WorldWideScience

Sample records for prom failure modes

  1. 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...

  2. 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)

  3. 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...

  4. 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

  5. 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....

  6. 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.

  7. 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...

  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. 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.)

  10. 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.

  11. 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.

  12. 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

  13. 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.

  14. 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.

  15. 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

  16. 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)

  17. 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

  18. 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)

  19. 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.

  20. 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.

  1. 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)

  2. 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

  3. 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...

  4. 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

  5. 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

  6. 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.)

  7. 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.

  8. 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.

  9. Patient reported outcome measures (PROMs)

    DEFF Research Database (Denmark)

    Bech, Per; Austin, Stephen Fitzgerald; Lau, Marianne Engelbrecht

    2018-01-01

    INTRODUCTION: Patient-reported outcome measures (PROMs) for anxiety and depressive disorders are an important aspect of measurement-based care. AIM: The aim of the study was to perform a clinimetric analysis of two PROMs scales in patents with depression and anxiety. METHODS: Patients completed...... recruited from two Danish mental health centers with anxiety or depression. The standardization of the SCL-10 and WHO-5 by T-scores indicated that a T-score of 65 corresponding to being moderately in need of treatment and a T-score of 75 to be severely in need of treatment. The coefficient of alpha...... with anxiety or depression undergoing psychotherapy treatment....

  10. 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.

  11. 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

  12. 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

  13. 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.

  14. 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

  15. 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.

  16. 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

  17. 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)

  18. 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.

  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. 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

  1. 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.

  2. 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

  3. 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

  4. 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

  5. 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.

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. 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

  15. 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...

  16. 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

  17. 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.

  18. 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

  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. 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.

  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. 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

  3. 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

  4. 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

  5. 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.

  6. 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.

  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. 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.

  9. 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

  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. 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...

  12. 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

  13. 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

  14. 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.

  15. [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.

  16. 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

  17. 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

  18. 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.

  19. Lunar Module Electrical Power System Design Considerations and Failure Modes

    Science.gov (United States)

    Interbartolo, Michael

    2009-01-01

    This slide presentation reviews the design and redesign considerations of the Apollo lunar module electrical power system. Included in the work are graphics showing the lunar module power system. It describes the in-flight failures, and the lessons learned from these failures.

  20. Maintenance of electrolytic cells with failure technologic mode

    International Nuclear Information System (INIS)

    Galushkin, N.V.

    1995-01-01

    This chapter of monograph is devoted to failures in regular operation of electrolytic cell and ways of their neutralization. Thus, the main failures in regular operation of electrolytic cell, including hot driving, cold driving of tank, carbides formation were studied. The emergency cases in operation of tanks and ways of their neutralization were described.

  1. A Study of Failure Modes in the ILC Main Linac

    CERN Document Server

    Eliasson, Peder; Krücker, Dirk; Latina, Andrea; Poirier, Freddy; Schulte, Daniel; Walker, Nicholas John; Xia, Guoxing

    2006-01-01

    Failures in the ILC can lead to beam loss or even damage the machine. In the paper quadrupole failures and errors in the klystron phase are being investigated and the impact on the machine protection is being considered for the main linac.

  2. 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.

  3. 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.

  4. 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)

  5. 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).

  6. 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

  7. 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

  8. 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

  9. 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.

  10. 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.

  11. 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

  12. 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...

  13. 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)

  14. 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

  15. 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

  16. 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 ...

  17. 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.

  18. 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.

  19. 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.

  20. 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

  1. 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

  2. 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...

  3. 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.

  4. 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.

  5. 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

  6. 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.

  7. 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.

  8. 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.

  9. 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

  10. 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

  11. 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.

  12. 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.

  13. 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

  14. 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

  15. Two Contrasting Failure Modes of Enteric Coated Beads.

    Science.gov (United States)

    Shi, Galen H; Dong, Xia; Lytle, Michelle; Kemp, Craig A J; Behme, Robert J; Hinds, Jeremy; Xiao, Zhicheng

    2018-04-09

    This study aimed to elucidate the mechanisms and kinetics of coating failure for enteric coated beads exposed to high-humidity conditions at different storage temperatures. Enteric coated beads were placed on high-humidity conditions (75 to 98% relative humidity (RH)) in the temperature range of 5 to 40°C. These stability samples of beads were tested for acid dissolution and water activity and also analyzed with SEM, X-ray CT, and DMA. Exposure of enteric coated beads to high humidity led to increased gastric release of drug which eventually failed the dissolution specification. SEM showed visible cracks on the surface of beads exposed to 5°C/high humidity and fusion of enteric beads into agglomerates at 40°C/high humidity. In a non-destructive time elapse study, X-ray CT demonstrated swelling of microcrystalline cellulose cores, crack initiation, and propagation through the API layer within days under 5°C/98% RH storage conditions and ultimately fracture through the enteric coating. DMA data showed a marked reduction in T g of the enteric coating materials after exposure to humidity. At 5°C/high humidity, the hygroscopic microcrystalline cellulose core absorbed moisture leading to core swelling and consequent fracture through the brittle API and enteric layers. At 40°C (high humidity) which is above the T g of the enteric polymer, enteric coated beads coalesced into agglomerates due to melt flow of the enteric coating. We believe it is the first report on two distinct failure models of enteric coated dosage forms.

  16. 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.

  17. 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.

  18. 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

  19. 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.

  20. 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.

  1. 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.

  2. 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

  3. 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.

  4. 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.

  5. 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 ...

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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)

  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. 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

  13. 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.

  14. 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

  15. 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.

  16. 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

  17. 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

  18. 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)

  19. 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.

  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. 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.

  2. 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.

  3. 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

  4. 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.

  5. PROM and Labour Effects on Urinary Metabolome: A Pilot Study

    Directory of Open Access Journals (Sweden)

    Alessandra Meloni

    2018-01-01

    Full Text Available Since pathologies and complications occurring during pregnancy and/or during labour may cause adverse outcomes for both newborns and mothers, there is a growing interest in metabolomic applications on pregnancy investigation. In fact, metabolomics has proved to be an efficient strategy for the description of several perinatal conditions. In particular, this study focuses on premature rupture of membranes (PROM in pregnancy at term. For this project, urine samples were collected at three different clinical conditions: out of labour before PROM occurrence (Ph1, out of labour with PROM (Ph2, and during labour with PROM (Ph3. GC-MS analysis, followed by univariate and multivariate statistical analysis, was able to discriminate among the different classes, highlighting the metabolites most involved in the discrimination.

  6. PROM and Labour Effects on Urinary Metabolome: A Pilot Study

    Science.gov (United States)

    Meloni, Alessandra; Palmas, Francesco; Mereu, Rossella; Deiana, Sara Francesca; Fais, Maria Francesca; Mussap, Michele; Ragusa, Antonio; Pintus, Roberta; Fanos, Vassilios; Melis, Gian Benedetto

    2018-01-01

    Since pathologies and complications occurring during pregnancy and/or during labour may cause adverse outcomes for both newborns and mothers, there is a growing interest in metabolomic applications on pregnancy investigation. In fact, metabolomics has proved to be an efficient strategy for the description of several perinatal conditions. In particular, this study focuses on premature rupture of membranes (PROM) in pregnancy at term. For this project, urine samples were collected at three different clinical conditions: out of labour before PROM occurrence (Ph1), out of labour with PROM (Ph2), and during labour with PROM (Ph3). GC-MS analysis, followed by univariate and multivariate statistical analysis, was able to discriminate among the different classes, highlighting the metabolites most involved in the discrimination. PMID:29511388

  7. 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

  8. 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.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. 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.

  15. 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.

  16. 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...

  17. 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)

  18. 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

  19. 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.

  20. 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)

  1. 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

  2. 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

  3. 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

  4. 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.

  5. 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)

  6. 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.)

  7. 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

  8. 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.

  9. 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

  10. 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.

  11. 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.)

  12. 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.

  13. 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

  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. 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 ...

  16. 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.

  17. 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.

  18. 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

  19. 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

  20. 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

  1. 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.

  2. 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.

  3. 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.

  4. 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

  5. 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)

  6. 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.

  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. 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

  9. 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

  10. 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.

  11. 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.

  12. 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

  13. 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.

  14. 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.

  15. 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.

  16. 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.

  17. 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)

  18. An introduction to patient-reported outcome measures (PROMs) in physiotherapy

    NARCIS (Netherlands)

    Kyte, D.G.; Calvert, M.; Wees, P.J. van der; Hove, R. Ten; Tolan, S.; Hill, J.C.

    2015-01-01

    The use of patient-reported outcome measures (PROMs) is set to rise in physiotherapy. PROMs provide additional 'patient-centred' data which is unique in capturing the patient's own opinion on the impact of their disease or disorder, and its treatment, on their life. Thus, PROMs are increasingly used

  19. 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

  20. 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

  1. 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.

  2. 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.

  3. 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.

  4. 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...

  5. 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...

  6. 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

  7. 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 ...

  8. 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...

  9. 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....

  10. Predicting the occurrence of mixed mode failure associated with hydraulic fracturing, part 2 water saturated tests

    Energy Technology Data Exchange (ETDEWEB)

    Bauer, Stephen J. [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Broome, Scott Thomas [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Choens, Charles [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Barrow, Perry Carl [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States)

    2015-09-14

    Seven water-saturated triaxial extension experiments were conducted on four sedimentary rocks. This experimental condition was hypothesized more representative of that existing for downhole hydrofracture and thus it may improve our understanding of the phenomena. In all tests the pore pressure was 10 MPa and confirming pressure was adjusted to achieve tensile and transitional failure mode conditions. Using previous work in this LDRD for comparison, the law of effective stress is demonstrated in extension using this sample geometry. In three of the four lithologies, no apparent chemo-mechanical effect of water is apparent, and in the fourth lithology test results indicate some chemo-mechanical effect of water.

  11. 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.

  12. [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.

  13. Mechanics of Unidirectional Fiber-Reinforced Composites: Buckling Modes and Failure Under Compression Along Fibers

    Science.gov (United States)

    Paimushin, V. N.; Kholmogorov, S. A.; Gazizullin, R. K.

    2018-01-01

    One-dimensional linearized problems on the possible buckling modes of an internal or peripheral layer of unidirectional multilayer composites with rectilinear fibers under compression in the fiber direction are considered. The investigations are carried out using the known Kirchhoff-Love and Timoshenko models for the layers. The binder, modeled as an elastic foundation, is described by the equations of elasticity theory, which are simplified in accordance to the model of a transversely soft layer and are integrated along the transverse coordinate considering the kinematic coupling relations for a layer and foundation layers. Exact analytical solutions of the problems formulated are found, which are used to calculate a composite made of an HSE 180 REM prepreg based on a unidirectional carbon fiber tape. The possible buckling modes of its internal and peripheral layers are identified. Calculation results are compared with experimental data obtained earlier. It is concluded that, for the composite studied, the flexural buckling of layers in the uniform axial compression of specimens along fibers is impossible — the failure mechanism is delamination with buckling of a fiber bundle according to the pure shear mode. It is realized (due to the low average transverse shear modulus) at the value of the ultimate compression stress equal to the average shear modulus. It is shown that such a shear buckling mode can be identified only on the basis of equations constructed using the Timoshenko shear model to describe the deformation process of layers.

  14. Finding an acceleration function for calculating the reliability of redundant systems - Application to common mode failures

    International Nuclear Information System (INIS)

    Gonnot, R.

    1975-01-01

    While it may be reasonable to assume that the reliability of a system - the design of which is perfectly known - can be evaluated, it seems less easy to be sure that overall reliability is correctly estimated in the case of multiple redundancies arranged in sequence. Framatome is trying to develop a method of evaluating overall reliability correctly for its installations. For example, the protection systems in its power stations considered as a whole are such that several scram signals may be relayed in sequence when an incident occurs. These signals all involve the same components for a given type of action, but the components themselves are in fact subject to different stresses and constraints, which tend to reduce their reliability. Whatever the sequence in which these signals are transmitted (in a fast-developing accident, for example), it is possible to evaluate the actual reliability of a given system (or component) for different constraints, as the latter are generally obtained via the transient codes. By applying the so-called ''equal probability'' hypothesis one can estimate a reliability acceleration function taking into account the constraints imposed. This function is linear for the principal failure probability distribution laws. By generalizing such a method one can: (1) Perform failure calculations for redundant systems (or components) in a more general way than is possible with event trees, since one of the main parameters is the constraint exercised on that system (or component); (2) Determine failure rates of components on the basis of accelerated tests (up to complete failure of the component) which are quicker than the normal long-term tests (statistical results of operation); (3) Evaluate the multiplication factor for the reliability of a system or component in the case of common mode failures. The author presents the mathematical tools required for such a method and described their application in the cases mentioned above

  15. 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.

  16. 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.

  17. 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)

  18. 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.

  19. 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

  20. 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.

  1. 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

  2. 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.

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

    LENUS (Irish Health Repository)

    Banks, Louisa N

    2012-02-01

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

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

    Science.gov (United States)

    Banks, Louisa N; McElwain, John P

    2010-04-01

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

  5. 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

  6. 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.

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

    Science.gov (United States)

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

    2012-04-01

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

  8. 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

  9. 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

  10. 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.

  11. Fracture Resistance and Failure Mode of Endodontically Treated Premolars Restored with Different Adhesive Restorations

    Directory of Open Access Journals (Sweden)

    Nasrin Sarabi

    2015-03-01

    Full Text Available Introduction: The restoration of endodontically treated teeth is a topic that has been studied extensively but it is still a challenge for dental practitioners. The aim of this study was to evaluate fracture resistance, fracture patterns and fracture location of endodontically treated human maxillary premolars restored with direct and indirect composite resin and ceramic restoration. Methods: Eighty non-carious maxillary premolars were selected and divided into four groups (n=20. Endodontic treatment and mesio-occluso-distal preparations were carried out in all the groups except for the control group (group I. Subsequently, the prepared teeth were restored as follows: group II: indirect composite restoration; group III: ceramic restoration; group IV: direct composite restoration. The specimens were subjected to compressive axial loading until fracture occurred. The mode of failure was also recorded. Results: Group I had higher fracture resistance (1196.82±241.74 than the other groups (P

  12. 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.

  13. 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.

  14. 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.

  15. 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

  16. Failure mode and fracture behavior evaluation of pipes with local wall thinning subjected to bending load

    International Nuclear Information System (INIS)

    Ahn, Seok Hwan; Nam, Ki Woo; Kim, Seon Jin; Kim, Jin Hwan; Kim, Hyun Soo; Do, Jae Yoon

    2003-01-01

    Fracture behaviors of pipes with local wall thinning are very important for the integrity of nuclear power plant. In pipes of energy plants, sometimes, the local wall thinning may result from severe Erosion-Corrosion (E/C) damage. However, the effects of local wall thinning on strength and fracture behaviors of piping system were not well studied. In this paper, the monotonic bending tests were performed of full-scale carbon steel pipes with local wall thinning. A monotonic bending load was applied to straight pipe specimens by four-point loading at ambient temperature without internal pressure. From the tests, fracture behaviors and fracture strength of locally thinned pipe were manifested systematically. The observed failure modes were divided into four types; ovalization, crack initiation/growth after ovalization, local buckling and crack initiating/growth after local buckling. Also, the strength and the allowable limit of piping system with local wall thinning were evaluated

  17. 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)

  18. 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)

  19. 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.

  20. 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.

  1. 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.

  2. 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.

  3. 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

  4. 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

  5. Predictions and Experimental Microstructural Characterization of High Strain Rate Failure Modes in Layered Aluminum Composites

    Science.gov (United States)

    Khanikar, Prasenjit

    Different aluminum alloys can be combined, as composites, for tailored dynamic applications. Most investigations pertaining to metallic alloy layered composites, however, have been based on quasi-static approaches. The dynamic failure of layered metallic composites, therefore, needs to be characterized in terms of strength, toughness, and fracture response. A dislocation-density based crystalline plasticity formulation, finite-element techniques, rational crystallographic orientation relations and a new fracture methodology were used to predict the failure modes associated with the high strain rate behavior of aluminum layered composites. Two alloy layers, a high strength alloy, aluminum 2195, and an aluminum alloy 2139, with high toughness, were modeled with representative microstructures that included precipitates, dispersed particles, and different grain boundary (GB) distributions. The new fracture methodology, based on an overlap method and phantom nodes, is used with a fracture criteria specialized for fracture on different cleavage planes. One of the objectives of this investigation, therefore, was to determine the optimal arrangements of the 2139 and 2195 aluminum alloys for a metallic layered composite that would combine strength, toughness and fracture resistance for high strain-rate applications. Different layer arrangements were investigated for high strain-rate applications, and the optimal arrangement was with the high toughness 2139 layer on the bottom, which provided extensive shear strain localization, and the high strength 2195 layer on the top for high strength resistance. The layer thickness of the bottom high toughness layer also affected the bending behavior of the roll-boned interface and the potential delamination of the layers. Shear strain localization, dynamic cracking and delamination were the mutually competing failure mechanisms for the layered metallic composite, and control of these failure modes can be optimized for high strain

  6. Amnioinfusion in preterm PROM: effects on amnion and cord histology.

    Science.gov (United States)

    Locatelli, A; Andreani, M; Ghidini, A; Verderio, M; Pizzardi, A; Vergani, P; Salafia, C M

    2008-02-01

    To investigate the effects of transabdominal amnioinfusion (TA) on the histology of amnion (A) and umbilical cord (UC). From a cohort of 56 singleton pregnancies with premature rupture of membranes (PROM) at PROM of 18.7 weeks and at delivery of 26.1 weeks, with a latency of 50 days. Compared with subjects who declined the procedure, TA had a beneficial effect on clinical variables, mediated primarily by a longer latency. TA was not associated with identifiable effects on the histologic features of A or UC. A and UC histology is not significantly affected by exposure to saline solution even for prolonged periods of time.

