Safety illusion and error trap in a collectively-operated machine accident

Workplace accidents involving machines are relevant for their magnitude and their impacts on worker health. Despite consolidated critical statements, explanation centered on errors of operators remains predominant with industry professionals, hampering preventive measures and the improvement of production-system reliability. Several initiatives were adopted by enforcement agencies in partnership with universities to stimulate production and diffusion of analysis methodologies with a systemic approach. Starting from one accident case that occurred with a worker who operated a brake-clutch type mechanical press, the article explores cognitive aspects and the existence of traps in the operation of this machine. It deals with a large-sized press that, despite being endowed with a light curtain in areas of access to the pressing zone, did not meet legal requirements. The safety devices gave rise to an illusion of safety, permitting activation of the machine when a worker was still found within the operational zone. Preventive interventions must stimulate the tailoring of systems to the characteristics of workers, minimizing the creation of traps and encouraging safety policies and practices that replace judgments of behaviors that participate in accidents by analyses of reasons that lead workers to act in that manner.

Safety illusion and error trap in a collectively-operated machine accident

Workplace accidents involving machines are relevant for their magnitude and their impacts on worker health. Despite consolidated critical statements, explanation centered on errors of operators remains predominant with industry professionals, hampering preventive measures and the improvement of production-system reliability. Several initiatives were adopted by enforcement agencies in partnership with universities to stimulate production and diffusion of analysis methodologies with a systemic approach. Starting from one accident case that occurred with a worker who operated a brake-clutch type mechanical press, the article explores cognitive aspects and the existence of traps in the operation of this machine. It deals with a large-sized press that, despite being endowed with a light curtain in areas of access to the pressing zone, did not meet legal requirements. The safety devices gave rise to an illusion of safety, permitting activation of the machine when a worker was still found within the operational zone. Preventive interventions must stimulate the tailoring of systems to the characteristics of workers, minimizing the creation of traps and encouraging safety policies and practices that replace judgments of behaviors that participate in accidents by analyses of reasons that lead workers to act in that manner.

Salute e sicurezza sul lavoro: significati e problemi della valutazione dei rischi da stress lavoro-correlato nelle aziende sanitarie

Work environment changes bring new risks, in particular an increase in certain diseases and illnesses caused by stress. The European Agreement of October 2004 defines stress as “a state accompanied by physical, psychological or social dysfunctions, due to the fact that people do not feel able to overcome the gap in relation to requests or expectations for them”. A new strategy aims to reduce accidents and occupational illnesses through a series of actions at European level. The approaches to prevent work related stress must specifically aim to face up organizational and social aspects, to provide training to managers and employees on management of stress, to reduce the impact and to develop suitable systems for rehabilitation and return to work for those who suffered health problems. The enterprises will have to carry out the obligations laid down by legislation, adopting detection systems customised on their size and on their specific interests. Currently manifold tools and methodologies are proposed from different subjects as employer associations, advisors for safety, psychologists etc., but none of these has been identified as a model to follow. After the reconstruction of the theoretical framework where the theme is placed in, the thesis, through a background analysis done by collecting the comments of experts who are involved in the management of occupational safety and the examination of a concrete assessment of work-related stress risk, carried out at a local health authority of Emilia-Romagna region, aims to highlight the main sociological implications related to the emergence of these new risks.

High precision swept volume approximation with conservative error bounds

In technical design processes in the automotive industry, digital prototypes rapidly gain importance, because they allow for a detection of design errors in early development stages. The technical design process includes the computation of swept volumes for maintainability analysis and clearance checks. The swept volume is very useful, for example, to identify problem areas where a safety distance might not be kept. With the explicit construction of the swept volume an engineer gets evidence on how the shape of components that come too close have to be modified.rnIn this thesis a concept for the approximation of the outer boundary of a swept volume is developed. For safety reasons, it is essential that the approximation is conservative, i.e., that the swept volume is completely enclosed by the approximation. On the other hand, one wishes to approximate the swept volume as precisely as possible. In this work, we will show, that the one-sided Hausdorff distance is the adequate measure for the error of the approximation, when the intended usage is clearance checks, continuous collision detection and maintainability analysis in CAD. We present two implementations that apply the concept and generate a manifold triangle mesh that approximates the outer boundary of a swept volume. Both algorithms are two-phased: a sweeping phase which generates a conservative voxelization of the swept volume, and the actual mesh generation which is based on restricted Delaunay refinement. This approach ensures a high precision of the approximation while respecting conservativeness.rnThe benchmarks for our test are amongst others real world scenarios that come from the automotive industry.rnFurther, we introduce a method to relate parts of an already computed swept volume boundary to those triangles of the generator, that come closest during the sweep. We use this to verify as well as to colorize meshes resulting from our implementations.

