957 resultados para human error


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Ghost fishing is the term used to describe the continued capture of fish and other living organisms after a fisherman has lost all control over the gear. Traps may be lost for a variety of reasons including theft, vandalism, abandonment, interactions with other gear, fouling on the bottom (i.e., traps and ropes are caught on rocky substrate), bad weather, and human error (Laist, 1995). Annual trap loss can be as high as 20% to 50% of fished traps in some fisheries (Al-Masroori et al., 2004). Because lost traps can continue to fish for long periods, albeit with decreasing efficiency over time (e.g., Smolowitz, 1978; Breen, 1987, 1990; Guillory, 1993), ghost fishing is a concern in fisheries worldwide.

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Since 2001, NOAA National Centers for Coastal Ocean Science (NCCOS), Center for Coastal Monitoring and Assessment’s (CCMA) Biogeography Branch (BB) has been working with federal and territorial partners to characterize, monitor, and assess the status of the marine environment across the U.S. Virgin Islands (USVI). At the request of the St. Thomas Fisherman’s Association (STFA) and NOAA Marine Debris Program, CCMA BB developed new partnerships and novel technologies to scientifically assess the threat from derelict fish traps (DFTs). Traps are the predominant gear used for finfish and lobster harvesting in St. Thomas and St. John. Natural phenomena (ground swells, hurricanes) and increasing competition for space by numerous user groups have generated concern about increasing trap loss and the possible ecological, as well as economic, ramifications. Prior to this study, there was a general lack of knowledge regarding derelict fish traps in the Caribbean. No spatially explicit information existed regarding fishing effort, abundance and distribution of derelict traps, the rate at which active traps become derelict, or areas that are prone to dereliction. Furthermore, there was only limited information regarding the impacts of derelict traps on natural resources including ghost fishing. This research identified two groups of fishing communities in the region: commercial fishing that is most active in deeper waters (30 m and greater) and an unknown number of unlicensed subsistence and or commercial fishers that fish closer to shore in shallower waters (30 m and less). In the commercial fishery there are an estimated 6,500 active traps (fish and lobster combined). Of those traps, nearly 8% (514) were reported lost during the 2008-2010 period. Causes of loss/dereliction include: movement of the traps or loss of trap markers due to entanglement of lines by passing vessels; theft; severe weather events (storms, large ground swells); intentional disposal by fishermen; traps becoming caught on various bottom structures (natural substrates, wrecks, etc.); and human error.

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In recent years unmanned vehicles have grown in popularity, with an ever increasing number of applications in industry, the military and research within air, ground and marine domains. In particular, the challenges posed by unmanned marine vehicles in order to increase the level of autonomy include automatic obstacle avoidance and conformance with the Rules of the Road when navigating in the presence of other maritime traffic. The USV Master Plan which has been established for the US Navy outlines a list of objectives for improving autonomy in order to increase mission diversity and reduce the amount of supervisory intervention. This paper addresses the specific development needs based on notable research carried out to date, primarily with regard to navigation, guidance, control and motion planning. The integration of the International Regulations for Avoiding Collisions at Sea within the obstacle avoidance protocols seeks to prevent maritime accidents attributed to human error. The addition of these critical safety measures may be key to a future growth in demand for USVs, as they serve to pave the way for establishing legal policies for unmanned vessels.

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Trabalho Final de Mestrado para obtenção do grau de Mestre em Engenharia Civil na Área de Especialização em Estruturas

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La seguridad del paciente constituye una prioridad y un reto para los organismos Gubernamentales y para las instituciones de salud tanto a nivel nacional como internacional (Sescam, 2007), quienes han emprendido una búsqueda de soluciones por medio de diferentes metodologías y estrategias que permitan reducir al máximo los riesgos de la atención de salud para el paciente (Ministerio de Sanidad y Consumo, 2002). Aunque se cuenta con mejores sistemas o metodología de análisis y sistemas de notificación la persistencia del fenómeno es constante. ( Requena, Aranaz, Gea, Limón, Miralles, & Vitaller , 2010). En esta tesis se plantea una nueva alternativa de gestión en la seguridad del paciente a través de la Teoría de Restricciones (TOC) para emprender acciones que permitan analizar el sistema bajo esta nueva metodología, intervenir de manera oportuna, impactar y estimular al personal de salud a trabajar en la búsqueda del mejoramiento continuo para el establecimiento de un sistema efectivo de gestión de la seguridad del paciente y una cultura de seguridad de los trabajadores de la institución de salud.