  7. Chemical failure modes of AlQ3-based OLEDs: AlQ3 hydrolysis.

    Science.gov (United States)

    Knox, John E; Halls, Mathew D; Hratchian, Hrant P; Schlegel, H Bernhard

    2006-03-28

    Tris(8-hydroxyquinoline)aluminum(III), AlQ3, is used in organic light-emitting diodes (OLEDs) as an electron-transport material and emitting layer. The reaction of AlQ3 with trace H2O has been implicated as a major failure pathway for AlQ3-based OLEDs. Hybrid density functional calculations have been carried out to characterize the hydrolysis of AlQ3. The thermochemical and atomistic details for this important reaction are reported for both the neutral and oxidized AlQ3/AlQ3+ systems. In support of experimental conclusions, the neutral hydrolysis reaction pathway is found to be a thermally activated process, having a classical barrier height of 24.2 kcal mol(-1). First-principles infrared and electronic absorption spectra are compared to further characterize AlQ3 and the hydrolysis pathway product, AlQ2OH. The activation energy for the cationic AlQ3 hydrolysis pathway is found to be 8.5 kcal mol(-1) lower than for the neutral reaction, which is significant since it suggests a role for charge imbalance in promoting chemical failure modes in OLED devices.

  8. Failure mode prediction for composite structural insulated panels with MgO board facings

    Science.gov (United States)

    Smakosz, Łukasz; Kreja, Ireneusz

    2018-01-01

    Sandwich panels are readily used in civil engineering due to their high strength to weight ratio and the ease and speed of assembly. The idea of a sandwich section is to combine thin and durable facings with a light-weight core and the choice of materials used allows obtaining the desired behaviour. Panels in consideration consist of MgO (magnesium oxide) board facings and expanded polystyrene core and are characterized by immunity to biological corrosion, a high thermal insulation and a relatively low impact on environment. Customizing the range of panels to meet market needs requires frequent size changes, leading to different failure modes, which are identified in a series of costly full-scale laboratory tests. A nonlinear numerical model was created with a use of a commercial ABAQUS code and a user-defined procedure, which is able to reproduce observed failure mechanisms; its parameters were established on the basis of small-scale tests and numerical experiments. The model was validated by a comparison with the results of the full-scale bending and compression tests. The results obtained were in satisfactory agreement with the test data.

  9. Electromechanical response and failure modes of a dielectric elastomer tube actuator with boundary constraints

    International Nuclear Information System (INIS)

    Zhou, Jianyou; Jiang, Liying; Khayat, Roger E

    2014-01-01

    As a widely used configuration for dielectric elastomer (DE) actuators, DE tube actuators (or cylindrical actuators) are also found to be susceptible to electromechanical instability (EMI), which may lead to a premature electrical breakdown (EB), and inhibit the potential actuation of DE actuators. This work investigates the electromechanical response of a DE tube actuator with and without boundary constraints to demonstrate an alternative to avoid EMI while achieving large actuation. Our simulation results based on the Gent strain energy model show that the EMI of a DE tube actuator can be eliminated, and larger actuation deformation can be achieved by applying boundary constraints. As a result of these constraints, consideration is also given to the possible mechanical buckling failure that may occur. Mechanisms of possible failure modes of constrained and unconstrained DE tube actuators, such as electromechanical instability, electrical breakdown and mechanical buckling, are elucidated. This paper should provide better theoretical guidance on how to improve the actuation performance of DE actuators, thus leading to the optimal design of DE-based devices. (paper)

  10. State of the art review of pressure liquefied gas container failure modes and associated projectile hazards

    Energy Technology Data Exchange (ETDEWEB)

    Leslie, I.R.M.; Birk, A.M.

    1989-08-01

    A study was carried out to investigate the state of knowledge about the failure of pressure liquified gas transport and storage tanks. A comprehensive literature search and review was carried out to assess the level of knowledge relating to the causes and characteristics of vessel ruptures. Specific parameters of interest were: the effect of vessel initial conditions (fill level, initial temperature, etc.) on rupture severity; the ability to predict the occurrence of boiling liquid expanding vapor explosions (BLEVE); and the effects of explosions such as blast waves and missile generation. The review revealed that there are several areas where knowledge is weak. These areas include: the effects of blast on structures, the prediction of hazards from, and size of, fireballs, and the understanding of failure modes of pressure liquified gas containers. It was concluded that an experimental program should be initiated to investigate the effects of container size, shape and loading conditions on the consequences of vessel rupture. 68 refs., 16 figs., 10 tabs.

  11. 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

  12. 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

  13. 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.

  14. 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

  15. 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

  16. 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.

  17. 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

  18. 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

  19. 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.

  20. 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)

  1. 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

  2. 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.

  3. 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.

  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. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. Failure modes induced by natural radiation environments on DRAM memories: study, test methodology and mitigation technique

    International Nuclear Information System (INIS)

    Bougerol, A.

    2011-05-01

    DRAMs are frequently used in space and aeronautic systems. Their sensitivity to cosmic radiations have to be known in order to satisfy reliability requirements for critical applications. These evaluations are traditionally done with particle accelerators. However, devices become more complex with technology integration. Therefore new effects appear, inducing longer and more expensive tests. There is a complementary solution: the pulsed laser, which triggers similar effects as particles. Thanks to these two test tools, main DRAM radiation failure modes were studied: SEUs (Single Event Upset) in memory blocks, and SEFIs (Single Event Functional Interrupt) in peripheral circuits. This work demonstrates the influence of test patterns on SEU and SEFI sensitivities depending on technology used. In addition, this study identifies the origin of the most frequent type of SEFIs. Moreover, laser techniques were developed to quantify sensitive surfaces of the different effects. This work led to a new test methodology for industry, in order to optimize test cost and efficiency using both pulsed laser beams and particle accelerators. Finally, a new fault tolerant technique is proposed: based on DRAM cell radiation immunity when discharged, this technique allows to correct all bits of a logic word. (author)

  12. On the failure modes of alternative containment designs following postulated core meltdown

    International Nuclear Information System (INIS)

    Chan, C.K.; Knee, H.E.; Okrent, D.

    1977-01-01

    The containment response to a postulated core meltdown accident in a PWR ice condenser containment, a BWR Mark III containment and a BWR non-inerted Mark I containment has been examined to see if the WASH-1400 containment failure mode judgement for the Surry large, dry containment and the Peach Bottom Mark I inerted-containment are likely to be appropriate for these alternative containment plant designs. For the PWR, the representative accident chosen for the analysis is a large cold leg break accompanied by a loss of all electric power while the BWR respresentative event chosen is a recirculation line break without adequate core cooling function. Two containment event paths are studied for each of these two cases, depending on whether or not containment vapor suppression function is assumed to be available. Both the core and the containment pressure and temperature response to the accident events are computed for the four time intervals which characterize (a) blowdown of the pipe break, (b) core melt, (c) vessel melt-through, and (d) containment foundation penetration. The calculations are based on a best esimate of the most probable sequence, but certain phenomena and events were followed down multiple tracks. It appears that the non-inerted Mark I containment is not so vulnerable to overpressurization from hydrogen burning as the Mark III; however, acceptable temperatures may be exceeded. (Auth.)

  13. 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.

  14. Strain distribution and failure mode of polymer separators for Li-ion batteries under biaxial loading

    Science.gov (United States)

    Kalnaus, Sergiy; Kumar, Abhishek; Wang, Yanli; Li, Jianlin; Simunovic, Srdjan; Turner, John A.; Gorney, Phillip

    2018-02-01

    Deformation of polymer separators for Li-ion batteries has been studied under biaxial tension by using a dome test setup. This deformation mode provides characterization of separator strength under more complex loading conditions, closer representing deformation of an electric vehicle battery during crash event, compared to uniaxial tension or compression. Two polymer separators, Celgard 2325 and Celgard 2075 were investigated by deformation with spheres of three different diameters. Strains in separators were measured in situ by using Digital Image Correlation (DIC) technique. The results show consistent rupture of separators along the machine direction coinciding with areas of high strain accumulation. The critical first principal strain for failure was independent of the sphere diameter and was determined to be approximately 34% and 43% for Celgard 2325 and Celgard 2075 respectively. These values can be taken as a criterion for internal short circuit in a battery following an out-of-plane impact. A Finite Element (FE) model was built with the anisotropic description of separator behavior, derived from tensile tests in orthogonal directions. The results of simulations predicted the response of separator rather well when compared to experimental results for various sizes of rigid sphere.

  15. 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.

  16. European Clearinghouse. Incidents related to reactivity management. Contributing factors, failure modes and corrective actions

    International Nuclear Information System (INIS)

    Bruynooghe, Christiane; Noel, Marc

    2009-01-01

    This work is part of the European Clearinghouse on Nuclear Power Plant Operational Experience Feedback (NPP-OEF) activity carried out at the Joint Research Centre/Institute for Energy (JRC/IE) with the participation of nine EU Regulatory Authorities. It investigates the 1999 Shika-1 criticality event together with other shortcomings in reactivity management reported to the IAE4 Incident Reporting System in the period 1981-2008. The aim of the work was to identify reactivity control failure modes, reactor status and corrective actions. Initiating factors and associated root causes were also analysed. Five of the 7 factors identified for all events were present in the 1999 Shika-1 event where criticality has been unexpectedly reached and maintained during 15 minutes. Most of the events resulted in changes in procedures, material or staff and management training. The analysis carried out put in evidence that in several instances appropriate communication based on operational experience feedback would have prevented incident to occur. This paper also summarises the action taken at power plants and by the regulatory bodies in different countries to avoid repetition of similar events. It identifies insights that might be useful to reduce the likelihood of operational events caused by shortcomings in reactivity management. (orig.)

  17. 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.

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

    Directory of Open Access Journals (Sweden)

    Jingjing He

    2018-01-01

    Full Text Available 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 fiber orientation angle is constant, the tensile strength, elastic modulus, and limiting strain of BF/EP composite material all increase with increasing fiber volume fraction. A certain degree of fiber clustering appears in the epoxy resin when the basalt fiber volume fraction is >1.2%. The fiber equidistribution coefficient and clustering fiber content were used to characterize the basalt fiber clustering effect. With the increase of fiber volume fraction, the clustering fiber content gradually increased, but the fiber equidistribution coefficient decreased. Meanwhile, based on Tsai theory, a geometric model and a tensile mechanical model of the clustering fiber are established. By considering the fiber clustering effect, the BF/EP composite material tensile strength is calculated, and the calculated values are close to the experimental results.

  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. 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.

  1. 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.

  2. 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

  3. 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.

  4. 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

  5. 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

  6. 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....

  7. 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.

  8. 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.

  9. An introduction to patient-reported outcome measures (PROMs) in physiotherapy.

    Science.gov (United States)

    Kyte, D G; Calvert, M; van der Wees, P J; ten Hove, R; Tolan, S; Hill, J C

    2015-06-01

    The use of patient-reported outcome measures (PROMs) is set to rise in physiotherapy. PROMs provide additional 'patient-centred' data which is unique in capturing the patient's own opinion on the impact of their disease or disorder, and its treatment, on their life. Thus, PROMs are increasingly used by clinicians to guide routine patient care, or for the purposes of audit, and are already firmly embedded in clinical research. This article seeks to summarise the key aspects of PROM use for physiotherapists, both in routine clinical practice and in the research setting, and highlights recent developments in the field. Generic and condition-specific PROMs are defined and examples of commonly used measures are provided. The selection of appropriate PROMs, and their effective use in the clinical and research settings is discussed. Finally, existing barriers to PROM use in practice are identified and recent physiotherapy PROM initiatives, led by the Royal Dutch Society for Physical Therapy are explored. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

  10. Creating guidance for the use of patient reported outcome measures (PROMS) in clinical palliatieve care.

    NARCIS (Netherlands)

    Vliet, L.M. van; Harding, R.; Bausewein, C.; Payne, S.; Higginson, I.J.

    2014-01-01

    Introduction: Routine use of Patient Reported Outcome Measures (PROMs) in clinical practice can influence care but is not always achieved. One reason for this seems to be a lack of guidance on how to use PROMs in palliative care practice. This project aimed to provide such guidance. Aim(s) and

  11. A systematic review of patient reported outcome measures (PROMs) used in child and adolescent burn research.

    Science.gov (United States)

    Griffiths, C; Armstrong-James, L; White, P; Rumsey, N; Pleat, J; Harcourt, D

    2015-03-01

    Patient reported outcome measures (PROMs) can identify important information about patient needs and therapeutic progress. The aim of this review was to identify the PROMs that are being used in child and adolescent burn care and to determine the quality of such scales. Computerised and manual bibliographic searches of Medline, Social Sciences Index, Cinahl, Psychinfo, Psycharticles, AMED, and HAPI, were used to identify English-language articles using English-language PROMs from January 2001 to March 2013. The psychometric quality of the PROMs was assessed. 23 studies met the entry criteria and identified 32 different PROMs (31 generic, 1 burns-specific). Overall, the psychometric quality of the PROMs was low; only two generic scales (the Perceived Stigmatisation Questionnaire and the Social Comfort Scale) and only one burns-specific scale (the Children Burn Outcomes Questionnaire for children aged 5-18) had psychometric evidence relevant to this population. The majority of PROMs did not have psychometric evidence for their use with child or adolescent burn patients. To appropriately identify the needs and treatment progress of child and adolescent burn patients, new burns-specific PROMs need to be developed and validated to reflect issues that are of importance to this population. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

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

    International Nuclear Information System (INIS)

    Hahm, Dae Gi; Choi, In Kil

    2009-01-01

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

  13. Contact Mechanics and Failure Modes of Compliant Polymeric Bearing Materials for Knee Cartilage Replacement

    Science.gov (United States)

    Tohfafarosh, Mariya Shabbir

    control samples. However, chemical spectra of electron beam sterilized samples revealed minor changes, which were absent in unsterilized and gamma sterilized samples. Upon successful sterilization evaluation, both polycarbonate urethane and the novel hydrogel were investigated for the contact mechanics of compliant-on-compliant artificial knee bearings using a finite element analysis approach. A simplified, axisymmetric, finite element model of a medial knee compartment was developed and validated, and a design of simulation experiments was carried out to evaluate the effect of implant conformity, implant thickness and material properties on the contact mechanics of compliant knee bearings under normal walking and stair climbing loads. All input parameters, namely, implant conformity, implant thickness and material properties, significantly (pengineering strain (39 - 53% true strain) without any signs of cracking or fracture. The tension was determined to be the primary failure mode for the proposed materials, and the tensile test was used to define the failure criteria of the materials. The unconfined compression tests were used to define the yield stresses and strains under compression, which is the main mode of loading for the knee joint. The results of the plane strain compression were modeled using a finite element model and the maximum principal stress, von Mises stress, maximum shear stress, and maximum principal strain failure criteria were predicted at the corresponding yield strain of each material formulation. Upon comparing the knee model contact stress and strain prediction under normal walking and stair climbing loads with those of the empirical failure criteria at yield, the polycarbonate urethane showed better overall potential for use in compliant knee implants, while the hydrogels exhibited higher potential for delamination or fracture, especially if appropriate implant conformity and thickness are not employed. The outcome of this study and the previous

  14. 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...

  15. 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)

  16. 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

  17. 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.

  18. 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.

  19. 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.

  20. 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.

  1. 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).

  2. 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

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  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. 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.

  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. Application of validity theory and methodology to patient-reported outcome measures (PROMs): building an argument for validity.

    Science.gov (United States)

    Hawkins, Melanie; Elsworth, Gerald R; Osborne, Richard H

    2018-07-01

    Data from subjective patient-reported outcome measures (PROMs) are now being used in the health sector to make or support decisions about individuals, groups and populations. Contemporary validity theorists define validity not as a statistical property of the test but as the extent to which empirical evidence supports the interpretation of test scores for an intended use. However, validity testing theory and methodology are rarely evident in the PROM validation literature. Application of this theory and methodology would provide structure for comprehensive validation planning to support improved PROM development and sound arguments for the validity of PROM score interpretation and use in each new context. This paper proposes the application of contemporary validity theory and methodology to PROM validity testing. The validity testing principles will be applied to a hypothetical case study with a focus on the interpretation and use of scores from a translated PROM that measures health literacy (the Health Literacy Questionnaire or HLQ). Although robust psychometric properties of a PROM are a pre-condition to its use, a PROM's validity lies in the sound argument that a network of empirical evidence supports the intended interpretation and use of PROM scores for decision making in a particular context. The health sector is yet to apply contemporary theory and methodology to PROM development and validation. The theoretical and methodological processes in this paper are offered as an advancement of the theory and practice of PROM validity testing in the health sector.

  18. 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.

