richard

    2005-01-01

    Previous end-to-end beam dynamics simulation studies* using experimentally-based input beams including alignment and rf errors and variation in charge-stripping foil thickness have indicated that the Rare Isotope Accelerator (RIA) driver linac proposed by MSU has adequate transverse and longitudinal acceptances to accelerate light and heavy ions to final energies of at least 400 MeV/u with beam powers of 100 to 400 kW. During linac operation, equipment loss due to, for example, cavity contamination, availability of cryogens, or failure of rf or power supply systems, will lead to at least a temporary loss of some of the cavities and focusing elements. To achieve high facility availability, each segment of the linac should be capable of adequate performance even with failed elements. Beam dynamics studies were performed to evaluate the linac performance under various scenarios of failed cavities and focusing elements with proper correction schemes, in order to prove the flexibility and robustness of the driver ...

  20. Constructing Ontology for Knowledge Sharing of Materials Failure Analysis

    Directory of Open Access Journals (Sweden)

    Peng Shi

    2014-01-01

    Full Text Available Materials failure indicates the fault with materials or components during their performance. To avoid the reoccurrence of similar failures, materials failure analysis is executed to investigate the reasons for the failure and to propose improved strategies. The whole procedure needs sufficient domain knowledge and also produces valuable new knowledge. However, the information about the materials failure analysis is usually retained by the domain expert, and its sharing is technically difficult. This phenomenon may seriously reduce the efficiency and decrease the veracity of the failure analysis. To solve this problem, this paper adopts ontology, a novel technology from the Semantic Web, as a tool for knowledge representation and sharing and describes the construction of the ontology to obtain information concerning the failure analysis, application area, materials, and failure cases. The ontology represented information is machine-understandable and can be easily shared through the Internet. At the same time, failure case intelligent retrieval, advanced statistics, and even automatic reasoning can be accomplished based on ontology represented knowledge. Obviously this can promote the knowledge sharing of materials service safety and improve the efficiency of failure analysis. The case of a nuclear power plant area is presented to show the details and benefits of this method.

  1. Distributed collaborative probabilistic design of multi-failure structure with fluid-structure interaction using fuzzy neural network of regression

    Science.gov (United States)

    Song, Lu-Kai; Wen, Jie; Fei, Cheng-Wei; Bai, Guang-Chen

    2018-05-01

    To improve the computing efficiency and precision of probabilistic design for multi-failure structure, a distributed collaborative probabilistic design method-based fuzzy neural network of regression (FR) (called as DCFRM) is proposed with the integration of distributed collaborative response surface method and fuzzy neural network regression model. The mathematical model of DCFRM is established and the probabilistic design idea with DCFRM is introduced. The probabilistic analysis of turbine blisk involving multi-failure modes (deformation failure, stress failure and strain failure) was investigated by considering fluid-structure interaction with the proposed method. The distribution characteristics, reliability degree, and sensitivity degree of each failure mode and overall failure mode on turbine blisk are obtained, which provides a useful reference for improving the performance and reliability of aeroengine. Through the comparison of methods shows that the DCFRM reshapes the probability of probabilistic analysis for multi-failure structure and improves the computing efficiency while keeping acceptable computational precision. Moreover, the proposed method offers a useful insight for reliability-based design optimization of multi-failure structure and thereby also enriches the theory and method of mechanical reliability design.

  2. Human failure event analysis and precautionary methods and their application to reactor system

    International Nuclear Information System (INIS)

    Zhang Li; Huang Shudong; Wang Yiqun; Gao Wenyu; Zhang Jin

    2003-01-01

    Making use of human factor engineering, control science and safety science and adopting the method of systemically collection and doing research work factually, the authors analyze the problem and tendency of human factor science, the classification system, the formation, the quantitative appraisal, data collection and data bank, the effect and influence of organization management, the root cause analysis technology, and human error failure mode and effect and criticality analysis, the method and strategy of defense-in-depth for preventing human-initiated accident. The human factor accidents theory and mechanism are constructed. All of the above was successfully applied to Daya Bay Nuclear Power Station and Lingao Nuclear Power Station. (authors)

  3. Vulnerability Identification and Design-Improvement-Feedback using Failure Analysis of Digital Control System Designs

    Energy Technology Data Exchange (ETDEWEB)