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Objetivos. El Objetivo general de este estudio es determinar si el Instrumento para evaluar las Fallas Cognitivas Ocupacionales (Occupational Cognitive Failures Questionnaire - OCFQ) desarrollado por Allahyari T. et al. (2011) , tiene validez transcultural y podría ser un Instrumento fiable y válido que se puede adaptar al contexto cultural Colombiano para la valoración de las Fallas Cognitivas en el ámbito laboral. Metodología. Se llevó a cabo la traducción, adaptación y validación del Cuestionario de Fallas Cognitivas Ocupacionales (OCFQ) al contexto cultural colombiano, siguiendo las recomendaciones de la Organización Mundial de la Salud (OMS) para el proceso de traducción y adaptación de instrumentos y posteriormente la evaluación de fiabilidad y validez del instrumento adaptado, en cuatro etapas: Etapa 1. Traducción - retro traducción, Etapa 2. “Debriefing” y Análisis de legibilidad, Etapa 3. Validez de contenido, usando el Índice de Validez de Contenido (CVI) y Etapa 4. Evaluación de propiedades métricas. Para la evaluación de Validez de Constructo se aplicó el Análisis Factorial por el Método de Componentes Principales y Rotación Varimax; la consistencia interna y la estabilidad temporal fueron evaluados mediante el Alpha de Cronbach (α) y el test-retest, respectivamente. Resultados. El Cuestionario OCFQ fue adaptado al contexto cultural Colombiano; el análisis de Legibilidad determinó que de acuerdo con el Grado en la escala Inflesz, el Cuestionario es Bastante Fácil de leer. Partiendo de la versión original de 30 ítems se obtuvo una nueva versión de 25 ítems, ya que después de la evaluación de Validez de Contenido se rechazaron 5 ítems. El Índice de Validez de Contenido (CVI) para la versión final del OCFQ adaptado es aceptable (CVI=0,84). Los resultados de las pruebas métricas muestran que la versión final del OCFQ adaptado tiene una buena Consistencia Interna (α=0.90) y el Índice de Correlación Interclases (ICC) fue de 0.91 mostrando una muy buena Estabilidad Temporal. El Análisis Factorial estableció para el Cuestionario OCFQ 4 factores que explican el 47% de la varianza total. Conclusión. La evaluación de las Fallas Cognitivas en el ámbito laboral requiere que se disponga de una herramienta válida y fiable. De acuerdo con los resultados en este estudio se puede establecer que el OCFQ adaptado al Contexto Cultural Colombiano podría ser un instrumento adecuado para medir las Fallas Cognitivas en el ámbito laboral en plantas industriales.

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Much of the published human factors work on risk is to do with safety and within this is concerned with prediction and analysis of human error and with human reliability assessment. Less has been published on human factors contributions to understanding and managing project, business, engineering and other forms of risk and still less jointly assessing risk to do with broad issues of ‘safety’ and broad issues of ‘production’ or ‘performance’. This paper contains a general commentary on human factors and assessment of risk of various kinds, in the context of the aims of ergonomics and concerns about being too risk averse. The paper then describes a specific project, in rail engineering, where the notion of a human factors case has been employed to analyse engineering functions and related human factors issues. A human factors issues register for potential system disturbances has been developed, prior to a human factors risk assessment, which jointly covers safety and production (engineering delivery) concerns. The paper concludes with a commentary on the potential relevance of a resilience engineering perspective to understanding rail engineering systems risk. Design, planning and management of complex systems will increasingly have to address the issue of making trade-offs between safety and production, and ergonomics should be central to this. The paper addresses the relevant issues and does so in an under-published domain – rail systems engineering work.

