913 resultados para error management

em Queensland University of Technology - ePrints Archive


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The paper presents an innovative approach to modelling the causal relationships of human errors in rail crack incidents (RCI) from a managerial perspective. A Bayesian belief network is developed to model RCI by considering the human errors of designers, manufactures, operators and maintainers (DMOM) and the causal relationships involved. A set of dependent variables whose combinations express the relevant functions performed by each DMOM participant is used to model the causal relationships. A total of 14 RCI on Hong Kong’s mass transit railway (MTR) from 2008 to 2011 are used to illustrate the application of the model. Bayesian inference is used to conduct an importance analysis to assess the impact of the participants’ errors. Sensitivity analysis is then employed to gauge the effect the increased probability of occurrence of human errors on RCI. Finally, strategies for human error identification and mitigation of RCI are proposed. The identification of ability of maintainer in the case study as the most important factor influencing the probability of RCI implies the priority need to strengthen the maintenance management of the MTR system and that improving the inspection ability of the maintainer is likely to be an effective strategy for RCI risk mitigation.

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Encompasses the whole BPM lifecycle, including process identification, modelling, analysis, redesign, automation and monitoring Class-tested textbook complemented with additional teaching material on the accompanying website Covers both relevant conceptual background, industrial standards and actionable skills Business Process Management (BPM) is the art and science of how work should be performed in an organization in order to ensure consistent outputs and to take advantage of improvement opportunities, e.g. reducing costs, execution times or error rates. Importantly, BPM is not about improving the way individual activities are performed, but rather about managing entire chains of events, activities and decisions that ultimately produce added value for an organization and its customers. This textbook encompasses the entire BPM lifecycle, from process identification to process monitoring, covering along the way process modelling, analysis, redesign and automation. Concepts, methods and tools from business management, computer science and industrial engineering are blended into one comprehensive and inter-disciplinary approach. The presentation is illustrated using the BPMN industry standard defined by the Object Management Group and widely endorsed by practitioners and vendors worldwide. In addition to explaining the relevant conceptual background, the book provides dozens of examples, more than 100 hands-on exercises – many with solutions – as well as numerous suggestions for further reading. The textbook is the result of many years of combined teaching experience of the authors, both at the undergraduate and graduate levels as well as in the context of professional training. Students and professionals from both business management and computer science will benefit from the step-by-step style of the textbook and its focus on fundamental concepts and proven methods. Lecturers will appreciate the class-tested format and the additional teaching material available on the accompanying website fundamentals-of-bpm.org.

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Morris' (1986) analysis of the factors affecting project success and failure is considered in relation to the psychology of judgement under uncertainty. A model is proposed whereby project managers may identify the specific circumstances in which human decision-making is prone to systematic error, and hence may apply a number of de-biasing techniques.

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In earlier cultures and societies, hazards and risks to human health were dealt with by methods derived from myth, metaphor and ritual. In modem society however, notions of hazard and risk have been transformed from the level of a folk discourse to that of an expert centred concept (Plough & Krimsky, 1987). With the professionalization of risk and hazard analysis came a preferred framework for decision making based on a range of 'technical' methodologies (Giere, 1991 ). This is especially true for decision processes relating to risk assessment and management, and impact assessment. Such approaches however, often entail narrow technical-based theoretical assumptions about human behaviour and the natural world, and the· methods used. They therefore carry 'in-built' error factors that contribute considerable uncertainty to the results.

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Road collisions negatively affect the lives of hundreds of Canadians per year. Unfortunately, safety has been typically neglected from management systems. It is common to find that a great deal of effort has been devoted to develop and implement systems capable of achieving and sustaining good levels of condition. It is relatively recent that road safety has become an important objective. Managing a network of roads is not an easy task; it requires long, medium and short term plans to maintain, rehabilitate and upgrade aging assets, reduce and mitigate accident exposure, likelihood and severity. This thesis presents a basis for incorporating road safety into road management systems; two case studies were developed; one limited by available data and another from sufficient information. A long term analysis was used to allocate improvements for condition and safety of roads and bridges, at the network level. It was confirmed that a safety index could be used to obtain a first cut model; meanwhile potential for improvement which is a difference between observed and predicted number of accidents was capable of capturing the degree of safety of individual segments. It was found that the completeness of the system resulted in savings because of the economies obtained from trade-off optimization. It was observed that safety improvements were allocated at the beginning of the analysis in order to reduce the extent of issues, which translated into a systematic reduction of potential for improvement up to a point of near constant levels, which were hypothesized to relate to those unavoidable collisions from human error or vehicle failure.