    Lee, Eunchan; Bae, Yeonkyoung [Korea Hydro and Nuclear Power Co., Ltd., Daejeon (Korea, Republic of)

    2013-05-15

    Fault tree analyses let analysts establish the failure sequences of components as a logical model and confirm the result at the plant level. These two analyses provide insights regarding what improvements are needed to increase availability because it expresses the quantified design attribute of the system as minimal cut sets and availability value interfaced with component reliability data in the fault trees. This combined failure analysis method helps system users understand system characteristics including its weakness and strength in relation to faults in the design stage before system operation. This study explained why a digital system could have weaknesses in methods to transfer control signals or data and how those vulnerabilities could cause unexpected outputs. In particular, the result of the analysis confirmed that complex optical communication was not recommended for digital data transmission in the critical systems of nuclear power plants. Regarding loop controllers in Design A, a logic configuration should be changed to prevent spurious actuation due to a single failure, using hardware or software improvements such as cross checking between redundant modules, or diagnosis of the output signal integrity. Unavailability calculations support these insights from the failure analyses of the systems. In the near future, KHNP will perform failure mode and effect analyses in the design stage before purchasing non-safety-related digital system packages. In addition, the design requirements of the system will be confirmed based on evaluation of overall system availability or unavailability.

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

    DEFF Research Database (Denmark)

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

    2013-01-01

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

  5. Data needs for common cause failure analysis

    International Nuclear Information System (INIS)

    Parry, G.W.; Paula, H.M.; Rasmuson, D.; Whitehead, D.

    1990-01-01

    The procedures guide for common cause failure analysis published jointly by USNRC and EPRI requires a detailed historical event analysis. Recent work on the further development of the cause-defense picture of common cause failures introduced in that guide identified the information that is necessary to perform the detailed analysis in an objective manner. This paper summarizes these information needs

  6. SU-E-T-179: Clinical Impact of IMRT Failure Modes at Or Near TG-142 Tolerance Criteria Levels

    Energy Technology Data Exchange (ETDEWEB)

    Faught, J Tonigan; Balter, P; Johnson, J; Kry, S; Court, L; Stingo, F; Followill, D [UT MD Anderson Cancer Center, Houston, TX (United States)

    2015-06-15

    Purpose: Quantitatively assess the clinical impact of 11 critical IMRT dose delivery failure modes. Methods: Eleven step-and-shoot IMRT failure modes (FMs) were introduced into twelve Pinnacle v9.8 treatment plans. One standard and one highly modulated plan on the IROC IMRT phantom and ten previous H&N patient treatment plans were used. FMs included physics components covered by basic QA near tolerance criteria levels (TG-142) such as beam energy, MLC positioning, and MLC modeling. Resultant DVHs were compared to those of failure-free plans and the severity of plan degradation was assessed considering PTV coverage and OAR and normal tissue tolerances and used for FMEA severity scoring. Six of these FMs were physically simulated and phantom irradiations performed. TLD and radiochromic film results are used for comparison to treatment planning studies. Results: Based on treatment planning studies, the largest clinical impact from the phantom cases was induced by 2 mm systematic MLC shift in one bank with the combination of a D95% target under dose near 16% and OAR overdose near 8%. Cord overdoses of 5%–11% occurred with gantry angle, collimator angle, couch angle, MLC leaf end modeling, and MLC transmission and leakage modeling FMs. PTV coverage and/or OAR sparing was compromised in all FMs introduced in phantom plans with the exception of CT number to electron density tables, MU linearity, and MLC tongue-and-groove modeling. Physical measurements did not entirely agree with treatment planning results. For example, symmetry errors resulted in the largest physically measured discrepancies of up to 3% in the PTVs while a maximum of 0.5% deviation was seen in the treatment planning studies. Patient treatment plan study results are under analysis. Conclusion: Even in the simplistic anatomy of the IROC phantom, some basic physics FMs, just outside of TG-142 tolerance criteria, appear to have the potential for large clinical implications.

  7. Definition of containment failure

    International Nuclear Information System (INIS)

    Cybulskis, P.