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Very large scale scheduling and planning tasks cannot be effectively addressed by fully automated schedule optimisation systems, since many key factors which govern 'fitness' in such cases are unformalisable. This raises the question of an interactive (or collaborative) approach, where fitness is assigned by the expert user. Though well-researched in the domains of interactively evolved art and music, this method is as yet rarely used in logistics. This paper concerns a difficulty shared by all interactive evolutionary systems (IESs), but especially those used for logistics or design problems. The difficulty is that objective evaluation of IESs is severely hampered by the need for expert humans in the loop. This makes it effectively impossible to, for example, determine with statistical confidence any ranking among a decent number of configurations for the parameters and strategy choices. We make headway into this difficulty with an Automated Tester (AT) for such systems. The AT replaces the human in experiments, and has parameters controlling its decision-making accuracy (modelling human error) and a built-in notion of a target solution which may typically be at odds with the solution which is optimal in terms of formalisable fitness. Using the AT, plausible evaluations of alternative designs for the IES can be done, allowing for (and examining the effects of) different levels of user error. We describe such an AT for evaluating an IES for very large scale planning.

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This study has explored the underlying causes of preventable drug-related admissions to hospital, from primary care through semi-structured interviews and review of patients’ medical records. Analysis of the data has revealed that communication failures between different groups of healthcare professionals and between healthcare professionals and patients contribute to preventable drug-related admissions, as do knowledge gaps about medication in both healthcare professionals and patients. In addition, working conditions for community pharmacists severely limit their ability to effectively act as a safety barrier to patients receiving inappropriate medication. Limitations include heavy workloads, lack of access to patients’ clinical information, poor relationships with general practitioners and time restrictions. The results of this study represent an important addition to our understanding of the contribution of human error as an underlying cause of preventable drug-related morbidity, and the factors which contribute to errors occurring in the primary healthcare setting.

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The motivation for this thesis work is the need for improving reliability of equipment and quality of service to railway passengers as well as a requirement for cost-effective and efficient condition maintenance management for rail transportation. This thesis work develops a fusion of various machine vision analysis methods to achieve high performance in automation of wooden rail track inspection.The condition monitoring in rail transport is done manually by a human operator where people rely on inference systems and assumptions to develop conclusions. The use of conditional monitoring allows maintenance to be scheduled, or other actions to be taken to avoid the consequences of failure, before the failure occurs. Manual or automated condition monitoring of materials in fields of public transportation like railway, aerial navigation, traffic safety, etc, where safety is of prior importance needs non-destructive testing (NDT).In general, wooden railway sleeper inspection is done manually by a human operator, by moving along the rail sleeper and gathering information by visual and sound analysis for examining the presence of cracks. Human inspectors working on lines visually inspect wooden rails to judge the quality of rail sleeper. In this project work the machine vision system is developed based on the manual visual analysis system, which uses digital cameras and image processing software to perform similar manual inspections. As the manual inspection requires much effort and is expected to be error prone sometimes and also appears difficult to discriminate even for a human operator by the frequent changes in inspected material. The machine vision system developed classifies the condition of material by examining individual pixels of images, processing them and attempting to develop conclusions with the assistance of knowledge bases and features.A pattern recognition approach is developed based on the methodological knowledge from manual procedure. The pattern recognition approach for this thesis work was developed and achieved by a non destructive testing method to identify the flaws in manually done condition monitoring of sleepers.In this method, a test vehicle is designed to capture sleeper images similar to visual inspection by human operator and the raw data for pattern recognition approach is provided from the captured images of the wooden sleepers. The data from the NDT method were further processed and appropriate features were extracted.The collection of data by the NDT method is to achieve high accuracy in reliable classification results. A key idea is to use the non supervised classifier based on the features extracted from the method to discriminate the condition of wooden sleepers in to either good or bad. Self organising map is used as classifier for the wooden sleeper classification.In order to achieve greater integration, the data collected by the machine vision system was made to interface with one another by a strategy called fusion. Data fusion was looked in at two different levels namely sensor-level fusion, feature- level fusion. As the goal was to reduce the accuracy of the human error on the rail sleeper classification as good or bad the results obtained by the feature-level fusion compared to that of the results of actual classification were satisfactory.