  19. Evaluation of the Prevalence of Different Treatment Failure Modes after Crown Lengthening Surgical Procedures

    Directory of Open Access Journals (Sweden)

    Amirreza Babaloo

    2016-07-01

    Full Text Available Introduction: Preservation of the health of periodontium is very important for the long-term success of restored teeth and a balance should always be created between the patients’ esthetic requirements and the periodontal health. Failures of crown lengthening procedures are classified into early and late failures. The aim of this study was to evaluate the prevalence of early failures of crown leathering surgical procedures. Materials and methods: In this descriptive/cross-sectional study, 96 patients were selected from those referring to the Department of Periodontitis, Tabriz Faculty of Dentistry, who required crown lengthening procedures. The particulars of these patients were recorded in special forms and the reasons for the failure of surgical procedures were separately determined at 2- and 6-week intervals. In addition, the frequencies of the reasons for failures were determined in percentages and absolute frequencies. Data were analyzed with descriptive statistics (frequencies and percentages using SPSS 21. Statistical significance was set at P<0.05. Results: Evaluation of patients 6 weeks after surgery showed a failure rate of 14.5% for crown lengthening procedures in patients referring to the Department of Periodontics, Tabriz Faculty of Dentistry. The most common reasons for such early failures in the 6th week, in descending order, were a lack of sufficient keratinized gingiva around in tooth in question, fracture of the tooth structure after surgery, inadequate surgery (not creating a proper distance between the healthy margin and the crest and the coronal returning of the gingival tissue on the tooth. A lack of sufficient keratinized gingiva around the tooth was the most frequent reason for the early failure of crown lengthening procedure at both study intervals. Conclusion: It can be concluded from the results of the present study that during the 6th postoperative week the crown lengthening procedures exhibited a 14.5% failure rate

  20. 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.

  1. 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)

  2. 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

  3. 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.

  4. Microstructurally Based Prediction of High Strain Failure Modes in Crystalline Solids

    Science.gov (United States)

    2016-07-05

    interfaces in hcp– fcc systems subjected to high strain-rate deformation and fracture modes, Journal of Materials Research, (8 2015): 0. doi: 10.1557/jmr...rupture • Comparison and validation with experimental observations/ measurements • New dislocation-density crystalline plasticity that accounts for...relationships between coherent interfaces in hcp– fcc systems subjected to high strain-rate deformation and fracture modes, Journal of Materials Research, Vol. 30

  5. 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.

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2009-06-01

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

  7. Strength Prediction and Failure Modes of Concrete Specimens Subjected to the Split Test

    DEFF Research Database (Denmark)

    Hoang, Linh Cao; Andersen, M.E.; Hansen, N.T.

    2014-01-01

    This paper deals with modelling and test of concrete specimens subjected to the Brazilian split test. Based on the fictitious crack concept, a simple model for the crack propagation process in the splitting plane is developed. From the model, it is possible to determine the distribution of residual...... tensile strength as crack propagation take place. The residual tensile strength is thereafter used in a rigid plastic analysis of the splitting failure. Based on this combined approach, the ultimate load may either be governed by crack propagation or by a plastic failure, which then terminates the crack...

  8. 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

  9. 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.

  10. Evaluation and demonstration of commercialization potential of CCSI tools within gPROMS advanced simulation platform

    Energy Technology Data Exchange (ETDEWEB)

    Lawal, Adekola [Process Systems Enterprise Inc., Cedar Knolls, NJ (United States); Schmal, Pieter [Process Systems Enterprise Inc., Cedar Knolls, NJ (United States); Ramos, Alfredo [Process Systems Enterprise Inc., Cedar Knolls, NJ (United States); Cano, Alejandro [Process Systems Enterprise Inc., Cedar Knolls, NJ (United States); Bhattacharyya, Debangsu [West Virginia Univ., Morgantown, WV (United States); Mebane, David [West Virginia Univ., Morgantown, WV (United States); Sahinidis, Nikolaos [Carnegie Mellon Univ., Pittsburgh, PA (United States); Chowdhury, Ananya [Process Systems Enterprise Inc., Cedar Knolls, NJ (United States); Liu, Xiaohui [Process Systems Enterprise Inc., Cedar Knolls, NJ (United States); Bellinghausen, Stefan [Process Systems Enterprise Inc., Cedar Knolls, NJ (United States)

    2017-05-29

    PSE, in the first phase of the CCSI commercialization project, set out to identify market opportunities for the CCSI tools combined with existing gPROMS platform capabilities and develop a clear technical plan for the proposed commercialization activities.

  11. 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.

  12. 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)

  13. Effect of Strain Rate on Joint Strength and Failure Mode of Lead-Free Solder Joints

    Science.gov (United States)

    Lin, Jian; Lei, Yongping; Fu, Hanguang; Guo, Fu

    2018-03-01

    In surface mount technology, the Sn-3.0Ag-0.5Cu solder joint has a shorter impact lifetime than a traditional lead-tin solder joint. In order to improve the impact property of SnAgCu lead-free solder joints and identify the effect of silver content on tensile strength and impact property, impact experiments were conducted at various strain rates on three selected SnAgCu based solder joints. It was found that joint failure mainly occurred in the solder material with large plastic deformation under low strain rate, while joint failure occurred at the brittle intermetallic compound layer without any plastic deformation at a high strain rate. Joint strength increased with the silver content in SnAgCu alloys in static tensile tests, while the impact property of the solder joint decreased with increasing silver content. When the strain rate was low, plastic deformation occurred with failure and the tensile strength of the Sn-3.0Ag-0.5Cu solder joint was higher than that of Sn-0.3Ag-0.7Cu; when the strain rate was high, joint failure mainly occurred at the brittle interface layer and the Sn-0.3Ag-0.7Cu solder joint had a better impact resistance with a thinner intermetallic compound layer.

  14. Reliability measurement for mixed mode failures of 33/11 kilovolt electric power distribution stations.

    Directory of Open Access Journals (Sweden)

    Faris M Alwan

    Full Text Available The reliability of the electrical distribution system is a contemporary research field due to diverse applications of electricity in everyday life and diverse industries. However a few research papers exist in literature. This paper proposes a methodology for assessing the reliability of 33/11 Kilovolt high-power stations based on average time between failures. The objective of this paper is to find the optimal fit for the failure data via time between failures. We determine the parameter estimation for all components of the station. We also estimate the reliability value of each component and the reliability value of the system as a whole. The best fitting distribution for the time between failures is a three parameter Dagum distribution with a scale parameter [Formula: see text] and shape parameters [Formula: see text] and [Formula: see text]. Our analysis reveals that the reliability value decreased by 38.2% in each 30 days. We believe that the current paper is the first to address this issue and its analysis. Thus, the results obtained in this research reflect its originality. We also suggest the practicality of using these results for power systems for both the maintenance of power systems models and preventive maintenance models.

  15. Stripper foil failure modes and cures at the Oak Ridge Spallation Neutron Source

    Directory of Open Access Journals (Sweden)

    M. A. Plum

    2011-03-01

    Full Text Available The Oak Ridge Spallation Neutron Source comprises a 1 GeV, 1.5 MW linear accelerator followed by an accumulator ring and a liquid mercury target. To manage the beam loss caused by the H^{0} excited states created during the H^{-} charge-exchange injection into the accumulator ring, the stripper foil is located inside one of the chicane dipoles. This has some interesting consequences that were not fully appreciated until the beam power reached about 840 kW. One consequence was sudden failure of the stripper foil system due to convoy electrons stripped from the incoming H^{-} beam, which circled around to strike the foil bracket and cause bracket failure. Another consequence is that convoy electrons can reflect back up from the electron catcher and strike the foil and bracket. An additional contributor to foil system failure is vacuum breakdown due to the charge developed on the foil by secondary electron emission. In this paper we detail these and other interesting failure mechanisms and describe the improvements we have made to mitigate them.

  16. An Independent Psychometric Evaluation of the PROMS Measure of Music Perception Skills.

    Science.gov (United States)

    Kunert, Richard; Willems, Roel M; Hagoort, Peter

    2016-01-01

    The Profile of Music Perception Skills (PROMS) is a recently developed measure of perceptual music skills which has been shown to have promising psychometric properties. In this paper we extend the evaluation of its brief version to three kinds of validity using an individual difference approach. The brief PROMS displays good discriminant validity with working memory, given that it does not correlate with backward digit span (r = .04). Moreover, it shows promising criterion validity (association with musical training (r = .45), musicianship status (r = .48), and self-rated musical talent (r = .51)). Finally, its convergent validity, i.e. relation to an unrelated measure of music perception skills, was assessed by correlating the brief PROMS to harmonic closure judgment accuracy. Two independent samples point to good convergent validity of the brief PROMS (r = .36; r = .40). The same association is still significant in one of the samples when including self-reported music skill in a partial correlation (rpartial = .30; rpartial = .17). Overall, the results show that the brief version of the PROMS displays a very good pattern of construct validity. Especially its tuning subtest stands out as a valuable part for music skill evaluations in Western samples. We conclude by briefly discussing the choice faced by music cognition researchers between different musical aptitude measures of which the brief PROMS is a well evaluated example.

  17. A collapse mode of failure in powder-filled fuel elements

    International Nuclear Information System (INIS)

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

    1964-01-01

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

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

    International Nuclear Information System (INIS)

    Murray, D.W.

    1978-06-01

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

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

    International Nuclear Information System (INIS)

    Cooke, Roger; Paulsen, Jette

    1997-01-01

    Measurement of maintenance performance is done on the basis of component history data in which service sojourns are distinguished according to whether they terminate in corrective or preventive maintenance. From the viewpoint of data analysis, corrective and preventive maintenance constitute competing failure nudes. 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 the Nordic TUD data system

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

    OpenAIRE

    Kouroush Jenab; Joseph Pineau

    2015-01-01

    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 impa...

  1. 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

  2. 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.

  3. 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

  4. 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

  5. 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.

  6. [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.

  7. 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.

  8. 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

  9. Canonical failure modes of real-time control systems: insights from cognitive theory

    Science.gov (United States)

    Wallace, Rodrick

    2016-04-01

    Newly developed necessary conditions statistical models from cognitive theory are applied to generalisation of the data-rate theorem for real-time control systems. Rather than graceful degradation under stress, automatons and man/machine cockpits appear prone to characteristic sudden failure under demanding fog-of-war conditions. Critical dysfunctions span a spectrum of phase transition analogues, ranging from a ground state of 'all targets are enemies' to more standard data-rate instabilities. Insidious pathologies also appear possible, akin to inattentional blindness consequent on overfocus on an expected pattern. Via no-free-lunch constraints, different equivalence classes of systems, having structure and function determined by 'market pressures', in a large sense, will be inherently unreliable under different but characteristic canonical stress landscapes, suggesting that deliberate induction of failure may often be relatively straightforward. Focusing on two recent military case histories, these results provide a caveat emptor against blind faith in the current path-dependent evolutionary trajectory of automation for critical real-time processes.

  10. Compressive failure modes and parameter optimization of the trabecular structure of biomimetic fully integrated honeycomb plates.

    Science.gov (United States)

    Chen, Jinxiang; Tuo, Wanyong; Zhang, Xiaoming; He, Chenglin; Xie, Juan; Liu, Chang

    2016-12-01

    To develop lightweight biomimetic composite structures, the compressive failure and mechanical properties of fully integrated honeycomb plates were investigated experimentally and through the finite element method. The results indicated that: fracturing of the fully integrated honeycomb plates primarily occurred in the core layer, including the sealing edge structure. The morphological failures can be classified into two types, namely dislocations and compactions, and were caused primarily by the stress concentrations at the interfaces between the core layer and the upper and lower laminations and secondarily by the disordered short-fiber distribution in the material; although the fully integrated honeycomb plates manufactured in this experiment were imperfect, their mass-specific compressive strength was superior to that of similar biomimetic samples. Therefore, the proposed bio-inspired structure possesses good overall mechanical properties, and a range of parameters, such as the diameter of the transition arc, was defined for enhancing the design of fully integrated honeycomb plates and improving their compressive mechanical properties. Copyright © 2016 Elsevier B.V. All rights reserved.

  11. 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.

  12. 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.

  13. Applying micromechanic failure models for description of failure modes in the ductile-brittle transition region; Einsatz mikromechanischer Schaedigungsmodelle im sproed-duktilen Uebergangsbereich

    Energy Technology Data Exchange (ETDEWEB)

    Bernauer, G.

    1997-07-01

    The work reported was to examine whether the modified Gurson model and the Beremin model can be applied to the brittle-ductile transition region of a ferritic steel, and whether the material`s behaviour can be characterized with a failure model integrating the two models mentioned above into one. Any possible improvements of this approach were to be found. The report at first gives a brief list of terminology and formulas used. Chapter 3 explains the microscopic processes typically observed in the transition region in connection with the failure modes of ductile fracture and cleavage fracture, and shows possible approaches for modelling. Chapter 4 defines the specimens and materials, and chapter 5 explains the experiments as well as the microscopic analyses of the fracture surfaces. Chapter 6 presents subsequent calculations representing the processes observed. Based on the stress distributions thus derived, the Beremin model is re-examined for further development. Chapter 7 summarizes the results obtained. (orig./CB) [Deutsch] Ziel der Arbeit ist, zu untersuchen, ob das modifizierte Gurson-Modell und das Beremin-Modell im sproed-duktilen Uebergangsbereich eines ferritischen Stahls einsetzbar sind und ob das Werkstoffverhalten mit einem aus beiden Modellen kombinierten Schaedigungsmodell berechnet werden kann. Gegebenenfalls sind Verbesserungen herbeizufuehren. Die vorliegende Arbeit beginnt mit einer kurzen Einfuehrung der verwendeten Begriffe und Formalismen. In Kap. 3 werden die mikroskopischen Vorgaenge bei den im Uebergangsbereich typischerweise auftretenden Versagensarten duktiler Bruch und Spaltbruch vorgestellt und verschiedene Moeglichkeiten ihrer Modellierung aufgezeigt. Nach der Vorstellung des Probenwerkstoffs werden in Kap. 4 die Experimente beschrieben und die mikroskopischen Untersuchungen der Bruchflaechen in Kap. 5 dargestellt. Die Nachrechnungen der Experimente werden in Kap. 6 vorgestellt. Auf der Grundlage der dadurch bereitgestellten

  14. Functional failure modes cause-consequence logic suited for mobile robots used at scientific facilities

    CERN Document Server

    Khan, Douzi Imran; Bonnal, Pierre; Verma, A K

    2014-01-01

    The scientific facilities emitting ionizing radiation may have some significant failures and hazard issues, in and around their infrastructure. Significantly, this will also cause risks to workers and environment, which has led engineers to explore the use and implementation of mobile robots (MR), in order to reduce or eliminate such risks concerned with safety issues. Safe functioning of MR and the systems working at hazardous facilities is essential and therefore all the systems, structures and components (SSC) of a hazardous facility have to correspond to high reliability, availability, maintainability and safety (=RAMS) demands. RAMS characteristics have a causal relationship with the risks related to the facility systems availability, safety and life cycle costs. They also form the basis for the operating systems and MR performance, to carry out the desired functions. In this paper we have developed and presented a method for how to consider and model a SSC with respect to its desired functions and also ...

  15. 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

  16. 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

  17. 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.

  18. Development of an Advanced Digital Reactor Protection System Using Diverse Dual Processors to Prevent Common-Mode Failure

    International Nuclear Information System (INIS)

    Shin, Hyun Kook; Nam, Sang Ku; Sohn, Se Do; Chang, Hoon Seon

    2003-01-01

    The advanced digital reactor protection system (ADRPS) with diverse dual processors has been developed to prevent common-mode failure (CMF). The principle of diversity is applied to both hardware design and software design. For hardware diversity, two different types of CPUs are used for the bistable processor and local coincidence logic (LCL) processor. The Versa Module Eurocard-based single board computers are used for the CPU hardware platforms. The QNX operating system and the VxWorks operating system were selected for software diversity. Functional diversity is also applied to the input and output modules, and to the algorithm in the bistable processors and LCL processors. The characteristics of the newly developed digital protection system are described together with the preventive capability against CMF. Also, system reliability analysis is discussed. The evaluation results show that the ADRPS has a good preventive capability against the CMF and is a highly reliable reactor protection system

  19. Software verification and validation methodology for advanced digital reactor protection system using diverse dual processors to prevent common mode failure

    International Nuclear Information System (INIS)

    Son, Ki Chang; Shin, Hyun Kook; Lee, Nam Hoon; Baek, Seung Min; Kim, Hang Bae

    2001-01-01

    The Advanced Digital Reactor Protection System (ADRPS) with diverse dual processors is being developed by the National Research Lab of KOPEC for ADRPS development. One of the ADRPS goals is to develop digital Plant Protection System (PPS) free of Common Mode Failure (CMF). To prevent CMF, the principle of diversity is applied to both hardware design and software design. For the hardware diversity, two different types of CPUs are used for Bistable Processor and Local Coincidence Logic Processor. The VME based Single Board Computers (SBC) are used for the CPU hardware platforms. The QNX Operating System (OS) and the VxWorks OS are used for software diversity. Rigorous Software Verification and Validation (V and V) is also required to prevent CMF. In this paper, software V and V methodology for the ADRPS is described to enhance the ADRPS software reliability and to assure high quality of the ADRPS software

  20. 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.

  1. Hydrogen in Ti and Zr alloys: industrial perspective, failure modes and mechanistic understanding

    Science.gov (United States)

    Chapman, T. P.; Dye, D.; Rugg, D.