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Observing the working procedure of construction workers is an effective means of maintaining the safety performance of a construction project. It is also difficult to achieve due to a high worker-to-safety-officer ratio. There is an imminent need for the development of a tool to assist in the real-time monitoring of workers, in order to reduce the number of construction accidents. The development and application of a real time locating system (RTLS) based on the Chirp Spread Spectrum (CSS) technique is described in this paper for tracking the real-time position of workers on construction sites. Experiments and tests were carried out both on- and off-site to verify the accuracy of static and dynamic targets by the system, indicating an average error of within one metre. Experiments were also carried out to verify the ability of the system to identify workers’ unsafe behaviours. Wireless data transfer was used to simplify the deployment of the system. The system was deployed in a public residential construction project and proved to be quick and simple to use. The cost of the developed system is also reported to be reasonable (around 1800USD) in this study and is much cheaper than the cost of other RTLS. In addition, the CCS technique is shown to provide an economical solution with reasonable accuracy compared with other positioning systems, such as ultra wideband. The study verifies the potential of the CCS technique to provide an effective and economical aid in the improvement of safety management in the construction industry.

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Insulated Rail Joints (IRJs) are safety critical component of the automatic block signalling and broken rail detection systems. IRJs exhibit several failure modes due to complex interaction between the railhead ends and the wheel tread near the gap. These localised zones could not be monitored using automatic sensing devices and hence are resorted to visual inspection only, which is error prone and expensive. In Australia alone currently there are 50,000 IRJs across 80,000 km of rail track. The significance of the problem around the world could thus be realised as there exists one IRJ for each 1.6 km track length. IRJs exhibit extremely low and variable service life; further the track substructure underneath IRJs degrade faster. Thus presence of the IRJs incur significant costs to track maintenance. IRJ failures have also contributed to some train derailments and various traffic disruptions in rail lines. This paper reports a systematic research carried out over seven years on the mechanical behaviour of IRJs for practically relevant outcomes. The research has scientifically established that stiffening the track bed for reduction in impact force is an ill-conceived concept and the most effective method is to reduce the gap size. Further it is established that hardening the railhead ends through laser coating (or other) cannot adequately address the metal flow problem in the long run; modification of the railhead profile is the only appropriate technique to completely eliminate the problem. Part of these outcomes has been adopted by the rail infrastructure owners in Australia.

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OBJECTIVE We aimed to 1) describe the peripartum management of type 1 diabetes at an Australian teaching hospital and 2) discuss factors influencing the apparent transient insulin independence postpartum. RESEARCH DESIGN AND METHODS We conducted a retrospective review of women with type 1 diabetes delivering singleton pregnancies from 2005 to 2010. Information was collected regarding demographics, medical history, peripartum management and outcome, and breast-feeding. To detect a difference in time to first postpartum blood glucose level (BGL) >8 mmol/L between women with an early (<4 h) and late (>12 h) requirement for insulin postpartum, with a power of 80% and a type 1 error of 0.05, at least 24 patients were required. RESULTS An intravenous insulin infusion was commenced in almost 95% of women. Univariate analysis showed that increased BMI at term, lower creatinine at term, longer duration from last dose of long- or intermediate-acting insulin, and discontinuation of an insulin infusion postpartum were associated with a shorter time to first requirement of insulin postpartum (P = 0.005, 0.026, 0.026, and <0.001, respectively). There was a correlation between higher doses of insulin commenced postpartum and number of out-of-range BGLs (r[36] = 0.358, P = 0.030) and hypoglycemia (r[36] = 0.434, P = 0.007). Almost 60% had at least one BGL <3.5 mmol/L between delivery and discharge. CONCLUSIONS Changes in the pharmacodynamic profile of insulin may contribute to the transient insulin independence sometimes observed postpartum in type 1 diabetes. A dose of 50–60% of the prepregnancy insulin requirement resulted in the lowest rate of hypoglycemia and glucose excursions. These results require validation in a larger, prospective study.

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