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Incidentes com medicamentos geram problemas aos pacientes e custos adicionais ao sistema de saúde. A variedade de termos utilizada para comunicá-los propicia divergências nos resultados de pesquisas e confundem notificadores. Objetivou-se revisar os termos utilizados para descrever estes incidentes confrontando-os com as conceituações/definições oficiais disponíveis. Pesquisaram-se as bases PubMed, MEDLINE, IPA e LILACS para selecionar estudos publicados entre janeiro de 1990 e dezembro de 2005. Selecionaram-se 33 publicações. Verificou-se que a terminologia supranacional recomendada para descrever incidentes com medicamentos é insuficiente, mas que há consenso de uso das expressões em função do gênero do incidente. O termo Reação Adversa a Medicamento é mais utilizado quando não se verifica intencionalidade. A expressão Evento Adverso a Medicamento foi mais usada quando se descreviam incidentes durante a hospitalização; e Problema Relacionado a Medicamento foi mais utilizada em estudos que avaliaram atenção/cuidados farmacêuticos (uso/falta do medicamento). Ainda assim, a linha divisória entre essas três categorias não é clara e simples. Futuros estudos das relações entre as categorias e investigações multidisciplinares sobre erro humano podem subsidiar a proposição de novas conceituações.

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In 2008, academic researchers and public service officials created a university extension studies platform based on online and on-site meetings denominated "Work-Related Accidents Forum: Analysis, Prevention, and Other Relevant Aspects. Its aim was to help public agents and social partners to propagate a systemic approach that would be helpful in the surveillance and prevention of work-related accidents. This article describes and analyses such a platform. Online access is free and structured to: support dissemination of updated concepts; support on-site meetings and capacity to build educational activities; and keep a permanent space for debate among the registered participants. The desired result is the propagation of a social-technical-systemic view of work-related accidents that replaces the current traditional view that emphasizes human error and results in blaming the victims. The Forum uses an educational approach known as permanent health education, which is based on the experience and needs of workers and encourages debate among participants. The forum adopts a problematizing pedagogy that starts from the requirements and experiences of the social actors and stimulates support and discussions among them in line with an ongoing health educational approach. The current challenge is to turn the platform into a social networking website in order to broaden its links with society.

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Pós-graduação em Agronomia (Energia na Agricultura) - FCA

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Due to the need of more agility, dynamism and reliability in stock management, the market has turned its attention to RFID, which offers a practical solution and live up to the big corporations' expectations. The search for continuous improvement establishes a direct link with RFID, for its technology offers accurate real time information in any monitored given place. RFID is a radio frequency communication technology. A reader communicates to a tag through waves. This tag can be active, with a battery, or passive, in which its power is supplied by currents induced by the field variation it is exposed to. The RFID technology has a well defined basic principle, but there are many constructive ways of implementing it. The adaptability as well as the flexibility regard to the several kinds of stock in industry, reaching their particular needs. RFID can lower maintenance costs in stock by collecting data more accurately, lowering human error and optimizing the item handling at its reception, exit and while it is inside the company. This paper presents an example of RFID technology applied in a company's stock management. It is possible to prove that there are, in fact, great advantages in implementing this technology, as it creates the opportunity for continuous improvement in stock management, with better application of material, labour and quality tools, since the data collected through an automatized process using RFID are more reliable and dynamic

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Electrical installations in industries involving high currents and voltages considered. On the other side is the common appearance of electrical failures, caused by human error, defects in electrical equipment or electrical installation aging itself. These failures are varied, those with the highest rate of occurrence and cause much damage to electrical installations, are overcurrent and overvoltage. Therefore there is a need to project a system that can detect and minimize possible effects caused by faults in electrical installations industries. Protection systems in electric industries emerge as an alternative to control especially voltage and current magnitudes. Engineered based on the functions of the relays, protection systems are an indispensable tool for any industrial substation. But the project of such systems becomes increasingly more complex, due to technological development. Electrical equipment not develop at the same speed that the protective devices (relays), making it indispensable knowledge of integration of technologies