    2017-06-01

    Titanium is widely used in demanding applications, such as in aerospace. Its strength-to-weight ratio and corrosion resistance make it well suited to highly stressed rotating components. Zirconium has a no less critical application where its low neutron capture cross section and good corrosion resistance in hot water and steam make it well suited to reactor core use, including fuel cladding and structures. The similar metallurgical behaviour of these alloy systems makes it alluring to compare and contrast their behaviour. This is rarely undertaken, mostly because the industrial and academic communities studying these alloys have little overlap. The similarities with respect to hydrogen are remarkable, albeit potentially unsurprising, and so this paper aims to provide an overview of the role hydrogen has to play through the material life cycle. This includes the relationship between alloy design and manufacturing process windows, the role of hydrogen in degradation and failure mechanisms and some of the underpinning metallurgy. The potential role of some advanced experimental and modelling techniques will also be explored to give a tentative view of potential for advances in this field in the next decade or so. This article is part of the themed issue 'The challenges of hydrogen and metals'.

  2. Survival and failure modes: platform-switching for internal and external hexagon cemented fixed dental prostheses.

    Science.gov (United States)

    Anchieta, Rodolfo B; Machado, Lucas S; Hirata, Ronaldo; Coelho, Paulo G; Bonfante, Estevam A

    2016-10-01

    This study evaluated the probability of survival (reliability) of platform-switched fixed dental prostheses (FDPs) cemented on different implant-abutment connection designs. Eighty-four-three-unit FDPs (molar pontic) were cemented on abutments connected to two implants of external or internal hexagon connection. Four groups (n = 21 each) were established: external hexagon connection and regular platform (ERC); external hexagon connection and switched platform (ESC); internal hexagon and regular platform (IRC); and internal hexagon and switched platform (ISC). Prostheses were subjected to step-stress accelerated life testing in water. Weibull curves and probability of survival for a mission of 100,000 cycles at 400 N (two-sided 90% CI) were calculated. The beta values of 0.22, 0.48, 0.50, and 1.25 for groups ERC, ESC, IRC, and ISC, respectively, indicated a limited role of fatigue in damage accumulation, except for group ISC. Survival decreased for both platform-switched groups (ESC: 74%, and ISC: 59%) compared with the regular matching platform counterparts (ERC: 95%, and IRC: 98%). Characteristic strength was higher only for ERC compared with ESC, but not different between internal connections. Failures chiefly involved the abutment screw. Platform switching decreased the probability of survival of FDPs on both external and internal connections. The absence in loss of characteristic strength observed in internal hexagon connections favor their use compared with platform-switched external hexagon connections. © 2016 Eur J Oral Sci.

  3. Aging and failure mode of electrochemical double layer capacitors during accelerated constant load tests

    Energy Technology Data Exchange (ETDEWEB)

    Koetz, R.; Ruch, P.W.; Cericola, D. [General Energy Research Department, Electrochemistry Laboratory, Paul Scherrer Institut, CH-5232 Villigen (Switzerland)

    2010-02-01

    Electrochemical double layer capacitors of the BCAP0350 type (Maxwell Technologies) were tested under constant load conditions at different voltages and temperatures. The aging of the capacitors was monitored during the test in terms of capacitance, internal resistance and leakage current. Aging was significantly accelerated by elevated temperature or increased voltage. Only for extreme conditions at voltages of 3.5 V or temperatures above 70 C the capacitors failed due to internal pressure build-up. No other failure events such as open circuit or short circuit were detected. Impedance measurements after the tests showed increased high frequency resistance, an increased distributed resistance and most likely an increase in contact resistance between electrode and current collector together with a loss of capacitance. Capacitors aged at elevated voltages (3.3 V) exhibited a tilting of the low frequency component, which implies an increase in the heterogeneity of the electrode surface. This feature was not observed upon aging at elevated temperatures (70 C). (author)

  4. Failure modes in high-power lithium-ion batteries for use in hybrid electric vehicles

    International Nuclear Information System (INIS)

    Kostecki, R.; Zhang, X.; Ross Jr., P.N.; Kong, F.; Sloop, S.; Kerr, J.B.; Striebel, K.; Cairns, E.; McLarnon, F.

    2001-01-01

    The Advanced Technology Development (ATD) Program seeks to aid the development of high-power lithium-ion batteries for hybrid electric vehicles. Nine 18650-size ATD baseline cells were tested under a variety of conditions. The cells consisted of a carbon anode, LiNi 0.8 Co 0.2 O 2 cathode and DEC-EC-LiPF 6 electrolyte, and they were engineered for high-power applications. Selected instrumental techniques such as synchrotron IR microscopy, Raman spectroscopy, scanning electron microscopy, atomic force microscopy, gas chromatography, etc. were used to characterize the anode, cathode, current collectors and electrolyte from these cells. The goal was to identify detrimental processes which lead to battery failure under a high-current cycling regime as well as during storage at elevated temperatures. The diagnostic results suggest that the following factors contribute to the cell power loss: (a) SEI deterioration and non-uniformity on the anode, (b) morphology changes, increase of impedance and phase separation on the cathode, (c) pitting corrosion on the cathode Al current collector, and (d) decomposition of the LiPF 6 salt in the electrolyte at elevated temperature

  5. Heat Transfer and Failure Mode Analyses of Ultrahigh-Temperature Ceramic Thermal Protection System of Hypersonic Vehicles

    Directory of Open Access Journals (Sweden)

    Tianbao Cheng

    2014-01-01

    Full Text Available The transient temperature distribution of the ultrahigh-temperature ceramic (UHTC thermal protection system (TPS of hypersonic vehicles is calculated using finite volume method. Convective cooling enables a balance of heat increment and loss to be achieved. The temperature in the UHTC plate at the balance is approximately proportional to the surface heat flux and is approximately inversely proportional to the convective heat transfer coefficient. The failure modes of the UHTCs are presented by investigating the thermal stress field of the UHTC TPS under different thermal environments. The UHTCs which act as the thermal protection materials of hypersonic vehicles can fail because of the tensile stress at the lower surface, an area above the middle plane, and the upper surface as well as because of the compressive stress at the upper surface. However, the area between the lower surface and the middle plane and a small area near the upper surface are relatively safe. Neither the compressive stress nor the tensile stress will cause failure of these areas.

  6. 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

  7. Modeling Freedom From Progression for Standard-Risk Medulloblastoma: A Mathematical Tumor Control Model With Multiple Modes of Failure

    International Nuclear Information System (INIS)

    Brodin, N. Patrik; Vogelius, Ivan R.; Björk-Eriksson, Thomas; Munck af Rosenschöld, Per; Bentzen, Søren M.

    2013-01-01

    Purpose: 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 pattern of failure data. Methods and Materials: Outcome data for standard-risk MB published after 1990 with pattern of relapse information were used to fit a tumor control dose-response model addressing failures in both the high-dose boost volume and the elective craniospinal volume. Estimates of 5-year event-free survival from 2 large randomized MB trials were used to model the time-to-progression distribution. Uncertainty in freedom from progression (FFP) was estimated by Monte Carlo sampling over the statistical uncertainty in input data. Results: The estimated 5-year FFP (95% confidence intervals [CI]) for craniospinal doses of 15, 18, 24, and 36 Gy while maintaining 54 Gy to the posterior fossa was 77% (95% CI, 70%-81%), 78% (95% CI, 73%-81%), 79% (95% CI, 76%-82%), and 80% (95% CI, 77%-84%) respectively. The uncertainty in FFP was considerably larger for craniospinal doses below 18 Gy, reflecting the lack of data in the lower dose range. Conclusions: Estimates of tumor control and time-to-progression for standard-risk MB provides a data-driven setting for hypothesis generation or power calculations for prospective trials, taking the uncertainties into account. The presented methods can also be applied to incorporate further risk-stratification for example based on molecular biomarkers, when the necessary data become available

  8. 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

  9. Structural integrity and failure mechanisms of a smart piezoelectric actuator under a cyclic bending mode

    International Nuclear Information System (INIS)

    Woo, Sung-Choong; Goo, Nam Seo

    2008-01-01

    Information on the onset and evolution of damage within materials is essential for guaranteeing the integrity of actuator systems. The authors have evaluated the structural integrity and the failure mechanisms of smart composite actuators with a PZT ceramic plate under electric cyclic loading. For this, two kinds of actuators, actuator 1 and actuator 2, were manufactured. Prior to the main testing, performance testing was performed on the actuators to determine their resonant frequencies. Electric cyclic tests were conducted up to twenty million cycles. An acoustic emission technique was used for monitoring the damage evolution in real time. We observed the extent of the damage after testing using scanning electron microscopy and reflected optical microscopy to support characteristics in the acoustic emission behavior that corresponded to specific types of damage mechanisms. It was shown that the initial damage mechanism of the smart composite actuator under electric cyclic loading originated from the transgranular micro-fatigue damage in the PZT ceramic layer. With increasing cycles, a local intergranular crack initiated and developed onto the surface of the PZT ceramic layer or propagated into the internal layer. Finally, short-circuiting led to the electric breakdown of the actuator. These results were different depending on the drive frequencies and the configuration of the actuators. Moreover, we differentiated between the aforementioned damage mechanisms via AE signal pattern analyses based on the primary frequency and the waveform. From our results, we conclude that the drive frequency and the existence of a protecting layer are dominant factors in the structural integrity of the smart composite actuator

  10. 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)

  11. 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....

  12. PROMs for pain in adult cancer patients: a systematic review of measurement properties.

    Science.gov (United States)

    Abahussin, Asma A; West, Robert M; Wong, David C; Ziegler, Lucy E

    2018-05-17

    Pain is one of the most devastating symptoms for cancer patients. One-third of patients who experience pain do not receive effective treatment. A key barrier to effective pain management is lack of routine measurement and monitoring of pain. Patient-Reported Outcome Measures (PROMs) are recommended for measuring cancer pain. However, evidence to guide the selection of the most appropriate measure to identify and monitor cancer pain is limited. A systematic review of measurement properties of PROMs for pain in cancer patients is needed to identify the best validated measure for adoption to an electronic platform. Systematically review measurement properties of PROMs used for adult cancer patients to measure pain and, as a secondary goal, investigate the evidence of validated mobile health (mHealth) applications used to measure pain (registration number: CRD42017065575). Medline, EMBASE and CINAHL were systematically searched in March 2018 for studies examining measurement properties for PROMs for pain in adult cancer patients. Both of the methodological quality of the studies and their results were appraised using the COSMIN checklist and specific measurement properties criteria respectively. Sixteen studies evaluating eight instruments were included. No studies using a PROM in a mHealth application were identified. The methodological quality of the measurement properties ranged between poor and fair. No instrument showed strong positive evidence for all the evaluated measurement properties. Based on the available evidence, the Brief Pain Inventory-Short Form (BPI-SF) had the strongest evidence to support its selection for the measurement of cancer pain. The BPI-SF was the best performing measure across all proprieties evaluated through COSMIN. Better quality validation studies of PROMs for cancer pain are needed to explore the full range of measurement properties. Utilising mHealth applications for measuring pain for cancer patients is an innovative approach worth

  13. 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)

  14. Protocols for Multimedia Systems : 6th International Conference, PROMS 2001 Enschede, The Netherlands, October 17–19, 2001 Proceedings

    NARCIS (Netherlands)

    van Sinderen, Marten J.; Nieuwenhuis, Lambert J.M.

    2001-01-01

    The goal of the PROMS series of conferences and workshops is to contribute to scientific, strategic, and practical cooperation between research institutes and industrial companies in the area of multimedia protocols. This is also the goal of PROMS 2001. The basic theme of this conference continues

  15. 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

  16. A failure of suppression within the default mode network in depressed adolescents with compulsive internet game play.

    Science.gov (United States)

    Han, Doug Hyun; Kim, Sun Mi; Bae, Sujin; Renshaw, Perry F; Anderson, Jeffrey S

    2016-04-01

    Individuals who are chronic, compulsive video game players experience an elevated incidence of major depression. Excessive or problematic game play can interact with depression clinically, and may magnify impulsive behavior associated with video gaming. Functional brain imaging was performed during a Wisconsin Card Sorting Test (WCST) task in 42 healthy control and 95 volunteers seeking treatment for compulsive video game playing, including 60 participants without major depression (pure internet gaming disorder, pure IGD) and 35 participants comorbid with major depression (IGD+MDD). In response to the WCST in contrast to fixation, activation was observed in canonical brain attentional networks including bilateral intraparietal sulcus, frontal eye fields, and middle temporal cortical regions as well as dorsolateral prefrontal, inferior parietal and anterior insula, anterior cingulate cortex in all participants. For WCST>Fixation contrasts, the IGD+MDD group exhibited greater relative activation within the left hippocampus, compared to healthy control participants. For WCST>Fixation contrasts, the IGD+MDD group exhibited greater relative activation within the left hippocampus and the right parahippocampal gyrus immediately posterior to the hippocampus, compared to the pure IGD group. In cohorts of individuals with a history of compulsive internet game play, individuals with depression showed failure to suppress default mode network activity during an attentionally demanding task, compared to individuals without depression, including comparison groups with and without a history of compulsive video gaming. This reduced suppression of the brain regions within the default mode network may be a consequence of depressive neurophysiology or represent a predisposition for depression within compulsive game players. Copyright © 2016 Elsevier B.V. All rights reserved.

  17. Patient reported outcome measures (PROMs) following forward planned field-in field IMRT: Results from the Cambridge Breast IMRT trial

    International Nuclear Information System (INIS)

    Mukesh, Mukesh B.; Qian, Wendi; Wilkinson, Jennifer S.; Dorling, Leila; Barnett, Gillian C.; Moody, Anne M.; Wilson, Charles; Twyman, Nicola; Burnet, Neil G.; Wishart, Gordon C.; Coles, Charlotte E.

    2014-01-01

    Background: The use of intensity-modulated radiotherapy (IMRT) in breast cancer reduces clinician-assessed breast tissue toxicity including fibrosis, telangectasia and sub-optimal cosmesis. Patient reported outcome measures (PROMs) are also important as they provide the patient’s perspective. This longitudinal study reports on (a) the effect of forward planned field-in-field IMRT (∼simple IMRT) on PROMs compared to standard RT at 5 years after RT, (b) factors affecting PROMs at 5 years after RT and (c) the trend of PROMs over 5 years of follow up. Methods: PROMs were assessed at baseline (pre-RT), 6, 24 and 60 months after completion of RT using global health (EORTC QLQ C30) and 4 breast symptom questions (BR23). Also, 4 breast RT-specific questions were included at 6, 24 and 60 months: change in skin appearance, firmness to touch, reduction in breast size and overall change in breast appearance since RT. The benefits of simple IMRT over standard RT at 5 years after RT were assessed using standard t-test for global health and logistic regression analysis for breast symptom questions and breast RT-specific questions. Clinical factors affecting PROMs at 5 years were investigated using a multivariate analysis. A repeated mixed model was applied to explore the trend over time for each of PROMs. Results: (89%) 727/815, 84%, 81% and 61% patients completed questionnaires at baseline, 6, 24 and 60 months respectively. Patients reported worse toxicity for all four BR23 breast symptoms at 6 months, which then improved over time (p < 0.0001). They also reported improvement in skin appearance and breast hardness over time (p < 0.0001), with no significant change for breast shrinkage (p = 0.47) and overall breast appearance (p = 0.13). At 5 years, PROMs assessments did not demonstrate a benefit for simple IMRT over standard radiotherapy. Large breast volume, young age, baseline surgical cosmesis and post-operative infection were the most important variables to affect PROMs

  18. Investigation on the Mechanism and Failure Mode of Laser Transmission Spot Welding Using PMMA Material for the Automotive Industry.

    Science.gov (United States)

    Wang, Xiao; Liu, Baoguang; Liu, Wei; Zhong, Xuejiao; Jiang, Yingjie; Liu, Huixia

    2017-01-01

    To satisfy the need of polymer connection in lightweight automobiles, a study on laser transmission spot welding using polymethyl methacrylate (PMMA) is conducted by using an Nd:YAG pulse laser. The influence of three variables, namely peak voltages, defocusing distances and the welding type (type I (pulse frequency and the duration is 25 Hz, 0.6 s) and type II (pulse frequency and the duration is 5 Hz, 3 s)) to the welding quality was investigated. The result showed that, in the case of the same peak voltages and defocusing distances, the number of bubbles for type I was obviously more than type II. The failure mode of type I was the base plate fracture along the solder joint, and the connection strength of type I was greater than type II. The weld pool diameter:depth ratio for type I was significantly greater than type II. It could be seen that there was a certain relationship between the weld pool diameter:depth ratio and the welding strength. By the finite element simulation, the weld pool for type I was more slender than type II, which was approximately the same as the experimental results.