    1982-01-01

    Core meltdown accidents of the types considered in probabilistic risk assessments (PRA's) have been predicted to lead to pressures that will challenge the integrity of containment structures. Review of a number of PRA's indicates considerable variation in the predicted probability of containment failure as a function of pressure. Since the results of PRA's are sensitive to the prediction of the occurrence and the timing of containment failure, better understanding of realistic containment capabilities and a more consistent approach to the definition of containment failure pressures are required. Additionally, since the size and location of the failure can also significantly influence the prediction of reactor accident risk, further understanding of likely failure modes is required. The thresholds and modes of containment failure may not be independent

  8. Integrated failure probability estimation based on structural integrity analysis and failure data: Natural gas pipeline case

    International Nuclear Information System (INIS)

    Dundulis, Gintautas; Žutautaitė, Inga; Janulionis, Remigijus; Ušpuras, Eugenijus; Rimkevičius, Sigitas; Eid, Mohamed

    2016-01-01

    In this paper, the authors present an approach as an overall framework for the estimation of the failure probability of pipelines based on: the results of the deterministic-probabilistic structural integrity analysis (taking into account loads, material properties, geometry, boundary conditions, crack size, and defected zone thickness), the corrosion rate, the number of defects and failure data (involved into the model via application of Bayesian method). The proposed approach is applied to estimate the failure probability of a selected part of the Lithuanian natural gas transmission network. The presented approach for the estimation of integrated failure probability is a combination of several different analyses allowing us to obtain: the critical crack's length and depth, the failure probability of the defected zone thickness, dependency of the failure probability on the age of the natural gas transmission pipeline. A model's uncertainty analysis and uncertainty propagation analysis are performed, as well. - Highlights: • Degradation mechanisms of natural gas transmission pipelines. • Fracture mechanic analysis of the pipe with crack. • Stress evaluation of the pipe with critical crack. • Deterministic-probabilistic structural integrity analysis of gas pipeline. • Integrated estimation of pipeline failure probability by Bayesian method.

  9. Time-frequency analysis : mathematical analysis of the empirical mode decomposition.

    Science.gov (United States)

    2009-01-01

    Invented over 10 years ago, empirical mode : decomposition (EMD) provides a nonlinear : time-frequency analysis with the ability to successfully : analyze nonstationary signals. Mathematical : Analysis of the Empirical Mode Decomposition : is a...

  10. Dynamic stability and failure modes of slopes in discontinuous rock mass

    International Nuclear Information System (INIS)

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

    1988-01-01

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

  11. X-framework: Space system failure analysis framework

    Science.gov (United States)

    Newman, John Steven

    Space program and space systems failures result in financial losses in the multi-hundred million dollar range every year. In addition to financial loss, space system failures may also represent the loss of opportunity, loss of critical scientific, commercial and/or national defense capabilities, as well as loss of public confidence. The need exists to improve learning and expand the scope of lessons documented and offered to the space industry project team. One of the barriers to incorporating lessons learned include the way in which space system failures are documented. Multiple classes of space system failure information are identified, ranging from "sound bite" summaries in space insurance compendia, to articles in journals, lengthy data-oriented (what happened) reports, and in some rare cases, reports that treat not only the what, but also the why. In addition there are periodically published "corporate crisis" reports, typically issued after multiple or highly visible failures that explore management roles in the failure, often within a politically oriented context. Given the general lack of consistency, it is clear that a good multi-level space system/program failure framework with analytical and predictive capability is needed. This research effort set out to develop such a model. The X-Framework (x-fw) is proposed as an innovative forensic failure analysis approach, providing a multi-level understanding of the space system failure event beginning with the proximate cause, extending to the directly related work or operational processes and upward through successive management layers. The x-fw focus is on capability and control at the process level and examines: (1) management accountability and control, (2) resource and requirement allocation, and (3) planning, analysis, and risk management at each level of management. The x-fw model provides an innovative failure analysis approach for acquiring a multi-level perspective, direct and indirect causation of

  12. Analysis of Energy Transmission Modes of Flyback Converter

    Directory of Open Access Journals (Sweden)

    GONG Shu

    2014-08-01

    Full Text Available It is of significance to investigate energy transmission modes of a flyback converter for its optimum design. In this paper, the ETMs of a flyback converter are divided into three modes, which are continuous conduction mode-complete inductor supply mode, continuous conduction mode- incomplete inductor supply mode and discontinuous conduction mode-incomplete inductor supply mode, respectively. A deep analysis of the operation is made, a reduction of the boundary condition between the modes is conducted and a comparison of current stress, transformer AP and output ripple voltage between the modes is performed. A 30W prototype is developed and its experiment is done. The experiment results are in agreement with the theoretical analysis quite well.