Design di un sistema di fault detection per un'architettura fail-safe di attuazione delle superfici di controllo di un UAV

In questo lavoro di tesi si affronta una delle problematiche che si presentano oggi nell'impiego degli APR (Aeromobili a Pilotaggio Remoto): la gestione della safety. Non si può più, in altri termini, negare che tali oggetti siano parte integrante dello spazio aereo civile. Proprio su questo tema recentemente gli enti regolatori dello spazio aereo stanno proiettando i loro sforzi al fine di stabilire una serie di regolamenti che disciplinino da una parte le modalità con cui questi oggetti si interfacciano con le altre categorie di velivoli e dall'altra i criteri di idoneità perché anche essi possano operare nello spazio aereo in maniera sicura. Si rende quindi necessario, in tal senso, dotare essi stessi di un sufficiente grado di sicurezza che permetta di evitare eventi disastrosi nel momento in cui si presenta un guasto nel sistema; è questa la definizione di un sistema fail-safe. Lo studio e lo sviluppo di questa tipologia di sistemi può aiutare il costruttore a superare la barriera oggi rappresentata dal regolamento che spesso e volentieri rappresenta l'unico ostacolo non fisico per la categoria dei velivoli unmanned tra la terra e il cielo. D'altro canto, al fine di garantire a chi opera a distanza su questi oggetti di avere, per tutta la durata della missione, la chiara percezione dello stato di funzionamento attuale del sistema e di come esso può (o potrebbe) interagire con l'ambiente che lo circonda (situational awarness), è necessario dotare il velivolo di apparecchiature che permettano di poter rilevare, all'occorrenza, il malfunzionamento: è questo il caso dei sistemi di fault detection. Questi due fondamentali aspetti sono la base fondante del presente lavoro che verte sul design di un ridotto ma preponderante sottosistema dell'UAV: il sistema di attuazione delle superfici di controllo. Esse sono, infatti, l'unico mezzo disponibile all'operatore per governare il mezzo nelle normali condizioni di funzionamento ma anche l'ultima possibilità per tentare di evitare l'evento disastroso nel caso altri sottosistemi siano chiaramente fuori dalle condizioni di normale funzionamento dell'oggetto.

Error recovery in a hospital pharmacy

A field study was performed in a hospital pharmacy aimed at identifying positive and negative influences on the process of detection of and further recovery from initial errors or other failures, thus avoiding negative consequences. Confidential reports and follow-up interviews provided data on 31 near-miss incidents involving such recovery processes. Analysis revealed that organizational culture with regard to following procedures needed reinforcement, that some procedures could be improved, that building in extra checks was worthwhile and that supporting unplanned recovery was essential for problems not covered by procedures. Guidance is given on how performance in recovery could be measured. A case is made for supporting recovery as an addition to prevention-based safety methods.

Bit-error probability for direct detection of optical RZ signal degraded by ASE noise and timing jitter

We analyze theoretically the interplay between optical return-to-zero signal degradation due to timing jitter and additive amplified-spontaneous-emission noise. The impact of these two factors on the performance of a square-law direct detection receiver is also investigated. We derive an analytical expression for the bit-error probability and quantitatively determine the conditions when the contributions of the effects of timing jitter and additive noise to the bit error rate can be treated separately. The analysis of patterning effects is also presented. © 2007 IEEE.

AGV Safety Areas Obstacle Detection and Interaction with Point Cloud Derived Map

This thesis project aims to the development of an algorithm for the obstacle detection and the interaction between the safety areas of an Automated Guided Vehicles (AGV) and a Point Cloud derived map inside the context of a CAD software. The first part of the project focuses on the implementation of an algorithm for the clipping of general polygons, with which has been possible to: construct the safety areas polygon, derive the sweep of this areas along the navigation path performing a union and detect the intersections with line or polygon representing the obstacles. The second part is about the construction of a map in terms of geometric entities (lines and polygons) starting from a point cloud given by the 3D scan of the environment. The point cloud is processed using: filters, clustering algorithms and concave/convex hull derived algorithms in order to extract line and polygon entities representing obstacles. Finally, the last part aims to use the a priori knowledge of possible obstacle detections on a given segment, to predict the behavior of the AGV and use this prediction to optimize the choice of the vehicle's assigned velocity in that segment, minimizing the travel time.

LATENT RANK CHANGE DETECTION FOR ANALYSIS OF SPLICE-JUNCTION MICROARRAYS WITH NONLINEAR EFFECTS

Alternative splicing of gene transcripts greatly expands the functional capacity of the genome, and certain splice isoforms may indicate specific disease states such as cancer. Splice junction microarrays interrogate thousands of splice junctions, but data analysis is difficult and error prone because of the increased complexity compared to differential gene expression analysis. We present Rank Change Detection (RCD) as a method to identify differential splicing events based upon a straightforward probabilistic model comparing the over-or underrepresentation of two or more competing isoforms. RCD has advantages over commonly used methods because it is robust to false positive errors due to nonlinear trends in microarray measurements. Further, RCD does not depend on prior knowledge of splice isoforms, yet it takes advantage of the inherent structure of mutually exclusive junctions, and it is conceptually generalizable to other types of splicing arrays or RNA-Seq. RCD specifically identifies the biologically important cases when a splice junction becomes more or less prevalent compared to other mutually exclusive junctions. The example data is from different cell lines of glioblastoma tumors assayed with Agilent microarrays.