  19. Investigation on the Mechanism and Failure Mode of Laser Transmission Spot Welding Using PMMA Material for the Automotive Industry

    Science.gov (United States)

    Wang, Xiao; Liu, Baoguang; Liu, Wei; Zhong, Xuejiao; Jiang, Yingjie; Liu, Huixia

    2017-01-01

    To satisfy the need of polymer connection in lightweight automobiles, a study on laser transmission spot welding using polymethyl methacrylate (PMMA) is conducted by using an Nd:YAG pulse laser. The influence of three variables, namely peak voltages, defocusing distances and the welding type (type I (pulse frequency and the duration is 25 Hz, 0.6 s) and type II (pulse frequency and the duration is 5 Hz, 3 s)) to the welding quality was investigated. The result showed that, in the case of the same peak voltages and defocusing distances, the number of bubbles for type I was obviously more than type II. The failure mode of type I was the base plate fracture along the solder joint, and the connection strength of type I was greater than type II. The weld pool diameter:depth ratio for type I was significantly greater than type II. It could be seen that there was a certain relationship between the weld pool diameter:depth ratio and the welding strength. By the finite element simulation, the weld pool for type I was more slender than type II, which was approximately the same as the experimental results. PMID:28772383

  20. Risiko Kegagalan pada Kualitas Produksi Air Minum Isi Ulang di Kecamatan Sukolilo Surabaya Menggunakan Failure Mode and Effect Analysis (FMEA

    Directory of Open Access Journals (Sweden)

    Egy Asri Yassin Utami

    2017-01-01

    Full Text Available Kebutuhan manusia terhadap air minum yang layak konsumsi semakin lama semakin berkembang sebanding dengan perkembangan penduduk yang kian lama kian meningkat. Untuk dapat memenuhi kebutuhan air minum sehari-hari, banyak industri yang membuka usaha air minum diantaranya adalah adanya depot air minum isi ulang (DAMIU. Pemilihan depot air minum isi ulang sebagai alternatif air minum menjadi risiko yang dapat membahayakan kesehatan jika kualitas depot air minum isi ulang masih diragukan. Penilitian ini menggunakan metode FMEA (Failure Mode and Effect Analysis untuk mencari prioritas terjadinya kegagalan dalam proses pengolahan air minum isi ulang. Risiko-risiko yang didapat harus memiliki nilai agar terukur sehingga ditemukan prioritas penanganan dan dicari upaya untuk perbaikan. Penilaian tersebut dikenal dengan nilai RPN (Risk Priority Number yaitu hasil pengalian dari tingkat keparahan (severity, frekuensi kejadian (occurrence dan tingkat deteksi (detection. Berdasarkan hasil analisa dan identifikasi menggunakan metode FMEA diketahui bahwa kegagalan yang terjadi pada sistem UV dengan 3 prioritas tertinggi yaitu penggunaan UV dengan nilai RPN 100, waktu kontak UV dengan nilai RPN 100 dan penggantian filter awal dengan nilai RPN 64. Pada sistem UV dan ozon, 3 prioritas tertinggi yaitu waktu kontak sistem ozon, waktu kontak UV dan penggunaan UV dengan masing-masing nilai RPN yaitu 100. Sedangkan pada sistem UV, ozon dan RO (Reverse Osmosis 3 prioritas tertinggi sama seperti dengan sistem UV dan ozon dengan nilai RPN yang berbeda yaitu lama pengoperasian dengan nilai 100, waktu kontak dan kesesuaian penggunaan UV dengan nilai 64.

  1. 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).

  2. Investigation on the Mechanism and Failure Mode of Laser Transmission Spot Welding Using PMMA Material for the Automotive Industry

    Directory of Open Access Journals (Sweden)

    Xiao Wang

    2017-01-01

    Full Text Available To satisfy the need of polymer connection in lightweight automobiles, a study on laser transmission spot welding using polymethyl methacrylate (PMMA is conducted by using an Nd:YAG pulse laser. The influence of three variables, namely peak voltages, defocusing distances and the welding type (type I (pulse frequency and the duration is 25 Hz, 0.6 s and type II (pulse frequency and the duration is 5 Hz, 3 s to the welding quality was investigated. The result showed that, in the case of the same peak voltages and defocusing distances, the number of bubbles for type I was obviously more than type II. The failure mode of type I was the base plate fracture along the solder joint, and the connection strength of type I was greater than type II. The weld pool diameter:depth ratio for type I was significantly greater than type II. It could be seen that there was a certain relationship between the weld pool diameter:depth ratio and the welding strength. By the finite element simulation, the weld pool for type I was more slender than type II, which was approximately the same as the experimental results.

  3. 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.

  4. Promõshlennõje zonõ ohvatil "mjortvõi sezon" / Ain Alvela

    Index Scriptorium Estoniae

    Alvela, Ain, 1967-

    2008-01-01

    Arendajad on tehnoparkide rajamise ooterežiimile pannud - ostjaid jaguks, kuid võimalusi napib. Diagramm: Za pjat let stoimost zemli promõshlennogo naznatshenija võrosla v pjat raz; Tabel: Naiboleje dorogaja zemlja - v promparke Lasnamäe. Kommenteerivad Enn Tosso, Nikolai Pitshugov ja Urmas Ahven

  5. An independent psychometric evaluation of the PROMS measure of music perception skills

    NARCIS (Netherlands)

    Kunert, R.; Willems, R.M.; Hagoort, P.

    2016-01-01

    The Profile of Music Perception Skills (PROMS) is a recently developed measure of perceptual music skills which has been shown to have promising psychometric properties. In this paper we extend the evaluation of its brief version to three kinds of validity using an individual difference approach.

  6. 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.

  7. 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. 

  8. 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.

  9. 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.

  10. 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

  11. 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

  12. Probability of Loss of Assured Safety in Systems with Multiple Time-Dependent Failure Modes: Incorporation of Delayed Link Failure in the Presence of Aleatory Uncertainty.

    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

    Probability of loss of assured safety (PLOAS) is modeled for weak link (WL)/strong link (SL) systems in which one or more WLs or SLs could potentially degrade into a precursor condition to link failure that will be followed by an actual failure after some amount of elapsed time. The following topics are considered: (i) Definition of precursor occurrence time cumulative distribution functions (CDFs) for individual WLs and SLs, (ii) Formal representation of PLOAS with constant delay times, (iii) Approximation and illustration of PLOAS with constant delay times, (iv) Formal representation of PLOAS with aleatory uncertainty in delay times, (v) Approximation and illustration of PLOAS with aleatory uncertainty in delay times, (vi) Formal representation of PLOAS with delay times defined by functions of link properties at occurrence times for failure precursors, (vii) Approximation and illustration of PLOAS with delay times defined by functions of link properties at occurrence times for failure precursors, and (viii) Procedures for the verification of PLOAS calculations for the three indicated definitions of delayed link failure.

  13. 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.

  14. 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

  15. 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.

  16. 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)

  17. Utilization of Failure Mode and Effects Analysis (FMEA) Method in Increasing the Revenue of Emergency Department; a Prospective Cohort Study.

    Science.gov (United States)

    Shahrami, Ali; Rahmati, Farhad; Kariman, Hamid; Hashemi, Behrooz; Rahmati, Majid; Baratloo, Alireza; Forouzanfar, Mohammad Mehdi; Safari, Saeed

    2013-01-01

    The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED) are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA) method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided into one main system and six subsystems, based on FMEA. The study was divided into two phases. In the first phase, the problems leading to the loss of revenue in each subsystem were identified and weighted into four groups using risk priority number (RPN), and the solutions for fixing them were planned. Then, in the second phase, discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after intervention using the repeated measure ANOVA test. 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousand US dollars/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousand US dollars/month after solving first, second, third, and fourth priority problems, respectively (337.75% increase in two years) (pFMEA could be considered as an efficient model for increasing the revenue of emergency department. According to this model, not recording the services by the nursing unit

  18. Administrative risk quantification of subcutaneous and intravenous therapies in Italian centers utilizing the Failure Mode and Effects Analysis approach

    Directory of Open Access Journals (Sweden)

    Ponzetti C

    2016-08-01

    Full Text Available Clemente Ponzetti,1 Monica Canciani,2 Massimo Farina,2 Sara Era,3 Stefan Walzer4,5 1Gruppo Policlinico di Monza, Alessandria, ANMDO National Association of Hospital Physicians, Bologna, 2Studio EmmEffe Srl, Milan, 3Roche Spa, Monza, Italy; 4MArS Market Access & Pricing Strategy GmbH, Weil am Rhein, 5State University Baden-Wuerttemberg, Health Care Management, Loerrach, Germany Background: In oncology, an important parameter of safety is the potential treatment error in hospitals. The analyzed hypothesis is that of subcutaneous therapies would provide a superior safety benefit over intravenous therapies through fixed-dose administrations, when analyzed with trastuzumab and rituximab.Methods: For the calculation of risk levels, the Failure Mode and Effect Analysis approach was applied. Within this approach, the critical treatment path is followed and risk classification for each individual step is estimated. For oncology and hematology administration, 35 different risk steps were assessed. The study was executed in 17 hematology and 16 breast cancer centers in Italy. As intravenous and subcutaneous were the only injection routes in medical available for trastuzumab and rituximab in oncology at the time of the study, these two therapies were chosen.Results: When the risk classes were calculated, eight high-risk areas were identified for the administration of an intravenous therapy in hematology or oncology; 13 areas would be defined as having a median-risk classification and 14 areas as having a low-risk classification (total risk areas: n=35. When the new subcutaneous formulation would be applied, 23 different risk levels could be completely eliminated (65% reduction. Important high-risk classes such as dose calculation, preparation and package labeling, preparation of the access to the vein, pump infusion preparation, and infusion monitoring were included in the eliminations. The overall risk level for the intravenous administration was estimated

  19. Utilization of Failure Mode and Effects Analysis (FMEA Method in Increasing the Revenue of Emergency Department; a Prospective Cohort Study

    Directory of Open Access Journals (Sweden)

    Ali Shahrami

    2013-12-01

    Full Text Available Introduction: The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. Methods: This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided based on FMEA into one main system and six subsystems. The study was divided in two phases. In the first phase, the problems leading to the loss in the revenue in each subsystem were identified and weighted to four groups using risk priority number (RPN, and the solutions for fixing them were planned. Then, at the second phase discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after interventions using the repeated measure ANOVA test. Results: At last, 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousands US dollar/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousands US dollar/month after solving of first, second, third, and fourth priority problems, respectively (337.75% increase in two years (p<0.001. 111.0% increase in the ED revenue after solving of first priority problems reveals that they were

  20. Utilization of Failure Mode and Effects Analysis (FMEA Method in Increasing the Revenue of Emergency Department; a Prospective Cohort Study

    Directory of Open Access Journals (Sweden)

    Ali Shahrami

    2015-05-01

    Full Text Available Introduction: The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. Methods: This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided based on FMEA into one main system and six subsystems. The study was divided in two phases. In the first phase, the problems leading to the loss in the revenue in each subsystem were identified and weighted to four groups using risk priority number (RPN, and the solutions for fixing them were planned. Then, at the second phase discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after interventions using the repeated measure ANOVA test. Results: At last, 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousands US dollar/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousands US dollar/month after solving of first, second, third, and fourth priority problems, respectively (337.75% increase in two years (p<0.001. 111.0% increase in the ED revenue after solving of first priority problems reveals that they were

  1. 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

  2. Evaluation of containment failure modes and fission product releases during core meltdown accidents in a BWR with a Mark III containment

    International Nuclear Information System (INIS)

    Ludewig, H.; Yu, W.S.; Jaung, R.; Pratt, W.T.

    1985-01-01

    An assessment is described of potential failure modes and fission product releases for a large number of postulated core meltdown accidents in a BWR with a Mark III containment. For this containment design, the most important failure mode was found to be due to hydrogen related phenomena. A one-dimensional lumped parameter computer code has been developed and used to determine the probability of various hydrogen phenomena for a range of postulated core meltdown sequences. Potential containment loads have been estimated and compared against the containment capacity to determine the probability of containment failure. The fission product release assessment began by using the MARCH/CORRAL system of codes with key input parameters varied over a reasonable range. The parameters relate to primary system retention, re-emission, pool scrubbing, and fission product release in-vessel vs ex-vessel. The final step used more mechanistic calculations based on the system of codes recently developed under sponsorship of the Accident Source Term Program Office, NRC, and compares these predictions with the range of releases calculated in the sensitivity study

  3. Patient-reported outcome measures (PROMs) for assessing perceived listening effort in hearing loss: protocol for a systematic review

    Science.gov (United States)

    Rapport, Frances L; Boisvert, Isabelle; McMahon, Catherine M; Hutchings, Hayley A

    2017-01-01

    Introduction In the UK, it is estimated that a disabling hearing loss (HL) affects 1 in 6 people. HL has functional, economic and social-emotional consequences for affected individuals. Intervention for HL focuses on improving access to the auditory signal using hearing aids or cochlear implants. However, even if sounds are audible and speech is understood, individuals with HL often report increased effort when listening. Listening effort (LE) may be measured using self-reported measures such as patient-reported outcome measures (PROMs). PROMs are validated questionnaires completed by patients to measure their perceptions of their own functional status and well-being. When selecting a PROM for use in research or clinical practice, it is necessary to appraise the evidence of a PROM’s acceptability to patients, validity, responsiveness and reliability. Methods and analysis A systematic review of studies evaluating the measurement properties of PROMs available to measure LE in HL will be undertaken. MEDLINE, EMBASE, CINAHL, PsychINFO and Web of Science will be searched electronically. Reference lists of included studies, key journals and the grey literature will be hand-searched to identify further studies for inclusion. Two reviewers will independently complete title, abstract and full-text screening to determine study eligibility. Data on the characteristics of each study and each PROM will be extracted. Methodological quality of the included studies will be appraised using the COnsensus-based Standards for the selection of health Measurement INstruments, the quality of included PROMs appraised and the credibility of the evidence assessed. A narrative synthesis will summarise extracted data. Ethics and dissemination Ethical permission is not required, as this study uses data from published research. Dissemination will be through publication in peer-reviewed journals, conference presentations and the lead author’s doctoral dissertation. Findings may inform the

  4. 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.

  5. 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

  6. Flexible Control of Small Wind Turbines With Grid Failure Detection Operating in Stand-Alone and Grid-Connected Mode

    DEFF Research Database (Denmark)

    Teodorescu, Remus; Blaabjerg, Frede

    2004-01-01

    nonlinear load and excess or deficit of generated power. Grid-connection mode with current control is also enabled for the case of isolated local grid involving other dispersed power generators such as other wind turbines or diesel generators. A novel automatic mode switch method based on a phase......-to-back power conversion configuration is chosen where the generator converter uses a built-in standard flux vector control to control the speed of the turbine shaft while the grid-side converter uses a standard pulse-width modulation active rectifier control strategy implemented in a DSP controller. The design...

  7. The PU-PROM: A patient-reported outcome measure for peptic ulcer disease.

    Science.gov (United States)

    Liu, Na; Lv, Jing; Liu, Jinchun; Zhang, Yanbo

    2017-12-01

    Patient-reported outcome measure (PROM) conceived to enable description of treatment-related effects, from the patient perspective, bring the potential to improve in clinical research, and to provide patients with accurate information. Therefore, the aim of this study was to develop a patient-centred peptic ulcer patient-reported outcome measure (PU-PROM) and evaluate its reliability, validity, differential item functioning (DIF) and feasibility. To develop a conceptual framework and item pool for the PU-PROM, we performed a literature review and consulted other measures created in China and other countries. Beyond that, we interviewed 10 patients with peptic ulcers, and consulted six key experts to ensure that all germane parameters were included. In the first item selection phase, classical test theory and item response theory were used to select and adjust items to shape the preliminary measure completed by 130 patients and 50 controls. In the next phase, the measure was evaluated used the same methods with 492 patients and 124 controls. Finally, we used the same population in the second item reselection to assess the reliability, validity, DIF and feasibility of the final measure. The final peptic ulcer PRO measure comprised four domains (physiology, psychology, society and treatment), with 11 subdomains, and 54 items. The Cronbach's α coefficient of each subdomain for the measure was >0.800. Confirmatory factory analysis indicated that the construct validity fulfilled expectations. Model fit indices, such as RMR, RMSEA, NFI, NNFI, CFI and IFI, showed acceptable fit. The measure showed a good response rate. The peptic ulcer PRO measure had good reliability, validity, DIF and feasibility, and can be used as a clinical research evaluation instrument with patients with peptic ulcers to assess their condition focus on treatment. This measure may also be applied in other health areas, especially in clinical trials of new drugs, and may be helpful in clinical

  8. An intronic deletion in the PROM1 gene leads to autosomal recessive cone-rod dystrophy.

    Science.gov (United States)

    Eidinger, Osnat; Leibu, Rina; Newman, Hadas; Rizel, Leah; Perlman, Ido; Ben-Yosef, Tamar

    2015-01-01

    To investigate the genetic basis for autosomal recessive cone-rod dystrophy (CRD) in a consanguineous Israeli Jewish family. Patients underwent a detailed ophthalmic evaluation, including eye examination, visual field testing, optical coherence tomography (OCT), and electrophysiological tests, electroretinography (ERG) and visual evoked potential (VEP). Genome-wide homozygosity mapping using a single nucleotide polymorphism (SNP) array was performed to identify homozygous regions shared among two of the affected individuals. Mutation screening of the underlying gene was performed with direct sequencing. In silico and in vitro analyses were used to predict the effect of the identified mutation on splicing. The affected family members are three siblings who have various degrees of progressive visual deterioration, glare, color vision abnormalities, and night vision difficulties. Visual field tests revealed central scotomas of different extension. Cone and rod ERG responses were reduced, with cones more severely affected. Homozygosity mapping revealed several homozygous intervals shared among two of the affected individuals. One included the PROM1 gene. Sequence analysis of the 26 coding exons of PROM1 in one affected individual revealed no mutations in the coding sequence or in intronic splice sites. However, in intron 21, proximate to the intron-exon junction, we observed a homozygous 10 bp deletion between positions -26 and -17 (c.2281-26_-17del). The deletion was linked to a known SNP, c.2281-6C>G. The deletion cosegregated with the disease in the family, and was not detected in public databases or in 101 ethnically-matched control individuals. In silico analysis predicted that this deletion would lead to altered intron 21 splicing. Bioinformatic analysis predicted that a recognition site for the SRSF2 splicing factor is located within the deleted sequence. The in vitro splicing assay demonstrated that c.2281-26_-17del leads to complete exon 22 skipping. A novel

  9. 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.

  10. 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.