  13. Stochastic failure modelling of unidirectional composite ply failure

    International Nuclear Information System (INIS)

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

    2012-01-01

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

  14. Importance analysis for the systems with common cause failures

    International Nuclear Information System (INIS)

    Pan Zhijie; Nonaka, Yasuo

    1995-01-01

    This paper extends the importance analysis technique to the research field of common cause failures to evaluate the structure importance, probability importance, and β-importance for the systems with common cause failures. These importance measures would help reliability analysts to limit the common cause failure analysis framework and find efficient defence strategies against common cause failures

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

    OpenAIRE

    BOUROUIS FAIROUZ; MILI FAYCAL

    2012-01-01

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

  16. Nanowire failure: long = brittle and short = ductile.

    Science.gov (United States)

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

    2012-02-08

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

  17. Seismic ratchet-fatigue failure of piping systems

    International Nuclear Information System (INIS)

    Severud, L.K.; Anderson, M.J.; Lindquist, M.R.; Weiner, E.O.

    1987-01-01

    Failures of piping systems during earthquakes have been rare. Those that have failed were either made of brittle material such as cast iron, were rigid systems between major components where component relative seismic motions tore the pipe out of the component, or were high pressure systems where a ratchet-fatigue fracture followed a local bulging of the pipe diameter. Tests to failure of an unpressurized 3-inch and a pressurized 6-inch diameter carbon steel nuclear pipe systems subjected to high-level shaking have been accomplished. The high-level shaking loads needed to cause failure were much higher than ASME Code rules would permit with present design limits. Failure analyses of these tests are presented and correlated to the test results. It was found that failure of the unpressurized system could be correlated well with standard ASME type fatigue analysis predictions. Moreover, the pressurized system failure occured in significantly less load cycles than predicted by standard fatigue analysis. However, a ratchet-fatigue and ductility exhaustion analysis of the pressurized system did correlate reasonably well. These findings indicate modifications to design analysis methods and the present ASME Code piping design rules to reduce unneeded conservatisms and to cover the ratchet-fatigue failure mode may be appropriate

  18. Improved methods for dependent failure analysis in PSA

    International Nuclear Information System (INIS)

    Ballard, G.M.; Games, A.M.

    1988-01-01

    The basic design principle used in ensuring the safe operation of nuclear power plant is defence in depth. This normally takes the form of redundant equipment and systems which provide protection even if a number of equipment failures occur. Such redundancy is particularly effective in ensuring that multiple, independent equipment failures with the potential for jeopardising reactor safety will be rare events. However the achievement of high reliability has served to highlight the potentially dominant role of multiple, dependent failures of equipment and systems. Analysis of reactor operating experience has shown that dependent failure events are the major contributors to safety system failures and reactor incidents and accidents. In parallel PSA studies have shown that the results of a safety analysis are sensitive to assumptions made about the dependent failure (CCF) probability for safety systems. Thus a Westinghouse Analysis showed that increasing system dependent failure probabilities by a factor of 5 led to a factor 4 increase in core. This paper particularly refers to the engineering concepts underlying dependent failure assessment touching briefly on aspects of data. It is specifically not the intent of our work to develop a new mathematical model of CCF but to aid the use of existing models

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

    Science.gov (United States)

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

    2012-04-01

    Basaltic rocks are the main component of the oceanic upper crust. This is of potential interest for water and geothermal resources, or for storage of CO2. The aim of our work is to investigate experimentally the mechanical behavior and the failure modes of porous basalt as well as the permeability evolution during deformation. Cylindrical basalt samples, from the Azores, of 30 mm in diameter and 60 mm in length were deformed the triaxial cell of the Laboratoire de Geologie at the Ecole Normale Supérieure (Paris) at room temperature and at a constant axial strain rate of 10-