Human Error Contribution in Collision and Grounding of Oil Tankers

The purpose of this article is to present a quantitative analysis of the human failure contribution in the collision and/or grounding of oil tankers, considering the recommendation of the ""Guidelines for Formal Safety Assessment"" of the International Maritime Organization. Initially, the employed methodology is presented, emphasizing the use of the technique for human error prediction to reach the desired objective. Later, this methodology is applied to a ship operating on the Brazilian coast and, thereafter, the procedure to isolate the human actions with the greatest potential to reduce the risk of an accident is described. Finally, the management and organizational factors presented in the ""International Safety Management Code"" are associated with these selected actions. Therefore, an operator will be able to decide where to work in order to obtain an effective reduction in the probability of accidents. Even though this study does not present a new methodology, it can be considered as a reference in the human reliability analysis for the maritime industry, which, in spite of having some guides for risk analysis, has few studies related to human reliability effectively applied to the sector.

A sensor array based on mass and capacitance transducers for the detection of adulterated gasolines

The simultaneous use of different sensors technologies is an efficient method to increase the performance of chemical sensors systems. Among the available technologies, mass and capacitance transducers are particularly interesting because they can take advantage also from non-conductive sensing layers, such as most of the more interesting molecular recognition systems. In this paper, an array of quartz microbalance sensors is complemented by an array of capacitors obtained from a commercial biometrics fingerprints detector. The two sets of transducers, properly functionalized by sensitive molecular and polymeric films, are utilized for the estimation of adulteration in gasolines, and in particular to quantify the content of ethanol in gasolines, an application of importance for Brazilian market. Results indicate that the hybrid system outperforms the individual sensor arrays even if the quantification of ethanol in gasoline, due to the variability of gasolines formulation, is affected by a barely acceptable error. (C) 2009 Elsevier B.V. All rights reserved.

Local search multiuser detection

In this work, a wide analysis of local search multiuser detection (LS-MUD) for direct sequence/code division multiple access (DS/CDMA) systems under multipath channels is carried out considering the performance-complexity trade-off. It is verified the robustness of the LS-MUD to variations in loading, E(b)/N(0), near-far effect, number of fingers of the Rake receiver and errors in the channel coefficients estimates. A compared analysis of the bit error rate (BER) and complexity trade-off is accomplished among LS, genetic algorithm (GA) and particle swarm optimization (PSO). Based on the deterministic behavior of the LS algorithm, it is also proposed simplifications over the cost function calculation, obtaining more efficient algorithms (simplified and combined LS-MUD versions) and creating new perspectives for the MUD implementation. The computational complexity is expressed in terms of the number of operations in order to converge. Our conclusion pointed out that the simplified LS (s-LS) method is always more efficient, independent of the system conditions, achieving a better performance with a lower complexity than the others heuristics detectors. Associated to this, the deterministic strategy and absence of input parameters made the s-LS algorithm the most appropriate for the MUD problem. (C) 2008 Elsevier GmbH. All rights reserved.

Jointly multi-user detection and channel estimation with genetic algorithm

This work aims at proposing the use of the evolutionary computation methodology in order to jointly solve the multiuser channel estimation (MuChE) and detection problems at its maximum-likelihood, both related to the direct sequence code division multiple access (DS/CDMA). The effectiveness of the proposed heuristic approach is proven by comparing performance and complexity merit figures with that obtained by traditional methods found in literature. Simulation results considering genetic algorithm (GA) applied to multipath, DS/CDMA and MuChE and multi-user detection (MuD) show that the proposed genetic algorithm multi-user channel estimation (GAMuChE) yields a normalized mean square error estimation (nMSE) inferior to 11%, under slowly varying multipath fading channels, large range of Doppler frequencies and medium system load, it exhibits lower complexity when compared to both maximum likelihood multi-user channel estimation (MLMuChE) and gradient descent method (GrdDsc). A near-optimum multi-user detector (MuD) based on the genetic algorithm (GAMuD), also proposed in this work, provides a significant reduction in the computational complexity when compared to the optimum multi-user detector (OMuD). In addition, the complexity of the GAMuChE and GAMuD algorithms were (jointly) analyzed in terms of number of operations necessary to reach the convergence, and compared to other jointly MuChE and MuD strategies. The joint GAMuChE-GAMuD scheme can be regarded as a promising alternative for implementing third-generation (3G) and fourth-generation (4G) wireless systems in the near future. Copyright (C) 2010 John Wiley & Sons, Ltd.