  11. Improved Re-Configurable Sliding Mode Controller for Reusable Launch Vehicle of Second Generation Addressing Aerodynamic Surface Failures and Thrust Deficiencies

    Science.gov (United States)

    Shtessel, Yuri B.

    2002-01-01

    In this report we present a time-varying sliding mode control (TV-SMC) technique for reusable launch vehicle (RLV) attitude control in ascent and entry flight phases. In ascent flight the guidance commands Euler roll, pitch and yaw angles, and in entry flight it commands the aerodynamic angles of bank, attack and sideslip. The controller employs a body rate inner loop and the attitude outer loop, which are separated in time-scale by the singular perturbation principle. The novelty of the TVSMC is that both the sliding surface and the boundary layer dynamics can be varied in real time using the PD-eigenvalue assignment technique. This salient feature is used to cope with control command saturation and integrator windup in the presence of severe disturbance or control effector failure, which enhances the robustness and fault tolerance of the controller. The TV-SMC is developed and tuned up for the X-33 sub-orbital technology demonstration vehicle in launch and re-entry modes. A variety of nominal, dispersion and failure scenarios have tested via high fidelity 6DOF simulations using MAVERIC/SLIM simulation software.

  12. 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

  13. Joint loads resulting in ACL rupture: Effects of age, sex, and body mass on injury load and mode of failure in a mouse model.

    Science.gov (United States)

    Blaker, Carina L; Little, Christopher B; Clarke, Elizabeth C

    2017-08-01

    Anterior cruciate ligament (ACL) tears are a common knee injury with a known but poorly understood association with secondary joint injuries and post-traumatic osteoarthritis (OA). Female sex and age are known risk factors for ACL injury but these variables are rarely explored in mouse models of injury. This study aimed to further characterize a non-surgical ACL injury model to determine its clinical relevance across a wider range of mouse specifications. Cadaveric and anesthetized C57BL/6 mice (9-52 weeks of age) underwent joint loading to investigate the effects of age, sex, and body mass on ACL injury mechanisms. The ACL injury load (whole joint load required to rupture the ACL) was measured from force-displacement data, and mode of failure was assessed using micro-dissection and histology. ACL injury load was found to increase with body mass and age (p < 0.001) but age was not significant when controlling for mass. Sex had no effect. In contrast, the mode of ACL failure varied with both age and sex groups. Avulsion fractures (complete or mixed with mid-substance tears) were common in all age groups but the proportion of mixed and mid-substance failures increased with age. Females were more likely than males to have a major avulsion relative to a mid-substance tear (p < 0.01). This data compliments studies in human cadaveric knees, and provides a basis for determining the severity of joint injury relative to a major ACL tear in mice, and for selecting joint loading conditions in future experiments using this model. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1754-1763, 2017. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

  14. SU-F-T-250: What Does It Take to Correctly Assess the High Failure Modes of an Advanced Radiotherapy Procedure Such as Stereotactic Body Radiation Therapy?

    International Nuclear Information System (INIS)

    Han, D; Vile, D; Rosu, M; Palta, J

    2016-01-01

    Purpose: Assess the correct implementation of risk-based methodology of TG 100 to optimize quality management and patient safety procedures for Stereotactic Body Radiation Therapy. Methods: A detailed process map of SBRT treatment procedure was generated by a team of three physicists with varying clinical experience at our institution to assess the potential high-risk failure modes. The probabilities of occurrence (O), severity (S) and detectability (D) for potential failure mode in each step of the process map were assigned by these individuals independently on the scale from1 to 10. The risk priority numbers (RPN) were computed and analyzed. The highest 30 potential modes from each physicist’s analysis were then compared. Results: The RPN values assessed by the three physicists ranged from 30 to 300. The magnitudes of the RPN values from each physicist were different, and there was no concordance in the highest RPN values recorded by three physicists independently. The 10 highest RPN values belonged to sub steps of CT simulation, contouring and delivery in the SBRT process map. For these 10 highest RPN values, at least two physicists, irrespective of their length of experience had concordance but no general conclusions emerged. Conclusion: This study clearly shows that the risk-based assessment of a clinical process map requires great deal of preparation, group discussions, and participation by all stakeholders. One group albeit physicists cannot effectively implement risk-based methodology proposed by TG100. It should be a team effort in which the physicists can certainly play the leading role. This also corroborates TG100 recommendation that risk-based assessment of clinical processes is a multidisciplinary team effort.

  15. SU-F-T-250: What Does It Take to Correctly Assess the High Failure Modes of an Advanced Radiotherapy Procedure Such as Stereotactic Body Radiation Therapy?

    Energy Technology Data Exchange (ETDEWEB)

    Han, D; Vile, D; Rosu, M; Palta, J [Virginia Commonwealth University, Richmond, VA (United States)

    2016-06-15

    Purpose: Assess the correct implementation of risk-based methodology of TG 100 to optimize quality management and patient safety procedures for Stereotactic Body Radiation Therapy. Methods: A detailed process map of SBRT treatment procedure was generated by a team of three physicists with varying clinical experience at our institution to assess the potential high-risk failure modes. The probabilities of occurrence (O), severity (S) and detectability (D) for potential failure mode in each step of the process map were assigned by these individuals independently on the scale from1 to 10. The risk priority numbers (RPN) were computed and analyzed. The highest 30 potential modes from each physicist’s analysis were then compared. Results: The RPN values assessed by the three physicists ranged from 30 to 300. The magnitudes of the RPN values from each physicist were different, and there was no concordance in the highest RPN values recorded by three physicists independently. The 10 highest RPN values belonged to sub steps of CT simulation, contouring and delivery in the SBRT process map. For these 10 highest RPN values, at least two physicists, irrespective of their length of experience had concordance but no general conclusions emerged. Conclusion: This study clearly shows that the risk-based assessment of a clinical process map requires great deal of preparation, group discussions, and participation by all stakeholders. One group albeit physicists cannot effectively implement risk-based methodology proposed by TG100. It should be a team effort in which the physicists can certainly play the leading role. This also corroborates TG100 recommendation that risk-based assessment of clinical processes is a multidisciplinary team effort.

  16. Marginal adaptation, fracture load and macroscopic failure mode of adhesively luted PMMA-based CAD/CAM inlays.

    Science.gov (United States)

    Ender, Andreas; Bienz, Stefan; Mörmann, Werner; Mehl, Albert; Attin, Thomas; Stawarczyk, Bogna

    2016-02-01

    To evaluate marginal adaptation, fracture load and failure types of CAD/CAM polymeric inlays. Standardized prepared human molars (48) were divided into four groups (n=12): (A) PCG (positive control group); adhesively luted glass-ceramic inlays, (B) TRX; CAD/CAM polymeric inlays luted using a self-adhesive resin cement, (C) TAC; CAD/CAM polymeric inlays luted using a conventional resin cement, and (D) NCG (negative control group); direct-filled resin-based composite restorations. All specimens were subjected to a chewing simulator. Before and after chewing fatigue, marginal adaptation was assessed at two interfaces: (1) between dental hard tissues and luting cement and (2) between luting cement and restoration. Thereafter, the specimens were loaded and the fracture loads, as well as the failure types, were determined. The data were analysed using three- and one-way ANOVA with post hoc Scheffé test, two sample Student's t-test (pmarginal adaptation for interface 1 showed significantly better results for TRX and PCG than for TAC (p=0.001-0.02) and NCG (p=0.001-0.047). For interface 2, marginal adaptation for TAC was significantly inferior to TRX (pmarginal adaptation of TAC and NCG. No significant differences in fracture load were found between all tested groups. Self-adhesive luted polymeric CAD/CAM inlays showed similar marginal adaptation and fracture load values compared to adhesively luted glass-ceramic inlays. Copyright © 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

  17. Is it too early to move to full electronic PROM data collection?: A randomized controlled trial comparing PROM's after hallux valgus captured by e-mail, traditional mail and telephone.

    Science.gov (United States)

    Palmen, Leonieke N; Schrier, Joost C M; Scholten, Ruben; Jansen, Justus H W; Koëter, Sander

    2016-03-01

    Patient reported outcome measures (PROM's) after hallux valgus surgery are used to rate the effectiveness as perceived by the patient. The interpretability of these PROM's is highly dependent on participation rate. Data capture method may be an important factor contributing to the response rate. We investigated the effect on response rate of traditional paper mail, telephone and e-mail PROM's after hallux valgus surgery. All consecutive patients operated between January and September 2013, were identified. Included patients were randomized by envelope in three groups: traditional pen and paper mail, e-mail and telephone. They were asked to fill in a FFI and EQ-5D. Two weeks later non-responders were sent a reminder. Of the 73 included patients, 25 were approached by mail, 24 by e-mail and 24 patients by telephone. The response rate on traditional mail was highest (88%), while response on e-mail was lowest (33%). Response rate on telephone was also high (79%). Response rate on traditional mail and telephone was significantly higher (pmail. Though electronic data collection has enormous potential, this study shows that e-mail yields unacceptable low response rates. It is too early to replace traditional pen-and-paper PROM's by electronic questionnaires. Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

  18. 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

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

    International Nuclear Information System (INIS)

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

    1985-09-01

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

  20. Transformer failure and common-mode loss of instrument power at Nine Mile Point Unit 2 on August 13, 1991

    Energy Technology Data Exchange (ETDEWEB)

    1991-10-01

    On August 13, 1991, at Nine Mile Point Unit 2 nuclear power plant, located near Scriba, New York, on Lake Ontario, the main transformer experienced an internal failure that resulted in degraded voltage which caused the simultaneous loss of five uninterruptible power supplies, which in turn caused the loss of several nonsafety systems, including reactor control rod position indication, some reactor power and water indication, control room annunciators, the plant communications system, the plant process computer, and lighting at some locations. The reactor was subsequently brought to a safe shutdown. Following this event, the US Nuclear Regulatory Commission dispatched an Incident Investigation Team to the site to determine what happened, to identify the probable causes, and to make appropriate findings and conclusions. This report describes the incident, the methodology used by the team in its investigation, and presents and the team's findings and conclusions. 59 figs., 14 tabs.

  1. Transformer failure and common-mode loss of instrument power at Nine Mile Point Unit 2 on August 13, 1991

    International Nuclear Information System (INIS)

    1991-10-01

    On August 13, 1991, at Nine Mile Point Unit 2 nuclear power plant, located near Scriba, New York, on Lake Ontario, the main transformer experienced an internal failure that resulted in degraded voltage which caused the simultaneous loss of five uninterruptible power supplies, which in turn caused the loss of several nonsafety systems, including reactor control rod position indication, some reactor power and water indication, control room annunciators, the plant communications system, the plant process computer, and lighting at some locations. The reactor was subsequently brought to a safe shutdown. Following this event, the US Nuclear Regulatory Commission dispatched an Incident Investigation Team to the site to determine what happened, to identify the probable causes, and to make appropriate findings and conclusions. This report describes the incident, the methodology used by the team in its investigation, and presents and the team's findings and conclusions. 59 figs., 14 tabs

  2. A periodic inspection and replacement policy for systems subject to competing failure modes due to degradation and traumatic events

    Energy Technology Data Exchange (ETDEWEB)

    Huynh, K.T., E-mail: tuan.huynh@utt.f [Universite de technologie de Troyes, Institut Charles Delaunay and STMR UMR CNRS 6279-12, rue Marie Curie, BP2060, 10010 Troyes cedex (France); Barros, A., E-mail: anne.barros@utt.f [Universite de technologie de Troyes, Institut Charles Delaunay and STMR UMR CNRS 6279-12, rue Marie Curie, BP2060, 10010 Troyes cedex (France); Berenguer, C., E-mail: christophe.berenguer@utt.f [Universite de technologie de Troyes, Institut Charles Delaunay and STMR UMR CNRS 6279-12, rue Marie Curie, BP2060, 10010 Troyes cedex (France); Castro, I.T., E-mail: inmatorres@unex.e [Departamento de Matematicas, Escuela Politecnica, 10071 Caceres (Spain)

    2011-04-15

    This paper deals with the condition-based maintenance of single-unit systems which are subject to the competing and dependent failures due deterioration and traumatic shock events. The main aim is to provide a model to assess the value of condition monitoring information for the maintenance decision-making. A condition-based periodic inspection/replacement policy is developed and compared with a benchmark time-based block replacement policy. Numerical results show that it is indeed useful to follow closely the actual evolution of the system to adapt the maintenance decisions to the true system state to improve the performance of maintenance policies. The analysis of the maintenance costs savings can be used to justify or not the choice to implement a policy based on condition monitoring information and to invest in condition monitoring devices.

  3. A periodic inspection and replacement policy for systems subject to competing failure modes due to degradation and traumatic events

    International Nuclear Information System (INIS)

    Huynh, K.T.; Barros, A.; Berenguer, C.; Castro, I.T.

    2011-01-01

    This paper deals with the condition-based maintenance of single-unit systems which are subject to the competing and dependent failures due deterioration and traumatic shock events. The main aim is to provide a model to assess the value of condition monitoring information for the maintenance decision-making. A condition-based periodic inspection/replacement policy is developed and compared with a benchmark time-based block replacement policy. Numerical results show that it is indeed useful to follow closely the actual evolution of the system to adapt the maintenance decisions to the true system state to improve the performance of maintenance policies. The analysis of the maintenance costs savings can be used to justify or not the choice to implement a policy based on condition monitoring information and to invest in condition monitoring devices.

  4. 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

  5. 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.

  6. 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.

  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. 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.

  9. Proceedings of Patient Reported Outcome Measure’s (PROMs) Conference Oxford 2017: Advances in Patient Reported Outcomes Research

    NARCIS (Netherlands)

    Velikova, Galina; Valderas, Jose M.; Potter, Caroline; Batchelder, Laurie; A’Court, Christine; Baker, Matthew; Bostock, Jennifer; Coulter, Angela; Fitzpatrick, Ray; Forder, Julien; Fox, Diane; Geneen, Louise; Gibbons, Elizabeth; Jenkinson, Crispin; Jones, Karen; Kelly, Laura; Peters, Michele; Mulhern, Brendan; Labeit, Alexander; Rowen, Donna; Meadows, Keith; Elliott, Jackie; Brazier, John E.; Knowles, Emma; Keetharuth, Anju; Brazier, John E.; Connell, Janice; Carlton, Jill; Buck, Lizzie Taylor; Ricketts, Thomas; Barkham, Michael; Goswami, Pushpendra; Salek, Sam; Ionova, Tatyana; Oliva, Esther; Fielding, Adele K.; Karakantza, Marina; Al-Ismail, Saad; Collins, Graham P.; McConnell, Stewart; Langton, Catherine; Jennings, Daniel M.; Else, Roger; Kell, Jonathan; Ward, Helen; Day, Sophie; Lumley, Elizabeth; Phillips, Patrick; Duncan, Rosie; Buckley-Woods, Helen; Aber, Ahmed; Jones, Gerogina; Michaels, Jonathan; Porter, Ian; Gangannagaripalli, Jaheeda; Davey, Antoinette; Ricci-Cabello, Ignacio; Haywood, Kirstie; Hansen, Stine Thestrup; Valderas, Jose; Roberts, Deb; Gumber, Anil; Podmore, Bélène; Hutchings, Andrew; van der Meulen, Jan; Aggarwal, Ajay; Konan, Sujith; Price, Andrew; Jackson, William; Bottomley, Nick; Philiips, Michael; Knightley-Day, Toby; Beard, David; Gibbons, Elizabeth; Fitzpatrick, Ray; Greenhalgh, Joanne; Gooding, Kate; Gibbons, Elizabeth; Valderas, Chema; Wright, Judy; Dalkin, Sonia; Meads, David; Black, Nick; Fawkes, Carol; Froud, Robert; Carnes, Dawn; Price, Andrew; Cook, Jonathan; Dakin, Helen; Smith, James; Kang, Sujin; Beard, David; Griffiths, Catrin; Guest, Ella; Harcourt, Diana; Murphy, Mairead; Hollinghurst, Sandra; Salisbury, Chris; Carlton, Jill; Elliott, Jackie; Rowen, Donna; Gao, Anqi; Price, Andrew; Beard, David; Lemanska, Agnieszka; Chen, Tao; Dearnaley, David P.; Jena, Rajesh; Sydes, Matthew; Faithfull, Sara; Ades, A. E.; Kounali, Daphne; Lu, Guobing; Rombach, Ines; Gray, Alastair; Jenkinson, Crispin; Rivero-Arias, Oliver; Holch, Patricia; Holmes, Marie; Rodgers, Zoe; Dickinson, Sarah; Clayton, Beverly; Davidson, Susan; Routledge, Jacqui; Glennon, Julia; Henry, Ann M.; Franks, Kevin; Velikova, Galina; Maguire, Roma; McCann, Lisa; Young, Teresa; Armes, Jo; Harris, Jenny; Miaskowski, Christine; Kotronoulas, Grigorios; Miller, Morven; Ream, Emma; Patiraki, Elizabeth; Geiger, Alexander; Berg, Geir V.; Flowerday, Adrian; Donnan, Peter; McCrone, Paul; Apostolidis, Kathi; Fox, Patricia; Furlong, Eileen; Kearney, Nora; Gibbons, Chris; Fischer, Felix; Gibbons, Chris; Coste, Joel; Martinez, Jose Valderas; Rose, Matthias; Leplege, Alain; Shingler, Sarah; Aldhouse, Natalie; Al-Zubeidi, Tamara; Trigg, Andrew; Kitchen, Helen; Davey, Antoinette; Porter, Ian; Green, Colin; Valderas, Jose M.; Coast, Joanna; Smith, Sarah; Hendriks, Jolijn; Black, Nick; Shah, Koonal; Rivero-Arias, Oliver; Ramos-Goni, Juan-Manuel; Kreimeier, Simone; Herdman, Mike; Devlin, Nancy; Finch, Aureliano Paolo; Brazier, John E.; Mukuria, Clara; Zamora, Bernarda; Parkin, David; Feng, Yan; Bateman, Andrew; Herdman, Mike; Devlin, Nancy; Patton, Thomas; Gutacker, Nils; Shah, Koonal

    2017-01-01

    The proceedings contain 36 papers. The topics discussed include: using patient reported outcome measures (PROMs) in cancer care; validation of the long-term conditions questionnaire (LTCQ) in a diverse sample of health and social care users in England; the national institutes of health

  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. Correction factor determination on failure rate equation of MacLaurin series for low and high mode application

    Directory of Open Access Journals (Sweden)

    Totok R. Biyanto

    2016-06-01

    Full Text Available Safety Instrumented Function (SIF is implemented on the system to prevent hazard in process industry. In general, most of SIF implementation in process industry works in low demand condition. Safety valuation of SIF that works in low demand can be solved by using quantitative method. The quantitative method is a simplified exponential equation form of MacLaurin series, which can be called simplified equation. Simplified equation used in high demand condition will generate a higher Safety Integrity Level (SIL and it will affect the higher safety cost. Therefore, the value of low or high demand rate limit should be determined to prevent it. The result of this research is a first order equation that can fix the error of SIL, which arises from the usage of simplified equation, without looking the demand rate limit for low and high demand. This equation is applied for SIL determination on SIF with 1oo1 vote. The new equation from this research is λ = 0.9428 λMC + 1.062E−04 H/P, with 5% average of error, where λMC is a value of λ from the simplified equation, Hazardous event frequency (H is a probabilistic frequency of hazard event and P is Probability of Failure on Demand (PFD in Independent Protection Layers (IPLs. The equation generated from this research could correct SIL of SIF in various H and P. Therefore, SIL design problem could be solved and it provides an appropriate SIL.

  12. 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

  13. 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.

  14. Enhancing rigour in the validation of patient reported outcome measures (PROMs: bridging linguistic and psychometric testing

    Directory of Open Access Journals (Sweden)

    Roberts Gwerfyl

    2012-06-01

    Full Text Available Abstract Background A strong consensus exists for a systematic approach to linguistic validation of patient reported outcome measures (PROMs and discrete methods for assessing their psychometric properties. Despite the need for robust evidence of the appropriateness of measures, transition from linguistic to psychometric validation is poorly documented or evidenced. This paper demonstrates the importance of linking linguistic and psychometric testing through a purposeful stage which bridges the gap between translation and large-scale validation. Findings Evidence is drawn from a study to develop a Welsh language version of the Beck Depression Inventory-II (BDI-II and investigate its psychometric properties. The BDI-II was translated into Welsh then administered to Welsh-speaking university students (n = 115 and patients with depression (n = 37 concurrent with the English BDI-II, and alongside other established depression and quality of life measures. A Welsh version of the BDI-II was produced that, on administration, showed conceptual equivalence with the original measure; high internal consistency reliability (Cronbach’s alpha = 0.90; 0.96; item homogeneity; adequate correlation with the English BDI-II (r = 0.96; 0.94 and additional measures; and a two-factor structure with one overriding dimension. Nevertheless, in the student sample, the Welsh version showed a significantly lower overall mean than the English (p = 0.002; and significant differences in six mean item scores. This prompted a review and refinement of the translated measure. Conclusions Exploring potential sources of bias in translated measures represents a critical step in the translation-validation process, which until now has been largely underutilised. This paper offers important findings that inform advanced methods of cross-cultural validation of PROMs.

  15. 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.

  16. SU-E-T-105: An FMEA Survey of Intensity Modulated Radiation Therapy (IMRT) Step and Shoot Dose Delivery Failure Modes

    International Nuclear Information System (INIS)

    Faught, J Tonigan; Johnson, J; Stingo, F; Kry, S; Court, L; Balter, P; Followill, D

    2015-01-01

    Purpose: To assess the perception of TG-142 tolerance level dose delivery failures in IMRT and the application of FMEA process to this specific aspect of IMRT. Methods: An online survey was distributed to medical physicists worldwide that briefly described 11 different failure modes (FMs) covered by basic quality assurance in step- and-shoot IMRT at or near TG-142 tolerance criteria levels. For each FM, respondents estimated the worst case H&N patient percent dose error and FMEA scores for Occurrence, Detectability, and Severity. Demographic data was also collected. Results: 181 individual and three group responses were submitted. 84% were from North America. Most (76%) individual respondents performed at least 80% clinical work and 92% were nationally certified. Respondent medical physics experience ranged from 2.5–45 years (average 18 years). 52% of individual respondents were at least somewhat familiar with FMEA, while 17% were not familiar. Several IMRT techniques, treatment planning systems and linear accelerator manufacturers were represented. All FMs received widely varying scores ranging from 1–10 for occurrence, at least 1–9 for detectability, and at least 1–7 for severity. Ranking FMs by RPN scores also resulted in large variability, with each FM being ranked both most risky (1st ) and least risky (11th) by different respondents. On average MLC modeling had the highest RPN scores. Individual estimated percent dose errors and severity scores positively correlated (p<0.10) for each FM as expected. No universal correlations were found between the demographic information collected and scoring, percent dose errors, or ranking. Conclusion: FMs investigated overall were evaluated as low to medium risk, with average RPNs less than 110. The ranking of 11 FMs was not agreed upon by the community. Large variability in FMEA scoring may be caused by individual interpretation and/or experience, thus reflecting the subjective nature of the FMEA tool

  17. 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.

  18. 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.

  19. Defense-in-depth and diversity evaluation to cope with design bases events concurrent with common mode failure in digital plant protection system for KNGR

    International Nuclear Information System (INIS)

    Shin, Lee Cheol; Park, Chan Eok; Jin, Choi Chul; Tae, Seo Jong

    2001-01-01

    The Korean Next Generation Reactor (KNGR) has been evolved to adopt an advanced design feature, a digital Plant Protection System (PPS) as an effort of enhancing reliability and safety of the plant. Although the digital PPS can be designed with high reliability, it is considered to be vulnerable to the Common Mode Failure (CMF) in the system software resulting in a total loss of the built-in hardware redundancy. Therefore, a comprehensive evaluation has been performed to demonstrate the intrinsic capability of the KNGR design in coping with the design basis events concurrent with CMF in the digital PPS. Instead of the conservative bounding analysis methodology, a best-estimate analysis methodology has been developed and utilized since the design basis events accompanied by CMF in the digital PPS are categorized as beyond design bases events. A variety of diverse means such as Alternate Protection System (APS), process control systems, and timely operator actions have been verified to be effective in mitigating the design basis events with CMF in the digital PPS

  20. 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

  1. A new anti-microbial combination prolongs the latency period, reduces acute histologic chorioamnionitis as well as funisitis, and improves neonatal outcomes in preterm PROM.

    Science.gov (United States)

    Lee, JoonHo; Romero, Roberto; Kim, Sun Min; Chaemsaithong, Piya; Park, Chan-Wook; Park, Joong Shin; Jun, Jong Kwan; Yoon, Bo Hyun

    2016-03-01

    Antibiotic administration is a standard practice in preterm premature rupture of membranes (PROM). Specific anti-microbial agents often include ampicillin and/or erythromycin. Anaerobes and genital mycoplasmas are frequently involved in preterm PROM, but are not adequately covered by antibiotics routinely used in clinical practice. Our objective was to compare outcomes of PROM treated with standard antibiotic administration versus a new combination more effective against these bacteria. A retrospective study compared perinatal outcomes in 314 patients with PROM 23 ng/mL). (1) Patients treated with regimen 2 had a longer median antibiotic-to-delivery interval than those with regimen 1 [median (interquartile range) 23 d (10-51 d) versus 12 d (5-52 d), p acute histologic chorioamnionitis (50.5% versus 66.7%, p hemorrhage (IVH) and cerebral palsy (CP) were significantly lower in patients allocated to regimen 2 than regimen 1 (IVH: 2.1% versus 19.0%, p acute histologic chorioamnionitis/funisitis, and improved neonatal outcomes in patients with preterm PROM. These findings suggest that the combination of anti-microbial agents (ceftriaxone, clarithromycin, and metronidazole) may improve perinatal outcome in preterm PROM.

  2. 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.

  3. 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)

  4. 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)

  5. SU-E-T-119: Analysis the Efficacy of Different Radiotherapy Methods and Failure Mode in No-Metastasis Esophageal Squamous Cell Carcinoma

    Energy Technology Data Exchange (ETDEWEB)

    Yankun, C; Zhihui, T; Runxiao, L; Shen, W [The Forth Hospital of Hebei Medical University, Shijiangzhuang, Hebei (China)

    2015-06-15

    Purpose: To evaluate the curative effect of radio (chemo) therapy and mode of treatment failure in no-metastasis and lesion length ≤ 5.0cm esophageal squamous cell carcinoma (ESCC). Methods: There were 158 eligible patients were retrospectively analyzed, to analysis the curative effect of radio (chemo) therapy, prognosis factors, toxicity and prognostic index model. Results: To all patients the 1, 3, 5 overall survival rate were 83.54%, 52.53%, 32.58%, the local recurrence rate were 15.08%, 33.60% and 38.14%; distant metastasis rate were 10.64%, 25.21% and 36.06%; tumor specific survival rate were 76.64%, 54.07% and 44.51%. Multivariate analysis showed that patients with ECOG grade (χ2=13.945, P=0.000), short-term effect (χ2=19.360, P=0.000) and different radiotherapy methods (χ2=9.866, P=0.002) as the independent prognostic factors. Prognostic index model showed that the survival rate was significantly higher in the lower value of PI group than in the larger value of PI group (χ2=49.19, P=0.0000). In our whole group, there were simple locoregional recurrence (LR) 40 cases (25.3%), simple Distant metastasis (DM) 31 cases (19.6%), LR and DM in 14 cases (8.9%) after treatment. The chi-square test showed that there were no significant difference in the incidence of Elective Nodal Irradiation (ENI )and Involved Field Irradiation (IFI) patients with LR and DM ( χ2=2.363, 2.950, P=0.124, 0.085). Conclusion: Radio (chemo) therapy has a good curative effect in no-metastasis and lesion length ≤ 5.0cm ESCC patients.

  6. SU-E-T-128: Applying Failure Modes and Effects Analysis to a Risk-Based Quality Management for Stereotactic Radiosurgery in Brazil

    Energy Technology Data Exchange (ETDEWEB)

    Teixeira, F [comissao nacional de energia nuclear, Rio De Janeiro, RJ (Brazil); Universidade do Estado do Rio de Janeiro, Rio De Janeiro, RJ (Brazil); Almeida, C de [Universidade do Estado do Rio de Janeiro, Rio De Janeiro, RJ (Brazil); Huq, M [University of Pittsburgh Medical Center, Pittsburgh, PA (United States)

    2015-06-15

    Purpose: The goal of the present work was to evaluate the process maps for stereotactic radiosurgery (SRS) treatment at three radiotherapy centers in Brazil and apply the FMEA technique to evaluate similarities and differences, if any, of the hazards and risks associated with these processes. Methods: A team, consisting of professionals from different disciplines and involved in the SRS treatment, was formed at each center. Each team was responsible for the development of the process map, and performance of FMEA and FTA. A facilitator knowledgeable in these techniques led the work at each center. The TG100 recommended scales were used for the evaluation of hazard and severity for each step for the major process “treatment planning”. Results: Hazard index given by the Risk Priority Number (RPN) is found to range from 4–270 for various processes and the severity (S) index is found to range from 1–10. The RPN values > 100 and severity value ≥ 7 were chosen to flag safety improvement interventions. Number of steps with RPN ≥100 were found to be 6, 59 and 45 for the three centers. The corresponding values for S ≥ 7 are 24, 21 and 25 respectively. The range of RPN and S values for each center belong to different process steps and failure modes. Conclusion: These results show that interventions to improve safety is different for each center and it is associated with the skill level of the professional team as well as the technology used to provide radiosurgery treatment. The present study will very likely be a model for implementation of risk-based prospective quality management program for SRS treatment in Brazil where currently there are 28 radiotherapy centers performing SRS. A complete FMEA for SRS for these three radiotherapy centers is currently under development.

  7. Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients.

    Science.gov (United States)

    Vélez-Díaz-Pallarés, Manuel; Delgado-Silveira, Eva; Carretero-Accame, María Emilia; Bermejo-Vicedo, Teresa

    2013-01-01

    To identify actions to reduce medication errors in the process of drug prescription, validation and dispensing, and to evaluate the impact of their implementation. A Health Care Failure Mode and Effect Analysis (HFMEA) was supported by a before-and-after medication error study to measure the actual impact on error rate after the implementation of corrective actions in the process of drug prescription, validation and dispensing in wards equipped with computerised physician order entry (CPOE) and unit-dose distribution system (788 beds out of 1080) in a Spanish university hospital. The error study was carried out by two observers who reviewed medication orders on a daily basis to register prescription errors by physicians and validation errors by pharmacists. Drugs dispensed in the unit-dose trolleys were reviewed for dispensing errors. Error rates were expressed as the number of errors for each process divided by the total opportunities for error in that process times 100. A reduction in prescription errors was achieved by providing training for prescribers on CPOE, updating prescription procedures, improving clinical decision support and automating the software connection to the hospital census (relative risk reduction (RRR), 22.0%; 95% CI 12.1% to 31.8%). Validation errors were reduced after optimising time spent in educating pharmacy residents on patient safety, developing standardised validation procedures and improving aspects of the software's database (RRR, 19.4%; 95% CI 2.3% to 36.5%). Two actions reduced dispensing errors: reorganising the process of filling trolleys and drawing up a protocol for drug pharmacy checking before delivery (RRR, 38.5%; 95% CI 14.1% to 62.9%). HFMEA facilitated the identification of actions aimed at reducing medication errors in a healthcare setting, as the implementation of several of these led to a reduction in errors in the process of drug prescription, validation and dispensing.

  8. SU-E-T-128: Applying Failure Modes and Effects Analysis to a Risk-Based Quality Management for Stereotactic Radiosurgery in Brazil

    International Nuclear Information System (INIS)

    Teixeira, F; Almeida, C de; Huq, M

    2015-01-01

    Purpose: The goal of the present work was to evaluate the process maps for stereotactic radiosurgery (SRS) treatment at three radiotherapy centers in Brazil and apply the FMEA technique to evaluate similarities and differences, if any, of the hazards and risks associated with these processes. Methods: A team, consisting of professionals from different disciplines and involved in the SRS treatment, was formed at each center. Each team was responsible for the development of the process map, and performance of FMEA and FTA. A facilitator knowledgeable in these techniques led the work at each center. The TG100 recommended scales were used for the evaluation of hazard and severity for each step for the major process “treatment planning”. Results: Hazard index given by the Risk Priority Number (RPN) is found to range from 4–270 for various processes and the severity (S) index is found to range from 1–10. The RPN values > 100 and severity value ≥ 7 were chosen to flag safety improvement interventions. Number of steps with RPN ≥100 were found to be 6, 59 and 45 for the three centers. The corresponding values for S ≥ 7 are 24, 21 and 25 respectively. The range of RPN and S values for each center belong to different process steps and failure modes. Conclusion: These results show that interventions to improve safety is different for each center and it is associated with the skill level of the professional team as well as the technology used to provide radiosurgery treatment. The present study will very likely be a model for implementation of risk-based prospective quality management program for SRS treatment in Brazil where currently there are 28 radiotherapy centers performing SRS. A complete FMEA for SRS for these three radiotherapy centers is currently under development

  9. The broad-host-range plasmid pSFA231 isolated from petroleum-contaminated sediment represents a new member of the PromA plasmid family.

    Science.gov (United States)

    Li, Xiaobin; Top, Eva M; Wang, Yafei; Brown, Celeste J; Yao, Fei; Yang, Shan; Jiang, Yong; Li, Hui

    2014-01-01

    A self-transmissible broad-host-range (BHR) plasmid pSFA231 was isolated from petroleum-contaminated sediment in Shen-fu wastewater irrigation zone, China, using the triparental mating exogenous plasmid capture method. Based on its complete sequence the plasmid has a size of 41.5 kb and codes for 50 putative open reading frames (orfs), 29 of which represent genes involved in replication, partitioning and transfer functions of the plasmid. Phylogenetic analysis grouped pSFA231 into the newly defined PromA plasmid family, which currently includes five members. Further comparative genomic analysis shows that pSFA231 shares the common backbone regions with the other PromA plasmids, i.e., genes involved in replication, maintenance and control, and conjugative transfer. Nevertheless, phylogenetic divergence was found in specific gene products. We propose to divide the PromA group into two subgroups, PromA-α (pMRAD02, pSB102) and PromA-β (pMOL98, pIPO2T, pSFA231, pTer331), based on the splits network analysis of the RepA protein. Interestingly, a cluster of hypothetical orfs located between parA and traA of pSFA231 shows high similarity with the corresponding regions on pMOL98, pIPO2T, and pTer331, suggesting these hypothetical orfs may represent "essential" plasmid backbone genes for the PromA-β subgroup. Alternatively, they may also be accessory genes that were first acquired and then stayed as the plasmid diverged. Our study increases the available collection of complete genome sequences of BHR plasmids, and since pSFA231 is the only characterized PromA plasmid from China, our findings also enhance our understanding of the genetic diversity of this plasmid group in different parts of the world.

  10. The broad-host-range plasmid pSFA231 isolated from petroleum-contaminated sediment represents a new member of the PromA plasmid family

    Directory of Open Access Journals (Sweden)

    Xiaobin eLi

    2015-01-01

    Full Text Available A self-transmissible broad-host-range (BHR plasmid pSFA231 was isolated from petroleum-contaminated sediment in Shen-fu wastewater irrigation zone, China, using the triparental mating exogenous plasmid capture method. Based on its complete sequence the plasmid has a size of 41.5 kb and codes for 50 putative open reading frames (orfs, 28 of which represent genes involved in replication, partitioning and transfer functions of the plasmid. Phylogenetic analysis grouped pSFA231 into the newly defined PromA plasmid family, which currently includes five members. Further comparative genomic analysis shows that pSFA231 shares the common backbone regions with the other PromA plasmids, i.e., genes involved in replication, maintenance and control, and conjugative transfer. Nevertheless, phylogenetic divergence was found in specific gene products. We propose to divide the PromA group into two subgroups, PromA-α (pMRAD02, pSB102 and PromA-β (pMOL98, pIPO2T, pSFA231, pTer331, based on the splits network analysis of the RepA protein. Interestingly, a cluster of hypothetical orfs located between parA and traA of pSFA231 shows high similarity with the corresponding regions on pMOL98, pIPO2T and pTer331, suggesting these hypothetical orfs may represent ‘‘essential’’ plasmid backbone genes for the PromA-β subgroup. Alternatively, they may also be accessory genes that were first acquired and then stayed as the plasmid diverged. Our study increases the available collection of complete genome sequences of BHR plasmids, and since pSFA231 is the only characterized PromA plasmid from China, our findings also enhance our understanding of the genetic diversity of this plasmid group in different parts of the world.

  11. LABOUR TERMINATION AND PERINATAL OUTCOME IN PREGNANT WOMEN WITH PLACENTA ABRUPTION WITH PPROM AND PROM

    Directory of Open Access Journals (Sweden)

    Ranko Kutlesic

    2007-10-01

    Full Text Available Placenta abruption is an obstetric accident which endangers life and health of both mother and embryo. It is one of the most serious obstetric complications, whose incidence ranges from 4.9-12.9 per 1,000 labours, and according to frequency, it represents the second cause of perinatal death. Retrospective analysis included the interval from 1996 to 2005. Total number of labours was analyzed and it was 32358. In addition, the number of labours complicated by placenta abruption was analyzed, and it was 119 or 0.37%. It analyzed the incidence of placenta abruption according to age of pregnancy and the integrity of embryonic membranes. It is established that there is no statistically significant difference in the incidence of placenta abruption appearing in pregnant women, with and without the disruption of embryonic membranes. The age of pregnant women was also analyzed, and it was found out that the pregnant women with placenta abruption and PPROM were 5 years older than those with placenta abruption without PPROM, and that this difference was very significant. Disruption duration was analyzed as well as the time from the first uterus bleeding to labour. The difference between PPROM and PROM duration was statistically significant, as well as the difference in duration between spontaneous and artificial rupture of embryonic membranes. The way of labour termination was analyzed in pregnant women with verified placenta abruption. In 80% of pregnant women, the labour was terminated by Caesarian section, and only 20% by vaginal labour. Also, the perinatal outcome was analyzed, according to Apgar score in the first and fifth minute. Apgar score showed that out of the total number of abruptions, 7 neonatuses was born dead (11.66%, 13 (21.66% was born in good condition (Apgar score>7, 26 (43.33% was marked with 4-7, while 14 (23.33% was in hard asphyxia (Apgar score 1-5.

  12. Evaluation of measurement properties of self-administered PROMs aimed at patients with non-specific shoulder pain and "activity limitations": a systematic review.

    Science.gov (United States)

    Thoomes-de Graaf, M; Scholten-Peeters, G G M; Schellingerhout, J M; Bourne, A M; Buchbinder, R; Koehorst, M; Terwee, C B; Verhagen, A P

    2016-09-01

    To critically appraise and compare the measurement properties of self-administered patient-reported outcome measures (PROMs) focussing on the shoulder, assessing "activity limitations." Systematic review. The study population had to consist of patients with shoulder pain. We excluded postoperative patients or patients with generic diseases. The methodological quality of the selected studies and the results of the measurement properties were critically appraised and rated using the COSMIN checklist. Out of a total of 3427 unique hits, 31 articles, evaluating 7 different questionnaires, were included. The SPADI is the most frequently evaluated PROM and its measurement properties seem adequate apart from a lack of information regarding its measurement error and content validity. For English, Norwegian and Turkish users, we recommend to use the SPADI. Dutch users could use either the SDQ or the SST. In German, we recommend the DASH. In Tamil, Slovene, Spanish and the Danish languages, the evaluated PROMs were not yet of acceptable validity. None of these PROMs showed strong positive evidence for all measurement properties. We propose to develop a new shoulder PROM focused on activity limitations, taking new knowledge and techniques into account.

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

    Energy Technology Data Exchange (ETDEWEB)

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

    1996-08-01

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

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

    International Nuclear Information System (INIS)

    Basu, S.; Ginsberg, T.

    1996-08-01

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

  15. Proceedings of Patient Reported Outcome Measure?s (PROMs) Conference Sheffield 2016: advances in patient reported outcomes research

    OpenAIRE

    Croudace, Tim; Brazier, John; Gutacker, Nils; Street, Andrew; Robotham, Dan; Waterman, Samantha; Rose, Diana; Satkunanathan, Safarina; Wykes, Til; Nasr, Nasrin; Enderby, Pamela; Carlton, Jill; Rowen, Donna; Elliott, Jackie; Brazier, John

    2016-01-01

    Table of contents S1 Using computerized adaptive testing Tim Croudace S2 Well-being: what is it, how does it compare to health and what are the implications of using it to inform health policy John Brazier O1 “Am I going to get better?”—Using PROMs to inform patients about the likely benefit of surgery Nils Gutacker, Andrew Street O2 Identifying Patient Reported Outcome Measures for an electronic Personal Health Record Dan Robotham, Samantha Waterman, Diana Rose, Safarina Satkunanathan, Til W...

  16. Proceedings of Patient Reported Outcome Measure’s (PROMs Conference Sheffield 2016: advances in patient reported outcomes research

    Directory of Open Access Journals (Sweden)

    Tim Croudace

    2016-10-01

    Full Text Available Table of contents S1 Using computerized adaptive testing Tim Croudace S2 Well-being: what is it, how does it compare to health and what are the implications of using it to inform health policy John Brazier O1 “Am I going to get better?”—Using PROMs to inform patients about the likely benefit of surgery Nils Gutacker, Andrew Street O2 Identifying Patient Reported Outcome Measures for an electronic Personal Health Record Dan Robotham, Samantha Waterman, Diana Rose, Safarina Satkunanathan, Til Wykes O3 Examining the change process over time qualitatively: transformative learning and response shift Nasrin Nasr, Pamela Enderby O4 Developing a PROM to evaluate self-management in diabetes (HASMID: giving patients a voice Jill Carlton, Donna Rowen, Jackie Elliott, John Brazier, Katherine Stevens, Hasan Basarir, Alex Labeit O5 Development of the Primary Care Outcomes Questionnaire (PCOQ Mairead Murphy, Sandra Hollinghurst, Chris Salisbury O6 Developing the PKEX score- a multimodal assessment tool for patients with shoulder problems Dominic Marley, James Wilson, Amy Barrat, Bibhas Roy O7 Applying multiple imputation to multi-item patient reported outcome measures: advantages and disadvantages of imputing at the item, sub-scale or score level Ines Rombach, Órlaith Burke, Crispin Jenkinson, Alastair Gray, Oliver Rivero-Arias O8 Integrating Patient Reported Outcome Measures (PROMs into routine primary care for patients with multimorbidity: a feasibility study Ian Porter, Jaheeda Gangannagaripalli, Charlotte Bramwell, Jose M. Valderas O9 eRAPID: electronic self-report and management of adverse-events for pelvic radiotherapy (RT patients Patricia Holch, Susan Davidson, Jacki Routledge, Ann Henry, Kevin Franks, Alex Gilbert, Kate Absolom & Galina Velikova O10 Patient reported outcomes (PROMs based recommendation in clinical guidance for the management of chronic conditions in the United Kingdom Ian Porter, Jose M.Valderas O11 Cross-sectional and

  17. Influence of hydrides orientation on strain, damage and failure of hydrided zircaloy-4; Influence de l'orientation des hydrures sur les modes de deformation, d'endommagement et de rupture du zircaloy-4 hydrure

    Energy Technology Data Exchange (ETDEWEB)

    Racine, A

    2005-09-15

    In pressurized water reactors of nuclear power plants, fuel pellets are contained in cladding tubes, made of Zirconium alloy, for instance Zircaloy-4. During their life in the primary water of the reactor (155 bars, 300 C), cladding tubes are oxidized and consequently hydrided. A part of the hydrogen given off precipitates as Zirconium hydrides in the bulk material and embrittles the material. This embrittlement depends on many parameters, among which hydrogen content and orientation of hydrides with respect to the applied stress. This investigation is devoted to the influence of the orientation of hydrides with respect to the applied stress on strain, damage and failure mechanisms. Macroscopic and SEM in-situ ring tensile tests are performed on cladding tube material (unirradiated cold worked stress-relieved Zircaloy-4) hydrided with about 200 and 500 wppm hydrogen, and with different main hydrides orientation: either parallel or perpendicular to the circumferential tensile direction. We get the mechanical response of the material as a function of hydride orientation and hydrogen content and we investigate the deformation, damage and failure mechanisms. In both cases, digital image correlation techniques are used to estimate local and global strain distributions. Neither the tensile stress-strain response nor the global and local strain modes are significantly affected by hydrogen content or hydride orientation, but the failure modes are strongly modified. Indeed, only 200 wppm radial hydrides embrittle Zy-4: sample fail in the elastic domain at about 350 MPa before strain bands could develop; whereas in other cases sample reach at least 750 MPa before necking and final failure, in ductile or brittle mode. To model this particular heterogeneous material behavior, a non-coupled damage approach which takes into account the anisotropic distribution of the hydrides is proposed. Its parameters are identified from the macroscopic strain field measurements and a

  18. The Post-Myocardial Infarction Pacing Remodeling Prevention Therapy (PRomPT) Trial

    DEFF Research Database (Denmark)

    Chung, Eugene S; Fischer, Trent M; Kueffer, Fred

    2015-01-01

    BACKGROUND: Despite considerable improvements in the medical management of patients with myocardial infarction (MI), patients with large MI still have substantial risk of developing heart failure. In the early post-MI setting, implantable cardioverter defibrillators have reduced arrhythmic deaths...

  19. 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

  20. Effect of welding parameters (plunge depths of shoulder, pin geometry, and tool rotational speed) on the failure mode and stir zone characteristics of friction stir spot welded aluminum 2024-T3 sheets

    Energy Technology Data Exchange (ETDEWEB)

    Paidar, Moslem; Sarab, Mahsa Lali; Taheri, Morteza; Khodabandeh, Alireza [Islamic Azad University, Tehran (Iran, Islamic Republic of)

    2015-11-15

    The main purpose of this study was to investigate the effect of welding parameters on the failure mode and stir zone characteristics of aluminum alloy 2024-T3 joined by friction stir spot welding. The welding parameters in this work are tool rotational speed, plunge depths of shoulder, and pin geometry. In accordance with the methods of previous investigations, the rotational speeds were set to 630 rpm to 2000 rpm. Two pin geometries with concave shoulder were used: triangular and cylindrical. The plunge depths of the shoulder were 0.3, 0.5 and 0.7 mm. The shoulder diameter and pin height for both geometries were 14 and 2.4 mm, respectively. The diameter of the cylindrical and triangular pins was 5 mm. Results show that the parameters mentioned earlier influence fracture mode under tension shear loading. Two different fracture modes were observed during the examinations. Low-penetration depths and low-rotational speeds lead to shear fracture, whereas high values of these factors cause the tension-shear fracture mode. Fracture of the lower sheet sometimes occurs at high rotational speeds.

  1. Investigaciones Terapéuticas en la Lepra: Ensayos con “Promín” o “Promanida'”

    Directory of Open Access Journals (Sweden)

    J. Ignacio Chala H.

    1948-07-01

    Full Text Available Con propósitos de observar, comprobar y valorar los resultados del "Promín"  o “Promanida” en la lepra, lo aplicarnos en un grupo de veintisiete enfermos seleccionados con criterio clínico y de investigación terapéutica. Iniciamos el estudio en julio de 1946. Ninguno de estos casos había sido tratado antes con otros medicamentos preconizados contra la enfermedad. Como lo he dicho en varias ocasiones, solamente teniendo esta precaución y seleccionando los pacientes para la investigación, podrá juzgarse científicamente de la eficacia terapéutica que puedan tener en los distintos tipos de lepra, las drogas aconsejadas para tratar esa enfermedad. Prescindimos de aquellos cases en los cuales, por lo avanzado del mal, los organismos no estaban en condiciones de reaccionar favorablemente con ninguna medicación.

  2. Psychometric validation of the Spanish version of the USS-PROM questionnaire for patients who undergo anterior urethral surgery.

    Science.gov (United States)

    Puche-Sanz, I; Martín-Way, D; Flores-Martín, J; Expósito-Ruiz, M; Vicente-Prados, J; Nogueras-Ocaña, M; Tinaut-Ranera, J; Cózar-Olmo, J M

    2016-06-01

    To translate into Spanish and validate the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) questionnaire, assessing its psychometric properties and determining its suitability for clinical use in our community. We also assessed the potential changes in ejaculatory function using the Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD). A systematic translation of the British version was performed. Patients scheduled for anterior urethral stricture surgery between September 2014 and September 2015 were prospectively included in the study. All patients completed the questionnaire before and after the surgery. We conducted an in-depth psychometric study of the questionnaire. We assessed the responses of a total of 40 patients. The questionnaire showed its validity, presenting an excellent negative correlation between the voiding symptom scores and the maximum flow (r=-0.6, P<.001), and also showed significant improvement in the EQ5D-VAS (visual analogue scale) and the time trade-off. For internal consistency, the Cronbach's alpha was 0.701. For the test-retest reliability, the overall intraclass correlation coefficient (ICC) was 0.974, and the ICC for each item separately ranged from 0.799 to 0.980. We observed significant improvement in all items regarding urinary symptoms and health-related quality of life (P<.001), thereby demonstrating the response capacity to changing the questionnaire. There were no significant changes in the MSHQ-EjD. The Spanish version of the USS-PROM questionnaire is a valid instrument for quantifying changes in voiding symptoms and the health-related quality of life of patients undergoing anterior urethral surgery. Copyright © 2016 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

  3. Component failure data base of TRIGA reactors

    International Nuclear Information System (INIS)

    Djuricic, M.

    2004-10-01

    This compilation provides failure data such as first criticality, component type description (reactor component, population, cumulative calendar time, cumulative operating time, demands, failure mode, failures, failure rate, failure probability) and specific information on each type of component of TRIGA Mark-II reactors in Austria, Bangladesh, Germany, Finland, Indonesia, Italy, Indonesia, Slovenia and Romania. (nevyjel)

  4. Fracture strength and failure mode of maxillary implant-supported provisional single crowns: a comparison of composite resin crowns fabricated directly over PEEK abutments and solid titanium abutments.

    Science.gov (United States)

    Santing, Hendrik Jacob; Meijer, Henny J A; Raghoebar, Gerry M; Özcan, Mutlu

    2012-12-01

    Polyetheretherketone (PEEK) temporary abutments have been recently introduced for making implant-supported provisional single crowns. Little information is available in the dental literature on the durability of provisional implant-supported restorations. The objectives of this study were to evaluate the fracture strength of implant-supported composite resin crowns on PEEK and solid titanium temporary abutments, and to analyze the failure types. Three types of provisional abutments, RN synOcta Temporary Meso Abutment (PEEK; Straumann), RN synOcta Titanium Post for Temporary Restorations (Straumann), and Temporary Abutment Engaging NobRplRP (Nobel Biocare) were used, and provisional screw-retained crowns using composite resin (Solidex) were fabricated for four different locations in the maxilla. The specimens were tested in a universal testing machine at a crosshead speed of 1 mm/minute until fracture occurred. The failure types were analyzed and further categorized as irreparable (Type 1) or reparable (Type 2). No significant difference was found between different abutment types. Only for the position of the maxillary central incisor, composite resin crowns on PEEK temporary abutments showed significantly lower (p Provisional crowns on PEEK abutments showed similar fracture strength as titanium temporary abutments except for central incisors. Maxillary right central incisor composite resin crowns on PEEK temporary abutments fractured below the mean anterior masticatory loading forces reported to be approximately 206 N. © 2010 Wiley Periodicals, Inc.

  5. 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

  6. An investment plan for preventing child injuries using risk priority number of failure mode and effects analysis methodology and a multi-objective, multi-dimensional mixed 0-1 knapsack model

    International Nuclear Information System (INIS)

    Bas, Esra

    2011-01-01

    In this paper, a general framework for child injury prevention and a multi-objective, multi-dimensional mixed 0-1 knapsack model were developed to determine the optimal time to introduce preventive measures against child injuries. Furthermore, the model maximises the prevention of injuries with the highest risks for each age period by combining